A moment of hope

Below is a poem of hope for those physicians out there, or anyone who works extremely hard for long periods of time, as physicians are apt to do, for William Carlos Williams was a poet-physician.

The Desolate Field
William Carlos Williams

Vast and grey, the sky
is a simulacrum
to all but him whose days
are vast and grey and —
In the tall, dried grasses
a goat stirs
with nozzle searching the ground.
My head is in the air
but who am I . . . ?
— and my heart stops amazed
at the thought of love
vast and grey
yearning silently over me.

There are three images in this poem.

The first image sets the background, the vast and grey sky, a simulacrum, or false representation, for everyone except for those of us whose days are vast and grey, those who work long hours, perhaps feeling burned out. For those people the vast and grey outside mirrors the vast and grey inside, and it is clear that the writer is one of those people.

The second image is a contrast between the mindless goat and the man with head in the air. He goes through a thought process of realizing his head is in the air, that he is better, that he can think, and then returning to the humble realization that, like the goat, he also does not know who he is.

The third image is the ultimate conclusion. Love. The experience of love is the answer to all questions. With the same intensity that we experience the bleakness of a numbed, blanketed grey sky monotony, the author flips his image in an instant to the prospect of a warm, existence-encompassing love.

This mental flip concretely describes a person experiencing hope. Hope is not this abstract, ill-defined thing–it can be articulated clearly, in terms of a specific psychological process as William Carlos William does here. Perhaps the cognitive-behavioral therapists among you are saying, duh! But for the rest of us, we sometimes need a reminder.

What a beautiful journey we have taken together in the space of 13 lines of poetry. From desolation, to self-awareness, love, and hope. To see that hope, my friends, is a concrete act.

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Firewheel Tree

Have you ever reflected back over your life? Your decisions, joys, hungers, fears?

When I was studying for my boards I was introduced to the work of Erich Fromm, a classic thinker in social science, perhaps best known among psychology students for his theory about development of the human personality. Fromm suggested that a healthy personality is built on a person going through various life stages, and acquiring normal, positive personality traits in the process.

For example, Fromm draws on Freud to argue that self-control is first learned through the process of potty training, while a certain work-ethic, an industrious productivity, is first developed in school. Finally, a person reaches old age–they have, hopefully, lived a good life. As the prototypical healthy elderly person walks the streets of their prototypical village, they develop a directedness towards the next generation, and to making their lives better. A tongue-in-cheek example of when an older person has developed this healthy attitude is that they will see lovers in the park and think, “Ah exquisite Love!”, instead of feeling despair at a past divorce.

I know that I will struggle with this final stage. Built into my personality is a certain cold realism, and so I present this poem by Douglas Stewart, an Australian poet born in 1913, to those of you who can relate to this attitude:

Firewheel Tree
Round and round, those wheels of fire,
My hurt, my fear, delight, desire,
Hung whirling in that dark-green tree.
I could not tell, so fast they spun
Like scarlet star and crimson sun
In all the leaves’ intricacy,
What incandescence clear or sombre
Might light one flower from another,
Delight or fear or agony;
But all in that same shape they blazed
Of flame whirled into symmetry.
And round they went — I stood amazed
In hurt, in fear, delight, desire,
To see my life in wheels of fire
Go round that dark and silent tree.

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Dying and Practical Identities

Let’s talk about dying the right way. Yes, there is such a thing.

Do not go gentle into that good night

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

-Dylan Thomas

To prepare for death we often prepare advance directives, a document that plans how medical providers will care for us in our final moments. But traditional advance directives often only tell doctors a small subset of the things that are important to someone in their final moments–whether they want CPR, and a handful of other life-sustaining procedures. But does someone want to die at home? What is the role of religion in their final days? If a risky procedure has a small percentage chance of success, would they rather take the risk or not?

Legally, when an advanced directive is not present physicians are expected to use “substituted judgment”, or what the patient would want. Using the same logic, before a situation presents itself where a person is unconscious or incapacitated, Kenneth Richman, the philosopher I’ve been reviewing lately suggests that an advanced directive document should be built with a patient’s goals and identities in mind–“what they would want”.

Advanced directives can be built by understanding a person’s “practical identities”. A person may be a mother, soccer player, or soup kitchen volunteer, and each of these identities is related to how they will make decisions when the final curtain approaches. A physician tries to get a better sense of a person’s practical identities by asking lots of questions over time, but also using a tool called a “Values History”. This involves examining ones values and attitudes, discussing them with loved ones or advisers and writing down a response to questions such as:

How do you feel about your current health?
How important is independence and self-sufficiency in your life?
How do you imagine handling illness, disability, dying, and death?
How might your personal relationships affect medical decision-making, especially near the end of life?
What kind of living environment is important to you if you become seriously ill or disabled?
How much should the cost to your family be a part of the decision-making process?”

