Xkam rute' Gerardo

I am filled with remorse and shame.  

Rosalina, always taking the pulse of her community, called a few minutes ago to inform me that Gerardo's mother passed away this morning.  I gasp.  How can this be?  My disbelief, refracted through my idiotic training, transmutes into an eruption of questions: What did she die of?  When?  Did they call the doctor?  Did she suffer a lot?  How is Gerardo's father?  

Rosa seems overwhelmed by my response but tries to answer my questions.  She died of her disease.  What disease?  The disease she had.  What disease???  She had a stroke a week ago.  I am searching for the proximal cause of death, but I give up.  It doesn't matter.  She had a stroke a week ago, and now she is gone.  She died very early this morning; they did call the doctor; the whole family is crying.

I thank Rosa for calling and tell her I will call again in a couple of days.  I close my eyes and put down the phone.  Suddenly, shame sweeps over me, and I cover my mouth, as Catholics often do when they enter the sanctuary and kneel in prayer.  Elena asks me who died and how it happened.  I become angry--not at Elena, but at myself as I realize my impotence, exclaiming, "I have no fucking idea!"

How disingenuous of me.  

She was treated for P. vivax in June when we left and got better.  According to Gerardo, she  began having fevers again in July or August, and they got progressively worse and more frequent.  She became weak and anorexic again after a few weeks of increased energy and appetite.  She was offered another course of treatment for P. vivax.  A thick and thin smear was not repeated prior to this second course of treatment with the same medication.  A week ago, she suddenly became unable to use one of her legs and to speak.  Rosa explained that she passed away because she did not want to have a cholecystectomy, recommended by a physician in Pan Ajachel who detected incidental gall bladder polyps on ultrasound, which was ordered when she visited complaining of cyclical fevers and anorexia (with no belly pain, mind you).  Her CBC was unremarkable except for her ESR, elevated to 150, but no other labs were ever drawn to follow up on the ESR.  

I sit down and prepare myself to call Gerardo.  No answer.  I find that I am incapable of expressing myself in Kaqchikel, fumbling through a sincere but incoherent message expressing my condolences.  

I cover my mouth again with my hand and begin to acknowledge my complicity in her death.  I, a fucking medical student, tried to help her family navigate their care decisions.  They did ask for my input, and I feel quite sincerely that the doctor in Pan Ajachel was trying to take advantage of them.  And if I had been  there when she was unsuccessfully retreated for malaria and given no more follow-up, I would have told them this was fucking bullshit.  I told Gerardo in June and again a few months ago that I thought she needed to see a rheumatologist, that I thought there was something funky going on and it didn't feel good.  But the fact is that I wasn't there when the fevers returned, and I can't help but feel ashamed that I did not do more.  I did not do everything I could.  I did not try hard enough.  I did not make sure she was worked up for immunologic markers.  And now she is gone.  

I call again and get Erick, Gerardo's brother, on the line.  Again, I fumble and become silent.  He thanks me for my call and for my prayers.  I mean to ask how his father is doing, and I mean to give him my condolences.  My Kaqchikel fails me, however, and I realize that I have asked him if his father is well, and I have asked him to forgive me.  How callous I must sound.  I fumble on.

I am struck by Erick's lament--"we prayed for a miracle, but it did not come; we prayed to God, but she had to go."  A similarly untrue teleology is indicated by Rosa's answers to what she must have thought were morbid questions.  "She died of her disease; the disease that she had."  Explaining indigenous peoples' resistance to family planning and apparent acceptance of child malnutrition and mortality, a quite racist ladino physician once told me that among populations with high infant and child mortality, the death of a child is met with muted pain and sorrow in comparison to more healthy populations.  

Of course these lies expose themselves for what they are in moments like this--they melt into thin air, as it were, and become transparent.  But I cannot avert my gaze, and I am obligated to contemplate the imperious immediacy of unnecessary suffering and premature death.  The simple truth is that something should have been done to get to the bottom of what was making her sick, and the absurdity of the care she received is revoltingly grotesque.  I return to my initial response: How can this be?  How can this have happened?

Lest we fall into the trap of mystified resignation, however, I feel moved to continue searching for an answer.  Per Levinas, the ethical should reign supreme when we regard the pain of others; that is, epistemology is a load of fucking crap.  Nonetheless, I wonder: how useful is my "acknowledgment and affirmation" of her and her family's illness experience now?  And given the abject failure of my praxis, doesn't my rhetorical question ("how can this be?") simply rationalize my succumbing to the moral paralysis induced by cultural relativism? 

Our failure to provide a diagnosis and effective treatment (or even palliation) arose from very simple and terrible causes.  To anyone who would deny those causes or throw their hands up in the air ("what is to be done?"), I retort with one last rhetorical question: aren't you ashamed of yourself?

