Over the last six months, I’ve tested more than 1,000 people for Covid in hospitals, shelters and homeless encampments
Suvendrini Lena, a neurologist who works at CAMH and Women’s College Hospital, is one of hundreds of health care professionals who’ve spent the last six months testing Torontonians for Covid. She’s worked in hospitals, women’s shelters and homeless encampments, leading mobile clinics across the city. Here, she describes what it looks like on the front lines of testing—and why she’s so worried about our current trajectory.
—As told to Isabel B. Slone
I am a displaced person. My parents come from opposite sides of the conflict in Sri Lanka—my father is Tamil from Batticaloa, and my mother is Sinhalese from Colombo. They met when my father saw my mother performing a traditional Kandyan dance. They fell in love, but couldn’t be together in Sri Lanka, so they moved to England in 1970. I was born two years later, and when I was about 10, we moved to Ottawa. There, our home became the first place of shelter for my father’s extended family: uncles, aunts, grandparents and cousins, all refugees of the Sri Lankan civil war.
Growing up around people who’d lost everything, I yearned for certainty. That’s partly why I became a doctor. Some medical problems are easy to fix: put a cast on a broken leg and you’ve made a tangible difference in someone’s life. I’m a neurologist by training, working between CAMH and Women’s College Hospital, as well as a playwright. I write about the uncertain things, like forced migration and mental illness.
I’m the only neurologist who works at CAMH. It’s my job to determine if someone with symptoms of a serious psychiatric illnesses like schizophrenia might really be dealing with something else—a brain tumour, perhaps, or a rare neurological disease like spinocerebellar ataxia or limbic encephalitis. For the last six months, I’ve worked on the front lines of the pandemic, administering Covid-19 tests. To date, I’ve performed more than 1,000 tests.
On March 13, I received an email from Women’s College Hospital looking for physicians willing to work in the Covid-19 assessment centre. That week I had planned to travel back to England with my mother and son. By that point, I knew it wasn’t safe to travel. I cancelled the trip, but I didn’t have any clinics booked. So I wrote back: “I can do it.” Working at the assessment centre gave me a sense of agency, a way to fight back against the problem. If I could help isolate this virus and help bring down the caseload, then I could feel like I was chipping away at the problem. There was something very comforting about that.
The next day, the medical director of the assessment centre, Sheila Riazi, called me. I heard adrenaline in her voice and a steely sense of determination, like she was driving a train ahead of a collapsing bridge. She asked me if I could come in early, before the testing centre opened at noon. She told me to wear scrubs. It had been at least 10 years since I’d worn scrubs. I didn’t feel any fear—just a sense of duty to do my part. I have a master’s degree in public health, and I kept thinking of the mantra I learned in school: “Screen. Detect. Trace. Connect.” If I did this intensively and fanatically, school would start again. Soccer would start again. Theatre would start again. If I worked hard enough, the pandemic would end and life would start again.
Before the pandemic, I’d never done a nasal swab. It’s not a difficult procedure, but there are some technical subtleties involved. You can’t just shove the swab in and out. For the best chance of getting a sample of the virus, you have to follow the lower nasal turbinates down into the back of the throat and twist the swab several times to pick up tissue as well as secretions. And if you go too far, it’s very painful. The tricky part is finding a way to administer it in a way that is kind to patients. A nostril is an extremely sensitive area—it’s finely innervated and when stimulated, it makes you cry, but only from one eye. Some people say a swab feels like swallowing too much wasabi; others say it feels like drowning. The swab itself matters too. In the early days, we were using thicker swabs, and people got a lot of nosebleeds. I’m short, and I had to learn how to position myself properly to swab tall individuals and little children.
In March and April, there were no lineups for testing because most people felt that entering a hospital would be like walking into the epicentre of the crisis. When patients arrived, I could sense their anxiety. People who appeared to be calm, perhaps just a little pale, were tachycardic. Their hearts were racing. A few people fainted after getting the test.
