MyRightSelf

December 21, 2011 at 1:48 pm

Arthur Robinson Williams is a PGY2 Resident in the Department of Psychiatry at New York University. He earned his M.D. and a Master in Bioethics at the University of Pennsylvania School of Medicine and Center for Bioethics. Williams studied photography at Princeton University with Emmet Gowin, Mary Berridge, and Lois Conner. His work, sponsored by an Open Society Foundations Documentary Photography Project grant, can be found at www.MyRightSelf.org.

The University of Toronto Press has recently published an anthology celebrating the 5-year history of its medical humanities journal Ars Medica. I have included excerpts from the article I first published as a medical student in the Fall 2008 issue of Ars Medica that has been reprinted in the anthology. The article grew out of a documentary photography project, MyRightSelf, that I developed with transgender individuals and couples in the Philadelphia area over the course of 2008 which was subsequently funded by an Open Society Institute Documentary Photography Project grant. Now working as a second-year psychiatry resident, the publication of the anthology has given me an opportunity to reflect on my travels- academic, clinical, spiritual, photographic, and otherwise- in the intervening three years.

Dane and Erin. "There are always things I think people would change about their bodies. I know no man whose chest is big enough, hairline is stable enough, abs are eight-pack enough. I don't think I am above all these influences. I wish I were taller and I wish my chest were without scars. Although they are fading slowly, my scars are pretty prominent."

Most striking is the loss I feel in acknowledging that this project was the last significant work of photographic portraiture I have completed. While I have occasionally engaged in some landscape work while vacationing, my long hours in the hospital during residency have largely eclipsed other meaningful forms of engagement and creativity in my day-to-day life. I have also found that successfully living in New York City demands its own toll- the scale, expense, and cacophony of the City adding to the fatigue engendered by 14-hour shifts.

Perhaps those are excuses however, rather than true explanations for the distance that has grown between my photographic lens and potential subjects. I remember writing in my personal statement when applying to residency programs:

The psychiatrist and the photographer have much in common. Whether relating to another person as a patient or a subject, both contemplate notions of identity and perception, of the Self. Both, at their best, similarly investigate their own biases in understanding those of others. Perhaps this is why Psychiatry felt so familiar to me- it was a role that I had already cherished. Part of what I was seeking in medicine was the opportunity to sit with someone, to be available to them, to learn more about the human experience.


Jake: "I gained confidence in my ability to pass, not only physically, but socially as well. From there I started going to gay bars-not to hook up, but just to be there, to be around gay men, again, to be in gay space that I felt safe navigating. I liked letting gay men flirt with me. It made me feel validated in my gender.

Clinical work in the mental health field is emotionally draining. I wonder if the reserve I needed to make photographic images has been otherwise spent on treating patients. The average doctor's day is filled with images, some radiologic, some metaphorical, others directly observed. Psychiatrists especially cultivate these images, drawing anecdotes, memories, and projections from their patients. The investment in this process consumes creative spirit as well as pathos. From Ars Medica:


For the participants with whom I have worked, the act of making a photograph has become-should be-as cathartic as the knowledge that the images will eventually reach a broader audience and as profound as the impact of the images upon viewers. For patients, likewise, the journey toward diagnosis and treatment may have as marked an impact on their latter years as their medical condition and/or disease state.

As a provider I have struggled not only to successfully complete a work up and treatment plan, but to find ways to enrich the process itself. Medicine-as-process, as a creative form imbued with empathy, becomes its own artistic medium in the act of naming and thwarting disease. Maintaining energy to do this well requires a source of renewal. I look forward to the day when once again this source may be found behind the lens.

A. Robin Williams, MD MBE
December 8th, 2011

Body and Soul: Selections from Ars Medica: A Journal of Medicine, the Arts and Humanities, was recently published by The University of Toronto Press. It is available at Caversham Books: (http://www.cavershambooksellers.com/search/1442612908).

