The Social Determinants of Health – a short story by Michael Fine

By Michael Fine, contributing writer

©2020 Michael Fine

This is a work of fiction. Names, characters, businesses, places, events, locales, and incidents are either the products of the author’s imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.

Brigetta was strong and ready when her sister Marianna came to Brigetta’s house to die.  Eduardo died a year before Marianna came.  If God had made Brigetta, Hector, and her children strong enough to survive the death of their brother and son, then they could also take care of Marianna, although watching her sister die was the last thing Brigetta thought she would ever have to do. 

Brigetta lived in Johnston in a new white house with a yard, a swing-set, and an above-ground pool in the back, with trees that had been recently planted and were starting to grow. There were no other people of color in their housing development. All the houses looked the same except for the colors of the houses and the different cars, pickup trucks, and boats parked out front.  Brigetta had a red riding mower in the garage just like everyone else. She had Hector, who went to work and came home every day and smiled almost all the time. And she still had Joao and Ana to keep her strong. Brigetta had to be strong for her kids and she had to be strong for Hector. Joao and Ana had to get to school every day despite what was happening at home because they had to learn and grow and be strong and make a life for themselves.  No one else can live your life for you. The kids had to learn to stand on their own two feet.

 Hector, Joao, and Ana kept Brigetta strong even while Eduardo was dying. Once Brigetta had been in charge. Brigetta made the meals and did the shopping and paid the bills and made sure the kids got to school and to soccer practice on time. When Eduardo first got sick, Brigetta was able to keep doing it all. Get up, make breakfast and lunches, get everyone else up, get them to school, get to work, work, run the office, pick up after school, shop, make dinner, call everyone in, have dinner, put away from dinner, pay the bills, make sure they got to sleep on time. Hector was good to drop off one or two of the kids when they went to different schools, even though only Ana was his real daughter, and he was reliable about it, but that was all he could manage.

When Eduardo first got sick, Brigetta just added on the extra things.  Doctor’s visit here.   Radiation there.  Chemo.  Just more to plan, organize, and do.  Brigetta didn’t really hear what the doctors told her, or maybe she just didn’t believe it.  Eduardo hurt his leg, that’s all.  Hurt legs get better.  Eduardo was seventeen, her best student, famous for rock climbing and soccer and dancing, strong and bright and polite.  Sometimes he persecuted his brother and his sister — more his sister than his brother — but Eduardo was going to have a strong and brilliant life. Everyone in his family, town, and community looked up to him.  Eduardo showed them how good we are as people and how much we bring to this place, to this country.

Until it became impossible to add on and impossible not to hear.  Until Eduardo stayed in the hospital.  Then there was a remission for sixteen months and for a while everything went back to how it had always been.  But then Eduardo had a relapse.  The doctor — the small, tough, woman doctor who never really looked at Brigetta — said there was going to be a relapse. Brigetta didn’t believe it. This cancer could not happen to Eduardo. It could not happen to her.  It could not happen to them.  Seventeen year old soccer stars don’t get cancer.  People get better from cancer.

Then they were in the hospital again, and at first Brigetta was there every moment she wasn’t working.  And then she was there every moment of every day.  Time went fast and slow all at once.  Even so, everything at home still happened anyway, without her.  The meals were made. The kids got to where they needed to go.  The lawn got mowed.  The shopping was done, and the bills were paid.  Brigetta still ran her office  — did the billing and the payroll, and ordered supplies — from Eduardo’s hospital room because there was no one else to do that, but the rest just happened.  Hector drove and shopped and cooked and kept smiling as he worked even though there was no smiling in his eyes. Joao brought in Eduardo’s schoolwork every day and cleaned the house.  Louise, still young, kept her room clean and the computer off.  They were together in the hospital most nights and on the weekends, in Eduardo’s room, as his school friends and their community came and went and came again to visit by the hundreds, so that his room was filled with cards and balloons and flowers and plants and fruits, and when he could, Eduardo sat up in bed, gossiping and laughing and he did not let anything – the pain or the dread — show.  Only love and dignity showed.  Eduardo taught them.  He had enough love and dignity for all of them, and he taught love and dignity to everyone who came near.

They don’t understand us, our community or our families, Brigetta always told her kids.  They are frightened by all the brothers and sisters. They don’t know what to make of same ma, different pa, or same ma, same pa, or same pa, different ma.  Of thirty-six brothers and sisters. Brigetta felt sorry for them, the others, with their one or two kids and their divorces and anger.  She didn’t ever explain.  Her kids heard her talking to the neighbors, and her kids didn’t explain either.  Brothers and sisters.  Aunts and uncles.  All the cousins.  Life was full enough without the neighbors.  Still, the neighbors saw the cars coming to the house on the weekends, and the neighbors’ kids came and saw all the people in Eduardo’s room, and Brigetta knew that the others — the neighbors — worried, wondered, judged, and feared what they did not know or understand.  But they came anyway.

Brigetta learned that nothing mattered besides Eduardo and being with him morning noon and night.