In those days, I tried to begin every test with a conversation. A test is an invitation for each person to share a small part of their own pandemic story, and some of the stories I heard will stay with me for the rest of my life. A 20-something woman with beautiful tattoos told me she needed a test because she was told she could finally see her husband, who had a stage 4 osteosarcoma. She was so full of bravery and hope, in spite of Covid, because her husband was getting stronger. She seemed completely unfazed by the test. Her seven-year-old son was with her. We decided to test him too.
Another day, I met a young man who had been sent in from a refugee shelter because he sneezed twice. He was from Ethiopia, and we communicated through a remote Amharic translator using a cellphone wrapped in cellophane. According to public health rules, he would need a negative test result before he could go back to the shelter. Four doctors, eight nurses and several administrators, all gowned and gloved, deliberated over where he could safely wait for his results. He sat through everything, patient and bemused, probably thinking the entire thing was ridiculous. I thought to myself, How many times has this man been cold, tired, sick, coughing, sneezing or worse as he travelled the lands and oceans between Ethiopia and here? And now we cared so very much about a sneeze. In those early days, even as a physician, I had no idea if it was ridiculous or entirely necessary.
Another woman I met worked at a long-term care home and had tested positive twice. She was at the Women’s College assessment centre because she had been symptom-free for 48 hours and her employer was calling her back to work. Her facility was so understaffed, they were afraid residents would be left sitting in their own feces if she didn’t return to work immediately. The woman was quiet and demure—she never expressed concern for her own health, or fear for her own children, only fear of spreading the virus to the residents. It made me furious that she was being forced back to work without time for a full recovery. I wrote her a doctor’s note requiring her to stay at home in isolation until the results of her test were available.
In April, women’s shelters reached out to Women’s College Hospital for help with testing. There’s no easy way for someone living in a shelter to self-isolate, so I helped spearhead a mobile testing unit to test people living in vulnerable conditions. Each mobile unit consisted of two or three physicians, with myself or my colleague Vanessa Wright coordinating, and one or two lab techs working collaboratively with shelter staff. I spent days wrapped in PPE like a stale blue hot dog, transporting our gear—swabs, labels, sanitizer, wipes, specimen bags—in light blue plastic crates.
Before testing in a shelter, Vanessa and I would meet with staff, sometimes on Zoom and then in person, to learn about the challenges residents and staff had experienced with the pandemic. Covid had already caused plenty of dislocation and chaos as shelters reduced capacity up to 50 per cent to maintain distancing and cleaning protocols. People who tested positive were uprooted from the shelters and isolated at a designated hotel. Fearing more loss of autonomy and agency, many were afraid to test and afraid to receive results.
Before we arrived at each shelter, we made white labels for our sample tubes. Each label had a name, each name had a story. At a shelter for women fleeing violence, Vanessa and I arranged our labels alphabetically on a large wooden table in a sunny room full of colourful inspirational paintings and sayings. I noticed that half of the women had the same last name: Hope Jones, Justine Jones, Alyssa Jones, Sarah Jones, Faith Jones. The women were using pseudonyms, afraid that testing might expose or identify them.
At another shelter, a young Black woman walked by me while I was testing and said, “No one is putting anything in any of my orifices.” For people who’ve survived sexual trauma or physical abuse, getting a Covid test is yet another example of a painful invasion and loss of agency. I couldn’t help her feel safe enough to have a test. And she remained at the shelter. The workers were very clear: shelter is a basic human right. Housing is not tied to testing. Testing is a choice.
After this experience, I began to look for ways to empower vulnerable people to have more control over Covid tests. I experimented with letting people administer their own tests. They would hold onto my hand while I inserted the swab into their nose, and I would withdraw it if they squeezed or pulled my hand. I wanted to do everything in my power to make people feel at ease. The first time I used this approach, my patient—a young woman who was coming down off something—was so surprised to get a say in the matter that she smiled. It felt good to let go of authority a bit.
