by Robert Coles
In the 1960s, in the days of Black Power, a white physician practicing in a black neighborhood might have been asked by black people what he was doing there, why he wasn’t fighting racism in his own environment. But thirty years later certain dreams have died. No black person has ever said to me directly or, as far as I can remember, even implied that I don’t belong on Belmont Street. The reason, I think, is obvious, the reality as clear as it is lamentable: If the white doctors and nurses and lawyers leave Belmont Street, no one will replace us. White theorists and organizers will, from time to time, accuse us of disempowering the people with whom we work, but until those critics show me how I can practice without disempowering my patients or where my patients will receive good medical care when I leave, I find it hard to justify departure.
But despite my pragmatic response to these issues, a problem persists. American history is often read as a long legacy of white people telling black people what to do; and the work of the inner-city doctor can seem like just another instance of this unequal dynamic. White people have historically exploited black communities—have come in, taken the money, and left. The poor inner-city black person has reason to see the white inner-city doctor as someone who comes into the community and earns handsome fees (even my “austerity salary” at Community of Hope is three times what many of my patients earn working full time), while his patients haven’t enough to pay the rent. I live at Christ House, but “upstairs,” where the patients never go; I live “in” the community, but not directly on Belmont Street. The history of American social reform is filled with white people “helping” black people by “doing for” them. The medical model itself, in which the doctor does for and does to the patient, is an inherently disempowering one.
So the white doctor of poverty medicine practices within a deeply troubled historical context. How do I deal with the sneaking suspicions (which I, on bad days, share) that I am—despite my best intentions—exploiting my patients? Racial prejudice is so thoroughly ingrained that no one of us—black or white—can be free of the charge of “racism.” The best we can do is acknowledge racism, try to understand it, and move on.
These reflections inevitably return me to the same questions: What am I doing here? What can I offer my patients? If I do so little good by traditional medical standards, if my very presence may be disempowering, what can I do? Ultimately, the answer is the same one every good doctor anywhere must come to: I can offer myself and my presence as a healer. The recent tide of technological medicine has tended to erode our understanding of the fundamental imperative for any physician—to be a healing presence. Because our antibiotics and our CAT scans and our heart transplants promise such power, we risk confusing the use of those tools with the most basic task of doctoring: to understand, to comfort, to encourage, to be with the patient in his or her distress. With its potentially distracting techniques and technology, traditional medicine may need poverty medicine as a reminder that the primary role of the good physician is to offer unconditional acceptance of the patient’s being; to clarify (without judging) the cause of the illness; to honor the pain, to recognize the fear, and to hold on to hope.
James Wright
IN TERROR OF HOSPITAL BILLS
James Wright’s poem describes life on the street for a Native American man. What is striking in this poem is the declaration by the homeless man that life is worth living and was never as precious to him as now. Understanding this has broad implications for practitioners who encounter the poor. The word “terror” in the title is particularly interesting, given that there is no mention of illness or hospitals in the poem.
JAMES WRIGHT (1927–1980) was a postwar poet and prose writer. This poem is taken from his collection titled Shall We Gather at the River?
I still have some money
To eat with, alone
And frightened, knowing how soon
I will waken a poor man.
It snows freely and freely hardens
On the lawns of my hope, my secret
Hounded and flayed. I wonder
What words to beg money with.
Pardon me, sir, could you?
Which way is St. Paul?
I thirst.
I am a full-blooded Sioux Indian.
Soon I am sure to become so hungry
I will have to leap barefoot through gas-fire veils of shame,
I will have to stalk timid strangers
On the whorsehouse corners.
Oh moon, sow leaves on my hands,
On my seared face, oh I love you.
My throat is open, insane,
Tempting pneumonia.
But my life was never so precious
To me as now.
I will have to beg coins
After dark.
I will learn to scent the police,
And sit or go blind, stay mute, be taken for dead
For your sake, oh my secret,
My life.
Veneta Masson
ANOTHER CASE OF CHRONIC PELVIC PAIN
A busy clinic is visited; the frequent complaint and its standard answer are heard. How to deconstruct the complaint and find the source of pain for the woman in the poem, when the source of her pain is woven inextricably into her life? If health care professionals are to identify factors that put individuals at risk for disease or injury—whether psychological or physical—aren’t they then obliged to begin that commitment with the first complaint?
VENETA MASSON is a family nurse practitioner. She has been a nurse for thirty-five years. Most of her poems and essays are based on the seventeen years she spent at a small, inner-city clinic she helped to found in Washington, D.C. This poem is taken from her collection of poetry titled Rehab at the Florida Avenue Grill.
Like the others, she is not from here
and when she came she left
all of what matters behind—
four children, a village
a father (not well), the lingering
scent of her man (who had fled)
Sunday walks in the plaza after mass
on days when the soldiers were gone
on days when no bodies were found.
