Fabulous Prizes III

This post has two functions: first, to award the latest in the series of unsolicited awards I announced some time ago; and second, to solicit responses from anybody reading this who is an investigative journalist or who knows one, since I think our winner is worthy of some public mention.

Today's prize goes to a previous winner in this series, an institution which for the moment I will refer to as Local University Hospital (LUH).  LUH won the first prize I awarded, the (in retrospect somewhat anemically phrased) award for "Least Flattering Response to a Conflict of Interest Between Patient Care and Hospital Finances."  Let me briefly recap the situation which landed them this dubious honor: about half-way through my internship I met a patient in clinic who had suffered from intractable diabetes, which resulted in renal failure and a number of other complications.  She was referred to the LUH transplant program, where their star team of surgeons and nephrologists elected to perform a kidney-pancreas transplant.  The operation was a miraculous success and a credit to her physicians, in that it cured her diabetes and her renal failure simultaneously, thereby massively extending her life expectancy and the quality of life she could be expected to enjoy.  So long, that is, as she continued to receive regular follow-up care from a physician experienced in the management of transplants. 

As I detailed in my last post on this case, transplants are themselves a disease.  The whole point is that they're usually preferable to the disease you used to have, but they nonetheless require constant expert monitoring and frequent titration of life-sustaining medications - not unlike, say, congestive heart failure, coronary artery disease, or diabetes.  LUH won the award because after her transplant, the patient no longer needed dialysis and therefore was no longer eligible for Medicaid, the federal insurance program which had covered her treatment, and they responded to her loss of coverage by declining to see her further in their clinic and advising her to follow up at a public hospital.  To put it simply, they cured her original disease by giving her a different, far more manageable one, which they then declined to treat, preferring to leave her care to an intern a few months out of medical school with no experience in transplant medicine working at a county hospital (i.e., me).

Since that original post, she has been admitted to LUH twice for episodes of serious transplant rejection (only, I should add, after I had arranged for the County to pay for her admission).  Would this have happened if she had been under the care of a transplant nephrologist, rather than an overworked medical resident who only has clinic once a week, and whose clinic is frequently cancelled because he is on-call or post-call?  Probably not.

However, these ignominious failures clearly fall under the remit of the original award LUH received back in 2009.  Whence this renewed recognition?  Well, last time I was on the wards I admitted a second patient with nearly the exact same story.  She also developed renal failure young, she also received at transplant at LUH, she also lost her insurance, and whe was also turfed out to fend for herself.  During her hospitalization, I finally actually spoke to a transplant nephrologist in the LUH clinic, and asked him (as you might imagine,) some fairly frank questions.  Yes, he said, it is the policy of the clinic to refuse further care to people who lose their insurance.  Yes, there are a fairly large cohort of people whom they have performed transplants on and who have subsequently lost insurance.  Of course, he hastily added, they now screen people financially prior to transplanting them (thank God, by the way, that we don't ration care in this country, like those atheist communists in Europe) and, he went on, they categorically refuse to perform transplants on people whose only coverage is through federal insruance programs which predicate eligibility on dialysis-dependence, and who will thus predictably lose coverage when their renal failure is cured by transplant.

So they no longer transplant people like my first patient.  However, this policy change would have made no difference to my second patient, since she had the kind of insurance all Americans are supposed to have and on which our "system" is founded, i.e. insurance through her employer - she was just unfortunate enough to be laid off after getting her transplant.

Given this second case, and the implication of many similar cases, LUH is being awarded an even more prestigious prize, for Grossest Institutional Failure to Recognize And Abide By A Fundamental Principal of Medical Ethics.  I am referring, of course, to cumbersomely-named principle of "Nonabandoment," of which a recent Annals of Internal Medicine article has this to say:

In medical ethics, the term “abandonment” has customarily meant unilateral withdrawal by a physician from a patient's care without first formally transferring that care to another qualified physician who is acceptable to the patient. Abandonment means leaving the patient without care. As such, abandonment has been universally condemned as a serious and punishable infraction of both the legal and ethical obligations that physicians owe patients. Its converse, nonabandonment, is therefore a fundamental ethical obligation of physicians once patient and physician mutually consent to enter into a relationship.

I think it is hard to make the argument, in either case, that LUH is thinking very hard about their obligations to the patients they transplant.  It seems obvious to me that if you intervene in someone's body to create a situation of lifelong dependence on technical expertise which you possess, regardless of their prior situation, you have entered into the kind of relationship which is supposed here.  LUH's actions seem to me to be directly analogous to a doctor who intubates a patient in respiratory failure and then neglects to connect them to a ventilator because he isn't being reimbursed to manage ventilators, or a cardiologist who orders a pacemaker implanted but then refuses to monitor its efficacy (or transfer the patient to another cardiologist) when the patient loses their insurance.  Anybody who disagrees (e.g. lawyers for the tobacco, pharmaceutical, or arms industries) is warmly invited to post a rebuttal.

The fact is that LUH makes clear by their actions that what they are primarily interested in is the prestige which comes with a transplant program, and the star faculty and grant funding such programs can attract.  If they were genuinely committed to the well-being of the patients they operate on, they would not, as the Annals author put it, "[unilaterally withdraw care] without first formally transferring that care to another qualified physician who is acceptable to the patient," which is exactly what I have seen them do twice and what their own physican has told me is a matter of policy.  You might answer that there's a limit to how many patients they can continue to treat for free, to which I would reply that there certainly is, and it should be integrally and explicitly related to the number of patients they perform transplants on in the first place. 

Their medical negligence in denying people follow-up care is a diffused crime - the responsibility is certainly not only the transplant physician's, but obviously also falls to the administrators who tell them what they have to do - but it's a crime nonetheless. 

While I'm at it, I realize that they deserve a second award, which would be for "Most Egregious Failure To Explain The Possible Ramifications Of A Therapeutic Intervention To The Patient."  The first patient of theirs I saw, I recently discovered, had visited our gynecology clinic complaining of infertility.  Unbenownst to me, (I take full responsibility for not asking insistently enough) she had been trying to get pregnant for several months.  Our perinatologist explained to her (in my defense I had already said something to this effect) that one of the medications she takes to suppress rejection is grossly teratogenic (Greek for "productive of monsters") and that it was inadvisable in the highest degree for her to attempt to conceive while taking it.  She said that she had never realized that this would be the case, and that had she known she would never have consented to the transplant.  This simply augments LUH's already strong contendership for this second award, since they also failed to explain to her that their proposed intervention would make her dependent on transplant specialists for the rest of her life, and that they would refuse to see her if she lost her insurance (which was a predictable consequence of the operation they were about to perform).  This award represents a violation of another well-known and often cited principle of medical ethics, i.e. "Informed Consent."

Thus ends another exciting award ceremony.  What shining exemplar of modern medicine will next attract the notice of our august panel of judges?  Who knows.  Fortunately, there is no shortage of candidates.  And if you are a reporter who likes to write stories on things like this, I know some transplant surgeons and university administrators who want nothing less than to talk to you.

Die Vicodin ist das Opium des Volkes

I hope this second post about drugs will be enhanced rather than sabotaged by the fact that I'm presently high on hydrocodone (details below).