In June, through a relationship with the Centre for Wise Practices, the Toronto Urban Native Ministry invited us to test at a homeless encampment at Trinity Church. The people in the encampment had discussed the need for testing and access to health care, and they wanted to protect each other as a community. The encampment communities pre-date Covid-19, but their numbers have swollen during Covid times. Many shelter residents have moved into encampments fearing disease transmission in shelters or because the new rigid rules in shelters are difficult to navigate.
The encampments are all different. Some are more autonomous than others. Supplies like food and tents are donated—either by religious organizations like Sanctuary, the organized efforts of citizens who’ve come together, like the Encampment Support Network Toronto, or individuals who simply drive up with tents or cases of bottled water. Some have Porta Potties, while others have no access to running water. Some encampments I visited looked like living rooms, with posters and photos hanging up on the trees.
The encampment at Trinity was nestled in the shadow of the Eaton Centre. The church supplied tents and drop-in meals throughout the week. I arrived on testing day, an hour before everyone else, and watched the encampment slowly wake up. The clusters of tents, the bags and boxes and personal belongings, reminded me of the encampments for the internally displaced where I had worked in Sri Lanka. The encampment was divided into two clusters of tents, around 40 in total. One cluster was a close-knit group of youth, young adults and even a pregnant mother and her partner. The other community was led by Indigenous elders, who were asserting their traditional rights by living with and on the land.
Earlier in the summer, the city had closed down all the nearby washrooms in Nathan Phillips Square, so there was no reliable access to basic facilities. The residents regularly cleaned up the space and carefully maintained the encampment, but it was challenging. Even in the middle of a pandemic, they couldn’t wash their hands regularly. It was hard to see people living without many of the basic things that we all need.
The first person to emerge from a tent was a young man in his 20s wearing a cape made of a discarded white hazmat suit graffitied with symbols and the words “witch doctor.” Anchored to his hands and feet were multi-coloured plastic gloves. Pink Naloxone kits, free for the taking, hung from the branches of a nearby tree; Covid has created a sharp increase in opioid-related overdose deaths, due to people being forced to use drugs without supports. The witch doctor greeted me with a smile and directed me towards the site office.
Testing began with a ceremony: Anishnawbe elders smudged, sang and invoked Bear the Healer. There was a serenity to testing at this site, perhaps because it was informed by the Indigenous idea of living on the land—a quiet assertion of right, of community, of a different way of doing things.
We tested 60 people that day, and there was only one positive case, an older man who called himself Z. He had no symptoms aside from feeling a bit under the weather. The diagnosis hit him hard, and he began talking about connecting with his estranged son to discuss his last rites. He was an American, and didn’t want to follow protocol and isolate himself in a Covid hotel because he was afraid he would be taking advantage of our universal health care. I convinced him that isolating himself would help out the community and flatten the curve. I waited with him as the city coordinated transportation from the shelter to a hotel, which took a total of five hours. We had a long conversation about Bacteriophage Lambda, a group of viruses that multiply inside bacterial cells and have had a huge impact on the course of evolution. I was embarrassed it was taking so long for a van to arrive, but Z was in no rush. “When you’re living on the street you do a lot of waiting.” After he finally left, one of the staff at the shelter approached me. “I have a medical condition, I’m immunocompromised and I just spent six hours with him,” he asked. “What is my risk?” He’d been wearing a mask and practising physical distancing, so I asked him to self-monitor carefully.
Another encampment we visited was at 69 Fraser, near Liberty Village. It was messier, less organized, almost anarchic. It had sprung up across from the city shelter, and encampments residents were able to use the facilities there. Despite the chaos, there was something here that every refugee and displaced person recognizes: the primacy and intensity of human relationships in the absence of things like shelter.
Here I met a man named Jamal, who told me that by living in the encampment, he was closer to nature, rising and sleeping with sun and moon. He suggested this natural rhythm was healing; since moving in, he’d been able to overcome an addiction, and felt a new optimism due to his newfound proximity to nature. Nobody tested positive at this site. Perhaps there was something to the natural healing.