Dr. Fleischmann Draws Dr. Munk In Terezin

September 28, 2009 at 10:21 am

Portrait of Dr. Erich Munk, by Dr. Karel Fleischmann. Collection of the Art Museum at Yad Vashem.

Commentary by Michael Nevins, M.D., author of Jewish Medicine: What it is and Why it Matters and A Tale of Two "Villages": Vineland and Skillman, NJ. This commentary written in conjunction with an exhibit at New York University School of Medicine, Sept. 24-Oct.19: Art and Medicine in Terezin.

All of us felt a sense of sliding helplessness, again and again, day after day, night after night, you descended toward the abyss whose bottom was unfathomable….you felt only the downward movement, the fear, what next?

These chilling words, reminiscent of an earlier Prague resident Franz Kafka, were written in April, 1942 by Bohemian dermatologist Karel Fleischmann. With the Nazi takeover of Czechoslovakia in 1939 the situation for Jews had deteriorated and anti-Semitic racial laws restricted the doctor's ability to practice. Now at age forty-five, Dr. Fleischmann (b. 1897) awaited deportation to Terezin, the recently established ghetto town some forty miles to the north.

The morning of our deportation was pitilessly cold. The clouds as black as ink, the rising sun blood red in the background…darkness on earth, darkness in our souls…a nightmare. We arrived in Terezin in the evening. Really, you did not arrive, you were consigned. Someone managed for us for we no longer were we - we had become an object, a number, a ground substance, a kneaded mix of humans….Tired to the bones, sick, longing for quiet and sleep, we came into the cellars and dark holes of the barrack…still the mass was mixed, kicked and reduced to nothing, dirtied, put on the floor, kneaded and rolled till we became a formless porridge, a heap of rubbish….poisoned with the taste of the stable.

Dr. Fleischmann had been advised that upon arrival in Terezin he should look up the head of the ghetto's Health Department Dr. Erich Munk, but making contact was difficult. Known for his scrupulous integrity and organizational ability, the thirty-eight year old radiologist Munk (b. 1904) had been selected by Zionist leaders to direct what would become a massive medical apparatus.

Whereas Karel Fleischmann was prolific with more than a thousand of his diary notes, poems and art work surviving the war, only a few fragments of Dr. Munk's words remain. The following probably written during his first year at Terezin describes his first unpleasant impressions:

We had not yet freed ourselves from the needs of comfort, social norms, social stratas, prejudices…We had not yet realized that we have been set apart for an unknown length of time into an uncertain future. The impressions are as damp as the weather had been. Muddy like the mood of us all. Was I desperate? No. I was only deeply touched. I needed two nights and two days to overcome my deep depression, to be able to overcome my own self. I was unable to concentrate my thoughts on work….It was at noon of the third day that I suddenly succeeded in breaking through and submerged myself straight into work. Work saved me…ever since then I haven't stopped working.

As they endured their personal metamorphoses, Drs.Fleischmann and Munk learned a crucial survival technique - they could help themselves best by helping others.

Terezin

In 1780 Emperor Franz Josef, the emperor of Austria, built a garrison town in Bohemia which he named Theresienstadt - the city of Theresa, after his mother Queen Maria Theresa. After the formation of Czechoslovakia in 1918 the town was called in Czech Terezin. Then with German occupation during World War II, again it was officially designated as Theresienstadt. In later years both names were used depending upon the perspective of the speaker or writer. English language references tend to prefer the shorter Czech version which is used in this essay.

The Terezin ghetto was euphemistically described by the Nazis as "a city of refuge" or sometimes as "Hitler's gift to the Jews." In truth it was an assemblage camp where Jews were concentrated for varying periods until they were deported to "the East" - another euphemism for death camps, particularly Auschwitz-Birkenau. At first,Terezin was intended for Czech Jews but, before long others mainly from central Europe were shipped there - affluent, privileged, older people — rabbis, scientists, war veterans, musicians, artists — as many as 58,491 in September, 1942, all sharing space with rats, lice and fleas. Few of them suspected what lay ahead; many felt fortunate to be in this safe haven - some even paid for the privilege. Famously, in June, 1944, a delegation from the International Red Cross visited and couldn't, or wouldn't, appreciate the masquerade. They reported favorably to the world on conditions in what Nazi called the "model city" — in truth it was a Potemkin's Village - a place of false facades.

