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NOTE: To view the article with Web enhancements, go to: http://www.medscape.com/viewarticle/496358 Women's Health in Context Literature and Social Injustice: Stories of the Disenfranchised

Martin Donohoe, MD, FACP

Posted 01/07/2005

Introduction

Since its inception, this column has dealt with the social factors that impact women's health.[1-4] The aggregate data presented in previous articles may make a powerful argument for social change but can obscure the suffering that occurs at the level of individual patients -- those who require our humanity, our caring, and our willingness to listen. In this column, I describe how reading literature can provide us with vicarious experience related to the health consequences of poverty and social injustice.

The Value of Reading Literature

Through literature, readers can vicariously experience new situations, explore diverse philosophies, and develop empathy with and respect for others whose place in society may be very different from their own.[5-7] Reading about the experiences of those who suffer the consequences of poverty, racism, stigmatization, violence, and impaired access to healthcare may help us to identify more closely with our patients, whose complex lives we glimpse only during periodic clinic visits.[5,6]

Literature and Medical Education

In the early 1980s, the National Endowment for the Humanities, the Association of American Medical Colleges, the Accreditation Council on Graduate Medical Education, and the Society for Health and Human Values called for increased emphasis on the humanities in both undergraduate and graduate medical education.[8] By 1994, approximately one third of US medical schools offered formal elective courses in literature, and more than 80% offered some form of humanities instruction.[7] Courses for medical and nursing students have been well received. Physical diagnosis, psychoanalysis, and medical history[9] and ethics are taught through poetry and prose. Poetry, creative writing, haiku, drama, essays, short stories, and novels have been a successful adjunct in the treatment of patients with depression and schizophrenia, intractable pain, cancer, and other chronic and terminal illnesses. These media have been employed to foster greater communication among hospital staff members and between physicians and patients and their loved ones. They are also used to teach healers about the experiences of illness, suffering, and death, and thereby promote humanism in the practice of medicine.[10-12] Anthologies, scholarly journals, student literary magazines, and compendia of articles on the rationale for teaching literature in medical schools and on the practical applications of literature in medicine have been published. An online database of literature, medicine, and the arts can be accessed via the Web; this database contains synopses of poems, short stories, and novels by physician-, nurse- and lay-writers.[13]

The following sections discuss some writers and a few of their works that relate to the health consequences of social injustice. Anton Chekhov

Drawing upon his experiences ministering to the sick, physician-writer Anton Chekhov created compelling, analytical stories that attacked the social injustices of his day.[14] Most of his patients were poor and unable to pay for his services. Highly influential in the formation of Chekhov's character were his observations at the penal colony of Sakhalin, to which he journeyed shortly after medical school to conduct a census of the population. Sympathy for the exiles on the island, most of whom he felt were the product of poor social conditions in Russia, motivated his pilgrimage. At Sakhalin, Chekhov "documented in great detail the profound human misery and degradation he found." He wrote:

Sakhalin is a place of unbearable sufferings, such as only human beings, free of bond, can endure... [W]e have let millions of people rot in prison, destroying them carelessly, thoughtlessly, barbarously; we drove people in chains through the cold across thousands of miles, infected them with syphilis, depraved them, [and] multiplied criminals.... [A]ll of us [are to blame], yet [outrageously] this is no concern of ours.[15]

Women suffered particularly hard. "A woman on Sakhalin," Chekhov opined, "is not exactly a human being...and not exactly a creature even lower than a domestic animal, but somewhere between the two."[15]

Chekhov returned to his native Moscow "shattered by what he had seen -- a spectacle of hell on earth, 'misery, ignorance, and incompetence that can drive you to despair.'"[15] His bold but sensitive writings on Sakhalin increased public awareness of the problems there and helped to initiate governmental policy changes and increase philanthropy for the area's citizens.

