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Comfort Measures Only

Campo, Rafael

Last Updated: Nov-26-2018
Annotated by:
Davis, Cortney

Primary Category: Literature / Poetry

Genre: Poetry

Summary:

Physician Rafael Campo's collection of new and selected poems is a lovely look back (selected poems are from 1994 to 2016) and an exciting look at thirty-one new poems that continue his trademark use of a variety of poetic forms (the title poem "Comfort Measures Only" is a Villanelle, pg 135) and the moving and personal examination of his interactions with patients.   This collection begins with Campo's excellent introductory essay, "Illness as Muse" (pgs 1-9).  

As the essay opens, an audience member tells Campo that his poems are "really depressing." Even Campo's spouse advises him to lighten things up, a counsel I hope the poet never heeds--for it is precisely Campo's unwavering examination of sorrow, regret, death, and despair that set his poems apart from poems that find "butterflies or snowflakes or flowers as more suitable." Campo responds: "Try as I might to take all of this concern to heart . . . I keep finding myself drawn to write about illness" (pg 1).


Campo recalls how singing and praying consoled his grandmother and seemed to lessen her physical ills: "No wonder I have come to believe in the power of the imagination if not to cure, then to heal" (pg 4).  On page five he notes "To write about illness, to heed this terrible muse, is to reject distancing and to embrace empathy, for which there is no reward or claim on greatness other than perhaps the perverse joy of recognizing oneself as being susceptible to the same foibles and neuroses as anyone."  Indeed it is this vulnerability--the ability to see physician and patient on the same plane, as equal players in a moment in time--that has become another hallmark of Campo's poetry.
Selected poems from previously published collections follow the essay: nine poems from "The Other Man Was Me" (1994); eight poems from "What the Body Told" (1997); nine poems from "Diva" (200); five poems from "Landscape with Human Figure" (2002); seven poems from "The Enemy" (2007); and twenty poems from "Alternative Medicine" (2013).  Of these collections, all but "Landscape with Human Figure" and "The Enemy" have been reviewed in the database.

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Summary:

Beth Macy has been a newspaper reporter in the Roanoke, Virginia area for three decades. In this book, she provides extensive reporting on the opioid crisis, how it developed and wreaked havoc in Appalachia, and how it grew into a national crisis across the United States.  

“Dopesick” is the colloquial term people who are addicted and addiction medicine specialists use to describe the constellation of wrenching and violent symptoms opioid withdrawal causes. As one of Macy’s subjects describes it:

You’re throwing up.You have diarrhea. You ache so bad and you’re so irritable that you can’t stand to be touched. Your legs shake so bad you can’t sleep. You’re as ill as one hornet could ever be. And believe me, you’ll do anything to make the pain go away.” (p. 41)
As a result, not long after a person is addicted to opioids, drug seeking behaviors are not motivated by the urge for the next and best high, but instead are driven “to avoid dopesickness at any cost” (p. 9). 

Macy divides her reporting into three major parts: 1) the ways Purdue Pharma fueled the explosion of opioid addiction beginning with the introduction of its product Oxycontin in 1996; 2) the ways in which people get addicted to opioids and how they get their supplies; and 3) the ways the U.S. health care system, criminal justice system, Congress, state legislatures, and regulatory agencies have failed in preventing and fixing the addiction crisis. 
 

As a journalist, Macy weaves the stories of individuals into the larger story of the opioid addiction crisis: people who became addicted to opioids and the effect it had on their families, and the stories of health care professionals who pulled alarms about the rapidly rising rate of opioid addiction and tried as best they could to treat addicted patients and protect the public. We read about the Purdue Pharma executives who were blamed and prosecuted for the marketing campaigns that turned localized opioid addiction patterns into a national opioid addiction epidemic. And we read about individual sheriffs, investigators, prosecutors, judges, and community activists who were trying to stem the tide of addition and death. These stories intersect throughout the book.

