Harmony Magazine, Volume 7 (2004-2005)

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A R I Z O N A H E A L T H S C I E N C E S C E N T E R M A G A Z I N E O F T H E H U M A N I T I E S

Art

Essays

Ideas

Photographs

Poetry

Prose

A R I Z O NA H E A LT H S C I E N C E S C E N T E R M AG A Z I N E O F T H E H U M A N I T I E S

EDITOR-IN-CHIEF

(Shad) Farshad Fani Marvasti, MD-MPH Student, Class of 2007

SENIOR EDITOR & DESIGN MASTER

Gabriel Sarah, MD Student, Class of 2008

ASSISTANT EDITORS

Katherine Glaser, MD-MPH Student, Class of 2007

Lisa Goldman, MD Student, Class of 2007

FACULTY EDITOR AND SPONSOR

Helle Mathiasen, Cand. Mag, PhD, Director, Medical Humanities Program,

Clinical Professor of Medical Humanities, College of Medicine

ADVISORY EDITORIAL BOARD

J. Lyle Bootman, PhD, Dean, UA College of Pharmacy

James E. Dalen, MD, MPH, Dean Emeritus, AHSC

Vincent A. Fulginiti, MD, Professor Emeritus, UA Department of Pediatrics

Keith A. Joiner, MD, MPH, Dean, UA College of Medicine

Marjorie A. Isenberg, DNSc, RN, FAAN, Dean, UA College of Nursing

Kenneth J. Ryan, MD, Dean for Academic Affairs, UA College of Medicine

G. Marie Swanson, PhD, MPH, Dean, UA College of Public Health

HARMONY is a publication of the Arizona Health Sciences Center (AHSC) sponsored by the UA

College of Medicine Medical Humanities Office, the Medical Student Council, and the Kenneth

Hill Memorial Foundation as a gift of perspective for the entire AHSC community.

All works in HARMONY, both visual and literary, are the exclusive property of the artist or

author and are published with their permission. Authors retain their copyright for all

submitted materials. Any use or reproduction of these works requires the written consent of

the author. Views expressed are solely the opinions of the individual authors and are not

representative of the editors, editorial board, or the AHSC.

For more information, please visit http://humanities.medicine.arizona.edu. Please direct any

inquiries or submissions to Harmony, Office of Medical Humanities Program, College of Medicine,

UA Health Sciences Center, 1501 N. Campbell, P.O. Box 245017, Tucson, AZ 85724-5017.

COVER DESIGN BY: Roma Krebs, Biomedical Communications, The University of Arizona Health Sciences Center

PAGE DESIGN/LAYOUT BY: Krista Nelson, OroGraphics Design & Printing, 520 219-4870, www.orographics.com

H A R M O N Y • A R I Z O N A H E A LT H S C I E N C E S C E N T E R M A G A Z I N E O F T H E H U M A N I T I E S 1

(SHAD) FARSHAD FANI MARVASTI • EDITOR-IN-CHIEF • MD-MPH STUDENT, CLASS OF 2007

MISSION STATEMENTHarmony is an outgrowth of the newly founded Medical Humanities Program in the College of Medicine.This Program aims to raise our consciousness about the importance of the Humanities in bringing aboutethical and humane health care professionals. The goals of this new Magazine are to value the differentperspectives, insights, and experiences present within the Arizona Health Sciences community throughthe publication of original works of personal expression.

In addition to accepting literary and visual art, Harmony also seeks to highlight editorial opinion piecesregarding any aspect of how health care is practized or organized and how it should be practised andorganized. We welcome expressions and opinions from students of health care as well as fromprofessionals established in their careers.

We hope that Harmony will serve as an inspiration to foster greater levels of collaboration and integrationof mutually important curricular activities between the Colleges of Medicine, Nursing, Pharmacy, andPublic Health. For this reason, we have established the Advisory Editorial Board with representatives fromeach of these colleges.

With this year’s publication we have a new focusand enthusiasm as we expand the Magazinebeyond the College of Medicine where it wasoriginally founded as Hermes to now include theentire Arizona Health Sciences community. We arechanging the purpose of the Magazine: this newMagazine is intended as a literary and arts journal,but also as a forum for the expression of differentopinions and ideas about how health care ispracticed and how professionals in training andthose already established believe it ought to be.Therefore, we wish to highlight reflections bystudents and faculty regarding their experiences ina format which will allow us to gain from eachothers’ perspectives.

Through the inevitable clash of conflictingindividual views, we hope to bring about aconversation leading to a spark of harmonybetween our collective roles as members of onehealth care team. The name Harmony fits with thedesire to bring balance while maintainingdifferences of opinion.

Hermes is not an appropriate name for this newMagazine since Hermes was the god of commercein ancient Greek mythology. In today’s system ofhealth care delivery, commerce plays a large role,but it finds physicians, pharmacists, nurses, andpublic health officials inundated with paperworkand constricted by bureaucratic procedures thateffectively prevent them from making a meaningfulconnection with their patients and communities.These market-driven demands on health careprofessionals hinder us from developing healingrelationships and thereby thwart our mission whichis to provide equal access of care to all human beings.

In moving from Hermes to Harmony, we as editorsof this year’s Magazine and active supporters of thenew Medical Humanities Program seek to returnmedicine and health care to their core mission. Weseek to rise above the confusion and injusticewhich are unintended consequences of thebusiness of health care delivery and arrive at thehigh ethical, humane, and professional ideals thatwe swear to in our oaths. We aspire to fulfil ourduty of service to anyone who is in need of ourexpertise and our care.

2 H A R M O N Y • A R I Z O NA H E A L T H S C I E N C E S C E N T E R M AG A Z I N E O F T H E H U M A N I T I E S

KARIBU AFRICA

MICHELLE MORRISON-GALLE • MD STUDENT, CLASS OF 2007

I.

Karibu AfricaIf you can send a manTo that moonIn the black sky,Dark as the potent streamsRolling by this house of mudAnd dead trees.

Asante sana,If you can right this very wrong,That leaves me burning trash,Barefoot,Upon broken pavement,Holding deathIn a child’s hand.

Oh mzungu,Karibu then.

II.

When lifeLong as the red road outIs but underThose thick grey clouds of morningIn the middle of the blueing hillsBeing pulled feet firstThrough green fieldsBy bullsFed large by the earthAnd these hands.In thisWhat need have IOf Einstein, pens,Your books piled up high?

Life isFirmly fixing toes in the martian mudKeeping these sticksUpon my headIn the graceful danceAbove the earthUntil to itUnder I go.

III.

What was true.

The horizon of grass,speckled with darker green of trees,Grey of the foraging beasts,And gold of the lounging kings.Then even the burst of red in the horizon,Leading goats in a lineWith extended ear lobesBared against the sun.

What will ever be true again.

Even stars are upside downAnd the cars drive their different directionChoking the air with thick, blackened clouds,Tires grinding up,Spitting out the red dustCoating the leavesAnd the white teethStained brown,Invading her toesAlong with the eyesOf her plump, living bundleLooking at me,My white skin blazingLike some flag of surrenderUpon a bloody field.

It was then that I gave myself up to it.The earth,The trees, flattened out against the sky,In praise.The dung on the roadMingling in the trash and their song,And the not knowing,The never being able to know,What the baby felt like, breathing against her back.

SWAHILI TERMS IN THE POEM:

Karibu: term of welcomeAsante sana: thank youmzungu: european or white persondala dala: Tanzanian “bus,”


IV.

Today when I felt I was fallingInto the skyPoked out with stars

Turning deeper shades of blueAs I stood,My back to the indoorsAnd foodI danced upon the drizzle of a breezePassing through the high treesAnd then sloshed in the puddles

Of it in the heavy leavesOf the bananas

Oh, tonight I’m on the green sideOf that painting in two,Too busy breathingAnd rolling in the grass

With the elephant and hippoTo worry about that crossSagging overhead,

As the choirsOn in the brownLift up their armsAnd their cantoFalling on their knees, eating the dust,With the snake,Hanging, hidden,

As their lord.

V.

Oh, cradle your children,

Cradle of manAnd kiss their darkSmiling cheeksWhile singing to the night skySo deepYou can swim atopIts oily blackness

Feeling the starsShine through your skin

And feel those drumsThat called swinging monkeysFrom their trees

To this earthAnd shout.

For you knowHow to put the childTo your drooping breast.Look out no more,

Blessed are you poorRich in such spirit.Clap your handsWe, we, we yaAnd dance your dance,Turning to this heart

Within your own song.

Infants rest on the patio floor at the orphanage in Beira, Mozambique. Mostinfants at the facility will die from AIDS before their second birthday.

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VI.

Denny’s mzunguAnd happy am ITo belong to someone

A child of these green hillsAnd this dirt road.

So now I walkNo longer guiltyBy this white face

Because she held itIn her earthen hands.

Laughing because I am one of themHumanHaving the African faceHolding one of theirs

Protecting him like my own.

VII.

This morning, when the dala dala

Birthed us from its loud, lurching bellyAnd I stumbled out on the dirt roadRunning atop the black, gurgling streamWhere wrinkled women wash their feet and legs,Turned grey by the dust each day,Something about the light

Shining amid the dark thundercloudsMorning’s renewalThe way it hit the roadAnd the leavesAnd something about the rain cooled airI felt myself a child againVisiting my grandparents

During the winter of my homeWhile the sun shone on their patioWith strange wooden masksHaunting us from the stone wallsAs we hunted for lizardsAmid the smell of oranges in bloom

Written throughout Michelle’s time in Arusha, Tanzaniaduring the summer of 2001

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Children are led in prayer before their lunch at theorphanage in Beira, Mozambique.

In the valley of the sun.

Then some of the painThe hurt that had been clawing within meSince I arrived in this land,From turning my eyes to the roadWhen the woman without legs called,“Mamma,” as I passedOr the dirty child grabbed my hand

And I had nothingI would not give.And suddenly every part of this place was rocking meAs the wind played on each leafOf every treeAnd clapped in the maiz

Some sort of ocean symphonyAnd even the bumps on the roadCradled my foot on their archNo longer calling my fall.


Adeniyi Alo, College of Public Health,Giving a lecture at a rural high school innorth east Nigeria. Speaking about local

public health issues such as malaria,sexually transmitted diseases, and

typhoid fever.

Women wait with their newborn babies outside of a clinic in Manga, Mozambique. Theclinic is rare — foreign support has provided the luxury of free antiretroviral treatment

to all women and children who test positive for HIV/AIDS.

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A lunch of noodles and chicken isserved to children at the orphanage

in Beira, Mozambique.

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PROTOCOL

QUINN SNYDER • MD STUDENT, CLASS OF 2007

I take a moment to ponder the rain before I stepout of the car. The sounds were indiscernible beforenow when my radio was blasting KXCI’s MorningBrew. The rhythmic beating of droplets bring amoment of peace. With a deep breath I throw openthe door to my Honda and jump into the thick of itwithout any cover. There is no point in bringing anumbrella to school. The rain is so rare andunpredictable that it is a simple pleasure to walkinto UMC with a drop or two of rain on your cheek.

“Way to get dressed up,” says a distant voice. I amwearing black slacks and a dark sweater with awhite shell necklace I picked up in Savannah a halfa year ago. At 7:55 this morning it takes someeffort to muster a reply. “Who wears light blue to afuneral?” I question. He is wearing a striped bluetie and a shirt lacking much contrast.

We have never been to such an event as what wassoon to take place this early morning. Chances arewe never will again. Unfortunately, there is noetiquette detailed in any book for the rules ofattending a ceremony to honor the cadavers givento a medical school for dissection.

