Harmony Magazine, Volume 7 (2004-2005)

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A R I Z O N A
H E A L T H
S C I E N C E S
C E N T E R
M A G A Z I N E
O F
T H E
H U M A N I T I E S
Art Essays Ideas Photographs Poetry Prose
A R I Z O NA H E A L T H S C I E N C E S C E N T E R M AG A Z I N E O F T H E H U M A N I T I E S
EDITOR-IN-CHIEF
(Shad) Farshad Fani Marvasti, MD-MPH Student, Class of 2007
SENIOR EDITOR & DESIGN MASTER

Gabriel Sarah, MD Student, Class of 2008
ASSISTANT EDITORS
Katherine Glaser, MD-MPH Student, Class of 2007 Lisa Goldman, MD Student, Class of 2007
FACULTY EDITOR AND SPONSOR

Helle Mathiasen, Cand. Mag, PhD, Director, Medical Humanities Program, Clinical Professor of Medical Humanities, College of Medicine
ADVISORY EDITORIAL BOARD

J. Lyle Bootman, PhD, Dean, UA College of Pharmacy James E. Dalen, MD, MPH, Dean Emeritus, AHSC Vincent A. Fulginiti, MD, Professor Emeritus, UA Department of Pediatrics Keith A. Joiner , MD, MPH, Dean, UA College of Medicine Marjorie A. Isenberg, DNSc, RN, FAAN, Dean, UA College of Nursing Kenneth J. Ryan, MD, Dean for Academic Affairs, UA College of Medicine G. Marie Swanson, PhD, MPH, Dean, UA College of Public Health
HARMONY is a publication of the Arizona Health Sciences Center (AHSC) sponsored by the UA
College of Medicine Medical Humanities Office, the Medical Student Council, and the Kenneth Hill Memorial Foundation as a gift of perspective for the entire AHSC community. All works in HARMONY, both visual and literary, are the exclusive propert y of the artist or author and are published with their permission. Authors retain their copyright for all submitted materials. Any use or reproduction of these works requires the written consent of the author. Views expressed are solely the opinions of the individual authors and are not representative of the editors, editorial board, or the AHSC. For more information, please visit http://humanities.medicine.arizona.edu. Please direct any inquiries or submissions to Harmony, Office of Medical Humanities Program, College of Medicine, UA Health Sciences Center , 1501 N. Campbell, P.O. Box 245017, Tucson, AZ 85724-5017.
COVER DESIGN BY: Roma Krebs, Biomedical Communications, The University of Arizona Health Sciences Center PAGE DESIGN/LAYOUT BY: Krista Nelson, OroGraphics Design & Printing, 520 219-4870 , www.orographics.com
(SHAD) FARSHAD FANI MARVASTI EDITOR-IN-CHIEF MD-MPH STUDENT, CLASS OF 2007
With this years publication we have a new focus and enthusiasm as we expand the Magazine beyond the College of Medicine where it was originally founded as Hermes to now include the entire Arizona Health Sciences communit y. We are changing the purpose of the Magazine: this new Magazine is intended as a literary and arts journal, but also as a forum for the expression of different opinions and ideas about how health care is practiced and how professionals in training and those already established believe it ought to be. Therefore, we wish to highlight reflections by students and faculty regarding their experiences in a format which will allow us to gain from each others perspectives. Through the inevitable clash of conflicting individual views, we hope to bring about a conversation leading to a spark of harmony between our collective roles as members of one health care team. The name Harmony fits with the desire to bring balance while maintaining differences of opinion.
Hermes is not an appropriate name for this new Magazine since Hermes was the god of commerce in ancient Greek mythology. In todays system of health care delivery, commerce plays a large role, but it finds physicians, pharmacists, nurses, and public health officials inundated with paperwork and constricted by bureaucratic procedures that effectively prevent them from making a meaningful connection with their patients and communities. These market-driven demands on health care professionals hinder us from developing healing relationships and thereby thwart our mission which is to provide equal access of care to all human beings. In moving from Hermes to Harmony, we as editors of this years Magazine and active supporters of the new Medical Humanities Program seek to return medicine and health care to their core mission. We seek to rise above the confusion and injustice which are unintended consequences of the business of health care delivery and arrive at the high ethical, humane, and professional ideals that we swear to in our oaths. We aspire to fulfil our duty of service to anyone who is in need of our expertise and our care.
MISSION STATEMENT
Harmony is an outgrowth of the newly founded Medical Humanities Program in the College of Medicine. This Program aims to raise our consciousness about the importance of the Humanities in bringing about ethical and humane health care professionals. The goals of this new Magazine are to value the different perspectives, insights, and experiences present within the Arizona Health Sciences communit y through the publication of original works of personal expression. In addition to accepting literary and visual art, Harmony also seeks to highlight editorial opinion pieces regarding any aspect of how health care is practized or organized and how it should be practised and organized. We welcome expressions and opinions from students of health care as well as from professionals established in their careers. We hope that Harmony will serve as an inspiration to foster greater levels of collaboration and integration of mutually important curricular activities between the Colleges of Medicine, Nursing, Pharmacy, and Public Health. For this reason, we have established the Advisory Editorial Board with representatives from each of these colleges.
H A R M O N Y A R I Z O N A H E A LT H S C I E N C E S C E N T E R M A GA Z I N E O F T H E H U M A N I T I E S
KARIBU AFRICA
MICHELLE MORRISON-GALLE MD STUDENT, CLASS OF 2007
I.
Karibu Africa If you can send a man To that moon In the black sky, Dark as the potent streams Rolling by this house of mud And dead trees. Asante sana, If you can right this very wrong, That leaves me burning trash, Barefoot, Upon broken pavement, Holding death In a childs hand. Oh mzungu, Karibu then.
III.
What was true. The horizon of grass, speckled with darker green of trees, Grey of the foraging beasts, And gold of the lounging kings. Then even the burst of red in the horizon, Leading goats in a line With extended ear lobes Bared against the sun. What will ever be true again. Even stars are upside down And the cars drive their different direction Choking the air with thick, blackened clouds, Tires grinding up, Spitting out the red dust Coating the leaves And the white teeth Stained brown, Invading her toes Along with the eyes Of her plump, living bundle Looking at me, My white skin blazing Like some flag of surrender Upon a bloody field. It was then that I gave myself up to it. The earth, The trees, flattened out against the sky, In praise. The dung on the road Mingling in the trash and their song, And the not knowing, The never being able to know, What the baby felt like, breathing against her back.
II.
When life Long as the red road out Is but under Those thick grey clouds of morning In the middle of the blueing hills Being pulled feet first Through green fields By bulls Fed large by the earth And these hands. In this What need have I Of Einstein, pens, Your books piled up high? Life is Firmly fixing toes in the martian mud Keeping these sticks Upon my head In the graceful dance Above the earth Until to it Under I go.
SWAHILI TERMS IN THE POEM: Karibu: term of welcome Asante sana: thank you mzungu: european or white person dala dala: Tanzanian bus,
H A R M O N Y A R I Z O NA H E A L T H S C I E N C E S C E N T E R M AG A Z I N E O F T H E H U M A N I T I E S
IV.
Toda y when I felt I was falling Into the sky Poked out with stars Turning deeper shades of blue As I stood, My back to the indoors And food I danced upon the drizzle of a breeze Passing through the high trees And then sloshed in the puddles Of it in the heavy leaves Of the bananas Oh, tonight Im on the green side Of that painting in two, Too busy breathing And rolling in the grass With the elephant and hippo To worry about that cross Sagging overhead,
As the choirs On in the brown Lift up their arms And their canto Falling on their knees, eating the dust, With the snake, Hanging, hidden, As their lord.
V.
Oh, cradle your children, Cradle of man And kiss their dark Smiling cheeks While singing to the night sky So deep You can swim atop Its oily blackness Feeling the stars Shine through your skin And feel those drums That called swinging monkeys From their trees To this earth And shout. For you know How to put the child To your drooping breast. Look out no more, Blessed are you poor Rich in such spirit. Clap your hands We, we, we ya And dance your dance, Turning to this heart Within your own song.
Infants rest on the patio floor at the orphanage in Beira, Mozambique. Most infants at the facility will die from AIDS before their second birthday.
KELLI DONLEY MD-MPH STUDENT
VI.
Dennys mzungu And happy am I To belong to someone A child of these green hills And this dirt road. So now I walk No longer guilty By this white face Because she held it In her earthen hands. Laughing because I am one of them Human Having the African face Holding one of theirs Protecting him like my own.
Children are led in prayer before their lunch at the orphanage in Beira, Mozambique.
VII.
This morning, when the dala dala Birthed us from its loud, lurching belly And I stumbled out on the dirt road Running atop the black, gurgling stream Where wrinkled women wash their feet and legs, Turned grey by the dust each day, Something about the light Shining amid the dark thunderclouds Mornings renewal The way it hit the road And the leaves And something about the rain cooled air I felt myself a child again Visiting my grandparents During the winter of my home While the sun shone on their patio With strange wooden masks Haunting us from the stone walls As we hunted for lizards Amid the smell of oranges in bloom In the valley of the sun. Then some of the pain The hurt that had been clawing within me Since I arrived in this land, From turning my eyes to the road When the woman without legs called, Mamma, as I passed Or the dirty child grabbed my hand And I had nothing I would not give. And suddenly every part of this place was rocking me As the wind played on each leaf Of every tree And clapped in the maiz Some sort of ocean symphony And even the bumps on the road Cradled my foot on their arch No longer calling my fall.
Written throughout Michelles time in Arusha, Tanzania during the summer of 2001
Women wait with their newborn babies outside of a clinic in Manga, Mozambique. The clinic is rare foreign support has provided the luxury of free antiretroviral treatment to all women and children who test positive for HIV/AIDS.
A lunch of noodles and chicken is served to children at the orphanage in Beira, Mozambique. Adeniyi Alo, College of Public Health, Giving a lecture at a rural high school in north east Nigeria. Speaking about local public health issues such as malaria, sexually transmitted diseases, and typhoid fever.
PROTOCOL
QUINN SNYDER MD STUDENT, CLASS OF 2007
I take a moment to ponder the rain before I step out of the car. The sounds were indiscernible before now when my radio was blasting KXCIs Morning Brew. The rhythmic beating of droplets bring a moment of peace. With a deep breath I throw open the door to my Honda and jump into the thick of it without any cover. There is no point in bringing an umbrella to school. The rain is so rare and unpredictable that it is a simple pleasure to walk into UMC with a drop or two of rain on your cheek. Way to get dressed up, says a distant voice. I am wearing black slacks and a dark sweater with a white shell necklace I picked up in Savannah a half a year ago. At 7:55 this morning it takes some effort to muster a reply. Who wears light blue to a funeral? I question. He is wearing a striped blue tie and a shirt lacking much contrast. We have never been to such an event as what was soon to take place this early morning. Chances are we never will again. Unfortunately, there is no etiquette detailed in any book for the rules of attending a ceremony to honor the cadavers given to a medical school for dissection. I have not arrived at school this early all semester, but it is the least I could do to pay my last respects to cadaver #4, the person who gave his body to four nave medical students so that we could see inside him. Look at the size of this guys lung, we once said. He had pneumonia and cancer, making it enough of a spectacle for us to play show and tell with around the lab. The mood here over our slightly above pathetic breakfast refreshments is awkward. Conversation is slow and jagged. More people are dressed up today than an average Frida y when a fourth of the class wears nice clothes for medical interview. In fact, I dont think I have ever seen so many people dressed up so nicely at this school. For the first time people who are wearing their usual threads feel out of place. The memorial has just started and Dr. R, our speaker, has been asked to come to the front. He withdraws a T.S. Eliot quote he probably got out of a book that morning. Unfortunately I never take quotes from profound anti-Semites very seriously. R is wearing a cornflower blue buttondown underneath a zip-up sweater. It is clear after his
two minutes on the podium that he did not prepare much for this speech. LG, wearing gaudy funeral clothes, claps and does her usual glance around the room. It makes me feel uncomfortable. GD, director of the Director of the Willed-Body Program, by which we are donated our cadavers, rises to the stage. He dons a black sportcoat with a beige buttondown underneath top button unfastened with no tie. He says that sometimes our cadavers are often rememorialized in a mausoleum or a cremation. The donors families, who he calls our extended family, will hopefully never have to see what we have done to their loved ones. GD offers us a moment of silence. Silently I say to my cadaver, Thank you cadaver #4. Thank you for giving me the last gift you could ever give. Your first and final possession. The knowledge gained will not be forgotten. What was there to say to this person? The owner of the body I would peel every other day for three hours in the afternoon last semester was unknown to me save his age, cause of death, and the contents of his body. I had little personal connection with cadaver #4. Perhaps it was better that way. Without knowing his name I refused to give him one. Other groups gave their cadavers new names, but I felt it unjust to call him by any name other than his own. The members of my group agreed. When I open my eyes, GD opens the stage up to the students. BM, a former TV news anchor, takes the mic and reads a snippet from a play by Seneca. She reads it like
LISA GOLDMAN MD STUDENT, CLASS OF 2007
she is reading a live-on-the-scene report in front of the camera. I imagine what that would sound like. This morning at the UofA College of Medicine students here are honoring the dead in an unusual way. No, it is not that any of their faculty or classmates have passed away recently. Instead, it is their cadavers, thats right, their cadavers LG, no shock, is up next. It is uncomfortable for everyone. We all know about the hairstyling, the nail painting, and the bracelet she gave to cadaver #2, but somehow as she reads her poem that all seems to fade away for me. By far it is the most elegant speech anyone gave this day. It is an excellent piece incorporating all parts of her experience with her cadaver. Fears, imagery, religion, and wonderment. I find myself putting down my pen for the first time since I began recording this event. She redeems herself from all the peculiarity. I will not think of her the same way again.
LISA GOLDMAN CLASS OF 2007
meaning, then our deaths will, too. In lab I often wondered how cadaver #4 worked for a living. Maybe he was a factory worker, or a farmer, or a carpenter. I will never know. He was a large muscular man with leathery hands and little fat for a man of 89 years. Before the upper third of his skull and his brain were removed, our group found it difficult to fit him inside his white plastic bin. After a while we learned to position him diagonally before covering him up for the night. Our class earth mother, AS, fills the stage with her presence. When she speaks it is like she is having a casual conversation with you. She is a touch of warmth permeating the room on this very strange day. For the first time today I latch onto someones emotions, that which I can understand with familiarity. This lukewarm mixture of respect and despair that I have witnessed all day has made me squirm until now. LH drops a little joke as she begins and proceeds to speak in a subdued tone. This is very abnormal for her. I find myself listening to her more intently than usual. She is opening up to us for the first time. It is very personal. She is talking to me. LH wonders what it would be like if her cadaver was a close relative of hers. She waxes eloquent on the uniqueness of this experience permitted to the select few the students of medicine. BM consoles LH with a arm touch as she sits down. I feel the bonds of our future profession tightening us all. That is all for the speakers, and now it is time for the flower ceremony. Each cadaver is given a flower by the members of his or her dissection team. When table 4 is called, AL, CD, and I go up to present the flower. We are missing a member of our group. Such is a reflection of the overall attendance of this event. AL takes hold and places the white long stem flower , the name of which escapes me, into the vase. We return to our seats and watch as all 36 flowers are placed together in the memorial vase. The ceremony ends and the members of the Anatomy class that took place in the fall of 2003 at the U of A College of Medicine are thanked for their presence. I grab my bagel and head out to the hallway to see if there is any coffee left in the big brown plastic containers. Class begins in four minutes. QS, 1/22/04
I bite into my bagel as the next speaker, KG, begins shakily. She is nervous about public speaking like myself, but today she has chosen to face her peers. I take a big bite of my bagel. I am proud of her. Watching her makes me wonder if I should have spoken toda y. I take another bite of my bagel and begin to wonder if eating during the ceremony is appropriate. Is my chewing audible? It certainly is to me. Now that I think about it, I wonder if writing is inappropriate. I put the bagel aside for later and continue. MR, a verbose yet eloquent and engaging fellow, opens his speech. He finds a beautiful quote from Octavio Paz that I can only paraphrase: If our liv es lacked
ONE HIPPOCRATIC OATH