Embedded among the individual story lines are digressions Macy uses to elaborate on certain aspects of the opioid addiction crisis. She provides historical perspectives on drug addiction, and how this crisis differs from those of the past. She puts an emphasis on how trends in medical practice to liberalize the use of opioids in the management of all types of pain—minor and major, acute and chronic—converged with Purdue Pharma marketing campaigns for its proprietary opioid products. She cites statistics to show how fast the epidemic was worsening, how widely it was spreading across the United States, and how deadly it had become with mortality rates exceeding those of AIDs mortality at its peak. Other digressions cover how illicit opioid supply chains are created and maintained, and how different levels of governments reacted to the crisis. 

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Primary Category: Literature / Nonfiction

Genre: Treatise

Summary:

This intelligent and compelling book invites us to evaluate the losses pertaining to “modern death” and to consider better ways—whether from the past or in the future—to care for the dying, their families, and all care-givers.   
            
Some chapters, such as “How Life (and Death) Were Prolonged,” are historical, describing changes in inoculations, living conditions, and medical care that extended the human life span but also changes in dying, now often prolonged by technology. Another chapter, “How We Learned Not to Resuscitate,” relates how CPR, initially lauded and popularized, is now widely understood as futile care, especially in older people. Warraich discusses various attempts to define death (brain-based, heart-based, American Bar Association, Harvard Criteria, Uniform Determination of Death Act, even NASA) and some of the issues that still remain. 
 

Other chapters are more physiological:  “How Cells Die” explains natural processes of cell death (necrosis, autophagy, and apoptosis). Most non-medical readers haven’t heard of these and perhaps some medical personnel as well. Unaware of them as regular and usual processes, we resolutely expect people to live some four-score and ten, perhaps even more. The next-to-last chapter, “When the Plug is Pulled” discusses “terminal sedation” (a legal dosage that eases pain but is not strictly speaking euthanasia or murder) and statutes that allow for assisted death and removal of life-sustaining machines. The Nancy Cruzan case and others illustrate many difficulties. (Cruzan was in a persistent vegetative state and supported by a feeding tube. A 1990 U.S. Supreme Court 5-4 decision allowed the removal of the tube.) Warraich argues further for “patients’ right to demand and acquire the means to end their suffering with the aid of a physician” (p. 263).              

Lack of resolution of these difficulties leads to problems for families of the dying and all medical personnel attending them, especially in ICU situations. Living wills are often of no help and “the end of life has become a battleground” (p. 211).
He argues that surrogate roles for decisions at the end of a life often do not represent what the patient actually wanted because the surrogate's values may be different from the patient's and family members may not reach agreement on decisions. He concludes, “All in all, overinvolved family and underinvolved doctors unsurprisingly make for a particularly caustic combo” (p.214).                      

In “When Death Transcends” we read that spiritual and religious matters are often ignored in medical settings. Such resources, however, “may be the only means that patients have of finding comfort” (p. 148). Warraich surveys various religions, including his own, Islam. This is one of the longest chapters in the book and carefully considers the wide range of faiths people have and the regrettable lack of training for doctors in this area.
           

Warraich concludes, “Death needs to be closer to home, preceded by lesser disability and less isolation” (p. 278). For deaths to be “truly modern,” we need to push past taboos and misunderstandings about death. 

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Exit West

Hamid, Mohsin

Last Updated: Oct-22-2018
Annotated by:
Redel-Traub, Gabriel

Primary Category: Literature / Fiction

Genre: Novel

Summary:

