Check out undergrad Sophia Li’s photo essay on chronic health patients at Duke Outpatient Clinic who are food insecure. This photo essay ties in the topic of Narrative Medicine with Chronic Health. 

By Sophia Li

“Stories from Root Causes: Fresh Produce Program” is a series of short written vignettes combined with photographs that captures my experience volunteering at a produce program for food insecure patients with chronic health conditions at the Duke Outpatient Clinic. The series was inspired by the candid interactions I had with individuals at Fresh Produce Program that revealed to me the diversity in food environments and livelihoods, and the different ways people navigate health challenges.

The outpatient clinic

Compared to the Duke University Hospital, The Duke Outpatient Clinic is rather unimpressive. It looks dinky on the outside—an old, chunky-looking brick building with the words “DURHAM MEDICAL CENTER” written over the entrance in all white capital letters in what appears to be Times New Roman font. Yet, what goes on inside is the opposite of dinky. People of all sorts come to the clinic to pick up bags of fresh produce weekly to feed and nourish themselves and their families. Some are wheelchair bound due to frailty, while others are unable to walk on their own due to morbid obesity. Some are old, and some are young. I am always taken aback by how old some of the patients are—for some reason they always look so much younger to me. When I picture eighty years old, I picture resignation to impending death. A sickly body lying in bed with a cloud of darkness looming over the brow. I do not expect shy smiles, bellowing laughter, and least of all, sass. Who knew eighty-year-old women could be even sassier than twelve-year-old girls? It is a pleasant surprise.

Death by 16-oz steak, and other diabetic musings

“Sometimes when I really crave a 16-oz steak so much it hurts, I ask myself: do I care about my health or the steak more? And if the answer is the 16-oz steak, I’ll compromise and make myself a delicious 8-oz steak for dinner.” —patient x

“I love fruit so much. I used to store giant Ziploc bags of fruit in my freezer, and use them to make smoothies. I can never just eat one piece of fruit—it’s just too tasty. I eat fruit until I literally can’t anymore.” —patient y

One day, we were giving out sugar-free, stevia-sweetened chocolate to patients. Before offering a bar to one woman, I asked if it was okay for her to eat chocolate. “I’m basically allergic to everything, so technically I can’t eat anything,” was her response. I paused, unsure how to respond. “I’ll take the chocolate,” she said eventually, “happiness is part of health, too.”

Packing eggs

“What are we giving out for today’s haul?” I asked Julian, one of the medical students who helped start and coordinated Fresh Produce Program, as I helped him carry the crates of food from his car trunk to the distribution center at the clinic.

“Have a look for yourself,” he replied, so I got unpacking. Sweet potatoes, collard greens, bags of pasta, all well and good until…

“Are these giant crates of one hundred eighty eggs each?” I exclaimed, peering over countless layers of egg trays stacked on top of one another. “How are we going to give these out to people?”

As I stared at the giant crates of eggs, patients slowly began to trickle into the clinic to pick up their produce bags. There was no time for deep deliberations. The other volunteers and I decided to construct packs of dozen egg cartons by cutting up egg trays and binding them together, with the eggs in between, using rubber bands we got from the clinic front desk. When we ran out of egg trays, we cut up cardboard boxes and used the cardboard as the top cover of our “egg cartons” instead. At first, we were scrambling to keep up with the demand, but pretty soon our egg-packaging operation became quite efficient. My fellow volunteers Thien and Osmay would have a carton finished and ready to hand off to me in minutes, and I would pack them gently into patient’s produce bags so that they wouldn’t break. One couple in the waiting area began calling me “the egg girl,” since I was always rushing around delivering eggs to people, carrying one carton in each hand. They made me smile so hard I wished I could bring them eggs every day.

The next time we had eggs at Fresh Produce Program, they came in individual commercial-packed dozens cartons. I guess whoever was in charge of picking out the food for each week’s distribution learned his or her lesson from the last occasion. As I transferred the sturdy Styrofoam egg cartons from the shipping box into patients’ bags, I told Thien,

“I kind of wished the eggs were in those giant crates again.”

“Yeah, that was fun,” she laughed, “but I guess this is better.”

Not enough

“Here you go,” I said, handing a woman her bag of produce, “Thank you for coming, and enjoy your weekend!”

She took the brown paper bag from me. Her brow furrowed as she rifled through its contents, once and then twice. Eventually she raised her head to look at me, an expression of frustration plastered across her features.

“How am I supposed to feed my family with these couple of leaves?”

“I’m very sorry ma’am, but it’s all we have this week. There might not be enough to cook a complete meal using only the greens, but maybe you can add them to some starches or meats to bulk up your other meals.”

