Off the back of my small apartment, I have a small balcony. It peers out peacefully over a courtyard that is bounded on its opposite side by the parallel wing of my building, two mirror halves that rise like medieval castle bulwarks above the kempt grass and decorative stone pathways that the management-company representative serenely called a “zen garden” when I first looked down on them a few years ago.
He told me that the “unit” was desirable because it opened out over the zen garden, but he didn’t elaborate and I didn’t know to ask, nor would I have understood had he said anything else. Now, I understand that he meant that the other sides of the complex stare into streets on which I would perform bystander CPR on a gunshot victim within my first week of moving in, on which sirens blaze regularly atop all manner of emergency response vehicles, below which some fraction of the local population descends to fall asleep with needles in their arms, slumped out in the newly installed bike storage room of the local transit stop as commuters bustle by numbly at breakneck speed, unable to avoid a forced rush-hour migration between the Muni and BART train levels.
This has been my home, and I have liked it, but I have also learned to appreciate the zen garden over time.
“I can live with the population or I can work with the population, but I can’t live with the population and work with the population.”
This was what my longtime friend told me shortly before he left San Francisco, probably forever, and I don’t think I’ll ever forget it. We were both working in the same city emergency departments at the time, often handing off to each other and often crossing paths with the same patients. That last year, he had seen his car window smashed three times, his bike stolen out of his locked garage, and his work bag with his keys and wallet snatched straight out of our hospital break room by a patient whom we had both cared for, in succession, over the previous twelve hours while he slowly regained consciousness after coming in by ambulance with a drug overdose and unstable vital signs.
“I can’t get screamed at by a naked guy on meth who the police brought to the ER because he was high as shit and smashing car windows, and then go home tired as shit and find my car window smashed, too. I can’t do it. I’m becoming too angry to be a good doctor.”
I didn’t know what to tell him, and I just had to watch him go.
The zen garden really is fairly zen, and my small balcony, by extension, is also reasonably zen. Lying down, even with my arms at my side, I would not be able to stretch out fully across its reddish brown two-by-four beams without hitting my head, but I can stand easily on it with another person and not feel more cramped than one would feel at the helm of a small boat. And that’s enough space for me.
Most of the time, I use it only as a portal to the cool, dusk air outside, an exhaust hatch for the stuffy hotness that builds up in a single-room apartment while its tenant is away for the workday. I return and flip open the deadbolt on its door, as I can almost feel the walls around me pant like a dog locked in a summer car, ready to bolt out through any new opening, about to greedily breathe in the zen garden after a day on its surrounding streets.
And there is no yelling, nobody peeing on their bed or screaming “faggot” at me or ripping our equipment off the walls, chunks of drywall in tow. Nobody to call the nurses bitches or demand a “sandwich you piece of shit, I hate this fucking piece-of-shit place” as their first conscious act after being brought in nearly dead only a matter of hours earlier.
Their urine is always full of amphetamines, too, a class of drugs that includes “crystal meth” or “ice” or whatever you want to call it. It’s all the same thing: methamphetamine.
Culture and medicine are not blameless in this, either, for even the squarest reaches of our society have had an enduring and sordid love affair with amphetamine stimulants. Air Force pilots took them for wakefulness and maybe still do. Professional baseball players took them, too, and called them “greenies,” enhancing their performance for years and years before anybody would even begin to whisper about a new thing called “steroids.” Homemakers took amphetamines to lose weight, partygoers took them to dance longer, and children took them under doctors’ orders to combat ADHD. Today, we call that latter drug “Adderall,” and it’s nothing but amphetamine, and it’s still given for ADHD.
Put an extra methyl group on that regular amphetamine (i.e., add a carbon and three hydrogen atoms to Adderall) and you’ve got meth. That’s actually why it’s called “meth,” simply that extra methyl group. Now, if nothing else, it lasts longer in the body, with a half-life that can extend to the 24-hour mark. As drugs go, meth is also easy and cheap to make, attributes which provide it a lucrative and nearly indestructible foundation as an illicit substance.
