In the summers of 1897 and 1898, the San Diego, Pacific Beach, and La Jolla Railroad hired “Professor” Horace Poole to provide Fourth of July weekend entertainment. The spry 20-something doused himself with a flammable liquid and likely took a deep breath before setting himself ablaze, and diving from the top of the La Jolla Cliffs into the sea.

For this miraculous feat, Horace Poole is remembered well in San Diego. Poole Street in La Jolla is a hat tip to him, and his name regularly appears on local history website pages that mention the La Jolla caves.

This essay isn’t about Horace Poole, though. It’s about a lesser-known member of his family whose name only appears briefly, fleetingly, in the annals of history: his daughter, Elizabeth Rose, an early 20th century San Diegan we prefer to forget—even though her story and experiences were far more common than those of her illustrious father.

Young women of Elizabeth’s time are nearly invisible in our history books. They are silent, transient figures in a historical record that obscures about as much as it tells. How should we understand the persistent erasure of women’s history—particularly of centuries of life altering experiences—that society has ignored, forgotten, or dismissed as quotidian and mundane?

On March 29, 1929, Elizabeth Rose Poole, then 17, grabbed a silver spoon and likely took a deep breath before inserting it into her vagina—in hopes of inducing a miscarriage. She became ill, and her condition got progressively worse. On March 31, her parents called on Dr. C.R. Brown to attend to her, but he was unable to do much, and Elizabeth died on April 3, 1929. The coroner listed her cause of death as a “septic pulmonary embolism following abortion” and “acute septicemia.”

We know precious little about Elizabeth. As a teenage girl in 1920s America, she had achieved few of the milestones that would cement a place for her in official records or archives. She hadn’t wed, so there was no marriage certificate. Though her father was at one point well-known, she wasn’t a socialite. There were no mentions of her in the society pages.

Census records help historians understand the people we study, but here, too, Elizabeth Rose eludes. The 1920 Census indicates that the Pooles had six children; only Elizabeth’s younger brother was in school at that time, and while two older siblings worked, Elizabeth (then eight) and two other siblings were unaccounted for. By the 1930 Census, her younger brother and sister (ages 17 and 16, respectively) were both in school, and her older siblings were all working. Elizabeth’s death record in the medical examiner’s office indicates her occupation as “at school,” but I couldn’t find her in any of the San Diego high school yearbooks from the time of her death that I found online.

We will likely never know with whom Elizabeth became pregnant. Was it a boy from the neighborhood or school? Perhaps an older man? Someone she met over the course of her daily routine? A newcomer to town?

Other women who died from illegal or self-induced abortions in San Diego around the same time—like Thelma Jeanne Ferrie, or Gertrude Freedman—share similar blips in the historical record. They’re there, and then they disappear, leaving only slim pieces of evidence (an address, a marriage date) of their brief time on this earth.

Elizabeth didn’t have the “privilege” of being a wife. But being married wouldn’t necessarily have made her pregnancy any less inconvenient. Thelma Jeanne Ferrie, who died after an abortion attempt in San Diego in 1931, was married and had a young son. She sought an abortion after she, her husband, and her mother—who all lived together—realized they could not afford another child in the household.

We know about Horace Poole because a railroad company paid him to jump from a cliff into the ocean a few times—something few of us will do (especially since jumping from the top of the La Jolla caves is now prohibited). His life and memory are preserved because somewhere along the way, someone thought that exceptional act was worthy of remembering.

Last year, when I taught a course on the moral and social aspects of studying history, I posed several questions about this phenomenon to my students: Who decides what history is important? What responsibilities do we have toward the dead? And, do our subjects have the right to be forgotten?

As someone who has extensively researched and written about women who have had and sometimes died from illicit abortions in the first half of the 20th century, I have often pondered on the ethics of what I do: dig through archives to write and tell stories of women’s experiences, stories about which they likely felt shame.

Since women themselves have never wanted to talk much about the procedure—abortion stigma still exists today, even though times have changed—archives reflect medical authorities’ and law enforcement agencies’ investigations, rather than women’s experiences and feelings. Historians such as Leslie Reagan and myself have noted that in the 19th and early 20th centuries, many women had illegal abortions, and they shared information about how to access the procedure through close networks of friends, family, medical providers, and druggists. But word-of-mouth does not produce a historical record as robust as the paperwork produced by professional medical societies or law enforcement.

This paucity of sources raises questions about what we think is worthy of, or important to, remember. When we glorify stories like Horace Poole’s, we commemorate individuals for their exceptionalism. When we deal with widely-shared but controversial experiences such as death and abortion, we sweep stories under the rug. When I tell people I meet that I wrote a book about the history of illegal abortion, they usually respond with raised eyebrows, arms crossed in front of the chest, or some apologia—pro or anti-abortion. They’re uncomfortable. I’m (slightly less) uncomfortable. We move on to another subject.

As much discomfort as these stories may bring, they are worth sharing. Otherwise, we contribute to historical amnesia—a historical amnesia that might lead some Supreme Court justices to opine that “abortion is not deeply rooted in the Nation’s history and tradition”—which simply isn’t true. For centuries, abortion was a pervasive, personal, and painful practice in the United States, and a common, shared experience that the historical record neglected, while elevating the random and seemingly extraordinary feats of otherwise inconsequential men—like Horace Poole’s illuminated dive.

The post Invisible Women, Invisible Abortions, Invisible Histories appeared first on Zócalo Public Square.

The belly pain is so bad that Mrs. Alves*, a woman in her 40s, is worming uncomfortably on the ER stretcher. “I need an answer,” she says. I promise her that pain medicine is on the way. What I can’t promise her—despite countless tests and specialists’ opinions already on record—is the definitive answer. The diagnosis, the root cause of her symptoms, proves elusive. But her distress is real. And when there’s distress, there’s a story.

To be an emergency physician for nearly 30 years is be humbled again and again by the mysteries of the body and the humans inhabiting them. Mrs. Alves is one of an endless number of patients I’ve seen with the urgent need not just for a diagnosis or treatment of some kind, but to be heard, to have an ear turn its clinical attention to their story.

Stories are not just listened to, they’re constructed, and both tellers and listeners are part of the process. And yet, discussions around doctor/patient communication ignore this fundamental truth.

Healthcare stresses evidence-based practice, clinical decision-making informed by well-designed research studies. However, it’s less interested in scholarship that complicates this paradigm. Knowledge is tied to belief, and the greater our confidence in our beliefs, the more likely we’ll consider it knowledge. Our confidence in our beliefs, experts say, depends less on the quality of the evidence than the coherence of the story constructed in our minds.

The best evidence-informed decisions are useless, if not dangerous, unless we first get the patient’s story right.

In healthcare professionals’ training, a patient’s story is generally shorthand for a medical history—current and past symptoms, medical and surgical problems, and social history. But a medical history isn’t the same as the patient’s story. A detailed description of symptoms can still miss the deep troubles and unspoken needs plaguing a particular person at a specific moment in their life.

I was taught that my job as a doctor was to find the patient’s story—this solid, complete entity—and bring it back by listening diligently, paying attention, and being present. Important practices, but they ignore a central challenge of working with stories—they’re less like polished jewels and more like first drafts.

Patient stories, like all stories, are created out of fragments of information. Deciding which details to include and what to leave out is daunting for writers blessed with quiet and time to revise. Imagine an ER patient in that pressured moment, surrounded by loud noises and strangers, expected to describe experiences that can be complicated, frightening, and embarrassing—and not knowing which details are relevant to their problem and which aren’t.

When we’re listening in this moment and others, doctors are not just receiving information. We’re continuously sorting, prioritizing, and interpreting fragments to create an orderly and coherent narrative. We’re making micro-decisions about which details might be relevant to the problem and discounting others. And our story-making brains don’t need much to construct a believable reality.

This tendency is demonstrated in a well-known 1944 social psychology study. Researchers Fritz Heider and Marianne Simmel showed subjects a simple animated movie where a large triangle, a small triangle, and a circle moved in and out of an opening and closing rectangle. Then, they asked research subjects to describe what happened. Respondents took these inanimate shapes and described drama, bullying, jealousy, and romance. Only one person told what their eyes observed—geometric objects moving about a screen.

When I played this film for my students, they created confident, specific, and even passionate narratives: a lesbian love story with a disapproving father, a terrified mother and child escaping from an abuser, children’s playground dynamics.

They laughed uneasily, as if catching their mischievous minds in the act. They also learned how subjectivity, assumptions, and their own personal histories contribute to the construction of an apparent objective experience. I illustrated the point with my own narrative mistakes, like the one I made with an uncooperative man with severe back pain and a history of opioid use disorder. I suspected drug-seeking behavior. I thought my words respectful and unbiased, but we began to knock heads. Then, he told me about how he was in recovery, and desperate for other types of treatment to control his pain. He was finally back at work and didn’t want to lose this job. He went on to explain how he could tell from the tone my colleagues and I used that we came into the room with a story fixed in our heads. And to my shame, he was right.

