In The Realm of Hungry Ghosts – Chapter One

The Only Home He’s Ever Had

As I pass through the grated metal door into the sunshine, a setting from a Fellini film reveals itself. It is a scene both familiar and outlandish, dreamlike and authentic.

On the Hastings Street sidewalk Eva, in her thirties but still waif-like, with dark hair and olive complexion, taps out a bizarre cocaine flamenco. Jutting her hips, torso and pelvis this way and that, bending now at the waist and thrusting one or both arms in the air, she shifts her feet about in a clumsy but concerted pirouette. All the while she tracks me with her large, black eyes.

In the Downtown Eastside this piece of crack-driven improvisational ballet is known as “the Hastings shuffle,” and it’s a familiar sight. During my medical rounds in the neighbourhood one day, I saw a young woman perform it high above the Hastings traffic. She was balanced on the narrow edge of a neon sign two storeys up. A crowd had gathered to watch, the users among them more amused than horrified. The ballerina would turn about, her arms horizontal like a tightrope walker’s, or do deep knee bends—an aerial Cossack dancer, one leg kicked in front. Before the top of the firemen’s ladder could reach her cruising altitude, the stoned acrobat had ducked back inside her window.

Eva weaves her way among her companions, who crowd around me. Sometimes she disappears behind Randall—a wheelchair-bound, heavy-set, serious-looking fellow, whose unorthodox thought patterns do not mask a profound intelligence. He recites an ode of autistic praise to his indispensable motorized chariot.  “Isn’t it amazing, Doc, isn’t it, that Napoleon’s cannon was pulled by horses and oxen in the Russian mud and snow. And now I have this!”  With an innocent smile and earnest expression, Randall pours out a recursive stream of facts, historical data, memories, interpretations, loose associations, imaginings, and paranoia that almost sound sane—almost.  “That’s the Napoleonic Code, Doc, which altered the transportational mediums of the lower rank and file, you know, in those days when such pleasant smorgasboredom was still well fathomed.”   Poking her head above Randall’s left shoulder, Eva plays peek-a-boo.

Beside Randall stands Arlene, her hands on her hips and a reproachful look on her face, clad in skimpy jean shorts and blouse—a sign, down here, of a mode of earning drug money and, more often than not, of having been sexually exploited early in life by male predators. Over the steady murmur of Randall’s oration comes her complaint: “You shouldn’t have reduced my pills.” Arlene’s arms bear dozens of horizontal scars, parallel, like railway ties. The older ones white, the more recent red, each mark a souvenir of a razor slash she has inflicted on herself. The pain of self-laceration obliterates, if only momentarily, the pain of a larger hurt deep in the psyche. One of Arlene’s medications controls this compulsive self-wounding, and she’s always afraid I’m reducing her dose. I never do.

Close to us, in the shadow of the Portland Hotel, two cops have Jenkins in handcuffs. Jenkins, a lanky Native man with black, scraggly hair falling to below his shoulders, is quiet and compliant as one of the officers empties his pockets. He arches his back against the wall, not a hint of protest on his face. “They should leave him alone,” Arlene opines loudly. “That guy doesn’t deal. They keep grabbing him and never find a thing.”  At least in the broad daylight of Hastings Street, the cops go about their search with exemplary politeness—not, according to my patients’ stories, a consistent police attitude. After a minute or two Jenkins is set free and lopes silently into the hotel with his long stride.

Meanwhile, within the span of a few minutes, the resident poet laureate of absurdity has reviewed European history from the Hundred Years’ War to Bosnia and has pronounced on religion from Moses to Mohammed.  “Doc,” Randall goes on, “the First World War was supposed to end all wars. If that was true, how come we have the war on cancer or the war on drugs? The Germans had this gun Big Bertha that spoke to the Allies but not in a language the French or the Brits liked. Guns get a bad rap, a bad reputation—a bad raputation, Doc—but they move history forward, if we can speak of history moving forward or moving at all. Do you think history moves, Doc?”

Leaning on his crutches, paunchy, one-legged, smiling Matthew—bald, and irrepressibly jovial—interrupts Randall’s discourse. “Poor Dr. Maté is trying to get home,” he says in his characteristic tone: at once sarcastic and sweetly genuine. Matthew grins at us as if the joke is on everyone but himself. The chain of rings piercing his left ear glimmers in the bronzed gold of the late afternoon sun.