Exit West, a novel by Mohsin Hamid, follows two young lovers as their (unnamed) Middle Eastern city descends into war. The story is an intimate look into how quickly war can warp the quotidian routines of daily life. It begins by introducing us to its protagonists. Nadia is a fiercely independent and thoroughly modern woman; she lives alone, rides her vespa around and listens to jazz records. Saeed is perhaps a bit more traditional—he lives with his parents—but is still a typical university student (he brings a joint to one of his and Nadia’s early dates.) The city is a cosmopolitan one, if not a bit outdated. However, as Nadia and Saeed’s relationship deepens, the initial hints of insurgency become apparent: drones and helicopters buzz constantly overhead, a night curfew is implemented, the window with a nice view becomes a liability as gunfire breaks out. The city descends bit by bit into all out war. As this happens, rumors of magical doors that whisk people away to distant lands begin to circulate. Nadia is keen to find one of these doors; Saeed is hesitant to leave in part because his parents are unwilling to join them. Eventually with growing violence in the city, the couple decides to enter a door and together are transported to Mykonos where they join hundreds of other migrants and refugees from all over world who are living in makeshift homes. The second half of Hamid’s novel follows the couple’s life as refugees, traveling from Greece to England and eventually to the USA. Hamid portrays the psychological cost of exile, loss and dislocation—a cost which slowly drives Nadia and Saeed apart.

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Sky the Oar

Nigliazzo, Stacy

Last Updated: Oct-16-2018
Annotated by:
Davis, Cortney

Primary Category: Literature / Poetry

Genre: Collection (Poems)

Summary:

"Sky the Oar," Stacy Nigliazzo's second full-length poetry collection, contains 52 poems in four sections. These poems are gems--and gem-like, each poem has been created by a compression of words into unique forms.  Nigliazzo's poems wander along the page, floating in white space as margins move in and out. In the three "Triptych" poems, pages 36, 46, and 61, Nigliazzo uses an article written in 2015, the report of a woman's murder, as a pale background. By choosing words to highlight, the poet creates spare poems that emerge as commentary on this crime--"Triptych III" offers only 6 highlighted words (pages 61-62). Nigliazzo has abandoned the more common narrative form--long or short lines that tell a story--and instead gives the reader hints, sign posts along the way. These poems are not meant to be read quickly. It is only by pondering them, allowing the imagination and intellect to fill in, so to speak, the white space around the words, that the impact and complexity of these stunning, impressionistic poems becomes evident. 

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Summary:

Naomi Oreskes and Erik Conway examine the successful efforts of a few scientists to jam the spokes in the wheel of science, delaying needed mitigations (e.g., regulations) to protect individuals, vulnerable populations, nations, and the earth.

The authors chose the well-known and controversial debates around second hand tobacco smoke, acid rain, the strategic defense initiative, the ozone hole, global warming, and the pesticide DDT as the substrate for their investigation. Each issue involves a large accumulation of evidence of the dangers it presents to humans. And each provoked skepticism and opposition from related industries, contrarian scientists, and anti-regulation politicians and institutes. Industry opposes regulations that could threaten their businesses. Free market ideologists do not want regulations that could threaten capitalism and accelerate a slide into socialism. 

Faced with mounting scientific evidence and general agreement amongst credible researchers, those whose interests were threatened needed a strategy to win that didn’t rely on scientific evidence. The tobacco industry led the way by hiring “a public relations firm to challenge the scientific evidence that smoking could kill you,” (p. 15) and to ensure that “scientific doubts must remain.” (p. 16) The authors drew from publicly available documents to best convey this idea:

‘Doubt is our product,’ ran the infamous memo written by one tobacco industry executive in 1969, ‘since it is the best means of competing with the ‘body of fact’ that exists in the minds of the general public.’ (p. 34)

The industry realized, however, that renowned scientists would be needed “to merchandize doubt,” (p. 33) and so they recruited some. First among them was Frederick Seitz. He was a physicist who had been involved in the atomic bomb program during World War II and later in Cold War weapons programs. He knew next to nothing about the science showing the harm of tobacco smoke. However, his time as president of the National Academy of Sciences and as president of Rockefeller University accorded him credibility on all matters of science, at least to constituencies outside of science. His attacks on the science showing the harms of tobacco smoke had a lot to do with the decades it took before governments and the public took meaningful actions.