Terezin is often remembered as the concentration camp where guards turned a blind eye to cultural activities that were put on by the prisoners. Perhaps these were permitted for the purpose of propaganda or to temporarily appease the doomed inmates. There was a cabaret of sorts with a jazz band and performances of Verdi's Requiem and the children's opera Brundibar were sung by doomed choruses. Hundreds of lectures were given by famous scholars. Why did they do it? For some it may have been an escape into a semblance of normalcy; for others it represented a proud act of defiance - of being able to act human in the midst of depravity. Yet, few prisoners actually could attend the cultural events - most were too exhausted from work or were literally starving. Although technically Terezin was not a death camp, between November 1941 and May 1945 of nearly 160,000 people sent there, some 36,000 died of illness or starvation; the rest, about 88,000, were deported to extermination or work camps with only a few thousand of these surviving the ordeal. When the Russians liberated Terezin in May 1945, there were only about 30,000 survivors, more dead than alive. Within weeks many more died of a typhus epidemic. Of more than 12,000 children who passed through Terezin, only 325 survived.

Health Care in the Ghetto

Terezin's main hospital was located in a large barrack which had been built in 1780 to service military and civilian populations of about 7,000 people. It was ill-suited to care for the needs of 40 or 50,000 prisoners at a time and although solidly built with high vaulted wards and a huge attic, it was a hospital with no beds or bandages, no sterilizing equipment or instruments. Nevertheless, there was an abundance of knowledge and resourcefulness among the physicians. Dr. Munk's Health Department was able to collect some antiquated or broken equipment; glasses, orthopedic shoes and trusses were fitted and repaired, test tubes were manufactured and eventually a central pharmacy was stocked from medicines confiscated from new arrivals. Later this was supplemented by supplies brought in from the defunct Jewish hospitals and clinics of Europe. And so, gradually, a semblance of a functional hospital emerged.

Fleischmann's Portrait of Dr. Munk

Concerning his art work at Terezin, Dr. Fleischmann once wrote "I wanted to see the world differently and I could perceive it by making many hundreds of drawings." His subject matter frequently was mundane while at other times his art hauntingly depicted life in the ghetto. He was especially intrigued by the thought of drawing "the Munk." Here Fleischmann considers how he might develop the boss's portrait in geometrical terms according to Cezanne's cubist style:

I have repeatedly tried to draw him. It's not easy. ..I made a whole lot of drawings with little success. Dr. Munk says about himself that he does not have a photogenic face. Maybe he is right. [But] from a painter's point of view his face is not only most interesting, but his entire stature and movements which are like counterpoint in a subconscious composed symphony movement

I'll have to set up two, slightly upstanding but beautifully formed ears, above the ears a wreath of shining dark brown hair on the crown of the head something that once had been a bushy mane - without being impertinent…[now] a head which can be called bald.. It should not be [overemphasized] because this is a weak point of the otherwise brave Maccabee…The head, although small is proportional to the upper part of the body [and] establishes symmetry and almost a monumental impression. Yet the most remarkable are the eyes - dark, deep, seemingly with no transition from the pupils to the iris, shadowed by the sleeplessness of long nights, supported by some striking crossbeams under the sunken cheeks.

The center is marked by an aristocratic finely-cut nose betraying a strong spirit, a proud person; it is a brave man who is facing you. In the physically small head lies a mighty brain. This small head is not the way a puppet's head is put on. It is a real organic entity, an integral part of the rest of the body. It's also the hands that impress you so. They are big, much too big for the small face but not malformed or clumsy, quite the contrary. They are strong and betray knowledge and feeling for what they hold… These are the hands of an energetic, yet gently touching surgeon.