I have not arrived at school this early all semester,but it is the least I could do to pay my last respectsto cadaver #4, the person who gave his body tofour naïve medical students so that we could seeinside him. “Look at the size of this guy’s lung,” weonce said. He had pneumonia and cancer, making itenough of a spectacle for us to play show and tellwith around the lab.

The mood here over our slightly above patheticbreakfast refreshments is awkward. Conversation isslow and jagged. More people are dressed up todaythan an average Friday when a fourth of the classwears nice clothes for medical interview. In fact, Idon’t think I have ever seen so many peopledressed up so nicely at this school. For the firsttime people who are wearing their usual threadsfeel out of place.

The memorial has just started and Dr. R, ourspeaker, has been asked to come to the front. Hewithdraws a T.S. Eliot quote he probably got out ofa book that morning. Unfortunately I never takequotes from profound anti-Semites very seriously.R is wearing a cornflower blue buttondownunderneath a zip-up sweater. It is clear after his

two minutes on the podium that he did not preparemuch for this speech. LG, wearing gaudy funeralclothes, claps and does her usual glance aroundthe room. It makes me feel uncomfortable.

GD, director of the Director of the Willed-BodyProgram, by which we are donated our cadavers,rises to the stage. He dons a black sportcoat with abeige buttondown underneath – top buttonunfastened with no tie. He says that sometimes ourcadavers are often rememorialized in a mausoleumor a cremation. The donor’s families, who he callsour “extended family,” will hopefully never have tosee what we have done to their loved ones.

GD offers us a moment of silence. Silently I say tomy cadaver, “Thank you cadaver #4. Thank you forgiving me the last gift you could ever give. Yourfirst and final possession. The knowledge gainedwill not be forgotten.” What was there to say tothis person? The owner of the body I would peelevery other day for three hours in the afternoonlast semester was unknown to me save his age,cause of death, and the contents of his body. I hadlittle personal connection with cadaver #4. Perhapsit was better that way. Without knowing his name Irefused to give him one. Other groups gave theircadavers new names, but I felt it unjust to call himby any name other than his own. The members ofmy group agreed.

When I open my eyes, GD opens the stage up tothe students. BM, a former TV news anchor, takesthe mic and reads asnippet from a playby Seneca. Shereads it like

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she is reading a live-on-the-scene report in front ofthe camera. I imagine what that would sound like.“This morning at the UofA College of Medicinestudents here are honoring the dead in an unusualway. No, it is not that any of their faculty orclassmates have passed away recently. Instead, itis their cadavers, that’s right, their cadavers…”

LG, no shock, is up next. It is uncomfortable foreveryone. We all know about the hairstyling, thenail painting, and the bracelet she gave to cadaver

#2, but somehow as shereads her poem that

all seems tofade awayfor me. Byfar it is themostelegantspeechanyone gavethis day. It isan excellentpieceincorporatingall parts of herexperiencewith hercadaver.Fears,imagery,

religion, andwonderment. I find myself putting down my penfor the first time since I began recording thisevent. She redeems herself from all the peculiarity.I will not think of her the same way again.

I bite into my bagel as the next speaker, KG,begins shakily. She is nervous about publicspeaking like myself, but today she has chosen toface her peers. I take a big bite of my bagel. I amproud of her. Watching her makes me wonder if Ishould have spoken today. I take another bite ofmy bagel and begin to wonder if eating during theceremony is appropriate. Is my chewing audible? Itcertainly is to me. Now that I think about it, Iwonder if writing is inappropriate.

I put the bagel aside for later and continue. MR, averbose yet eloquent and engaging fellow, openshis speech. He finds a beautiful quote from OctavioPaz that I can only paraphrase: “If our lives lacked

meaning, then our deaths will, too.” In lab I oftenwondered how cadaver #4 worked for a living.Maybe he was a factory worker, or a farmer, or acarpenter. I will never know. He was a largemuscular man with leathery hands and little fat fora man of 89 years. Before the upper third of hisskull and his brain were removed, our group foundit difficult to fit him inside his white plastic bin.After a while we learned to position him diagonallybefore covering him up for the night.

Our class earth mother, AS, fills the stage with herpresence. When she speaks it is like she is havinga casual conversation with you. She is a touch ofwarmth permeating the room on this very strangeday. For the first time today I latch onto someone’semotions, that which I can understand withfamiliarity. This lukewarm mixture of respect anddespair that I have witnessed all day has made mesquirm until now.

LH drops a little joke as she begins and proceeds tospeak in a subdued tone. This is very abnormal forher. I find myself listening to her more intentlythan usual. She is opening up to us for the firsttime. It is very personal. She is talking to me. LHwonders what it would be like if her cadaver was aclose relative of hers. She waxes eloquent on theuniqueness of this experience permitted to theselect few – the students of medicine. BM consolesLH with a arm touch as she sits down. I feel thebonds of our future profession tightening us all.

That is all for the speakers, and now it is time forthe flower ceremony. Each cadaver is given aflower by the members of his or her dissectionteam. When table 4 is called, AL, CD, and I go upto present the flower. We are missing a member ofour group. Such is a reflection of the overallattendance of this event. AL takes hold and placesthe white long stem flower, the name of whichescapes me, into the vase. We return to our seatsand watch as all 36 flowers are placed together inthe memorial vase.

The ceremony ends and the members of theAnatomy class that took place in the fall of 2003at the U of A College of Medicine are thanked fortheir presence. I grab my bagel and head out tothe hallway to see if there is any coffee left inthe big brown plastic containers. Class begins infour minutes. — QS, 1/22/04

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ONE HIPPOCRATIC OATH

ANONYMOUS FROM THE HEALER’S ART CLASS

I shall seek to enliven the truest depths of my soul

and find in my spirit the essence of existence and

the vision that pertains to all of us. Help me to

follow that vision in the creation of my path

towards the truth in the service of my better, the

betterment of those I come into contact with, and

the betterment of all humanity and nature. Guide

me to act from the depths of my emotions with

sincerity, humility, and respect and embrace my

truth for only it will lead me to the answers I seek.

I kneel before myself and all humanity hoping to

perceive the immensity of our potential. May the

greatness, both in concept and reality, of that

potential not burn my eyes. May my eyes follow

the immensity towards its resolution not seeking to

quicken its pace or guide its direction. May I follow

in reverence and calmness the path of my eyes

knowing with self-assurance that the journey along

the path does serve others if only given the chance

to commence. Help me serve the path with the

peace of mind of one who lives in the moment and

brings joy to his and others lives.

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Loon, Wells Gray, BC


CONTAMINATION OF WATER, SOIL, AIR, BODY, MIND AND SOUL

CHRISTINE KRIKLIWY • PUBLIC HEALTH GRADUATE STUDENT

Off to work we go

Dump dump dump

No one will ever know

Molecules lose and gain electrons

Fission and fusion occur

Restless free radicals search for homes

Changing our DNA is their goal

Chemicals seep into the water and soil

To silently pollute our lives

Rivers and ground, contaminated

Companies large and small, created

Money is the bottom line

At the expense of human lives

Companies become extinct

But we live on

Enduring dire consequences our lives changed forever

Off to work we go

Dump dump dump

No one will ever know

Media, books, computers

Enter our lives innocently

Greed becomes a major factor

At the expense of human minds

Killing, violence, sex and porn

We search for anything that offends

We target fresh, clean minds

Occasionally flashing obscene material

Whetting the appetite of innocent children

We catch a few fish at first

But then the pond becomes a lake

When the flashing stops

It has done its work

To corrupt computer files and gray matter of young minds

To successfully contaminate the body, mind and soul

Witness this latent corruption

Abolish it

Let the healing begin

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South Fork, Cave Creek, Portal, Arizona

1 0 H A R M O N Y • A R I Z O NA H E A L T H S C I E N C E S C E N T E R M AG A Z I N E O F T H E H U M A N I T I E S

STORY FROM SHUBITZ FAMILY CLINIC PATIENT

Last night at clinic one of our favorite clients and Iwere conversing about raising children.

He had just had a conversation with his daughterthe day before (she still lives there) and it wentsomething like this:

Daughter, how are you doing?

Fine father but I am troubled becauseMother will not give me a pen.

She won’t give you a pen? Why is that?

Because she gave me a pen Friday andnow I do not have it.

What happened to the pen?

I gave it to another student becausethey did not have a pen.

That is good.

But now Father I do not have a pen!

Let me talk to Mother.

(Mother) Hello. Would you like to hearthe story of our daughter and the pens?

Pens? I know she gave one pen away atschool on Friday. She should haveanother pen, please give one to her.

I gave her a pen on Friday and shegave it away. I gave her a penThursday and she gave it away. I gaveher a pen on Wednesday and she gaveit away. I have given her seven pensand she gives them all away! Every dayI give her a pen, she gives them away!What should I do?

My dear wife, we have a choice. If we do not giveher a pen, she will not go to school, or she willsteal one from another student. If we give her apen, she will go to school and will give it away.Which is the better lesson? We must teach her thatschool is important. We must teach her that givingis important. Please go buy 100 pens and give herone every day. I am far away but I am still herfather and do not want her to lose these lessons.Someday when you come to America I will havemany pens for every day of the year....

The Shubitz Family Clinic is part of the Commitment to

Underserved People Program (CUP), a medical student

directed service learning program. CUP provides early clinical

experience in the context of community service to rural and

underserved populations in Arizona. CUP also provides

learning opportunities in program leadership, health

advocacy, and health education programs starting in their

first year and continuing throughout their four years of

medical school. For more information visit the CUP website at

http://www.medicine.arizona.edu/pcrm/CUP/cup.html.

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H A R M O N Y • A R I Z O N A H E A LT H S C I E N C E S C E N T E R M A G A Z I N E O F T H E H U M A N I T I E S 1 1

“Valuing self-awareness and developing acapacity for reflection are critical. Whopractitioners are as persons is most relevant tothe quality of care they give and to the qualityof the relationships they are able to form.”

— NORMAN COUSINS

TWO KINDS OF INTELLIGENCE

RUMI, FROM MATHNAWI, IV

There are two kinds of intelligence: One acquiredas a child in school memorizes facts and conceptsfrom books and from what the teacher says,collecting information from the traditional sciencesas from the new sciences.

With such intelligence you rise in the world. Youget ranked ahead or behind others in regard toyour competence in retaining information. Youstroll with this intelligence in and out of fields ofknowledge, getting always more marks on yourpreserving tablets.

There is another kind of tablet, one alreadycompleted and preserved inside you. A springoverflowing its springbox. A freshness in the centerof the chest. This other intelligence does not turnyellow or stagnate. It’s fluid and it doesn’t movefrom outside to inside through the conduits ofplumbing-learning.

This second knowing is a fountainhead from withinyou, moving out.

THE SPIRITUAL SELF

THANKS TO: DONNA E. SWAIM • CLINICAL LECTURER,

MEDICAL HUMANITIES PROGRAM, COLLEGE OF MEDICINE

POEMS

It is difficult to get the

news from poems. Yet

men die miserably every

day for lack of what is

found there.

— WILLIAM CARLOS WILLIAMS

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HERPES FOR HARMONY

JOEL BETZ • MD STUDENT, CLASS OF 2006

JOSEPH PACK • MD STUDENT, CLASS OF 2006

Oh Herpesvirididae, how have I had thee,let me count the ways…

I contracted you first as a small child.All in all Varicella was quite mild.But Know that Zoster is latent in my ganglia,It makes me feel vulnerable, like my immunesystem’s a faila.