Low-cost, long-lasting, addictive, and sometimes pleasurable: the rapid spread of the meth mycelium in recent years is then no puzzle. The sick joke, though, is that the drug also frequently causes its users to become psychotic.
“Psychotic” is an important word, but it is often misunderstood and muddled beyond repair when used colloquially. In medicine, however, “psychotic” is neat and expressive: a psychotic patient is one who is experiencing a “loss of contact with reality.” This can be caused by drugs or by mental illness or by some other medical condition entirely. It can also be profound, such as in a patient who thrashes against hallucinations while not reacting to any true outside stimuli, or subtle, such as in a patient who is entirely alert and calm except for their belief that every lightbulb has a camera in it.
Meth, when it chooses to, tends to cause a psychosis somewhere between these two extremes, perfectly finding the optimized maximum for loud, senseless destruction. The user is aware enough of their surroundings to interact with them but too detached for any appropriate behavior. This leads to most emergency departments receiving ambulances, fairly regularly, bearing young disheveled people strapped to backboards, screaming with neck veins distended, as apathetic and underpaid EMS workers wheel them in on expensive electric gurneys.
“Sorry, doc, the owner of the cafe a few streets down called 911 because this guy was kicking and breaking their planter pots and screaming at customers. Fingerstick was 89, heart rate’s 120s. Couldn’t get any history from him. We gave him 5 of Versed to settle him down.”
I already know it’s meth. The man or woman lying in front of me has a white mesh hood on because they were spitting at the ambulance crew, and they look like a misunderstood beekeeper because of it. They’re shrieking from beneath it, obscenities and hallucinatory rants flying forth a mile a minute from a body coated in skin that has been neurotically picked at with dirty nails and blasted by the elements of the homeless streets for weeks, months, or sometimes longer.
I pull the hood off and look at them, introduce myself, try to make sure that they’re moving both of their arms and legs, that their face moves symmetrically, that they haven’t had a stroke or a serious head injury. I try to talk to them, as they jerk their body violently to and fro, sometimes fixing me for a split second with a dead-eyed, far-away gaze, but there is no real or sustained interaction. They won’t tolerate a thermometer in the mouth, so the staff and I try to hold them down and get a temperature by ear, or by rectum if we don’t have an ear thermometer, just anything to make sure that they don’t have a fever that could indicate that they might have a deadly infection like meningitis underlying their altered mental state.
It’s almost never meningitis or a head bleed or anything except for meth, though. And I know, because eventually the Versed takes effect and they calm down or go to sleep while we get basic tests. When those are normal, I then observe the patient for hours while the nurses keep them on constant cardiac and oxygenation monitoring, making sure that they slowly return to normal and that no other pathology is actually present. During this extended period, we often eventually collect some urine that the lab tells us has amphetamines in it—we don’t test directly for methamphetamine, but that’s what it is.
When the meth finally abates and releases its formerly willing victim, the social worker in the department investigates. They generally find that the patient is uninterested in any community resources, or, if they are interested, that they have been banned from every shelter and halfway house or equivalent program within all of the surrounding zip codes due to repeated hostile, deranged behavior or other unforgivable transgressions. Medically clear and out of options, we then discharge the patient back to the street to repeat the cycle.
There is no other safety net. This is the safety net. It prevents death, usually, yes, but it does not really provide life. And the blatant, repetitive futility of the medical care required can also be outright draining for the people who are entrusted with its provisioning. Each meth patient is like another sand mandala, a forced project to be worked on painstakingly until it is completed, at which exact moment it will be immediately reset to its starting state of maximum, unrecognizable entropy, retaining no trace of the efforts invested in it. It can feel like the stone of Sisyphus, except the stone calls you a faggot-ass motherfucker as it crushes you on its way out the emergency department doors.