So when Marianna came to her house to die, Brigetta was ready.  It was less than a year after Eduardo died.  Life had resumed, less than it was before, but it was still life.  Hector was tired and sometimes came home late.  Ana and Joao stayed in their rooms, often with their doors closed.  Brigetta moved through that time without thinking or remembering.

Then Ana and Joao came out of their rooms and began to do homework at the kitchen table and sometimes asked for help. Then there were kids at the door looking for Ana and Joao.  Even so the house was quieter than before and in quiet moments you could still feel the sadness and loss rolling about in the corners of the rooms, like dust balls in a room no one had swept.

But the empty spaces soon filled with voices and the music and the chatter of those kids. Hector, Brigetta, Ana, and Joao planned a memorial concert, set up a scholarship fund, and raised money for the Cancer Fund.  Brigetta was back in the office, and all the bills got paid. Sometimes they were a few weeks late mowing the lawn. You don’t get time off to take a vacation and catch up after your son and brother dies at nineteen.  You just keep living.

Marianna was a good sister, but she wasn’t the closest. She had a man who wasn’t that good, and three children. Two with the same man, one with a different man.  She had sparkle.  She finished high school by GED after the first baby, and worked as a CNA in a nursing home in Warwick.  It was not fair that she got breast cancer at thirty-two, because she was the one with the most pizzazz, the most dance.  They could all dance, the whole family, but when Marianna danced you always watched out of the corner of your eye because she made you feel alive and jealous and even a little aroused.  She danced with all of her.  She danced with the full joy of living, even the good, dirty, sexual parts, and she made them all proud.

 Marianna farmed out her children and kissed them goodbye.  Two to sisters.  One to the last man’s sister.  They would come by once a week to hug her.  They had big eyes and no understanding about what was happening.  Children don’t understand.  They just do, and then they make up stories for themselves about the places they have been put and why they have been put there.

  Ana was good with those kids.  She took them outside to the swing set and played with them while the adults sat in the living room, down the hall from where Marianna was dying.  The sisters came and brought food. Brigetta walked in and out of Marianna’s room, bringing in one person at a time.

Sometimes the men were there, but mostly the sisters came, the women.  Their sister Carolina. Their sister Sarah.  Their sister-in-law Ana, who was better than a sister most of the time. Their sister Ariana. Their sister Romana.  Their aunt Maria, who was younger than Carolina and who grew up more a sister than an aunt. Maria would come Sundays, and sometimes she would bring the other aunts —  Monica, Carla, Victoria and Yvette.  The sisters brought the good things to eat that Brigetta passed out to the people sitting in the living room, but no one ate. The sisters stood together in the kitchen, while the aunts and uncles sat together in the living room and the kids ran in and out of the house and no one had the energy to look at one another, not really.

At night, and in the morning, Brigetta sat with Marianna.  Marianna had pain.  Marianna’s lungs were filling. They put a catheter into one lung so Brigetta could drain the fluid out once a day.  But the catheter was very tender and touching it made the pain worse so Brigetta gave Marianna pills an hour before.  The pain pills were every three to four hours, but sometimes, when Marianna cried out from breathing, Brigetta gave her the pills early.  Sometimes Marianna slept between the pills. Sometimes Marianna dreamt, and sometimes she  talked in those dreams and sometimes she didn’t know where she was or who was there. Sometimes she talked Crioulo.  Sometimes she cried out as if a man with a knife was cutting her.  Sometimes she soiled the bed.

Sometimes they talked.  There was a chair next to Marianna’s bed. At night, when the house quieted, Brigetta sat next to the bed paying bills or doing the office billing on her laptop while Marianna slept. For a little while — a few hours after the last pill, and an hour before the next pill — Marianna was awake. Just a little while. Before the need for the next pill made her angry and tense.

“You are the strong one,” Marianna said, one night.

“Not that strong,”

“I wish I lived in Johnston.”

“You are living in Johnston now.”

“I wanted a man like Hector.”

“Hector is just a man. You had good men. Not good enough for you though. You have good kids.”

Marianna began to cry.

Brigetta began to cry.

“They need a mother,” Marianna said. “I love my kids.”

“They will be strong,” Brigetta said. “They will remember their mother, and they will be strong.”

“There is no one…”

“We will be there.” Brigetta said. “You are part of us. They are part of us. We love them and will always love them. The way we love you.”

Then Brigetta’s arms locked around Marianna’s chest, and they were crying together. They held each other until it was time for the medicine.  Until the medicine kicked in and Marianna’s breathing slowed and she slept.

Marianna died three days later.

The sisters and the aunts came. Hector was there and so were Joao and Ana. They were all standing about the house when the car came from Dove’s.

A polite young woman in a dark suit rang the bell. It was the same woman who had been there for Eduardo. Brigetta opened the door and met the woman’s eyes for a moment, but looked away when she saw the woman recognized her as well.  She didn’t remember the woman’s name. She had spoken to a man on the phone, a man who was also polite and somehow Brigetta hoped that it would be the man who came and not the woman.

“Mrs. DeCosta?” the woman said. “I’m Yvette Dove. I’m so sorry for your loss.”