Then in high school there was a cute girl.She had long blond hair that had a slight curl.She had a small sore on her lip, that was just fine,But the next sore I saw on a lip, was on mine.I have to admit, about herpes I had not a clue.But at least I did not get from her Herpes type 2.

And that time in college I was too tired to live,I went to the doctor, took a monospot test, positive.I had a trip planned to see the Serengeti,I was so very tired I could hardly get ready.When I got there I began having facial elongation,So I had to cut short my African vacation.I was scared because it was the weirdest thing Iever had seen,But my doctor said it’s a translocation from 8 to 14.

When I stared medical school I didn’t know the slightest,About the nearly ubiquitous Cytomegalovirus.Who would have thought that retinitis you wouldnever see,Unless you were immunocompromised or had HIV.The professor said, “know the distinct owl eyeappearance”,Then I learned about Hodgkin’s and caused thattheory interference.So in order to know you I had to study and learnUntil my own retinas started to burn.

Then during residency I was the cutest child,First came the fever followed by a rash that looked mild.I said to myself this rash is no phantom,It is caused by HHV-6, its Roseola Infantum.The infection is self-limiting and so I thought best,To give the child fluids and plenty of rest.

I finally got a job, to get paid felt great.It was there I ran into HHV-8.I saw you in Africa causing a tumor,It was Kaposi Sarcoma if I believe the rumor.While in the U.S. your presence is rare.In Africa you cause 10% of cancer there.

Herpesvirididae, you will always be my friend,This ode to thee, however, must come to an end.How to end such a poem, I do not know,Oh wait, there goes my pager, gotta go.


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POMEGRANATE

ANONYMOUS

i am like a pomegranateborn of the harvest, rosy and full

not so sweet, as we are refreshingjuicy and playful, she and I

you’ll need your full attention to handle usnot soft and easy like a banana or cool and crisplike an apple that youcan enjoy whilewalking down the street

firm and gentle pressing will strip us barelayer folded in upon layeryou’ll want to uncover every jewel

and you’re left with a reminder of us upon yourfingertipswondering when you can get moreon the responsibility of a physician…

responsibilitya thick full heavinessof a fur coat.

worn not only inwinterbut as thesun beats down.

me? I wear alight woven silk throw.it can be lifted by a passing breezeorheld tight

or brushed back andforth over my left cheek.

I won’t let it be thickliquid to breathe through.or an excuseto growl, to roar.only

another chance to fly.(another chance to shift, to sift wind)

UNIVERSITY OF ARIZONA RESIDENTS SYNTHESIZE FICTION AND FACT:THEIR READINGS OF FAMOUS MEDICAL HUMANITIES STORIES

SREELEKHA SUSARLA, MD • MAY 2004

Dr. William Carlos Williams is one of the mostfamous physician-writers of the 20th century. Hecontinued to practice medicine while he wrote. Hepracticed pediatrics for the most part which isreflected in his writings.

The story “The Use of Force” was written in 1938and shows how medicine was practiced in the pre-antibiotic era. The story is about Dr. Williams’ orthe narrator’s encounter with a sick, young girlnamed Mathilda. He visits her in her house becauseher parents are concerned that she might havediphtheria. It depicts the emotions of all thecharacters very nicely. Mathilda’s parents are verygrateful to the doctor for coming to their house andtaking care of their daughter and at the same timeembarrassed by their daughter’s behavior. The

speaker begins to approach the child to examineher throat very gently which turns into a battlewhere he goes beyond reason to win. He does thiswith the good intention of saving the girl’s life.

This reminds me of one of my experiences with anelderly demented patient who came from a nursinghome very sick, dying. She had no family aroundand we decided to do everything possible at thattime. It was very difficult to get an IV line in withthe contractions of her legs and arms. Severaldoctors struggled and we all were lost in the ideaof getting an IV line so that no one realized andcared for her pain and how she felt about all this.Finally we got hold of her son who clearlyexpressed her wishes about no resuscitation andshe passed away in peace.


MY LOVE HATE RELATIONSHIP WITH HUMANITY

LISA GOLDMAN • MD STUDENT, CLASS OF 2007

DECEMBER 2003

I am having another one of those dreams whereI’m flying naked over housetops at night. Only thistime my white coat is reflecting moonlight. Nolonger nursing, my round-faced infant has nowlearned to read, and is losing baby teeth. Thesepearls are saved in a tiny glass jar. Their formerowner has become a careful steward, caring for herfallen out teeth like a serious millionaire watchesher stocks and bonds. Careful, like her mother,conscientious to a fault, this daughter has growninto a spiraling vortex of verbal competence andgood will for all humanity. A future brain surgeon orthe first female president of the United States? Shefills with energy and intelligence as mine aredepleted. Losing my mind, or just stuffed with facts?

My white coat does little to protect me from thetops of trees as I fly in a weaving pattern overmoonlit parks and cityscapes. I am searchingrestlessly for a landing place, and there is none. Icomb the western border of the United States inthe starlight, while cities twinkle beneath me.

My white coat has mutated into feathers and mydaughter and her father are flapping birds flyingbeside me in formation in the cold night air as wesearch for a place to land. Seattle, Portland, SanDiego? Which city offers a landing place for anexhausted white bird and her two pigeons? Can Ifind somewhere, anywhere that won’t suck me dryand spit me out?

Is there a little corner of humanity that doesn’tmistreat its residents, doesn’t drain them of theirlife essence, doesn’t flog them with merciless pettydetails? Details that stand between me and sleep,

coming between me and my goofy pigeons? I lovehumanity, its just people I can’t stand.

The raving bitch insomniac will kick and scream itsway to a resting-place, taking on the fool whocomes between me and a good night’s sleep.

“Where did you put my socks I can’t find anysocks... but I don’t like chicken when it’s spicy...DoI have to eat all these peas I already ate five ofthem? ... Will I get dessert?” Even my pigeons canmake me crazy with their endless petty demands.No, this dream is pigeon free.

I’m sailing through the night, my white coat tornoff by a tree a few miles back, and I’m naked inthe moonlight, way up high over the city wherenudity is no issue, and the night air is warm, itmakes me relaxed, and finding a spot to land isirrelevant because the clouds are soft andsupportive like a couch. The pager has droppedinto the sea. The patients have either gone homeor have died and been picked up by the morgue.

The charts have written and signed themselves. Noone tries to humiliate me. Everyone loves andrespects me, and I’m lost in a good dream aboutmilk and peas and clean laundry and children whobrush their own teeth, and husbands who find theirown socks.

The child has grown, the need for mother’s milkhas dissipated and gone, but the memory lives onof milk flowing like a river, a mother and childcurled up together in a warm nest that is eternaland etched into the subconscious, a refuge fromcold night winds.

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LIVING FOR FAILURE

DAVID ANDRESKI • MD STUDENT, CLASS OF 2004

Hours turn to days, weeks, months, and years.Now that I am on the verge of completing medicalschool, I have been forced to decide if everythingthat I have done is truly my “success” story. It istrue that I am graduating from medical school andam preparing to enter into a fairly competitiveresidency position, but I have a few doubts in mymind as to whether or not I am ready for thischange.

The more that I have reflected, it seems morelikely that my education is nothing more than afacade for failure. Is it knowledge that I lack? Myscores all indicate that I am competent and readyto pass into the next phase of my career. I havemanaged to pass through all of the academic hoopsthat were laid before me and have proved, even tomyself, that I can actually perform as a physician.Knowledge, it seems, is not the missing link.

This failure that I speak of is more of a life inbalance issue. Throughout my training I have notbeen allowed to lead by example, for instance,following the accepted diet and exerciserecommendation each and every day. The cultureof the profession seems to remain that only theweak stop to take care of themselves. Thisparticular institution proclaims that they arecommitted to humanistic medicine and thedevelopment of a balanced lifestyle. On anyparticular day, the advice given to preclinicalstudents, who are very far removed from criticaldecisions, is to spend more time studying. I waseven advised to plan sleep time and an hour a dayfor “wasting” time. I did not take this disastrousadvice. Micromanagement of my life would beparallel to a malignancy slowly eating at a life untilit finally causes death. I had to remind myself thatI am not in control, and may become ill at times.Other times I may have to take time to help afriend get through an unplanned event, which isnot allowed in the planned 1 hour of time “wasted”that I was to be allotted. Living a life planned tothe extreme is in effect living for failure. In thisscenario, there will be a time that everyone will failon many levels while trying to maintainappearances.

Instead, the advice I would give from myperspective, is to embrace failure. I do notadvocate using this as an excuse to not perform

and learn information critical to your future. Thefailure I speak of is more of a recognition that youwill never be an expert at everything, and you mayneed to reevaluate the priorities in your life. I ask,how terrible would it be if you discovered on yourdeathbed, that your life was not the facade thatyou display each day. Ivan Ilyich, one of Tolstoy’scharacters, did just that. In the famous story Ivanwas a very “successful” person, until he was dyingand reflected on his life and reevaluated whathappiness really is. It is true that medicine is afield in which many decisions do in fact alter thelives of your patients. It is critical that everyphysician has the knowledge to act in thesesituations, but this does not mean that you mustkill yourself in the process. Once you recognize thatyou will fail from time to time, you can then learnfrom the mistakes that you have made. This isoften thought of as one of the more importantaspects of effective learning. I also firmly believethat each failure I have had has been an excellentopportunity to learn more about my perspective onlife as I know it.

I cannot tell every person what it means for themto be happy. Even if I could, I would not. What Ican tell you, is that you might want to start lookingfor happiness by taking care of yourself physically,mentally, and spiritually. And remember, theimportant things in life do not have to be scored!People with much more wisdom that I have writtenon the importance of using history to shape thefuture. Maybe they have found their personal keyto success.


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ON DEMAND AND WITHOUT APOLOGY

GABRIEL SARAH • MD STUDENT, CLASS OF 2008

Many opponents of abortion argue that, from themoment of conception, an embryo or fetus is aliving being who should be treated separately fromthe woman carrying it. While one can argue aboutwhen “life begins” until blue in the face, the basicfacts surrounding choice, privacy, and access tocare are undeniable. A woman, for whateverreason, should be allowed access to an abortion inour country, on demand, and without apology aslong as the fetus is not yet to the point of viability.

Choice. One word has caused such extensiveamounts of debate in this country. What does thismean? It’s a simple answer: a woman has the rightto choose what she is going to do with her body.Each person has their own morality, and it is bythose beliefs that they will lead their lives.Proselytizing or evangelizing is not the place ofthose surrounding this woman. It is only our jobs,as practitioners, to share our concern and offerguidance. We can not force someone to believe inwhat we believe, nor can we deny care for thosewhose lifestyles we do not like.

A woman has the opportunity to privacy in allmatters of her medical care. After she has decidedupon a treatment plan, with the guidance from herphysician, she must be able to make decisions thatshe deems to be in her best interest. Many abortion

opponents argue about patient irresponsibilityleading to an abortion. As we all know, many birthcontrol methods do fail often or have differenteffects on each patient. Also, we do not know thepersonal circumstances surrounding a woman’s life,such as domestic violence or abuse. Her husbandor partner may not allow her to take birth controlpills, or may be abusing her and raping her. Thiswoman may only feel in control of her life at themoment she is speaking privately with herpractitioner and will at this point be able to make adecision about whether or not to end herpregnancy.

While we may each have our own personal or moralbeliefs regarding surgical or medical abortion, weas medical practitioners are in no way living up toour professional responsibilities by parlaying ourmorals on to our patients. It is our job to work withour patients to help them solve their medicalproblems. If you are not willing to perform anabortion, you should refer your patient to someonewho is willing after discussing with her all heroptions. If after this, your patient is still seeking anabortion, keeping referral information from her willonly lead to an increase in injury and death fromabortions performed by practitioners not licensedor knowledgeable about the procedure.