Eva prances out from behind Randall’s back. I turn away. I’ve had enough street theatre and now I want to escape. The good doctor no longer wants to be good.

We congregate, these Fellini figures and I—or I should say we, this cast of Fellini characters—outside the Portland Hotel, where they live and I work. My clinic is on the first floor of this cement and glass building designed by Canadian architect Arthur Erickson, a spacious, modern, utilitarian structure. It’s an impressive facility that serves its residents well, replacing the formerly luxurious turn-of-the-century establishment around the corner that was the first Portland Hotel. The old place, with its wooden balustrades, wide and winding staircases, musty landings and bay windows had a character and history the new fortress lacks. Although I miss its Old World aura, the atmosphere of faded wealth and decay, the dark and blistered windowsills varnished with memories of elegance, I doubt the residents have any nostalgia for the cramped rooms, the corroded plumbing or the armies of cockroaches. In 1994 there was a fire on the roof of the old hotel. A local newspaper ran a story and a photograph featuring a female resident and her cat. The headline proclaimed, “Hero Cop Saves Fluffy.” Someone phoned the Portland to complain that animals should not be allowed to live in such conditions.

The nonprofit Portland Hotel Society for whom I am the staff physician turned the building into housing for the nonhousable. My patients are mostly addicts, although some, like Randall, have enough derangement of their brain chemicals to put them out of touch with reality even without the use of drugs. Many, like Arlene, suffer from both mental illness and addiction. The PHS administers several similar facilities within a radius of a few blocks: the Stanley, Washington, Regal and Sunrise hotels. I am the house doctor for them all.

The new Portland faces the Army and Navy department store across the street, where my parents, as new immigrants in the late 1950s, bought most of our clothing. Back then, the Army and Navy was a popular shopping destination for working people—and for middle-class kids looking for funky military coats or sailor jackets. On the sidewalks outside, university students seeking some slumming fun mixed with alcoholics, pickpockets, shoppers and Friday night Bible preachers.

No longer. The crowds stopped coming many years ago. Now these streets and their back alleys serve as the centre of Canada’s drug capital. One block away stood the abandoned Woodward’s department store, its giant, lighted “W” sign on the roof a long-time Vancouver landmark. For a while squatters and antipoverty activists occupied the building, but it has recently been demolished; the site is to be converted into a mix of chic apartments and social housing. The Winter Olympics are coming to Vancouver in 2010 and with it the likelihood of gentrification in this neighbourhood. The process has already begun. There’s a fear that the politicians, eager to impress the world, will try to displace the addict population.

Eva intertwines her arms, stretches them behind her back and leans forward to examine her shadow on the sidewalk. Matthew chuckles at her crackhead yoga routine. Randall rambles on. I glance out eagerly at the rush-hour traffic flowing by. Finally, rescue arrives. My son Daniel drives up and opens the car door. “Sometimes I don’t believe my life,” I tell him, easing into the passenger’s seat.  “Sometimes I don’t believe your life either,” he nods. “It can get pretty intense down here.” We pull away. In the rearview mirror the receding figure of Eva gesticulates, legs akimbo, head tilted to the side.


The Portland and the other buildings of the Portland Hotel Society represent a pioneering social model. The purpose of the PHS is to provide a system of safety and caring to marginalized and stigmatized people—the ones who are “the insulted and the injured,” to borrow from Dostoevsky. The PHS attempts to rescue such people from what a local poet has called the “streets of displacement and the buildings of exclusion.”

“People just need a space to be,” says Liz Evans, a former psychiatric nurse, whose upper-tier social background might seem incongruous with her present role as a founder and director of the PHS. “They need a space where they can exist without being judged and hounded and harassed. These are people who are frequently viewed as liabilities, blamed for crime and social ills, and . . . seen as a waste of time and energy. They are regarded harshly even by people who make compassion their careers.”

From very modest beginnings in 1991, the Portland Hotel Society has grown to participate in activities such as a neighbourhood bank; an art gallery for Downtown Eastside artists; North America’s first supervised injection site; a community hospital ward, where deep-tissue infections are treated with intravenous antibiotics; a free dental clinic; and the Portland Clinic, where I have worked for the past eight years. The core mandate of the PHS is to provide domiciles for people who would otherwise be homeless.

