Summary:

Professor Samuel D. Gross of Jefferson Medical College is demonstrating an operation for osteomyelitis of the femur in the surgical amphitheater in 1875 in this highly dramatic, powerful scene. Light glints off his forehead, and his visage is stern, calm, and surrounded by a halo of gray-white hair. The bloody fingers of his right hand hold a blood-tipped scalpel. He appears to have just made an incision and is turning away to demonstrate his work.

To the surgeon’s left is the patient, lying in right lateral decubitus position, with exposed leg and buttocks. Assistants are retracting the wound, further dissecting within it, and holding the patient’s legs. Blood is on their hands, instruments, and the patient’s leg. The patient’s face is obscured by the chloroform soaked towel that the anesthetist is using to administer general anesthesia. The white of this towel and the operating table’s sheet are the only other bright white values besides the surgeon’s head in this mostly dark painting.

Adding to the drama is the stricken pose of the patient’s female relative--to the surgeon’s right. For charity cases, a family member was required to be present during the surgery. She averts her head and raises her hands, clenched in a claw-like fashion, to block her view.

In the gallery are variously interested and disinterested observers--mostly medical students--in casual poses and dimly seen. The exception is the artist’s self-portrayal--he is studiously drawing in the front row. Dr. Gross’s son (also a surgeon) is standing in the entry tunnel.

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As Audrey Young describes her process of becoming a compassionate internist in a besieged public hospital, she simultaneously argues for turning the hospital's patient care and financial practices into a model for improving health care in America.  Young, a compelling storyteller, first entered Seattle's Harborview Medical Center in 1996 as a third-year medical student on trauma surgery service.  She completed a residency there in general internal medicine and stayed on as an attending for six more years.  She stayed, she tells us, because she met physicians "committed to a vision of equality" who were "the sort of people I hoped to become" (xiii).   She also "fell in love" with "the story of a unique place" (xiii).  Young's stories of that often chaotic place, where ambulances regularly transport homeless, indigent, addicted, and mentally ill refugees from neighboring private hospitals, emphasizes the ways the Harborview staff manages to treat patients with dignity and to choose an ethic of hope in the face of dire circumstances.           

We quickly learn that at Harborview compassion is expressed concretely as actions toward patients.  Michael Copass, known as "the mostly benign dictator of emergency operations," pronounced the core of these actions in what came to be known as his commandments:  "1. Work hard.  2. Be polite.  3. Treat the patient graciously, even if he is not the president of the United States" (9).  Politeness always meant asking "'How may I help you, sir?'" regardless of the patient's social status or addiction history.  Politeness sometimes meant finding a way to reach the patient who regularly threatened the staff.  Young finds ways and creates a therapeutic bond.  But working hard and treating patients considerately also took measurable forms, such as not allowing emergency patients to wait.  Facing a flurry of admissions, the Emergency Department (ED) staff interpreted a young Ethiopian's complaints about pain as a drug addict's ploy.  Because Young glanced at the admissions board and noticed that he remained unattended for three hours--far longer than Copass could tolerate--she jumped into action.  He suffered, she discovered, from a collapsed lung. 

However, Young moves her narrative beyond individual doctor and patient encounters and into the larger, interrelated social and financial structures in which medicine is practiced.  For instance, she links meager funding for drug and alcohol rehabilitation programs with expensive ED admissions and rising healthcare costs.  In the chapter "Bunks for Drunks," Young visits an experimental residence that houses homeless addicts in furnished studios with private baths and cooking appliances.  Although residents can keep alcohol in their rooms and elect not to participate in the home's social services, including counseling, alcohol consumption and ED admissions decrease.  While the chapter points out the cost savings of such arrangements, Young further urges readers to value the dignity residents experience there.

In "Black Friday," Young details the hospital's tense, but ingenious responses to a Mass Casualty Incident, the result of carbon monoxide poisoning, which almost depleted the resources of all of Seattle's medical centers.  The final chapter, "A Vision," outlines how Harborview has tried to succeed as both a charitable institution and a business, as a provider of both indigent and luxury care, with the hope that others will follow the medical center's example.  However, in presenting her recommendations for "health justice," Audrey Young also makes the case that "seemingly ordinary citizens" are implicated in healthcare reform (231).  To enable their informed participation in making changes, Young includes an appendix with further readings and another that lists strategies for effecting reform.  

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Séraphine (Yolande Moreau) is a housekeeper, ill-treated by her employers, but she finds solace in painting naïve images of flowers, fruit, and birds, using vivid colours that she makes herself from plants and animals. Her mistress rejects the art as junk.

Séraphine sympathizes with the apparent loneliness of the German tenant Uhde (Ulrich Tukur) who is a connaisseur of art. He admires one of her tableaux and is astonished to discover that the artist is his housekeeper. He encourages her and buys some paintings.  But war in 1914 forces him to return to Germany.