MEDICAL HUMANITIES:CAN LITERATURE OFFER POSITIVE ROLE MODELS FOR PHYSICIANS?

HELLE MATHIASEN, CAND. MAG., PHD • DIRECTOR OF MEDICAL HUMANITIES, CLINICAL PROFESSOR OF MEDICAL HUMANITIES, COLLEGE OF MEDICINE

With this essay, I would like to open a discussionabout whether good literature, meaning fiction of acertain quality, can help the medical student ordoctor choose the kind of professional ethic she/hewill aspire to embody during the day in, day out lifeof doctoring. The answer, for now, is that fictionoffers both negative and positive doctor models.The final answer is that no matter how intriguing orwell written, a literary text offers just limitedunderstanding; a fuller understanding of what weaspire to be must be reached through experience.Ethical choice is existential. But to begin with:There are plenty of negative literary role models forthe scientist/physician.

Victor Frankenstein and Dr. Henry Jekyll arecharacters in two great nineteenth-century Britishworks of fiction. However, they are evil, and notworthy of imitation by today’s physicians. In bothcases, their ambition to play god by attempting tocreate human life leads to assault, murder, andsuicide. Victor Frankenstein, created by MaryShelley, dies a miserable death while his evilmonster, the serial killer he has made, survives. Dr.Jekyll, created by Robert Louis Stevenson,becomes addicted to the potion he has invented toallow him to roam the London streets at night asMr. Hyde. He finally commits suicide. Frankensteinhas become the prototype for the mad scientist. Dr.Jekyll’s story illustrates the evil effects of unethicalmedical research. Yet, through their remarkableartistry, specifically in their use of point of view,Shelley and Stevenson manage to humanize thesemen to the point where we can almost pity them.Both authors know that there is a monster insideeach of us, and that we will recognize this monsterif we are honest with ourselves. However, they warnus not to let the monster out. Clearly, both stories carrya moral lesson.

The most admirable, positive literary doctor that Iknow of is of French origin: He is Dr. Bernard Rieuxin Albert Camus’s Nobel Prize winning novel, ThePlague (La Peste). The plot concerns a bubonicplague outbreak in the North-African city of Oran inthe nineteen-forties, Camus’s own time. The townofficials first deny that the dead rats in the streetindicate plague, but, prompted by Dr. Rieux, aclinical physician, statistician and chronicler of theplague, they concede that the situation warrants

quarantining the town. Dr. Rieux and his friendsnow face an ethical choice: should they stay andfight the epidemic or try to leave? Dr. Rieuxremains with his patients as he revolts against thisabsurd, unpredictable, and evil plague. Hecontinues to lance buboes, inject serum, and keepstatistics of the increasing number of cases, as heworks night and day. Ironically, the plague finallyceases by itself. Dr. Rieux’s doctoring has alleviatedbut not eradicated the disease. However, he haslearnt an important lesson through this experienceof crisis: “…that there are more things to admire inmen than to despise” (287). Despite hisfrustrations, Dr. Rieux chooses to retain hope aboutthe goodness of human nature.

What are the instructive details embodied inCamus’s creation, and why is the author’s morallesson of limited use?

Clearly, Dr. Rieux stands out as an example ofmedical professionalism. He puts his patients first,altruistically sacrificing his private life, his sleep,and risking infection, in order to alleviate hispatients’ suffering. He treats indigent patientsgratis. He accounts to the public health officers ofOran for the dead rats, forcing them to admit thatthe plague exists. He works under physically tryingconditions: “Some minutes later, as he was drivingdown a back street redolent of fried fish and urine,a woman screaming in agony, her groin drippingblood, stretched out her arms toward him” (49).The doctor assumes leadership and solidarity withthe sick, saying, “Oh, I know it’s an absurdsituation, but we’re all involved in it, and we’ve gotto accept it as it is” (80). He feels empathy with hispatients, but eventually, to save his waningenergies, he concludes: ”One grows out of pitywhen it’s useless. And in this feeling that his hearthad slowly closed in on itself, the doctor found asolace, his only solace, for the almost unendurableburden of his days. This, he knew, would make histask easier, and therefore he was glad of it” (86).Dr. Rieux faces a medical catastrophe, thereforehe must ration his emotional energy. We cancompare the plague conditions described byCamus to the horrendous effects of an outbreak inthe United States of SARS, smallpox, or an attackof bioterrorism.


Interestingly, though he isclearly a hero, Dr. Rieux’s moralintegrity leads him to identifyhimself simply as a human, ashe tells his friend Rambert: “However, there is something Imust tell you: there is noquestion of heroism in all this.It’s a matter of commondecency” (154). By commondecency, Dr. Rieux means doinghis job. This is perhaps thesingle most important lesson ofCamus’s fictional physician:“The thing was to do your jobas it should be done” (39). Thisstatement is true, but sogenerally stated that it canapply to anyone in any job. Justdo a good job.

Even the most ethical and self-sacrificing fictional doctorremains a fiction to us. Onlyexperience can really teach thedetails of skill, knowledge, andbehavior and the nuances oflanguage that will make for agood physician. Observingpositive, living role models isprobably the most effective wayto learn medicalprofessionalism. Reflection andself-analysis can also be usefultools for improving medicalskills. Literature is helpful;however, life provides the mostenduring lessons.

The quotations from Camuscome from: Albert Camus, ThePlague (trans. Stuart Gilbert.Random House, 1972).

I’d like to recommend threerelatively recent texts aboutdoctors: Abraham Verghese, My Own Country(Vintage, 1994). Richard Reynolds and John Stone,eds., On Doctoring. Stories, Poems, Essays (Simonand Schuster, 2001). And Tracy Kidder, Mountainsbeyond Mountains. The Quest of Dr. Paul Farmer, AMan Who Would Cure the World (Random, 2003).

Winter Sotol Sonoita, Arizona

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BAD NEWS

SHARON LYNN SANBORN, MD • RESIDENT, GERIATRICS, VA HOSPITAL • MAY 2004

It was one of those highs that leave a huge smileon your face. I had just signed the lease to mynew, beautiful apartment with my new roommate. Iwas so excited to leave my old apartment with itsmoldy ceiling, crappy windows, rude landlord, andsloppy roommates. My first year of medical schoolwas almost over, summer was coming, andfreedom was on the horizon. The only thing on myshoulders was the final interim exam in three daysand the comprehensive exam in two weeks. I ranupstairs to my room in my old apartment to call myparents to tell them the good news. My dad pickedup the phone. I think I was expecting to get theanswering machine. I told him of the grand signingof the lease. He seemed pleased at my happinessbut distracted at the same time. How are youdoing, Dad? Why are you home so early? Well, Ihave some kind of bad news. I paused as a millionthings ran through my head. I think I should waitfor Mom to get home to tell you. No, you can’t dothat. Please tell me. My heart and head wouldburst if he left me hanging until my Mom camehome. Is someone there with you? Oh God, Ithought, someone died. My friend Ken is right nextdoor. I had that doctor’s appointment (he wasreferring to a second neurologist that he had beenreferred to after having some weakness andtwitching for a few months). What did he say?Honey, they are not absolutely sure, but they areabout 98% certain that I have Lou Gehrig’sdisease. You probably thought that already. No, Ididn’t already think that. My mind was racing backto the neuromuscular committee. I felt I shouldknow more about this than my dad, but I didn’t.What does that mean? It is a degenerativedisorder. I’ll lose my muscles. Eventually you can’tswallow, and you die because your breathingmuscles don’t work. But my brain will be ok whichmight not be such a good thing. And I won’t loseany of my bathroom functions. My eyes swelled atall of this but I had to stay calm. The last thing mydad would ever want to do would be to cause mepain. My dad was so athletic when he was younger.He used to go hiking, backpacking, running up amile high mountain after work a few times a week.The thought of my dad lying in bed, immobile,

seemed totally unreal and nauseating. How fastdoes this happen? My voice cracked, and he couldtell that I was crying. The average is about 1-3years. My heart sank and I wanted to puke.

At that moment, I didn’t want to be a medicalstudent. I just wanted to be a daughter, a sister, afriend. I stopped going to class. We only had a fewmore days anyway, then our last exam and thecomprehensive exam. After talking many moretimes with my family, it was made very clear to methat the last thing my dad wanted was for me toleave school even though that was the first thing Iwanted to do. But my mom kept telling me thatone of my dad’s wishes, one of his goals, was tomake it to see me graduate from medical school.Even though it killed me to stay in Cleveland,trying to study for the biggest test of my life so far,while my parents were all the way in Arizona, I hadto obey my dad’s wishes. But in a way havingsomething to focus on helped me through theinitial shock. I would force myself to concentrate onmy work.

People often tell me that they don’t know what tosay after I tell them about my dad. There is nomagical statement or action that can take all thepain away. But people can offer their support to theperson being affected and their family. It means somuch to me when people ask me about my momand my brother. My mom gets control by findingout all she can about ALS. She even asks me tolook up articles at the medical library and to callexperts in Cleveland for her. I gain power bytalking about the situation with my friends andclassmates to get them to realize how this canimpact a family. I have learned how important thewill to live is and how impending death can openeyes. My parents have not always gotten alongextremely well. Now my dad expresses his love formy mom, compliments her cute little figure,appreciates her kindness as a wife and mother, andshuts off the TV when they have dinner. I think mymom realizes what she wants in life. She loves mydad very much and realizes what it might be like tobe alone.


My eyes have once again been opened to thebeauty of life. Stop and look sometimes, smell theroses if you will. Take notice of the changingseasons, of the feel of water washing over yourbody, of the smell of a chimney, of a peacefulsilence, of a relaxing walk, of a stranger’s smile, ofa friend’s hug. Our world goes so fast and we getso bogged down in memorization that wesometimes forget to appreciate our lives. Slowdown time. My advice is to learn all you can aboutthe people around you because they will not alwaysbe there. Listen to your patients and think of themas one piece of a larger family, group of friends,and part of society. Take the time to explain thingsto patients and realize that they will not always do

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everything you want them to. Tell people howmuch they mean to you. Find something good inevery bad. Learn how to say, I’m sorry.

I wrote this after my first year in medical school atCase Western Reserve in 1999. I am now aresident. My dad died December 19, 2002, duringmy third year clerkship. My flight did not make it intime to see him alive one last time, but I spokewith him on the phone before my plane took off. Hewas clear in his speech even though his speech haddeteriorated greatly. He told me how much heloved me. He told me how proud he was. I willcarry him in my heart and mind for the rest of mylife. He will always be with me in spirit.


Reclining Buddha

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A RESIDENT REACTS TO “TELL ME A RIDDLE”, A STORY BY TILLIE OLSEN

WILDER DIAZ-CALDERON, MD • RESIDENT, GERIATRICS, VA HOSPITAL • MAY 2004

Painful fragment displaying two interestingconcepts. What I call the wear of a relationship bydifficult times (economic, social, etc.) and thepainful process of a prolonged death.

Regarding the first concept I will only say twothings. First, as cold and rotten as it sounds, thelack of all those things we tend to classify as notessential (money and pleasure in all differentmanifestations), does have a permanent negativeimpact on life and how we perceive it. It candestroy a beautiful relationship by all the wear andtear it exposes the relationship to. Second, nobodywins alone in a couple… nobody can win forever.Sooner or later the mounting years of “ losing”explode and terminate what is good in arelationship … better sooner than later. At home,either we both win by sharing or we both lose.