The statistics are stark. A review done shortly after the Portland was established revealed that among the residents three-quarters had over five addresses in the year before they were housed, and 90 per cent had been charged or convicted of crimes, often many times over, usually for petty theft.  Currently 36 per cent are HIV positive or have frank AIDS, and most are addicted to alcohol or other substances—anything from rice wine to mouthwash, to cocaine or heroin. Over half have been diagnosed with mental illness. The proportion of Native Canadians among Portland residents is five times their ratio in the general population.

For Liz and the others who developed the PHS, it was endlessly frustrating to watch people go from crisis to crisis, with no consistent support. “The system had abandoned them,” she says, “so we’ve tried to set up the hotels as a base for other services and programs. It took eight years of fundraising and four provincial government ministries and four private foundations to make the new Portland a reality. Now people finally have their own bathrooms, laundry facilities and a decent place to eat food.”

What makes the Portland model unique and controversial among addiction services is the core intention to accept people as they are—no matter how dysfunctional, troubled and troubling that may be. Our clients are not the “deserving poor”; they are just poor—undeserving in their own eyes and in those of society. At the Portland Hotel there is no chimera of redemption nor any expectation of socially respectable outcomes, only an unsentimental recognition of the real needs of real human beings in the dingy present, based on a uniformly tragic past. We may (and do) hope that people can be liberated from the demons that haunt them and work to encourage them in that direction, but we don’t fantasize that such psychological exorcism can be forced on anyone. The uncomfortable truth is that most of our clients will remain addicts, on the wrong side of the law as it now stands. Kerstin Stuerzbecher, a former nurse with two liberal arts degrees, is another Portland Society director.  “We don’t have all the answers,” she says, “and we cannot necessarily provide the care people may need in order to make dramatic changes in their lives. At the end of the day it’s never up to us—it’s within them or not.”

Residents are offered as much assistance as the Portland’s financially stretched resources permit. Home support staff clean rooms and assist with personal hygiene for the most helpless. Food is prepared and distributed. When possible, patients are accompanied to specialists’ appointments or for X-rays or other medical investigations. Methadone, psychiatric medications and HIV drugs are dispensed by the staff. A laboratory comes to the Portland every few months for mass screening for HIV and hepatitis and for follow-up blood tests. There is a writing and poetry group, an art group—a quilt based on residents’ drawings hangs on the wall of my office. There are visits from an acupuncturist, hairdressing, movie nights and, while we still had the funds, people were taken away from the grimy confines of the Downtown Eastside for an annual camping outing. My son Daniel, a sometime employee at the Portland, has led a monthly music group.

“We had this talent evening at the Portland a few years ago,” says Kerstin, “with the art group and the writing group, and there was also a cabaret show. There was art on the wall and people read their poetry—we changed the venue into a café. A long-time resident came up to the microphone. He said he didn’t have a poem to recite or anything else creative. . . . What he shared was that the Portland was his first home. That this is the only home he’s ever had and how grateful he was for the community he was part of.  And how proud he was to be part of it, and he wished his mom and dad could see him now.”

“The only home he’s ever had”—a phrase that sums up the histories of many people in the Downtown Eastside of “the world’s most liveable city.” [1]


The work can be intensely satisfying or deeply frustrating, depending on my own state of mind. Often I face the refractory nature of people who value their health and well-being less than the immediate, drug-driven needs of the moment. I also have to confront my own resistance to them as people. As much as I want to accept them, or as much as I do so in principle, some days I find myself full of disapproval and judgment, rejecting them and wanting them to be other than who they are. That contradiction originates with me, not with my patients. It’s my problem—except that, given the obvious power imbalance between us—it’s all too easy for me to make it their problem.

My patients’ addictions make every medical treatment encounter a challenge. Where else do you find people in such poor health and yet so averse to taking care of themselves or even to allowing others to take care of them?  At times, one literally has to coax them into hospital. Take Kai, who has an immobilizing infection of his hip that could leave him crippled, or Hobo, whose breastbone osteomyelitis could penetrate into his lungs.  Both men are so focused on their next hit of cocaine or heroin or “jib”—crystal meth—that self-preservation pales into insignificance. Many also have an ingrained fear of authority figures and distrust institutions, for reasons no one could begrudge them.

