There are moments in life when we are doing something and we realize that this is absolutely something we need to keep doing. The impact is undeniable because of this human connection you have created with someone, and their reaction to what you are trying to do to assist them.
Born and raised in the city of Brampton, Ontario, Brandon Au is 27 years old third year medical student. In this interview, Brandon will be sharing about his experiences working with CIME (Collaboration Interprofessionnelle Montréalaise Étudiante) and the asylum seeking community, as well as an Inuit community in Kuujjuaq.
I was happy to do this interview with the hope that it wouldn’t be [completely] focused on me. While I understand that details from me are necessary, I was hoping that whoever reads this, the purpose is to help give them some impetus to work with the kind of communities I’ve been working with. Perhaps to take on risks for the betterment of communities they’re working with. And to continue striving. That’s what I’m hoping to convey overall.
Please tell us about yourself and your journey to medical school.
I’m from Ontario, born and raised almost entirely in [the city of] Brampton. My first undergraduate degree was at McMaster University, in the Arts and Science program. The program mixed different things together, some arts and science, and then saw what happens from it. I also got the chance to specialize; personally, I took a bunch of electives in political science that seemed interesting to me. Around my third and a half year, I hit kind of a low point in my life. I realized I wanted a life of some amount of purpose that can create some amount of good. So I did a lot of soul searching and looked around at what I wanted to do in my life. I [initially] thought about what I was interested in. I was interested in political sciences, but more [so] interested in disasters, conflicts and suffering that occur on no fault of a particular individual, but rather because of whatever circumstance that they had been born into or happen to be in. [That helped me realize] that international relations and developmental politics is what interested me most.
So [then] I thought, I wanted to do something about these problems as I was kind of bored of writing essays all the time in my [political sciences] courses. And in the little bit of volunteering I had done at that point in my life, I [knew that] I really liked working with people and making an impact on a person-to-person level. And eventually I thought, hey, I want to be a doctor. But I didn’t have the grades, or anything at that point. So I was told by the infamous premed 101 forums that, “Hey, you need to do a second undergraduate Brandon!” So I did [just] that. At the University of Toronto Scarborough [campus], I lived in my parents’ basement for three years to study, work and try to reach that somewhat ephemeral goal, [even though] it seemed like a pipe dream at that time. But I eventually got here!
We wanted to congratulate you and the Collaboration Interprofessionnelle Montréalaise Étudiante (CIME) team for your recent receipt of the prestigious Forces AVENIR award in the health category! Could you tell us more about CIME and what made you interested in leading health promotion efforts for asylum seekers in Montreal?
First of all, thank you for the congratulations to our team, it was a group category award and I was happy to be a part of it and represent it at the time. CIME is a bit of a long story, but I will try to summarize it as best as I can. Before I [started] medical school in 2018, I had heard about the concept of student-led clinics. It seemed like a cool idea! The core concept of student-led clinics is that students would provide services to communities that need it, in whatever city or community you are in, [while] supervised by an [practicing] professional. Oftentimes, these are communities that are marginalized in some way, that lack access in some way, and who could benefit from the provision of free services that are focused on them.
When I came here, I remember talking with Julie who was the McGill Student Society (MSS) Global Health Representative at the time and she said there was a project like that called the McGill Student Led Clinic project, and [she suggested that I could] liaise with them. [The project] had been ongoing for a year; [however], there were at least 2 or 3 iterations where McGill medical students have tried to create student-led clinics, but evidently they would meet a hard barrier and were unable to continue. At that point, a proposal was then sent to the McGill Faculty of Medicine [for approval].
Around December 2018, we realized that we needed to build relationships with the community so that when [it comes time to] create this clinic, [the community] will trust us and come. We didn’t want to just have open doors, but with no one hearing of us or trusting us. So I started working on the community engagement part of the team.