Not particularly my first choice as far as readingafter the hospital and the dealing with life anddeath issues relatively frequently. It didnevertheless provide me with a vivid story thatputs in words what I can only imagine, with imagesthat can not get me even close to what happenswhen I send a patient home to continue to dealwith this daily slow process of dying. It is alwaysencouraging the idea of there being a strong formof love supporting a couple that has been togetherfor a lifetime. As grouchy as they become,regardless of how much hatred and frustrationthere is, Eva has been a virtuous woman. She haspushed this family with courage, and they all knowit. He, after all the fight and the names filled withrage that he used to call her, falls asleep sufferingfor her … loving her, for she has been the womanof his life.


BLACK AND WHITE

JENNIFER SLACK • MD STUDENT, CLASS OF 2004

The first thing I notice is her smile, its glowradiating out from under her soft, velvety, blackhat across her face, subtly hiding her swollencheeks. I smile too, trying to take some of herwarmth, her happiness, for myself. She is the lastpatient in clinic today and I’m tired of following thewhite coat into stuffy shoebox exam rooms,listening to cookie cutter interviews.

He turns away from her and points out the tumor’sdimensions and location on her scans, noting thatit is back and has now migrated. He misses themoment. Her sudden realization, the cancer isworse instead of better? I catch it, the instantwhen her radiance freezes in place, reflected onthe radiology films next to her growing tumor. Thesoft, velvety, black hat is still atop her head andher hands are folded neatly in her lap. But herbeautiful lopsided smile is disintegrating. As shecrumbles to pieces in front of me, I’m acutelyaware of the smile still frozen on my face. I’mafraid to let it go, because then I too may crumble,overpowered by her intense sadness.

He sees, now, the problem. She expectedeverything to be better. The message she receivedbefore this appointment was that her tumor hadnot changed. Now, to find instead that everythingis worse? It’s asking too much of anyone. So sheasks him for answers. She asks what happened,how a mistake of this magnitude could be made.She asks him a question for which he has norespectable answer and heknows it. He can’t tell herwhy the other doctor saidthere had been no changesince her surgery. Heinstinctively crosses hisarms to defend himselfagainst her anguish,letting her words slide offthe sleeves of his whitecoat and onto the floor,where he can push themunder the examinationtable with the toe of hispolished boot.

On cue, she leans back,away from his crossedarms. Her body begins to

collapse and her head drops into her hands. Hersoft, velvety, black hat falls to the floor revealingher naked scalp. And she sobs. Deep, soulful sobs.Her back rises with each breath in and hershoulders rock with each painful release.

He’s hurt, too. Hurt by the doctor who read only thelast line of the radiology report to his patient. Hurt byher pain. Hurt by his inability to help her. He uncrosseshis arms and extends his hands across their mutualemotion, leaning towards her as he places them onher knees. They sit this way for minutes, she sobbing,he watching her intently, absorbing her pain andreleasing his own. Then she looks up, and withoutwords their moment is shared, an understanding isreached. The tumor is hers alone, but the battleagainst it will be fought together.

As the expression of her intense sadnessdiminishes, an appointment is made with theoncologist. There is no more surgery he canperform, but he schedules a follow-up with heranyway. Once more he looks at her intently andwhen she meets his eyes, their partnership isforged. She begins to gather her thoughts as sherescues her soft, velvety, black hat from the floor,and I follow the white coat out of the shoebox witha new smile on my face. Smiling for the subtleshades of compassion and comfort which liesomewhere between the ability to do nothing andthe ability to cure.

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THE RONALD MCDONALD HOUSE & THE RIVADAVIA

RONALD P. SPARK, MD • ASSOCIATE PROFESSOR OF CLINICAL PATHOLOGY, DEPARTMENT OF PATHOLOGY

She was crashing thorugh the high sea, darksmoke billowing out her two funnels, her nose andforecastle pointed into the wind: The Rivadavia.What a glorious sepia-toned photo, grand at 4 ½ ft.by 2 ft., smartly matted and oak framed behindage tinted glass. I wasn’t hesitant. The picture ofthe 1911 Argentine dreadnought was mine for $5,a real Tanque Verde swap meet bargain. I wasflushed with awe and inspiration as I mused overher beautiful design, her six 12 inch guns, herlength at 595 feet and sheer mass at 27, 840 tons.

“Who did you buy that ugly dust collector for?”carped my loving wife. “You’re not bring that oldbattleship picture into my housel. Better dry-dockit at your office!”

Thus, The Rivadavia found a safe harbor on thewall across from my office desk. I would catchmyself gazing upon the large photo several times aday and think of the ocean and not being desertland locked hundreds of miles away. The Rivadaviagave me both dreams and solace.

But then I got orders from the “Admiral” to move toa smaller office that had no room for a photo of the27,840 ton dreadnought. I couldn’t bear the thoughtof having to scuttle her in the middle of the SonoranDesert. Then a breeze blew in from the Sea ofCortez. Tucson’s Ronald McDonald House justopened. I could permanently loan the photo of theQueen of the WWI Argentine Navy. There she couldbuoy the spirits of the kids and their families, givingsome relief from their distressful situations. Yes,they too would savor the photo, as I had done, witha sense of wonder, romance and thoughts of amagical time far removed from their pressing cares.The Director was delighted to have the foreigneremigrate to the walls of the McDonald House.

I was so mixed about giving up my gift that I putoff visiting her for some time. But one day, goingdown Speedway, I couldn’t resist and swung intoMcDonald’s driveway. I bolted up the steps,through the door to the hallway. No Rivadavia! Iturned tight rudder and bore down into theDirector’s office. I was breathless. The Directorlooked up to greet me. Then I saw her, hangingwith great glory, on the wall just above theDirector’s desk.

“Yes?” the Director asked. But I knew the episodewas a portent of the future.

Several years past and it happened. I saw signs ofthe inevitable. There were trucks and workmenoutside of the now remodeling Ronald McdonaldHouse. I didn’t even bother to inquire. I knew theRivadavia had hoisted anchor and steamed off to abetter port.

That’s not the end of the story. Back at the swapmeet last year I rounded a row of vendors and sawa part of an enormous oak wooden frame. It wasthe Rivadavia! She was still crashing through therough sea billowing dark smoke from her twinfunnels. She again had me in her power. I drank inher graceful lines, her six 12” guns, and hermajestic forecastle. My wife saw it, too, just as Isaid the inevitable, “How much?” My friend wants $35 and that’s firm,” the woman said dispassionately.”It’s just an old boat but the frame is usable.” Thatwas the extent of the sales pitch. “You’re not going tobuy that…” my wife started. But I cut her off. “No,now she deserves another Captain and more ports ofcall. One can never really own a spirit with such arestless soul.” I felt a sense of resolution andpassage as I walked away, never looking back to seeher one more time.

Some beautiful things sail into and then out of yourlife. The Rivadavia was just such a gift to me. Shemade me swoon. But now she needed to sail on toinspire someone else. And I have to resign myselfto living land locked in the desert, so far from theocean and the likes of the Rivadavia.

Coatimundi, Portal, Arizona

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ONE PREMISE AND ABORTION

PETER STOCKTON • MD STUDENT, CLASS OF 2007

Abortion is a divisive issue with a sharp linesegregating the two views. The arguments used byeither side are hard to compare because they startfrom two different premises. In most of thediscussions on this subject, I have found that noargument is breached that the developing fetus isliving; instead the center of contention is whenpersonhood is conferred. With personhood comesrights. If you are not a person then you are notprotected under the Constitution. Because theopinion of when a conceptus becomes a personvaries, controversy arises as to when it should belegal to end a pregnancy. Either you believe thatwhen the sperm fertilizes the egg a person is madeor you believe that somewhere on the continuum oflife, the fetus becomes a person.

I have reached some interestingconclusions in my own life that I am surewill impact my future practice of medicine.I start with the premise that the embryois alive and is a person because it hasdifferent genetics than the mother orfather. Since the baby is a person, she/hehas all the rights of any other patientunder my care. Thus a pregnant woman istwo patients, the mother and child. If Ioffered abortion as an option to thewoman under my care then I would beessentially ending the life of the patientinside the mother. I would not recommendcessation of life to any one as atreatment, because a physician’s role is toheal not to harm. Since I start with thefact that the child is a patient I cannot, ingood conscience, offer abortion as anoption to any of my pregnant patients,and cannot refer them to a physician thatwould perform an abortion. Doing sowould negatively impact the health of thechild under my care.

I believe that life is a continually unfoldingprocess and that from the moment yourgenes are turned on, you are a physicallydistinct life and human being. In line withthat, I could not suggest an abortion to arape or incest victim because that would berecommending that one of my patients die.

The preponderance of abortions in America isperformed not because of the mother being in direstraits or a serious birth defect but due to anunwanted pregnancy. We have tried to divorce sexand procreation in our society and the two areindivisible. Every time sex happens there is achance, however remote, that a pregnancy willoccur. As a physician I will not suggest abortion asa treatment option nor will I refer to a physicianwho would. Instead I will work to build arelationship with my patients that will includeinformation on the responsibilities inherent in sex.

Statues destroyed by The Taliban, Spring 2001, Bamian, Afghanastan

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GRADUATION SPEECH, CLASS OF 2004

JOSEPH S. ALPERT, MD

ROBERT S. AND IRENE P. FLINN, PROFESSOR OF MEDICINE

HEAD, DEPARTMENT OF MEDICINE

Deans Joiner and Ryan, Faculty of the COM,graduates of the class of 2004, honored guests,family and friends of the graduates:

I am most grateful and honored to have beenasked by the class of 2004 to deliver a few remarkson the day that they receive their MD degrees.When first asked to deliver this address, I did whatmost individuals in my position do, I consulted myheart. Thereafter, I consulted my spouse, mytrusted friends on the faculty, and myadministrative team. Finally, I did something that Ihave learned from my interactions with medicalstudents and undergraduates:

I consulted the web!!

It turns out that many graduation speeches arerecorded on the web—just ask Google for“graduation speeches” in order to read some of thebest of these remarks given over the last 50 years.There was JFK’s commencement address to theYale Class of 1962; Kurt Vonnegut’s remarks to thegraduation class of Rice University, Hillary Clinton’sspeech at the Harvard Medical School graduation of1998, as well as wonderfully humorous addressesby Oprah Winfrey, Bill Cosby and columnist RussellBaker. Cosby told the graduates to stop askingtheir parents for money!! Baker advised thegraduating class of Connecticut College in 1995NOT to graduate. He told them that the worldoutside of Connecticut College was a mess, andthat his generation had created it. Baker suggestedthat the potential graduates shouldn’t graduate—rather, they should stay in college!!

I am not going to give you this advice, since, afterall, we need you desperately in the healthcarelabor force. Indeed, you are about to become thebest cheap labor that we can manage to find. Thesystem can’t make it without you!!

I would like to say a few words to the people whohelped to get you here today: your parents,spouses, partners, significant others, children, andfriends. After the ceremony is over, graduates ofthe class of 2004, remember to say thank you. Sayit many, many times. One time for each dinnermissed, each appointment not kept, each eventmissed, each remark not heard because of fatigueor preoccupation with this or that sick patient, andso on, and so on, and so on. You can never sayenough thank yous. And guess what—it is about toget a lot worse. For example, given the fact that I

have been at this business a lot longer than youhave, I now owe 43,289 thank yous to my spousewho is sitting here tonight among you. Perhaps,she will forgive me some of them, and perhapsyour family and friends will too. Maybe we shouldhave a big thank you debt forgiveness sessiontonight after we all march out. One thing is certain.All of us: you, me, the deans up here beside me,the faculty sitting behind you, every last one of us,owes a huge number of thank yous to our lovedones who have lived the “blood, sweat, and tears”alongside of us. So remember tonight to say thankyou to them. They deserve it more than you know.