“The reason I do drugs is so I don’t feel the fucking feelings I feel when I don’t do drugs,” Nick, a forty-year-old heroin and crystal meth addict once told me, weeping as he spoke. “When I don’t feel the drugs in me, I get depressed.” His father drilled into his twin sons the notion that they were nothing but “pieces of shit.” Nick’s brother committed suicide as a teenager; Nick became a lifelong addict.

The Hell Realm of painful emotions frightens most of us; drug addicts fear they would be trapped there forever but for their substances. This urge to escape exacts a fearful price.

The cement hallways and the elevator at the Portland Hotel are washed clean frequently, sometimes several times a day. Punctured by needle marks, some residents have chronic draining wounds.  Blood also seeps from blows and cuts inflicted by their fellow addicts or from pits patients have scratched in their skin during fits of cocaine-induced paranoia. One man picks at himself incessantly to get rid of imaginary insects.

Not that we lack real infestation in the Downtown Eastside. Rodents thrive between hotel walls and in the garbage-strewn back alleys. Vermin populate many of my patients’ beds, clothes and bodies: bedbugs, lice, scabies. Cockroaches occasionally drop out from shaken skirts and pant legs in my office and scurry for cover under my desk.  “I like having one or two mice around,” one young man told me. “They eat the cockroaches and bedbugs. But I can’t stand a whole nest of them in my mattress.”

Vermin, boils, blood and death: the plagues of Egypt.

In the Downtown Eastside the angel of death slays with shocking alacrity. Marcia, a thirty-five-year-old heroin addict, had moved out from her PHS residence and was now living in a tenement half a block away. One morning, I received a frantic phone call about a suspected overdose. I found Marcia in bed, her eyes wide open, lying on her back and already in rigor mortis. Her arms were extended, palms outward in a gesture of alarmed protest as if to say: “No, you’ve come to take me too soon, much too soon!”  Plastic syringes cracked under my shoes as I approached her body. Marcia’s dilated pupils and some other physical cues told the story—she died not of overdose but of heroin withdrawal. I stood for a few moments by her bedside, trying to see in her body the charming, if always absent-minded, human being I had known. As I turned to leave, wailing sirens signalled the arrival of emergency vehicles outside.

Marcia had been in my office just the week before, in good cheer, asking for help with some medical forms she needed to fill out, to get back on welfare. It was the first time I’d seen her in six months. During that period, as she explained with nonchalant resignation, she had helped her boyfriend, Kyle, blow through a hundred-and-thirty-thousand-dollar inheritance—a process selflessly aided by many other user friends and hangers-on. For all that popularity, she was alone when death caught her.

Another casualty was Frank, a reclusive heroin addict who would grudgingly let you into his cramped quarters at the Regal Hotel only when he was very ill.  “No fucking way I’m dying in hospital,” he declared, once it became clear that the grim reaper AIDS was knocking at his door. There was no arguing with Frank about that or anything else.  He died in his own ragged bed, but his bed, in 2002.

Frank had a sweet soul that his curmudgeonly abrasiveness could not hide. Although he never talked to me about his life experience, he expressed the gist of it in “Downtown Hellbound Train,” a poem he wrote a few months before his death. It is a requiem for himself and for the dozens of women—drug users, sex trade workers—said to have been murdered at the infamous Pickton pig farm outside Vancouver:

Went downtown—Hastings and Main
Looking for relief from the pain
All I did was find
A one-way ticket on a Hellbound Train

On a farm not far away
Several friends were taken away
Rest their souls from the pain
End their ride on the Hellbound Train

Give me peace before I die
The track is laid out so well
We all live our private hell
Just more tickets on the Hellbound Train

Hellbound Train
Hellbound Train
One-way ticket on a Hellbound Train

Having worked in palliative medicine, care of the terminally ill, I have encountered death often. In a real sense, addiction medicine with this population is also palliative work. We do not expect to cure anyone, only to ameliorate the effects of drug addiction and its attendant ailments and to soften the impact of the legal and social torments our culture uses to punish the drug addict.  Except for the rare fortunate ones who escape the Downtown Eastside drug colony, very few of my patients will live to old age. Most will die of some complication of their HIV or Hepatitis C or of meningitis or a massive septicemia contracted through multiple self-injections during a prolonged cocaine run. Some will succumb to cancer at a relatively young age, their stressed and debilitated immune systems unable to keep malignancy in check. That’s how Stevie died, of liver cancer, the sweet-sardonic expression that always played on her face obscured by deep jaundice. Or they’ll do a bad fix one night and die of an overdose, like Angel at the Sunrise Hotel or like Trevor, one floor above, who always smiled as if nothing ever bothered him.