Through a chain of correspondances started by Shermaine Lee and Tanya Chen, we connected with Dr. Chirgwin, an amazing family doctor at CLSC Parc Extension. He is a very passionate doctor who cares very much about asylum seekers around the area, who come from parts of India and who spoke primarily Punjabi, Hindi, Urdu. Through him, we met Monique Leger who is an incredible and passionate person who serves these communities at the William Hingston Community Center. She is the head of RAA, Resource Action Alimentation, who provide a number of social services i.e. helping them complete forms, provide emergency food banks, clothing and general assistance to asylum seekers.
So after speaking with Monique, we started to organize our first workshop in partnership with students from four different faculties: Medicine, Nursing, Dietetics and Social Work. I thought to myself, “Let’s create and share some information, and at the same time let’s collect their opinions and thoughts. Let’s find out what they need assistance with, what they want to learn more about.” So we [held] our first workshop around February 2019 with a primarily dietetics topic [centered on] general eating and how to eat healthy, and it had a decent turnout of around 20 people. This set a spark in terms of where we could take this whole project. It was there [where] we really met the community for the first time. We held a post-workshop feedback session by asking the attendees: 1) What’s important to you? 2) What do you want to learn about? 3) What can we do on our part?
We learned quite a bit from that discussion. There [is a general misconception] that asylum seekers are trying to jump the line or [are desperate] in finding their way into Canada. But when we spoke to them, they never asked us, “How can we improve our application status to stay in Canada?” Their questions to us were instead: “I am worried about my children. What can I do to ensure they grow up healthy? What do I need to feed them [well] here because the food is different back home [in India]? How can we get them the vaccines and medical care, and how can we get it for ourselves and our families?” Those were the concerns that rose again and again, and that [really] showed our commonalities. What more can you really say when you see someone who wants their children to be healthier and better. I remember at the end of the first workshop, there was this kind old woman who barely spoke English. She took my hand and said to me, “My son”. That was a turning point for me. Now that we could see who the community was, who they were composed of, the very real concerns they had, [and most of all], we could see how [healthcare] students could impact this problem. We started to see that we can do something about this, that they are asking questions that we can answer with our combined knowledge of dietetics, nursing, social work and medicine. As students, we realized that we could research these health topics and present this information in a way that is concise, that is practical for them, [and] that they can apply in their own lives. And I emphasize this because as much as we are medical students, we all [probably] want to make a positive difference in the world. And maybe that is why we all went to medicine in the first place. As much as we want that to happen, it is also critical to understand what you can affect with your current abilities and of course not to place a limit [upon yourself] but to critically assess what is possible and what is the most effective use of your time in creating a positive difference in these communities.
So, fast forward about a month we had done two workshops at that point with similar turnout and lots of excitement. These workshops were incredibly interactive; we would present them with some information, and they would ask many questions because they wanted to know more. [It was] to the point where we would prepare 10 to 15 minutes of material to present in total but the workshops would run 1hr to 1.5 hrs because of the sheer amount of questions that they had [about topics] that they wanted to learn more about.
During the month of March 2019, our proposal had [unfortunately] reached a hard barrier. I cannot say all the specifics, but all I can say is that Dr. Chirgwin was on our side the entire time. He went into a meeting with representatives of the McGill Faculty of Medicine and the CIUSSS, major entities whose buy-ins and approvals were required for our student-led clinic idea. For one reason or another, the student-led clinic [was not allowed to] continue. It was really unfortunate. Our team had been working really hard. We received letters of approval from Dietetics, Social Work, and [the Faculty of] Nursing was waiting on Medicine and Medicine couldn’t get it done. So we had a team meeting to discuss [what we would do if] we couldn’t do the core thing we set out to do. In some ways it was a failure and quite disheartening. But [after] seeing what we were able to [achieve through our] workshops and the potential for students to realistically provide assistance to this community, I knew we had to keep going.