ANONYMOUS FROM THE HEALERS ART CLASS
I shall seek to enliven the truest depths of my soul and find in my spirit the essence of existence and the vision that pertains to all of us. Help me to follow that vision in the creation of my path towards the truth in the service of my better, the betterment of those I come into contact with, and the betterment of all humanity and nature. Guide me to act from the depths of my emotions with sincerity, humility, and respect and embrace my truth for only it will lead me to the answers I seek. I kneel before myself and all humanity hoping to
perceive the immensity of our potential. May the greatness, both in concept and reality, of that potential not burn my eyes. May my eyes follow the immensity towards its resolution not seeking to quicken its pace or guide its direction. May I follow in reverence and calmness the path of my eyes knowing with self-assurance that the journey along the path does serve others if only given the chance to commence. Help me serve the path with the peace of mind of one who lives in the moment and brings joy to his and others lives.
Loon, Wells Gray, BC
ESKILD A. PETERSEN, MD SECTION CHIEF, INFECTIOUS DISEASE, COLLEGE OF MEDICINE
CONTAMINATION OF WATER, SOIL, AIR, BODY, MIND AND SOUL

CHRISTINE KRIKLIWY PUBLIC HEALTH GRADUATE STUDENT
Off to work we go Dump dump dump No one will ever know Molecules lose and gain electrons Fission and fusion occur Restless free radicals search for homes Changing our DNA is their goal Chemicals seep into the water and soil To silently pollute our lives Rivers and ground, contaminated Companies large and small, created Money is the bottom line At the expense of human lives Companies become extinct But we live on Enduring dire consequences our lives changed forever Off to work we go
Dump dump dump No one will ever know Media, books, computers Enter our lives innocently Greed becomes a major factor At the expense of human minds Killing, violence, sex and porn We search for anything that offends We target fresh, clean minds Occasionally flashing obscene material Whetting the appetite of innocent children We catch a few fish at first But then the pond becomes a lake When the flashing stops It has done its work To corrupt computer files and gr ay matter of young minds To successfully contaminate the body, mind and soul Witness this latent corruption Abolish it Let the healing begin
South Fork, Cave Creek, Portal, Arizona
INFECTIOUS DISEA SE, COLLEGE OF MEDICINE
ESKILD A. PETERSEN, MD SECTION CHIEF,
STORY FROM SHUBITZ FAMILY CLINIC PATIENT

Last night at clinic one of our favorite clients and I were conversing about raising children. He had just had a conversation with his daughter the day before (she still lives there) and it went something like this: Daughter, how are you doing? Fine father but I am troubled because Mother will not give me a pen. She wont give you a pen? Why is that? Because she gave me a pen Friday and now I do not have it. What happened to the pen? I gave it to another student because they did not have a pen. That is good. But now Father I do not have a pen! Let me talk to Mother. (Mother) Hello. Would you like to hear the story of our daughter and the pens? Pens? I know she gave one pen away at school on Friday. She should have another pen, please give one to her. I gave her a pen on Friday and she gave it away. I gave her a pen Thursday and she gave it away. I gave her a pen on Wednesday and she gave it away. I have given her seven pens and she gives them all away! Every day I give her a pen, she gives them away! What should I do? My dear wife, we have a choice. If we do not give her a pen, she will not go to school, or she will steal one from another student. If we give her a pen, she will go to school and will give it away. Which is the better lesson? We must teach her that school is important. We must teach her that giving is important. Please go buy 100 pens and give her one every day. I am far away but I am still her father and do not want her to lose these lessons. Someday when you come to America I will have many pens for every day of the year....
Motherhood
The Shubitz Family Clinic is part of the Commitment to Underserved People Program (CUP), a medical student directed service learning program. CUP provides early clinical experience in the context of community service to rural and underserved populations in Arizona. CUP also provides learning opportunities in program leadership, health advocacy, and health education programs starting in their first year and continuing throughout their four years of medical school. For more information visit the CUP website at http://www.medicine.arizona.edu/pcrm/CUP/cup.html.
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ANON
THE SPIRITUAL SELF

THANKS TO: DONNA E. SWAIM CLINICAL LECTURER, MEDICAL HUMANITIES PROGRAM, COLLEGE OF MEDICINE
TWO KINDS OF INTELLIGENCE

RUMI, FROM MATHNAWI, IV
Valuing self-awareness and dev eloping a capacity for reflection are critical. Who practitioners are as persons is most relevant to the quality of care they give and to the quality of the relationships they are able to form.
NORMAN COUSINS
There are two kinds of intelligence: One acquired as a child in school memorizes facts and concepts from books and from what the teacher says, collecting information from the traditional sciences as from the new sciences. With such intelligence you rise in the world. You get ranked ahead or behind others in regard to your competence in retaining information. You stroll with this intelligence in and out of fields of knowledge, getting always more marks on your preserving tablets. There is another kind of tablet, one already completed and preserved inside you. A spring overflowing its springbox. A freshness in the center of the chest. This other intelligence does not turn yellow or stagnate. Its fluid and it doesnt move from outside to inside through the conduits of plumbing-learning. This second knowing is a fountainhead from within you, moving out.
POEMS
It is difficult to get the news from poems. Yet men die miserably every day for lack of what is found there.
WILLIAM CARLOS WILLIAMS
CHRISTINA MENOR MD STUDENT, CLASS OF 2007
11
HERPES FOR HARMONY