One darkening February evening, Leona, a patient who lives in a nearby hotel, awoke on the cot in her room to find her eighteen-year-old son, Joey, lifeless and rigid in her bed. She had taken him in from the street and was keeping watch to save him from self-harm. Mid-morning, after an all-night vigil, she fell asleep; he overdosed in the afternoon. “When I woke up,” she recalled, “Joey was lying motionless. Nobody had to tell me. The ambulance and fire guys came, but there was nothing anybody could do. My baby was dead.” Her grief is oceanic, her sense of guilt fathomless.

One constant at the Portland Clinic is pain. Medical school teaches the three signs of inflammation, in Latin: calor, rubror, dolor—heat, redness and pain. The skin, limbs or organs of my patients are often inflamed, and for that my ministrations can be at least temporarily adequate. But how to soothe souls inflamed by the intense torment imposed first by childhood experiences almost too sordid to believe and then, with mechanical repetition, by the sufferers themselves? And how to offer them comfort when their sufferings are made worse every day by social ostracism—by what the scholar and writer Elliot Leyton has described as “the bland, racist, sexist and ‘classist’ prejudices buried in Canadian society: an institutionalized contempt for the poor, for sex trade workers, for drug addicts and alcoholics, for aboriginal people.”[i] The pain here in the Downtown Eastside reaches out with hands begging for drug money. It stares from eyes cold and hard or downcast with submission and shame. It speaks in cajoling tones or screams aggressively. Behind every look, every word, each violent act or disenchanted gesture is a history of anguish and degradation, a self-writ tale with new chapters added each day and scarcely a happy end.


As Daniel drives me home, we’re listening to CBC on the car radio, broadcasting its whimsical afternoon cocktail of light-hearted patter, classics and jazz. Jolted by the disharmony between the urbane radio space and the troubled world I’ve just left, I recall my first patient of the day.

Madeleine sits hunched, elbows resting on her thighs, her gaunt, wiry body convulsed by sobbing. She clutches her head in her hands, periodically clenching her fists and beating rhythmically at her temples. Straight brown hair, fallen forward, veils her eyes and cheeks. Her lower lip is swollen and bruised, and blood trickles from a small cut. Her thick, boyish voice is hoarse with rage and pain. “I’ve been fucked over again,” she cries. “It’s always me, the sucker for everyone else’s bullshit. How do they know they can do it to me every time?”  She coughs as the tears trickle down her windpipe. She’s like a child telling her story, asking for sympathy, pleading for help.

The tale she tells is a variation on a theme familiar in the Downtown Eastside: drug addicts exploiting each other. Three women Madeleine knows well give her a hundred-dollar bill. The deal is, she buys twelve “rocks” of crack[2] from the person she calls “the Spic.” She gets one; they’ll keep some for themselves and resell the rest.  “We can’t let the cops see us buy that much,” they tell her. The transaction is completed, money and rocks are exchanged. Ten minutes later the “great big Spic” catches up with Madeleine, “grabs me by the hair, throws me on the ground, gives me a punch in the face.” The hundred-dollar bill is counterfeit.  “They set me up. ‘Oh, Maddie, you’re my buddy, you’re my friend.’ I had no idea it was a bogus hundred.”

My clients often speak about the “Spic,” but he’s an unseen presence, a mythical figure I only hear about. On the street corners near the Portland Hotel, young, olive-hued Central Americans congregate, black baseball caps over their eyes. As I walk by, they call out to me in a low whisper, even with my signal stethoscope around my neck: “up, down” or “good rock.”  (Up and down are junkie slang for cocaine—an upper, a stimulant—and for heroin—a downer, a sedative. Rock is crack cocaine.) “Hey, can’t you see that’s the doctor?” someone occasionally hisses. The “Spic” may well be amongst that group or perhaps the epithet is a generic term that refers to any of them.

I don’t know who he is or the path that led him to Vancouver’s Skid Row, where he pushes cocaine and slaps around the emaciated women who steal, deal, cheat or sell cheap oral sex to pay him. Where was he born? What war, what deprivation forced his parents out of their slum or their mountain village to seek a life so far north of the Equator?  Poverty in Honduras, paramilitaries in Guatemala, death squads in El Salvador?  How did he become the “Spic,” a villain in a story told by the rake-thin, distraught woman in my office who, choking on her tears, explains her bruises and asks that I don’t hold it against her that she failed to show for last week’s methadone visit.