I remember there was this Community Health and Social Medicine Incubator (CHASM) presentation that we presented in the month of January 2019, where an individual who I am sure had the best intentions and had a lot of experience in this field, said we were just another of those student groups that is going to parachute in for a few weeks, do something to make ourselves feel better, and then abandon the community again. And I knew that this was something that we absolutely could not do, given what is possible. So I thought to myself, that we are going to work on these workshops, we are going to continue and expand them, and we are going to address all their concerns. Also, we realized that through our interactions [with the community] that one of the major barriers to care is the lack of information about what [programs] they can actually access and where they can access [them]. This led us to the idea of pursuing a health navigation program. The idea of health navigation is that someone comes to us, tells us about their problems, and we figure what resources are nearby that we can direct them towards. Again, this is something that a student can practically do! In no point during the workshops or health navigation programs are we taking in a patient, and diagnosing or treating them. Instead, we are [identifying] these [social] issues and providing practical and useful advice.
So we worked on this through the month of March, and we then heard that through the Community Health Alliance Project (CHAP) [that is a compulsory part of the Med-2 curriculum at McGill], some students can perform medical-like acts like history taking. And we thought that maybe we could get authorization to supervise medical students through the CHAP program, and so we pursued this and rushed to make the deadline. [After] multiple emails and multiple different calls, we eventually got it, the CHAP approval!
Over the next few months we continued [holding] our workshops 1 - 2 times per month and they were in many ways a success. At around the same time, [we built a framework for our health navigation services] by understanding [and documenting] the resources around us. We partnered with Victoire who is also in the third year of medicine to create this health navigation program and come October 2019, we launched that.
There are moments in life when we are doing something and we realize that this is absolutely something we need to keep doing. The impact is undeniable because of this human connection you have created with someone, and their reaction to what you are trying to do to assist them. That is what we felt in the Health Navigation sessions. So for these sessions, we had a medical student, a social worker, and a translator sit down with one asylum seeker at a time. We would go through this complete medical and social interview to 1) identify what problems they had so that we can relay and connect them to the appropriate services, and 2) to create a document of this social and medical history that they could take with them to future appointments, where translation is often an issue, so that the doctor or social worker can look through this and quickly see what this individual needs help with. There were many powerful and personal moments that pushed us forward.
We tried to keep doing them once a month, but then COVID-19 hit. With COVID-19 being COVID-19, we couldn’t continue with these in-person services so we have been working very hard to create online systems and assisting in other ways. Now our health navigation program is online as well, and turns out it’s actually easier! Since one of the issues we had with prior health navigation sessions is that it was sometimes troublesome to get them to arrive for one reason or another. But with Zoom, they just need a [wi-fi] connection and they can turn on their phone and we make it happen. So that’s more or less the development of CIME!
And I would like to stress once again that CIME is an interprofessional effort. Absolutely, without dietetics, our workshops could never be what they are at this point. That without nursing or social work our efforts with health navigation could never be what they are. I think, in addition to providing service to the community, this has been an interesting learning experience for us students. [As medical students] we have those interprofessional education sessions, where we learn about interprofessionalism and understand what we all do together as a team. But [it is different] when you actually work together as a team, with a real person in front of you [who you are trying to] help out in whatever [way] you can. When we have social workers take the social history, the expertise they had in interviewing was unparalleled. They can see when the patient has problems but they aren’t quite willing to say it, and they know how to dig deeper to get that information. It has been a very good learning experience for all participating students as well.
Also, the people we have worked with outside McGill have been important to our development, like Dr. Chirgwin who has been along with us every step of the way, encouraging us and providing us with his time. With him, and Monique Leger, it was clear that to be able to find someone with the same core values and mission is so critical for a fruitful collaboration. She has been invaluable to work with. She is the main one who connects us to the community, who spreads the word, who gives us the ropes to do our work. None of this would have physically and logistically been possible, especially in the first few years of CIME, without her. Of course we had other people that helped us, such as the people that we met through CHASM at their [social entrepreneurship] workshops.
