After Ike, the demographics of Galveston Island changed dramatically. The historically black neighborhoods on Galveston took the brunt of the flooding, and many black residents were forced off the island. Galveston’s political leaders fought against rebuilding the public housing that had been vital to many of the people of St. Vincent’s. The House began to serve more white people. This transition bothered some of the African American workers and volunteers at St. Vincent’s. “When stuff started to change, folks said, ‘Gosh, we serving the enemy. They wouldn’t serve us, now we serving them,’ ” Mr. Jackson told me.
But the people of the House did not stop serving Galveston. “Folks come here for hope, and whatever we materially can provide for them, that’s our job,” Mr. Jackson said. “That’s what we do.”
In my first months at St. Vincent’s, I never turned left. I hurried through the waiting room toward the safety of the clinical area, where students in short white coats huddled around charts like birds around a handful of seed. That was where, in the clinical space, I belonged.
THE FIRST PATIENT I SAW that first day at St. Vincent’s had a most ordinary problem: she needed a preemployment physical exam. I trailed after a third-year medical student who called the patient back into an exam room and began to rattle off questions from memory. Had she had fevers? Chills? Sweating? Dizziness? Cough? Coughing any blood? Pain in her belly? Tingling in her arms and legs? Waking up at night to pee? Did she feel short of breath when she lay down? How many pillows did she sleep on? The questions went on and on. She was a healthy twenty-six-year-old. I was amazed that this student knew all those questions from memory. I would learn them soon as the review of systems: a handy tool that screens for symptoms in all the organ systems of the body. I sat silently on a chair beside the other student and let the questions wash past me, just as the tour of the clinic—explaining everything from which antibiotics we had to how to check blood sugar to where the speculums are stored—would wash over me. The student talked a mile a minute, and I knew I would never remember it all. I didn’t even know exactly what blood sugar was.
After a quick physical exam and a check-in with the doctor, we signed that first patient’s note and sent her on her way.
“She wasn’t your usual St. Vincent’s patient,” the student told me as she disappeared back out toward the waiting room. “Most of the people you see here will be really sick.”
AT THE END OF AUGUST, I got my own white coat in a massive ceremony with my class of 230 new medical students. As the first class of medical students to join UTMB after Hurricane Ike, we were told that we were a symbol of hope for the whole island. We got little gold pins for our white coats that read, “UTMB: We Stop for No Storm.” My parents drove down to Galveston for the ceremony, and barbecued a celebratory brisket in the yard of the yellow house.
Along with our white coats and our hurricane pins, each new medical student received an identical black backpack with the UTMB logo. We all used these backpacks, and we all had the same class schedule. So when classes began, we would travel in a pack from lecture hall to anatomy lab and back across campus to a building called Graves, which had rooms for labs and small-group discussion classes called PBL: problem-based learning.
The cases we discussed were based on actual patients who’d been seen at UTMB. In my first PBL class, we discussed a patient who required plastic surgery to repair a wound he’d received while fleeing from the police.
“Okay, so what’s the anatomy you need to know for this surgery?” our group leader asked the ten of us gathered in the discussion room. We could hear the hum and thud of construction on the first story below us, which had flooded during Ike.
“He’s in prison, right?” one of my classmates asked. She was a white woman from outside Dallas who had worked in an emergency room before medical school. She knew the definitions of all the medical words, and snapped out answers before the rest of us had time to think. “I don’t think we need to know any anatomy at all,” she said.
“What?” I said.
“I mean, he broke the law,” she said. “Why should he get medical care?”
I expected the class to erupt in protest, but there was a general shrug. Finally I said, “Well, the Constitution prevents cruel and unusual punishment. So that’s why prisoners get medical care.”
“Maybe so, but I don’t have to treat them,” she said.
At first, all my classmates seemed like her: young, anxious, and conservative. There were women who woke up at seven a.m. and meticulously curled their eyelashes before a long morning of dissecting a human cadaver. There were men who lived in an all-male medical fraternity known for cheating on tests. There was an annual “white trash”–themed party. (What am I supposed to do, go as myself?) These students seemed poised to become the kind of doctors that Frank and I had imagined, and I felt like the only outsider.
I could not imagine that woman from Dallas with all the right answers working to help a patient at the prison hospital on the UTMB campus. She would, though; we all would. In the beginning I stood apart, watching the sea of classmates in identical backpacks flowing from class to class. There on campus, medical school did not feel revelatory, life altering, or transcendent. It felt like junior high.
I GRAVITATED TOWARD ST. VINCENT’S, where Margaret and her cool friends were running the show. As soon as I learned a new skill on campus—part of the physical exam, or history taking—I could put it into practice as a volunteer at the clinic. I started out shadowing the more advanced students, then seeing patients along with an upper-level student, and then along with a fellow first-year.