“I haven’t had juice for seven days,” Madeleine says. (“Juice” is slang for methadone:  the methadone powder is dissolved in orange-flavoured Tang.) “And I won’t ask anybody for help on the street because if they help you, you owe them your goddamn life. Even if you pay them back, they still think you owe them. ‘There’s Maddie, we can hustle her for it. She’ll give it to us.’ They know I won’t fight. ’Cause if I ever fight I’m going to fucking kill one of these bitches down here. I don’t want spend the rest of my life in jail because of some goddamn cunt I never should’ve got involved with in the first place. That’s what’s going to happen. I can only take so much.”

I hand her the methadone prescription and invite her back to talk after she’s had her dose at the pharmacy. Although Madeleine agrees, I won’t see her again today. As always, the need for the next fix beckons.

Another visitor that morning was Stan, a forty-five-year-old Native man just out of jail, also here for his methadone script. In his eighteen months of incarceration he has become pudgy, and this has softened the menacing air bestowed by his height, muscular build, dark, glowering eyes, Apache hair, and Fu Manchu moustache. Or perhaps he’s mellowed, since he’s been off cocaine all this time. He peers out the window at the sidewalk across the street, where a few of his fellow addicts are involved in a scene outside the Army and Navy store. There is much gesticulation and apparently aimless striding back and forth. “Look at them,” he says. “They’re stuck here. You know, Doc, their life stretches from here to maybe Victory Square to the left and Fraser Street to the right. They never get out.  I want to move away, don’t want to waste myself down here anymore.

“Ah, what’s the use. Look at me, I don’t even have socks.”  Stan points at his worn-out running shoes and baggy, red-cotton jogging pants with the elastic bunched a few inches above his ankles. “When I get on the bus in this outfit, people just know. They move away from me. Some stare; most don’t even look in my direction. You know what that feels like?  Like I’m an alien. I don’t feel right ’til I’m back here; no wonder nobody ever leaves.”

When he returns for a methadone script ten days later, Stan is still living on the street. It’s a March day in Vancouver: grey, wet and unseasonably cold. “You don’t want to know where I slept last night, Doc,” he says.

For many of Vancouver’s chronic, hard-core addicts, it’s as if an invisible barbed-wire barrier surrounds the area extending a few blocks from Main and Hastings in all directions. There is a world beyond, but to them it’s largely inaccessible. It fears and rejects them and they, in turn, do not understand its rules and cannot survive in it.

I am reminded of an escapee from a Soviet Gulag who, after starving on the outside, voluntarily turned himself back in. “Freedom isn’t for us,” he told his fellow prisoners. “We’re chained to this place for the rest of our lives, even though we aren’t wearing chains. We can escape, we can wander about, but in the end we’ll come back.”[ii]


People like Stan are among the sickest, the neediest and the most neglected of any population anywhere. All their lives they’ve been ignored, abandoned and, in turn, self-abandoned time and again. Where does a commitment to serve such a community originate? In my case, I know it is rooted in my beginnings as a Jewish infant in Nazi-occupied Budapest in 1944. I’ve grown up with the awareness of how terrible and difficult life can be for some people—through no fault of their own.

But if the empathy I feel for my patients can be traced to my childhood, so can the reactively intense scorn, disdain and judgment that sometimes erupt from me, often towards these same pain-driven individuals. Later on, I’ll discuss how my own addictive tendencies stem from my early childhood experiences. At heart, I am not that different from my patients—and sometimes I cannot stand seeing what little psychological space, what little heaven-granted grace separates me from them.

My first full-time medical position was at a clinic in the Downtown Eastside. It was a brief, six-month stint but it left its mark, and I knew that someday I’d come back. When, twenty years later, I was presented with the opportunity to become the clinic physician at the old Portland, I seized it because it felt right: just the combination of challenge and meaning I was seeking at that time in my life. With hardly a moment’s thought I left my family practice for a cockroach-infested downtown hotel.