The first overarching thing that I’ve learnt from my experiences with CIME comes back to a quote from Isaac Asimov, “There’s no way I can single-handedly save the world or, perhaps, even make a perceptible difference - but how ashamed I would be to let a day pass without making one more effort.” When things looked bleak, such as when our student-led clinic was turned down, [this quote provides some guidance about how to move forward]. When you see that something positive can be made, that is possible and that you can reach, then you have to try! Right now as medical or dental students, we are in incredibly privileged positions to be able to work and start projects like this. And we have time, [even though] I know [that] it's hard to study and do things on the side. And to be honest, I never got the highest of grades, but I was able to have the time and put it [towards the community]. It was why I went into the [medical] program in the first place. So it is important [to recognize] that if you see something [that is] worthwhile to do, it is important to continue even if it is difficult and even if there are barriers.
Secondly, it is critical to work with others in a way that is collaborative. One of the most important features of CIME, [is that] we [always] spoke with other faculties on equal grounds. It is never “medicine and friends,” it’s CIME, an interprofessional project. That has been critical. This brings us to the point of team culture. This can be overlooked and it takes effort to build. It is built by literally every word and every action. For example, during our team meetings, [this interprofessional culture is built when] everyone is given a chance to speak and their voices are actually heard. So when dietetics thinks we should do something for a workshop, we don't just say, “We will consider it and take your opinion under review.” We say, “Yeah, that makes total sense. You are the expert on this.” That's interprofessionalism, and that is what we see in the hospital as well with our meetings with different patients.
Other perhaps more minor lessons, I think that it is important that when you work with and for the community, that the community comes first. That is the simplest way to put it. Everything else is secondary. Whether the student benefits from it is a convenient and happy after effect, but it is secondary as the community is first and foremost. And I think having that value in our culture and community is also important to us being able to do our work, and so that people trust us and want to work with us. Lilla Watson, an Indigenous writer from Australia, said something along the lines of “If you have come here to help me, you are wasting your time. But if you have come because your liberation is bound up with mine, then let us work together.” That is key. There is a drastic difference between trying to help and save someone out of pity, and on the complete other end is recognizing their humanity out of a feeling of love and brotherhood/sisterhood or whatever compels you to see that they have the same access and same health and safety that you enjoy out of your own privileged position. They are completely different.
The main messages I am hoping to convey with telling my story with CIME is how to work collaboratively, and how to work with an understanding of each other’s basic human dignity and respect. [I also hope to impart upon you] the willingness to strive even if the hope for success seems unlikely, and that there is a need for continued recognition of the universal healthcare that everyone deserves.
Please tell us about your experiences working with an Inuit community in Northern Quebec, Kuujjuaq.
To preface this, I only spent a month there. In the long scheme of things, that was just a snapshot. That was like I was never even really there to begin with. And I also want to say that in no way do I have the right, the knowledge or the understanding to speak on behalf of the community there, so I won’t. If people are interested in learning more about the problems that Inuit communities especially in Nunavik are facing, I would direct them to read this truth commission report (https://www.qtcommission.ca/en/home). There are many interviews that were done that you can watch and there is a good summary explaining what happened, why it happened and the effects of it.
The only thing I hope to achieve with this part of the story is to encourage people to seek these opportunities. [I want to] encourage people to see beyond only the medical aspect of a patient, because in many ways it is what is “not medical” that affects what is medical. I understand that we are in the medical field. Specializations are there for a reason. There is a reason why we have social workers, [and] why we have doctors and nurses. I know that we should not be expected to constantly seek out and to fix social problems. But I think it is wrong to ignore them. At the very least we have to make sure that there is adequate follow up and that a social worker is seen for the problems, whatever they may be. Thankfully this is largely ingrained in our curriculum today, though I would say that from my short experience in clerkship, this doesn’t always hold to be true.