Somerset Maugham

Somerset Maugham, qualified in medicine at St. Thomas' Hospital, London, worked for over a year in the London slums, and served in the Red Cross during World War I.[14] He then turned to literature, but he always appreciated the unparalleled experiences with "human nature taken by surprise"[16] that his medical education offered. His background as a physician provided fertile soil in which his literary abilities could flower:

I do not know a better training for a writer than to spend some years in the medical profession. I suppose you can learn a great deal about human nature in a solicitor's office; but on the whole you have to deal with men in full control of themselves.... The interests [the solicitor] deals with, besides, are usually material....But the doctor...sees human nature bare.[17]

Maugham drew upon his medical experiences to discuss the effects of poverty on health and to depict the psychological and physical sufferings of his characters. His first novel, Liza of Lambeth, [18] takes place in the poverty-stricken, cockney slum of Lambeth and describes the attempts of Liza, the independent-minded heroine, to escape the drudgery of her life through an affair with a married man. Throughout the novel, Maugham decries the social ills that pervade Liza's community, where alcohol is accepted as a panacea for all problems and the physical abuse of women is tolerated, even accepted, by most men.

In the semi-autobiographical Of Human Bondage,[16] Maugham continues his critique of social evils by attacking the neglect and abuse of unwanted children. The protagonist Philip feels that there exists "a hideous resentment against those poor atoms who [have] come into the world unwished for."[16] He notices "accidents" occurring and wonders if "perhaps errors of diet [are] not always just the result of carelessness."[16] In the same novel, Philip's discovery of Fanny Price's suicide shocks him into an awareness of the conditions of those "oppressed by dire poverty."[16] Having previously felt only disgust for Fanny's tawdry dress and disgusting eating habits, Philip is overcome with anguish when he considers the agonies she must have endured. He berates himself for not having recognized her situation and come to her aid; through his remorse he counsels us to be more aware of the undeclared needs of others.

William Carlos Williams[19]

William Carlos Williams trained in pediatrics and obstetrics and spent his life practicing among impoverished immigrants in the small community of Rutherford, New Jersey.[20] Writing and practicing medicine were complementary pursuits, "two parts of a whole."[21] He wrote: "As a writer I have never felt that medicine interfered with me, but rather that it was my very food and drink, the thing which made it possible for me to write."[21] Medical experiences provided the subjects for many of Williams' works:

I would learn so much on my rounds, [and] making home visits. At times I felt like a thief because I heard words, lines, saw people and places, and used it all in my writing.[21]

Being a doctor permitted Williams to observe firsthand "human beings at all times and under all conditions, coming to grips with the intimate conditions of their lives."[21] It showed him weakness and strength, cowardice and courage, and provided him an unparalleled opportunity to discover the nature of man:

No matter where I might find myself, every sort of individual which it is possible to imagine, in some phase of his development, from the highest to the lowest, at some time exhibited himself to me.[21]

Williams believed that desperate social conditions, the "anarchy of poverty,"[22] contributed to the development of mental, as well as physical, illness. In "The Insane,"[23] Williams traces a 9-year- old boy's psychological trauma to the violent environment in which he was raised. "The [boy's] old man beat up his wife regularly," explains the author, "and the child had to witness it." The boy's mother, moreover, hated not only her husband, but her son as well, because she thought of "it" as "his [her husband's]" child. "All the love the kid ever knew came from his old man," continues the physician. "So when the father died the only person the boy could look to for continued affection was his mother, who hated him." Reacting to his emotional isolation, the child "doesn't eat", loses weight, "doesn't sleep", suffers from constipation, and becomes a "complete failure" in school. He steals from his mother in order to compensate for the love that she refuses to proffer:

The child substitutes his own solution for the reality that he needs and cannot obtain. Unreality and reality become confused in him. Finally he loses track. He doesn't know one from the other and we call him insane.[23]

The boy's mental health, opines Williams, can be restored if the mother begins to treat him as her own -- and love him.

In "The Paid Nurse,"[24] Williams comes to the aid of a man incapacitated by severe burns inflicted during an on-the-job accident. The company's doctor and nurse downplay the severity of the employee's wounds and warn him to continue working or risk being fired. Enraged by this injustice, Williams calls his senator and threatens to go to the Labor Commission on the man's behalf. The next day at work, the man receives the care and concern due him.

