Openings

I looked at the name of the last patient on my list for a Friday afternoon clinic session in November. Magda* was in her early 30s, and I had been caring for her for close to 10 years at a community clinic in the South Bronx. I thought back to when I had first seen her in early 2002, soon after she had been diagnosed with HIV through routine prenatal screening. I remembered clearly how Magda had come into the exam room, hesitantly holding the lab report with her positive HIV test results in one hand, like a ticket for a new, unwelcome, and uncertain journey. She was short, thin, with delicate features and long black hair in a tight ponytail. Her fingernails were meticulously painted with rainbow colors that seemed a little incongruous with the gravity of her new diagnosis. Magda was both excited to be pregnant and overwhelmed by the implications of her positive HIV test. Would she get sick? Would the baby? How would she tell her boyfriend? She wasn’t sure if he would stay with her, and had only recently told him that she was pregnant. She began to cry as we sat there, I gave her a tissue and waited; there didn’t seem to be words to say just yet.

Once she had stopped crying, I told her that the medications now available for treating the virus could help prevent the baby from getting the infection, and could also help Magda stay healthy, as long as she was able to take a few pills every day. (How different from those same conversations I recall with patients earlier in the epidemic, before antiretroviral therapy was available; now it seems almost commonplace.) Once Magda understood that she could keep her baby and herself safe by taking medications to control the virus, she filled the prescriptions right away and never looked back. I was struck by how quickly she seemed to incorporate this new information and reorient her approach to daily life in such a profound way: she had HIV, she could take medication to keep healthy and protect her baby, and she would start tomorrow and continue for the rest of her life.

Magda started taking the antiretrovirals and kept all her prenatal visits; her labor and birth were uncomplicated, and the baby boy was born healthy and uninfected. Relieved and exhausted, she immediately set about learning how to be a good mother. In her follow-up visits with the baby, I became increasingly aware of both her self-sufficiency and her fundamental isolation. Her boyfriend, who had tested negative for HIV, had been supportive and engaged following the diagnosis, but started to pull away after the baby was born. He eventually moved to another part of the city, and became increasingly disconnected from Magda and the baby.

Magda was afraid to tell anyone else among her family and friends, or especially at her job, that she was HIV-positive. Over time, her immune system tests fully normalized, the virus remained suppressed, and she had almost no side effects from the medication, which continued to be very effective. This continued for years, as her life took on a normal routine that was both a relief and a source of alienation. On the outside, she was a single mother with a healthy, growing child, a decent job working in a furniture store, and a safe place to live. On the inside, she felt like she carried a terrible, dark, secret that defined who she was and that she could not share with anyone.

On that Friday afternoon in November, her son had just turned 9, and Magda was feeling increasingly burdened by the stresses in her life. She had had to take time off from work to meet with the assistant principal at the school after her son had gotten into trouble fighting. If this continued, she was afraid that he might be suspended or put in a special class. She felt bad that the boy’s father was not involved and she had no other men in her life to help teach him how to grow up right. Things at work were more difficult, too; there was a new demanding supervisor. Some part-time people had been laid off, and Magda had to work longer hours and more weekends, afraid to complain and lose her job.

Listening to her, I suddenly had an impulse to hold her and sing her a lullaby; somehow my paternal instincts (though my daughters were now well into their 20s) were being called forth by Magda’s forlorn state. Instead, I began reviewing lab test results with her, which in the past usually gave her reassurance. Everything was normal, as it always was with her labs, yet something seemed so fundamentally wrong.

After we had finished with the mundane details, and the visit was coming to its routine—but somehow unsatisfying —conclusion, it occurred to me that something else might help. She was putting on her coat to leave the exam room; I was feeling a little tired myself at the end of the long week, thinking about all the medical charts I would have to write up for the next hour. I paused for a moment and asked her, “Have you ever heard of meditation? It’s relaxing and easy, and I think it might help with your feelings of stress. Would you like to learn how to do it?”

She stopped and looked at me a little hesitantly. “I think I saw something on TV but I don’t know anything about it. What do you do?”