So, a couple summers ago after my first year of medical school, I had the great opportunity to take part in the Global Health Scholars Program. I was attached to Dr. Razek’s trauma registry research programs. He had [built them] in many different areas of the world and he had one up North in Kuujjuaq. The idea of this trauma registry, as it was sold to me when I first applied to it, was “Hey, we really don’t have a good grasp about what traumatic accidents or injuries are occurring in this community.” And the only real way to address the problem is to understand it. So that is what the trauma registry is for. What I didn’t know is that it was almost entirely a chart review [when I had] thought that I was going to go there and try to encourage people to join this program. But anyway, I got there with a basic understanding that some history has occurred [in Kuujjuaq] and that it is probably affecting the present, but I’m going to do my job.
I got there and started to do my chart review by looking for the different kinds of trauma injuries that occured. A large number of them were accidents with the infamous All Terrain Vehicles (ATVs). They are everywhere and people just ride them without helmets. The more I dug into [the data], I realized that there seemed to be a high correlation between traumatic injuries and the patient being inebriated, or having some form of alcohol at the time of it happening. This was really curious to me. I saw my job as helping to understand why this is happening, to find the problems and hopefully to make an intervention, which is of course a completely unreasonable [expectation] for a student to complete within one month’s time. But I thought I could perhaps find something or do something. Of course, it is important not to stereotype. But it would also be an incredible disservice for not recognizing facts for what they are. And the fact is that there is an alcohol abuse problem in this community and most likely in other communities. This is not new. This is not something that some western researchers, some Qallunaat as they call anyone who is an outsider, is coming in to diagnose. This is something the community knows, and feels, and is impacted by on a daily basis.
I wanted to understand this problem more, so I talked to the doctors who were around. They said that it isn’t so much our problem, and that they think it has something to do with history, but they just deal with medical issues right now. So then I went and spoke with the social workers around. They are the ones who referred me to the truth commission and explained to me that there were systematic reasons for why things are happening now. The forced settlement of these people by the Canadian government. Even stuff like the TB medical programs, where they sent people down in ships, with many of those people dying in the South or coming back to vastly changed lives. The residential school systems, and not only that, but also the churches were implicated in this. But you have to read the literature for this. There were all these historical factors, which led to a cycle of abuse, violence, hardship and intergenerational trauma that we have heard about in our lectures, that we have been told about. But when we go to the communities, it is not a theory anymore. It is real, and it is lived, and it is utterly undeniable.
It is important to recognize that our preclerkship Indigenous health lectures are very useful and important but they cannot be expected to do what I wish they could have done. There is a level of personal disconnect as a result of you not working personally with those communities and not being there. They talk about stats: the rates of tuberculosis are so much higher in these communities in the North and the rates of suicide are so much higher. But they remain numbers and statistics, at least in my mind. It is hard to grasp, and this might partially be human psychology, but I don't know. I’m not a psychologist! It’s like when you hear about one person’s death, it hits hard. But for some reason, if you hear about 10 thousand people’s deaths, the effect is not proportional! You do not feel the sorrow of 10 thousand people’s deaths because stats are just stats.
I also went on medivacs to the outlying villages. I got to speak with the people there and see the conditions there. They have these representatives of the Inuit in Kuujjuaq who relay with the local health board in order to get things done in a more respectful manner. So I spoke with them to hear their stories and to try to understand what was happening. We talked about these historical factors, the underlying context which lead to societal issues like depression and loss of identity. And there are also other factors involved, like racism and inequity on the part of the government and the health boards. There are difficulties and blatant wage inequalities that make no sense whatsoever.
[I learned] that they do not have their own doctors up north. So, the doctors need to come from the south, from the “foreigners”. They come for a few months at a time but then go. It is considered an extremely long time for someone to stay there for 2 or 3 years. This creates difficulties, because first of all, it is difficult to create a doctor-patient relationship when they know that you are going to leave soon anyway. The way it was put to me was “Why should I say the story that I’ve told to all these other people already who have also left? Why should I share the traumas I’ve experienced with these people if they're just going to abandon me too?” It is a band-aid solution, and it is exactly what is happening right now because how else can you get doctors up north? And it is also that they can see these foreigners coming in who are getting massive paychecks and massive benefits. It is lucrative to work up north as a doctor. And then they just leave, you know?