For all the attention given to medical harm in hospitals, or instances where patients felt their needs went unheard by clinicians, doctors rarely examine these situations as narrative missteps.

Narrative is defined in various ways, including a report of connected events and chronology with meaning. A more expansive interpretation draws on the word itself, which is derived from the Latin narrare, which means “to tell” or “to know,” and invites us also to consider narrative’s capacity for knowledge production. Sometimes, the narrative the patient wants us to hear is what’s unsaid. But physicians are poor at picking up on these cues.

Take the older patient who presents to the ER after a fall. The physician asks about the circumstances, including why he fell, his history with falls, and possible injuries. She learns he’s not eating or drinking. He’s not getting around like he used to. He lives alone. She could stop there and move on to the physical exam. Or she could keep him talking.

Studies show that patients may cue their negative emotions or their real concerns indirectly. In this case, the man’s family lives out of state, his wife recently died, he’s been grieving, and he won’t leave the apartment that holds a lifetime of memories. He’s not eating because getting up and down the two flights of stairs is not as easy as it once was. This proud man wearing a Navy cap won’t offer up these details, but his vulnerability unspools once he’s asked.

Patients want their physicians to ask questions. Unfortunately, health providers often respond by focusing on logistical or biomedical issues. By neglecting emotional communication, we miss opportunities to express empathy.

Such behavior is often attributed to time constraints, but research shows that when we pick up on patients’ often quiet or even silent cries for help about psychological or social issues, time is often saved.

When we work with stories and recognize the different ways they are constructed and communicated, we begin to appreciate not only their power but their fragility. For patients to tell their stories, they must first overcome the vulnerability that results from admitting fears and insecurities, new frailties, and limitations. And as physicians reaching branch points in the conversation, we must be sensitive to the presence of other directions the narrative might go, and how and why we might be motivated to steer it down a particular path. Is this path safer, or clearly marked, leading to an identifiable destination?

We must be willing to interrogate our story-building process as rigorously as our research methods. What stories are we listening for, what assumptions or beliefs are we bringing into the story, and how are these value judgments influencing the stories we hear?

As I listen to Mrs. Alves crying for an answer, my first instinct is to order more labs and diagnostic imaging. Instead, I take a seat, and ask her not only to describe her pain but the experience of being in pain, and what distressed her enough to come to the ER. She tells me about the specialists who won’t call her back or dismiss her symptoms when tests come back normal. Her doctor is hard to reach. Besides, he thinks it’s all in her head. What she wants from them is what she desires from me: someone willing to listen for a few minutes, who will be curious about the pain, but more importantly, appreciate how it’s disrupted her life. Quality and compassionate patient care are only possible when the physician and patient work from the same story.

*The names in this piece have been changed.

The post The Stories Doctors Tell appeared first on Zócalo Public Square.

Tattoos and medicine may seem an unlikely pairing, but medical tattoos are nothing new. Religious tattoos of ancient Egyptians honored the gods and, possibly, directed divine healing to ailing body parts. Circa 150 CE, Galen, a Greek physician working in the Roman Empire, tattooed pigment onto patients’ corneas to reduce glare and improve their eyesight. In the past century, more and more people have tattooed their medical histories, such as blood type, hereditary conditions, and even medical requests such as “do not resuscitate,” on their wrists and chests. Modern doctors have also used tattoos in reconstructive and cosmetic procedures to disguise scars and restore the appearance of lost body parts, such as nipples for mastectomy patients.

Today, that history comes full circle—as researchers now try to determine if tattooing could be used as a medical tool, giving healthcare providers a better way to administer drugs and vaccines.

It was only recently, in 2018, that scientists figured out exactly what happens in the immune system when you get a tattoo. They identified macrophages, a type of immune cell, as critical players in the process. Macrophages are part of the first responder unit of immune cells, also known as innate immunity. To understand what macrophages do, look no further than the Greek roots of its name: Macro–phage means “large-eater.” These pliable cells, which develop deep in our bone marrow, travel through the bloodstream and target microbial invaders in tissues, engulfing and “eating” them through a process called phagocytosis, thus clearing infections. Often, the response is so fast and effective that we don’t realize we’ve been infected at all.

Macrophages are also the accomplices that make tattoos permanent. When a tattoo needle punctures the skin, it tears apart the skin, fat, and connective tissue in its path. As they’re damaged, these cells release chemical distress signals, which travel into the bloodstream and surrounding tissue. The signals attract immune cells to the damage site and put adjacent cells on high alert. Depending on its size and complexity, a typical tattoo will inflict hundreds of thousands, and possibly millions, of these puncture wounds. Macrophages near the tattoo site, ever on the prowl, ingest any mysterious, foreign substance they happen to find—in this case, targeting the ink the tattoo artist has applied with the tip of their needle. In a twist that researchers still don’t fully understand, the macrophage “eats” the ink but cannot destroy it (one theory is that tattoo inks, which nowadays are usually carbon-based and suspended in a carrier fluid such as distilled water, isopropyl alcohol, or glycerin, are simply resistant to the cell’s enzymatic breakdown strategies).

The macrophage then does one of two things: 1) carry the ink away to a nearby lymph node for disposal or 2) sit there. “Sitting there” is a strategy macrophages sometimes employ with trickier foes. Macrophages and other immune cells will try to engulf as much of the invading material as possible but can’t fully destroy it, so the macrophages hunker down and form a blockade structure with their bodies, called a granuloma, to isolate the pathogen from the uninfected tissues (the macrophage motto: “If you can’t destroy them, trap them.”). When you get a tattoo, some of your macrophages sit and hold the ink to “protect” you, in the process becoming inadvertent guardians, preserving your tattoo design.

Your tattoo design, then, is an artful, exterior display of your body’s immune response.

Tattoo artists have harnessed the body’s defense network to inscribe and preserve art within your skin. It begs the question: Why can’t researchers leverage the same approach to advance medical treatments?

In 2016, the American Academy of Dermatology estimated that one out of every four people in the U.S. is impacted by skin ailments such as microbial infections or various cancers. Another study, in 2019, reported that Americans spend $13.8 billion dollars battling skin and soft tissue infections each year. Physicians today treat serious skin infections by giving patients intravenous or oral medication, which can be costly and can cause side effects. Minor infections may respond to topical ointments and creams, but these don’t always work well because the drugs may have to penetrate the skin barrier to reach the target site, resulting in variable absorption.

Tattooing medications into infected tissues might work better. A fluid dynamics study from 2021 (preliminary version here) used a gelatin block to simulate flesh, and characterized how needles deliver ink to skin. As a needle punctures tissue it creates a brief opening, which draws ink in as the wound closes back. Repetitive needling over the same puncture increases the total volume drawn in. The mechanism yields interesting possibilities for difficult-to-deliver drugs and vaccines.

In a proof-of-concept study using laboratory mice with cutaneous leishmaniasis, a parasitic skin infection marked by inflamed lesions, researchers administered an anti-parasitic drug using three routes: administering it topically as a cream, injecting it into the torso with hypodermic needles (the kind widely used in healthcare) to mimic drug circulation through the bloodstream, and using a commercial tattoo needle to inject medicine directly into the infection site. Tattooing treatment directly into the wound decreased parasite numbers within infected tissues and decreased lesion size and tissue inflammation more effectively than the other techniques. It ensured high drug concentration at the target site, while using less of the drug than other methods. Researchers and pharma companies are also evaluating a similar mechanism, microneedles, for treating skin infections. Microneedle patches for common woes such as acne are already available on the consumer market.

Tattoos may also ease the delivery of vaccinations to prevent disease. Today, most vaccines are administered by hypodermic needles that inject into the muscle. The thicker the vaccine, the larger the needle—and often, the more painful the injection. Human skill impacts pain levels, too. An injection may hurt more if an administrator is inexperienced, and doesn’t know, for instance, how much pressure to apply to the plunger. Tattooing eliminates such problems. Tattoo needles are small compared to traditional hypodermic needles, and are designed to puncture the skin superficially, potentially eliminating the discomfort and pain associated with intramuscular injections. And since puncture frequency is automated by machinery and puncture wounds naturally draw in fluid, tattooing may also reduce human error. One research cohort has designed microneedle patches with needles coated with vaccine to “tattoo” it into the recipient.  Such designs, which can be stuck to the skin like a simple adhesive bandage, can eliminate administration problems created by human error as well as the risk of disease transmission from needle handling and biohazard waste disposal. Solid vaccine patches are also easier to transport and store, as they take up less space than liquid-based vaccines.