JOEL BETZ MD STUDENT, CLASS OF 2006 JOSEPH PACK MD STUDENT, CLASS OF 2006
Oh Herpesvirididae, how have I had thee, let me count the ways I contracted you first as a small child. All in all Varicella was quite mild. But Know that Zoster is latent in my ganglia, It makes me feel vulnerable, like my immune systems a faila. Then in high school there was a cute girl. She had long blond hair that had a slight curl. She had a small sore on her lip, that was just fine, But the next sore I saw on a lip, was on mine. I have to admit, about herpes I had not a clue. But at least I did not get from her Herpes type 2. And that time in college I was too tired to live, I went to the doctor, took a monospot test, positive. I had a trip planned to see the Serengeti, I was so very tired I could hardly get ready. When I got there I began having facial elongation, So I had to cut short my African vacation. I was scared because it was the weirdest thing I ever had seen, But my doctor said its a translocation from 8 to 14.
When I stared medical school I didnt know the slightest, About the nearly ubiquitous Cytomegalovirus. Who would have thought that retinitis you would never see, Unless you were immunocompromised or had HIV. The professor said, know the distinct owl eye appearance, Then I learned about Hodgkins and caused that theory interference. So in order to know you I had to study and learn Until my own retinas started to burn. Then during residency I was the cutest child, First came the fever followed by a rash that looked mild. I said to myself this rash is no phantom, It is caused by HHV-6, its Roseola Infantum. The infection is self-limiting and so I thought best, To give the child fluids and plenty of rest. I finally got a job, to get paid felt great. It was there I ran into HHV-8. I saw you in Africa causing a tumor, It was Kaposi Sarcoma if I believe the rumor. While in the U.S. your presence is rare. In Africa you cause 10% of cancer there. Herpesvirididae, you will always be my friend, This ode to thee, however, must come to an end. How to end such a poem, I do not know, Oh wait, there goes my pager, gotta go.
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ADRIENNE YARNISH CLASS OF 2007
13
POMEGRANATE
ANONYMOUS
i am like a pomegranate born of the harvest, rosy and full not so sweet, as we are refreshing juicy and playful, she and I youll need your full attention to handle us not soft and easy like a banana or cool and crisp like an apple that you can enjoy while walking down the street firm and gentle pressing will strip us bare layer folded in upon layer youll want to uncover every jewel and youre left with a reminder of us upon your fingertips wondering when you can get more on the responsibility of a physician responsibility a thick full heaviness of a fur coat.
worn not only in winter but as the sun beats down. me? I wear a light woven silk throw. it can be lifted by a passing breeze or held tight or brushed back and forth over my left cheek. I wont let it be thick liquid to breathe through. or an excuse to growl, to roar. only another chance to fly. (another chance to shift, to sift wind)
UNIVERSITY OF ARIZONA RESIDENTS SYNTHESIZE FICTION AND FACT: THEIR READINGS OF FAMOUS MEDICAL HUMANITIES STORIES
SREELEKHA SUSARLA, MD MAY 2004
Dr. William Carlos Williams is one of the most famous physician-writers of the 20th century. He continued to practice medicine while he wrote. He practiced pediatrics for the most part which is reflected in his writings. The story The Use of Force was written in 1938 and shows how medicine was practiced in the preantibiotic era. The story is about Dr. Williams or the narrators encounter with a sick, young girl named Mathilda. He visits her in her house because her parents are concerned that she might have diphtheria. It depicts the emotions of all the characters very nicely. Mathildas parents are very grateful to the doctor for coming to their house and taking care of their daughter and at the same time embarrassed by their daughters behavior. The
speaker begins to approach the child to examine her throat very gently which turns into a battle where he goes beyond reason to win. He does this with the good intention of saving the girls life. This reminds me of one of my experiences with an elderly demented patient who came from a nursing home very sick, dying. She had no family around and we decided to do everything possible at that time. It was very difficult to get an IV line in with the contractions of her legs and arms. Sever al doctors struggled and we all were lost in the idea of getting an IV line so that no one realized and cared for her pain and how she felt about all this. Finally we got hold of her son who clearly expressed her wishes about no resuscitation and she passed away in peace.
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MY LOVE HATE RELATIONSHIP WITH HUMANITY

LISA GOLDMAN MD STUDENT, CLASS OF 2007
DECEMBER 2003
I am having another one of those dreams where Im flying naked over housetops at night. Only this time my white coat is reflecting moonlight. No longer nursing, my round-faced infant has now learned to read, and is losing baby teeth. These pearls are saved in a tiny glass jar . Their former owner has become a careful steward, caring for her fallen out teeth like a serious millionaire watches her stocks and bonds. Careful, like her mother, conscientious to a fault, this daughter has grown into a spiraling vortex of verbal competence and good will for all humanity. A future brain surgeon or the first female president of the United States? She fills with energy and intelligence as mine are depleted. Losing my mind, or just stuffed with facts? My white coat does little to protect me from the tops of trees as I fly in a weaving pattern over moonlit parks and cityscapes. I am searching restlessly for a landing place, and there is none. I comb the western border of the United States in the starlight, while cities twinkle beneath me. My white coat has mutated into feathers and my daughter and her father are flapping birds flying beside me in formation in the cold night air as we search for a place to land. Seattle, Portland, San Diego? Which city offers a landing place for an exhausted white bird and her two pigeons? Can I find somewhere, anywhere that won t suck me dry and spit me out? Is there a little corner of humanity that doesn t mistreat its residents, doesnt drain them of their life essence, doesnt flog them with merciless petty details? Details that stand between me and sleep, coming between me and my goofy pigeons? I love humanity, its just people I cant stand. The raving bitch insomniac will kick and scream its way to a resting-place, taking on the fool who comes between me and a good nights sleep. Where did you put my socks I cant find any socks... but I dont like chicken when its spicy...Do I have to eat all these peas I already ate five of them? ... Will I get dessert? Even my pigeons can make me crazy with their endless petty demands. No, this dream is pigeon free. Im sailing through the night, my white coat torn off by a tree a few miles back, and Im naked in the moonlight, way up high over the city where nudity is no issue, and the night air is warm, it makes me relaxed, and finding a spot to land is irrelevant because the clouds are soft and supportive like a couch. The pager has dropped into the sea. The patients have either gone home or have died and been picked up by the morgue. The charts have written and signed themselves. No one tries to humiliate me. Everyone loves and respects me, and Im lost in a good dream about milk and peas and clean laundry and children who brush their own teeth, and husbands who find their own socks. The child has grown, the need for mothers milk has dissipated and gone, but the memory lives on of milk flowing like a river, a mother and child curled up together in a warm nest that is eternal and etched into the subconscious, a refuge from cold night winds.
TESSIE OTALLEY ARIZONA HEALTH SCIENCES CENTER
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LIVING FOR FAILURE

DAVID ANDRESKI MD STUDENT, CLASS OF 2004
Hours turn to days, weeks, months, and years. Now that I am on the verge of completing medical school, I have been forced to decide if everything that I have done is truly my success story. It is true that I am graduating from medical school and am preparing to enter into a fairly competitive residency position, but I have a few doubts in my mind as to whether or not I am ready for this change. The more that I have reflected, it seems more likely that my education is nothing more than a facade for failure. Is it knowledge that I lack? My scores all indicate that I am competent and ready to pass into the next phase of my career. I have managed to pass through all of the academic hoops that were laid before me and have proved, even to myself, that I can actually perform as a physician. Knowledge, it seems, is not the missing link. This failure that I speak of is more of a life in balance issue. Throughout my training I have not been allowed to lead by example, for instance, following the accepted diet and exercise recommendation each and every day. The culture of the profession seems to remain that only the weak stop to take care of themselves. This particular institution proclaims that they are committed to humanistic medicine and the development of a balanced lifestyle. On any particular day, the advice given to preclinical students, who are very far removed from critical decisions, is to spend more time studying. I was even advised to plan sleep time and an hour a day for wasting time. I did not take this disastrous advice. Micromanagement of my life would be parallel to a malignancy slowly eating at a life until it finally causes death. I had to remind myself that I am not in control, and may become ill at times. Other times I may have to take time to help a friend get through an unplanned event, which is not allowed in the planned 1 hour of time wasted that I was to be allotted. Living a life planned to the extreme is in effect living for failure. In this scenario, there will be a time that everyone will fail on many levels while trying to maintain appearances. Instead, the advice I would give from my perspective, is to embrace failure. I do not advocate using this as an excuse to not perform
and learn information critical to your future. The failure I speak of is more of a recognition that you will never be an expert at everything, and you may need to reevaluate the priorities in your life. I ask, how terrible would it be if you discovered on y our deathbed, that your life was not the facade that you display each day. Ivan Ilyich, one of Tolstoys characters, did just that. In the famous story Ivan was a very successful person, until he was dying and reflected on his life and reevaluated what happiness really is. It is true that medicine is a field in which many decisions do in fact alter the lives of your patients. It is critical that every physician has the knowledge to act in these situations, but this does not mean that you must kill yourself in the process. Once you recognize that you will fail from time to time, you can then learn from the mistakes that you have made. This is often thought of as one of the more important aspects of effective learning. I also firmly believe that each failure I have had has been an excellent opportunity to learn more about my perspective on life as I know it. I cannot tell every person what it means for them to be happy. Even if I could, I would not. What I can tell you, is that you might want to start looking for happiness by taking care of yourself physically, mentally, and spiritually. And remember, the important things in life do not have to be scored! People with much more wisdom that I have written on the importance of using history to shape the future. Maybe they have found their personal key to success.
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ON DEMAND AND WITHOUT APOLOGY