There are other factors too, which are common to many healthcare systems, one of which is a disconnect between the people at the top making decisions and the people at the bottom. It is even more evident here. I went to the elder’s home. [It was clear that] there is an epidemiological shift occurring in this community, most likely due to the arrival of modern medicine to this community. There are more people who are living [to] older [ages], who are now living with chronic conditions that the community never had to face before, or certainly not to this extent. They’ve never had to deal with the effects of chronic diabetes and dementia, for example, [and thus], there are more people who need care at the elder's home. And it has gotten to the point where the housing board needed to step in to build another house to place more people because the health boards were unable to provide more beds and rooms in the elder's home. So, there are these disconnects that have very real impacts on the community.
So this is all to say that there are these real historical and contextual factors that drive ongoing societal problems that result in real medical problems, like trauma from falls, violence and abuse, [including] alcohol abuse. It is impossible to approach the medical problem of trauma without first recognizing and addressing these underlying issues. Thankfully there are efforts on their way. I'm not trying to make this sound hopeless. I’m only raising the stories I’ve been told that illustrate the ongoing problems. There are many efforts being made now to make things right and to make things better. They are working hard, but there are of course major difficulties. When I spoke to one of the representatives, I asked her what can be done moving forward. She had a few different answers, but the main one was reclaiming their cultural identity as a people and perhaps spirituality. That is critical and that is not something that can be done over a year. That is something that will take time and effort.
I [would also like to share] one more story, about the idea of universal health care, that all people should have access regardless of who they are or what their circumstances are. Speaking back on CIME, in our discussions with community workers, the point was raised that not all asylum seekers are running away from violence. Some of them could more accurately be characterized as economic migrants, [people] who [have been] trying to build a better life. The question raised by some of our team members initially, was [whether] this is really the community that we want to work with. Should we not find someone who is more “deserving” of our assistance? In the end, none of that should matter! And that’s the basis of universal care. It is not our place to judge or to say, “Thou art not worthy.” And really it shouldn’t be anyone’s place to make that judgement of whose life is worth saving. The idea of human worth is important, and I saw that again when I was in Kuujjuaq on my first medivac flight.
We had gone to see a woman who had suffered horrible abuse throughout her life. She was suicidal and had attempted suicide multiple times. And now this time she had tried to hang herself, though she was brought to the hospital and she was still alive. You can see the resources that were mobilized to assist her. You had to have the plane, you needed the fuel for the plane, and you needed all the people at the airport to make these logistics happen. You needed the nurse who was going to go on the plane to get there; you needed the doctors who would care for her when we brought her here. And she was not in a good state.
There is sometimes an economic argument that is made about healthcare. And I think this argument is made more by people who are more self-serving and who don’t necessarily comprehend or agree about the basic human [right] for healthcare. We can say if our people are healthier, they will be more productive, our economy will do better and society will be better, you will be better. That is a more self-serving argument for free healthcare for all. It is horrible to contemplate this, but with this woman and perhaps with other patients, it is not clear what their contributions will be. This argument does not hold true in her case. But at no point was this a consideration for us, or for the team, the nurses and the doctors. At no point do we have to even think about that because we know what our job is, we know what our duty is. We know that this person needs care, and that’s it, fullstop. There is no need to go further or to question whether all these resources should be mobilized for her. One of the reasons why working with this community or other communities seems so powerful to me, is because it is the basis for universal care.
Another thing I will say about Kuujjuaq, is that it is one of the most beautiful places I’ve ever been to. I’ve done a bit of travelling, I’ve been to parts of Asia, Europe, and the States. At Kuujjuaq, one of the things we would talk about is going on the land. This is healing for them, going hunting is healing for them. When you go there, you can walk out and not see a soul, and you are the only one surrounded by the rolling hills, berries of every colour, and stone that sparkles with pink quartz. It is stunningly beautiful.
Note: The above is a direct transcript from a live interview with Brandon Au conducted by the Resonance Humans team.