It behooves the medical and research community to innovate when existing techniques fail; as a tattooed immunologist myself, it seems to me that developing tattoos for medical applications just makes sense. Tattoos, research, and medicine share a rich history, and the convergence of tattoos and science is a continuation of the human desire to explore and innovate—and beautify and prolong our lives.

If medicine is an art, then art too can be medicine.

The post Could a Tattoo Cure What Ails You? appeared first on Zócalo Public Square.

It was late March, early in the pandemic, and tests were scarce across the United States. But there had been an outbreak on his floor. One resident had died already. The medical and scientific community still knew little about the disease.

I liked his caretakers. They’d called him Dr. Kurt and showered him with song and touch, even though his Alzheimer’s disease had advanced to a phase where he couldn’t say anything but “yes,” “no,” and “stop it,” much less know what kind of doctorate he held.

But our relationship with the facility had gone to hell when the pandemic hit. They’d failed to tell me and my family that we’d been exposed when we visited. They’d waited several days after the first staff member was diagnosed to email families. They’d ignored my attempts to find tests and protective personal equipment for my father and other residents.

So, against their wishes, I demanded a posthumous test.

Over the next few days, my family and I were told a lot of things. Massachusetts said it was our legal duty to get him a test, both to track the outbreak and to protect the other people at his facility. The Boston Public Health Commission said that under no circumstance could he get a test because there were not enough, and living people needed the tests more than him. We even received notification that he was turned down for hospice because, when evaluated the day before his death, he’d been “too healthy.”

But simmering underneath almost every conversation was a sentiment I heard out loud from one man at the Boston Public Health Commission. “With all due respect,” he said, “he’s passed either way.”

It still mattered, I thought but didn’t say. My dad, by many accounts a “scholarly giant” in the fields of developmental psychology and education, had lived his life devoted to scientific ways of thinking, so much so that he thought quoting research studies at me would persuade me to behave as a teen. To him, a lack of structured curiosity would not just lead to moral and scientific ruin; it was also a sign of disrespect. So during all of the bureaucratic conversations I had after his death, I could hear his voice, being the scientist that he was, insisting on learning the why and the how.

Courtesy of Seth Fischer.

Though I knew he was a successful academic, I knew little about the specifics of his research until I heard his colleagues speak at his retirement colloquium, after his Alzheimer’s disease had made it too late for him to discuss it. Thankfully, about a year before he died, I had the chance to excavate his basement office in my childhood home just outside Cambridge. It was a place he had forbidden me from entering as a kid, but now, it was mine.

I breathed in mold and papers that had spent decades wallowing in his colleagues’ cigarette smoke. Dozens of boxes filled with typewritten and dot-matrix paper were balanced awkwardly around the room.

Maybe here I could get some answers about who he was. We weren’t estranged, but he was the kind of dad who, when we had a disagreement, would tell me, “That’s typical for someone your age”—even when I was 7. This approach to fatherhood, coupled with the disaster that is modern masculinity and a fight when I was 15 over my parents’ custody agreement, had made us near-strangers who also loved each other more than anything. I can’t think of a single time as an adult, pre-Alzheimer’s, when we both acted authentically in a room together.

I was fascinated by his professional legacy. He consulted with everyone from Pope John Paul II to Sesame Street to the Chinese government. His colleagues at the Harvard Ed School, where he taught for 27 years, told me his research had improved the lives of thousands, if not millions, of students and educators. He did this in part by creating “dynamic skill theory,” which argued that human development was a complex and dynamic interaction between culture, context, and child.

This was and is a revolutionary idea because it implies that we are all complex individuals with different trajectories. Many other theoretical frameworks are built around the “normal” person, focus on “teaching to the mean” or average student, and can sometimes lead to punishment, neglect, or other less-than-ideal results for people who develop differently or in ways we don’t understand. He urged, instead, innovation and a respect for complexity. One of his mantras was, “Explain variation. Don’t explain it away.”

He also co-created the journal Mind, Brain, and Education and its entire field of study, bringing together educators, psychologists, neuroscientists, and others—a tough sell in the rather siloed corridors of academia at the time. After speaking with his students, I learned that one of his core beliefs was that children, educators, and scientists of all kinds are important to understanding development, no matter how different their perspectives. And he fiercely believed that we could all change the world if we respected each other and worked together.

It’s astonishing to learn how much he accomplished and grew, especially after reading the Frodi journals I found in his basement.

When my dad was in graduate school in developmental psychology, his professor encouraged each of his students to get a rhesus monkey, raise it, and take notes to better understand its development. My dad was the only one in his class to do so. When he found one, he named it Frodo, then renamed it Frodi when he realized she was a girl, and moved her into his tiny Cambridge apartment in May 1966.

In the year or so he lived with Frodi, he filled two notebooks with handwritten notes. Many revolve around my dad’s quest to make her stop peeing on him in the shower. At one point, he took her through Grand Central Station during rush hour, and, not surprisingly, she made more noise than he wished.

But what is most intriguing about these notes is the tone.

“Two things have been salient, especially about her recent behavior to strangers. She has reacted especially warmly to a few stranger girls or women, but has begun to show threat gestures to some other strangers, especially when they poke at her.”

The language and content are absurd. Does anyone like to be poked? Is it not obvious to him that Frodi might be taking cues from his body language, rather than reacting to the gender of human strangers? How could he pretend to write in the language of an impartial scientific observer when he is so clearly a part of what is happening? How could he be so bad at listening?

I chuckled and put them aside. Fine, I thought. He was only 23.

But then, in the next box over, I found something more disturbing: a black, 11-inch-by-13-inch three-ring binder from when he was in his late 30s. I looked inside. My name was everywhere. These notes were just like the ones he’d taken on Frodi, but they were all about me. What’s more, he’d convinced my mom, another psychologist who had once been a student of his, to take notes, too.

Courtesy of Seth Fischer.

The first page I read held notes on an experiment: He picked up a pacifier and kept it always just out of my reach, to see if I moved my hand to grab it. Then he repeated it with my stuffed Woodstock. He changed the position eight times. By his account, I “continued to try to grasp it,” he wrote, “but the grasp continued to be awkward.”

The notes have the same frigid, judgmental tone as the journals about Frodi. I pass and fail. I’m awkward or successful. In the most disturbing of these experiments, my parents repeatedly sat me in front of a mirror and tried to get me to pass something called the “rouge test,” which measures self-awareness by putting rouge on a kid’s nose and testing whether they touch their own nose or the mirror. At first, they just wanted me to sit there, to get me used to it, starting at about six months. Then, a couple months in, they started the tests.

I resisted this experiment more than any of the others, but they kept making me stare at myself, no matter how much I cried. The number of attempts each time, over a period of seven months, is put in terms of n: “N=8.” “N=12.” “N=3.” It was never clear what counted as a full attempt. I can only guess that each “attempt” meant they persisted until I became so frustrated they had to stop.

Finding these made me wonder if he ever thought of me as a person, or if he thought of me only as a test subject. They made me wonder if he knew how to love.

But then, under the folder, I found hundreds of pages of my childhood drawings. Then I found another box full of my art. Then another.

The art was uninspired, of course, even for a kid my age. Red and orange and green and blue blobs. When I got slightly older, a blobby stick figure, or a blobby house, or a blobby sun. I was not a gifted artist. Still, each one of them was marked with my name and the date, as if they were intended for a future research project.

Or was it because he cared about me?

Maybe, I thought, it was both.

On my father’s death certificate, the doctors listed four primary causes of death: probable aspiration, dysphagia (difficulty swallowing), Alzheimer’s disease, and adult failure to thrive.

“Adult failure to thrive” is a common cause of death for Alzheimer’s patients, because there is no good scientific way to say that everything kind of stopped working.

Courtesy of Seth Fischer.

Reading these four words, I recognized the same language he’d used in his notes on Frodi and me: cold, judgmental—and morbidly funny. This is the nature of so much of the language of medicine and science. It is used, I assume, in service to objectivity, but it makes scientists and doctors seem more obtuse than objective. Science’s fundamental impulse, we hope, is to better humanity, but it often forgets that the way it answers our most important questions matters.

My dad took notes on me because he was curious, and because he believed that the best way to love me was to study me. This also meant, to our detriment as father and son, that his love sometimes looked like whatever brand of science he was using at the time. And if my recent experiences with the medical, scientific, and government communities during his death are any indication, the oblivious way of approaching science that he used all those years ago is alive and thriving today.

We never got the test. COVID-19 was hitting Boston hard, the mortuary needed the space, so we had to bury him before we could get his doctor to return our calls.

Last summer, I spent a month reading through everything my father ever wrote. I could see an evolution in his work over the last 40 years, an evolution I missed until it was too late to ask him about it. I could see this shift most clearly in an address he gave to the Swedish Parliament in 2011.

In the talk, he completely loses control of his hands—which he does when he’s excited—while talking about dyslexia. People with dyslexia look at the world differently, he says, not better or worse than anyone else. He points out that astronomers with dyslexia are far better at finding black holes, and that thinking about dyslexia without judgement has transformed what is possible for children with dyslexia.