(Questions are from Page 142 of Richman’s book Ethics and the Metaphysics of Medicine.)

I always say that to die well it helps to have lived well. This is something we can all do better right now. Dylan Thomas, Ireland’s great poet, penned a war cry to his father to fight on, and depending on the circumstances, this is the right attitude–but land mines and shifting paths characterize the murky swampland of the final years, and having a plan for how to approach that final journey is empowering when circumstances take a turn for the worst.

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Health Qua Organism

In my last post I talked about a distinction between “health of the organism” versus “health of the person.” To reflect on this distinction, I want to present a poem by R.D. Fitzgerald, an Australian poet born in 1902.

Bog and Candle
By R.D. Fitzgerald

At the end of life paralysis or those creeping teeth,
the crab at lung or liver or the rat in the brain,
and flesh become limp rag, and sense tap of a cane —
if you would pray, brother, pray for a clean death.

For when the work you chip from age-hard earth must pause,
face with the dark, unfinished, where day gave love and jest,
day and that earth in you shall pit you to their test
of struggle in old bog against the tug of claws.

What need had such a one for light at the night’s rim?
Yet in the air of evening till the medley of sound —
children and birds and traffic — settled in the profound
meditation of earth, it was the blind man’s whim
to set at his window the warm gift of flame
and put a match to wick for sight not like his own —
for his blank eyes could pierce that darkness all known,
the thought: ‘What use the light, or to play out the game?’

Yet could disperse also the fog of that queer code
which exalts pain as evidence of some aim or end
finer than strength it tortures, so sees pain as friend —
good in iteself and guiding to great ultimate good.

Then he would touch the walls of the cold place where he sat
but know the world as wider, since here, beside his hand,
this flame could reach out, out, did touch but understand…
Life in a man’s body perhaps rayed out like that.

So it is body’s business and its inborn doom
past will, past hope, past reason and all courage of heart,
still to resist among the roof-beams ripped apart
the putting-out of the candle in the blind man’s room.

To summarize this poem in a few words, I think it captures the absurdity evoked by our existence as organisms and as persons. A blind man lighting a candle in a dark room serves as a reflection on aging, and a “goal as a person.” Even at death’s door this man has goals, goals to “put a match to wick for sight not like his own”, goals that continue to flicker and eventually diminish as the body, the organism, breaks down while he “struggles in old bog against the tug of claws”.

The absurdity, tragedy, and beauty of this poem lies in the fact that as the organism breaks down this man’s personal goals shrink, until they become nothing more than lighting a candle to light the way for others while standing at death’s door. This is the power of the human spirit manifest in poem.

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The Philosophy of the Social Determinants of Health

With a title like that, I’m glad you’re still here dear reader.

Is menstruation a disease?

We treat it with medication, and in fact from an evolutionary perspective no dog, monkey, or alligator forced to take a pill to stop its menstrual cycle would be considered healthy–it goes against the basic meaning of health for an organism, for an entity that wants to reproduce.

However, borrowing ideas from Kenneth Richman, I want to point out that health for an organism and health for a person are two different things. A person with a life plan that involves travelling the world and learning to salsa dance would not be doing well by having 8 children, and given the opportunity to control reproduction through medication, we commonly speak as if it would be unhealthy for a person with certain personal goals (world travel + salsa) to be pursuing contradictory personal goals (8 babies).

Why am I making all this fuss about health of the organism and health of the person. I want to, in a few short sentences, explain why medical education, especially medical education that attempts to explain to students the importance of the social determinants of health, should include an introduction to medical philosophy.

Plastic surgery is a medical specialty. It is partly concerned with the health of the human organism, as in reconstructive facial surgery, but more often it attempts to serve personal goals through breast implants or liposuction.

Understanding this distinction between health of the person and health of the organism is crucial, because if plastic surgeons were directed to providing health of the person, then the logical conclusion is that they should be allied with public health practitioners and psychologists in an interdisciplinary team to be promoting ideals about self-acceptance of the body. They ought to be pushing for billboards and commercials that idealize unrealistic body images to be removed from the environment. All this talk about changing the social environment is starting to sound suspiciously like social medicine! And the same arguments can be made for every other medical specialty…

I’ve tried to show you through these simple examples that Richman’s ideas about distinguishing between health of the organism and health of the person are powerful and radical explanatory concepts that can quickly transform the way we see medicine. If we care about health of the person, then classical medicine that teaches us to enhance the health of the organism can only take us so far, and social determinants theory that focuses on health of the person is needed to carry us the last few miles.