When you see the gaunt man with his inflamed eyelids and tired mouth, how relentlessly he works for the welfare of the Ghetto inmates… then you can't lag behind him. For me personally, Dr. Munk has become a real experience. Rarely have I met people of his stature. It will be an honor for us all to be able to say that commissioned by the Health Department of Ghetto Terezin we were permitted to work together with Dr. Munk.

(Karrel Fleischmann's drawing of Dr. Munk is in the collection of the Art Museum at Yad Vashem.)

Remembering Karel Fleischmann

Karel Fleischmann began one of his last poems with these words:

Nobody will hear my song
The world of my time ends behind these walls.

But the doctor was mistaken. After the war's end, more than a thousand of Fleischmann's drawings, written notes and poems were found and collected in archives in Czechoslovakia and Israel. They provided valuable testimony because as doctor-artist-writer he was able to see and record the entire panorama of suffering including hunger, fear, overcrowding, sickness and brutality. Gradually the world became aware of Karel Fleischmann's unique contribution but only a small amount of written material was translated into English. Then in 2004 an article appeared in the International Journal of Dermatology which described the doctor's life. The authors Leonard Hoenig of Florida and Tomas Spenser and Anita Tarsi of Israel concluded their review by noting that although Karel Fleischmann perished, his dream for a better future endured, declaring that it is up to each of us to help make it a reality.

This blog essay has been adapted from a longer paper.

References and Acknowledgements

Primary material that has been reproduced here in italics was extracted from unpublished documents found in files of the Theresienstadt Martyrs Remembrance Association, Beit Theresienstadt (BT) at Kibbutz Givat Haim-Ihud in Israel. These had been translated by others into English and, in turn, I have slightly edited or resequenced portions for the sake of coherence. If in the process, factual errors may have inadvertently occurred, they are my own responsibility. Lydia Shmolka of BT translated some documents into English from their Health, Altestenrat and Erich Munk files. Several of Dr. Fleischmann's journals and poems which depicted the doctor-writer-artist's prewar work were translated into English by Hana Houskova and reproduced an unpublished biography Rack of Time (BT Karel Fleischmann File No. 601.) Other useful sources were Vera Schiff's memoir Theresienstadt: The Town the Nazis Gave to the Jews (Toronto: Lugus, 1996) and Ruth Bondy's Jakob Edelstein. Elder of the Jews (New York: Grove Press, 1981.) The best English language biography of Dr. Fleischmann is the reminiscence Dr. Karel Fleischmann: The story of an artist and physician in Ghetto Terezin by Leonard J. Hoenig, MD, Tomas Spenser, FRCGP and Anita Tarsi of Beit Theresienstadt (International Journal of Dermatology 2004: 43. 129-135) and the accompanying Commentary by A. Bernard Ackerman, MD The Importance of Remembering Karel Fleischmann. I wish to acknowledge Oded Breda, the manager of Beit Theresienstadt, and historian Dr. Margalit Shlain for their constructive suggestions.

The Family Portrait Project

June 29, 2009 at 10:57 am

deformities.jpg

Commentary by Mary Spano, Medical Photographer, The Institute of Reconstructive Plastic Surgery, NYU Langone Medical Center. Spano's work is on exhibit from June 29-August 31 in the Smilow Gallery at NYU School of Medicine. Free and open to the public.

In October of 2006 I joined the team at the Institute of Reconstructive Plastic Surgery at NYU Langone Medical Center, as its medical photographer. At the time, I was a professional photographer with a 20-year commercial background. In addition, I had worked as a Radiologic Technologist over the years to keep my photography career going, but I wasn't sure what medical photography was. I soon found out that I had gotten my "dream job." It combined everything that I loved about photography and knew about medical imaging. My job is to photograph people with facial differences, mostly children, and to provide diagnostic images for our doctors to plan surgeries that change those children's lives.