He had long ago evolved beyond the young man who had framed Frodi’s actions, and mine, in terms of passing and failing. If we view subjects as humans, he had learned over the decades, if we take off the veneer of coldness and judgement at the heart of much scientific thought, we will soon find ourselves getting better answers.

And it was his dual focus, late in life, on both humanity and finding answers that makes me think he would have been livid at the way his death was handled. It wasn’t just that knowing whether he had COVID-19 would have been kind to his family and to his caretakers, though that would have been foremost on his mind. It was also that his case might have helped scientists learn something.

If he were alive and well today, if he were watching millions sick or dead of a new illness while our political and medical institutions crumble around us, I like to think the advice he’d give us is this: It is time to fight fiercely for a warm and broadminded approach to science and medicine, for a humble understanding of humans as complex, varied, and dynamic creatures.

This is true for moral reasons, but it is also true for practical reasons. The best way to be kind is to be curious, and the best way to be curious is to be kind.

The post The Renowned Psychologist Who Fathered a Theory of Child Development, a Rhesus Monkey, and Me appeared first on Zócalo Public Square.

Our friend, a physician, had just witnessed the death of a 27-year-old man with no chronic conditions. In his hospital, doctors were already making decisions about who to put on ventilators. “It’s a mess and there’s no help,” he told us. The young residents—doctors in training—were completely disillusioned; one of them told him, “When this is over, I don’t want to do this anymore, if this is what our health care system has come to.”

We should all be afraid about that reaction to COVID-19. If this pandemic can be compared to a war, we have sent our soldiers—our medical professionals—to the front lines without the protection and protocols they need to survive. Physicians, nurses, and other hospital workers are overwhelmed by endless streams of patients, the extra-long hours, and the deaths they see all around them. Scared and confused, they fight on. We should expect that when their duty is done, some of our best and brightest will decide never to return to the battlefield again.

In this respect, this pandemic is an extension of the ordinary. The United States routinely neglects the needs of one of its most vital workforces. If COVID-19 has any silver linings, the most important one will be its exposure of the fault lines in American healthcare, including the fact that even before the epidemic hit, healthcare professionals were suffering from toxic levels of burnout that hampers their ability to care about their patients.

More broadly, this epidemic shows that many aspects of the way we speak and think about healthcare, and the way we provide it, need to be reconceived and redesigned. To do that, we need to listen to doctors, nurses, and other healthcare professionals.

Despite the health risks of treating COVID-19 patients and the lack of masks and basic protection in many hospitals, healthcare professionals are not running from the challenge. Instead, they are building their own masks out of office supplies, coming out of retirement to offer aid, and isolating themselves in garages and trailers to protect their families.

Such commitment is particularly impressive when you consider that even before COVID-19, a significant proportion of them were unhappy in their jobs. According to research from the National Academy of Medicine, between 35 percent and 54 percent of U.S. nurses and physicians feel substantial symptoms of burnout, including exhaustion, depression, and emotional numbness. For medical students and residents, the prevalence of burnout ranges from 45 to 60 percent.

Our caregivers are not just tired or stressed—they are experiencing “moral injury.” The term moral injury was coined in 2009 to describe how soldiers’ mental health suffered from having to act against their own moral compass in times of war. Dr. Simon G. Talbot and Dr. Wendy Dean applied this term to the healthcare setting to describe the “suffering, anguish, and loss” clinicians feel when they cannot deliver the care patients need in our profit-based healthcare system.

In our profit-based healthcare industry, billing is king, and clinicians bear the brunt of the busy work that’s required. According to an annual survey conducted by Medscape, an online medical news outlet, the most common contributor to moral injury is the absurd number of bureaucratic tasks healthcare workers now do. For example, a 2016 study found that physicians in four specialties spend about half of their work day filling out electronic medical records and paperwork. Family physicians spend another 1 to 2 hours at home after work doing coding and billing in the electronic medical record.

Another casualty of profit-driven healthcare is the time doctors get to spend with patients. More patients per day means more billing opportunities, and many clinicians are pressured to fit as many patients in their schedule as possible. The “15-minute visit” in primary care has become routine. Many physicians barely have time to listen to patients’ concerns before sending them for one test or another. This diminished time with patients gives doctors and nurses the feeling that they are mere cogs in a computerized system that cares little about people and their health problems.

This is not what most practitioners signed up for, and the mismatch between the ideals of medicine and the reality takes a high toll. Physicians in the U.S. have the highest suicide rate of any profession. That statistic may reflect the fact that physicians are stigmatized and sometimes punished for seeking mental healthcare.

Of course, the COVID-19 pandemic has reinforced the sense of purpose driving many medical professionals. But as they’re putting themselves in danger, and their mental health is suffering as they watch patients and even colleagues die. For many, including our friend in Queens and his colleagues, the crisis has already inflicted a devastating emotional impact.

In order to retain health professionals after this epidemic, we must do more than recognize their sacrifices, or address their current anger. We must answer their long-held concerns—and involve them in charting new policies and ways of keeping them healthy enough to tend the sick. Call it the GI Bill for Healthcare Professionals, if you will.

Some of these new policies should be financial. Nursing and medical students often leave school with thousands of dollars in debt, and the mental stress that accompanies it. Educational debt also adds pressure for doctors to choose a high-paying specialty rather than primary care and geriatrics, where the need for a larger workforce is most urgent. Steps can be taken to address that: Erase all health professionals’ school debt to help those already in the field. In addition, medical, nursing, and physician’s assistant training should be free for all low-income students, to encourage more people from disadvantaged neighborhoods and regions to pursue these necessary careers.

We also need to ease some of the burdens of daily work life. Electronic health records, as currently configured, are primarily tools for maximizing billing. Beyond the time required to fill them out, they create all kinds of headaches for doctors and nurses, who find them incredibly frustrating to use. These record systems need to be redesigned into one single, easy-to-use platform, with the primary purpose of improving care. A committee of healthcare workers should be the principal advisors in this endeavor.

We also need to adjust regulations to make it easier to deliver care to patients. In this state of emergency, the federal government has eased regulatory requirements to allow increased flexibility in where and how patients are treated. For example, Medicare is now paying clinicians for a wide range of telehealth services. We have heard from frontline clinicians that the reprieve from many regulatory and administrative burdens has reminded them of how much better it feels to devote time to caring for patients, rather than navigating paperwork and rules.

One primary care doctor told us that before COVID, she would have to see patients in person to determine that they did not need to see her for in-person visits. Now, she is encouraged to care for patients virtually whenever possible, without an unnecessary in-person visit beforehand. Common-sense policy changes like these should be made permanent if possible, with recommendations from healthcare workers helping to drive decisions.

Unfortunately, it isn’t enough to make health jobs easier and more patient-focused. After this pandemic, doctors, nurses, and other healthcare workers will need to recover from what they’ve recently experienced. Hospitals should expand access to counselors and other mental health services we need, and teaching hospitals must do the same for trainees. Health professional schools should follow the example of Weill Cornell Medicine in offering free mental health counseling for all students. Mental health services should be accompanied by safe and confidential screening services for depression, PTSD, and other mental health issues, to reduce barriers to access.

Finally, in the wake of COVID-19, the U.S. public health response to pandemics will have to be re-evaluated and overhauled. One priority must be to make sure healthcare workers are never forced to beg for masks and other basic protections again. To that end, we should establish a Clinician’s Affairs agency within the Department of Health and Human Services with representation from nurses and doctors. By putting clinician representation at HHS, and also at the Department of Homeland Security, it would position healthcare professionals to give direct input on national health and security policies.

For years, Americans have stood by as the healthcare system pushes our doctors and nurses to the breaking point. Now, our need for them is as great as it’s ever been, and we are pushing them further. World War II veterans got the GI Bill. Clinicians today deserve the same assurances. We need a Healthcare Professionals Bill that eases their educational debt and also includes them in redesigning multiple aspects of our broken system.

The post What Do We Owe Doctors and Nurses? appeared first on Zócalo Public Square.

But Brabeck was lucky; in 1955 he underwent experimental open-heart surgery—made possible by a new heart-lung bypass machine that kept him alive during the procedure. The operation succeeded, and Brabeck lived a long and productive life as a cardiologist. When he passed away in 2018 at his home in Carmel Valley, California, Brabeck was one of the last survivors of a small group of children whose surgeries at the Mayo Clinic represented a turning point in medical history when the heart-lung machine suddenly enabled life-saving surgeries that are now commonplace.

Portrait of Stephen Brabeck with his parents. Courtesy of Irwin Speizer.