Mr. C is in his early thirties.  He's a soft-spoken, slightly scruffy man who wears an air of simultaneous cageiness and vulnerability which I have come to recognize as a companion of lot of chronic pain.  About ten years ago he suffered a serious, work-related injury to his lumbar spine.  Basically his spinal canal was crushed in like a can, and now the deformed bone impinges on his spinal cord and the nerve roots that provide motor innervation to, and carry sensory information from his lower half.  Over the last few years he has gradually lost function in his legs (and the ability to control his bladder), and become wheelchair-bound.  His condition is, as you might imagine, agonizing, and he has only been able to control the pain with a succession of vertiginously increasing opiate regimes. 

Patients like Mr. C. have a really big problem, which is that we (the Medical Profession,) have a complicated attitude to the morality of chronic opiate use.   As far as doctors are concerned, we believe that giving drugs for “legitimate” conditions is a therapeutic imperative, but that giving them to “addicts” is fundamentally immoral.  This is because we believe, of patients, that those who take drugs for legitimate conditions (defined, basically, as those for which we recognize an indication for the drug in question) to be morally neutral, whereas we think that people who take drugs because they are “addicts,” (which we might define as any reason we don’t understand or accept) to be basically immoral.  Crucially, both of these distinctions presuppose that there is a clear line, which doctors can discern, and which divides the huge diversity of reasons people have for chronically taking drugs into “legitimate” and “illegitimate” subsets.

Today, Mr. C. and I met in interestingly symmetrical circumstances which made some trouble for this presupposition.  Let me give a little background on the adventures which brought both of us to our specific positions in the Adult Medicine Clinic at 10:20 AM on this particular morning. 

The last time I was on the wards, one of my interns admitted Mr. C to the hospital for urinary tract sepsis (a common complication of paraplegia).  At that time he was under the care of a graduate of our program, whom I know and admire, with whom he had a "pain contract."  These are pretty standard documents which are commonly used to legitimate chronic opiate dependency, and basically stipulate that patient X can have so much of drugs Y and Z a month, and that in return he has to submit to random urine testing and promise not to try to get drugs from anybody but the provider with whom he has the contract.  They also stipulate that should his urine tests be suspicious or should evidence emerge that he's been "doctor-shopping," the provider has the right to terminate all narcotic prescriptions and, if he or she feels like it, stop seeing the patient.  So he came to our team with all these dire warnings in his ED note about suspicions of "drug-seeking," and he also came complaining of excruciating pain.  There was some initial controversy about what to do about this.  While I know doctors who would have said, "Look, the best thing we can do for this guy is deny him all opiates and therefore reduce his dependence on them," I happen to be of the opinion that opiate dependency, whatever its etiology, isn't something you should try to fix during an acute hospital visit.  I generally take the view that it is, in and of itself, a chronic medical problem - probably most closely analogous to diabetes, in the sense that trying to get somebody who's been using heavy doses of opiates for years over the course of a five-day hospital admission to stop is approximately akin to trying to cure somebody with type 2 diabetes by starving them for a week.  In both cases, you’re just creating another medical problem – in these examples, starvation and opiate withdrawal, respectively.  So my attitude to people who come into the hospital with opiate dependence and pain tends to be that they need more opiates than they usually get, not less - after all, by definition they have a higher tolerance for opiates than the average bear.  If we want to get them off opiate medications, we first have to fix their underlying problem, and then we have to slowly taper the medications off to avoid upsetting withdrawal syndromes.  I gave a short speech to this effect to my intern in front of Mr. C when he was admitted, and I have to admit that I had a mild sinking feeling when Mr. C. immediately asked me to be his primary doctor, and said that he wasn't interested in seeing my colleague any more.

The other important piece of background information is that I had a rather catastrophic bicycle accident last night.  The entire front fork of my steel-frame bike broke in half while I was going about thirty miles an hour.  I had just left the ICU on my way to a meeting, I was brought right back to the Emergency Department as a "Level 2" trauma (a recurring nightmare of mine was thus finally realized.)  I got away with a mild concussion and some really impressive bruises and abrasions, and I was in a significant amount of pain until I got the Vicodin a friendly ED attending prescribed for me before I limped home.

So I was in a fine position to appreciate the subtlety of Mr. C's situation and those of patients like him as I sat, listening to his story and feeling the hydrocodone kneading my painful shoulders with its warm, dulcet fingers.  What struck me about my own state was that I didn't feel like I was on drugs.  I just felt more like myself; I just felt the way Dr. Benway always wants to feel when he's in clinic: free from pain, interested in the patient in front of me, and free from the distractions which might impinge on that interest.  Now, I know that the reason I felt that way was because I had taken five milligrams of hydrocodone and three-hundred and twenty-five milligrams of acetaminophen about an hour before I walked into the room.  But my phenomenal experience was simply of feeling well, as opposed to the way I had felt when I woke up, which was injured.  And this sense of well-being wasn't limited to my shoulder, or my face - it wasn't the case that there was a neatly delineable line between me and me plus the pain - it was all the same thing. 

I realized, listening to Mr. C. telling me about how much agony he had been in, that the drugs do the same thing for him.  It isn’t the case that there’s an easily recognizable, dose-related distinction between him feeling free from pain and him deriving a self-consciously sinful, sybaritic pleasure from the euphoric effects of fentanyl.  His experience of his drug dependence is the same as my experience of taking the Vicodin – when he doesn’t have it, he feels a sense of incompleteness and discomfort which is very complicated.  Sure, it involves a lot of physical pain, but it also involves the loss of self-esteem that comes with being an invalid, a gnawing preoccupation with getting his meds which elbows all the other things he might want to think about out of his mind, etc.  When he takes his drugs, he doesn’t just feel pain-free, or just feel euphoric, he feels more like the self he wants to be.  And the reason he has this cagey air is because he’s used to doctors not appreciating the complexity of the situation.  He’s used to doctors who are constantly probing him, trying to get him to slip up and admit that he needs the drugs for something other than pure physical pain, because they feel that to give him medications for anything else would involve them in his immorality.

This forced me to appreciate viscerally what I had heretofore suspected intellectually, which is that he distinction we make between taking drugs because you're in pain and taking drugs because you're an addict is ludicrously simplistic and totally incoherent.  Whether your pain is from a broken leg or a broken soul, whether you take opiates because you've become physiologically dependent on them or because you have an acutely painful condition that necessitates them, they do the same thing - they make you feel like yourself.  There isn't a moral distinction between using opiates (or any drug) for psychic pain and using them for physical pain, because one's experience of all those forms of dis-ease in the moment are contiguous - as are the drug's effect on them.

The question a lot of doctors ask themselves when they see somebody like Mr. C. is "Does this guy have legitimate pain, or is he just drug-seeking?"  They expect the answer to this question to help them establish what are called "goals of treatment" - if the pain is "real" the goal is the alleviation of pain; if it's "not" the goal is the termination of opiate dependency.  The problem is that whether your a "drug-seeker" or a "legitimate" chronic pain patient depends far more on the attitude of your physician to your problem than it does on the problem itself.  The question is, in that sense, circular; what the physician is actually asking is, “How do I feel about the moral legitimacy of this guy’s drug use?”  And because it’s basically a question about the provider’s attitude, the provider can can turn either category of person into the other simply by relating to them differently.

 

I think this is clearly demonstrated by two examples, one from my experience and the other from the Medical Literature. 