GABRIEL SARAH MD STUDENT, CLASS OF 2008
Many opponents of abortion argue that, from the moment of conception, an embryo or fetus is a living being who should be treated separately from the woman carrying it. While one can argue about when life begins until blue in the face, the basic facts surrounding choice, privacy, and access to care are undeniable. A woman, for whatever reason, should be allowed access to an abortion in our country, on demand, and without apology as long as the fetus is not yet to the point of viability. Choice. One word has caused such extensive amounts of debate in this country. What does this mean? Its a simple answer: a woman has the right to choose what she is going to do with her body. Each person has their own morality, and it is by those beliefs that they will lead their lives. Proselytizing or evangelizing is not the place of those surrounding this woman. It is only our jobs, as practitioners, to share our concern and offer guidance. We can not force someone to believe in what we believe, nor can we deny care for those whose lifestyles we do not like. A woman has the opportunity to privacy in all matters of her medical care. After she has decided upon a treatment plan, with the guidance from her physician, she must be able to make decisions that she deems to be in her best interest. Many abortion
opponents argue about patient irresponsibility leading to an abortion. As we all know, many birth control methods do fail often or have different effects on each patient. Also, we do not know the personal circumstances surrounding a womans life, such as domestic violence or abuse. Her husband or partner may not allow her to take birth control pills, or may be abusing her and raping her. This woman may only feel in control of her life at the moment she is speaking privately with her practitioner and will at this point be able to make a decision about whether or not to end her pregnancy. While we may each have our own personal or moral beliefs regarding surgical or medical abortion, we as medical practitioners are in no way living up to our professional responsibilities by parlaying our morals on to our patients. It is our job to work with our patients to help them solve their medical problems. If you are not willing to perform an abortion, you should refer your patient to someone who is willing after discussing with her all her options. If after this, your patient is still seeking an abortion, keeping referral information from her will only lead to an increase in injury and death from abortions performed by practitioners not licensed or knowledgeable about the procedure.
LISA GOLDMAN CLASS OF 2007
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MEDICAL HUMANITIES: CAN LITERATURE OFFER POSITIVE ROLE MODELS FOR PHYSICIANS?
HELLE MATHIASEN, CAND. MAG., PHD DIRECTOR OF MEDICAL HUMANITIES, CLINICAL PROFESSOR OF MEDICAL HUMANITIES, COLLEGE OF MEDICINE
With this essay, I would like to open a discussion about whether good literature, meaning fiction of a certain quality, can help the medical student or doctor choose the kind of professional ethic she/he will aspire to embody during the day in, day out life of doctoring. The answer, for now, is that fiction offers both negative and positive doctor models. The final answer is that no matter how intriguing or well written, a literary text offers just limited understanding; a fuller understanding of what we aspire to be must be reached through experience. Ethical choice is existential. But to begin with: There are plenty of negative literary role models for the scientist/physician. Victor Frankenstein and Dr. Henry Jekyll are characters in two great nineteenth-century British works of fiction. However, they are evil, and not worthy of imitation by todays physicians. In both cases, their ambition to play god by attempting to create human life leads to assault, murder, and suicide. Victor Frankenstein, created by Mary Shelley, dies a miserable death while his evil monster, the serial killer he has made, survives. Dr. Jekyll, created by Robert Louis Stevenson, becomes addicted to the potion he has invented to allow him to roam the London streets at night as Mr. Hyde. He finally commits suicide. Frankenstein has become the prototype for the mad scientist. Dr. Jekylls story illustrates the evil effects of unethical medical research. Yet, through their remarkable artistry, specifically in their use of point of view, Shelley and Stevenson manage to humanize these men to the point where we can almost pity them. Both authors know that there is a monster inside each of us, and that we will recognize this monster if we are honest with ourselves. However, they warn us not to let the monster out. Clearly, both stories carry a moral lesson. The most admirable, positive literary doctor that I know of is of French origin: He is Dr. Bernard Rieux in Albert Camuss Nobel Prize winning novel, The Plague (La Peste). The plot concerns a bubonic plague outbreak in the North-African city of Oran in the nineteen-forties, Camuss own time. The town officials first deny that the dead rats in the street indicate plague, but, prompted by Dr . Rieux, a clinical physician, statistician and chronicler of the plague, they concede that the situation warrants
quarantining the town. Dr. Rieux and his friends now face an ethical choice: should they stay and fight the epidemic or try to leave? Dr. Rieux remains with his patients as he revolts against this absurd, unpredictable, and evil plague. He continues to lance buboes, inject serum, and keep statistics of the increasing number of cases, as he works night and day. Ironically, the plague finally ceases by itself. Dr. Rieuxs doctoring has alleviated but not eradicated the disease. However, he has learnt an important lesson through this experience of crisis: that there are more things to admire in men than to despise (287). Despite his frustrations, Dr. Rieux chooses to retain hope about the goodness of human nature. What are the instructive details embodied in Camuss creation, and why is the authors moral lesson of limited use? Clearly, Dr. Rieux stands out as an example of medical professionalism. He puts his patients first, altruistically sacrificing his private life, his sleep, and risking infection, in order to alleviate his patients suffering. He treats indigent patients gratis. He accounts to the public health officers of Oran for the dead rats, forcing them to admit that the plague exists. He works under physically trying conditions: Some minutes later, as he was driving down a back street redolent of fried fish and urine, a woman screaming in agony, her groin dripping blood, stretched out her arms toward him (49). The doctor assumes leadership and solidarity with the sick, saying, Oh, I know its an absurd situation, but were all involved in it, and weve got to accept it as it is (80). He feels empathy with his patients, but eventually, to save his waning energies, he concludes: One grows out of pity when its useless. And in this feeling that his heart had slowly closed in on itself, the doctor found a solace, his only solace, for the almost unendurable burden of his days. This, he knew, would make his task easier, and therefore he was glad of it (86). Dr. Rieux faces a medical catastrophe, therefore he must ration his emotional energy. We can compare the plague conditions described by Camus to the horrendous effects of an outbreak in the United States of SARS, smallpox, or an attack of bioterrorism.
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Even the most ethical and selfsacrificing fictional doctor remains a fiction to us. Only experience can really teach the details of skill, knowledge, and behavior and the nuances of language that will make for a good physician. Observing positive, living role models is probably the most effective way to learn medical professionalism. Reflection and self-analysis can also be useful tools for improving medical skills. Literature is helpful; however, life provides the most enduring lessons. The quotations from Camus come from: Albert Camus, The Plague (trans. Stuart Gilbert. Random House, 1972). Id like to recommend three relatively recent texts about doctors: Abraham Verghese, My Own Country (Vintage, 1994). Richard Reynolds and John Stone, eds., On Doctoring. Stories, Poems, Essays (Simon and Schuster, 2001). And Tracy Kidder, Mountains beyond Mountains. The Quest of Dr. Paul Farmer, A Man Who Would Cure the World (Random, 2003).
Winter Sotol Sonoita, Arizona
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JAY W. SMITH, MD PROFESSOR EMERITUS, DEAN, ACADEMIC AFFAIRS, RETIRED, COLLEGE OF MEDICINE
Interestingly, though he is clearly a hero, Dr. Rieuxs moral integrity leads him to identify himself simply as a human, as he tells his friend Rambert: However, there is something I must tell you: there is no question of heroism in all this. Its a matter of common decency (154). By common decency, Dr. Rieux means doing his job. This is perhaps the single most important lesson of Camuss fictional physician: The thing was to do your job as it should be done (39). This statement is true, but so generally stated that it can apply to anyone in any job. Just do a good job.
BAD NEWS
SHARON LYNN SANBORN, MD RESIDENT, GERIATRICS, VA HOSPITAL MAY 2004
It was one of those highs that leave a huge smile on your face. I had just signed the lease to my new, beautiful apartment with my new roommate. I was so excited to leave my old apartment with its moldy ceiling, crappy windows, rude landlord, and sloppy roommates. My first year of medical school was almost over, summer was coming, and freedom was on the horizon. The only thing on my shoulders was the final interim exam in three days and the comprehensive exam in two weeks. I ran upstairs to my room in my old apartment to call my parents to tell them the good news. My dad picked up the phone. I think I was expecting to get the answering machine. I told him of the grand signing of the lease. He seemed pleased at my happiness but distracted at the same time. How are you doing, Dad? Why are you home so early? Well, I have some kind of bad news. I paused as a million things ran through my head. I think I should wait for Mom to get home to tell you. No, you cant do that. Please tell me. My heart and head would burst if he left me hanging until my Mom came home. Is someone there with you? Oh God, I thought, someone died. My friend Ken is right next door. I had that doctors appointment (he w as referring to a second neurologist that he had been referred to after having some weakness and twitching for a few months). What did he say? Honey, they are not absolutely sure, but they are about 98% certain that I have Lou Gehrigs disease. You probably thought that already. No, I didnt already think that. My mind was racing back to the neuromuscular committee. I felt I should know more about this than my dad, but I didnt. What does that mean? It is a degenerative disorder. Ill lose my muscles. Eventually you cant swallow, and you die because your breathing muscles dont work. But my brain will be ok which might not be such a good thing. And I wont lose any of my bathroom functions. My eyes swelled at all of this but I had to stay calm. The last thing my dad would ever want to do would be to cause me pain. My dad was so athletic when he was younger. He used to go hiking, backpacking, running up a mile high mountain after work a few times a week. The thought of my dad lying in bed, immobile,
seemed totally unreal and nauseating. How fast does this happen? My voice cracked, and he could tell that I was crying. The average is about 1-3 years. My heart sank and I wanted to puke. At that moment, I didnt want to be a medical student. I just wanted to be a daughter, a sister, a friend. I stopped going to class. We only had a few more days anyway, then our last exam and the comprehensive exam. After talking many more times with my family, it was made very clear to me that the last thing my dad wanted was for me to leave school even though that was the first thing I wanted to do. But my mom kept telling me that one of my dads wishes, one of his goals, was to make it to see me graduate from medical school. Even though it killed me to stay in Cleveland, trying to study for the biggest test of my life so far, while my parents were all the way in Arizona, I had to obey my dads wishes. But in a way having something to focus on helped me through the initial shock. I would force myself to concentrate on my work. People often tell me that they dont know what to say after I tell them about my dad. There is no magical statement or action that can take all the pain away. But people can offer their support to the person being affected and their family. It means so much to me when people ask me about my mom and my brother. My mom gets control by finding out all she can about ALS. She even asks me to look up articles at the medical library and to call experts in Cleveland for her. I gain power by talking about the situation with my friends and classmates to get them to realize how this can impact a family. I have learned how important the will to live is and how impending death can open eyes. My parents have not always gotten along extremely well. Now my dad expresses his love for my mom, compliments her cute little figure, appreciates her kindness as a wife and mother, and shuts off the TV when they have dinner. I think my mom realizes what she wants in life. She loves my dad very much and realizes what it might be like to be alone.
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My eyes have once again been opened to the beauty of life. Stop and look sometimes, smell the roses if you will. Take notice of the changing seasons, of the feel of water washing over your body, of the smell of a chimney, of a peaceful silence, of a relaxing walk, of a strangers smile, of a friends hug. Our world goes so fast and we get so bogged down in memorization that we sometimes forget to appreciate our lives. Slow down time. My advice is to learn all you can about the people around you because they will not always be there. Listen to your patients and think of them as one piece of a larger family, group of friends, and part of society. Take the time to explain things to patients and realize that they will not always do
everything you want them to. Tell people how much they mean to you. Find something good in every bad. Learn how to say, Im sorry. I wrote this after my first year in medical school at Case Western Reserve in 1999. I am now a resident. My dad died December 19, 2002, during my third year clerkship. My flight did not make it in time to see him alive one last time, but I spoke with him on the phone before my plane took off. He was clear in his speech even though his speech had deteriorated greatly. He told me how much he loved me. He told me how proud he was. I will carry him in my heart and mind for the rest of my life. He will always be with me in spirit.
Black Bear, Wells Gray Park, BC
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A RESIDENT REACTS TO TELL ME A RIDDLE, A STORY BY TILLIE OLSEN