Simply put, we had run out of produce. We didn’t have much supply in the first place that day, and more patients came during the latter half of the program than we had anticipated. As a result, we had to take out and redistribute the food from the existing bags we had already made in order to create more bags.

The woman stared at me, and stared at the contents of her bag again: a handful of lettuce and kale, a bundle of turnips, and some sweet potatoes.

“It’s not enough,” she said flatly.

I did not—could not—argue with her. What were you supposed to say when you were trying your best, but your best still was not enough?

“I’m sorry.”

Take it out

“What is this?”

I turned my head toward the voice.

“What is this?” the woman repeated again, pointing at a bunch of dark green leaves sticking out of her produce bag.

“Oh, those are sweet potato greens. The leafy plant part of the sweet potato that grows above ground.”

She frowned, seemingly bewildered by my response.

“I don’t want them.”

“Um,” I did a double take. “You don’t want the sweet potato greens?”

“No, no. Take them out for me, would you, please?”

“Oh, okay, I suppose so then.”

Hesitating, I removed the greens from her bag. She thanked me smilingly, and then left. I was perplexed. Usually people asked me to put more food items into their bags, not to take food out. Why would someone who was food insecure want less food?

After wracking my brain for hours, I still could not figure it out, so I consulted Julian. He explained to me that sometimes patients felt intimidated by foods they didn’t recognize. They might leave unfamiliar produce sitting on their countertops for days, until they started to rot. The spoiled food would then cause the patients to feel guilty and anxious. It was better to just take out the food they didn’t want.

“Why don’t we just show them how to use the produce we give them, then?” I asked.

“Well, there used to be this really cool guy who came and did mini cooking demos for us using the produce, but we haven’t seen him around lately anymore,” Julian replied.

“Couldn’t some of the volunteers just do the cooking demos?” I suggested.

“Well, if you all are up for it, I don’t see why not…”

The Salty, the Spicy, and the “I don’t even know what this is”

“How does the okra taste, Ms. Jones?”

It was the first time that the volunteers were running the cooking demo at the program, and needless to say, I was nervous. As undergraduates who relied on the student meal plan at the campus dining hall for all our meals, none of us were particularly experienced chefs. Today’s produce bag contained okra, so we decided to stir-fry some okra for our demo. After all, how could you go wrong with stir-fried okra? We did three iterations of the cooking demo, since patients arrived to the program at different times throughout the distribution hours. Two volunteers, Yen and Osmay, took turns cooking the food. One of the patients at the program, Ms. Jones, was present for all three cooking demos and therefore tasted all three batches of our stir-fried okra dish. We asked her for feedback, and she graciously complied:

“Well, the first okra dish was kind of salty, the second one was spicy, and this third one…” She took another bite. “I don’t even know what this is!”

Me and Osmay doubled over with laughter, while Yen’s jaw dropped wide open.

“‘I don’t even know what this is?’ Did you hear that scathing critique of my stir-fried okra?” Yen huffed indignantly.

Of course, there was no malicious intent behind Ms. Jones’ comments whatsoever. Osmay had put salt in the first okra dish and chili flakes in the second dish, hence, the “salty” and “spicy” flavors respectively. However, in the third iteration of the dish, Yen had decided to use a mysterious seasoning in a bottle labeled “savory.” Evidently, the “savory” seasoning had an ambiguous taste. After that, we all agreed to leave “savory” on the shelf for a while.

Eat your greens

One of the patients at Fresh Produce Program regularly brought his son, Ty, with him. Ty was a small boy—I didn’t know his age, but he looked around five or six years to my eye. Ty was usually always fidgeting or climbing under chairs or tables, but ever since we brought back the cooking demos, he became obsessed with watching us cook and tasting the food.

“Can you pleeeeaaaaaseeee do the cooking demo?” Ty begged me, drumming his hands eagerly on the table.

“Of course, Ty, but it’s pretty boring this week. Just spinach. Do you like spinach?”

“I love spinach!” Ty exclaimed.

“Really, you do? What’s your favorite food?”
“SPINACH!” he yelled.

Ty’s dad, who was sitting right behind his son and had overheard our entire exchange, broke in at this point,

“Ty, stop messing around. You don’t even like greens. All you eat is hamburgers and fries.”

“No, I LOVE spinach!”

As soon as we finished sauteeing the spinach, we served Ty some up on a small paper plate for him to try. Eagerly, he stabbed a bunch of leaves with his plastic fork and shoved it into his mouth. His eyes bulged with delight as he swallowed them.

“Mm!” he gushed, before turning to his father. “Dad, try some! It’s yummy!”

His dad looked up from his cellphone, his face distorting into a grimace of disgust.