I tested another young man with an angry-looking, swollen abscess on his leg that was clearly in need of medical attention. He told me he had been cleaning it himself, afraid that all of his belongings would be stolen if he left his tent site to go to the hospital. After he went back to his tent, I asked the shelter staff to look in on him and check on his leg. Jane, a clinician from Anishnawbe Health Mobile Healing Team, and my mentor in the field, took me aside and asked, “Did you ask his permission to tell the shelter workers?” No. I hadn’t. I realized that I had invaded this man’s privacy and autonomy—even with the best of intentions.
The experience made me realize how much I’ve come to take my own shelter for granted. As a kid, I understood the impermanence of home. I understood that anyone could become homeless in the face of post-colonial violence and civil war. Covid has made me see that here in Toronto there are thousands of people who are internally displaced—by colonial history, economics, politics, trauma, addiction and mental illness. It’s not an accident that many people who are homeless or living in the encampments—often Black, Indigenous, people of colour—are at higher risk of Covid infection. The lesson I’ve learned is we’re not all in this together.
Throughout the pandemic, I’ve also been doing my best as a single parent to my 13-year-old son. And I’ve found myself constantly coming up short. One evening in June, I’d been testing in a shelter until 11 p.m. I cycled back to my home in High Park to find that the power in my building had gone out and my son was sitting alone in the dark. He had gone outside to the balcony where he could see the lights of other people, just to feel like he was safe. I felt like I’d let him down.
I’ve effectively become an absent parent. I don’t have time to supervise my son or monitor his screen time. And because I’m in contact with Covid all day, we have to isolate from friends. His only companion is our dog. I see how lonely he is, and it breaks my heart. But I have to believe that if I work hard enough, this will go away soon, and we’ll be able to go back to something more like a normal life. He understands I am working to restore some of the freedom and autonomy he and his friends were beginning to enjoy as 13-year-olds discovering the city. And when case counts came down to single digits in early August, I was briefly able to breathe and spend more time at home with my son. I tested and saw my parents. I felt like the work had paid off, and we were safe. Then Doug Ford announced the Stage 3 re-opening.
In the past few weeks, as bars, gyms, workplaces and schools have re-opened, Covid testing has been a nightmare. After two months in shelters and encampments, I’m back at the Women’s College Hospital CAC because fewer resources are being allocated towards mobile testing. Since the beginning of September, more than 1,000 people have come through the doors each day. Amid news reports of rising cases, so many Torontonians young and old need testing, or want testing. If you are afraid, or worried or exposed, or sick or uncertain, you test.
People begin to line up at 6:30 or 7 a.m., and by the time we open at 9, the line wraps all the way around the building, through the courtyard and down to Bay Street. In line are children with mild symptoms, who sometimes need to be coaxed for 45 minutes to take the test, or elderly people in wheelchairs who’ve been waiting outside for hours. With this volume of people, I’m no longer able to connect with my patients. I’m no longer a healer or a helper; instead I’m a machine tasked with completing tests as fast as possible.
Health care workers—physicians, nurses, administrators and cleaners—are being asked to absorb the burden by working longer hours in crowded centres. This is despite the fact that we have already worked relentlessly under stressful conditions for the past six months. I’m not afraid of Covid. I understand what we need to do to interrupt transmission, and I used to feel a sense of hope that we could live with this virus, as we do with so many others.
I’ve taken solace in a wonderful new sense of common purpose with other physicians, shelter workers, public health workers, environmental staff, and advocates whom I’ve come to know in these times. But now I’m burned out and disillusioned, and my optimism is fading fast. I see the burnout in my co-workers, too.
As I test as many as I can, as fast as I can, I want a different story. One where we prevent outbreaks through systematic, well-funded collaboration between health and educational and business sectors, and where we use what we’ve learned to address our vulnerabilities. Let’s make temporary shelters permanent. Let’s make sure that all people live in secure housing with access to green space and safe transit. Let’s make class sizes smaller permanently, increase health care access for racialized communities permanently, reform elder care and end-of-life care permanently. Let’s use this hard look at death to live better together. Its past time for a durable and preventative strategy.