In the beginning I photographed pre and post surgical protocols. Many of our patients are young and vulnerable; they are apprehensive about everything "clinical." I began building my studio as a child friendly environment. I brought in child-sized posing chairs, dancing toys, and bubble machines - anything that would make the children comfortable enough to obtain the diagnostic photographs that the surgeons needed to plan their surgery.

Then one day around Christmas 2008, I was photographing a small child who was particularly apprehensive about letting go of Daddy's hand and I asked him if he wanted Daddy and Mommy in the photo with him. He said yes, and the "Family Portrait Project" was born. I took that first portrait not knowing what it would mean to the families or our department. Here, our families can sit for a portrait in a private setting, without any inhibition. Many of our families might not otherwise have a family portrait. These portraits are now displayed at the Institute in the gallery in our conference room.

The portraits have become the face of the Institute. They also help the staff illustrate to new families that whatever they may face along their path, they have the support of everyone at the Institute as well as the families we treated before them.
Working at the Institute is the most humbling and rewarding experience that I have ever had. I enjoy every day, and look forward to continuing to illustrate the incredible work the Institute does to transform the lives of children with facial differences.

Ethics and Aesthetics: Photographing Patients

February 5, 2009 at 1:12 pm

Arthur, 2007

Commentary by Ana Blohm, M.D., Assistant Professor of Medicine, Mount Sinai School of Medicine; physician in Mount Sinai’s Visiting Doctors Program; co-director, Humanities and Medicine Program in the Division of General Internal Medicine

"Is it OK if I take your picture?"
"Of course Doc, you can do anything you want."

For almost five years I have been taking care of homebound persons in upper Manhattan. The majority of my patients are elderly and frail, the rest are disabled by the advanced stages of chronic or terminal medical illness. A small minority suffers from psychiatric illness that prevents them from leaving the home. At any one time, I care for approximately ninety patients and I see them at regular intervals in their homes. If it weren't for our Visiting Doctors Program, these people would mainly be getting medical care through the ER, often when it is too late to affect the outcome of the acute event that brought them there.

Also for five years, I have been photographing many of these patients. It is impossible for me to clearly articulate why I started to document my visits, except to say that for me it seems more inexplicable not to photograph the world my patients live in.

From Chart to Art

At first, I started taking Polaroids to help inform the medical history. We are a group practice and often care for each other's patients over the phone, and in such a setting a photograph can be an invaluable aide in medical decision-making. The photos also helped me recall my patients when I was new on the job. I didn't think twice about the propriety of taking these pictures, they were an invaluable part of the medical record and were only used as such. The consent form was signed as a bureaucratic formality.

Almost immediately, I started to appreciate the Polaroids aesthetically. There was something touching in my patient's expression, something timeless in the corners of the room that were visible in the background. I found myself composing the images deliberately; I tried to include a colorful quilt, a glowing Christmas tree, a stuffed animal collection.

On my end, this still implied no conflict. Despite the fact that I was taking some artistic liberties, the photos of my patients remained destined for the chart as a useful part of the medical record; I was just having more fun at it. And again, the consent form was completed and never thought about again.

The Polaroid project ended when our practice adopted an electronic medical record, and at around the same time I upgraded to a digital camera. It would not be entirely truthful to say that this was just to continue to get images into the medical chart; by this time I had been overcome with a compulsion to photograph my patients and their home environment.

I took my camera along with my doctor bag, and after completing the medical visit I would sometimes ask for permission to photograph. Often, the patient caught unaware would say "next time" and I would return to find them dressed up with a wig and make-up, the bed perfectly made, and the apartment cleaned and dusted. This often altered what I had liked about the scene initially, but at least it validated for me that my patient had understood the far-reaching implications of my request. So I photographed sometimes for them, and sometimes for myself. But clearly, a line was drawn, and these pictures were no longer for the chart.