First, I referred earlier to Mr. C's air of cageiness and vulnerability - you see this a lot in people who have undeniably "legitimate" chronic pain, because anybody who is seen to ask repeatedly for increasingly high doses of opiate pain killers will get treated, even if it's in the most subliminal of ways, like a drug addict.  There is always the background fear, in the provider's mind, that they are engendering or enabling addictive behavior.  I have seen many patients end up in this situation - probably my favorite example was a young woman who was on chronic opiates for a thigh muscle infarction (viewers of the show House, MD will be familiar with this condition as the excuse for the protagonist's chronic opiate addiction,) and a soft tissue infection of her labia (even men should be able to imagine how painful that would be), who was repeatedly accused by the nurse taking care of her of being a "drug-seeker" because she asked, on schedule, for exactly the amount of pain medication which I had explicitly prescribed for her (and no more). 

I think it’s fairly intuitive to most people that when you treat people who need drugs like drug addicts, they start to behave like drug addicts - because "behaving like a drug addict" simply means "employing whatever means are available to get a drug you need from people who don't want to give it to you."  Your reasons for needing the drug are ultimately irrelevant to the patterns of behavior its need induces.  If you deny somebody who has a "legitimate" condition, (like, say, reflex symathetic dystrophy or sickle-cell anemia,) access to painkillers, they will do all the things that "drug addicts" do in order to get the drugs, because they need them to feel like the selves they want to be, and there are few things more motivating than the prospect of being a person you can feel OK about.  Or, to continue the diabetes comparison above, if you treated insulin-dependent diabetics like morally deficient criminals and denied them their insulin, you can be sure that you would observe all the complex behavioral adjustments which are currently held to be characteristic of “drug addicts” in diabetics, as they skulked around the shadier parts of town looking for their next “fix.”

And it cuts both ways - if you treat "drug addicts" like they have a medical, rather than a moral illness, they stop behaving "like drug addicts" (which is to say, in terms of the way I defined it above, that if you stop witholding the things people need from them they stop trying to subvert you in order to get them.)  My second example is a large, multinational, randomized controlled trial (the "gold-standard" of medical research) which was published in the New England Journal of Medicine.  The authors took a bunch of heroin addicts who were on lifelong methadone maintenance therapy (i.e., people who were so thoroughly dependent on opiates that their physicians had given up trying to cure their addiction and settled for trying to manage it), and randomized them to a group which continued to receive methadone, and one which received actual heroin.  Their primary end-points were relapse to using street heroin, and getting arrested - which is to say, rather neatly, "behaving like a drug addict."  The people  in the heroin arm of the study had a significantly lower incidence of using street heroin and going to jail - i.e., they started behaving less like "drug addicts" and more like people receiving therapy for chronic medical illness. 

So, sitting across from Mr. C. this morning, high on Vicodin, it struck me that there were two ways to play this.  I could consider his opiate dependency a moral failing on his part, and try to whip him into shape - after all, he broke his last pain contract (under my watch,) and he clearly wanted me as his primary care doc because I expressed a willingness to give him drugs when he was an inpatient.  Or, I could consider his opiate dependency to be a legitimate medical problem in and of itself, and recognize its full complexity, it's multiple determination by his "physical" pain, his "psychic" pain, and his long series of dysfunctional relationships with healthcare providers.  Put more simply, I could ask myself one of two questions in order to determine my "goals of care:"

1) Is this guy a drug addict who's trying to manipulate me?

or

2) What would have to change in this guy's life so that he wouldn't need a daily dose of opiates that would stun an adult giraffe? 

What struck me, (as I contemplated the difference between how I was feeling in the moment and how I had felt when I woke up, and the fact that I owed it all to Vitamin V,) was that the answer to question number 1 is obviously "Yes," and that the goals of treatment that answer would dictate are ones that are, equally obviously, not going to get either of us anywhere.  I'd end up treating him with cold suspicion, he'd grow to fear and resent me, and eventually there would be some kind of bust-up and he'd go and find another doctor, and the whole grim cycle would start again.  The answer to question 2, however, is not at all obvious.  It will take a lot of getting to know one another, a lot of creative thinking, and probably some surgery to arrive at an understanding of how to turn his interior world into one that's not solely sustained by liberal infusions of hydromorphone.  And trying to answer that question is likely to cast us both in much more interesting roles than the first - for instance, instead of making him a disempowered drug addict, it will require him to assume creative responsibility for his life and its direction; and it will make me something much more difficult and complicated than a reticent pusher.  The first approach will keep us both in our pre-defined roles, and doom us to the same, stupid, pre-defined interaction – the second has at least the potential to help him become  a person who’s engaged with and assumes responsibility for his health, and to help me become a decent primary care doctor.

On Smelly Bugs

I observed here too the otherwise frequent phenomenon that friendly souls always tended more towards the region of my sexual organs (of the abdomen, etc.), where they did little or no damage and hardly molested me, whereas inimical souls always aspired towards my head, on which they wanted to inflict some damage, and sat particularly on my left ear in a highly disturbing manner.
Daniel Paul Schreber, Memoirs of my Nervous Illness, n.57

If the cells that constitute the thing you normally consider to be your body could vote, every initiative on the ballot would be about unchecked reproduction and parasitic greed. This is because the bacterial cells which colonize the interior and exterior surfaces of your anatomy (which are really a single surface; every vertebrate body is basically a very convoluted donut,) outnumber your "own" cells significantly. Mammalian, eukaryotic cells are an elite minority which can dictate policy because our tissues are organized into various layers of oligarchy, all concerned with perpetuating their own hegemony as a class, (and a powerful subset of which is explicitly dedicated to repressing and marginalizing bacteria); if simple democracy obtained on the cellular level and turnout was uniform between prokaryotes and eukaryotes, you would find yourself at the mercy of an implacable and eternal majority of unicellular anarchist libertarians, contemptuous of the resources allocated to the ponderous, overgrown liver for the sake of producing glucose to feed freeloading brain cells, and of the repressive authority invested in the hated killer T-cell.

During a biology class I took in college, as a practical experiment, we all cultured our own commensal bacteria. What was immediately apparent upon cursory examination of the resulting agar plates (aside from the anti-welfare messages the furry little colonies had spelled out with their secretions) was that a lot of the smells that one associates with humanity are actually produced by bacterial metabolism. My roomate Chris Jillson's plate smelled like your face smells after a long journey. This is a general phenomenon: bad breath has nothing to do with "your" mouth; it's produced by bacteria living there which metabolize the exogenous and endogenous sulfur-containing compounds they find ther to create new, foul-smelling molecules. Likewise "B.O."; the odor we try to suppress with liberal slatherings of aluminum salts isn't wholly ours; in large part, it's the excresence of innumerable microscopic bugs eating our sweat. The same applies to decomposition, which isn't so much a separate process from life as one logical extreme of its organizing principles. Bacteria feeding on corpses, not the corpses themselves, produce such fragrantly named substances as "putrescine" and "cadaverine".