This became the approach opponents took against of science-based initiatives they wanted to scuttle. Seitz was recruited for other campaigns, but so were other physicists with similar backgrounds to form what Oreskes and Conway call a “small network of doubt mongers.” (p. 213) They make a point that this network only threw darts—poisonous darts—at the science they targeted and never once contributed their own original research to support their opposition to any scientific findings or consensus.

Oreskes and Conway tie the motives of these scientists primarily to their fierce devotion to liberty, which then meant fighting Communism and any other forms of socialism. They suggest that some degree of curmudgeonry and contrarianism is involved as well, but they focus more on political ideologies as the primary drivers for these people:

they were working to ‘secure the blessings of liberty’…if science was being used against those blessings—in ways that challenged the freedom of free enterprise—then they would fight it as they would fight any enemy. For indeed, science was starting to show that certain kinds of liberties are not sustainable—like the liberty to pollute.” (p. 238-239)

The authors hold the news media responsible for much of what the doubt mongers accomplished, specifically faulting them for applying the “fairness doctrine”—each side of an argument will get equal time—to the point of absurdity.

it especially does not make sense to dismiss the consensus of experts if the dissenter is superannuated, disgruntled, a habitual contrarian, or in the pay of a group with an obvious ideological agenda or vested political or economic interest. Or in some cases, all of the above. (p. 272-273)

The news media, they assert, are the gatekeepers and should be able to distinguish charlatans and snake oil salesmen from legitimate scientists. In this role, they failed as far at the authors are concerned. There can be no network of doubt mongers without a news media that either can’t or won’t call them out.

In contrast, the authors give the scientists who didn’t call out the doubt mongers a more forgiving critique. For the most part, they say, scientists facing a fight will retreat to their labs and concentrate on their work—they’re discovers, not fighters. On them, “intimidation works.” (p. 265)

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Written on the Body

Winterson, Jeanette

Last Updated: Sep-24-2018
Annotated by:
Galbo, Sebastian

Primary Category: Literature / Fiction

Genre: Novel

Summary:

In this uncommonly sensual novel, the narrator has neither name nor gender; the object of the narrator’s frenetic love is a woman, Louise, who is married to a prominent medical researcher. The marriage is loveless, without empathy, affection, and sex. Undaunted by Louise’s relationship, the narrator quips knowingly, “Marriage is the flimsiest weapon against desire. You may as well take a pop-up gun to a python” (78). Louise’s marriage eventually crumbles, and the lovers flee. Their happiness, though, is disastrously brief. Louise’s husband, Elgin, discloses to the narrator that, before their affair, Louise was diagnosed with chronic lymphocytic leukemia. As a globally distinguished cancer expert, Elgin exacts his revenge on the lovers by promising treatment available only at a clinic abroad, which would force the couple to split. Fearing that Louise will forgo treatment to stay (and eventually die) the narrator writes a letter pleading her to go abroad, then vanishes into the countryside—a decision that haunts the narrator for the rest of the novel.

In rural isolation, the narrator pores obsessively over anatomy books: “Within the clinical language, through the dispassionate view of the sucking, sweating, greedy, defecating self, I found a love-poem to Louise. I would go on knowing her, more intimately than the skin, hair and voice that I craved. I would have her plasma, her spleen, her synovial fluid” (111). In a kind of medicalized elegy, Winterson breaks the novel out into a standalone section divided into individual segments that juxtapose excerpts from anatomical textbooks with deeply felt recollections of the beloved’s leukaemic body. In one section, “The Cells, Tissues, Systems and Cavities of the Body,” the narrator entreats, “Will you let me crawl inside you, stand guard over you, trap them [white T-cells] as they come at you?” (115). Winterson’s narrator, far removed from the realities of Louise’s treatment, apostrophizes her physical features, performing a kind of poetic embalmment of her lover’s body as she once knew it.