WILDER DIAZ-CALDERON, MD RESIDENT, GERIATRICS, VA HOSPITAL MAY 2004
Painful fragment displaying two interesting concepts. What I call the wear of a relationship by difficult times (economic, social, etc.) and the painful process of a prolonged death. Regarding the first concept I will only say two things. First, as cold and rotten as it sounds, the lack of all those things we tend to classify as not essential (money and pleasure in all different manifestations), does have a permanent negative impact on life and how we perceive it. It can destroy a beautiful relationship by all the wear and tear it exposes the relationship to. Second, nobody wins alone in a couple nobody can win forever. Sooner or later the mounting years of losing explode and terminate what is good in a relationship better sooner than later. At home, either we both win by sharing or we both lose.
Not particularly my first choice as far as reading after the hospital and the dealing with life and death issues relatively frequently. It did nevertheless provide me with a vivid story that puts in words what I can only imagine, with images that can not get me even close to what happens when I send a patient home to continue to deal with this daily slow process of dying. It is always encouraging the idea of there being a strong form of love supporting a couple that has been together for a lifetime. As grouchy as they become, regardless of how much hatred and frustration there is, Eva has been a virtuous woman. She has pushed this family with courage, and they all know it. He, after all the fight and the names filled with rage that he used to call her, falls asleep suffering for her loving her, for she has been the woman of his life.
Reclining Buddha
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JENNIFER SLACK MD STUDENT , CLA SS OF 2004
BLACK AND WHITE

JENNIFER SLACK MD STUDENT, CLASS OF 2004
The first thing I notice is her smile, its glow radiating out from under her soft, velvety, black hat across her face, subtly hiding her swollen cheeks. I smile too, trying to take some of her warmth, her happiness, for myself. She is the last patient in clinic today and Im tired of following the white coat into stuffy shoebox exam rooms, listening to cookie cutter interviews. He turns away from her and points out the tumors dimensions and location on her scans, noting that it is back and has now migrated. He misses the moment. Her sudden realization, the cancer is worse instead of better? I catch it, the instant when her radiance freezes in place, reflected on the radiology films next to her growing tumor. The soft, velvety, black hat is still atop her head and her hands are folded neatly in her lap. But her beautiful lopsided smile is disintegrating. As she crumbles to pieces in front of me, Im acutely aware of the smile still frozen on my face. Im afraid to let it go, because then I too may crumble, overpowered by her intense sadness. He sees, now, the problem. She expected everything to be better . The message she received before this appointment was that her tumor had not changed. Now, to find instead that everything is worse? Its asking too much of anyone. So she asks him for answers. She asks what happened, how a mistake of this magnitude could be made. She asks him a question for which he has no respectable answer and he knows it. He cant tell her why the other doctor said there had been no change since her surgery. He instinctively crosses his arms to defend himself against her anguish, letting her words slide off the sleeves of his white coat and onto the floor, where he can push them under the examination table with the toe of his polished boot. On cue, she leans back, away from his crossed arms. Her body begins to
collapse and her head drops into her hands. Her soft, velvety, black hat falls to the floor revealing her naked scalp. And she sobs. Deep, soulful sobs. Her back rises with each breath in and her shoulders rock with each painful release. Hes hurt, too. Hurt by the doctor who read only the last line of the radiology report to his patient. Hurt by her pain. Hurt by his inability to help her . He uncrosses his arms and extends his hands across their mutual emotion, leaning towards her as he places them on her knees. They sit this way for minutes, she sobbing, he watching her intently , absorbing her pain and releasing his own. Then she looks up, and without words their moment is shared, an understanding is reached. The tumor is hers alone, but the battle against it will be fought together. As the expression of her intense sadness diminishes, an appointment is made with the oncologist. There is no more surgery he can perform, but he schedules a follow-up with her anyway. Once more he looks at her intently and when she meets his eyes, their partnership is forged. She begins to gather her thoughts as she rescues her soft, velvety, black hat from the floor, and I follow the white coat out of the shoebox with a new smile on my face. Smiling for the subtle shades of compassion and comfort which lie somewhere between the ability to do nothing and the ability to cure.
TESSIE OTALLEY ARIZONA HEALTH SCIENCES CENTER
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THE RONALD MC DONALD HOUSE & THE RIVADAVIA

RONALD P. SPARK, MD AS SOCIATE PROFESSOR OF CLINICAL PATHOL OGY, DEPARTMENT OF PATHOLOGY
She was crashing thorugh the high sea, dark smoke billowing out her two funnels, her nose and forecastle pointed into the wind: The Rivadavia. What a glorious sepia-toned photo, grand at 4 ft. by 2 ft., smartly matted and oak framed behind age tinted glass. I wasnt hesitant. The picture of the 1911 Argentine dreadnought was mine for $5, a real Tanque Verde swap meet bargain. I was flushed with awe and inspiration as I mused over her beautiful design, her six 12 inch guns, her length at 595 feet and sheer mass at 27, 840 tons. Who did you buy that ugly dust collector for? carped my lo ving wife. Youre not bring that old battleship picture into my housel. Better dry-dock it at your office! Thus, The Rivadavia found a safe harbor on the wall across from my office desk. I would catch myself gazing upon the large photo several times a day and think of the ocean and not being desert land locked hundreds of miles away. The Rivadavia gave me both dreams and solace. But then I got orders from the Admiral to move to a smaller office that had no room for a photo of the 27,840 ton dreadnought. I couldnt bear the thought of having to scuttle her in the middle of the Sonoran Desert. Then a breeze blew in from the Sea of Cortez. Tucsons Ronald McDonald House just opened. I could permanently loan the photo of the Queen of the WWI Argentine Navy. There she could buoy the spirits of the kids and their families, giving some relief from their distressful situations. Yes, they too would savor the photo, as I had done, with a sense of wonder, romance and thoughts of a magical time far removed from their pressing cares. The Director was delighted to have the foreigner emigrate to the walls of the McDonald House. I was so mixed about giving up my gift that I put off visiting her for some time. But one day, going down Speedway, I couldnt resist and swung into McDonalds driveway. I bolted up the steps, through the door to the hallway. No Rivadavia! I turned tight rudder and bore down into the Directors office. I was breathless. The Director looked up to greet me. Then I saw her, hanging with great glory, on the wall just above the Directors desk. Yes? the Director asked. But I knew the episode was a portent of the future.
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Several years past and it happened. I saw signs of the inevitable. There were trucks and workmen outside of the now remodeling Ronald Mcdonald House. I didnt even bother to inquire. I knew the Rivadavia had hoisted anchor and steamed off to a better port. Thats not the end of the story. Back at the sw ap meet last year I rounded a row of vendors and saw a part of an enormous oak wooden frame. It was the Rivadavia! She was still crashing through the rough sea billowing dark smoke from her twin funnels. She again had me in her power. I drank in her graceful lines, her six 12 guns, and her majestic forecastle. My wife saw it, too, just as I said the inevitable, How much? My friend wants $ 35 and thats firm, the woman said dispassionately. Its just an old boat but the frame is usable. That was the extent of the sales pitch. Youre not going to buy that my wife started. But I cut her off. No, now she deserves another Captain and more ports of call. One can never really own a spirit with such a restless soul. I felt a sense of resolution and passage as I walked away, never looking back to see her one more time. Some beautiful things sail into and then out of your life. The Rivadavia was just such a gift to me. She made me swoon. But now she needed to sail on to inspire someone else. And I have to resign myself to living land locked in the desert, so far from the ocean and the likes of the Rivadavia.
Coatimundi, Portal, Arizona
ESKILD A. PETERSEN, MD SECTION CHIEF, INFECTIOUS DISEA SE, COLLEGE OF MEDICINE
ONE PREMISE AND ABORTION

PETER STOCKTON MD STUDENT, CLASS OF 2007
Abortion is a divisive issue with a sharp line segregating the two views. The arguments used by either side are hard to compare because they start from two different premises. In most of the discussions on this subject, I have found that no argument is breached that the developing fetus is living; instead the center of contention is when personhood is conferred. With personhood comes rights. If you are not a person then you are not protected under the Constitution. Because the opinion of when a conceptus becomes a person varies, controversy arises as to when it should be legal to end a pregnancy. Either you believe that when the sperm fertilizes the egg a person is made or you believe that somewhere on the continuum of life, the fetus becomes a person. I have reached some interesting conclusions in my own life that I am sure will impact my future practice of medicine. I start with the premise that the embryo is alive and is a person because it has different genetics than the mother or father. Since the baby is a person, she/he has all the rights of any other patient under my care. Thus a pregnant woman is two patients, the mother and child. If I offered abortion as an option to the woman under my care then I would be essentially ending the life of the patient inside the mother . I would not recommend cessation of life to any one as a treatment, because a physicians role is to heal not to harm. Since I start with the fact that the child is a patient I cannot, in good conscience, offer abortion as an option to any of my pregnant patients, and cannot refer them to a physician that would perform an abortion. Doing so would negatively impact the health of the child under my care. I believe that life is a continually unfolding process and that from the moment your genes are turned on, you are a physically distinct life and human being. In line with that, I could not suggest an abortion to a rape or incest victim because that would be recommending that one of my patients die.
The preponderance of abortions in America is performed not because of the mother being in dire straits or a serious birth defect but due to an unwanted pregnancy. We have tried to divorce sex and procreation in our society and the two are indivisible. Every time sex happens there is a chance, however remote, that a pregnancy will occur. As a physician I will not suggest abortion as a treatment option nor will I refer to a physician who would. Instead I will work to build a relationship with my patients that will include information on the responsibilities inherent in sex.
Statues destroyed by The Taliban, Spring 2001, Bamian, Afghanastan
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GRADUATION SPEECH, CLASS OF 2004