What is now a routine and low-risk process was anything but back in the 1950s. Brabeck, son of a traveling glove-and-knit-cap salesman father and a former schoolteacher mother, was born and raised in St. Paul, Minnesota. His condition, called tetralogy of Fallot, is an unusual combination of four heart defects. As a child, young Stephen’s heart was so weak that even slight exertion could send his body into an oxygen-deprived crisis.

One of Brabeck’s older brothers, Michael, who is now a doctor at Bellevue Hospital in New York City, wrote a short book in 2010 about Stephen’s saga, called simply, Heart. Michael recalls in the book how he and his two brothers were instructed to keep a close eye on little Stephen when they went out to play. If Stephen started “puffing” and his skin color began to turn a grayish blue, one brother would immediately force Stephen into a squat (which seemed to help) while the other ran to alert their parents.

In 1953, seeking divine intervention for their son’s condition, the family piled into their Buick and drove 1,400 miles to the shrine of Sainte Anne de Beaupre near Quebec City. Brabeck’s mother climbed the steps to the shrine on her knees to pray for Stephen. One of her vows: If the child was cured, she would give up chocolate.

The answers to the family’s prayers actually lay within a 100-mile radius of St. Paul. The Mayo Clinic and the nearby University of Minnesota were then the only institutions in the world performing open-heart surgery at the time.

In 1954 at the University of Minnesota, Dr. C. Walton Lillehei started using another human being (generally the patient’s parent) as a surrogate heart-lung machine, linking the patient and parent together during the operation. The controversial procedure risked two lives during a single operation, but Lillehei went on to perform 45 procedures in the early 1950s—with a 40 percent mortality rate for patients.

Meanwhile, just 10 miles away at the Mayo Cinic, Dr. John H. Kirklin pursued a mechanical solution that had so far proved elusive. As a medical student, he had long dreamed of the possibilities of open-heart surgery, including a treatment for the very ailment afflicting Brabeck. In a paper he co-authored on the first 50 years of open-heart surgery, Dr. Richard C. Daly, a Mayo cardiovascular surgeon, related comments Kirklin later made about the challenges of open-heart surgery in the 1940s and 1950s: “My fellow residents and I filled pages of notebooks with drawings and plans of how we would close ventricular septal defects and repair the tetralogy of Fallot once science gave us a method to get inside the heart.”

In 1952, Kirklin assembled a team of doctors and engineers at Mayo to find such a method. Working off blueprints from a machine developed by John H. Gibbon, Kirklin’s team refined and modified the device, crafting a sophisticated heart-lung machine that regulated blood flow and pressure and used a series of wire mesh screens to add oxygen to the blood. In tests, nine of 10 dogs survived up to 60 minutes on the heart-lung machine without discernable ill effects. By 1955, the time had come to test the new heart-lung bypass machine on humans.

Kirklin focused on children with potentially fatal heart defects that could be repaired with surgery. At the time, only one in five children born with serious heart defects lived to celebrate their first birthdays. Desperate parents, like the Brabecks, volunteered their ailing children to Kirklin in hope of a cure.

Thus, at the age of five, Brabeck, was among a group of 16 children with potentially fatal heart maladies who were selected for the first operations employing the new but still unproven heart-lung bypass machine at the Mayo. Of the first eight children, half did not make it out of the hospital alive. Brabeck was patient number nine.

“It is hard to imagine it today, consenting to an operation where the mortality rate was running 50 percent at the time,” Daly says. “He [Brabeck] was as much a pioneer as the surgeons and cardiologists. He and his family were the ones taking the risks.”

But in Brabeck’s case, the heart-lung machine worked. Tetrology of Fallot was a particularly tricky malady that eluded accurate diagnosis at the time. Once the heart was opened, these patients were in danger of swiftly bleeding to death before doctors could make repairs. Stephen was one of the lucky ones with tetralogy of Fallot who survived the early tests of the machine.

Once recovered from surgery, young Stephen became somewhat of a local celebrity. Later in life, he related in a letter to his older brother Michael how he recalled a reporter and photographer from the St. Paul Pioneer Press arriving right after Christmas in 1955. “I still remember how odd it felt,” he wrote. “Why all the pictures and questions? I still very much remember the flash of the lightbulbs.” A photo of him under the Christmas tree holding a toy airplane ran with the story.

Open-heart procedures evolved rapidly as Kirklin did more surgeries. At the University of Minnesota, Lillehei soon switched to a heart-lung machine, and other doctors and hospitals began using the machine for open-heart surgery as well. Better diagnosis and improved surgical and anesthetic techniques whittled away at the mortality rate. While open-heart surgery for tetralogy of Fallot had a 50 percent mortality rate in 1955, by 1960 that rate had fallen to just 15 percent. By 1980, the risk factor approached zero.

Stephen Brabeck didn’t squander his second chance at life. Inspired by his older brother Michael, who became a doctor, Stephen obtained his medical degree from the University of Minnesota. He went to work as an internist, including four years as the sole Indian Health Service Physician on the Leech Lake Reservation in northern Minnesota.

Later in his career, he specialized in cardiology, a decision that those who know him assume was a result of his own life experience as a heart patient. Brabeck insisted that was not entirely the case. As he related to his brother, he was frightened and intimidated by cardiology during his medical internship, even shuddering when he encountered a cardiac patient. He finally decided that if he hoped to be a competent doctor, he needed to face this fear and so accepted a fellowship in cardiology. He quickly discovered he loved the field. He started as a cardiologist in New England and when the opportunity presented to practice in Monterey County, California, he took it. When he finally retired from his practice, he opened a shop in Carmel Valley that sold locally sourced olive oil and specialty vinegars, which gave Brabeck a platform to promote heart-healthy cooking.

In 2007, he had to return to Mayo for a second heart operation to replace a faltering valve that had begun to sap his vitality. In an email to his brother after his recovery from this second surgery, Brabeck related the feeling of elation at being given yet a third chance. He said he now recognized his tetralogy and recovery from it as a “gift” that enabled him to see the world more clearly. In elegant prose, he described the sights, sounds, and smells as he renewed his hikes through the wilderness: “Deep purple fields of small bush lupines;” “The dry whoosh of long stem grass against your pants leg;” “The soft musty moss of the forest.”

“I didn’t miss a thing yesterday,” he wrote. “It was probably the most mindful I have ever been … Our bodies are truly wonders and the environment in which we exist is only what we make of it, which means it can be miraculous any time we let it be.”

For Brabeck, a revelatory walk in the wilderness was one more gift from a miraculous medical invention: The heart-lung machine had enabled a little boy with a sick heart to live, and to pursue a life mending the hearts of others.

The post The Minnesota Invention That Rescued a Boy With a Hole in His Heart appeared first on Zócalo Public Square.

How did this major abdominal surgery—which poses significant risks—become mainstream in less than a generation? Many factors, including new obstetric technology, the effect of that technology on malpractice threats and costs, and changes in the way doctors are trained converged to make cesareans seem less risky than vaginal births, changing both obstetricians’ and pregnant women’s notions of what constitutes “normal” and “necessary” medical treatment during childbirth.

To see how quickly pregnant women’s attitudes toward childbirth changed, consider two contrasting stories about a woman’s reaction to her cesarean birth—one in 1971 and the other in 1984. Both women were first-time mothers. Both enjoyed problem-free pregnancies. And both were carrying full-term babies, facing head down, when they gave birth. In other words, they each experienced classically low-risk pregnancies—even though both women had a cesarean.

In 1971, the first woman—let’s call her Carol—checked into a big-city hospital at 2 a.m., shortly after going into labor spontaneously. Although only 20, she was not nervous. Her mother had given birth to nine children vaginally and Carol assumed that her own first birth would be a similarly “natural thing.”

In the labor room, someone came in periodically to check the baby’s heart rate with a fetal stethoscope. By dawn, Carol remembered, “they were having a little more trouble finding his heartbeat.” Nurses and doctors began to complain that Carol’s cervix was only two centimeters dilated. At 10 a.m., doctors decided to perform a cesarean, although they didn’t tell Carol their plan. Rather, they informed her husband, who was consigned to the waiting room—the custom in the early 1970s. Carol did sign a consent form to allow the surgery, but no one explained to her what she was signing and she didn’t ask. She was in labor and in no mood to question anything.

Consequently, when an orderly wheeled Carol into the operating room, she was bewildered despite having just consented to the surgery. “I’m going, like, ‘What’s happening?’” A doctor responded cryptically, “We’re going to operate.” Carol was flabbergasted. “Why?” Everyone ignored her. “It was like I was a non-entity.”

Only after her son’s birth did Carol learn the reason for the surgery. Facing difficulty finding a steady heartbeat, doctors feared fetal distress. But the explanation did not satisfy Carol. Her son’s Apgar score, a numerical rating of a newborn’s condition formulated one minute after birth by assessing five vital signs including heart rate and skin tone, had been first-rate. “There was nothing distressed about this baby! When they pulled him out there was nothing distressed!” Today, she remains certain the cesarean was unnecessary. “I really felt that it was clinic day. The doctors were going to make sure that they didn’t have to come in later.”