Spiralling downward deeper into poverty and mental alienation, Séraphine continues to paint works that grow larger, bolder, and more colorful. Finally her bizarre behavior leads to her arrest and commital in an insane asylum, and her painting ceases.

Uhde eventually returns to France and organizes the first Naïve Art exhibition featuring work by Henri Rousseau and Séraphine. But only years later does he bother to look for her. She is miserable. He arranges for her to be given a more comfortable room, but he doesn’t speak to her and she never paints again.

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The story centers on Tsotsi (meaning thug), an adolescent in Soweto, the shantytown slum of modern Johannesburg, South Africa.  There Tsotsi (Presley Chweneyagai) leads a loose-knit gang of menacing thugs.  When gang members are first encountered, Butcher reveals his disturbing and sinister nature; Boston (Mothusi Magano), except for his alcoholism, represents a potentially thoughtful but ineffective source of goodness and decency; Aap (Kenneth Nkosi), a simpleton, is devoted to Tsotsi; and Tsotsi seethes with, as yet, inexplicable rage. 

As the story unfolds, a petty crime leads to senseless murder and an old wheelchair-bound man is threatened and cruelly abused.  Finally, Tsotsi, without gang participation, shoots a woman during an auto theft.  When he drives recklessly away, he discovers an infant in the stolen car's backseat.  Rather than killing the baby, his first inclination, he puts it into a paper bag and takes the baby home.  This new relationship--and responsibility becomes the harrowing twist in the story.   

Throughout, short and disturbing flash backs of Tsotsi's childhood reveal unimagined beginnings that have led to the boy's simmering rage and the string of unforgiving actions.  While concerns about vulnerable children within a context of social injustices are foremost in the minds of film viewers, the overwhelming circumstances and complexities frustrate thoughts about realistic interventions. 

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The film opens on the Coeur d'Alene Indian Reservation -- called "the rez" by its inhabitants -- in 1998. Immediately there is a flashback to July 4, 1976 when the community was celebrating "white man's Independence Day" in drunken abandon. Accidentally Arnold Joseph (Gary Farmer) sets an uncontrollable fire to his neighbor's house, killing the couple who live there. But Joseph catches the baby, Thomas, when he is thrown out of a second story window from the burning house. The rescued Thomas (Evan Adams) is brought up by his grandmother and along side of Victor (Adam Beach), Arnold Joseph's son of about the same age. Joseph keeps on drinking but is in despair about the conflagration and its consequences.

12-year-old Victor watches sullenly while his parents drink until one night he smashes all their beer bottles. This action is a wake-up call for Victor's mother, Arlene (Tantoo Cardinal), who insists that she and Arnold both stop drinking. She chases Arnold out of the house; he leaves, never to return, while Victor watches, sobbing. These elements of the story occur in flashbacks while the 20-year-old Victor and Thomas travel by bus to retrieve whatever they can of Arnold Joseph, who has died outside of Phoenix. The remaining story unfolds in that forsaken spot where Joseph lived in a trailer and befriended Suzy Song, a young Indian woman originally from New York.

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This is an anthology of 32 pieces, many directly relating to war and its aftermath, or, in general, kinds of violence humans inflict upon each other and the ensuing suffering: hence the title, "echoes of war." The pieces include short fiction, essay, a dozen poems, and a photo collection. Since none are lengthy, this is a good reader to supplement other longer texts or to serve as an anthology for a reading group. A short essay, "Suggested Longer Readers," mentions some three dozen pivotal topics, including "homecoming" and "sense of identity." 

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Sometimes overlooked by those attracted to Wharton's longer, more ironic novels, this novella is one of stark simplicity set against a bleak New England countryside at the beginning of the 20th century. With characteristic economy, Wharton tells a compelling story about the human need for passion and affection in a situation where only abject coldness exists.

Ethan Frome is introduced by the narrator in this way: "It was there that, several years ago, I saw him for the first time; and the sight pulled me up sharp. Even then he was the most striking figure in Starksfield, though he was but the ruin of a man" (3). Determined to learn more about Ethan, while temporarily located in an appropriately-named village, the narrator manages to gather pieces of information about the figure who seemed an "incarnation of frozen woe in the melancholy landscape" (11).

The spark of hope that might have led young Ethan toward education and escape expired when care for his chronically-ill mother fell first to him and then to a cousin named Zenobia. Unable to abandon his mother and their needy homestead, he was easily attracted to Zenobia, the kindly young woman who assisted in his mother's care. They married, the mother died, and Zenobia inexplicably assumed a sick-role that would make Ethan's life loveless and tragic. Permanently stuck in Starksfield, his years become emotionally and economically depressed. Barely able to eke out a living hauling lumber and subjected to his bed-ridden wife's petty and constant demands, Ethan's impoverishment seems unending.