Williams was intolerant of corrupt bureaucrats and doctors. In his Autobiography,[21] Williams relates his decision to resign as Resident-Surgeon at Nursery and Child's Hospital in New York rather than sign a falsified registry of admissions and discharges, which was likely part of a petty graft scheme. Despite warnings from his colleagues ("We doctors can't go against the bureaucracy of a system like this"), Williams remained steadfast in his refusal to sign. His willingness to speak truth to power, even at the expense of his own position, is inspiring.

Doris Lessing's "An Old Woman and Her Cat"[25]

Doris Lessing's "An Old Woman and Her Cat" provides a moving fictional entrée into the world of society's dispossessed. This short story details the struggles of two unwanted creatures, an aged gypsy, ignored by her surviving relatives, and her adopted alley cat, trying to cope with the daily struggles of life on the streets of London. When the woman becomes ill with pneumonia, she takes refuge in a dilapidated, condemned house. She feeds on pigeons, caught by her cat, which she roasts on rotting floorboards, until she succumbs to a lonely, isolated death from pneumonia. There are many reasons behind the woman's progression from the disordered thinking associated with mild dementia, to stubbornness and an unwillingness to accept solutions proffered by social service agencies -- as when, for instance, she refuses housing because no pets are allowed in the building. Readers may be incredulous that the woman would rather starve to death in a hovel than accept charity but will undoubtedly appreciate her pride in not wanting to accept handouts, her desire for independence, and her loyalty to the pet who has been her only solace in a world where the human beings she encounters ignore or even scorn her. Readers should gain a greater appreciation of the survival skills necessitated by a life on the streets and come to appreciate why the homeless have lower rates of preventive care and medication compliance and are more likely to visit emergency rooms for their primary care.[3]

Grace Paley's "An Interest in Life"[26]

Grace Paley's "An Interest in Life" is a single mother's somewhat tongue-in-cheek story of searching for companionship, trying to raise her children, and navigating through the often- illogical vagaries of the welfare system after her husband leaves her. Readers will hopefully appreciate the difficulties the mother faces and confront some of society's (and their own) stereotypes about "welfare mothers." They may struggle with whether or not to sympathize with the woman, who, despite being taken advantage of by her ex-husband and a friend, continues to turn to them for emotional support and even sexual solace.

Ernest J Gaines' "The Sky is Gray"[27]

"The Sky is Gray" is Ernest J. Gaines' tale of a poor, single, African-American farm mother trying to obtain dental care for her ill child. Readers will sympathize with the boy, who stoically hides his pain in order to save his mother money, and can share in their struggle to overcome both overt and subtle racism. Regrettably, as many studies have confirmed, the 2-tiered medical system portrayed in the story still exists, with disparities in access to care, timely diagnosis, treatment, and morbidity and mortality, based on both race and social class. De facto segregation of healthcare continues to exist due to socioeconomic differences in access to care and the diminishing funding for inner-city public hospitals, despite the fact that suburban facilities have an excess of MRI scanners and other high technology equipment. Even academic medical centers have begun to abandon their historic mission to serve the poor, instead entering into economic agreements with corporate polluters (Donohoe MT. GE – Bringing Bad Things to Life: The Unholy Alliance between General Electric Medical Systems and New York-Presbyterian Hospital; submitted to Left Turn Magazine, December 2004) and opening profitable luxury primary care, or executive health, clinics for the well-to-do.[28,29] Gaines' tale challenges us to examine our own roles in both perpetuating and responding to the injustices of the US healthcare system. For those interested in a historic comparison regarding the care of the poor, I suggest "How the Poor Die,"[30] George Orwell's timeless essay describing the abysmal conditions in certain public hospitals. Observation and Empathic Listening

The above stories deal not with statistics, but with individuals, much like the patients for whom we care. While it is critical for health professionals to use their knowledge and privileged position in society to advocate for the collective needs of society's disenfranchised, it is equally important that we recognize, acknowledge, and empathize with the private sufferings of our individual patients. Reading the above (and other) stories of human suffering may enhance our ability to understand better our patients' difficult lives and to communicate with them in a nonjudgmental fashion that enhances trust. This requires keen powers of observation and the willingness to listen.