Smell, as is commonly known, is one of the more evocative senses, and there's a neuroanatomical correlate for this: the olfactory nerves, unlike the nerves which transmit and transduce most of your other senses, are plugged directly into the limbic system, an ancient and scary group of structures in the bottom of the brain which mediate powerful, atavistic affective states. (Incidentally, there is an emphatically non-commensal free-living amoeba called Naegleria fowlerii which exploits this connection in a particularly grisly way: it latches on to the exposed olfactory nerve endings in the roof of the nose and crawls up them into the brain, where it multiplies freely and feeds on your very being, producing a fulminant and almost uniformly fatal illness which begins with olfactory hallucinations and ends, a few days later, in abject brain death. You get it from swimming in fresh water. It lives everywhere.) The limbic system is also integrally involved in the formation of new memories, which accounts for the nostalgic power of scent. Everyone has had the experience of being transported back to a distant period in their past, in near hallucinatory detail, by a whiff of one of that time's characteristic odors. It has occurred to me that I might start trying to exploit this by prospectively identifying periods which I would later like to be invested with that immediacy of memory and picking something singular to sniff regularly during that time, so that I could conjure each forgotten milieu at will later simply by digging, say, the little sachet of opium I carried around during my time in Bognor Regis out of some elaborate card-catalogue and inhaling deeply.

However, I realized the other day that my current occupation naturally incorporates a similar, fortuitous index of memory when I became aware that I have now come to know some of my patients by smell. One, particularly, I could recognize in a dark room from ten feet, not because she is unkempt or incontinent (the nursing staff are conscientious and efficient) but because her natural odor is highly distinctive; she smells like a minor by-product of tire reclamation, or something equally specific, industrial, and petroleum-based. Moreover, I now recognize her scent in error; I lifted a cup of hospital coffee (which I have often suspected of also being an industrial afterthought) to my lips and got a powerful blast of Mrs. S.. Likewise, I had a close encounter in an odd place yesterday with Mr. B., who smells like you would expect a sick human to smell, only more so: I took my towel off the prominence sticking out of the water heater where I hang it the other day and was momentarily but vividly transported back to the last time I asked him to lean forwards so I could listen to his lung bases, thereby instigating a mass, aerosol exodus of prokaryotes which had been proliferating in the warm, moist space between his butt and the bed.

Now, a lot of this (a circumscription I vehemently maintain includes my towel) is explicable by appealing to our general mania for recognition. Humans are compulsive about this: we see spectral figures standing over our beds in the night which we know to be our own wardrobes, we hear voices in the pounding surf, we recognize the faces of old acquaintances on crowded buses in distant cities, we think the New Testament is about us. I smell Mr. B on the towel because something in me is hard-wired to prefer familiar interpretations, however gnarly, to radically alien phenomena like the highly specialized smelly molecules the bugs in my towel (which I have already burned, thank you) are (were! were!) busy producing.

However, this interpretation is also a happy fiction. In fact, it is inescapably the case that I am daily taking on small inocula of my patients' commensal flora; after all, every morning I lay my hands upon them, under them, around them. I ask them to breath deeply and to expel whatever facultatively aethereal organisms are living in their mouths onto my person. I usually don't wear gloves or a gown, and even if I did the efficacy of such paraphenalia would be questionable. As Lister proved, the only way to really sterilize a normal environment, outside of a rigorously controlled modern operating theater, is to fill the air with a fine mist of carbolic acid. It would be ridiculous to imagine that somehow my native flora are such a hardy master race of Aryan super-bacteria that they effortlessly deflect the miscegenating influence of Mrs. S.'s epidermal menagerie. On the contrary, it is only reasonable to expect that I and represent an undiscovered, (and, I like to think, more vibrantly appealing) continent for them to explore. Like bold space explorers (or maybe rats from a sinking ship) they take that giant leap to the brave new frontier that is my exterior surface and start gnoshing on my exfoliated cells, continuing their definite way of life and elaborating the aromatic hydrocarbons which they are accustomed to produce and in which, one imagines, they take an admittedly provincial but nonetheless fierce pride, like Swedes do in that horrible fermented herring stuff you're no longer allowed to carry on planes.

Sometimes, I smell Mrs. S. when I scratch my ear.

This gives one a new perspective on the distinctive smell of any given hospital ward. You can also tell them apart in the dark. Each is a gestalt entity, and has its own distinctive smell, which is partly disinfectant and hospital "food", but is more noticeably exhaled by the rainforest of its inmates' diverse microflora. Over time it changes, as they come and go, producing an evolving great cloying symphony which is the product of perhaps thirty or forty individual concatenations of scent, some pathological, some natural, some the product of neglect, some deliberately cultivated. Each patient is a section in the orchestra. Mrs. S. is brass. Mr. B. is percussion. And, of course, they cross-pollinate; the scions of the first violin get restless and strike out for the promised land of wind. We know this is happening all the time, and how difficult it is to prevent, by observing what happens with the infinitessimal percentage of bacterial species that we keep track of because they cause hospital-acquired infections (to strain the orchestral metaphor here, Clostridium difficile is a chainsaw set loose among the woodwinds).

It is really the case, then, in a biologically determinable sense, that we are contingent on and contiguous with one another, at least insofar as our fleshly communications enable the migrations of bacteria which, remember, outnumber us within our own bodies. The distribution of genes capable of or actively elaborating the proteins which produce "our" bodies are in flux. The thirty-thousand odd genes tightly packaged in the big, expensive nuclei of our huge cells are actually in the minority as the intrepid colonies of bugs we unconsciously cast upon each other grow like ripples on our skin and in our guts, only to be gradually subverted and supplanted by other nuclei of wildly multiplying creatures producing their own highly specific molecular plumage. It is probable that the reason I smell Mrs. S. when I scratch my ear is that the things that make her smell the way she does are actually living on my ear. To take a more universal example: the process of disentangling yourself from a romantic relationship goes on long after you have really, finally, with a bathos that defies all attempts at romanticization, decided that you just don't care about that person anymore. His or her commensal flora are still breeding in your secret places, elaborating the intimate perfumes of your first excited encounters in dark silence.

All this stuff about smelly bugs, which is fascinating in a twelve-year-old-boy kind of way, should really come as no surprise since it illustrates the same dynamics that create who we (think we) are in a much more immediately important way. An analogous proliferation and wild, often random migration of arguments, trains of thought, ethical committments, jokes, myths, and other micro-organisms of consciousness, whose operations are even more subterranean and difficult to elucidate as those of bacteria, come together to constitute the shifting terrain that is our subjectivity. I am now, statistically, commensurable with Mrs. S. from the point of view of some hypothetical Martian biologist because, if you were to grind me up and analyze the distribution of genes that constitute whatever it was that you ground up, you would discover (in addition to the 99.999% of human genes we share,) specific genetic and proteomic patterns attributable solely to the (smelly) bacteria we now host in common. But, and of much more immediate relevance to me at least, a Martian anthropologist would discover the same to be the case of our internal narratives. Mrs. S.'s occasional delirious assertions that if I she can just "get my hands around your scrawny neck, you're going to know about it" have infected my subconscious, where they are multiplying and mutating and will, presumably, eventually find some point of egress onto some other fertile narrative ground. Hopefully I will not actually strangle anyone. Mr. B.'s dry, irritable, flat sense of humor is colonizing my own; I am already stealing his poingnant, depressing jokes. These are superficial examples, but what I'm trying to indicate is that just as the integrity of our bodies is called into question by the gigantic population of helot bacteria they environ, so the identity we like to think is ours is pervaded by other dimly guessed at (and sometimes really pungent) influences.