So then I have grown to respect the zen garden within the walled-fortress of my apartment building, even if its origin story is no bigger than an architect’s sales strategy. I have also come to suspect that others who both live in this city and interact with its meth-afflicted population must have found similar sites of respite, quiet places that never have human feces on the walkways or orange-tipped needles in the grass.
This is also why it slowly started to bother me when my zen balcony began to turn into a pigeon roost.
The birds are everywhere in the city, of course, but they clearly pick favorite spots. A year or so ago, they discovered the balcony of my next-door neighbor, and they set up shop there while he wasn’t paying attention. By the time he noticed, neither fake owls nor bird spikes on the railings could discourage them, and our adjacent outside spaces had a new and permanent chorus of constant fluttering, cooing, and, most importantly, off-white crapping.
The sounds started to wake me up in the morning. When I opened my balcony door, dirty discarded feathers would blow in. I couldn’t walk outside without looking like I was playing drunken hopscotch, due to the piles of excrement. It was not particularly zen.
I deep-cleaned my balcony several times in an attempt to discourage the pigeons from nesting, but they continued to return and terraform the auburn planks with more glistening white-green bombs. I eventually even bought a small water gun to add some teeth to the complaints I had been yelling at them, but nothing really worked.
In a fit of desperation, I hatched a scheme to cover my entire balcony with a retractable shade, planning to withdraw it only when I went outside and forever prevent poop from derailing my zen. It took some searching, but I found a suitable cover online and ordered it, retiring with the door shut to wait for its arrival.
The day before it came, however, there was a pigeon sitting huddled in the very corner of the balcony, under a chair. This was unusual. The birds had, before then, been keeping to the railings so that they could promenade and coo with their friends. This particular pigeon didn’t scare, either, when the door was opened or even when soft shots from the water gun hit it. When it finally flapped away, it did so only reluctantly, and it didn’t travel far before landing and staring back at my balcony.
I felt it pin me down immediately and ardently with its half-faced monocular gaze, one walleyed, ocher-ringed pupil fixing me from within swirling layers of brick red and coral, urging me off while simultaneously taking my measure, motionless and silent underneath flat features. Palpably waiting to return to its spot, quietly but unmistakably, like a beset Grecian Colossus temporarily pried from its stone moorings and forced to sit apart from the harbor. Eye unwavering, yearning, planning clearly toward some singular purpose as essential as it was inscrutable.
And in its loath-abandoned corner lay two small, white eggs.
The common pigeon, or rock dove, I soon learned, typically lays one to three eggs in the spring within a flimsy nest of straw and sticks. These eggs will gestate for about 18 days before hatching, and then the fledgling squabs will be in the nest for the next 30 or so before leaving. The parents are a mating pair, and they take turns sitting on the eggs to keep them warm so that the other can go off to feed and, probably, befoul a different but nearby balcony.
Though the species evolved to nest on coastal cliff faces, the roofs and ledges of modern apartment buildings apparently mimic these structures adequately, making the transformation of my balcony into dovecote and nursery a predictable occurrence. If the new family stayed, it seemed, I wouldn’t get my zen space back for about two months.
I continued my research in anger, trying to figure out if there was a health reason to get rid of the eggs. There didn’t seem to be.
I then checked to see if the eggs could be moved somewhere else, instead. There wasn’t a definitive answer, but there was enough country wisdom online about birds abandoning moved nests to discourage me from that type of potential cruelty.
Then I found discussion forums with distraught posters who had discovered eggs that absolutely needed to be removed. Compassionate dove-keepers were there, too, reassuring them that the birds would adapt quickly and make new nests elsewhere, likely laying more eggs that same season. Others pointed out that the species was certainly not endangered.
I began to relax. I could remove these eggs without feeling guilty. The birds were dumb, just acting on instinct. They didn’t even know if the eggs were fertilized! I also remembered that we eat chicken eggs regularly, and those were removed from their hens, so how is that any different? Hell, we kill and eat the hens, too. At least I’d be letting these pigeons go, even if I binned their eggs.