Fast forward 13 years. By 1984, when Leanne gave birth to her first child, the surgery had become common, constituting 22 percent of births in the U.S. Unlike in 1971, when Carol had her first baby, by the mid-1980s everyone knew someone who had had the surgery.

Leanne was two weeks past her due date when her obstetrician told her she had to come to the hospital. He ruptured her amniotic sac, hoping to jumpstart labor. By then, the electronic fetal monitor, a device that provides continuous information about the fetal heart rate, had replaced doctors’ intermittent use of the fetal stethoscope. Nurses connected Leanne to the monitor. Her baby’s heart rate began to fluctuate, probably in reaction to the drain of amniotic fluid. The obstetrician told Leanne, “We’ve got to get this baby out of here.” Leanne reacted unhesitatingly. “Just do what you need to do.”

After the birth, she harbored no regrets. She was certain that the surgery had been necessary given what seemed to be the potential risks to her child as indicated by the fetal monitor. “We got him out. We got him healthy. We didn’t lose me. We didn’t lose him. Everything was fine.” Leanne, unlike Carol, was sure her cesarean had been necessary. By the mid-1980s, due to the increasing number of cesareans, the notion that vaginal childbirth was risky had become common. Leanne’s favorable reaction to cesarean surgery had become the norm, Carol’s anger the aberration.

Cesareans can indeed be lifesaving. But the grave conditions that demand the surgery are rare—each occurs in fewer than one percent of births. These conditions include the umbilical cord dropping into the birth canal before the baby does, several different placental complications that include premature detachment and obstruction of the cervical opening, and a full-term fetus lying sideways in the uterus. Yet the electronic fetal monitor helped cement the view that vaginal birth is far riskier than it actually is.

In hindsight, it is clear that physicians and hospitals adopted the monitor too quickly. The monitor had been introduced in 1969 but the first clinical trial of the device was not published until 1976. By then, all but one of the hospitals housing obstetric residency programs in the U.S. had adopted the machine, making its use central to the training of new obstetricians.

The authors of the 1976 article that appeared in the American Journal of Obstetrics and Gynecology found that the monitor—although considered by most obstetricians to be a vital tool—did not change outcomes. Apgar scores; stillbirths; neonatal and perinatal deaths; incidence of cerebral palsy; and admissions to the neonatal intensive care unit were effectively identical whether the fetal heartbeat had been tracked constantly by the electronic monitor or intermittently by a nurse or doctor wielding a fetal stethoscope.

The only difference between the two groups was that the mothers connected to monitors had a cesarean rate of 16.5 percent while those checked intermittently with a fetal stethoscope had a cesarean rate of 6.5 percent. Seven subsequent studies, one of 35,000 births, confirmed these findings. But having been taught that the electronic fetal monitor was vital to their own professional success, as well as their patients’ well-being, obstetricians ignored the studies.

Edward Hon, the Yale University obstetrician who invented the monitor, complained of his colleagues around the country, “They’re dropping the knife with each drop in the fetal heart rate.” Before electronic monitoring, continual observation of the fetal heartbeat was impossible, so no one knew precisely how the fetus responded to the many nuances of labor. “As we started seeing these dips and things all over,” another obstetrician observed of the monitor strip, “it helped increase the section rate a lot.”

The monitor also helped to create the current malpractice climate in obstetrics. Since the mid-1980s, the continual record produced by fetal monitors has become a tool of trial lawyers to “prove” to juries that a timely cesarean would have prevented cerebral palsy, even though the cerebral palsy rate, at one in 500 births, has not decreased even slightly with the advent of the monitor. As one seasoned obstetrician explained, a lawyer can now point to a squiggle on a page and claim, “‘Well, that’s where the baby was damaged.’ How do you disprove that?”

The litigious atmosphere in obstetrics, aided in no small part by the unreliable but tangible data produced by the fetal monitor, has prompted an ever-increasing number of obstetricians to perform a cesarean in the face of even niggling doubt about the course of a birth. In the legal and medical worlds, no matter the outcome of the operation, an obstetrician who has performed the surgery is considered “covered.” And that has increased the cesarean rate further still.

Through the 1980s and ’90s, the surgery became the first resort for younger obstetricians treating virtually any complication of labor. As one obstetric resident at a large, urban hospital said recently of herself and her cohorts, cesarean section is “probably the skill that we get the most experience in.” She joked, “We could do a C-section on a desert island.” Significantly higher reimbursement rates for cesareans versus vaginal births add to the tangle of factors contributing to the rise in cesareans.

Forty years ago, Helen Marieskind, the author of a 1979 U.S. Department of Health, Education, and Welfare report on the increase in cesareans and ways to mitigate it, noted, “The question must be raised as to how much a climate accepting of C-sections in and of itself promotes more Cesareans.” Marieskind’s “question” was clearly prophetic. Carol’s and Leanne’s contrasting stories indicate how quickly mothers came to accept cesarean surgery. The claim of the obstetric resident that she could perform a cesarean on a desert island demonstrates how casually physicians now view this major abdominal surgery.

And yet this dramatic change in obstetric practice has not been good for mothers. Cesareans carry risks, including intractable postpartum infections, that vaginal births seldom do. One of the most frightening downstream effects of a cesarean is placenta accreta, when the placenta grows into the uterine scar left by a previous cesarean. The condition, which causes life-threatening hemorrhage, has increased 55-fold since the 1950s. Accretas almost always require emergency hysterectomies; seven percent prove fatal.

Undoing the medical ethos that led to the epidemic of cesareans will likely take time and will require concerted effort from, and the education of, a number of players: obstetricians; hospitals, particularly hospitals with obstetric residency programs; insurers; and patients. But it can be done.

History demonstrates that changes in society and medical culture, rather than medical need, prompted the surge in the cesarean rate. There is a lesson here. As new treatments and diagnostic tools become available, no matter the field of medicine, it’s important to remember that medicine is not a dispassionate science, but an art continually shaped by changes in culture and society.

The post How Cesarean Births Became a ‘Global Epidemic’ appeared first on Zócalo Public Square.

We had decided to create a Jeopardy game for Women’s History Month based on women who were involved in the early years of the physician’s practice that evolved into our internationally renowned academic medical center. I offered to visit the clinic’s historical archive, expecting to glean a few little-known facts about the handful of women who were staples of the organization’s 150-year-old history.

To my surprise, the staff in the archive brought me lists, files, and boxes of information about many women I never had heard of before. As a native of Rochester, Minnesota, where the clinic originated, and as an employee for nearly two decades, I was mystified as to how I missed knowing about these women and their important contributions.

Weeks after completing the Jeopardy game, the absence of these women in our local history still unsettled me. I consulted several histories of the region that cover the years when the Mayo practice was emerging from the prairie, expecting to find that women were included and that I had merely missed seeing their stories previously.

But I found very little about women at all.

The most comprehensive early history of the city of Rochester is a pictorial history. I counted 270 photographs in the book and only 49 of them—18 percent—are of women. There are nearly as many images of horses in the book as there are of women. That was my tipping point, and I embarked on a quest to uncover the stories of these significant women.

Mayo Clinic’s early years were documented in an 800-page book with hundreds of citations, but this seemingly comprehensive history included only scant mention of women. So I dove into the many files provided by the archive staff, and over four years I collected the stories of more than 40 women who made important contributions during Mayo Clinic’s founding years.

Dr. William Worrall Mayo began practicing medicine in Rochester during the Civil War. His sons joined him after medical school and together they built a practice in leased office space downtown.

In 1883, a devastating tornado hit the small prairie town, killing 40 people and leaving 500 people homeless.

As the town was recovering, Mother Alfred Moes, the mother superior of a Franciscan congregation of sisters, envisioned the need for a hospital to meet the needs of the community. She persistently approached Dr. Mayo, who was reluctant to start a hospital because of the cost and poor reputations of hospitals at the time. But eventually he agreed that, if she and the sisters built it, he and his sons would care for patients there. In 1889, after six years of giving music lessons and selling handicrafts to fund the hospital, the Sisters opened Saint Marys Hospital with 27 beds and two operating rooms, a venue that became the cornerstone of a successful surgical practice.

The Clinic’s renowned nursing care began within weeks of the hospital opening. Edith Graham, the youngest of 13 children from a farm outside of Rochester, took the train to Chicago with three other young women to obtain nursing diplomas. After graduation, Edith returned to Rochester and began teaching the Sisters the latest in nursing practices, establishing a sound basis for nursing care in the facility.

Alice Magaw, who also went to Chicago for nurse’s training, would develop a method for administering anesthesia at Saint Marys that set the national standard. Considered the “Mother of Anesthesia,” she documented 14,000 cases without an anesthesia-related death, greatly contributing to the excellent surgical outcomes that Mayo physicians achieved in the early days and upon which they established their reputation.