The journey from home was perilous—
sometimes on foot, or crowded
into the back of a truck, over hills
through dense forests, arroyos
dark rivers, toward menacing lights,
the eyes of hostile cities.
The trip cost her more than
she wanted to pay—
all the crumpled bills
from the earthenware jar
in the wall of the house,
the silver bracelets and earrings
passed down from her mother.
Her body they took along the way
again and again as if for a debt
that can never be paid.
What drove her on was a woman’s
fixed and singular faith that
she is the giver of life
the mother of God.
By bus from the border
by phone from the station
by foot to the room of the friend
of a cousin who knew of a place
and jobs cleaning offices at night
where no questions were asked
and dollars were paid
unless you missed work
or were caught by the migra—
all this distance she came
numb to the pain in her feet and back
and the ache in her lower heart.
She spent her days trying to sleep.
Nights she roamed large empty halls
as wide as the streets
that gave onto the plaza
pushing a cart full of cleaning supplies
bagging the trash, sweeping the floors
washing away the stains of another
day in the upper world.
Paydays she sent her money home
by the man at Urgente Express.<
br />
Sunday she sometimes walked
down the street at the edge
of the park, watching
with shaded eyes among the men
for one she might know.
Months passed this way
and with each one she wept
the tears of blood that women weep
and felt the ache in her belly
grow stronger until at last
there was no relief,
come new moon or full,
and no poultice, tea or prayer
that helped her bear
what she must bear.
She sits in the clinic—
“a 32-year-old Hispanic female
complaining of chronic pelvic pain.”
The results of all the tests
are negative, they say.
That means there’s nothing we can find
to blame for all the pain.
There is a cause, of course—
perhaps a scar deep inside.
Surgery might tell us more—or not,
but then there’s the matter of money.
I see, she says simply.
Well, if you can’t find
anything wrong—and you know
there is no money . . .
There are some pills
you could take, they say,
for the pain, when it
bothers you most.
You are kind, she says
and stands up to go,
like the others,
from here to her job,
her room, and perhaps twice a year
to a telephone that spans the miles
of dense forest, dark river
to the house of a friend
of an aunt of her father
to ask if the children
are well and in school
on days when the soldiers are gone
on days when no bodies are found.
I will send for them
one day soon, she says.
For now there is only the ache in her belly,
come new moon or full,
and no poultice, pill or prayer
to help her bear
what she must bear.
What drives her on is a woman’s
fixed and singular faith that
she is the giver of life
the mother of God.
Lori Arviso Alvord
from THE SCALPEL AND THE SILVER BEAR
This selection by Navajo surgeon Lori Arviso Alvord is her attempt to understand “the economic, psychological, occupational, social, and cultural factors that contribute to the development and/or perpetration of conditions that impair health.” Alvord writes about the patients she sees at the Indian Medical Center in Gallup, New Mexico, many of whose difficulties “had a common denominator: alcohol.” She describes in detail how alcohol, “through its pervasiveness and its availability, ... has touched the lives of Navajos on many levels.” The issue is personally as well as professionally relevant for Alvord, whose father died in an alcohol-related car crash.
LORI ARVISO ALVORD is the first Navajo female surgeon. She is associate dean of minority and student affairs at Dartmouth Medical School.
ELIZABETH COHEN VAN PELT co-authored The Scalpel and the Silver Bear with Lori Arviso Alvord. She is a staff writer for the New York Post.
I was on morning rounds in the intensive care unit. The smell of coffee, cooling in the bottom of Styrofoam cups, mixed with the smell of freshly cleaned linens. A computer screen, divided into bright purple and green lines, traced the activities of the patients’ hearts, a stack of their charts lay on the counter.
With my fellow surgeon Susan Stuart and a specialist in internal medicine, Terry Sloan, I waited for everyone else to arrive. As people filed in, several nurses chatted by the doorway. An old audiotape was playing, and music poured through the serious air like honey. Then someone turned down the music, and we began to make our rounds, going over the histories of each patient.
Bed 66: Slim, Ray, a 38-year-old male with early cirrhosis and active hepatitis, fevers, a high white count, and pancreatitis. He was described as a “binge-type drinker who spends his weekends intoxicated.”
Bed 65 : Thompson, Robert, a 51-year-old male with severe cirrhosis, ulcers, and internal bleeding. Needs an esophagogastroduodenoscopy, or “scope,” to locate the source of bleeding in his intestinal tract.
Bed 67: Redhouse, Betty, a 29-year-old woman with a bleeding ulcer, heart condition, and severe liver damage. In the hospital because of a beating that was believed to have been the result of a domestic violence incident. She has lacerations and cuts to the head and neck, as well as a long knife wound to the abdomen.