One of the first patients I interviewed was a young man from El Salvador who had a rash on the backs of his hands. We spoke Spanish. My conversational Spanish was good, and in a class for bilingual medical students, I had learned how to do the review of systems in Spanish. “Have you had any palpitations—when you noticed your heart beating in your chest?” I asked. I happily rattled off the questions about coughing blood, trouble with urinating, and difficulty maintaining erections. I was so proud to know these terms in Spanish that I didn’t feel embarrassed at all.
The only trouble I discovered in the review of systems was tinnitus: ringing in his ears.
“Okay, when did that start?” I asked him brightly.
“When I was fourteen,” he said.
“And what was going on then?” I asked. “Were you listening to a lot of loud music?”
“Not really,” he said. “I was in the war.”
“The war,” I repeated.
“I guess it was because there was a lot of shooting, and my gun was very close to my ear.”
He had come from El Salvador, where a bloody civil war that I knew little about had raged for thirteen years. He had been forced to join a paramilitary group after his father was disappeared and his sisters were murdered. And now he was in Galveston, working for a landscaping company.
After the review of systems, I moved to the physical exam. The rash on the backs of his hands was red and a little bit flaky. I wondered if it could be related to his work, but wasn’t sure. I needed to ask the doctor.
His heart sounded good, and his lungs sounded fine. On his right calf, there was a huge scar. “Where did you get this scar?” I asked.
“In El Salvador,” he said.
“What happened?”
“Well, one day they were shooting at me, and I fell down a mountain.”
If I hadn’t been a first-year student then, I probably would not have asked all the questions in the review of systems. I would have done a focused physical exam instead of a full physical, and not looked much further than the rash on his hands. I might not have heard his story about being forced to become a soldier when he was still a child.
Is this important, though? None of that information changed how we cared for his rash: a simple steroid cream and a recommendation to wear gloves at work. It was the most ordinary of problems, and the cure was easy.
As I w
as leaving the room, he reminded me of the tinnitus. “Do you have medicine for this ringing in my ears?” he asked.
I didn’t.
“It’s okay,” he said, shrugging his shoulders with his palms toward the ceiling. “It’s really nothing.”
OUTSIDE OF CLINIC, I spent most of my time either dissecting a cadaver or frantically memorizing the names and locations of nerves, arteries, and muscles. I had hoped to be disturbed by anatomy lab. If it really upset me to dissect a dead person, then surely I was normal: human, healthy, and emotionally intact. But instead of being disturbed, I was fascinated. Anatomy lab itself rapidly became normal: normal to cut flesh and saw bone, normal to hold a human heart in my hands, normal to slide my own gloved hand under the skin of a dead woman’s arm.
There is a history to anatomy lab. The earliest anatomy texts we know of were written by Egyptian physicians around 2000 BC. Physicians have been dissecting ever since—even though human dissection has been, in many societies, illegal. The most famous dissector of them all was Andreas Vesalius, a brilliant and progressive anatomist who lived in the 1500s. Before Vesalius, both Ottoman and European physicians had trusted the work of Galen, a Greek physician who died around the year 200. Galen’s anatomy text was thought infallible, and physicians from around Vesalius’s time let technicians dissect while they themselves stood high above the body, reading from Galen’s text. It was not fit for a physician to dirty his hands in a human body—not when real knowledge came on high from the Greeks.
The young Vesalius showed doctors another path to knowledge. In his early twenties, he set about making meticulous dissections that proved that Galen had misidentified several structures. In some cases—as in Galen’s claim that tiny pores in the heart allowed the blood to circulate from left to right—Vesalius found that Galen was completely wrong. This was a significant challenge to the physicians of the sixteenth century. Vesalius’s work called on physicians to descend, and to look for truth within the body itself.
As Vesalius grew famous, he dissected before audiences—both medical professionals and the curious public. Many of the bodies that he used to make his great discoveries were those of condemned, and recently executed, criminals.
Why did Vesalius dissect criminals? In some cases, to be dissected by physicians after death was part of the punishment for a crime. To dissect a body is to desecrate it—literally, to take away its sacredness.
In my experience, dissection was indeed desecration: If we students felt a holy awe and terror on the first day we approached the cadavers we would dissect, that awe faded as the bodies were sliced, chopped, and disarticulated. We approached a body that had a kind of sacredness, and we dissected it into its very material parts.
Western doctors would shy away from dissecting people we know and love, because they are so sacred to us. Strangers are less sacred. And those who seem to have committed some great sin against society fall into the group most vulnerable to dissection: those whose lives seem, to others, to have no sacredness. And because the lives of condemned criminals were not considered sacred, it hardly mattered what befell their cadavers.
Yet the knowledge gained from their bodies was meant to enrich us all. In the introduction to his famous On the Fabric of the Human Body, Vesalius writes to Emperor Charles V, whose patronage he needed in order to get his book published. “Nothing could be produced more pleasing or welcome to your majesty,” Vesalius writes, “than research in which we recognize the body and the spirit, as well as a certain divinity that issues from a harmony of the two, and finally in our own selves.” Knowledge gained from the disarticulation of criminals could shed light on the spiritual body of an emperor.