Some of the portraits became teaching slides for students and residents, figures in journal articles, illustrations for our program's brochure, and images that helped in raising funds needed to help maintain our program. One photograph was reproduced and used by the family of a patient as the picture for her funeral service; another one became a Christmas card. On my end, I hesitantly began to show the images of my homebound patients in my photography classes, and started to wonder if I would ever find it acceptable to myself to publish them in entirely non-medical and non-academic arenas.

My Patient/My Muse

Over the years I have cared for hundreds of patients and photographed less than thirty of them. I limit my portraits only to those patients that I judge can give informed consent in the truest possible sense, and I only ask patients that appear to be extroverts and empowered enough to say "no" to me. I make it clear that I am taking a picture because I like what I see: the person, their room, or their belongings, and that it might be shown to others outside Mount Sinai. I do not ask surrogate decision makers for permission; if my patient is incapacitated I can't allow myself to make their portrait, period.

I discard photos that are unflattering, and all that seem to be ironic, sensationalistic, or morbid. I am vigilant about avoiding "illness pornography." Occasionally I will open the blinds or move something out of the camera's way, but I do not compose scenes, direct my patient to pose, or place anything in the photo that is not there. After I photograph, I bring a copy of the photo as a gift and again ask for permission to share it with others. Finally, I embrace my institutional subjugation by asking my obliging patient to sign (originally two, now three) HIPAA forms.

My consent standards are higher than those of the average photojournalist or fine art photographer, and yet, I get butterflies every time I think about what I am doing. Why is that?

I suppose the answer lies in the fact that I feel that it is easy to be "ethical" in the trivial sense: ensuring informed consent, respecting confidentiality, signing forms, etc, etc. But ethically speaking this is low-hanging fruit, and being satisfied with this level of compliance is a sign that one is missing the actual moral issues inherent in patient photography.

My patients are often surprised about the way in which I ask to take their picture. The majority seems to feel that all my explanations are unnecessary… after all: "it's just a picture not a blood draw." And often enough, for most of them, that is all it is: "just a picture." The reality is that most of them have more important things going on in their lives than to care about pleasing their doctor, about whether an image of them will be floating around the world, or about the subtleties of whether their consent is truly informed. But there are a few patients that deeply desire to be "good" for me and they probably feel that this includes being agreeable to my eccentricities. Despite the power differential, although plausible, I don't think this is an issue of them feeling that if they were to object they would loose me as their doctor or that it would affect the quality of the care I will provide. It is simply that they value our relationship and genuinely wish to help me. But by placing them in this situation I may be overstepping my boundaries as their doctor.

Ethics and Aesthetics: What Now?

How should I approach this dual role as a physician and a photographer? Are the ethical standards higher for me than they are for a healthcare provider taking a teaching photo (say, documenting the medical care in an underdeveloped country)? Are they higher for me than for a photojournalist illustrating a story on healthcare? (1) And interestingly, is there something inherent in photography that makes it a more "objectionable" artistic pursuit for a physician than writing about a patient, or even sketching, painting, and sculpting the likeness of a patient? The answers are yes, yes, and yes.

A physician that photographs a patient for illustrating a journal article is first and foremost a healthcare provider; a journalist reporting in healthcare is first and foremost a journalist. The roles in these cases are clear, and there are no expectations beyond the obvious ones associated with the interaction. Doctors involved in the arts do grapple, consciously or unconsciously, with competing and sometimes opposing drives: a situation that is approached medically is often experienced aesthetically and vice versa.

More has been written about ethical and moral principles to guide physician-writers than to guide any other physician-artist. Rita Charon argues that patients own their story and we must seek their approval before we publish any literature in which they might be recognizable, even if only to themselves or to close relatives. (2) This may not be applicable to all types of medical stories (for example medical errors) or to all patients (the "difficult" patient, the psychiatrically ill, or those for whom disclosure may be distressing), but it is a good general rule. Dr. Charon states there can be a therapeutic value in sharing a story with the patient that inspired it, and I find a similar value for patients and their caregivers when I bring photographs into the home.