In 1892, Sister Joseph Dempsey followed Mother Alfred as the administrator of Saint Marys Hospital, a role she held for 47 years. Under her competent leadership, the hospital grew from 27 beds to 600, making it the largest and arguably finest privately owned hospital in the country. At the opening reception of the seven-story expansion of the hospital in 1922, Dr. Henry S. Plummer, one of the most esteemed physicians in the Mayo practice, declared: “Only someone of great genius and great faith would dare to double the size of this already great hospital…. Sister Joseph had the vision and greatness to do it.”

In 1899, Dr. Gertrude Booker Granger became the second physician outside of the Mayo family to join the practice. She assumed responsibility for the ophthalmology cases, making her the first specialist at the clinic. She also made many important contributions to public health in Rochester. Shortly after Granger’s arrival, several more women physicians became part of the clinical practice and research.

Another important addition was Mayo’s head librarian. From her arrival in 1907 to her death in 1936, Maud Mellish Wilson expanded the clinic’s national and international reputation. As a gifted editor as well as librarian, she assured that the medical articles the Mayo doctors wrote were of the highest quality. She also started the highly influential medical journal known today as Mayo Clinic Proceedings.

Women joined the Mayo practice as social workers, caring for the non-medical needs of patients. These included unescorted children sent from across the country, and Jewish patients whose dietary needs and customs at death were unfamiliar to the Mayo doctors. Women, mostly nurses, from Mayo Clinic also deployed to France during World War I and cared for wounded and ill soldiers 50 miles from the front.

Put simply, Mayo Clinic would not be the internationally renowned medical center that it is today without the contributions of many women who are left out of the history.

To its credit, Mayo Clinic supported my research and writing to fill in the missing pieces of history, but the Mayo history is not the only record that has overlooked women. I am now researching the contributions that women in the Midwest made during World War II in the military, industry, and home. I am running into more gender bias as I consult books, even recently published, with titles such as World War II: A Complete History, which include very few women, despite the reality that millions served in the armed forces, millions worked in industries, and millions supported home front activities vital to the war effort.

And of course, the problem of underrecognition is broader, to the point of being pervasive. Very few trade biographies published each year are about women. Our daily newspapers and news feeds, which form our most immediate historical records, reveal significant gender inequity as well.

The trouble with biased histories is that they endure. Even Ken Burns’ documentary of Mayo Clinic, which first aired in September 2018, gives well-deserved recognition to the Sisters of Saint Francis, but only briefly acknowledges a few other women, mostly the spouses. The critical contributions of Alice Magaw, Maud Mellish Wilson, and other important women are left unrecognized.

What began for me as a desire to set the Mayo Clinic record straight has become a commitment to find and proliferate the contributions of as many women as I can during my career. I hope others will join me in this endeavor.

The post The Women Who Built Mayo Clinic appeared first on Zócalo Public Square.

Among the many unforeseen consequences of this transformation was this peculiar note: Body snatchers digging up graves could quickly ship corpses to medical schools needing dissection material. The story of how grave robbing flourished in Baltimore for more than 70 years reveals both the dysfunctional underside of medicine in a place that liked to call itself the “Monumental City,” as well as its racial fault line.

Baltimore became a center of “resurrections”—as grave robbers referred to their business—because a half-dozen medical schools in the city needed a steady supply of corpses. It also helped that the Maryland’s largest population center was located in a temperate zone that often allowed digging in winter when the ground in New England and in the Midwest froze solid.

The plunderers began by shoveling at the head of a freshly buried coffin, breaking the lid, placing a hook around the deceased’s neck or armpit and, with the help of a rope, easing the body out of the grave. For shipment elsewhere, the corpses were folded into barrels filled with whiskey—to mask the odor. At the destination, a medical school took the remains for dissection.

And that wasn’t the end of it: The “rotgut” whiskey was sold to all comers as “stiff drinks.”

Grave robberies and body trafficking for profit were distinctly Anglo-Saxon phenomena; in Central Europe, the authorities usually distributed unclaimed corpses to medical schools. No such mechanism existed in the United States, England, or Scotland. So medical schools needing dissection material acquired corpses the best way they could—by sending janitors, students, and medical doctors to rob fresh graves.

Such pillaging, while technically a misdemeanor, was seldom prosecuted. Politicians protected it in the name of common good, and the police looked the other way, unless forced to take action. Lawyers argued that because the previous occupant had vacated the body, its ownership was in doubt. So why bother? There was no victim, or so lawyers contended, unless a cemetery sued, which never happened because many were in cahoots with resurrectionists.

An 1880 grave robbery brought Baltimore’s bodysnatching racket into the headlines for a time, highlighting the state university’s central role. The story began with Mrs. Elizabeth Joiner’s bad dream. Her niece, Jane Smith, had been buried earlier that evening and the more the Federal Hill matron tossed and turned, the more she became convinced that grave robbers had stolen the body afterward.

In the morning, the “handsomely attired lady” from a “wealthy and respectable family” went to Baltimore Cemetery, a 100-acre hillside necropolis that still exists at Gay Street and North Avenue. There in disturbed earth she found the evidence—a crucifix that Jane had worn to the grave when she was laid to rest next to her mother, who had died six months earlier. Now four robbers—all medical school janitors—had pillaged both graves. In the darkness, they first opened Jane’s mother’s grave by mistake. Reburying would take too much time, so they took her putrid remains along and the school used her skeleton.

Supervising this expedition was “Professor Jensen,” a 45-year old Danish medical student (he was still enrolled at the university) who dug up and sold corpses, shipping them as far west as St. Louis and south to Atlanta. He solicited advance orders for winter deliveries—“as a merchant contracts for pork and other goods,” one critic said—when the ground froze in the north.

No one admitted involvement. Dr. L. McLane Tiffany, the medical dean at Maryland, stated that “so far as his personal knowledge goes” no corpses of the description had been taken there. Then an anonymous postcard surfaced, saying that “two colored men” had taken Jane’s body to Davidge Hall, where the University of Maryland conducted dissections. Students there had gasped when they witnessed her naked nubility. Whoever the freckle-faced young woman was on the dissecting slab, she was nothing like the ravaged wretches that came from the potter’s fields. Even with her hair shorn, Jane Smith exuded “refinement,” The Sun wrote.

A grand jury indicted Jensen, along with Emil A. Runge, a white janitor at the University of Maryland medical school, and two “colored” dissecting room helpers, William Warren and Ezekiel Williams. The medical school dean, Tiffany, bailed them out. To defend them, the university provided one of the state’s most influential lawyers, John P. Poe. He was the law dean (soon to be attorney general), a white-supremacist Democrat who would expel black students from the university and impose segregation for decades. But then he defended grave robbers. Judge Campbell W. Pinkney, without a jury, found the accused men innocent. “The testimony implicated Jensen in the affair, but it was not such as to warrant a verdict of guilty,” he ruled.

Frequently, being involved in grave robbery had no adverse consequences to the culprit’s career. Dr. Randolph Winslow, the medical demonstrator at Maryland, had previously relied on Jensen’s services but when that source dried up, he began digging himself. He was apprehended at 5:30 p.m. one October afternoon in 1883, with a “colored” helper, shovels, and bags. Nevertheless, Winslow, a Quaker from a North Carolina plantation family, went on to an illustrious career as an eye and ear, nose, and throat specialist at the University of Maryland, becoming president of the American Surgical Association, the Southern Surgical and Gynecological Association, the Medical and Chirurgical Faculty of Maryland, and the Baltimore Medical Association. His papers are archived at the Smithsonian’s Museum of American History and include material about grave robbing.

To be fair, grave robbing in Baltimore had been thriving for six decades before Johns Hopkins medical school opened in 1893. That year, 1,200 students in the city’s seven medical schools had to contend with a meager total of 49 cadavers legally received from official sources. Thus, from the first day onward, Hopkins was confronted with a shortage of bodies.

Its much-anticipated inaugural dissection on November 15 had to be delayed until a proper human “subject” could be found. “We postponed the work until the 16th and then the 17th, and late that evening a subject was mysteriously left in the basement,” recorded Dr. Franklin P. Mall, the famous anatomist.

A janitor was put in charge of securing a reliable supply of corpses. Nicknamed “King Bill,” William Hartley kept a sorrel mare, carriage, sleigh, picks and shovels in the basement of the anatomy building. Thus equipped, he and his wife roamed around searching for fresh graves or bodies left unguarded at the city morgue. His reputation grew—Hopkins soon had 20 cadavers in an ice box built to hold five.