“Pleaaaaaseeeee, try some!” Ty insisted, shoving the plate towards his dad.

His dad rolled his eyes. “Get that away from me—spinach is gross.”

Ty shrugged, and inhaled the rest of his spinach in seconds. I watched, amused, as I pictured how hard most parents had to struggle to get their children to eat even a handful of vegetables. I wondered if it was the rarity of vegetables that made them so appetizing to Ty. Or, perhaps he just really enjoyed vegetables.

Grocery shopping

Growing up, grocery shopping with my mom was one of my favorite things to do. My favorite part of the store was the fruit section. I used to hover over the rows of apples, admiring the colors and scents of the different varieties, before putting one of each type into one of those impossibly hard-to-open plastic produce bags that came on giant rolls. I remember running from the pungent smell of the seafood section to the sweet aroma of the bakery, and listening to the constant sound of shopping carts clashing and cashiers ringing—it was like sensory overload.

At Fresh Produce Program, I learned that grocery shopping meant something completely different for food insecure individuals. Buying groceries was not an exciting adventure. It was strategically shopping so that you would have enough food to feed your family for indefinite periods of time. Usually, this meant going to the nearest Dollar Tree and buying out all the bread on the shelves when there was a bargain, and rationing until the next big sale. If someone had already beat you to it, you would try the next Dollar Tree over. And if all the Dollar Trees were empty, as was often the case because they somehow never restocked enough, you might make your way to a Kroger. Worst case scenario, you could order Meals on Wheels. But never in your right mind would you walk into a WholeFoods store—WholeFoods was the biggest joke in the world. Who in their right mind would spend two dollars fifty cents on a singular organic avocado? You had to be ludicrous.

Kombucha

During one of the discussion groups we held, we asked patients what kinds of food they would like to see more of in their produce bags.

“Kombucha!” one woman chimed in, “that stuff’s like my non-alcoholic beer. I’m not allowed to have alcohol, so I just pour myself a nice glass of kombucha instead and it hits the spot.”

For those unfamiliar, kombucha is a fizzy, fermented cold tea beverage that tastes sort of sour and sort of sweet at the same time. When I thought of kombucha, I thought of bottles with hippie labels like “enlightenment” or “rebirth” stacked on the cooler shelves of trendy cafes and health food stores—certainly not something one would find at an outpatient clinic program for food insecure patients. So when Julian walked into the clinic next week carrying boxes of kombucha, I found myself gaping with incredulity.

“What?” Julian said when he noticed me staring at him and the kombucha. “The people have spoken, and they want kombucha! We don’t have loads of funding, but we try to do nice things when we can.”

Let’s trade

“Hey Sophia, do you have a moment?” Julian asked me.

“Yeah, what’s up?” I replied, looking up from the patient surveys I was sorting.

“Do you mind facilitating an exchange for Ms. Mary here?”

The situation was this: Ms. Mary loved kale. In fact, she loved kale so much that she was willing to trade some of her other greens with someone else for some more kale. She wanted to ask the gentleman sitting next to her to trade, but she was too embarrassed to talk to him. That was where I was supposed to step in and help.

“Excuse me, sir,” I began, standing right in between the two. “This lovely woman here would like to know if you would be willing to give her some of your kale in exchange for some other greens.”

The man raised an eyebrow, but did not respond. Silence ensued. I waited a bit, and then awkwardly repeated my question. “I really like kale,” Ms. Mary added sheepishly.

The man smiled amusedly and shook his head no.

“That’s ok,” I told him.

I gave Ms. Mary an apologetic shrug, and went back to my paperwork. Then, I felt a light tap on my shoulder. Turning around, I watched the man reach into his produce bag and take out a bunch of kale. He presented it to me and pointed to Ms. Mary.

“Oh! I’m sure she will appreciate it,” I thanked him. The corners of his mouth turned upward in a small smile. I passed the kale to Ms. Mary, who blushed and then shyly gave me some of her other vegetables, which I put in the man’s bag. He nodded in acceptance before directing his attention elsewhere, never speaking a word the whole time.

Volunteering for others, taking photos for myself

As a volunteer at the Fresh Produce Program, my job is to assist patients and help operations run smoothly. Patients come to the program to pick up fresh produce, not to get their picture taken. While some are happy to comply with my photography requests, many tense up at the sight of the camera around my neck. When I am taking photos, I am focused on composition and aesthetics. My hands are full and my attention is occupied. I am not serving others. I am creating my vision. Though I make sure to show patients their pictures on the back of my camera after I take them, I have no way of knowing whether the narrative I have constructed faithfully captures the voices of those within it. Thus, I extend thanks to all those who have participated in this project for trusting me to tell their stories with the hope that some good will come out of it.