Somerset Maugham wrote: "Most people have a furious itch to talk about themselves and are restrained only by the disinclinations of others to listen." He encouraged physicians, "Have an open mind and an interest in human beings." He then warned them, "Human nature may be displayed before you and if you have not the eyes to see you will learn nothing."[31]

William Carlos Williams recognized self-discovery as a valuable byproduct of careful listening. He counseled doctors to immerse themselves in their patients' medical and social problems. "It's important," he advised, "to listen...to the complaints of your patients...[for] sometimes you're not only being told about your patients, but told about yourself."[32]

The importance of listening is best demonstrated by Anton Chekhov's brief but moving story, "Grief,"[33] which tells of an elderly carriage driver's intense emotions surrounding the recent death of his son:

[He had] an immense, illimitable grief. Should his heart break...and the grief pour out, it would flow over the whole earth it seems, and yet no one sees it. It has managed to conceal itself in such an insignificant shell that no one can see it even by day and with a light.

The old man searches desperately for a willing listener with whom he can share his story of despair:

It will soon be a week since his son died, and he has not been able to speak about it properly to anyone. One must tell it slowly and carefully; how his son fell ill, how he suffered, what he said before he died, how he died. One must describe every detail of the funeral, and the journey to the hospital to fetch the defunct's clothes. Was it nothing he had to tell? Surely the listener would gasp and sigh, and sympathize with him?

Yet no one does sympathize, not one character with whom he interacts sighs or gasps, because none listen. He is unsuccessful in his attempts to communicate his pent-up misery to another human being. Eventually his "feelings become too much for [him], and he tells his horse the whole story."

Conclusions

This holiday season, and throughout the year, may we be grateful for our loved ones and our health, and mindful of the loneliness, grief, and pain of others. May we be like Chekhov's horse, always ready and willing to listen to those who may be suffering in silence. And may we then become the loud and clear voices of those individuals, translating their private sufferings into demands for public action, so that all may share in the many blessings life can offer (Donohoe MT. The roles and responsibilities of medical educators, ethicists and humanists in confronting the health consequences of environmental degradation and social injustice; submitted to Kennedy Institute of Ethics Journal, November 2004). References