This state of affairs did not happen on its own. As I learned while researching a new book on the life and legacy of Johns Hopkins, the school had anticipated the shortage of dissection material. Two years before it opened, university trustees proposed a solution that would have eradicated grave robberies and taken care of the various schools’ anatomy needs. Approved physicians would have been appointed to do postmortem examination in all cases deemed necessary, and Hopkins would have allocated dissection material to other schools. Although they would have benefited, its rivals howled in protest. “It would be in effect saying that only the Johns Hopkins Medical University shall teach anatomy,” declared James Aloysius Stewart, the city health commissioner.

Potter’s fields for the poor and forgotten were among other preferred marauding destinations, as was the Bayview Asylum, now a satellite medical campus of Hopkins. There in a section in the woods, simple pine boxes were laid out in open pits under a thin veneer of earth cover until a section filled up. Only then were the graves packed and sodded. Pickings were easy, and resurrectionists raided Bayview day and night, once in the middle of the asylum’s board meeting. Even today, old-timers who live near the Hopkins medical school remember having been warned as kids to be back home before street lights came on, or else “a John’ Hopkin’ doctor man will catch you and cut you up.”

The provenance of the early cadavers Hopkins acquired for dissection and distribution underscored how blacks were used a clinical material. “There was a predatory dimension to anatomical dissection, in part because the cadavers sent to Johns Hopkins belonged disproportionately to the poor black, and downtrodden,” writes the medical anthropologist Lynn Morgan.

Race also played a role in prosecutions for grave robbery, as can be seen in the 1886 case of a 28-year-old black man named John T. Ross, who murdered his mother’s white boarder, Ellen Brown, 60, and sold the corpse for $15 at the instigation of the mother’s live-in lover, a Maryland medical school dissecting room attendant. This is so far the only known incident of “burking” in the United States. The term commemorates Edward Burke, who killed at least 16 people and sold their bodies to medical schools in Edinburgh, Scotland before he was hanged in 1829.

The murdered Ellen Brown came from the Eastern Shore, where a brother owned the Easton Ledger newspaper. She drifted to Baltimore at the age of 50, working as a dressmaker. An alcoholic, she became addicted to morphine and opium. She panhandled around Lexington Market and roomed with blacks in a house on Pig Alley in a section near the university called Pigtown because it was a slaughterhouse district. She owed back rent.

After killing her, Ross confessed: “I waited until I got a good aim and hit her [with a brick]. She fell to the floor and then I jumped on her, and hit her again. Then I stabbed her.”

Some 900 curious came to gawk at Ross’s hanging. An hour before the noose and black hood were placed on him, he expressed his sentiments in a verse that a fellow inmate penned for him:

I’ve no excuse to offer,
My guilt I freely own,
But does it look like justice
I must suffer all alone?
Is it fair, kind Christians,
In this land of liberty,
That I alone must suffer,
And the other two go free?

The instigator, his mother’s lover Anderson Perry, indeed went free, and so did Albert Hawkins, another participant in the killing. Perry’s lawyers took a gamble with an all-white jury, arguing that Perry was too dense to do anything as complicated as organizing a grave robbery. “He is known to those who come in contact with him as an exceptionally stupid man,” lawyer John E. Bennett declared. The 60-year-old Perry himself declared: “The doctors will clear me.” And so they did.

After Ross’s hanging, Baltimore moved on but grave robbing continued. One June night in 1887, Dr. William T. Cathell, Jr., an assistant demonstrator of anatomy at the Baltimore University Medical School, was caught at 10:35 p.m. on a joyride of sorts, headed back to the dissecting room with a dead young black woman (and with three medical students). Drinking was involved. “The doctor and his companions had playfully stuck a pipe in the mouth of the corpse, which appeared to be enjoying a smoke,” The Sun reported. Cathell, “arrayed in a pair of high rubber boots and a hunting cap jauntily on his head,” drove “a large dayton wagon, drawn by a handsome pair of bay horses.” He said he needed a “subject” for his anatomy class. No prosecution followed such arrest.

It wasn’t until 1900—several years after the state Anatomy Board was created to allocate unclaimed corpses—that the trafficking ended. The board was headed by the Hopkins anatomist Franklin Mall. Bodies that could not be used immediately were kept in cold storage at Hopkins. Any school in good reputation was entitled to them.

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Micronesians, mostly from the Republic of the Marshall Islands (RMI) and Chuuk State in the Federated States of Micronesia (FSM), are the newest group of migrants to Hawaiʻi. They come in search of opportunities: better education for their children, better jobs, and better health care. In this way, they are no different from other immigrants who preceded them. Only the Kanaka Maoli (Native Hawaiian) people are indigenous to KaPaeʻaina, the Hawaiian Islands. The rest of us are settlers and some of us are colonialists.

Those who have come before control the political economy. Lacking marketable skills, many Micronesians end up with minimum-wage jobs: dishwashing, serving fast food, hotel housekeeping, or attending parking lots. The high cost of housing forces them to stay in public housing or in crowded housing conditions in neighborhoods where their children attend underfunded public schools.

The slights suffered by Micronesian migrants—from name-calling in the schoolyard to maltreatment by law enforcement—have been many. But the bigotry and backlash against them did the most damage when they provided the inspiration to exclude migrants from Medicaid, the federal health program for the indigent.

This is a recent story of how a group of people, living in the United States, were reduced to second-class status.

In 2009, in the face of budgetary constraints during the Great Recession, the State of Hawaiʻi removed from the Medicaid rolls all migrants from the Compact Nations (the Marshall Islands, the Federated States of Micronesia, and Palau), who are permitted by a compact with the United States to live and work here. A court battle ensued, in which a federal district judge ruled that Micronesians and their allies were entitled to Medicaid benefits under the U.S. Constitution’s equal protection clause. Subsequently, the 9th Circuit Court of Appeals reversed the decision. And so the state rolled out its plan to remove the migrants from Medicaid.

I am a family physician in Hawaiʻi who has learned firsthand about the special health challenges of these migrants. Over the years that I have taken care of Micronesian patients, I have had a number die from hematological or thyroid cancers, legacies of nuclear testing in Micronesia. The scale of that testing is stunning. The total yield of U.S. nuclear tests in Micronesia between 1946 and 1962 was 152 megatons. The total yield of all the tests at the Nevada Test Site was one megaton. The nuclear bomb dropped on Hiroshima (my hometown) was 15 kilotons.

The most powerful detonation that the U.S. conducted was the Castle Bravo test of March 1, 1954, at Bikini Atoll in the Marshall Islands. As the thermonuclear device was encased in uranium, which underwent fission, the test released extraordinarily dirty radionuclides. This fallout was deposited over the populated atolls of the Northern Marshall Islands.

Afterward, Marshallese people who had been exposed were followed in a U.S. government study called Project 4.1. (That Project 4.1 was included in the planning documents, from fall 1953, four months before the test, demonstrates that the human experimentation conducted on Marshallese people without their knowledge or consent was deliberate.) Over the subsequent decades, this cohort of people, including children, were subjected to human radiation experiments—again without their knowledge or consent. Is it any wonder that many Marshallese believe that their human rights were ignored because they were viewed as less than human?

Despite the toll of these tests, there is another, larger factor in the social production of disease for Micronesians: population displacement from land. Traditional food production, based on indigenous plants and reef resources, has been abandoned, creating an unhealthy dependence on poor-quality, commodity foodstuffs such as white rice and canned meat. Ironically, many now prefer canned fish to fresh fish. The result has been an epidemic of obesity, diabetes, cardiovascular disease, and other non-communicable diseases such as cancer.

Now with global warming and sea-level rise, life in Micronesia is becoming more precarious. Much of Micronesia, including all of the Marshall Islands, consists of low-lying atolls with an average elevation just a few feet above sea level. It isn’t only the inch-by-inch rise in sea level that poses the greatest threat. With more severe weather come storm surges and higher waves that inundate croplands with saltwater. These gardens are used to produce taro—a Micronesian staple crop—and when they are flooded with salt water they cannot produce taro again unless they remain salt-water free for five years. Father Francis X. Hezel, the foremost scholar of Micronesia, says it is questionable how much longer human habitation will be possible in the remote islands.

While the compacts allow the citizens of Micronesia, the Marshall Islands, and Palau free entry to the United States and the right to work without a visa, there is no pathway to permanent residency or citizenship. The current compacts between the United States and the Marshall Islands and the Federated States of Micronesia end in 2023, encouraging many to migrate before its expiration. These days many Marshallese skip over Hawaiʻi and settle in Northwest Arkansas, where there are many jobs in chicken processing, the cost of living is lower, and they feel more welcome.

Since Compact Migrants in Hawaiʻi were removed from the Medicaid rolls, many have become uninsured. This makes it more difficult for me to take care of their medical needs. It is difficult enough to deliver medicine to vulnerable populations. It becomes more difficult when the state ignores the human right to health.

The post How an Oahu Doctor Struggles to Care for His Micronesian Patients appeared first on Zócalo Public Square.