If my time in the anatomy lab was spiritual—showing me the divinity in the union of body and spirit—this spirituality came only in flashes. I was fascinated by anatomy, but mostly unmoved. Without the breath of life, the body before me had become a useful object.
Just as dissection has a history, the dissected bodies have a politics. In the early years of the United States, cadavers for dissection in medical schools came almost exclusively from communities of color.*Doctors in the Southwest dissected the bodies of Native Americans. Slave owners sold the bodies of enslaved people, who were considered property even after death, to medical schools. African American soldiers who died in the Civil War were dissected by Army surgeons eager to hone their craft. Because the white medical profession did not recognize the sacredness—the symbolic life—of people of color, their bodies were seen as fit for dissection.†
In some cases, enslaved people were actually made to dig up and steal the bodies of other African Americans. In 1852, the Medical College of Georgia bought an enslaved man named Grandison Harris. Harris was put to the task of snatching the bodies of other black people from the local cemetery. Through his work in the medical school, Harris grew knowledgeable about dissection. After emancipation, he became a teacher at the very medical college where he had been enslaved.
It is now—as it was then—illegal to steal bodies for dissection. It is also technically illegal to sell bodies and body parts. So, in American medical schools today, cadavers are donated. Some are donated by people who are grateful for the medical care they received, and want to give something back to the profession and to other patients. Some are donated by people who don’t want to—or can’t—burden their families with the expense of cremation or burial. Websites seeking people to donate their bodies to science often emphasize that all costs will be covered. (“MedCure arranges services at NO COST including: transportation, cremation, and return of cremated remains to family in approximately 6 to 12 weeks or a scattering at sea,” one such website reads.)
There is no hard data on what percentage of donated bodies come from people living in poverty. Nor is there hard data on race. In fact, the ongoing issue of medical abuses of African Americans dissuades some people in the black community from donating. A 2004 survey of Maryland households found that people who agreed with the statement “White patients receive better care in hospitals than other racial or ethnic groups” were much less likely to consider donation.‡ Yet the economic incentive for donation means that some people who do donate are impelled by poverty as much as, or rather than, gratitude.
Medical students are taught to think of the grateful donors—the ones who wanted to give something back to the medical profession. We are encouraged to consider their cadavers as a “gift.”
There is a tyranny in giving, though—especially the gift that cannot be equaled. “How can I ever repay this gift?” I asked my friend Katie. We were sitting on the front porch of the yellow house one evening after her day in the hospital, and mine in the anatomy lab.
“You can’t,” she said. “It’s impossible. It’s too great. You just have to learn as much as you can, and try to pay it back by becoming a really good doctor.” In Katie’s eyes, it was right that medical students should begin our learning under the debt of a gift we cannot repay.
I find Katie’s point beautiful and right. But another side of this politics concerns those patients—those people, those bodies—who were too poor to pay for burial or cremation. Already in anatomy lab, we medical students begin by learning on the bodies of the poor. Knowledge gained from them makes us into doctors: I would never again look at a shoulder without being able to imagine the muscles, bones, nerves, and arteries that course under the skin. I learned to see as a doctor sees, from these particular bodies.
Were the people whose bodies I dissected victims of symbolic death while they were still living? Were they poor? I had no way of knowing. Along with my classmates, I disarticulated the body completely. Lungs and guts went into a sack. Skin was removed. The body was chopped in half at the pelvis. The top of the skull was sawed off and the brain was removed. (I did this. I move into the passive voice to describe it, but the truth is: I did it. I held the circulating saw as chips of bone flew into the air around me.) We sawed off an areola, sliced through an eyeball, cut penises in half
to see the chambers of flesh inside. If these people had been poor, it did not matter to me, because all I saw was the body in its parts.
This is the precise strangeness of learning to see like a doctor. If you believe hard enough in the truths of biochemistry and anatomy, what surrounds them—people with their suffering, the politics of a society that lay this particular body into your hands—seems not to matter at all.
One week, the air-conditioning across UTMB, which had been tetchy since Ike, failed completely. Classes were canceled, and our anatomy professors spent those days dumping ice into the coffinlike steel tanks that held our cadavers. These tanks work with a winch on both ends: two medical students pull the winch on either end of the tank, and the cadaver rises from a bath of preserving fluid (“cadaver juice”) to the top for the day’s dissection. When we winched up our bodies after the air-conditioning was restored, the tanks were so full of melted ice that cadaver juice slushed out all over our shoes. In the chest of our cadaver, between the pectoral muscles and the space where the lungs had been removed, a fluffy white mold had blossomed in the heat. I wiped it away with a gloved hand, and we carried on with the dissection.
No Apparent Distress Page 7