Miraculously, a third person, Mattie, enters the narrative. A distant cousin with no resources, she has been summoned by Ethan's increasingly mean-spirited wife to do chores within the house. The scene is set for two lonely and isolated people, despite age differences, to discover small bits of warmth in stolen moments together. Walks through the snow or gentle kindnesses in the dull household routine sustain the otherwise desolate pair of innocent lovers. An unexpected turn of events transforms a hopeless set of circumstances into permanent desolation and trauma. The conclusion is one of unimaginable horror.

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Four doomed characters illustrate the downward course of drug initiation and addiction. Aronofsky's innovative portrayal is arrestingly brutal and compelling; many viewers will be disturbed by penetrating and darkly lucid visual effects guiding the descending spiral--from spring to winter, from life and hope to destruction and death.

One character, Sara Goldfarb, played courageously and brilliantly by Ellen Burstyn, becomes addicted to diet pills prescribed by a despicably careless physician. The other characters--her son, Harry (Jared Leto) and his two friends (played by Marlon Wayon and Jennifer Connelly)--are heroin addicts and dealers. In separate ways all move toward the same abyss.

Although graphic and, at times, extremely difficult to watch, the frightening nightmare of addiction should be required viewing for those who might yet succumb and those who think that just saying "no" works. The grisly and unbearably sad storyline and its explicit horror recalls the 1989 film and novel on which it was based, Last Exit to Brooklyn, also written by Hubert Selby, Jr.

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The story is based on an actual 1950's trip by two university friends, Ernesto 'Che' Guevara (Gael Garcia Bernal) and Alberto Granado (Rodrigo De la Serna). Guevara is studying medicine, Granado biochemistry. They plan to travel from Buenos Aires across the Andes Mountains to Chile, Peru, and, then, to Venezuela. Before too many miles their derelict 1939 motorcycle fails, and the two young men continue by whatever means is available. The journey intent is one of adventure--drinking, meeting women, seeing the world.

The young men do discover South America's impressive natural beauty but more strikingly, their eyes and sensibilities are directed to abject poverty and shocking injustices. These blatant inequities, as well as an extended period of time in a leper colony, contribute to the reframing of their original happy-go-lucky adventure and explain, in part, the impulses that eventually would shape Guevara's role in the Cuban Revolution.

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Because this lucid, rich, and incisive book has not, as yet, been published in the United States, it has not acquired the readership it deserves. For those teaching Medical Humanities or those interested in broader or more global stories and perspectives about physician training, practice, and experiences, Helman’s most recent publication should be considered.

Part One (“Setting Out”) begins in South Africa where Helman’s family, comprised of a dozen doctors, has lived for generations and where his own medical studies occurred. As a child, he accompanied his father on rounds while other children spent holidays at the beach. Before long he discovered how hospitals, during the madness of Apartheid, were to “some extent a distorted mirror-image of the world outside” (3). Appalled by the differences in care and treatment, the keenly aware young man kept notes. His vivid observations of the harsh context of social injustices provide an unequivocal, eloquent, and disturbing critique of medicine then and there. His acute observations of physician behaviors and indigent populations in the city and in the bush contribute, as readers discover in later chapters, to the author’s expanded and compelling interests in cultural anthropology.

Part Two (“The Family Doctor”) leads to London. “After all the heat and light and space of Africa, London—with its low leaden sky and constant drizzle—was like living inside a Tupperware box, one stored deep inside a refrigerator” (47). In the 60s Helman’s migration required an adjustment to a world of technology and order, where as a family practitioner, he had become, in fact, a suburban shaman. In any society, patients wanted “relief from discomfort, relief from anxiety, a relationship of compassion and care, some explanation of what has gone wrong, and why, and a sense of order or meaning imposed on the apparent chaos of their personal suffering to help them make sense of it and to cope with it” (xvi).

Gradually Helman saw connections between the role of family physician and traditional healer: both involved an understanding of “not only a body’s internal equilibrium but also the equilibrium of the patient’s relationships with the world he or she lives in and how treatment should aim not only to treat the diseased organ but also to restore the patient’s life that equilibrium of relationships” (xvii). His encounters with patients and the stories they reveal suggest how important these often overlooked connections are and why they ought to be included in medical training and practice.

By the time readers reach Part Three ("States of the Art”), the author has moved into broader realms of thinking, in which medicine and illnesses are examined anthropologically. After 27 years of clinical practice Helman’s white coat and stethoscope are placed on a hook. Now, as a credentialed anthropologist at University College London, his larger lens allows for sustained scrutiny of the complexities, ambiguities, and nuances in such chapters as “Grand Rounds,” “Hospitals,” “Placebos,” “Third Worlds.” Helman’s range of experiences, multi-disciplinary training, intellectual conclusions, and abundant common sense argues for techno-doctors to learn from holistic practitioners. Whether devastating or humorous, the critiques reflect not just care provision but shared human capacities: the insights are thoughtful and fresh and very worthwhile.

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