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Primary Category: Literature / Nonfiction

Genre: Treatise

Summary:

This important and much needed book describes the psychological difficulties of doctors in training and in practice and the woeful lack of support to them from teachers, colleagues, and institutions. When there are over 50 percent of doctors suffering burnout (or depression, even suicide), shouldn't we see and ameliorate this "significant public health crisis" (p. 263)?
Carolyn Elton is a vocational psychologist who has spent the last 20 years working with doctors in England and the U.S.  She has worked with over 600 doctors in a wide variety of specialties. 
  
 
Introduction: “Medicine in the Mirror”
Elton starts with a real-life email from a desperate medical student. She cites examples of med. students who commit suicide, studies of depressed doctors, and surveys that show impacts on medical care for all of us when it is given by doctors suffering from poor morale.

Ch. 1, "Wednesday's Child" discusses young doctors suddenly thrown into clinical practice; many are unready for the stress, and many training programs do not support them sufficiently.

Ch. 2,  "Finding the Middle." Many senior doctors are inhospitable to young doctors, especially those trained in other countries, for example India. There’s hope for sharing and support in  Schwartz Rounds, where staff (clinical and nonclinical) meet and discuss issues.

Ch. 3,  "Which Doctor." We learn that many troubled doctors have chosen the wrong specialty for them, often because of a specific illness in their families. They should have more time to chose or, even, to change specialties.

Ch. 4, "Brief Encounter."  Psychological concepts of transference and counter-transference are helpful in understanding sexual issues (examining patients' sex organs, homosexuality, sexism, inappropriate humor, attraction to a patient, even past sexual abuse). Many of these are common but so taboo that they are ordinarily—and unfortunately—not discussed in training. 


Ch. 5, “Role Reversal.” The book’s title “also human” is front and center here, because doctors become sick, injured, or otherwise compromised so that they must have medical assistance. Regrettably, other doctors often dismiss such problems or even blame the doctor for causing them or not overcoming them. Further, doctors often try to avoid a sick role. Psychological dilemmas and physical disabilities are often stigmatized.

Ch. 6, “Leaky Pipes.” Women doctors are often ill-treated, especially in surgery, where “surgical culture embodies masculinity” (p. 152). Women wishing to have children and family life in general are seen as slackers. Women doctors often “leak out” from hospital work to part-time community-based roles.


Ch. 7, “Risky Business.” Once again, we read that there is bias against Asian, black, disabled, or female doctors.  Specific examples and studies from social science make this dramatically clear. This unfortunate dynamic makes careers in medicine for such doctors “psychologically risky” (p. 192).

Ch. 8, “No Exit.” For many reasons it is hard to quit medical school, later training, or work in medicine, even when this is the best choice. Doctors often feel pain, even guilt when patients die, and they have little support.

Ch. 9, “Natural Selection.” Reviewing many problems already discussed, Elton summarizes: “sometimes the dream of training as a doctor turns out to be a nightmare in reality” (p. 229).  There’s bias in selection of students, reliance on tests with limited accuracy, insensitivity to the whole person, and inappropriate retention of students who should not become doctors. The Darwinian chapter title is ironic; much of the medical world as structured today is not natural.

Epilogue, “There’s No Such Thing as a Doctor.” This arresting subtitle brings us back to the personhood of doctors, who have psychological needs right along with the rest of us. Regrettably, “doctors’ psychological needs are denied, ignored, not thought about. Unmet” (p. 258). Sexism and racism are common. Lister’s reforms took a long time but are now pervasive and standard; can we similarly expand better care for doctors?  “Improving the emotional well-being of the medical workforce requires interventions that tackle three interconnected levels—the individual, the organization, and the culture of medicine as a whole” (p. 265).