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Design Thinking and Lebanese Medicine

As someone who intends to work in Lebanon, I do not have the luxury not to borrow innovation. There is a historical trend of importing ideas from Western Countries that are more “advanced” that has flourished since Ottoman times. The Lebanese clearly idolize Western models. When I first discussed the problem of how to address counterfeit pharmaceuticals with colleagues in Lebanon the first question they asked me was: “How does America do it? Tell us, and then we can talk about how we should do it.”

But borrowing innovation is not importation, and the Diwali delivery service, Ferrari handoff, and sterile cockpit each represent genuinely new solutions. It is perceived as arrogant for a Lebanese person to say: “we can do it “better” than the Americans”, and, most of the time, we can’t. We idolize the David in David and Goliath stories—but Goliath usually wins. It takes a certain comfort with failure, an acknowledgement of the strengths and limitations of small organizations–which Lebanon as a nation forever will be—and an ability to believe that we can do better than blind “copy-paste” importation to create innovation instead of importation. The Lebanese have an entrepreneurial spirit, but we cannot progress without overcoming our historical preconceptions about importing “the original product” from the West and without nurturing a paradoxical combination of humility (recognizing our limitations) and self-confidence (recognizing our unique needs and strengths) to create local solutions.

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Chiapas 15

(If this is the first time you see this blog I suggest starting to read from “Chiapas 1” and onwards so that it all makes more sense.)

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Graveyard of Las Abejas massacre. See: http://en.wikipedia.org/wiki/Acteal_massacre

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Look at a community in which there is Oportunidades, the government program we discussed earlier that pays you to send your kids to school and seek healthcare. Look how the entire town is gathered around looking for their money.

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town "Here the people order, and the government obeys."

Compared to the previous photo, look at how different a Zapatista community is with a slogan at the entrance to town “Here the people order, and the government obeys.”

A photo of where the pacifist resistance group Las Abejas was killed and buried.A photo of where the pacifist resistance group Las Abejas was killed and buried.

photo (5)

A Zapatista school

A Zapatista school

Lucky 13 will be my final post, and as I sit in the Jaltenango office waiting to fly home in a few days–doing hardcore Excel and Access manipulations to support the pasante’s information technology system and researching Chiapas history, I am enjoying a light 38C fever and stomach ache. After the course the team have each gone their separate ways, some back to work in their communities and some to vacation, and I am locked up in the office trying to accomplish something productive to contribute to the team.

This final post will focus on the Zapatista movement and its influence, and a brief note on the threat of mining corporations.

On January 1, 1994, rumors of war traveled throughout the Sierra Madre. It was said that “indigenous brothers” had taken over the municipal capitals of Altamirano, Chanal, Huixtan, Las Margaritas, Oxchuc, Ocosingo, and San Cristobal.1 That day the local radio station did not broadcast, and people would later learn that the indigenist radio station had been occupied by Zapatista troops and that technical problems had prevented them from broadcasting to borderland inhabitants “The First Declaration of the Lacandon Rain Forest,” a beautifully written document that summarizes some of the history we reviewed together in my posts:


We are a product of 500 years of struggle: first against slavery, then during the War of Independence against Spain led by insurgents, then to avoid being absorbed by North American imperialism, then to promulgate our constitution and expel the French empire from our soil, and later the dictatorship of Porfirio Diaz denied us the just application of the Reform laws and the people rebelled and leaders like Villa and Zapata emerged, poor men just like us. We have been denied the most elemental preparation so they can use us as cannon fodder and pillage the wealth of our country. They don’t care that we have nothing, absolutely nothing, not even a roof over our heads, no land, no work, no health care, no food nor education. Nor are we able to freely and democratically elect our political representatives, nor is there independence from foreigners, nor is there peace nor justice for ourselves and our children.

But today, we say ENOUGH IS ENOUGH.

We are the inheritors of the true builders of our nation. The dispossessed, we are millions and we thereby call upon our brothers and sisters to join this struggle as the only path, so that we will not die of hunger due to the insatiable ambition of a 70 year dictatorship led by a clique of traitors that represent the most conservative and sell-out groups. They are the same ones that opposed Hidalgo and Morelos, the same ones that betrayed Vicente Guerrero, the same ones that sold half our country to the foreign invader, the same ones that imported a European prince to rule our country, the same ones that formed the “scientific” Porfirsta dictatorship, the same ones that opposed the Petroleum Expropriation, the same ones that massacred the railroad workers in 1958 and the students in 1968, the same ones the today take everything from us, absolutely everything.