JOSEPH S. ALPERT, MD ROBERT S. AND IRENE P . FLINN, PROFESSOR OF MEDICINE HEAD, DEPARTMENT OF MEDICINE
Deans Joiner and Ryan, Faculty of the COM, graduates of the class of 2004, honored guests, family and friends of the graduates: I am most grateful and honored to have been asked by the class of 2004 to deliver a few remarks on the day that they receive their MD degrees. When first asked to deliver this address, I did what most individuals in my position do, I consulted my heart. Thereafter, I consulted my spouse, my trusted friends on the faculty, and my administrative team. Finally, I did something that I have learned from my interactions with medical students and undergraduates: I consulted the web!! It turns out that many graduation speeches are recorded on the webjust ask Google for graduation speeches in order to read some of the best of these remarks given over the last 50 years. There was JFKs commencement address to the Yale Class of 1962; Kurt Vonneguts remarks to the graduation class of Rice University, Hillary Clintons speech at the Harvard Medical School graduation of 1998, as well as wonderfully humorous addresses by Oprah Winfrey, Bill Cosby and columnist Russell Baker. Cosby told the graduates to stop asking their parents for money!! Baker advised the graduating class of Connecticut College in 1995 NOT to graduate. He told them that the world outside of Connecticut College was a mess, and that his generation had created it. Baker suggested that the potential graduates shouldnt graduate rather, they should stay in college!! I am not going to give you this advice, since, after all, we need you desperately in the healthcare labor force. Indeed, you are about to become the best cheap labor that we can manage to find. The system cant make it without you!! I would like to say a few words to the people who helped to get you here today: your parents, spouses, partners, significant others, children, and friends. After the ceremony is over, graduates of the class of 2004, remember to say thank you. Say it many, many times. One time for each dinner missed, each appointment not kept, each event missed, each remark not heard because of fatigue or preoccupation with this or that sick patient, and so on, and so on, and so on. You can never say enough thank yous. And guess whatit is about to get a lot worse. For example, given the fact that I
have been at this business a lot longer than you have, I now owe 43,289 thank yous to my spouse who is sitting here tonight among you. Perhaps, she will forgive me some of them, and perhaps your family and friends will too. Maybe we should have a big thank you debt forgiveness session tonight after we all march out. One thing is certain. All of us: you, me, the deans up here beside me, the faculty sitting behind you, every last one of us, owes a huge number of thank yous to our loved ones who have lived the blood, sweat, and tears alongside of us. So remember tonight to say thank you to them. They deserve it more than you know. And finally we arrive at that part of the address where the speaker intones some easily forgotten advice for the graduates themselvessomething along the lines of Remember to listen to your patients. Or, Medicine is a sacred profession keep it going. Or, how about The healthcare system of the 21st century belongs to youtake good care of it!! Of course, all of these statements are true, but they are also somehow easily forgotten in the excitement of the moment. So I am not going to say any of them, even though I just did!! What I do want to sayand I hope that you will remember this alongside of saying thank you to your family and friendswhat I do want to say has grown out of more than 25 years of teaching a course with my wife, Helle Mathiasen. Let me give you a little background information about this course which, by the way, Helle calls literature and medicine and I call medicine and literature. More than 30 years ago, when most of you werent yet born, my wife and I were in graduate school and medical school respectively. She was earning a PhD in English and American literature, and I, of course, was in medical school. On a number of evenings, we would have wonderful discussions, as well as some disagreements, about the nature of truth (with a capital T). I argued that Truth could only be found through appropriately controlled scientific observations, and she countered with arguments in favor of the many truths revealed in great works of literature, art, and music. Eventually these discussions became a course, first for undergraduates and later for medical students. Last month, we finished teaching this course for the 27th year to 14 senior medical students here at the COM. The literature and medicine course
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focuses on the large body of literaturepoetry, novels, plays, short stories, etc. that have a medical theme or have been written by doctor/ writers. You might be surprised to learn how many physician/authors there have been. For example, there was Sir Arthur Conan Doyle, the creator of Sherlock Holmes and his physician side-kick, Dr. Watson. There was Somerset Maugham who wrote Of Human Bondage, there was the American poet, novelist, and short story writer William Carlos Williams who won a Pulitzer Prize. Others include Lori Alviso Alvord, the first Navajo woman surgeon, who wrote The Scalpel and the Silver Bear; Abraham Verghese (who was a visiting professor here at the U of A last fall). He wrote, among other works, My Own Country and The Tennis Partner; and there is my medical school classmate, Michael Crichton, as well as many, many others. Our literature and medicine course seeks to give medical students a sense of the effect of illness on the patient, the family, and society. It also attempts to place medical ethics and medical professionalism in a context where they are easily understood. A frequently read book in our course (and my own personal favorite) is the Nobel prize winning novel, The Plague, (1947) by the French novelist Albert Camus. In this work, a primary care doctor, Dr. Bernard Rieux, finds himself treating thousands of patients struck down by deadly bubonic plague in the northern Algerian city of Oran sometime in the nineteen forties. Dr. Rieux is a modern physician: he understands what causes the plague and how it spreads. But this plague epidemic rages at a time when antibiotics effective against Yersinia pestis were not yet available. Well, you can imagine what happens: people die by the hundreds, and by the thousands. Dr. Rieux and a small band of faithful health workers and friends battle the plague by lancing buboes, injecting immune serum, placing patients and family in quarantine, and utilizing a variety of sanitation measures but with little success. Finally, at the end of the novel, the epidemic recedes. During the worst phase of the plague epidemic, Dr. Rieux discusses with his friends the fatigue and frustration that he faces daily because there is no effective treatment for this highly contagious and lethal disease. Dr. Rieux admits that resisting the plague is a never ending defeat, but that it is nevertheless important to continue to do his job. In fact, Dr. Rieux equates doing his job with being a decent human being.
This idea has come to be the touchstone of my own life, and I hope it will become a central theme in yours. No matter how difficult the situation, just keep doing your job! Eventually, you will prevail despite many losses and discomforts suffered along the way. Just do your job the way it should be donethat is my main message for you tonight. During the preparation of these remarks several weeks ago, I w as inspired to summarize them in a short poem dedicated to you, the graduating class of 2004. This poem reiterates some of the things that I have been saying for the last ten minutes. It is definitely not great literature, but it does express my feelings and my message for you tonight. In the interest of full disclosure, I admit that I borrowed a line from Dr. William Carlos Williamss very short poem, The Red Wheelbarrow that goes like this: So much depends on a red wheelbarrow, glazed with rainwater, besides the white chickens. I also borrowed a line from Abraham Lincolns Gettysburg address. The poem is titled Go Forth. So much depends on your family and friends, And on doing your job until it ends; The world will little note nor long remember what I say tonight, But please do your job until its done right As you walk down the aisle in single file, and with style, forget for awhile the blood, sweat and tears trials that are coming your way. O, theyre coming all right as sure as dawn as sure as death as sure as birth as sure as love, and friendship, and pain. As the spiritual says Go forth go forth and do your job as it should be done. You wont regret it, ever. Thank you, Doctores Medicinae Novi , the graduating class of 2004, for allowing me to take some time to speak to you on this your v ery special night. Congratulations on doing your job, and doing it well.
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TRANSITIONS; FROM STUDENT TO CLERK TO PHYSICIAN: ADVICE FOR THIRD YEAR STUDENTS
JAMES E. DALEN, MD, MPH DEAN AND PROFESSOR EMERITUS, RETIRED, COLLEGE OF MEDICINE
There are many transitions in the educational path that leads to becoming a physician; from grade school to middle school to high school to college to medical school to residency. However, I believe that the most profound transition is from the second year to the third year of medical school. The first day of the third year of medical school is in many ways the first day of the rest of ones life as a physician. After having gone to school for at least 18 years, everything changes. The rules change. It is no longer: listen to the lecture, read the book and then repeat what you heard or read in order to pass the test. Now the rule is: do it! Take the history, do the physical examination, interpret the laboratory tests and then put it all together with your knowledge of the basic sciences to determine what is wrong with this patient and what you can do to help him or her. In fact, this is what you will be doing for the rest of your life as a physician! You will learn how modern hospitals and clinics operate. A wise mentor once told me when I was a third year clerk that everyone who works in this hospital or clinic knows things that you dont know. If you are smart you will learn from all of them; the nurses, technicians, social workers as well as the physicians and other students. Most of all, you will learn by listening to your patients. If you listen carefully you will learn what they really feel, what they really fear, and, if you listen very carefully, you may learn what it is that is wrong with them. We are fortunate that patients allow third year students to examine them and assist in their care. It is a privilege that we must honor by treating every patient with the respect that we would give our parents. Most patients become quite attached to their medical students. In most cases the third year clerk is the one person who has listened to everything that the patient wants to say. There is an old story of a world famous Professor of Surgery who told a patient that she needed urgent surgery. The patient said: I will have to talk that over with my doctor to make sure that she agrees. Who was her doctor? A third year clerk- who fortunately did agree with the need for surgery. For the first time in your educational career, you and your classmates will not be exposed to the same data base. You may see patients with
problems different from those of your classmates and you will be exposed to different mentors. It isnt important that you see every possible disease. The main thing that you will learn is how to approach, and how to try to solve your patients problems. The learning curve in the third year of medical school is very steep; it is equalled only by the first year of residency. Unlike the prior 18 years, virtually everything that you learn in the third year of medical school needs to be remembered. Its probably ok to forget some of what you learned in calculus (or even organic chemistry!) after you have passed the course, but what you learn in the third year needs to be kept, and expanded throughout a life time of learning as a physician. The main reason that most medical students have excelled in their first 18 years of school is because they are bright (thanks to a wise choice of parents!) Things are different when you practice medicine. Being bright is not enough. The world is full of bright people. In basketball being tall helps, but does not ensure success. The best basketball players are the tall players who work the hardest at it. The best physicians are the bright ones who work the hardest at it. A good example is the ability to take an accurate history and perform an accurate physical examination; the sine qua non of making an accurate diagnosis. The best physician improves his/her history taking and physical examination by working at it! As a clerk, you should check your history and physical findings with that of more experienced physicians. When you miss something on history or physical examinationrecognize it, dont make excusesgo back and repeat parts of the history and physical examination. When one of your patients has an abnormal physical finding repeat that part of the examination every day that you see the patient, after asking the patients permission. You can read about diastolic heart murmurs and answer test questions about them, but you need to listen to as many diastolic murmurs as you can in order to be able to accurately recognize one in a patient. You need to read during your clerkshipbut it is a different kind of reading than you have done in the past. The purpose of your reading is not just to pass a test. Your reading should be selective; you need to read about the problems that your patients have. It is a very special experience to read about
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a disease that one of your patients has and to compare what the textbook says with what you found by history and physical examination. Often you will go back to ask the patient further questions or repeat parts of the physical examination based upon what you read in the textbook. Most physicians remember the first patient with specific diseases that they worked up during their third year clerkship. One of the most important responsibilities of third year clerks is to follow the daily progress of each of their patients. In addition to being a responsibility, this provides an extremely valuable learning experience. When it is possible the clerk should be present when her/his patient is seen by a consultant and when the patient undergoes
diagnostic procedures. When possible the clerk should review the results of diagnostic studies with the specialist who performed the study. When a clerk has a choice as to which patient to work-up, she /he would be wise to select a patient with a common disorder. Common diseases are common because they are common! There is a great tendency in teaching hospitals to focus on the rare diseases. Remember, rare diseases are rare because they are rare! Clerks are often asked questions about diseases or clinical findings that they couldnt possibly know. Clerks may be embarrassed that they dont know, but the appropriate answer to such questions is: I dont know., and then ask what is the answer? Clerks must realize that as physicians they must always be intellectually honest. We can do no less for our patients! Intellectual honesty means that if you are asked for the results of various laboratory tests, and you dont know the results- you dont say they were normal, you say I dont know, but Ill find out. If a patient asks his physician for his prognosis and the physician doesnt know - the answer should be: I dont know, but Ill find out. Third year clerks are evaluated on their ability to workup and follow the progress of their patients as well as on their knowledge of the pathophysiology of the diseases and disorders that they encounter. Unlike previous evaluations (i.e. grades), which were based almost entirely on test results, clerks are also evaluated on their ability to relate to their patients and the other members of their health care team (doctors, nurses, technicians, other students). In fact, this is the same way that interns are selected, and residents are evaluated, and this is the same way that physicians are evaluated! The brightest physician with the highest test scores will be ineffective as a physician if she/he can not relate well with patients and other members of the health care team. The third year of medical school is one of the most important and most exciting stops on the path from student to physician! I think that you will enjoy the third year, and I know that you will always remember it!
Nakisha Ranch, Well Gray Park, BC
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OPERA AND MEDICINE: VIOLETTA, THE GREATEST WOMAN