Bed 64: Antonio, Henry, a 38-year-old man with massive trauma to the neck, mild wheezing, mild hypoxia, severely lacerated tongue, a lumbar fracture, and multiple fractures in the left ankle.
As the physicians talked, this last patient’s story began to unfold. Henry Antonio had been jailed the previous night for drunk and disorderly behavior and had tried to hang himself in his jail cell. He suffered back and ankle injuries when he fell. It was believed he had a seizure after the hanging attempt. That was when he bit off part of his tongue.
Listening to the doctors describe these patients in detail on that late winter morning, the fractured and unharmonious parts of our community came into focus, as did one of its chief causes. These patient cases and many of those that followed on that round had a common denominator: alcohol. Much of what I was dealing with medically in the intensive care unit was either directly related to or a side effect of alcohol. Daily, again and again, I found myself forced to consider this toxic substance and the serious damage it was doing to people.
I was not naive about alcohol. In some ways drugs are not unknown to Native cultures, which traditionally used some form of hallucinogenic or mindaltering substance as a part of their religious practices. Yet alcohol is different. It has a devastating, dramatic, and negative effect. Very early on in our history, alcohol was outlawed on reservations, possibly for paternalistic reasons, but bars and liquor stores always spring up nearby.
The lives of the patients at GIMCd were scarred by the disease of alcoholism. Making rounds in the intensive care unit made it obvious: this was an epidemic.
Gallup has about fifty bars to serve fifty thousand people, and arrests for driving intoxicated exceed ten thousand a year. The opening of several new government alcohol treatment programs and the city of Gallup’s ban on driveup liquor sales improved the situation somewhat, but the problem did not go away. The incidence of fetal alcohol syndrome, a condition caused by mothers drinking during pregnancy, is the highest in the country among Native people. Through its pervasiveness and its availability, alcohol has touched the lives of Navajos on many levels.
Alcohol has been called one of the “lubricants of domination,” given to non-Europeans by Europeans. Every day I saw cirrhosis, hepatitis, ulcers, internal bleeding, pancreatitis, domestic violence–related injuries—all pathologies that could be associated with the excessive or habitual ingestion of alcohol. We bandaged them up, dried them out, and sent them on their way, but many times they’d be back.
Even after I had been in Gallup only a short while I had already encountered a vast number of patients whose lives were trapped and tangled in alcohol-related problems.
One day as I was operating at GIMC with Greg Stephens and one of our anesthesiologists, Daryl Smith, both of whom were black, I overheard their conversation about people they’d grown up with. They cited the well-known tragedy about young black men in this country: that many of their male childhood friends have been killed or were in jail. They named names, ticking them off on their fingers, and remembered the casualties. Suddenly it dawned on me: many of the children I grew up with on the reservation were no longer alive either—but nobody ever really talked about the high number of teenage Indian casualties: Rena Craig, Ernie Henry, Adrian Tenequer, Alfred Chav
ez, Peter and David Howard, Rickey Estevan, Perryson Perry, Elmer Morgan, Leroy Etcitty, Roger Etcitty. Dead not from guns and drugs but from alcohol, suicide, and automobiles—our own lethal combination.
The leading cause of death among Navajos isn’t liver disease or pancreatitis—it is motor vehicle accidents. The rate is three times higher for men than for women; the highest percentage of all is for men in the 25-to-34 age range. Indian Health Service statistics estimate that 60 percent of those accidents are alcohol related, and the numbers are rising.
Besides accidents, other alcohol-related incidents were also common. Everett Nelson, a teenager, was brought in with long tears and crisscross rips in his body from knife wounds. He said his brother and he had gotten in a fight, but his tattoos and clothing told a different story. Gangs on the reservation had been increasing for a decade or so and I was seeing the result.
Young Navajo men like Everett, not yet seventeen, would come in with gunshot or stab wounds. There was even a gang-related fatality in Shiprock: a fourteen-year-old Navajo boy named Shoshonnie Francisco. The gang culture was yet one more outside influence—this time of imported violence and territoriality—that threatened Navajo culture. No one knows for sure how it first infiltrated the far-flung sheep camps and washes of the rez, but it did. Before long Navajo schoolchildren were wearing the symbols and colors of the Bloods and Crips of the West Coast gangs. Soon afterward they began to show up in GIMC, like Everett, and were some of my most seriously injured patients. Navajo communities have become increasingly alarmed by this trend. The elders say that it is a result of the fact that parents have not taught their children the traditional ways. Without the teachings of Walking in Beauty, these children attempted to create their own tribe, but with devastating effects. The blueprint for tribal lifeways had not been handed down to them. Alcohol only made the violence and gang-related crime worse. Usually it took place when they were drunk.