But every time I looked out at the pigeon on the eggs, I couldn’t muster the resolve to evict it.
This was dumb, I thought. Should I be vegan, then, if my delicate constitution couldn’t even handle “killing” a few unborn eggs? I grappled with that idea for some time before I realized that the alternative to vegan is not “kill every single living thing you come upon.” What I found distasteful, in the end, is that I didn’t need the birds or their eggs for food, and I didn’t need them gone for any serious practical purpose in my life. They were just temporarily in the way of cleanliness, and when the scales came to rest, it ended up that I didn’t feel like water gunning literal parents off their eggs so that I could do a home improvement project.
The thought of removing the pigeons and their nest didn’t bother me logically, but it bothered me emotionally, especially because it was directly in front of me. I’m aware that this is inconsistent, but I’m inclined to give the benefit of the doubt to the parts of me that produce unexpected clemency, rather than to the parts that yield predictable, calculated violence. The birds and their eggs stay.
Sometimes, if the timing is right, I’ll see the same meth-addicted patient twice in one shift. They’ll be brought in, zombie-like on EMS benzodiazepines, after being found throwing rocks at an elementary school or whatever other police-inducing thing they’ve stumbled onto. They’ll sober for a while and then eventually walk out while apologizing or screaming, asking for new scrub pants to replace their urine-soaked ones.
An hour later, the police will bring them back again, this time with a quiet glare. Evidently our handshake gentleman’s agreement to stop with the meth, or at least to do slightly less meth, did not pan out.
I always look at them and try to politely ask why they are back, while they grind their teeth and hiss about bizarre nonsense. Their heart rate is 140 and they are sweating.
“Did you do more meth after you left here an hour ago?”
“Okay then, sounds good. Bedtime.”
I give them sedatives to relax them and bring their heart rate down from its dangerous level. I rehydrate them. If I didn’t check labs before, I do it then. The nurses and I do the same monitoring we did before, just for longer this time, really trying to give the patient long enough to clear the meth out so that they won’t make bad choices when they eventually leave again.
But we all know that we’re trying to bail out a boat with no bottom. Yes, we see a biased sample because anybody who actually manages to get clean won’t come back, but in the moment, it feels like we’re fighting an endless tide of cheap meth. It is a dehumanizing drug that makes all of its victims look upsettingly similar, robbing them of all dignity and individuality and replacing these with tragic psychosis and other medical and social issues.
I can look at it logically and make an argument that it’s not worth it, and in my head, I often do. The odds that this person will recover are vanishingly small, and the odds that they will instead continue to suffer beyond comprehension while simultaneously taxing the system to its breaking point are staggeringly high.
This time, I think, I won’t even bother considering meningitis. I won’t waste time rehydrating them. The nurses and I won’t fight to monitor their heart rate or to treat their incidentally discovered scabies. I won’t ask the security guard to risk a needlestick injury so that yet another meth user can get treatment that they have made themselves too psychotic to understand. I won’t check labs because I’m going to discharge them no matter what. They don’t care about their own life or my life or any life on this planet, so why should I treat them any differently?
If you understand what true end-stage meth addiction looks like, you will recognize this thought process, cold as it may seem. It’s similar in some ways to the final throes of alcoholism or other serious drug addictions, but right now the meth problem in this city is the one that is most prominent to me.
But then I can’t do it. I have to take care of them; I have to continue my diligence. I will monitor them and check to see if they have any medical symptoms. I am blindingly angry, but I can’t act any differently. I am back in my apartment, staring out my balcony door again at the pigeon sitting on its eggs, locking eyes with me, coral iris flaring. I can’t harm it. I feel the inconsistency thrashing inside me; I feel how indefensible both sides are.
I feel how zen the garden is.