To prevent the continuation of the above and as our last hope, after having tried to utilize all legal means based on our Constitution, we go to our Constitution, to apply Article 39 which says:

“National Sovereignty essentially and originally resides in the people. All political power emanates from the people and its purpose is to help the people. The people have, at all times, the inalienable right to alter or modify their form of government.”

Therefore, according to our constitution, we declare the following to the Mexican federal army, the pillar of the Mexican dictatorship that we suffer from, monopolized by a one-party system and led by Carlos Salinas de Gortari, the maximum and illegitimate federal executive that today holds power.

According to this Declaration of War, we ask that other powers of the nation advocate to restore the legitimacy and the stability of the nation by overthrowing the dictator.

We also ask that international organizations and the International Red Cross watch over and regulate our battles, so that our efforts are carried out while still protecting our civilian population. We declare now and always that we are subject to the Geneva Accord, forming the EZLN as our fighting arm of our liberation struggle. We have the Mexican people on our side, we have the beloved tri-colored flag highly respected by our insurgent fighters. We use black and red in our uniform as our symbol of our working people on strike. Our flag carries the following letters, “EZLN,” Zapatista National Liberation Army, and we always carry our flag into combat.

Beforehand, we refuse any effort to disgrace our just cause by accusing us of being drug traffickers, drug guerrillas, thieves, or other names that might by used by our enemies. Our struggle follows the constitution which is held high by its call for justice and equality.

Therefore, according to this declaration of war, we give our military forces, the EZLN, the following orders:
First: Advance to the capital of the country, overcoming the Mexican federal army, protecting in our advance the civilian population and permitting the people in the liberated area the right to freely and democratically elect their own administrative authorities.
Second: Respect the lives of our prisoners and turn over all wounded to the International Red Cross.
Third: Initiate summary judgments against all soldiers of the Mexican federal army and the political police that have received training or have been paid by foreigners, accused of being traitors to our country, and against all those that have repressed and treated badly the civil population and robbed or stolen from or attempted crimes against the good of the people.
Fourth: Form new troops with all those Mexicans that show their interest in joining our struggle, including those that, being enemy soldiers, turn themselves in without having fought against us, and promise to take orders from the General Command of the Zapatista National Liberation Army.
Fifth: We ask for the unconditional surrender of the enemy’s headquarters before we begin any combat to avoid any loss of lives.
Sixth: Suspend the robbery of our natural resources in the areas controlled by the EZLN.

To the People of Mexico: We, the men and women, full and free, are conscious that the war that we have declared is our last resort, but also a just one. The dictators are applying an undeclared genocidal war against our people for many years. Therefore we ask for your participation, your decision to support this plan that struggles for work, land, housing, food, health care, education, independence, freedom, democracy, justice and peace. We declare that we will not stop fighting until the basic demands of our people have been met by forming a government of our country that is free and democratic.

General Command of the EZLN2

Where did this movement that burst forth in 1994 come from? Apparently in the 1970s indigenous people from all over the state were gathering together to colonize a rain forest East of the Sierra area where our medical team works. Immigrant Guatemalans and mestizo peasants converged with indigenous people of many ethnicities along with a Maoist organization called Popular Politics. The exchange of experiences has allowed many global perspectives and political and religious ideologies to coalesce into a political-military movement.3 After the Zapatista uprising the government set up a huge military base nearby, but this did not deter local communities who now felt a radical sense of empowerment. On January 27, 1994, the Mam Supreme Council of the lowlands led a demonstration in front of the local office of the Ministry of Agrarian Reform, demanding restitution of the lands of Finca La Patria (remember Fincas are the old farms that began during plantation times, 1910-1930s): “If you are not going to grant us the rights over our ancestral lands, then make the necessary formalities so that our fifty families can have passports to go work in the United States, for we are already foreigners in our own territory, being displaced by finqueros from other countries who have become lords of the Soconusco.”4 (Recall the finqueros that started in plantation time 100 years ago were American, German, Swiss, Italian, Ladino, and of other international origins, and apparently the people see this as unchanged to this day.) A flurry of peaceful civil protests supporting the Zapatista cause began throughout Mam and Sierra populations, causing friction in indigenous organizations when some members chose to support the cause while others preferred to stay out of the conflict. “The organization, the religious group, the community, and even the family are now crossed over by a line dividing those who favor the Zapatistas and those who favor the government[!]”5