KENNETH J. RYAN, MD DEAN FOR ACADEMIC AFFAIRS, COLLEGE OF MEDICINE
There is no shortage of death, suffering, and dying on the operatic stage. While we would categorize most of these as business for the trauma service (murders, poisoning, immolation) a few depict the evolution of disease as an integral part of the plot. Of operas in the standard repertory the most common medical conditions are tuberculosis (La Traviata, La Boheme, Tales of Hoffman) and the many depictions of mental illness in mad scenes ( Lucia di Lammermoor, Boris Godunov, Peter Grimes). Of these the one in which disease is most integral to character development is the depiction of the title character in Guiseppe Verdis middle period masterpiece La Traviata. In this opera Verdi and his librettist Francesco Piave make use of prevailing attitudes about consumption (tuberculosis) and sexual liberation to create a woman of Shakespearean proportions. In fact their creation Violetta is the most heroic role any woman can play. La Traviata (The Fallen One) is a v ariant of a timetested plot which goes back to Romeo and Juliet; that is, young lovers going against the approval of family. In this version, Violetta, a beautiful, young courtesan, is reentering mid 19th Century Paris society after a relapse of her consumption. Alfredo, a young man of good family who has admired her from afar, offers love and an escape from her decadent life. They live together (unmarried) in bliss in the country until the arrival of Alfredos father, who prevails on Violetta to end the disgrace their relationship is bringing to his family. Although still in love with Alfredo, she agrees to make this sacrifice by making Alfredo believe she wishes to return to her former patron and life as a courtesan. He responds by declaring her a common prostitute in front of her friends. In the last act the dying Violetta is reunited with a repentant Alfredo, but it is too late and she dies at the curtain. The character of Violetta is taken from that of Marguerite in The Lady of the Camellias, a novel by Alexandre Dumas fils, illegitimate son of the author of The Three Musketeers , and The Count of Monte Christo. The novel and a later play are in turn taken from Dumass affair with Marie Duplessis, who was mistress to many other members of the Parisian elite class including ministers of state. Charles Dickens happened to be in Paris in 1847
when she died at the age of 23 and was shocked by the attention accorded her funeral. He commented: Paris is corrupt to the core. For days every political, artistic, and commercial question has been neglected by the newspapers for an event of the highest importance, the romantic death of the celebrated Marie Duplessis. You would have thought it was the death of Joan of Arc. There are those who feel the character of Violetta owes more to Verdis mistress Giuseppina Strepponi than to Marie Duplessis or Marguerite of The Lady of the Camellias . Verdi was a widower, having lost his wife and both of his children before he was 30. He met Strepponi, a soprano, when she created the role of Abigaille in his first hit Nabucco in 1842. Five years later she became his mistress, and Verdi was living openly with her in Paris at the time he attended the world premiere of The Lady of the Camellias. This created a great scandal, particularly when they returned to his home near Bussetto in Parma, Italy. Paris was one thing, but in rural Italy the locals and Verdis family ostracized her. It was not just that they were unmarried; she was known to have taken multiple lovers before Verdi and given birth to at least 3 illegitimate children, all abandoned to orphanages. Verdi stood by Peppina even at the expense of a formal break with his parents, which unfortunately never healed. Verdi and Strepponi eventually married in 1859. Mary Jane Phillips-Matz in her 1995 biography Verdi speculates that the reason Verdi waited so long to marry Strepponi was to be certain all her illegitimate children had reached the age of 21 and thus could have no claim to his estate under Italian law. Without doubt The Lady of the Camellias was the starting point for Verdis Violetta, but whatever the source, it was only the starting point for the creation of an indelible portrait of a noble woman. To accomplish this, Verdi used a favorite technique of presenting a character the audience would instinctively dislike and then painting a more sympathetic portrait in words and music. In Rigoletto it was a deformed, spiteful, court jester. In La Traviata Violetta Valery is a courtesan, which is essentially a prostitute accepted in social circles by the wealthy and powerful. This acceptance, of
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course, would not extend to family or any kind of commitment beyond money. 19th Century audiences considered it scandalous that such a woman would be given a prominent role on stage, much less a sympathetic one. 150 years ago Violettas illness would have hardened, not softened, the audiences view of her as it does today. At the time of the premiere in Venice (1853) Louis Pasteurs proof of the origin of infectious diseases was still to come, and it would be 30 years before Robert Kochs isolation of Mycobacterium tuberculosis would define consumption as an illness acquired by inhalation from another infected person. In Verdis time, tuberculosis was viewed to derive from a constitutional weakness associated with poverty or some occult inherited defect. It was stigmatizing too, and often hidden by families. Aspects of lifestyle such as sexual excesses were felt to aggravate the course. All of this would have marked Violetta as a woman who had somehow displeased Heaven and whose behavior deserved any punishment that befell her. Another difference between modern and earlier audiences is that the Great White Plague of tuberculosis was the leading cause of early death in 19th Century Europe. One of every four deaths in Paris was due to tuberculosis. Every member of the audience would have had some experience with the disease, either themselves or through a family member or friend. Many would have observed a loved one go through the slow, wasting, internal fire, from which the term consumption derives. In Nicholas Nickleby Charles Dickens describes it as: A dread disease in which the struggle between soul and body is so gradual, quiet and solemn, and the result so sure that day by day, and grain by grain, the mortal part wastes and withers away. A disease which sometimes moves in giant strides and sometimes at a tardy sluggish pace, but, slow or quick, is ever sure and certain. In those times it would only take a cough or a swoon onstage to evoke these memories and associated feelings of shame or loss. Actually, tuberculosis is still the leading cause of premature death in the world with 50,000 deaths each week. We are just shielded from this in countries wealthy
enough to afford the expensive and prolonged treatment required to cure the disease and prevent its spread. It is somewhat ironic that the authors of the rock musical Rent , which is based on the story of Puccinis La Boheme, saw the need to update Mimis disease from tuberculosis to AIDS. For most of the world, tuberculosis would work just fine.
THE OPERA
Verdi makes no attempt to soften the image of Violetta in her initial presentation in Act I. She is a full-fledged party girl. Alfredo ardently introduces what will become their love theme declaring that love is the universal heartbeat ( amor ch e palpito) of the world. Violetta is tempted but rejects commitment to love in the brilliant coloratura aria Sempre libera (forever free) in which she declares she will live for pleasure only. This affirmation of Violettas decadence perfectly sets up the turnabout to come. The only comparable operatic declaration of sexual freedom by a woman comes in the Habanera of Bizets Carmen (1875). Sempre libera also indulges the smug view of the audience that they are above this weak and indulgent woman. The major scene of the opera is the Act II duet between Alfredos father Giorgio Germont and Violetta. Germont appears unannounced with Violetta alone in the house and addresses her with contempt: Germont: I am Alfredos father, whose son you are leading to ruin. Violetta: Sir, I am a woman and in my own house. Please allow me to leave you, more for your sake than mine.
Germont: What dignity! Germont is taken aback by her dignified response and instantly recognizes he is dealing with a woman of substance. Undaunted, he accuses her of spending the family money, but she shows him receipts documenting the reverse. She is supporting Alfredo. Continuing, he describes Alfredos little sister, pure as an angel, in an aria sung in the lush warm tone associated with a Verdi baritone singing to one of his children. He explains that this angel now cannot marry the man she
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loves because of the disgrace Violetta and Alfredos relationship has brought on the family. Heaping it on, Germont then tells Violetta her beauty will fade, and since that is all he feels she has to offer, implies Alfredos ardor will fade as well. Through this Violetta is sobbing, E vero, e vero (its true, its true) and in agony makes her decision. She knows that Alfredo will see through anything short of her leaving him to return to one of her former lovers and resolves to do just that. Go tell your daughter that a poor and wretched woman, who has but one thing left in life, will sacrifice it for her and then will die! Violetta, Germont, and the audience firmly believe this will not only deny her happiness but will cause a resumption of her consumption. Germont is stunned: Generosa, O generosa What can I do for you? Violetta asks only one thing: Let him not curse my memory. When I am dead, let someone tell him of my suffering. As the great duet unfolds, Germont goes through a dramatic and musical transformation. The initial distain and harshness in his voice give way to respect, and by the end she is in his arms with him singing to her with the same warmth he used for his daughter a few minutes earlier. This could be Rigoletto singing to Gilda, Simon Boccanegra to Maria or any of the other Verdi father/daughter duets. Violetta has surpassed Germont in nobility and he knows it. He would not be willing or able to make the sacrifice he is asking of her and neither would his son. The audience also knows they would be incapable of such an unselfish and noble gesture. For 19th Century audiences who could clearly see that Germont represented them this was unbearable. So unbearable, in fact, that although Verdi clearly intended La Traviata to be a contemporary drama, producers refused to take the risk of subjecting their audiences to this kind of moral discomfort. Instead they provided some distance by setting it around 1700 with the men in powdered wigs, silk stockings, and buckled shoes. The first Italian performance of La Traviata in contemporary dress was not until 1906. This sets the scene for the agony of Violettas public denunciation by the unknowing Alfredo at Floras party in the following scene. From the time Violetta enters on the arm of Baron Douphol, her former consort, the orchestral music becomes halting and interrupted, suggesting the progression
of Violettas consumption. When Alfredo throws his gambling winnings in her face in front of her friends, all are horrified including those in theater seats, because by now everyone is in love with Violetta. Germont makes a dramatic entrance rebuking his sons behavior but stops short of revealing the truth. He speaks only in the terms of society, No man of honor even in anger, ever, ever, insults a woman. As the entire cast and chorus join in lament, the music again takes on an interrupted staccato cadence. These are the gasps of Violettas withered lungs dissolving as M. tuberculosis literally consumes their lipid membranes. With the possible exception of Desdemonas degradation in Act III of Verdis Otello, no woman has ever been more publicly and unjustly humiliated. The final act begins with an orchestral prelude containing the most tender and heartbreaking music in all of Verdis 27 operas. Violetta is deserted, destitute, and hours from death. Still she refuses to be bitter, asking God for the forgiveness society would not grant her. When Alfredo and his father enter, they are filled with remorse, certain they have killed her. The orchestra begins repetitive dirge-like lines confirming the end is near. Violetta has only one last request. Her love for Alfredo is absolute, and she gives him a medallion with her image and encourages him to love again and marry if he finds the right girl. Give her this medallion, Tell her of one you knew, Who then will be in heaven above Praying for her, for you. Then instead of dying in the manner we are used to on the operatic stage, Violetta does something which would have been familiar to physicians of the day. Near the end consumption patients often had a lucid interval accompanied by an illusion their disease had left them. As a solo violin repeats the heartbeat of love (palpito) theme introduced in Act I, Violetta has a sudden surge of hope and loss of pain. Rising from her bed she declares I am reborn! O joy, and then falls limp to the floor.
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THE GREATEST WOMAN