The ethical question in writing fiction, non-fiction, and creative non-fiction, is not necessarily about the propriety of using your patients as inspiration for artistic work-it has more to do with the subsequent dissemination of your aesthetic output. The issue becomes one of privacy and of authorship. If privacy is protected by changing recognizable facts, then at what point are the particulars altered so much that the distinction between fiction and non-fiction becomes absurd? If the fiction is tinted with the hue of a real interaction, then is the physician-writer guilty of thieving (3) from her patients for the benefit of her characters?

Photography by its very nature multiplies the issues privacy, confidentiality, and authorship. More than a sketch or a painting, a photographic image implicitly tends to be equated with reality. What can be more real than what we see with our own eyes? Some practitioners of the art even gave photography the power of being more "authentic" than reality itself. Photographer Edward Weston spoke of achieving "the stark beauty that a lens can so exactly render… without interference of artistic effect." (4) But the whole reason photographs are powerful and bewitching is precisely due to this "artistic effect" coupled with the cultural and social contexts in which the picture is made and subsequently viewed.

In photographing my patients and their home environment, I am harnessing their aesthetic to fuel my own. They arranged their clothes, their bed, their couch, and their paintings a certain way, and all I do is respond to the scene visually by composing a photograph in a way that was interesting to me.A Again, I am facing an issue of authorship akin to that of the thieving physician-writer.A And even worse, in terms of confidentiality, what can be more sacred than a patient-physician interaction in the privacy of the patient's own home?

Embracing the Gray Areas: Incorporating Ethical Conflict into the Work

All these issues are troubling to me, and yet I continue to photograph. My thinking is precisely that if I ever cease to be troubled by what I do, then I will have reached the point at which it would be morally wrong from me to continue the project.A I try to navigate this ethically grey area by choosing my subjects carefully, by seeing my patient as my collaborator, and by being candid about my motives.A Transparency is key for achieving what I would call "artistic" informed consent (there is no form to sign for this one.)

I enjoy showing my patients and their caregivers the images we make. Overwhelmingly, the response is one of amusement, and the snapshots tend to get a lot more attention than the "serious" work. But occasionally there is a deep appreciation of being shown their own environments in a different way: "I didn't know it looked like that!" "Who would have thought my room looks so nice?" They may never enjoy the print for the same reasons I do, but at least we will have reached an understanding that there is some meaningful value in it for both of us.

Ultimately, the validation comes from seeing the growing Ana Blohm collection of photographs on the walls of my patients' homes.

References
(1)See for example the work of Eugene Richards and Nicholas Nixon
(2)Charon, Rita. Narrative Medicine: form, function, and ethics. Annals of Internal Medicine. 134:83-7 (2001).
(3)Baruch, Jay. The Story Always Comes First. Commentary in Literature, Arts, and Medicine Blog. October 17, 2008.
(4)Weston, Edward, In Newhall, Nancy, ed. The Daybooks of Edward Weston, Volume II, p. 147. (New York:Aperture) 1973.

Editor’s note: For a video of the work of The Visiting Doctors Program, featuring Dr. Blohm, see: www.aarp.org/family/caregiving/articles/doctor_in_the_house.html

Grey Land: Soldiers on War

November 22, 2007 at 3:53 pm

Soldier

Commentary by Barry M. Goldstein, M.D., Ph.D., Associate Professor of Medical Humanities at University of Rochester School of Medicine and Dentistry

In June and July of 2007, I spent a month in Iraq photographing and interviewing soldiers of the Army’s 2/69 Combined Arms Battalion of the 3rd Brigade Combat Team, 3rd Infantry Division. The visit was the culmination of a project intended to convey a sample of the variety of faces and voices of those who serve in our armed forces. I began the project with no political agenda, preferring to let the soldiers speak for themselves. You will find no more powerful an indictment of war than from an experienced professional soldier, nor a more eloquent enumeration of the reasons for serving.