1. Donohoe MT. Violence and human rights abuses against women in the developing world. Medscape Ob/Gyn and Women's Health 2003;8(2). Posted 11/26/03. Available at: http://www.medscape.com/viewarticle/464255. 2. Donohoe MT. Trouble in the fields: effects of migrant and seasonal farm labor on women's health and well-being. Medscape Ob/Gyn and Women's Health 2004;9(1). Posted 3/4/04. Available at: http://www.medscape.com/viewarticle/470445. 3. Donohoe MT. Homelessness in the United States: history, epidemiology, health issues, women and public policy. Medscape Ob/Gyn and Women's Health 2004;9(2). Posted 7/7/04. Available at: http://www.medscape.com/viewarticle/481800. 4. Donohoe MT. War, rape and genocide: Never again? Medscape Ob/Gyn and Women's Health. 2004;9(2). Posted 10/22/04. Available at: http://www.medscape.com/viewarticle/491147. 5. Donohoe MT. Exploring the human condition: literature and public health issues. In: Hawkins AH, McEntyre MC, eds. Teaching Literature and Medicine. New York: Modern Language Association; 2000. 6. Donohoe MT, Danielson S. A community-based approach to the medical humanities. Medical Education. 2004;38:204-217. 7. Charon R, Banks JT, Connelly JE, et al. Literature and medicine: contributions to clinical practice. Ann Intern Med. 1995;122:599-606. 8. Povar GJ, Keith KJ. The teaching of liberal arts in internal medicine residency training. J Med Educ. 1984;59:714-721. 9. Donohoe MT. Advice for young investigators: Historical perspectives on scientific research. Adv Hlth Sci Educ. 2003;8:167-171. 10. Donohoe MT. Reflections of physician-authors on death: literary selections appropriate for teaching rounds, J Palliative Med. 2002;5(6):843-8. 11. Donohoe MT. Perspectives of physician-authors Lewis Thomas and Samuel Shem on the art of medicine and the training of doctors. Am Med Writers Assn J 1988;3(4):2-7. 12. Morris J, Donohoe MT. The history of hysteria. The Pharos. 2004(Spring):40-43. 13. Aull F, ed. On-line database of literature and medicine. The Literature, Arts, and Medicine Project in collaboration with the Hippocrates Project. New York University. Available at http://endeavor.med.nyu.edu/lit-med/lit-med-db/index.html. Accessed 12/21/04. 14. Donohoe MT. Literature and medicine: perspectives of physician-authors on the art of medicine. Honors Thesis in Psychiatry, UCLA School of Medicine, 1988. Available through the UCLA School of Medicine Library, History of Medicine collection. 15. Chekhov A. Journey to Sakhalin. Cambridge, Mass: Cambridge University Press; 1993 (originally published in book form in 1895). 16. Maugham WS. The Summing Up. As quoted in Van Doren C, The doctor as hero and villain. MD Medical Newsmagazine. 1984(Aug):124. 17. Maugham WS. Of Human Bondage. New York, NY: Penguin Books; 1986. 18. Maugham WS. Liza of Lambeth. New York, NY: Penguin Books, 1986. 19. Donohoe MT. William Carlos Williams, MD. Lessons for physicians from his life and writings. The Pharos. 2004(Winter):12-17. 20. Morris DB. Williams' force. Literature and Medicine. 1986;5:122-140. 21. Williams WC. "The Practice" (from The Autobiography). In: The Doctor Stories. New York, NY: Random House; 1948. 22. Williams WC. "The Poor." In: Eastman AM, Allison AW, Barrow H, et al, eds. The Norton Anthology of Poetry. New York, NY: WW Norton; 1970. 23. Williams WC. "The Insane." In: The Doctor Stories. New York, NY: Random House; 1948. 24. Williams WC. "The Paid Nurse." In The Doctor Stories. New York, NY: Random House; 1948. 25. Lessing D. "An Old Woman and Her Cat." In: The Doris Lessing Reader. New York, NY: Knopf; 1988. 26. Paley G. "An interest in life." In: Martin W, ed. We Are the Stories We Tell: The Best Short Stories by North American Women Since 1945. New York, NY: Pantheon; 1990. 27. Gaines EJ. "The Sky is Gray." In: Secundy MG, editor, Trials, Tribulations, and Celebrations: African-American Perspectives on Health, Illness, Aging, and Loss. Yarmouth: Intercultural; 1992. 28. Donohoe MT. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Intern Med. 2004;19:90-94. 29. Donohoe MT. Retainer practice: Scientific issues, social justice, and ethical perspectives. American Medical Association Virtual Mentor 2004;6(4). Available at http://www.ama- assn.org/ama/pub/category/12249.html. Accessed 12/21/04. 30. Orwell G. "How the Poor Die." In: Sonia Orwell and Ian Angus, eds. The Collected Essays, Journalism and Letters of George Orwell, IV; In Front of Your Nose, 1945-1950. New York, NY: Harcourt, Brace and World, Inc. 31. Maugham WS. The Summing Up. As quoted in Cousins N, ed. The Physician in Literature. Philadelphia, Pa: WB Saunders Company; 1982. 32. Coles R. Literature and medicine. JAMA. 1986;165:2125-2126. 33. Chekhov A. "Grief." In: Stone AA, Stone SS, eds. The Abnormal Personality Through Literature. Upper Saddle River, NJ: Prentice Hall, Inc; 1966.

Martin Donohoe, MD, FACP, is a practicing internist and teaches public health.

Disclosure: Martin Donohoe, MD, has no significant financial interests or relationships to disclose.

Public Health and Social Justice Website http://www.phsj.org [email protected]