And finally we arrive at that part of the addresswhere the speaker intones some easily forgottenadvice for the graduates themselves—somethingalong the lines of “Remember to listen to yourpatients”. Or, “Medicine is a sacred profession—keep it going”. Or, how about “The healthcaresystem of the 21st century belongs to you—takegood care of it!!” Of course, all of these statementsare true, but they are also somehow easilyforgotten in the excitement of the moment. So Iam not going to say any of them, even though Ijust did!!

What I do want to say—and I hope that you willremember this alongside of saying thank you toyour family and friends—what I do want to say hasgrown out of more than 25 years of teaching acourse with my wife, Helle Mathiasen. Let me giveyou a little background information about thiscourse which, by the way, Helle calls literature andmedicine and I call medicine and literature. Morethan 30 years ago, when most of you weren’t yetborn, my wife and I were in graduate school andmedical school respectively. She was earning a PhDin English and American literature, and I, of course,was in medical school.

On a number of evenings, we would havewonderful discussions, as well as somedisagreements, about “the nature of truth (with acapital T)”. I argued that Truth could only be foundthrough appropriately controlled scientificobservations, and she countered with arguments infavor of the many truths revealed in great works ofliterature, art, and music. Eventually thesediscussions became a course, first forundergraduates and later for medical students.Last month, we finished teaching this course forthe 27th year to 14 senior medical students here atthe COM. The literature and medicine course


focuses on the large body of literature—poetry,novels, plays, short stories, etc. that have amedical theme or have been written by doctor/writers. You might be surprised to learn how manyphysician/authors there have been. For example,there was Sir Arthur Conan Doyle, the creator ofSherlock Holmes and his physician side-kick, Dr.Watson. There was Somerset Maugham who wroteOf Human Bondage, there was the American poet,novelist, and short story writer William CarlosWilliams who won a Pulitzer Prize. Others includeLori Alviso Alvord, the first Navajo woman surgeon,who wrote The Scalpel and the Silver Bear;Abraham Verghese (who was a visiting professorhere at the U of A last fall). He wrote, among otherworks, My Own Country and The Tennis Partner;and there is my medical school classmate, MichaelCrichton, as well as many, many others.

Our literature and medicine course seeks to givemedical students a sense of the effect of illness onthe patient, the family, and society. It alsoattempts to place medical ethics and medicalprofessionalism in a context where they are easilyunderstood.

A frequently read book in our course (and my ownpersonal favorite) is the Nobel prize winning novel,The Plague, (1947) by the French novelist AlbertCamus. In this work, a primary care doctor, Dr.Bernard Rieux, finds himself treating thousands ofpatients struck down by deadly bubonic plague inthe northern Algerian city of Oran sometime in thenineteen forties. Dr. Rieux is a modern physician:he understands what causes the plague and how itspreads. But this plague epidemic rages at a timewhen antibiotics effective against Yersinia pestiswere not yet available. Well, you can imagine whathappens: people die by the hundreds, and by thethousands. Dr. Rieux and a small band of faithfulhealth workers and friends battle the plague bylancing buboes, injecting immune serum, placingpatients and family in quarantine, and utilizing avariety of sanitation measures but with littlesuccess. Finally, at the end of the novel, theepidemic recedes. During the worst phase of theplague epidemic, Dr. Rieux discusses with hisfriends the fatigue and frustration that he facesdaily because there is no effective treatment forthis highly contagious and lethal disease. Dr. Rieuxadmits that resisting the plague is a never endingdefeat, but that it is nevertheless important tocontinue to do his job. In fact, Dr. Rieux equatesdoing his job with being a decent human being.

This idea has come to be the touchstone of my ownlife, and I hope it will become a central theme inyours. No matter how difficult the situation, justkeep doing your job! Eventually, you will prevaildespite many losses and discomforts suffered alongthe way. Just do your job the way it should bedone—that is my main message for you tonight.

During the preparation of these remarks severalweeks ago, I was inspired to summarize them in ashort poem dedicated to you, the graduating classof 2004. This poem reiterates some of the thingsthat I have been saying for the last ten minutes. Itis definitely not great literature, but it does expressmy feelings and my message for you tonight. Inthe interest of “full disclosure”, I admit that Iborrowed a line from Dr. William Carlos Williams’svery short poem, “The Red Wheelbarrow” that goeslike this: “So much depends on a red wheelbarrow,glazed with rainwater, besides the white chickens”.I also borrowed a line from Abraham Lincoln’sGettysburg address. The poem is titled “Go Forth”.

So much depends on your family and friends,And on doing your job until it ends;The world will little note nor long remember what Isay tonight,But please do your job until it’s done rightAs you walk down the aislein single file, and with style,forget for awhilethe blood, sweat and tears trialsthat are coming your way.

O, they’re coming all right—as sure as dawnas sure as deathas sure as birthas sure as love,and friendship,and pain.

As the spiritual says—“Go forth”—go forth and do your jobas it should be done.

You won’t regret it,ever.

Thank you, Doctores Medicinae Novi, thegraduating class of 2004, for allowing me to takesome time to speak to you on this your very specialnight. Congratulations on doing your job, and doingit well.


TRANSITIONS; FROM STUDENT TO CLERK TO PHYSICIAN: ADVICE FOR THIRD YEAR STUDENTS

JAMES E. DALEN, MD, MPH • DEAN AND PROFESSOR EMERITUS, RETIRED, COLLEGE OF MEDICINE

There are many transitions in the educational paththat leads to becoming a physician; from gradeschool to middle school to high school to college tomedical school to residency. However, I believe thatthe most profound transition is from the secondyear to the third year of medical school.

The first day of the third year of medical school is inmany ways the first day of the rest of one’s life as aphysician. After having gone to school for at least18 years, everything changes. The rules change. Itis no longer: listen to the lecture, read the book andthen repeat what you heard or read in order to passthe test. Now the rule is: do it! Take the history, dothe physical examination, interpret the laboratorytests and then put it all together with yourknowledge of the basic sciences to determine whatis wrong with this patient and what you can do tohelp him or her. In fact, this is what you will bedoing for the rest of your life as a physician!

You will learn how modern hospitals and clinicsoperate. A wise mentor once told me when I was athird year clerk that everyone who works in thishospital or clinic knows things that you don’t know.If you are smart you will learn from all of them;the nurses, technicians, social workers as well asthe physicians and other students.

Most of all, you will learn by listening to yourpatients. If you listen carefully you will learn whatthey really feel, what they really fear, and, if youlisten very carefully, you may learn what it is thatis wrong with them. We are fortunate that patientsallow third year students to examine them andassist in their care. It is a privilege that we musthonor by treating every patient with the respectthat we would give our parents. Most patientsbecome quite attached to their medical students.In most cases the third year clerk is the one personwho has listened to everything that the patientwants to say. There is an old story of a worldfamous Professor of Surgery who told a patientthat she needed urgent surgery. The patient said:“I will have to talk that over with my doctor tomake sure that she agrees.” Who was her doctor?A third year clerk- who fortunately did agree withthe need for surgery.

For the first time in your educational career, youand your classmates will not be exposed to thesame data base. You may see patients with

problems different from those of your classmatesand you will be exposed to different mentors. It isn’timportant that you see every possible disease. Themain thing that you will learn is how to approach,and how to try to solve your patients’ problems.

The learning curve in the third year of medicalschool is very steep; it is equalled only by the firstyear of residency. Unlike the prior 18 years,virtually everything that you learn in the third yearof medical school needs to be remembered. It’sprobably ok to forget some of what you learned incalculus (or even organic chemistry!) after youhave passed the course, but what you learn in thethird year needs to be kept, and expandedthroughout a life time of learning as a physician.

The main reason that most medical students haveexcelled in their first 18 years of school is becausethey are bright (thanks to a wise choice ofparents!) Things are different when you practicemedicine. Being bright is not enough. The world isfull of bright people. In basketball being tall helps,but does not ensure success. The best basketballplayers are the tall players who work the hardest atit. The best physicians are the bright ones whowork the hardest at it. A good example is theability to take an accurate history and perform anaccurate physical examination; the sine qua non ofmaking an accurate diagnosis. The best physicianimproves his/her history taking and physicalexamination by working at it! As a clerk, youshould check your history and physical findingswith that of more experienced physicians. Whenyou miss something on history or physicalexamination—recognize it, don’t make excuses—goback and repeat parts of the history and physicalexamination. When one of your patients has anabnormal physical finding repeat that part of theexamination every day that you see the patient,after asking the patient’s permission. You can readabout diastolic heart murmurs and answer testquestions about them, but you need to listen to asmany diastolic murmurs as you can in order to beable to accurately recognize one in a patient.

You need to read during your clerkship—but it is adifferent kind of reading than you have done in thepast. The purpose of your reading is not just topass a test. Your reading should be selective; youneed to read about the problems that your patientshave. It is a very special experience to read about


a disease that one of your patients has and tocompare what the textbook says with what youfound by history and physical examination. Oftenyou will go back to ask the patient furtherquestions or repeat parts of the physicalexamination based upon what you read in thetextbook. Most physicians remember the firstpatient with specific diseases that they worked upduring their third year clerkship.

One of the most important responsibilities of thirdyear clerks is to follow the daily progress of each oftheir patients. In addition to being a responsibility,this provides an extremely valuable learningexperience. When it is possible the clerk should bepresent when her/his patient is seen by aconsultant and when the patient undergoes

diagnostic procedures. When possible the clerkshould review the results of diagnostic studies withthe specialist who performed the study.

When a clerk has a choice as to which patient to“work-up”, she /he would be wise to select apatient with a common disorder. Common diseasesare common because they are common! There is agreat tendency in teaching hospitals to focus onthe rare diseases. Remember, rare diseases arerare because they are rare!

Clerks are often asked questions about diseases orclinical findings that they couldn’t possibly know.Clerks may be embarrassed that they don’t know,but the appropriate answer to such questions is:” Idon’t know.”, and then ask what is the answer?Clerks must realize that as physicians they mustalways be intellectually honest. We can do no lessfor our patients! Intellectual honesty means that ifyou are asked for the results of various laboratorytests, and you don’t know the results- you don’tsay they were normal, you say I don‘t know, butI’ll find out. If a patient asks his physician for hisprognosis and the physician doesn’t know- theanswer should be: I don’t know, but I’ll find out.

Third year clerks are evaluated on their ability toworkup and follow the progress of their patients aswell as on their knowledge of the pathophysiologyof the diseases and disorders that they encounter.Unlike previous evaluations (i.e. grades), whichwere based almost entirely on test results, clerksare also evaluated on their ability to relate to theirpatients and the other members of their healthcare team (doctors, nurses, technicians, otherstudents). In fact, this is the same way that internsare selected, and residents are evaluated, and thisis the same way that physicians are evaluated!The brightest physician with the highest test scoreswill be ineffective as a physician if she/he can notrelate well with patients and other members of thehealth care team.

The third year of medical school is one of the mostimportant and most exciting stops on the path fromstudent to physician! I think that you will enjoy thethird year, and I know that you will alwaysremember it!