Where else in the world of art can we find such heroic beauty in a woman? Certainly not in the movies. The American Film Institutes list of the 100 greatest films includes none with a heroic woman, unless you want to consider the gritty Scarlet OHara a heroine. Greta Garbos Camille doesnt count because its the same story. In a lighter sense, so is Julia Robertss prostitute in Pretty Woman. In case you miss the point in that film, Ms. Roberts and Richard Gere go to the opera for a performance of, guess what, La Traviata. In the theater we have Shakespeares Juliet, Ibsens Hedda Gabbler and Nora, but only a few others. No, one has to turn to the opera for true larger than life heroines and even there they are scarce. The greatest are Brunhilde in Wagners Ring cycle, who rides into fire to save the world, and Mozarts Countess in The Marriage of Figaro, who demonstrates the unconditional forgiveness of true love. Here Mozart should get extra points, since his heroine does not have to die in the process. In the end it is the
VINCENT FULGINITI, MD PROFESSOR EMERITUS, PEDIATRICS, RETIRED , AHSC
tender human qualities of the frail Violetta which make her the greatest woman ever created for the stage. Every time we watch the story of La Traviata unfold, our hearts surge, break, and forge a bond with the Lady of the Camellias. The palpito of Violettas universal love is eternal.
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FINDING OUR WAY

DEDICATED TO THE MEMORY OF WARREN BUD DAY
MARY FOOTE MD-MPH STUDENT, CLASS OF 2006
I had heard his name when I was just beginning to feel the flutter of excitement that comes with youthful idealism and a great, life-changing idea. I contacted him to see if I could join him on one of his many trips to exotic lands so I could start saving the world. All I wanted was a trip to Africa. Somehow I ended up registering for his class instead. I walked into the classroom that first day of International Environmental Health and met Bud Day, a white-haired man with twinkling blue eyes who emitted a palpable energy. His class gave me some of my first exposure to real-world health disparities. I started to look forward to every class, when Bud would share stories of designing innovative pit latrines in Bangladesh or of fighting against landmine use in Mozambique. I realized that I had been given the honor of learning from a real-life hero. What was it that made him so special? Pushing well into his seventies, Bud remained passionate about his work, fought tirelessly for what he believed in, and challenged us to take a closer look at the larger world that surrounds us. One of the main lessons Bud taught me is that injustice and its effects on human health can be seen nearly everywhere. On one memorable field trip he took the class to the Navajo reservation, in order to explore an area with an unexplained cluster of lung cancer and respiratory illnesses. Many of those ill were uranium miners emplo yed by the US government from the 1940s to the 1970s. The limited compensation that has been doled out to the victims has been hard won, and many have had to make due with the limited health care offered by a perpetually strained Indian Health Services. And their health threat seemed far from over: open waste piles sat close to restaurants and homes, and one could still see yellow-tinged uranium dust rising up into the air with each strong gust of wind. My most recent experience with health disparities led me to Mulukuku, a rural community in central Nicaragua, as a volunteer with the organization Doctors for Global Health (DGH). The inhabitants of this area saw some of the heaviest fighting during the U.S.-backed Contra Wars, only to face
Hurricane Juana in 1988. After Juana destroyed the village, a small group of local women joined together to form the Maria Louisa Ortiz Cooperative to start rebuilding their community. After realizing that many of the villages women were unable to read, the Cooperative established a literacy campaign, built schools and started a scholarship program for higher education. When it was noted that women were dying unnecessarily from cervical cancer, they worked to build a womens health center, which opened in 1991 and is now looked to as a model primary care facility serving a population of more than 30,000 people. Most recently, they set up a legal defense program as well as a safe house for women and children who are victims of domestic violence. Throughout their struggle they have identified what resources they lacked and formed equal outside partnerships with groups like DGH to address those needs. All these gains have not been earned without tremendous hardships. Nicaragua still maintains an intense political climate, which seems to permeate every aspect of day-to-day life. The Cooperative has often been seen as a threat to those in power, mostly due to their ability to organize and fight for their rights as a community and as women. A cycle of violence was created and reinforced throughout the brutal 40-year reign of the Somoza dynasty and during the preceding American occupation, and this violence persists in insidious ways. Although the women and men of the Cooperative fight against it, there is an undercurrent of resignation that violence in some ways will always be a part of their culture. However, as a community, they are working in solidarity and partnership with others to improve their lives and restore human dignity. The social environment of Mulukuku inspired me to seek out members of the Cooperative and learn from them those skills necessary for community organization. Yet, the more I learned from these women, the more questions kept coming up in my mind. I want to know how, as a future health professional, I can work for social justice in my own practice, as well as in everyday life. And how can I help those members of our global society that suffer the worst effects of devastating conflicts, namely when violence has become institutionalized
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in a way that will persist long after the weapons are gone? I am a witness to examples of structural violence* every day here at home. For a long time, it was invisible to me; other times, I chose not to see it. But now, when I am in the hospital as a medical student or working in the field, I see plenty of glaring examples in the faces of those traumatized by spousal abuse, child abuse, rape, and poverty. Paul Farmer explains, Liberation theologys first lesson is that there is something terribly wrong. Things are not the way they should be. But the problem is with the world, even though it may be manifest in the patient. This idea crystallizes when I think about those I have seen in the CUP clinics. The fact that they require care in such a context suggests that they are victims in some way of a greater system of oppression. All of the people we have the opportunity to serve through the program have been disenfranchised in some way from society and its privileges, whether as refugees, homeless, or victims of domestic abuse. Most often these men, women, and children have been placed in these positions through factors largely beyond their control that have been allowed to flourish too long in our society. Many of us have been involved in charitys good work, and hear the motto: The poor are every bit as deserving of good medical care as are the rest of us. Well, if we truly accept and donate time and energy into this belief, then wouldnt it make sense to put some of that effort into creating more sustainable and just solutions such as universal health care or improved social services? The challenge of working to right the social wrongs that affect the health of our patients should be a fundamental part of our calling to medicine. To do otherwise is to place band-aids over the wounds of greater harms. Our own Tracy Carroll has instructed us in how to begin to enact change by focusing on the liberation theology principle of ver, pensar, actuar (to see, to think, to act). We need to be aware of the greater societal issues such as poverty, racial inequalities, and lack of access to healthcare. We need to see how these issues manifest themselves in the lives and health of our patients. Only then can we mobilize for
change in partnership with the patients and communities that we serve. Something as simple as our education and social standing gives us a voice that we can use to speak for those who may not have such privilege. Its true that not all of us will, or even want to, spend our lives in a dramatic fight to improve health and justice in the developing world like my hero Bud Day or the women of Mulukuku. But for each of us there is a way to contribute to improving health and respecting the basic human rights that should be afforded to all in every nation. Think of your own heroes. Reflect on what they did to make a difference, and challenge yourself to mirror in your own lives what makes them noble to you. As physicians we may not always be of the people, but we should always be for the peoplewherever our paths may lead us. *Structural violence occurs whenever people are disadvantaged by political, legal, economic or cultural traditions. Because they are long standing, structural inequities usually seem ordinary, the way things are and always have been. For more information about Liberation Medicine and opportunities with Doctors for Global Health go to www.dghonline.org.
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HEALTH, DISEASE AND BALANCE

LEILA ALI-AKBARIAN MD-MPH STUDENT, CLASS OF 2006
As I was applying to medical school, one of the schools asked me to answer the following question: What do health and disease mean to you? Why do you think people get sick? What do you think the physicians role is in the healing process? These were such refreshing questions because they didnt ask about me and my achievements. They allowed me to explore health and disease in ways that I have rarely done so far in my formal training as a student doctor, yet I think these questions were essential in understanding my own foundation for the practice of medicine. I encourage anyone who reads this to think of his or her own responses to these questions. Below are mine. Health and disease are both vital to the human experience. Health is a condition of physical and mental well-being, and I believe it is a function of balance. When a person is out of balance, either internally, or in conjunction with the external environment, then the body is more susceptible to disease. It is my opinion that disease is a way for the body to communicate with the mind, in an attempt to regain balance. Regaining balance, in this sense, can imply returning the body to homeostasis, or creating mental harmony, and often a physician can facilitate both processes. The human body is designed to maintain balance by adapting to internal or external changes in its environment. These changes usually result in stress on the body. How quickly and effectively the body reacts to stress is an important determinant of whether the body will be free of disease. For example, people with weak immune systems cannot respond efficiently to foreign organisms in the body. Although the organisms come from the external environment, it is the internal chemistry of the body that is stressed. The foreign organisms are then able to survive and replicate within the body, often becoming a disease. The chemistry of the body can be skewed as a result of a myriad of stresses. Internal stresses such as prolonged fear or anxiety create chemical changes in the body, often leading to slower immune responses. The body is then less equipped to react to external stresses effectively . Many people become sick as a response to a combination of these internal and external
stresses. Just as some emotions can have diminishing effects on the immune system, others, such as deep relaxation or happiness, can hav e stimulating effects. This creates an internal environment more prepared to adapt to external stresses. Ancient sources claim that Hippocrates, the father of Western medicine, believed that natural forces within us are the true healers of disease. This elegant and simple philosophy of healing emphasizes the bodys inherent intention to return to a state of equilibrium. There is no distinct separation between body and mind, for both are involved with the higher purpose of maintaining stability and adaptability. When a system in the body is out of balance, the mind sends messages to the body to restore its internal harmony. If it can be restored behaviorally , the mind often translates the message in a way that is interpretable by our conscious awareness. Becoming healthy is often a matter of listening closely to messages from the body and responding accordingly. For example, if a body is being stressed physically and is cooled by sweating, then water levels within the body decrease. By receiving messages of thirst, the person is able to restore the balance by drinking water. Likewise, if a person is experiencing neck pain, the mind might make subtle suggestions that a vacation from a stressful or uncomfortable work environment would allow the body to heal itself. I believe that sickness and disease often occur when messages coming from the body are ignored. There are, of course, situations where a body is not able to easily stabilize itself. A persons body chemistry can be stressed as a result of various factors, including predetermined genetic factors. Type I (juvenile) diabetes mellitus, for instance, is characterized by a loss of insulin-producing cells. The resulting increase in blood glucose levels seriously alters the homeostatic stability within the body. The balance can mostly be restored with proper diet and exercise in conjunction with timely insulin injections. There are many instances when a person caring for his or her own body benefits greatly from medical expertise, including emotional guidance. It is the
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role of the physician to contribute such expertise, but not to conduct the healing. The healing occurs within the patient. The doctor can help to determine the sources of the stresses affecting the body and provide suggestions for quickly and effectively restoring the natural balance, sometimes making physical adjustments to hasten adaptability to the stresses. A physician should be fully educated about the extensive pharmacology and various other modalities of treatments, choosing each time the one that will allow the patients body to most effectively heal itself, considering the delicate balance of the entire system. The role of the physician should also be to help the patient discover stresses in his or her own environment, and to listen to messages being revealed by the body to the conscious mind. In this capacity, a disease may create an opportunity for restoring greater health in all aspects of a patients life.
ANON
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Muleshoe, Arizona
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