No one restrains my arms above my head when I lie back on the gurney. The doctor, an anesthesiologist, does not wear an apron soaked in blood as he goes through his pre-operative checklist. And the needle the nurse nests in my punctured cephalic vein has not been threaded first in another’s.
Here, the air is empty and scentless. Not heavy with humidity, ill with iodine vapors, peppered by the sun-stoned flight of half-slumbering flies. Here, attendant faces are uncovered and curious, hold eyes that meet mine, move mouths to answer every question and offer every answer. As if, here, every question has one.
I too am a doctor, a doctor whose pursuit of medicine is fraught with self-doubt, who questions his own motives, who fears that in delivering medicine, other things, unseen and unsalutary, are delivered as well. But I’m here, at Oregon Health and Science University Hospital, I remind myself, about to be operated upon by the best otolaryngologist in the city. My wife is succumbing to the same surgery right now, by the same doctor, sharing and suffering from the same injuries and the same cure.
Doctors are patients all the time. There is nothing special about it. Doctors remove the outer ears of other doctors every day, the auricles of fellow physicians for the sake of freer fingers, freed to spin cartilage-grafted eardrums for their eardrum-less colleagues. But I have trouble with doctors, with doctoring, with being a doctor myself, long-standing troubles that began as a nineteen-year-old pre-med student, a volunteer in a rural east-African hospital, one summer twenty-one years ago.
It was the eighties. Anti-apartheid, Central American solidarity, and antinuclear student movements were catching fire on college campuses. The culture at large, however, the “moral majority,” fretted over other issues: the corrupting influence of sex outside marriage, the moral danger of Dungeons & Dragons, of the Dead Kennedys, of communism, of the “gay disease” spreading as a lesson and punishment across the nation. “We Are the World” and “Do They Know It’s Christmas?”—a double-punch of thick-headed white-savior Africa-aid songs—dominated the airwaves as famine spread across Ethiopia.
From an early age, cloistered in lily-white and liberal Boulder, Colorado, I was susceptible to the sentiment in these songs, that if only people cared, if only people stopped their lives for a moment and stepped away from their routines, the very desire for something to be solved would be enough in itself to solve it. I watched the Exxon Valdez oil spill and the Chernobyl nuclear disaster on the family TV and wished I could skip high school, fly there, and be part of the solution. Now, finally, I was going off to college where I would become a doctor, and not any kind of doctor, but one who treated people in the worst scenarios, one who made a difference.
In that first year away from my parents, I let my hair grow wild, my clothes baggy, tie-dyed, and Guatemalan. I gravitated toward this aesthetic instinctively, I suspect. It was as an effective if inelegant way, not knowing any other, to cut ties with my conservative high school background, one of skinny leather ties and feathered hair, of polos and pastels and Miami Vice white blazers for the prom, a world of homecoming queens and kings, football stars and Ivy League dreams.
My mother taught aerobics. I made the mixtapes for her classes. And it was an older student of hers whose son, a doctor in rural Massachusetts, had set up a sister-city exchange with a rural Kenyan hospital near the border with Uganda. Buoyed by the “shantytown” anti-apartheid protests I participated in the previous winter, sleeping outside in cardboard boxes with activists and the homeless on the campus quad, headlining the local nightly news each night, visited by the likes of Jesse Jackson, appearing in the papers as far away as South Africa itself, I would go to Kenya that summer and make a difference there as well.
And at first, our arrival met my triumphal expectations. My companions, a nurse and dietician, two Massachusetts women much older than me, would stay a short time before I began my work at the hospital without them. We explored Nairobi together, went on safari, traveled to the sister-city village north of Kisumu where we were greeted by a choir of colorfully clad singers, and invited into the chief’s hut for a meal. A long-time vegetarian, I accepted the wooden bowl of chicken hearts with grace. I ferried the rubbery organs to the back of my estranged throat, nodding with approval as I did so. I gagged them down, one after the next, only to have my effort rewarded with yet more hearts for my bowl.
Our lodgings in the village were spartan but the absence of comfort was exotic. Each morning we washed from buckets of cold water carried from the river. Each night the hot air filled with fireflies, and moths the size of birds. Each day we crossed the equator during the long sweltering walk beyond the village to the hospital and back. Imagine that, I thought, a life in both hemispheres. It seemed otherworldly, romantic, important to me. We’d pass hunched women carrying outsize loads across their bony backs, erect women balancing the same atop their stiff-necked heads, husbands limp in the distance, lying drunk in the shade of a field’s only tree. We’d say hello to the strolling village priest with his tattered bible, his neatly ironed and creased polyester slacks, his button-down wide-lapelled polyester shirt, his penny loafers, blazer, and Rolex knockoff. Regardless of how painfully ill-suited it was for the climate, it was the imported attire of the men.