What draws me here?  All of us who are called to this work are responding to an inner pull that resonates with the same frequencies that vibrate in the lives of the haunted, drained, dysfunctional human beings in our care. But of course, we return daily to our homes, outside interests and relationships while our addict clients are trapped in their Downtown Gulag.

Some people are attracted to painful places because they hope to resolve their own pain there. Others offer themselves because their compassionate hearts know that here is where love is most needed. Yet others come out of professional interest: this work is ever challenging. Those with low self-esteem may be attracted because it feeds their egos to work with such powerless individuals. Some are lured by the magnetic force of addictions because they haven’t resolved, or even recognized, their own addictive tendencies. My guess is that most of us physicians, nurses and other professional helpers who work in the Downtown Eastside are impelled by some mixture of these motives.

Liz Evans began working in the area at the age of twenty-six. “I was overwhelmed,” she recalls. “As a nurse, I thought I had some expertise to share. While that was true, I soon discovered that, in fact, I had very little to give—I could not rescue people from their pain and sadness. All I could offer was to walk beside them as a fellow human being, a kindred spirit.

“A woman I’ll call Julie was locked in her room and force-fed a liquid diet and beaten by her foster family from age seven on—she has a scar across her neck from where she slashed herself when she was only sixteen. She’s used a cocktail of painkillers, alcohol, cocaine and heroin ever since and works the streets. One night she came home after she’d been raped and crawled into my lap, sobbing.  She told me repeatedly that it was her fault, that she was a bad person and deserved nothing. She could barely breathe. I longed to give her anything that would ease her pain as I sat and rocked her. It was too intense to bear.”  As Liz discovered, something in Julie’s pain triggered her own. “This experience showed me that to keep our own issues from turning into barriers, we have to look at ourselves.”

“What keeps me here?” muses Kerstin Stuerzbecher.  “In the beginning I wanted to help.  And now . . . I still want to help, but it’s changed.  Now I know my limits. I know what I can and cannot do.  What I can do is to be here and advocate for people at various stages in their lives, and to allow them to be who they are. We have an obligation as a society to . . . support people for who they are, and to give them respect. That’s what keeps me here.”

There’s another factor in the equation. Many people who’ve worked in the Downtown Eastside have noticed it: a sense of authenticity, a loss of the usual social games, the surrender of pretense—the reality of people who cannot declare themselves to be anything other than what they are.

Yes, they lie, cheat and manipulate—but don’t we all, in our own ways? Unlike the rest of us, they can’t pretend not to be cheaters and manipulators. They’re straight-up about their refusal to take responsibility, their rejection of social expectation, their acceptance of having lost everything for the sake of their addiction. That isn’t much by the straight world’s standards, but there’s a paradoxical core of honesty wrapped in the compulsive deceit any addiction imposes.  “What do you expect, Doc?  After all, I’m an addict,” a small, skinny forty-seven-year-old man once said to me with a wry and disarming smile, having failed to wheedle a morphine prescription. Perhaps there’s a fascination in that element of outrageous, unapologetic pseudo-authenticity. In our secret fantasies who among us wouldn’t like to be as carelessly brazen about our flaws?

“Down here you have honest interactions with people,” says Kim Markel, the nurse at the Portland Clinic. “I can come here and actually be who I am. I find that rewarding.  Working in the hospitals or in different community settings, there’s always pressure to toe the line. Because our work here is so diverse and because we’re among people whose needs are so raw and who have nothing left to hide, it helps me maintain honesty in what I do. There’s not that big shift between who I am at work and who I am outside of work.”

Amidst the unrest of irritable drug seekers hustling and scamming for their next high, there are also frequent moments of humanity and mutual support. “There are amazing displays of warmth all the time,” Kim says.  “Although there’s a lot of violence, I see many people caring for each other,” adds Bethany Jeal, a nurse at Insite, North America’s first supervised injection site, located on Hastings, two blocks from the Portland. “They share food, clothing and makeup—anything they have.”  People tend to each other through illness, report with concern and compassion on a friend’s condition and often display more kindness to someone else than they usually give themselves.

“Where I live,” Kerstin says, “I don’t know the person two houses down from me.  I vaguely know what they look like, but I certainly don’t know their name. Not down here. Here people know each other, and that has its pros and its cons. It means that people rail at each other and rage at each other, and it also means that people will share their last five pennies with each other.