This where the meditation on foul odors has to peter out, because I don't think, first of all, that it could be any other way, nor, second, that the narrative colonizations through which we help each other build towards something that feels like a subjectivity are bad.  Patrick Suskind, in his wonderful novel Perfume, has elaborated the monstrous terror of a human being who does not smell like anything at all, even himself. It is difficult to imagine what, besides inchoate monstrosity, could characterize a human bereft of the innumerable, multiplying, mutating inocula of other subjects - most of which smell pretty good.

Anthropology and Crack Cocaine

If, like me, you grew up in the 1980s watching dark urban Jeremiads like Robocop and Alien Nation, your immediate associations with crack cocaine are probably similar to what mine were when I started residency.  I used to think, as I was taught to by DARE et al., that crack was basically hedonistic degradation in crystal form; that one hit was enough to transform a graduate of Harvard Divinity School into a slavering fiend who would instantly lose the capacity to think about anything but where he was going to score his next fix, and would cut wedding rings from the fingers of corpses to get it.  I was taught from an early age that casual use of cocaine, and particularly crack cocaine, was a physiological impossibility - probably the equivalent of pawning your soul to the devil and thinking you were going to get it back.

I have since had extensive opportunity to reconsider.  I first started to appreciate some of the misrepresentations incorporated in my '80s nightmare-of-urban-decay conception of the drug when a friend lent me a riveting ethnography of Harlem crack dealers by the anthropologist Phillipe Bourgeois called In Search of Respect.  Bourgeois' book is based on an absurdly long period of clearly gruelling fieldwork living with crack dealers, and I highly recommend it to anybody who is at all interested in the relationship between domestic drug policy and social class.

I really started to realize just how incommensurate with reality our unexamined cultural narrative about crack is when I started working in a county hospital, and immediately became acquainted with an enormous number of casual crack users.

I should probably take a moment here to say explicitly that I am absolutely not for crack cocaine in any conceivable sense.  This is not a call for legalization, nor do I wish to downplay the consequences of using crack for one's cardiovascular health regardless of whether one is addicted to it or not.  I have seen my share, and probably yours, of crack-induced medical problems in every conceivable setting - I'm just suggesting that the reality of crack cocaine, in the population I work with, is very different from what I was lead to believe by Nancy Reagan, and we can probably learn more about it from well-informed anthropologists than we did from her.

Among a certain subset of my patients, (mainly the American-born working poor,) casual crack use is surprisingly common.  When I say "casual," what I mean to convey is that there are a lot of people out there who use crack like most middle-class white Americans use alcohol - occasionally, functionally, and without any overt social consequences.  And I'm not just talking about wild young men who also drink Steel Reserve and smoke heroic amounts of marijuana.  I have at least one respectable grandmother in my primary care clinic who admits to taking the occasional hit and is not, by any stretch of the imagination, some kind of antisocial monster.  Quite the contrary.  In fact, I think I could say without doing violence to the facts that crack use the American metropolis can be loosely analogous to, say, the way that other cultures use betel nuts or coca leaves.  Again, I stress that this comparison has nothing to do with physiology; drinking a bottle of Smoking Loon (or, for that matter, Carlo Rossi) a few times a month is better for you by several orders of magnitude than smoking crack with the same frequency.  This is a point about cultural significance and the reality (or unreality) of pathological addiction, not the incidence of cardiovascular disease.

The reason that I think this is important is that all of my colleagues come from cultural milieus like my own which, although they are highly diverse (Germany, India, Iran, Mexico, Argentina, etc.) definitely do not involve casual crack use, and are also similar to mine in that their primary access to what crack is really like is via highly mediated and agenda-driven cultural artifacts like Robocop.  This has profound significance for the way that we relate to patients as diagnostic and therapeutic agents; we (the doctors) have a variety of highly charged notions about crack use, which aren't particularly commensurate with those of the users and, (more importantly if you belong to the standard school of medical epistemology) don't cohere particularly well with the ethnographic reality.

An interesting consequence of this is that crack is authorized as an etiological agent in a variety of contexts precisely by these thoroughly cultural attitudes towards it, rather than by that increasingly valorized commodity, "evidence."  The menagerie of conditions I have seen attributed to cocaine continues to expand monthly.  Many of these attributions are just - cocaine does, in fact, cause hypertension, stroke, myocardial infarction, cardiomyopathy, renal failure, thrombotic microangiopathy, etc. - but a significant number of them are, if one takes a few steps back, bizarre.  For instance, I admitted a woman a few weeks ago who was incidentally found to have astronomically elevated liver function tests.  No obvious etiology was apparent, although salient historical features included the fact that she had taken cocaine during the previous week, and that she had a new sexual partner.  When I presented the case to my supervisor in the morning, I duely mentioned that she had used cocaine four or five days prior to her presentation and gave my conjecture, which I expected to be borne out by pending serology, that she had an acute, sexually transmitted viral hepatitis.  He gave me an mercifully avuncular smile and said, "There's nothing mysterious about this - it's cocaine-induced hepatitis.  We see it all the time."

Cocaine-induced hepatitis is (I checked,) not widely reported in the literature, and she did, in fact, turn out to have acute hepatitis B.  The point here is not to tout my diagnostic acumen; the doctor in question is definitely more knowledgeable and very probably just plain cleverer than I am.  The point is that cross-cultural perceptions influence diagnosis.  Casual crack use represents a cultural littoral between the physicians at my institution and their patients, and as such it lends itself to overdetermination.

The significance of this fact was impressed upon me when an emergency medicine attending told me that of all the urine toxicology screens which are sent at my hospital (and the ED sends them on just about everyone) something like sixty percent are positive for cocaine.  This indicates both the incredible prevalence of casual cocaine usage in the general population, and the fact that whenever you're stumped for a diagnosis, roughly sixty percent of the time you have the option of blaming it on cocaine.  And what I have come to appreciate is that this option is vastly over-used, and that this amounts (in cases where the diagnosis is not clearly referrable to cocaine) to blaming medical problems on cultural differences.

This means, fundamentally, that we have a propensity to explain things we understand (e.g., that Mr. A. is suffering from a hypertensive emergency because he just smoked a bunch of crack and given that cocaine is an indirectly acting sympathomimetic amine it can be expected to facilitate the release of noradrenaline from presynaptic sympathetic axon terminals, causing peripheral vasoconstriction and a corresponding acute elevation in blood pressure,) in a completely different way from things we don't understand, (e.g., Ms. B has an elevated white blood cell count in conjunction with an accelerated erythrocyte sedimentation rate and a diffuse pustular rash for which no explanation is apparent, and she smoked cocaine this weekend, so presumably this is an atypical adverse cocaine reaction.)  The historian of science Stephen Schaffer makes the same claim (and I am indepted to him for this formulation) about the way we tend to think about science: we are accustomed to attribute scientific developments to social context only when they are wrong, and to attribute what is currently construed as correctly reflecting the actual nature of things to the pure and untainted light of reason; but this is pretty much the same (this is his example,) as saying that Newton thought that a principle of mutual attraction is active between the center of any given massive body and all other massive bodies which acts instantaneously across empty space because it actually does, and Leibniz disagreed because he was German.