The hospital was like that too, similarly ill-suited to the village it served. A collection of stately cement buildings painted white on clean and well-manicured grounds, it stood physically apart from and above the town, distanced from it.
We conducted rounds with the on-shift doctor on our first day. The patient ward, a long, high-ceilinged cement room, was lined on both sides with cot after cot into the far distance. The air was humid with iodine and each bed bore a body, sometimes two for lack of space. We walked between countless beds, to the left and right of us, between countless patients ailing beneath threadbare sheets, waiting for their moment with the doctor. Or for that moment to pass.
Curtain dividers on wheels existed here and there but privacy had been mainly abandoned for expediency. We stopped at the foot of the bed of a man being catheterized, the rubber tube threaded forcefully through his urethra until urine burst into the kidney-shaped pan between his legs. The doctor pulled off sheets from this patient or that one, revealing a thigh or a breast to show us a rash or a growth or an ulceration, without pausing to say hello, to make eye contact, to ask permission. That is, if there was time for such things. He was the only doctor on-shift, one doctor with over a hundred beds, and there were only two doctors available at all.
Yet no one complained, neither doctor nor patient, and there were no displays of shame. If people were angry or wounded they hid it behind an impenetrable, unnerving impassivity. Earlier in the week, driving to a site where the Massachusetts sister city had funded an agricultural project for high-yield corn, we encountered a man who had impaled his eye. A rod extended several feet from his eye socket. We were asked to give him a ride for help, but he himself showed no emotion, did not exhibit pain or anguish over an eye whose sight would clearly not be retrieved. I was haunted by this silence and stoicism. Could it simply be a difference of culture, or was this how any culture would respond in the face of so much death and misfortune? I didn’t know.
I was brought to meet the nurse who would supervise my time at the hospital, a short, wide, heavy-jowled man with ribs of skin below his bloodshot eyes. Here the patients were outpatients, people who walked from the village for diagnosis and stood behind the nurse in something halfway between a line and a crowd as he addressed me.
“We’re going to have you feel spleens,” he said, looking at me, at my long disheveled hair, my batik shirt, my cargo pants and sandals, with suspicion.
He pushed the closest patient forward, who obliged by lifting his shirt to just above his nipples. I was taken aback by the mention of a spleen. Why the spleen? Where was it? What exactly was a spleen for ?
Impatient with me, the nurse took my hand and pressed it firmly into the patient’s abdomen, up and under his ribs. “On the left,” he said, catching on to my immense ignorance. “Tell us if it is enlarged. We have to screen malaria this way.”
I yanked my hand from under his and backed away. I knew right then I wouldn’t touch another spleen. Not one more. There had been some terrible mistake. A terrible confusion. I thought I’d be taught some basic skill, taking blood pressures or temperatures, swabbing throats or performing introductory intakes, like I had as a volunteer in a free clinic back in Colorado. Pre-med students didn’t study medicine—not anatomy, pathology, microbiology, or clinical and physical diagnosis. Not in America at least. Just the basic sciences: biology, chemistry, and physics. I couldn’t be relied on to diagnose malaria, to diagnose anything at all. I didn’t know that malaria affected the spleen, let alone what a spleen was . Perhaps they learned these things here by the necessity of doing them, but no one would be checking my work. I couldn’t bear that responsibility, of someone dying because I said their spleen was not swollen when, in fact, it was. I stood against the wall and watched the rest of the shift with hands in my pockets.
The patient ward, my brief tour of it, the spleen I’d touched and the countless I hadn’t, had shaken me with the fear, the knowledge that the world’s suffering was never-ending and bottomless. And if the doctor himself was drowning in the face of it, what in the world could I, armed with nothing, offer anyone? The idea of being alone here, of being left here alone, the alarm that this wasn’t an idea at all but my looming reality, the terror of it began to take hold of me. I could still smell the iodine, the acrid tang of urine spitting out the catheter, feel the impatient hand pushing mine into the mysterious organ of another. I couldn’t stay.
Yet the nutritionist and dietician left as planned, and I was still there, carried by the inertia of previously-agreed-to plans, doomed but living in a mostly unoccupied dormitory on the hospital grounds, in a cement room next to Solomon, the medical student, the real medical student who had taken me under his wing, or been asked to do so. This is what they must’ve thought I was, a medical student, not a first-year undergraduate who hadn’t taken any classes remotely related to the human body and its failures.