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Summary:

Barbara Ehrenreich wants to manage her health and all that is available to address various aspects of it. She makes clear that she will do the managing and has written this book to reflect on how she plans to do it.  Ehrenreich explains why managing her health is necessary. She puts it this way:

We would all like to live longer and healthier lives; the question is how much of our lives should be devoted to this project, when we all, or at least most of us, have other, often more consequential things to do (p. xv)  

Ehrenreich doesn’t reject the project of getting longer and healthier lives per se, but she believes that what this project requires isn’t always worth the results it produces. The time and energy needed could be put towards better ends.  

Like many other critics, Ehrenreich details how Biomedicine often comes up short on outcomes for all the time, effort, and money it requires from the people it serves. She covers the familiar territories of over diagnosis and over utilization of health care products and services, and goes further to suggest that many common medical practices are more ritualistic and humiliating than evidence-based and effective.

Unlike other critics, Ehrenreich takes on other activities directed at health outside of Biomedicine. She questions whether the physical fitness industry delivers on its promises to produce healthier lives and especially whether there is a net benefit based on the time and energy required from people who take it on. She crosses to the other side of the mind-body continuum when she next aims at the “madness of mindfulness” (p. 71).  She finds the mindfulness movement offers more hubris than solutions.  

Ehrenreich worries that the combined effects of the authority of Biomedicine, the physical fitness frenzy, and the madness of mindfulness have created a social context that treats death as something that can be avoided or at least delayed. This social context thereby implies that not actively engaging in efforts to fight off death “can now be understood as a suicide” (p. 97).

Ehrenreich offers some reasons for why these efforts to improve health and prolong life do not always produce benefits that in her view are worth pursuing to the exclusion of other activities resulting in a better life (or death). Drawing on examples from cell biology and immunology, she suggests that what is at work are disease processes too complex for the human mind to apprehend completely combined with the human impulse to  simplify, which lead to practices, procedures, and prescriptions that in the best case are ineffective and in the worst case harmful.   

At the end of the book, Ehrenreich laments the efforts health care professionals, nonprofit organizations, government agencies, and commercial entities make to push older people into commitments for “successful aging.” Those making these efforts argue “aging itself is abnormal and unacceptable” (p. 164).  This commitment requires older people to spend a lot of time in clinics, gyms, and wellness classes—“The price of survival is endless toil,” is how Ehrenreich formulates it (p. 163).  She doesn’t think this price is worth what is required of people who are supposed to benefit, and advises her friends to insist “on a nonmedical death, without the torment of heroic interventions to prolong life by a few hours or days” (p. 208).

I continue to elude unnecessary medical attention and still doggedly push myself in the gym, where, if I am no longer a star, I am at least a fixture. In addition, I retain a daily regimen of stretching, some of which might qualify as yoga. Other than that, I pretty much eat what I want and indulge my vices, from butter to wine. Life is too short to forgo these pleasures, and would be far too long without them (p. 207).

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Histories

Guglani, Sam

Last Updated: Sep-18-2018
Annotated by:
Miksanek, Tony

Primary Category: Literature / Fiction

Genre: Collection (Short Stories)

Summary:

One British hospital. Seven days and nights. Plenty of perspectives from those who work there, train there, and are treated there. Over the course of one week (October 24 thru October 30), the characters in these connected stories spill their secrets and shame, tout their triumphs and tragedies. And the danger of professional and emotional exhaustion looms very large: "Maybe this is how doctors and nurses finally burn out. Past their failures, their hours, all their inhaled sadness" (p40). What ultimately triggers burnout is "the accrued weight of so many tiny things" (p41).

Readers are privy to the thoughts and sometimes nuanced actions of medical personnel - attending physicians, residents, a medical student, and nurses. The musings of a hospital chaplain, cleaning woman, medical secretary, hospital porter, and patients (a hairdresser and a farmer) are also divulged. But the protagonist is the hospital. More than a physical structure, it is a kind of human hive with many strata of workers, occupants, and those (MD's) at the top. The hospital is portrayed as "a place of brokenness," propped up with occasional promises of hope and the might of technology. But decay can be insidious as some physicians no longer appear capable of compassion or empathy.

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