I am enraged and ashamed by her death.  I am ashamed that I had to write this entry, and I am ashamed that I feel compelled to share it with you, and that I have done so in this format and in this language.  Indeed, I am ashamed that I am able to share it with you at all, and that I am able to reconstruct the story without the direct input of Gerardo, Erick, their mother, Rosa, or anyone else living in Pa Poqolaj.  And I am ashamed that I do not have a picture of Gerardo's mother, and I am ashamed at my selfish sadness that I will not have another opportunity to sit at the edge of her bed, listening as she tells me how she is feeling.

Lover of men

Philanthrope - lover of men.

Philos - love.

Anthropos - man.  

The common usage of this word should be unsettling.  After all, who does not consider himself a lover of men?

Epistemic ruptures

Last week, in my section for the global health course, we were deconstructing commonly used algorithms for pharmacotherapy in major depressive disorder and DSM IV's diagnostic criteria for PTSD, and I described how I had been taught by psychiatry residents to use mnemonic checklists to diagnose pathology (e.g., D-I-G-F-A-S-T for manic episodes, S-I-G-E-C-A-P-S for depressive episodes), and one of my incredibly wise premed students asked, "How do we avoid becoming like that?"  She meant, I think, "How, in the many years we ultimately spend immersed in the hierarchical world of medical education, do we avoid becoming socialized and unreflexively adopting biomedicine's elitist, egotistical, and technocratic view of humans and communities?" 

I didn't have a good answer.  Initially, I thought about how this particular exercise would not be particularly forthcoming in a medical school class, requiring the application of discourse analysis to psychiatry.  So I said, "interdisciplinarity."  That was an unsatisfying answer,  though.   After all, in my own experience, I didn't simply decide to care about political economy and take time away from studying medicine and public health because I thought anthropology would prevent me from falling into the trap of cynicism.  Of course, I've taken to Arthur Kleinman's notion of "the interior intellectual life," and I believe anthropology will provide a regenerative balm that will help me to live a moral life in a world of danger and uncertainty.  

Nonetheless, I realized, even in my own life, that it is my lived experience of being present with others that has--albeit gradually--made me discern and acknowledge the imperative for analysis and praxis founded on justice and solidarity. At times, the more momentous experiences are accompanied by sudden, intensely embodied awareness (e.g., out-of-body transcendence in mapping political-economic history onto landscapes; deep gut-wrenching sadness as I am penetrated by a mother's lament).  At other times, these experiences seem unremarkable but remain with us nonetheless, shaping us in powerful ways that defy reason.  Reading La Prensa, for instance, before tearing it into strips to use as toilet paper in our outhouse in Pampojilá, I realized that this "respectable" publication contained little of relevance to the lives of the functionally illiterate women who were our neighbors and patients, providing little more than colorful advertisements for commodities worth a month's wages and Ladinos' analyses of national Ladino politics.  Indeed, those pages were not worth anything more than to wipe my ass with.  Whatever it is that triggers us to feel the presence of the numinous, and whatever it is that causes toilet truths to be indelibly imprinted in our minds, it has been in trying to understand such experiences--and elaborate plans for praxis based on them--that I have realized that, to develop accurate, honest analyses of health and illness that are in solidarity with the poor and marginalized, I must engage the methods and modes of analysis of anthropology, which were my first vehicle into the study of inequality and resultant suffering.  

In Mountains Beyond Mountains, Tracy Kidder asks Paul how he came to the perspective he has on Haiti and on the world.  Paul explains that it was a sort of gradual process in which he witnessed a lot of things and learned a lot of things about history and liberation theology, and that he eventually just came to see the world the way he does.  Then, he second-guesses himself, saying, well, there was this one time... and he describes the story from very early on in his engagement in Haiti of a pregnant woman with severe malaria who needed a blood transfusion to survive.  Paul didn't have enough money on him, so he ran around trying to collect money for the unit of blood, but ended up getting just enough too late.  The woman died, and her sister, who had accompanied her to the clinic, began wailing,"Tout moun se moun! ("Every man is  a man!")  This caused what Kidder calls an "epiphany," and which I think it'd be better to call an "epistemic break."  That is, we walk around and have a certain understanding and established knowledge of the world and our place in it, and sometimes things don't turn out as they're supposed to but overall things are pretty stable and normal.  Then come moments that suddenly turn our whole epistemology on its head--or, perhaps, back onto its feet--because we can find nothing in our previous understanding or experience that explains away the moment.  Living and working among the poor does often cause a slow epistemic shift, as Paul initially describes, but the centrality of epistemic breaks in the narratives of those we seek to emulate is important to note, because we stand to learn a great deal on how to approach our own personal struggles to live moral lives.  If nothing else, we might come away understanding the importance of alertness or receptivity to "epistemic breaks" in all their potentially mundane and extraordinary manifestations.