All the medical staff, of which I somehow now belonged, ate in a large cafeteria, at long tables with floral-patterned vinyl table cloths. Chickens ran between our legs and under the chairs while we ate, surely the same chickens as those in our stew that we ate every day with ugali and sukuma wiki. I drank my five daily chais here, at meals and during the mid-morning and mid-afternoon tea times, milky and sweet. I listened to stories of the last white person to visit and work at the hospital, an Irish doctor, ages ago, who they all laughed about and loved. I regularly met eyes with a beautiful young woman here, a woman who kept her hair, unlike mine, so short you could see the true shape of her skull. And I’d watch the meaningless screen of the always-on TV here, with its flickering and ever-flipping half-image, its fuzzy, crackling sound cutting in and out, a tease of a connection to an unreachable elsewhere.
My attempt to be a wallflower for the next month was interrupted by Solomon during the first week in the dormitory bathroom. “We could use you in the operating room,” he said, simply stating a fact. He was a surgical assistant and he was my only steady social connection. Each night I sat in the back of the doctors’ car with Solomon. Our shoulders banged against each other as the doctors maneuvered the deeply-rutted dirt road in a darkness so strong it swallowed the headlights before they illuminated anything at all. We got drunk on Tusker at the nearby bar, downing beer after unrefrigerated Kenyan beer to the Zairean music of Tabu Ley Rochereau on the jukebox. The waitress-prostitutes looked upon me with a motherly curiosity, variably adding new bottles among the empties amassing at our table, or disappearing upstairs with one customer or the next.
I was terrified, not of surgery, but of what they thought I could do to help. As the doctor created a wound, and a wound within the wound, as Solomon pulled and peeled back layers of connective tissue and fat, teasing away flesh, a glistening pink, yellow, and brown, with his surgical clips and clamps, he gestured to me with one of them, beckoning me to approach and help, to assist with the pulling back and securing of tissue so the doctor could go deeper within. But I couldn’t.
In their blood-soaked aprons, standing in pools of blood of their own making, the stagnant air peppered with slow-motion flies frozen in the heat, they looked like butchers.
During the tour of the patient ward, back when I was still a visitor, the doctor had gestured to the half-open door at the far end of the room, to an unlit windowless space at the end of the building. I could just make out a few shadowy forms past the doorway, shrouded in a dungeon-like darkness.
“A room originally for lepers,” he said. “There are still some, but it’s for AIDS now.”
The doctor did not go into this room, did not check on these patients apparently left to die with their stigma. We were close to the epicenter of the worldwide epidemic, the highest incidence of AIDS, nearly one in four people, occurring just over the border in Uganda. And the eighties were also the height of ignorance about what AIDS was . American parents pulled their kids from school if there was an HIV-positive student, President Reagan had prevented his Surgeon General from addressing the disease because it befell those who deserved it, and in Kenya we heard tales, true or tall no one knew, of how it could pass through condoms or be passed by saliva, by a mosquito, by a toothbrush or a small unknown cut on one’s finger or in one’s mouth.
I couldn’t approach this blood, stand on the floor still tacky with it, slide my hands into it at ground zero of the planet’s greatest plague, baptize myself in its hemic spray. I couldn’t.
Sensing, yet again, that their American visitor was not adding his two hands to their efforts, they found a way for me to help nevertheless. Anesthesia would often wear off mid-operation due to inadequate supplies. And patients would begin to revive and want to sit up. I would stand behind their heads, far from the work of the surgeon, and my hands would hold down, above their heads, the arms of those unfortunate enough to revive prematurely. This became my job for the rest of my stay.
Yet it wasn’t the blood, the heat, the flies, the lack of anesthesia, that sometimes made me want to pass out as I held down a half-open, half-aware patient in pain. Or not mainly these things. It wasn’t the bandages soaked in iodine, washed and drying in the sun waiting to be reused on another. It wasn’t the surgical equipment that looked better suited for an auto shop, boiled between uses for lack of an autoclave, the only way to kill viruses and retroviruses. It wasn’t the surgical manual, dating from World War II, and its regularly missing pages. It was the emotional distance between doctor and patient, the patient I was purportedly holding down to help, the half-unconscious prematurely-aged woman having her tubes tied after innumerable pregnancies, whose abdominal skin could be lifted up like an accordion of crepe paper, who the doctors mocked because her vaginal tissue was too lax to hold a speculum.