This is a really problematic observation, because in medicine we tend to assume that the correlation of two phenomena for which robust evidence of association is lacking is the basis of a publishable case report, not evidence of a lack of anthropological sophistication and reflexive discipline on the part of the clinician.  As a mentor of mine recently said, "There's this thing called Occam's Razor, which says that when two rare things happen at the same time they're probably connected."

What I'm suggesting is that actually we have to be much more careful.  To take the example at hand, correlation of patchy pulmonary infiltrates on chest X-ray with recent cocaine use might indicate a case of "Crack-Lung" which could be written up as a case report; but, on the other hand, it might indicate a diagnosis of coccidoidomycosis for the patient and a diagnosis of conflation-of-cultural-difference-with-biological-determinism for the physician.

And this isn't, by any means, limited to the attribution of otherwise inexplicable disorders to cocaine (or, put another way, to the synonymous use of the terms "cocaine-induced" and "idiopathic"): let me tell you a story which was presented at a recent joint emergency-medicine internal-medicine conference.  An African-American woman in early middle age with a long history of crack use, whose urine had tested positive for cocaine every time anybody cared to test it, presented to our emergency department repeatedly with emergently elevated blood pressure.  Looking back over the case files, (which span months) the story does not add up; she did not respond in the way one would have expected to the standard interventions for cocaine-induced hypertension or essential hypertension, yet she was routinely discharged from both the emergency room and the hospital ward with incongruously high blood pressures, (albeit lower than those she presented with) without anybody batting an eye.  Eventually somebody did notice that, for some reason, the drugs weren't working, and she got a full-body CT scan in the ED which disclosed a near-total renal artery stenosis.  This is a classic cause of refractory hypertension, as any third-year medical student could tell you.  Had she been a middle-class white woman without a history of cocaine use, she would have fit a classic diagnostic profile and this would have been discovered much earlier, possibly at her initial presentation; but because she fit a certain classic cultural profile, several doctors (all of whom are, I am not being sarcastic, brilliant diagnosticians and deeply empathic individuals who work at the county hospital because they want to serve the disenfranchised) bent the circumstances they actually saw to fit a culturally motivated conception which they expected to cohere with reality.  And I probably would have done the same thing.  In fact, it is more than likely that I already have.

So what's the point?  It certainly isn't that we shouldn't, like, you know, pass judgment on people, just because they smoke crack, or that racism is a common facilitator of hypertension.  It's that anthropology offers as much discriminant information, under many circumstances, as does biomedicine (narrowly construed).  You can learn as much information of important diagnostic utility about people by attempting to understand their cultural milieu or, (actually more importantly,) by reflecting in a disciplined manner on your own and its implications for your apprehension of theirs, as you can from their Chem7 or their complete blood count.

Much of the basic science that has created the immensely powerful apparatus of modern biomedicine was (at least allegedly) founded on the distinction between primary properties (like mass or velocity, which can be demonstrated by universally reproducible means in any cultural context,) and secondary properties, (like color, taste, or justice, which only exist for specific observers under specific circumstances).  The point is that this distinction, at least in clinical medicine, is going to have to break down, and we are going to have to start taking seriously the prospect of doing anthropology at the bedside.

Postcard from the Carribean

Sorry there hasn't been a post in a while - I was in Haiti for a little while and came back to a rotation which doesn't leave a huge amount of free time.

Working in Haiti, even for such a short time, was an extremely large experience, and I struggle to find any narrative inroads which will allow me to talk about it in any way that feels responsible or complete.  I worked at a tent hospital which is located within the grounds of the Port au Prince airport (seen in the photo to the right) for a week, during which I spent one day in the Port au Prince public hospital, the Hospital Université d'Etat d'Haïti.   I spent the most time working on the wards (the second tent from the right in the picture) which are shown in this Associated Press shot:

This is pretty much what they were like when I was there.  There were basically four of these rows of cots, each about a foot apart, extending from one end of the tent to the other - about thirty-three beds or so per row.  The rope running overhead between the rows was for IVs and bed numbers.  The daily modus operandi was to start at the beginning of a row and work your way to the end, doing whatever you thought the right thing probably was as you went.  Each row had two nurses (at most) who ended up working much harder than me since their responsibilities tend to be more time-consuming and physically active.

The facilities were exceptional when compared to those available in the surrounding area, but nonetheless rudimentary - there was a diagnostic X-ray machine, a lab which could to basic blood tests, and a pharmacy which consisted of several shelving units behind a folding table stacked with donated drugs.

Now that the wave of acute trauma caused by the earthquake is mainly over, the tent hospital is functioning as a general hospital for the area and seeing what I guess is a typical range of urban Haitian pathology.  This consists, as far as I could tell, of a lot of trauma (earthquake or not), from car accidents and gunshot wounds (more of the former and less of the latter than in my West coast teaching hospital), a lot of infectious disease, mainly malaria, HIV, and TB, and an undertone of familiar conditions which I see a lot of here, e.g. diabetes, hypertension, emphysema, etc.

I complain frequently about the lack of resources and funding at my county hospital, and I will continue to do so, but as you can imagine I now have a rather different perspective.  Next to the tent hospital, the county looks like the Mayo Clinic.  One of the things that was most frustrating, however, was not the absence of some piece of diagnostic equipment or therapeutic intervention, it was the lack of any kind of continuity.  Except for wound care, we had no capacity for an outpatient clinic or any of the infrastructure (particularly medical records) that one requires, and in any case most of the volunteers were only there for a week.  This made for a lot of extremely sad and frustrating discharges, where we were sending people out from the hospital basically to tent cities or just to the streets, and not only could we not get them housing or other material resources we couldn't even tell them to come back for a check-up.  This was particularly maddening for me as a primary care physician who is deeply committed to a model of chronic care.  Ironically, I felt relatively comfortable with cases of malaria since they can be cured - cases of diabetes or hypertension were upsetting because there was no real choice available other than palliative care for what are essentially treatable diseases.

That's as close as I can get to a five-minute summary.  I'll try to intercalate some discrete stories in later posts.

Good Morning From NecroCorps!

Dear NecroCorps Family Member,

February is Palliative Care Month at NecroCorps, and you know what that means!

HUGE SAVINGS!

NecroCorps Research and Development scientists have been working hard over the past year, and we are proud to offer you a variety of new mortality-solutions for those awkward end-of-life moments.

Orifice Plugs

Studies have shown that soon-to-be-bereaved relatives react negatively to incontinence of feces and urine, and to drooling. These quality orifice plugs are "just what the doctor ordered"! Precision-milled from medical-grade transluscent polymer, in several exciting colors, they are ergonomically designed to gently but firmly obstruct any bodily orifice and stop the flow of unsightly fluids. Pack of 10.

Smile Helmet

Who hasn't heard a friend say, "she just didn't know when to go."  Too many Americans meet their makers with a bitter frown on their lips, unreconciled to the temporality of all things. But there's no reason for Gramma to bring down the whole family with the cumulative vitriol of six decades' wasted life! The Smile Helmet gently adheres to the corners of the mouth, using the same technology that allows geckos to cling to glass, and draws them into a pre-set beatific smile. Leave the Smile Helmet on after death, and rigor mortis will guarantee that special someone looks like she's in a better place when the relatives come filing by!