Since the first violent conflict with the government, which became a ceasefire within weeks due to international pressure, the Zapatistas have operated peacefully and are actually running the government instead of the federal government in several municipalities in the area. In December, 2012 a silent march demonstrated to the world that the Zapatista are still active, still working hard in their communities. To quote Roar Magazine: “The Story of the Sword” is an ancient parable that demonstrates how the indigenous peoples of Mexico can finally defeat the European invader. “The tree”, says Subcomandante Marcos when narrating the story, “tried to fight the sword, but was defeated. The stone likewise.” But not the water. “It follows its own road, it wraps itself around the sword and, without doing anything, it arrives at the river that will carry it to the great water where the greatest of gods cure themselves of thirst, those gods that birthed the world, the first ones.”6

I asked a friend I met who had visited Zapatista areas to get a personal account of a Zapatista’s life:  “The Zapatistas are campesinos. They work in their lands. They suffer a lot because they are separate from the system. Both men and women work hard, and they share food–they barter e.g. jam for coffee. They feel that they are a different community because they have dignity–and this comes from having autonomy. They have a hospital and clinics in each town served by health promoters. The level of education of these medical personnel is not the highest but they are open to any volunteer who wishes to teach. Preventive care did not seem to be prominent, but they seemed to have the same medications as the government hospital.”

When I asked this friend about a critique of the Zapatistas, that the community is very hierarchical, that Sub Commandante Marcos and his colleagues are very controlling of the population, he responded: “In fact I was told that the government is a direct democracy: all decisions are made by every member of the community, both men and women. In Zapatista communities the women’s voice is more heard and respected, and they are leaders in feminist thought. Zapatista feminist claims have trickled into other communities of Chiapas. When the decision requires coordination between many municipalities a representative is chosen to represent the opinion of the town. If this representative gives his own opinion instead of the communities opinion she or he is immediately deposed.” When someone asks them “Can I work with you?” The answer was “We are not looking for people to join us. We are asking people to join the revolution. We don’t need more people.”

A final challenge to the Zapatista model is their application of communism. So if someone works hard he or she does not receive more, he still needs to distribute his production to his neighbors. If a Coca-Cola is being drunk, everyone has to drink it together… Some people have emigrated to the United States when given the opportunity because of their distaste for this system. Let me end this summary of the Zapatistas by saying that first, to be clear Companeros en Salud is not affiliated with this group, that the Zapatista communities work very hard and suffer, and that their lives are not a romantic vacation in the jungle. Perhaps this is the cost of human dignity, and perhaps it is too high a price for most people to pay. The comforts that the mass market and multinational politics can bring are tempting.

Before ending I will describe a new controversy with the government pushing privatization of ejido land (land that began to be distributed by the government starting in the 1930s) that would allow multinational corporations to buy pieces of land in the community. When you purchase any piece of land in Chiapas the first 20m are owned by the land-owner, but deeper than that the land is owned by the federal government. Thus if a single piece of land is purchased and mining rights are given the company can dig deep under other community lands until the soil is polluted and entire communities stop being able to produce coffee. This is scary, but so far the communities in which we are working are fiercely opposed to these mining operations, which limits the government’s ability to give mining rights.

Although violent gangs still exist, the communities in which Companeros en Salud operates are peaceful and not sites of active conflict. So do not start panicking with all these stories of guerrilla warfare and mining.

I am going to end these thoughts with an invitation to support the wonderful team here doing excellent preventive medicine and primary care in isolated communities throughout Chiapas, to do so with a deep knowledge of the people and their experiences, their feelings, thoughts, and beliefs. In the month I was here I did no more than learn how little I know. If your experience is anything like mine, you will laugh often, eat well, work too hard, be touched by the stories of people’s lives and a shared humanity that has been oppressed in the most inhumane ways. This is one of the places where I can express my solidarity with those who wish to work the land free from oppression, as I work to fulfill my childhood aspiration to become a member of an international community of people that sustainably live off the land.

1: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.204
2: http://flag.blackened.net/revolt/mexico/ezln/ezlnwa.html
3: Histories and Stories from Chiapas; Border Identities in Southern Mexico. R Aida Hernandez Castillo. 2001. pp.206
4: ibid. pp. 208.
5: ibid. pp. 214.
6: Roar Magazine: http://roarmag.org/2012/12/zapatistas-march-chiapas-mayas/

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