Nakisha Ranch, Well Gray Park, BC

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OPERA AND MEDICINE: VIOLETTA, THE GREATEST WOMAN

KENNETH J. RYAN, MD • DEAN FOR ACADEMIC AFFAIRS, COLLEGE OF MEDICINE

There is no shortage of death, suffering, and dyingon the operatic stage. While we would categorizemost of these as business for the trauma service(murders, poisoning, immolation) a few depict theevolution of disease as an integral part of the plot.Of operas in the standard repertory the mostcommon medical conditions are tuberculosis (LaTraviata, La Boheme, Tales of Hoffman) and themany depictions of mental illness in mad scenes(Lucia di Lammermoor, Boris Godunov, PeterGrimes). Of these the one in which disease is mostintegral to character development is the depictionof the title character in Guiseppe Verdi’s middleperiod masterpiece La Traviata. In this opera Verdiand his librettist Francesco Piave make use ofprevailing attitudes about consumption(tuberculosis) and sexual liberation to create awoman of Shakespearean proportions. In fact theircreation Violetta is the most heroic role any womancan play.

La Traviata (The Fallen One) is a variant of a time-tested plot which goes back to Romeo and Juliet;that is, young lovers going against the approval offamily. In this version, Violetta, a beautiful, youngcourtesan, is reentering mid 19th Century Parissociety after a relapse of her consumption. Alfredo,a young man of good family who has admired herfrom afar, offers love and an escape from herdecadent life. They live together (unmarried) inbliss in the country until the arrival of Alfredo’sfather, who prevails on Violetta to end the disgracetheir relationship is bringing to his family. Althoughstill in love with Alfredo, she agrees to make thissacrifice by making Alfredo believe she wishes toreturn to her former patron and life as a courtesan.He responds by declaring her a common prostitutein front of her friends. In the last act the dyingVioletta is reunited with a repentant Alfredo, but itis too late and she dies at the curtain.

The character of Violetta is taken from that ofMarguerite in The Lady of the Camellias, a novel byAlexandre Dumas fils, illegitimate son of the authorof The Three Musketeers, and The Count of MonteChristo. The novel and a later play are in turntaken from Dumas’s affair with Marie Duplessis,who was mistress to many other members of theParisian elite class including ministers of state.Charles Dickens happened to be in Paris in 1847

when she died at the age of 23 and was shockedby the attention accorded her funeral.He commented:

Paris is corrupt to the core. For days … everypolitical, artistic, and commercial question hasbeen neglected by the newspapers for an event ofthe highest importance, the romantic death of …the celebrated Marie Duplessis. You would havethought it was … the death of … Joan of Arc.

There are those who feel the character of Violettaowes more to Verdi’s mistress GiuseppinaStrepponi than to Marie Duplessis or Marguerite ofThe Lady of the Camellias. Verdi was a widower,having lost his wife and both of his children beforehe was 30. He met Strepponi, a soprano, when shecreated the role of Abigaille in his first hit Nabuccoin 1842. Five years later she became his mistress,and Verdi was living openly with her in Paris at thetime he attended the world premiere of The Lady ofthe Camellias. This created a great scandal,particularly when they returned to his home nearBussetto in Parma, Italy. Paris was one thing, butin rural Italy the locals and Verdi’s family ostracizedher. It was not just that they were unmarried; shewas known to have taken multiple lovers beforeVerdi and given birth to at least 3 illegitimatechildren, all abandoned to orphanages. Verdi stoodby “Peppina” even at the expense of a formalbreak with his parents, which unfortunately neverhealed. Verdi and Strepponi eventually married in1859. Mary Jane Phillips-Matz in her 1995biography Verdi speculates that the reason Verdiwaited so long to marry Strepponi was to becertain all her illegitimate children had reachedthe age of 21 and thus could have no claim to hisestate under Italian law.

Without doubt The Lady of the Camellias was thestarting point for Verdi’s Violetta, but whatever thesource, it was only the starting point for thecreation of an indelible portrait of a noble woman.To accomplish this, Verdi used a favorite techniqueof presenting a character the audience wouldinstinctively dislike and then painting a moresympathetic portrait in words and music. InRigoletto it was a deformed, spiteful, court jester.In La Traviata Violetta Valery is a courtesan, whichis essentially a prostitute accepted in social circlesby the wealthy and powerful. This acceptance, of


course, would not extend to family or any kind ofcommitment beyond money. 19th Centuryaudiences considered it scandalous that such awoman would be given a prominent role on stage,much less a sympathetic one.

150 years ago Violetta’s illness would havehardened, not softened, the audience’s view of heras it does today. At the time of the premiere inVenice (1853) Louis Pasteur’s proof of the origin ofinfectious diseases was still to come, and it wouldbe 30 years before Robert Koch’s isolation ofMycobacterium tuberculosis would defineconsumption as an illness acquired by inhalationfrom another infected person. In Verdi’s time,tuberculosis was viewed to derive from aconstitutional weakness associated with poverty orsome occult inherited defect. It was stigmatizingtoo, and often hidden by families. Aspects oflifestyle such as sexual excesses were felt toaggravate the course. All of this would havemarked Violetta as a woman who had somehowdispleased Heaven and whose behavior deservedany punishment that befell her.

Another difference between modern and earlieraudiences is that the “Great White Plague” oftuberculosis was the leading cause of early death in19th Century Europe. One of every four deaths inParis was due to tuberculosis. Every member of theaudience would have had some experience with thedisease, either themselves or through a familymember or friend. Many would have observed aloved one go through the slow, wasting, internalfire, from which the term consumption derives. InNicholas Nickleby Charles Dickens describes it as:

A dread disease in which the struggle between souland body is so gradual, quiet and solemn, and theresult so sure that day by day, and grain by grain,the mortal part wastes and withers away. A disease… which sometimes moves in giant strides andsometimes at a tardy sluggish pace, but, slow orquick, is ever sure and certain.

In those times it would only take a cough or aswoon onstage to evoke these memories andassociated feelings of shame or loss. Actually,tuberculosis is still the leading cause of prematuredeath in the world with 50,000 deaths each week.We are just shielded from this in countries wealthy

enough to afford the expensive and prolongedtreatment required to cure the disease and preventits spread. It is somewhat ironic that the authors ofthe rock musical Rent, which is based on the storyof Puccini’s La Boheme, saw the need to updateMimi’s disease from tuberculosis to AIDS. For mostof the world, tuberculosis would work just fine.

THE OPERA

Verdi makes no attempt to soften the image ofVioletta in her initial presentation in Act I. She is afull-fledged party girl. Alfredo ardently introduceswhat will become their love theme declaring thatlove is the universal heartbeat (amor ch’ e palpito)of the world. Violetta is tempted but rejectscommitment to love in the brilliant coloratura ariaSempre libera (forever free) in which she declaresshe will live for pleasure only. This affirmation ofVioletta’s decadence perfectly sets up theturnabout to come. The only comparable operaticdeclaration of sexual freedom by a woman comesin the Habanera of Bizet’s Carmen (1875).Sempre libera also indulges the smug view of theaudience that they are above this weak andindulgent woman.

The major scene of the opera is the Act II duetbetween Alfredo’s father Giorgio Germont andVioletta. Germont appears unannounced withVioletta alone in the house and addresses herwith contempt:

Germont: I am Alfredo’s father, whose son you areleading to ruin.

Violetta: Sir, I am a woman and in my ownhouse. Please allow me to leave you,more for your sake than mine.

Germont: What dignity!

Germont is taken aback by her dignified responseand instantly recognizes he is dealing with awoman of substance. Undaunted, he accuses her ofspending the family money, but she shows himreceipts documenting the reverse. She issupporting Alfredo. Continuing, he describesAlfredo’s little sister, “pure as an angel,” in an ariasung in the lush warm tone associated with a Verdibaritone singing to one of his children. He explainsthat this angel now cannot marry the man she


loves because of the disgrace Violetta and Alfredo’srelationship has brought on the family. Heaping iton, Germont then tells Violetta her beauty willfade, and since that is all he feels she has to offer,implies Alfredo’s ardor will fade as well. Throughthis Violetta is sobbing, “E vero, e vero (it ’s true,it’s true)” and in agony makes her decision. Sheknows that Alfredo will see through anything shortof her leaving him to return to one of her formerlovers and resolves to do just that. “Go tell yourdaughter that a poor and wretched woman, whohas but one thing left in life, will sacrifice it for her– and then will die!” Violetta, Germont, and theaudience firmly believe this will not only deny herhappiness but will cause a resumption of herconsumption. Germont is stunned: “Generosa, Ogenerosa – What can I do for you?” Violetta asks onlyone thing: “Let him not curse my memory. When Iam dead, let someone tell him of my suffering.”

As the great duet unfolds, Germont goes through adramatic and musical transformation. The initialdistain and harshness in his voice give way torespect, and by the end she is in his arms with himsinging to her with the same warmth he used forhis daughter a few minutes earlier. This could beRigoletto singing to Gilda, Simon Boccanegra toMaria or any of the other Verdi father/daughterduets. Violetta has surpassed Germont in nobilityand he knows it. He would not be willing or able tomake the sacrifice he is asking of her and neitherwould his son. The audience also knows they wouldbe incapable of such an unselfish and noblegesture. For 19th Century audiences who couldclearly see that Germont represented them thiswas unbearable. So unbearable, in fact, thatalthough Verdi clearly intended La Traviata to be acontemporary drama, producers refused to takethe risk of subjecting their audiences to this kind ofmoral discomfort. Instead they provided somedistance by setting it around 1700 with the men inpowdered wigs, silk stockings, and buckled shoes.The first Italian performance of La Traviata in“contemporary” dress was not until 1906.

This sets the scene for the agony of Violetta’spublic denunciation by the unknowing Alfredo atFlora’s party in the following scene. From the timeVioletta enters on the arm of Baron Douphol, herformer consort, the orchestral music becomeshalting and interrupted, suggesting the progression

of Violetta’s consumption. When Alfredo throws hisgambling winnings in her face in front of herfriends, all are horrified including those in theaterseats, because by now everyone is in love withVioletta. Germont makes a dramatic entrancerebuking his son’s behavior but stops short ofrevealing the truth. He speaks only in the terms ofsociety, “No man of honor even in anger, ever, ever,insults a woman.” As the entire cast and chorusjoin in lament, the music again takes on aninterrupted staccato cadence. These are the gaspsof Violetta’s withered lungs dissolving as M.tuberculosis literally consumes their lipidmembranes. With the possible exception ofDesdemona’s degradation in Act III of Verdi’sOtello, no woman has ever been more publicly andunjustly humiliated.

The final act begins with an orchestral preludecontaining the most tender and heartbreakingmusic in all of Verdi’s 27 operas. Violetta isdeserted, destitute, and hours from death. Still sherefuses to be bitter, asking God for the forgivenesssociety would not grant her. When Alfredo and hisfather enter, they are filled with remorse, certainthey have killed her. The orchestra beginsrepetitive dirge-like lines confirming the end isnear. Violetta has only one last request. Her lovefor Alfredo is absolute, and she gives him amedallion with her image and encourages him tolove again and marry if he finds the right girl.

Give her this medallion,

Tell her of one you knew,

Who then will be in heaven above

Praying for her, for you.

Then instead of dying in the manner we are usedto on the operatic stage, Violetta does somethingwhich would have been familiar to physicians of theday. Near the end consumption patients often hada lucid interval accompanied by an illusion theirdisease had left them. As a solo violin repeats theheartbeat of love (palpito) theme introduced in ActI, Violetta has a sudden surge of hope and loss ofpain. Rising from her bed she declares “I amreborn! O joy,” and then falls limp to the floor.


THE GREATEST WOMAN

Where else in the world of art can we find suchheroic beauty in a woman? Certainly not in themovies. The American Film Institute’s list of the100 greatest films includes none with a heroicwoman, unless you want to consider the grittyScarlet O’Hara a heroine. Greta Garbo’s Camilledoesn’t count because it’s the same story. In alighter sense, so is Julia Roberts’s prostitute inPretty Woman. In case you miss the point in thatfilm, Ms. Roberts and Richard Gere go to the operafor a performance of, guess what, La Traviata.