Fun Lethal Virus Demonstration Kit

No doctor likes to break bad news, and there is no magic solution to this difficult area of practice. But the Fun Lethal Virus Demonstration Kit is close! Show your patients what is happening to their beleagured cells...and give them a head massage at the same time! Your patients will laugh out loud.

Fetor Eliminator

Many diseases, such as end-stage liver disease, produce characteristic, unpleasant odors on the breath. Distal bowel obstruction can even cause the regurgitation of fecal material through the mouth! Avoid this embarassing phenomenon with the Fetor Eliminator. It's carbon-mesh filtering system removes smelly particles from exhaled air, so that Uncle Frank, whose habits finally caught up with him, will go to meet his Maker smelling like roses instead of St. Ides Malt Liquor.

The Death Rattle Silencer

Need we say more? Who wants to hear that last gurgle?

"Turtles Don't Matter" Turtle Prosthesis

Studies of small children have shown that the pet whose death affects them least emotionally is the turtle. And aren't we all kids at heart...just a little? Strap your dying patients into the "Turtles Don't Matter" Turtle Prosthesis for instant detachment.

Brain Sucker

There are few things more wrenching than talking to an intelligent, well-oriented person who knows they are going to die soon. This handy gizmo is the answer. Small enough to fit in a lab-coat pocket, it uses eight boring stainless steel trocars to penetrate the skull, then applies microwave radiation directly to the cerebreal cortex, quickly and hygienically obliterating personality and awareness. You'll be more objective when your patient is an object!

Fake Pulse Oximeter

This is the carefully crafted replica based on real pulse oximeters used in top-tier American hospitals like the Clevelend Clinic and Massachusetts General, and lovingly cast in archival-quality, acid-free designer resin. The only difference is, with the Fake Pulse Oximeter your patients will always have an oxygen saturation of 97%! Don't let your patients loved ones down with a beeping monitor - attach a Fake Pulse Oximeter to your terminal patients today.

Cachexia-B-Gone Prosthesis

This handy gadget takes its inspiration from the silicone implants used to replace breasts removed by mastectomy - except the Cachexia-Be-Gone prosthesis is designed for patients with metastatic, terminal cancer. This group of patients are usually terribly wasted from their disease, and relatives find this distressing. So simply unpackage the sterile "body-supplementer", inflate, and apply for an instantly helathy look.


As always, we at NecroCorps know you have a choice among outlets of the medico-industrial complex, and we appreciate your business.

Fond Regards,

Schemendemen J. Feltschnapper, MD
Director of Medical Sales
NecroCorps Headquarters, Milwaukee WI

All images from www.skymall.com.  These statments have not been evaluated by the FDA.

Syndrome X

Sorry I haven't posted anything in a while - I've been working nights a lot recently and it's surprising how disruptive something as simple as sleep-wake reversal is.

I've been trying to identify precisely what people mean when they say that somebody is a "typical" county hospital patient.  It's usually said with a knowing look, a look which alerts you to the fact that the word is overdetermined; but just how it is so has been a little elusive.

I admitted a woman last night whom I immediately recognized as "typical" (it's a property of this kind of category that we can deploy them long before we actually understand how they work.)  Ms. A is a 50 year old lady who's here for shortness of breath.  I can tell just by looking her up in one of our data systems that her case is not simple, because she has several discharge summaries and a confused forest of diagnoses attached to her name.  I can quickly tell, at least, that she's 50 years old and definitely has diabetes and HIV, neither of which are very well controlled.  Her last discharge summary is written in a tone of cold professionalism and describes numerous infractions of hospital rules and altercations with staff during her last stay.  I'm already guessing that she lives under difficult circumstances, and that she will have a constellation of factors related to poverty as part of her presentation, i.e. malnutrition, neglect, lack of education, drug use, infectious disease, poor social support, inadequate living conditions.

As an aside, I am coming to think of this "constellation" as a discrete syndrome.  Obviously the specific manifestations vary with environment, e.g. in the Midwest it's methamphetamine and in coastal California it's crack, but the conspiracy of self-sustaining pathologies that develop around people who fall below a certain socioeconomic bracket are pretty consistent.  I think it deserves an eponym, but I'm struggling to find a good one - part of the problem being, no doubt, the dearth of potential candidates who are famous for being impoverished and brutalized by pedestrian circumstance.  Whoever submits the winning proposal can be co-author on the article I'll be submitting to the New England Journal of Medicine describing my new syndrome.  The provisional diagnostic checklist is:

Syndrome X is present when two or more major and two or more minor criteria, or five or more minor criteria without major criteria, are met:

Major Criteria:

• Poverty
• Education less than or equal to twelfth grade
• Chronic Disease
  

 Minor Criteria:

• Membership in a persecuted ethnic minority
• Anxiety and/or depression
• Alcohol or drug dependence
• Other psychiatric problems
• Dearth of family relationships or other durable social connections
  
• Unstable housing
• Lack of marketable skills
• Childhood sexual and/or physical abuse

Somehow I doubt it will get published, except maybe in the Christmas issue of the BMJ.  On purely semantic grounds these criteria are actually a lot more specific than those by which we diagnose many conditions that insurance companies will actually fund treatment for like, say, the Rome III criteria for irritable bowel syndrome.  But a lot of time and effort goes in to maintaining the alleged distinction between the "medical" and the "social."  If it were to break down, well, we would have serious problems - not least that the structure of late capitalist society would be exposed as inherently pathological - and we don't have the money to deal with the problems we do acknowledge.   

In any case, whatever we're going to call this medico-social syndrome, she has it.  When I went to see her I found an emaciated woman with end-stage dentition lying in bed with her oxygen tube on the floor, breathing heavily and emitting grotesque coughs.  A napkin dripping green sputum lay on the table beside her.  She perked up a little after I put her oxygen back on.  She was reticent at first, clearly somewhat suspicious of people with ID badges after her last, controversial stay in the hospital, but after a few minutes she loosened up and soon became impossible to interrupt.  She told me a lot of things - notably that she lives with her daughter, who coordinates her care, and that her daughter has been gone for nine days.  She also told me, with a twinge of guilt, that she is radically disobedient to her various health regimens when her daughter is gone.


"She buys me diabetic ice-cream," she rasped,  "She might give me a cookie - just one.  But when she leaves the room, I eat four or five."


She thinks about her HIV with deep shame and guilt - she says that her "blood is bad" and she still holds a deep grudge against the mother of the boy who gave it to her more than ten years ago, maintaining that she knew he had it but didn't tell her.


As she became more and more talkative I kept trying to slip in questions about her current symptoms, some of which elicited answers but many of which were swept away on her swelling monologue.  Somehow, as part of some smalltalk gambit, the fact came up that I have two cats.  This prompted her to tell me the following story:


Ms. A's daughter, years ago, had a kitten named "Kitch."  Her daughter loved the kitten, and so did everybody else - "Kitch had more friends than she did," she told me - and when Kitch was small, everything was fine.  But then Kitch grew up, and she and her daughter moved to a different apartment, and Ms. A didn't want a cat living in it.  Her daughter, however, smuggled Kitch in and managed to keep the cat in her room for a while before she was discovered.  When the inevitable revelation came, Ms. A was furious and demanded that her daughter take Kitch back to the old apartment - although what the cat was supposed to do there, aside from rent the place itself, I couldn't figure out.  After vain remonstrations, her daughter grudgingly complied.  Ms. A repented shortly after her daughter left, realizing that she had been mad at her, not the cat, but by the time she got in touch with her she had already deposited the animal in the old apartment and sulkily refused to return for it.  The next day, Kitch was run over by a car and killed.  Ms. A was devastated, and clearly still feels deeply ashamed of having indirectly caused the cat's death.