The origins of the project began in New York City on September 11, 2001. Like many New Yorkers, I photographed the attacks and the city’s response in the days that followed. Subsequently, I undertook a project photographing and interviewing a group of New York University medical students who had volunteered to work in the medical examiner’s morgues helping to identify human remains. This was their first exposure to the results of extreme and deliberate violence, and it had a profound effect on them. This work was ultimately published in a collection called Being There (Master Scholars Press, 2005).

By the time Being There came out, the war in Iraq was well under way-a direct consequence of the events I’d witnessed of 9/11. There were parallels between the young medical students I’d worked with, and the young soldiers serving overseas. Soldiers train extensively for their work, take it very seriously, and may experience levels of violence that most of us scarcely imagine. But despite their uniform dress and appearance, soldiers are individuals, and have many of the same concerns, desires and problems as the rest of us. I wanted to learn more about those who’ve chosen this particularly demanding profession in post-9/11 America.

After a year of initial inquiries, I was fortunate enough to be introduced to members of the 2/69 Battalion of the 3rd Brigade Combat Team, 3rd Infantry Division, stationed at Ft. Benning (Georgia). My contact was (then) Lieutenant Colonel Kathy Platoni, Ph.D., a practicing psychologist and combat stress specialist with over 25 years of service. I made my first trip to Ft. Benning in April of 2006, only three months after the brigade’s return from Iraq. During much of that time, the approximately 400 soldiers of the battalion were deployed in Ar Ramadi, then the "seat of the insurgency" and home to a particularly violent form of urban warfare. As one soldier noted:

Ramadi taught me the true nature of war. I’d spent years studying waraits philosophy, rulesabut war is ugly, chaotic, confusing. Everyone gets hurt. No one survivesabecause you’re not the same afterwards. You experience the crushing depression of seeing someone you love die violentlyaand think that you’re responsible. A 24-year-old should not have to do that.

I subsequently made eight trips to Ft. Benning, photographing and interviewing members of the brigade, and, when possible, their families. I asked the soldiers about where they grew up and why they joined the military, about whatever experiences during their deployment they cared to share, and about the difficulties of maintaining a family life both during and after deployment. Again, my goal was to convey something about who these individuals are, via their own words.

In January of 2007, it became clear that the brigade would be re-deployed. I decided to finish the project with a visit to the 2/69 in Iraq. When I arrived at Forward Operating Base Rustamiyah on the eastern edge of Baghdad in mid- June, the battalion had been deployed for three months. This was the second deployment for over half of these soldiers, and the third deployment for many.

The battalion lost three men the day before I got there. I photographed and spoke with their company commander a week later, and realized something I hadn’t before, despite all of my interviews. He knew these men intimately-knew them more closely than family. When the rest of us suffer this kind of loss, we take time for ourselves. These folks don’t have the luxury of a day off. They have to go right back out the next day- usually performing two 4-6 hour patrols a day, under constant stress. The weather is extreme-between 110-120 deg F-and these men and woman carry over 60 lbs of gear and weaponry. I near about died every time I went out carrying just a helmet, body armor and a camera. I still don’t entirely know how they do it.

Our soldiers have to be warriors, politicians, civil engineers, judges, and anything else that’s called for in their particular area of operations. The issue as to what we’re doing there, or whether we’re being at all successful, is moot to these soldiers. They go where they’re sent, do what they’re told, and try and make the best possible job of it.

I feel an enormous sense of responsibility to the men and women who have shared their stories with me. My travel is finished, and I’m now faced with the hard part-editing several thousand photographs, and several hundred pages of transcribed interviews. The intent is to collect these in a book, tentatively titled Grey Land: Soldiers on War. The title comes from the poem "Dreamers" by the WWI soldier and poet Siegfried Sassoon:

Soldiers are citizens of death’s gray land,
Drawing no dividend from time’s to-morrows.
In the great hour of destiny they stand,
Each with his feuds, and jealousies, and sorrows.

You can see a slide show of Dr. Goldstein’s images from Iraq at www.bgoldstein.net/iraq. The show will start automatically, and takes about five minutes.