In the theater we have Shakespeare’s Juliet,Ibsen’s Hedda Gabbler and Nora, but only a fewothers. No, one has to turn to the opera for truelarger than life heroines and even there they arescarce. The greatest are Brunhilde in Wagner’s Ringcycle, who rides into fire to save the world, andMozart’s Countess in The Marriage of Figaro, whodemonstrates the unconditional forgivenessof true love. Here Mozart should getextra points, since his heroine doesnot have to die in the process.In the end it isthe

tenderhuman qualities ofthe frail Violetta which make herthe greatest woman ever createdfor the stage. Every time we watchthe story of La Traviata unfold, ourhearts surge, break, and forge a bondwith the Lady of the Camellias. The palpitoof Violetta’s universal love is eternal.

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FINDING OUR WAYDEDICATED TO THE MEMORY OF WARREN “BUD” DAY

MARY FOOTE • MD-MPH STUDENT, CLASS OF 2006

I had heard his name when I was just beginning tofeel the flutter of excitement that comes withyouthful idealism and a great, life-changing idea. Icontacted him to see if I could join him on one of hismany trips to exotic lands so I could start saving theworld. All I wanted was a trip to Africa. Somehow Iended up registering for his class instead.

I walked into the classroom that first day ofInternational Environmental Health and met BudDay, a white-haired man with twinkling blue eyeswho emitted a palpable energy. His class gave mesome of my first exposure to real-world healthdisparities. I started to look forward to every class,when Bud would share stories of designinginnovative pit latrines in Bangladesh or of fightingagainst landmine use in Mozambique. I realizedthat I had been given the honor of learning from areal-life hero. What was it that made him sospecial? Pushing well into his seventies, Budremained passionate about his work, foughttirelessly for what he believed in, and challengedus to take a closer look at the larger world thatsurrounds us.

One of the main lessons Bud taught me is thatinjustice and its effects on human health can beseen nearly everywhere. On one memorable fieldtrip he took the class to the Navajo reservation, inorder to explore an area with an unexplainedcluster of lung cancer and respiratory illnesses.Many of those ill were uranium miners employed bythe US government from the 1940’s to the 1970’s.The limited compensation that has been doled outto the victims has been hard won, and many havehad to make due with the limited health careoffered by a perpetually strained Indian HealthServices. And their health threat seemed far fromover: open waste piles sat close to restaurants andhomes, and one could still see yellow-tingeduranium dust rising up into the air with each stronggust of wind.

My most recent experience with health disparitiesled me to Mulukuku, a rural community in centralNicaragua, as a volunteer with the organizationDoctors for Global Health (DGH). The inhabitants ofthis area saw some of the heaviest fighting duringthe U.S.-backed Contra Wars, only to face

Hurricane Juana in 1988. After Juana destroyed thevillage, a small group of local women joinedtogether to form the Maria Louisa Ortiz Cooperativeto start rebuilding their community. After realizingthat many of the village’s women were unable toread, the Cooperative established a literacycampaign, built schools and started a scholarshipprogram for higher education. When it was notedthat women were dying unnecessarily from cervicalcancer, they worked to build a women’s healthcenter, which opened in 1991 and is now looked toas a model primary care facility serving apopulation of more than 30,000 people. Mostrecently, they set up a legal defense program aswell as a safe house for women and children whoare victims of domestic violence. Throughout theirstruggle they have identified what resources theylacked and formed equal outside partnerships withgroups like DGH to address those needs.

All these gains have not been earned withouttremendous hardships. Nicaragua still maintains anintense political climate, which seems to permeateevery aspect of day-to-day life. The Cooperativehas often been seen as a threat to those in power,mostly due to their ability to organize and fight fortheir rights as a community and as women. A cycleof violence was created and reinforced throughoutthe brutal 40-year reign of the Somoza dynastyand during the preceding American occupation, andthis violence persists in insidious ways. Althoughthe women and men of the Cooperative fightagainst it, there is an undercurrent of resignationthat violence in some ways will always be a part oftheir culture. However, as a community, they areworking in solidarity and partnership with others toimprove their lives and restore human dignity.

The social environment of Mulukuku inspired me toseek out members of the Cooperative and learnfrom them those skills necessary for communityorganization. Yet, the more I learned from thesewomen, the more questions kept coming up in mymind. I want to know how, as a future healthprofessional, I can work for social justice in myown practice, as well as in everyday life. And howcan I help those members of our global society thatsuffer the worst effects of devastating conflicts,namely when violence has become institutionalized


in a way that will persist long after the weaponsare gone? I am a witness to examples of structuralviolence* every day here at home. For a long time,it was invisible to me; other times, I chose not tosee it. But now, when I am in the hospital as amedical student or working in the field, I see plentyof glaring examples in the faces of thosetraumatized by spousal abuse, child abuse, rape,and poverty.

Paul Farmer explains, “Liberation theology’s firstlesson is that there is something terribly wrong.Things are not the way they should be. But theproblem is with the world, even though it may bemanifest in the patient.” This idea crystallizes whenI think about those I have seen in the CUP clinics.The fact that they require care in such a contextsuggests that they are victims in some way of agreater system of oppression. All of the people wehave the opportunity to serve through the programhave been disenfranchised in some way fromsociety and its privileges, whether as refugees,homeless, or victims of domestic abuse. Most oftenthese men, women, and children have been placedin these positions through factors largely beyondtheir control that have been allowed to flourish toolong in our society. Many of us have been involvedin charity’s good work, and hear the motto: “Thepoor are every bit as deserving of good medicalcare as are the rest of us.” Well, if we truly acceptand donate time and energy into this belief, thenwouldn’t it make sense to put some of thateffort into creating more sustainable and justsolutions such as universal health care orimproved social services?

The challenge of working to right the social wrongsthat affect the health of our patients should be afundamental part of our calling to medicine. To dootherwise is to place band-aids over the wounds ofgreater harms. Our own Tracy Carroll hasinstructed us in how to begin to enact change byfocusing on the liberation theology principle of“ver, pensar, actuar (to see, to think, to act).” Weneed to be aware of the greater societal issuessuch as poverty, racial inequalities, and lack ofaccess to healthcare. We need to see how theseissues manifest themselves in the lives and healthof our patients. Only then can we mobilize for

change in partnership with the patients andcommunities that we serve. Something as simpleas our education and social standing gives us avoice that we can use to speak for those who maynot have such privilege.

It’s true that not all of us will, or even want to,spend our lives in a dramatic fight to improvehealth and justice in the developing world like myhero Bud Day or the women of Mulukuku. But foreach of us there is a way to contribute toimproving health and respecting the basic humanrights that should be afforded to all in every nation.Think of your own heroes. Reflect on what they didto make a difference, and challenge yourself tomirror in your own lives what makes them noble toyou. As physicians we may not always be “of” thepeople, but we should always be “for” thepeople…wherever our paths may lead us.

*Structural violence occurs whenever people aredisadvantaged by political, legal, economic orcultural traditions. Because they are long standing,structural inequities usually seem ordinary, the waythings are and always have been.

For more information about Liberation Medicineand opportunities with Doctors for Global Health goto www.dghonline.org.


HEALTH, DISEASE AND BALANCE

LEILA ALI-AKBARIAN • MD-MPH STUDENT, CLASS OF 2006

As I was applying to medical school, one of theschools asked me to answer the following question:“What do health and disease mean to you? Whydo you think people get sick? What do you thinkthe physician’s role is in the healing process?”These were such refreshing questions because theydidn’t ask about me and my achievements. Theyallowed me to explore health and disease in waysthat I have rarely done so far in my formal trainingas a student doctor, yet I think these questionswere essential in understanding my own foundationfor the practice of medicine. I encourage anyonewho reads this to think of his or her own responsesto these questions. Below are mine.

Health and disease are both vital to the humanexperience. Health is a condition of physical andmental well-being, and I believe it is a function ofbalance. When a person is out of balance, eitherinternally, or in conjunction with the externalenvironment, then the body is more susceptible todisease. It is my opinion that disease is a way forthe body to communicate with the mind, in anattempt to regain balance. Regaining balance, inthis sense, can imply returning the body tohomeostasis, or creating mental harmony, andoften a physician can facilitate both processes.

The human body is designed to maintain balanceby adapting to internal or external changes in itsenvironment. These changes usually result instress on the body. How quickly and effectively thebody reacts to stress is an important determinantof whether the body will be free of disease. Forexample, people with weak immune systemscannot respond efficiently to foreign organisms inthe body. Although the organisms come from theexternal environment, it is the internal chemistry ofthe body that is stressed. The foreign organismsare then able to survive and replicate within thebody, often becoming a disease.

The chemistry of the body can be skewed as aresult of a myriad of stresses. Internal stressessuch as prolonged fear or anxiety create chemicalchanges in the body, often leading to slowerimmune responses. The body is then lessequipped to react to external stresses effectively.Many people become sick as a response to acombination of these internal and external

stresses. Just as some emotions can havediminishing effects on the immune system,others, such as deep relaxation or happiness,can have stimulating effects. This creates aninternal environment more prepared to adapt toexternal stresses.

Ancient sources claim that Hippocrates, the fatherof Western medicine, believed that natural forceswithin us are the true healers of disease. Thiselegant and simple philosophy of healingemphasizes the body’s inherent intention to returnto a state of equilibrium. There is no distinctseparation between body and mind, for both areinvolved with the higher purpose of maintainingstability and adaptability. When a system in thebody is out of balance, the mind sends messagesto the body to restore its internal harmony. If itcan be restored behaviorally, the mind oftentranslates the message in a way that isinterpretable by our conscious awareness.Becoming healthy is often a matter of listeningclosely to messages from the body and respondingaccordingly. For example, if a body is beingstressed physically and is cooled by sweating, thenwater levels within the body decrease. Byreceiving messages of thirst, the person is able torestore the balance by drinking water. Likewise, ifa person is experiencing neck pain, the mind mightmake subtle suggestions that a vacation from astressful or uncomfortable work environment wouldallow the body to heal itself. I believe thatsickness and disease often occur when messagescoming from the body are ignored.

There are, of course, situations where a body is notable to easily stabilize itself. A person’s bodychemistry can be stressed as a result of variousfactors, including predetermined genetic factors.Type I (juvenile) diabetes mellitus, for instance, ischaracterized by a loss of insulin-producing cells.The resulting increase in blood glucose levelsseriously alters the homeostatic stability within thebody. The balance can mostly be restored withproper diet and exercise in conjunction with timelyinsulin injections.

There are many instances when a person caring forhis or her own body benefits greatly from medicalexpertise, including emotional guidance. It is the


role of the physician to contribute such expertise,but not to conduct the healing. The healing occurswithin the patient. The doctor can help todetermine the sources of the stresses affecting thebody and provide suggestions for quickly andeffectively restoring the natural balance,sometimes making physical adjustments to hastenadaptability to the stresses. A physician should befully educated about the extensive pharmacologyand various other modalities of treatments,choosing each time the one that will allow thepatient’s body to most effectively heal itself,considering the delicate balance of the entiresystem. The role of the physician should also be tohelp the patient discover stresses in his or her ownenvironment, and to listen to messages beingrevealed by the body to the conscious mind. Inthis capacity, a disease may create an opportunityfor restoring greater health in all aspects of apatient’s life.

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Harmony Magazine, Volume 7 (2004-2005)

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Transcript of Harmony Magazine, Volume 7 (2004-2005)