The villagers called the hospital “The Place of Sad Faces” and many wouldn’t come here except as a last resort. I could see them in the distance, carried on stretchers by loved ones, sometimes even dying of a disease the hospital would’ve had the means to prevent. Often at night, lying in bed, I could hear the drums, a wailing to the beat of them, out in the distance. The sounds of funerals for those who had died, or a healing ritual for those still drawing breath? I did not know. Though neither ritual would’ve been welcome here at the hospital compound. I was coming to understand something about why this place was called what it was.
One day, a mother brought her daughter with the most commonplace of problems: a bean stuck in her ear. There were no rooms to examine her so the doctor met her in the shade of the cement courtyard. The girl shook with terror behind her mother when the doctor arrived with a surgical mask still obscuring his face. He held before him a giant metallic syringe meant to irrigate her ear that must’ve looked like the world’s largest needle to her. Her mother sat next to her daughter on the cement bench and held her but every time the menacing masked figure tried to approach with the tip of his syringe, she shook her head in adamant and violent refusal.
The girl was laid down on the bench sideways, her mom securing her arms and head, Solomon and I trying to secure her legs. The surgeon hovered over her, but before he could get the tip of the syringe to her ear, the girl summoned a strength powerful enough to kick and thrash despite our combined efforts. The doctor returned with a sedative and injected it into her arm but to no avail. He prepared another cc of sedative and injected her again. And yet again she kept thrashing. A third cc was injected when finally she became quiet, unresponsive. That is, until the cold metal of the irrigating syringe touched her outer ear, its presence awakening her body, if not her consciousness, into rebellion. Finally the doctor abandoned the syringe and worked on her ear with a pair of tweezers, pressing down on her head with his forearms. His gloved fingers blindly fished for the unseen bean as blood gurgled up around them. Her head was lifeless but bleeding. He retrieved the bean but later when I asked, he said matter-of-factly, she’d probably be unable to hear in that ear any longer.
My wife is probably out of surgery now, a new eardrum built from cartilage they harvested from her own body. Her outer ear reattached, I imagine she is resting, her hearing and her facial nerve hopefully still intact post-surgery. I am on my own gurney, lying back with a properly sterilized needle in my unrestrained arm, awaiting the same fate, performed by the same doctor, But I’m not thinking of this personable man, a doctor with tinnitus himself, a doctor who uses a white noise machine to fall asleep at night.
I’m thinking of the girl with the bean in her ear. And I’m wondering why her doctor did not remove his mask, did not kneel, explain and reassure. The absence of these small gestures, these small kindnesses at the hospital puzzle me to this day. Were the hospital staff from different tribes than that of the village? Were they, as medical professionals, from the city and unable to relate to their rural counterparts? Was it the hospital’s origin as a mission hospital and the legacy such a mission implies? Or was it the medicine’s own self-regard, as the one true medicine, universal and value-free, that kept it from going down into the village and bending itself towards it? Perhaps it was the never-ending suffering at the hospital, in daily life, the lack of human resources to match it, the absence of money, that made it impossible to slow down, to stop and open one’s heart? Or was it something else?
I’m thinking now of two eardrumless girls, not in Kenya but India, sisters, street children, the last people my wife and I remember before the blast wind blew us, two travelers, off our feet, unconscious, to somewhere else, ultimately to here. They too have surely lost their eardrums yet likely they live and will live, unlike us, without them now.
I’m marveling, that I still became a doctor myself somehow. A self-skeptical doctor, one who talks more than treats, who over-explains the dangers of every intervention, of every failure to intervene, who uses food and botanicals more often than pharmaceuticals, who won’t wear a white coat or address his patients from behind a desk.
And I’m thinking now of the terrorist who bombed us, a member of the Indian Mujahideen in Pakistan, a man who, improbably, completes the circle by being a doctor himself. Others might ask how a doctor could be a terrorist, could go to work one day to help a patient and the next to make a bomb. Others might say he is a psychopath, which he very well might be. But I do not say or wonder these things. Instead I wonder what he has seen in his practice in Pakistan, what daily horrors he witnesses, what unspoken messages are sent within the medicine he delivers, how those horrors and messages connect to the hierarchy of power and submission in the world at large.
When the young Pakistani doctor claimed responsibility for his attack, he did so by an email to the press. But its subject line reads less like a declaration of victory than a script, a medicine delivered from doctor to patient, to this doctor-patient, as if his prescription, “Let’s Feel The Pain Together,” was written for me.