by Elison Alcovendaz

A few days ago, I was at a work training in a building next to the public library in Downtown Sacramento. During one of our breaks, I went to use the restroom, but both were occupied, so I walked over to the library to use one of theirs.

When I walked into the restroom, I was vaguely aware of a man standing by the sinks, looking at himself in the mirror. As I passed him, he said in a cracking voice, “Sir, sir, can you help me?”

I was annoyed and somewhat nervous. I really needed to pee, but more than that, what could a grown man in a public restroom possibly need from me? I knew that homeless people, many of whom dealt with mental health issues, hung in and around the downtown library. I had all kinds of crazy thoughts. Maybe he’d have his pants down or have a knife or need help cleaning himself. I turned around reluctantly.

The man was about my height, six-feet tall, with his oily, brownish-grey hair tied back into a bun. He was probably in his mid-50s and looked like he’d selected his clothes from several different wardrobes. He had on a wrinkled blue dress shirt, khaki pants that were at least three sizes too big for him, and dirty sneakers.

“Can you help me?” he asked again, this time pointing at his neck.

An old tie, the kind of brown, green, ugly-patterned tie you can find at thrift stores all the time, hung in an entangled mess halfway down his chest.

“I have an interview in a few minutes. Can you help?”

I stepped in front of him, loosened his tie, slid it to the proper starting position, then weaved it together and pulled the knot close to his neck. I looked at the tie the entire time, but I could feel his eyes on me.

“Thank you so much,” he said.

I glanced up at him. His face was skeletal and covered in acne-like scars that hadn’t quite fully healed. His breath smelled like he hadn’t used a toothbrush in a few days, and all the teeth he had remaining were coated in a dark shade of yellow.

“Good luck,” I said.

He grabbed a large plastic bag from the floor and hurried out of the restroom.

The theme of my training that day had been the social determinants of health. One of the very first slides earlier that morning displayed a chart that described what contributed to the worst health care outcomes - individual behaviors were 40%, genetics 30%, social and environmental factors 20%, and actual health care 10%. The data seemed to validate a shift that I’d been progressively growing through as I got older - people’s behavior, their choices, were the most important factor in what happened to them. So why did it seem that we stopped holding people accountable for their choices and actions? Why were we focusing so much on what society must do, but not enough on what the individual must do?

For the rest of the training, we talked about how those of us in health care must start thinking of things typically outside of the services we provide to better serve the patients. If only 10% of outcomes can actually be attributed to health care, what other factors are there? We talked about access to nutritional foods, stable shelters, walkable pathways, reliable transportation, social activities, etc. It became clear that perhaps my viewpoint had become too narrow. When the instructor asked if there were any realizations from the day, I raised my hand and said that I had become aware of how much the 20% affected the 40%.

What had happened to the man in the restroom during his life? What had driven him to drugs and/or homelessness? What could we have done better to help him or prevent what had happened to him? What could I have done better?

Later, in a different restroom, I stared at the mirror, me in my crisp dress shirt, new leather belt, dry-cleaned slacks. Though I was born into a situation with limited economic resources and grew up in and around neighborhoods with high crime rates, I clearly had access to food, clean water, toiletries, reliable transportation, stable housing, education, parks, health care, physical security, etc. As I type this on my MacBook, I’m sitting on a couch bought new from Macy’s, a Mission Impossible movie on our 60-inch TV in the background, in our suburban tract home set at a cool 72 degrees, baby monitor on our coffee table showing our daughter asleep in her crib in her own room, my wife playing Candy Crush on her iPhone with her leg propped up lovingly on me. Much of this has to do with choices I made (of course), but how much does this middle-class snapshot have to do with the facts that I was born into a family that valued education, to parents who created a loving and supportive environment, to parents who weren’t addicts or neglectful or abusive, to parents who had college degrees and full-time jobs, in a country where opportunities are allowed to me?

Can we hold people accountable for their actions while also being empathetic and kind to understand why they might have made those decisions? Maybe if I hadn’t been so judgmental, I would have given him a ride or some cash or some tips on how to handle himself in the interview. But I didn’t think of these things until after.

Always after.

I used to be an empathetic person. I always sought understanding. I always thought of how something I did or said would impact other people. But when I went through a rough period, it seemed like no one would or could be there for me in the way I needed them to. I turned that anger and confusion to what was happening in the world. I grew tired of hearing how other people had it so bad. Life will never be fair, I would say to myself after reading another news article. Stop saying society needs to change. The only person you should look at is yourself.

I was wrong, of course. It only took a class and a man needing help with his tie to show me that.

But how do I hold onto this feeling? The desire to be non-judgmental and patient and empathetic and kind without expecting it in return?

I hope he gets the job and I hope this is a turning point for him. But if not, I hope there are people better than me, or at least better than I’ve been, to help him get there.