When this story started out I had two thoughts.  First, I knew that the cat was going to die and that it would somehow be her fault.  She had a wretched look of contrition that gave it away.  It was a long story, and I spent the whole thing dreading the end and trying, despite myself, to predict how the cat was going to die.  Plunging from an open window?  Killed by an enraged boyfriend?  Drug overdose?  Accidentally baked alive?  Second, I wondered why she was spinning this prosaic but earnest yarn about a dead cat, when what I had asked her about was her cough.


In retrospect I think that, in fact, she was trying to give me the full picture of her disease process that I was trying to elicit - I just didn't quite see how at the time.  What I had asked her, essentially, was "how did you get to be like this?"  Her answer was to tell me a story which typifies much of her life and probably felt resonant to her in the moment for that reason.

She feels guilt and shame about her chronic illness.  The fact that HIV is one of her conditions may be a little bit of a red herring, since it appears to explain this.  It is, after all, a disease of intense social stigma that still is widely held (not least by Ms. A) to imply sexual transgression, and lots of people feel guilty about it.  But diabetes can be equally freighted with self-loathing and implications of personal irresponsibility, since it is widely held to be a result of gluttony, and its progression indicates a failure on the part of the sufferer to take adequate control of their life, take their medications regularly, and stop eating so many cookies.  Similar feelings attend obesity, and the whole category of "medication non-compliance," which some people appear to think is a diagnosis in and of itself, invests many other conditions with such feelings of moral inadequacy.  She feels guilt and shame about her poverty as well - who wouldn't, in a society which tells us that the primary indicator of personal worth is financial success, and that such success is available to anybody with a little gumption and initiative?  This is America, after all.  These feelings of personal contamination and inability (or "spoiled identity" as Erving Goffman put it,) attach to the things she wants and loves; things which are vitiated, for her, precisely by the circumstances that generate the feelings to begin with.  Poor, sick people cannot have the things that everyone wants - the sick part is that they often feel that this is their fault for being poor and sick.

This dead cat story is about her present illness, insofar as it's story is about the relationship in which one stands to objects of desire when one is poor, marginal, and diseased.  While I might have liked her to give me a discrete history of bacterial pneumonia, she was giving me a more general narrative about how she's ended up as the kind of being that she is; through a million little tragedies like the idiotic death of her daughter's beloved pet.  She was telling me about her ambivalence towards the things she loves, her wounded anxiety, about how difficult real happiness is to achieve in circumstances like hers, and about her pervasive sense that the objects of her desire are so fickle and potentially dangerous because she, with her "bad blood," is somehow poison.  The things she loves and wants always either escape her or turn on her, and somehow it is always her fault.  Maybe she poisons them by her very existence, by imparting some essence of her disease to them, or maybe she destroys them out of weakness in her frustration with other people, as she did Kitch - but one way or another, the story of her life is one of reaching for something everyone wants and many people have only to have it turn into strife, disease, and death.

This, I think she's saying, is why she has this pneumonia: because for her the pursuit and enjoyment of the objects of her desire has always been vitiated by her poverty, illness, and marginality; because everything has been like cat's death, or the lover who gave her AIDS; and because when her daughter left she ate too many cookies, and now, as always, pleasure has refracted into pain.

Typical.

Social Amputation

Roger N. is a stolid American working-class guy.  He's a little overweight, he wears shapeless t-shirts and blue jeans, he has a mop of salt-and-pepper hair and a black moustasche.  He's divorced and lives with his seventeen-year-old son, who's finishing high school.  He has an expressive face which is capable of surprising nuance and an irrepressible, if somewhat dark sense of humor.  He's worked a lot of jobs - he's been a shop floor supervisor with other men working under him, a union employee, and most recently a hazardous materials truck driver and instructor.  Now he's unemployed.

Most of my patients are on one side or another of the line dividing the working poor from the irretrievably destitute.  People on the right side of the line are HMO refugees who lost their jobs and have found new ones which don't provide insurance, elderly people who spent their lives working low-pay jobs with no benefits who now subsist on social security, and illegal immigrants who get paid under the table.  The people on the wrong side are those for whom that last critical thing failed to happen - they didn't get the job before they were evicted, they couldn't get loans from family or stay on friends couches any more, they couldn't hack the inpatient drug rehabilitation program, whatever - they are the people who define the "safety-net" because they are underneath it. 

I am watching Roger cross the line.

I first saw him as an inpatient when he was admitted with a diabetic foot ulcer.  Back then he was only recently unemployed.  He had been forced to quit his job driving "hazmat" trucks because of the expanding sore on his foot.  By the time he came to the hospital it was big enough that there was some concern that it might extend to the bone and have set up osteomyelitis, a chronic bone infection which is hard to treat.  Fortunately these worries were unfounded.  At the time, his foremost priority was getting out of the hospital in time to see his teenage daughter graduate from high school. 

After discharge he struggled to make ends meet on disability, until that ran out a few weeks ago.  He has no savings left, and will have to get unemployment.  He told me in clinic this week about the humiliating ritual he had to go through at the unemployment office, where they grilled him as to any saleable assets or unnecessary expenses he might have - jewelry worth over $100, life insurance, sporting equipment, expensive furniture, etc.

"I've always been able to get work," he said, "always been able to provide for my family - my son.  And now it's like things are just falling apart, and none of that matters." 

Having ascertained that he is destitute, the State is offering him 800 dollars a month - enough, maybe, to get a studio apartment in a remote and/or dangerous neighborhood for himself and his son. 

"You be good, doc," he said, flashing me a poignant smile, "and keep your job."

He has an appointment with podiatry tomorrow for his non-healing foot ulcer.  His plan is to plead with them to certify him as fit to return to work, even though he can't really do anything with his right foot.  The problem is, he tells me, that if he takes a job without his work restrictions being lifted by a qualified doctor, the State will demand the disability money back.

I had a frustrated conversation with my clinic supervisor about Roger - I already put him in touch with our Social Worker, who didn't have a whole lot to offer him, and from a medical point of view he is (somewhat surprisingly) doing pretty well.  It's his inexorable slide towards social marginalization, bad living conditions, refractory poverty, and understandable depression that are the real problems - not ones I'm equipped to do a lot about.

My supervisor, who has worked in this environment for longer than me, had a creative solution.

"How bad is his foot ulcer?" she asked.

"Pretty bad," I said, "why?"

"Well, because if it's bad enough, they could amputate his foot."

"I'm not following you."

"Well, if they amputate his foot he could get permanent disability."

I refrained from passing on this macabre suggestion to Roger.  I wish I could say that I didn't tell him because it would be completely insane to encourage him to be permanently, unnecessarily mutilated in order to ensure a life of slightly more comfortable penury than he's otherwise faced with.  That choice may well come up.  It's just that I think if I suggested it to him now, with things going the way they are, he might take matters into his own hands.  And to be fair, if I had to choose between my right foot and my dignity and self-respect as a man and a father, well... they make very good prostheses these days.