I asked her to take off her coat and sit down, letting her feet rest comfortably on the floor. I have done mindfulness meditation on and off for years, but had never taught anyone else to do this before. “Let’s see,” I said. “OK, now sit up straight, let your eyes gently close, and take a few slow, deep breaths from your belly. I’ll do it with you.”

Together we sat, slowly breathing together. I could feel a calm energy come into the room, connecting us, wordlessly. “Good,” I continued, “now just focus on your breath, noticing when you are breathing in, and when you are breathing out. Don’t comment on this or think about it too much, just let yourself notice your breathing, in and out, in and out. If thoughts come into your mind, don’t worry and don’t pay too much attention to them. Just focus on your breathing. Let’s do this for 5 minutes and then we will open our eyes.”

As we sat together, I felt a soft, new connection with Magda that had quietly entered our relationship, a different kind of awareness than we had experienced over all the visits of the prior 10 years. I didn’t want it to end, but when I looked at my watch after 5 minutes, I reluctantly said, “Now slowly start to open your eyes and feel yourself sitting in your chair, in the room, and wiggle your fingers and toes a little bit.” Slowly, she opened her eyes, and smiled, suddenly looking much younger, her shoulders not so tight, her eyes a little brighter, sitting up a little straighter. “That was great,” she said, “I feel so much lighter!” I laughed and agreed, suggesting that this was something she could do on her own, even on the subway or during a break at work, that it could help her feel less stressed, maybe more connected to herself. She sat for a minute, then started to talk about her son, laughing about the funny things he did even as she admitted to being exasperated when he got into trouble. She took out her cell phone and showed me a picture of him from his birthday party. A boy with a cute, cherub-like face peered out laughing from the screen. She started scrolling back to show me other pictures of him, in the park with his baseball team, at the mall eating a huge cookie. We laughed together, patient, doctor, meditation partners, 2 parents sharing memories. Maybe it was just my projection, but I sensed that Magda was feeling less alone.

She got up to leave, I wished her a happy Thanksgiving, and as I stood up I glanced out the window. My exam room faces out from the rear of the clinic over a small unused area between several buildings and an abandoned lot, a typically neglected urban space that contains some garbage cans, abandoned furniture and appliances, and scraggly weeds. The window has bars on it, and there is a small ledge formed by the windowsill on the inside of the bars. As I looked out, I noticed at first that the ledge was covered with dry grasses and weeds, and then my eye caught a plump brown pigeon sitting on the sill, nestled up against the window. You had to look carefully, so as not to miss her, but there she was. She was cooing, and looking up at me through the window, protected by the bars, fully supported by the grass-covered windowsill. What a resourceful bird, I thought to myself, and then I noticed that under her breast, peering out from beneath the feathers, was another little head, with a tiny beak and 2 small, darting eyes. A mother and her baby, making their home in a sometimes hostile environment, alone but, at least for now, safe and together. I excitedly called Magda, who by that time was already out the door of the room, and as she came back in I pointed to show her the mother and baby bird. She stared down out the window, then giggled and cried out, “Oh my God, look at how she is protecting that little baby!” The mother bird turned her head up for a moment, then resumed cooing, looking straight ahead. Magda looked at me and smiled, saying, “Thank you for everything, have a nice Thanksgiving!” and gave me a hug.

I watched her as she walked off down the hall. And then, for an instant, looking back at the birds, I flashed on an image of my own mother, now in her 90s, wondering what she had looked like following the suicide of my father almost 60 years ago, when she was abruptly widowed in her early 30s with an infant son. The 2 of us, alone and together, finding our way in the world. Taking care of those we love, making a home, using whatever tools we can find. In our own ways, we’re all on the same path.

The next week when I came back to the clinic, the first thing I did was to look out onto the windowsill of that exam room. I had been wondering what I would do if the birds were still there. Was the mother OK, could she get out from behind the bars? Should I give her some food? Would the little bird be able to fly off the window ledge? I eagerly bent over the sink and looked down: the mother and baby bird had gone. I felt disappointed, slightly sad, maybe slightly relieved. I gave a little prayer for Magda, her son, and the 2 birds, then got down to work for the afternoon.

• Received for publication September 19, 2014.
• Revision received February 1, 2015.
• Accepted for publication February 22, 2015.

• © 2015 Annals of Family Medicine, Inc.