“People here are very raw, so what comes out is the violence and ugliness that often gets highlighted in the media.  But that rawness also brings out raw feelings of joy and tears of joy—looking at a flower I hadn’t noticed but someone living in a one-room at the Washington Hotel has noticed because he’s down here every day. This is his world and he pays attention to different details than I do. . . .”

Nor is humour absent. As I walk my Hastings rounds from one hotel to another, I witness much back-slapping banter and raucous laughter.  “Doctor, doctor, gimme the news,” comes a  jazzy sing-song from under the archway of the Washington. “Hey, you need a shot of rhythm an’ blues,” I chant back over my shoulder. No need to look around. My partner in this well-rehearsed musical routine is Wayne, a sunburned man with long, dirty blond curls and Schwarzenegger arms tattooed from wrist to biceps.

I wait to cross an intersection with Laura, a Native woman in her forties, whose daunting life history, drug dependence, alcoholism and HIV have not extinguished her impish wit. As the red hand on the pedestrian cross light yields to the little walking figure, Laura chimes up, her tone a shade sardonic: “White man says go.”  Our paths coincide for the next half-block, and all the while Laura chuckles loudly at her joke. So do I.

The witticisms are often fearlessly self-mocking. “Used to bench press two hundred pounds, Doc,” Tony, emaciated, shrivelled and dying of AIDS, said to me. “Now I can’t even bench press my own dick.”

When my addict patients look at me, they are seeking the real me. Like children, they are unimpressed with titles, achievements, worldly credentials. Their concerns are too immediate, too urgent. If they come to like me or to appreciate my work with them, they will spontaneously express pride in having a doctor who is occasionally interviewed on television and is an author. But only then. What they care about is my presence or absence as a human being. They gauge with unerring eye whether or not I am grounded enough on any given day to co-exist with them, to listen to them as persons with feelings, hopes and aspirations as valid as mine. They can tell instantly whether I’m genuinely committed to their well-being or just trying to get them out of my way. Chronically unable to offer such caring to themselves, they are all the more sensitive to its presence or absence in those charged with caring for them.

It is invigorating to operate in an atmosphere so far removed from the regular workaday world, an atmosphere that insists on authenticity. Whether we know it or not, most of us crave authenticity, the reality beyond roles, labels and carefully honed personae. With all its festering problems, dysfunctions, diseases and crime, the Downtown Eastside offers the fresh air of truth, even if it’s the stripped, frayed truth of desperation. It holds up a mirror in which we all, as individual human beings and collectively as a society, may recognize ourselves. The fear, pain and longing we see are our own fear, pain and longing. Ours, too, are the beauty and compassion we witness here, the courage and the sheer determination to surmount suffering.


[1] So selected by The Economist for several years in a row. Or, “one of the world’s most liveable cities,” as described in the New York Times, 8 July, 2007
[i] Elliot Leyton, “Death on the Pig Farm: Take one,” review of The Pickton File, by Stevie Cameron, The Globe and Mail, 16 June, 2007, D3.
[ii] Anne Applebaum, Gulag: A History (New York:  Anchor Books, 2004), 291

Dr. Maté, who for twelve years practiced medicine in Vancouver’s notorious Downtown Eastside – North America’s most concentrated area of drug use, begins by telling the stories of his patients, who, in their destitution and uniformly tragic histories, represent one extreme of the addictive spectrum. With his trademark compassion and unflinching narrative eye, he brings to life their ill-fated and mostly misunderstood struggle for relief or escape, through substance use, from the pain that has tormented them since childhood. He also shows how the behavioural addictions of society’s more fortunate members – including himself – differ only in degree of severity from the drug habits of his Downtown Eastside patients, and how in reality there is only one addiction process, its core objective being the self-soothing of deep-seated fears and discomforts.

Turning to the neurobiological roots of addiction, Dr. Maté presents an astonishing array of scientific evidence showing conclusively that:

  1. addictive tendencies arise in the parts of our brains governing some of our most basic and life-sustaining needs and functions: incentive and motivation, physical and emotional pain relief, the regulation of stress, and the capacity to feel and receive love;
  2. these brain circuits develop, or don’t develop, largely under the influence of the nurturing environment in early life, and that therefore addiction represents a failure of these crucial systems to mature in the way nature intended; and
  3. the human brain continues to develop new circuitry throughout the lifespan, including well into adulthood, giving new hope for people mired in addictive patterns. Dr. Maté then examines the current mainstream.