 The woman was wearing black gloves which she left on when she was shaking Brigetta’s hand.  She reached over with her left hand, and held Brigetta’s hand between her  hands. An embrace, not a handshake.  The gloves were smooth and cool, like the cold polished stone of the counter in a government building.

“Thank you. Marianna is in the bedroom.”

The woman came through the door, and followed Brigetta down the hall, shaking the hands of everyone in the hall as she passed them, and saying those words over and over. I’m sorry for your loss. I’m sorry for your loss. I’m sorry for your loss.

Marianna’s eyes were closed, and she was quiet. She had lost so much weight, and her hair was just a few inches long — all that had been able to grow back after the last chemo. Brigetta could not see the sadness and the struggle of the last few weeks, when Marianna had pushed back against death.

The woman touched Marianna’s arm, and forehead.

“She’s so young,” the woman said.

 Suddenly Brigetta realized that the woman and Marianna were about the same age, and probably knew one another growing up.

But the woman did not pause.

“Cancer?”

“Cancer.  Yes cancer. Only 11 months.” Brigetta said. “She was hospice.”

“Hospice called. Who was her doctor?” the woman said. “For the death certificate.”

Brigetta gave the name of the doctor.

“I’ll get the gurney,” the woman said.

Brigetta stayed in the bedroom. Marianna was young but so gaunt. There was a sweet smell in the room, like the smell of the wood of a tree that had just been cut and split, the smell of sap, of growing things.

The woman came back with a man in a dark suit and a gurney. They lowered the gurney so it was just a little lower than the bed, rolled up the sheet on the nearside of the bed so it was touching Marianna’s left side and stood next to Brigetta.

“One, two, three, pull,” the woman said, no louder than a whisper.

Brigetta closed her eyes to be strong.

There were people. Strong hands under Brigetta’s arms. Voices giving orders. Strong arms lifting her back and legs. Voices calling out. Arms around her, holding her close. 

And then Brigetta was very light but she was alone.  She was alone in the air, floating  above the telephone poles and the wires that ran from one to the next. She alone was in the sunlight.  The air was sweet. There was nothing holding her back, and she floated higher, floating free through the air above the trees, looking back on the earth and all its beauty. Where was everyone she loved?

When Brigetta awoke, she was laying on the couch in the living room, and her sisters and her children were holding her. Hector was kneeling next to her holding a moist compress on her forehead.

 Everyone was there with her.

They were together now, and they were strong, strong as trees, strong as mountains, strong as the earth and perhaps even stronger than death itself.

All of Michael Fine’s stories and books are available on MichaelFineMD.com or by clicking here.  Join us!

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Michael Fine, MD is currently Health Policy Advisor to Mayor James Diossa of Central Falls, Rhode Island and Senior Population Health and Clinical Services Officer at Blackstone Valley Health Care, Inc. He is facilitating a partnership between the City and Blackstone to create the Central Falls Neighborhood Health Station, the US first attempt to build a population based primary care and public health collaboration that serves the entire population of a place.

He has also recently been named Health Liaison to the City of Pawtucket. Dr. Fine served in the Cabinet of Governor Lincoln Chafee as Director of the Rhode Island Department of Health from February of 2011 until March of 2015, overseeing a broad range of public health programs and services, overseeing 450 public health professionals and managing a budget of $110 million a year.

Dr. Fine’s career as both a family physician and manager in the field of healthcare has been devoted to healthcare reform and the care of under-served populations. Before his confirmation as Director of Health, Dr. Fine was the Medical Program Director at the Rhode Island Department of Corrections, overseeing a healthcare unit servicing nearly 20,000 people a year, with a staff of over 85 physicians, psychiatrists, mental health workers, nurses, and other health professionals.

He was a founder and Managing Director of HealthAccessRI, the nation’s first statewide organization making prepaid, reduced fee-for-service primary care available to people without employer-provided health insurance. Dr. Fine practiced for 16 years in urban Pawtucket, Rhode Island and rural Scituate, Rhode Island. He is the former Physician Operating Officer of Hillside Avenue Family and Community Medicine, the largest family practice in Rhode Island, and the former Physician-in-Chief of the Rhode Island and Miriam Hospitals’ Departments of Family and Community Medicine. He was co-chair of the Allied Advocacy Group for Integrated Primary Care.

He convened and facilitated the Primary Care Leadership Council, a statewide organization that represented 75 percent of Rhode Island’s primary care physicians and practices. He currently serves on the Boards of Crossroads Rhode Island, the state’s largest service organization for the homeless, the Lown Institute, the George Wiley Center, and RICARES. Dr. Fine founded the Scituate Health Alliance, a community-based, population-focused non-profit organization, which made Scituate the first community in the United States to provide primary medical and dental care to all town residents.

Dr. Fine is a past President of the Rhode Island Academy of Family Physicians and was an Open Society Institute/George Soros Fellow in Medicine as a Profession from 2000 to2002. He has served on a number of legislative committees for the Rhode Island General Assembly, has chaired the Primary Care Advisory Committee for the Rhode Island Department of Health, and sat on both the Urban Family Medicine Task Force of the American Academy of Family Physicians and the National Advisory Council to the National Health Services Corps.