replacing the romans

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Graffiti artwork from Hamra, ras Beirut.

[O]nly from within the world of poverty and exploitation that the bourgeois world produces can that same world be overcome.

– Gustavo Gutiérrez, “The Limitations of Modern Theology: On a Letter of Dietrich Bonhoeffer”

Over the past week, I’ve been shuttling myself between clinics throughout Lebanon – from Shatila and Jdeideh, just north of Beirut, to Zahleh in the Beka’a valley to the east, I’ve been keeping myself busy with the break in the weather. It’s been beautiful here in Lebanon, with spring-like sunny days and no rain in sight. Yesterday, going to the Beka’a valley and working in a free clinic in Zahleh [1] and going up into the mountains to help with home visits with the elderly in Chatura, one could see snow lining the roads and covering the distant mountaintops (see below). My friends for the past week have been talking about going skiing in the Chouf, or seeing the famous cedars of Lebanon in the north with snow – this is the perfect time, they say, for seeing the wonders of the country.

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This picture, taken in Chtaura, shows the snow-capped peaks of the mountaintops from the storms that came through Lebanon when I landed.

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Arriving at a patient’s house in the mountains, we were all taking turns walking down a narrow, icy pathway.

Throughout all of the beautiful scenery surrounding me throughout the week, we had to deal with some sad, yet complicated issues. From having to help manage the family and economic complications of sending a ninety-year old man to the emergency room due to hypertensive urgency, leaving his disabled, elderly cousin, for whom he cares, alone and at the dependence of neighbors, to seeing over one-hundred patients (many of whom were Syrians fleeing the violence in the country) with a handful of selfless nurses, pharmacists, residents, and attendings, I haven’t had much time to reflect on the meaning of all of this work. Seeing the injection of illness and disease into the social and economic structuring of everyday lives, and seeing how something as simple as getting an individual access to clean water, housing, and clothing becomes the largest challenge of the day, has been extremely tiring. Indeed, for many of the refugees whom I’ve had the honor of interacting with over the past week, illness is not the major issue on their mind [2]. As a future physician, how do I contend with that?

I’ve been grappling with the story of Fatima [3], a woman I saw with another medical student in the Shatila VOC a few days ago. Coming in for digestive complaints, she, after some questioning, revealed to us her dire social situation. Beyond her witnessing death and destruction in Syria during the recent civil uprising, leaving her psychologically traumatized, she related her complex housing situation, wherein her husband, disabled from an explosion in her home country during the uprising, was unable to secure work to support her and her children. Compounding this issue was her subsequent food insecurity, describing what little she had to eat at home as potatoes and bread. All of these issues are embedded in a complex sociopolitical schema, drawing on insecurity and fear of one’s status as both a refugee and a Syrian national in both a Palestinian refugee settlement and in Lebanon [4]. In an environment where refugees are extremely suspicious regarding their status in society and are simultaneously at the mercy of such a society, one is left with a paradox regarding both how to help and if such help is even beneficial. In the clinic, we can contribute to care regarding her digestive symptoms and offer some social supports and access to NGOs for some of her complex socioeconomic needs. But, in an environment where fear pervades and one’s access to needed goods and services is extremely tailored [5], one feels lost in a catch-22 situation: do too little or too much, and you end up in the same position.

There’s a famous scene in Martin Scorsese’s controversial 1988 film The Last Temptation of Christ, when Jesus and Judas Iscariot are having a discussion about the philosophy of the burgeoning Christian movement. In the film, as in Kazantzakis’ novel, there is a dialectic between the strictly political motives of the Zealots to which Judas ascribes, and the inward (though philosophically conflicting) movement that Jesus is attempting to propose. Judas worries about decolonization, via independence of Israel from Roman rule, and bread, while Jesus worries about the hearts and minds of the populace. Likening a house to liberation, Judas says, “You don’t build a foundation from the top down, you build from the bottom up. The body is the foundation.” Jesus replies, “No, the soul is the foundation. If you don’t change the soul, you’ll just replace the Romans with someone else.” That phrase, replacing the Romans, has stuck with me for years, since I saw the film when I was fifteen. What does it mean to replace the Romans, to change your philosophy and align it with solidarity, social justice, and equality, rather than only the material world of food, clothes, and medicine [7]?

This brings me full-circle to Fatima and the epigraph. Gutiérrez reminds us that the politics of witnessing, and the medical gaze made so famous by Foucault and Davenport [7], is the key to understanding how to stand in solidarity and fight for social justice for our patients. Looking at Fatima and the violence – structural, interpersonal, symbolic [8] – that occupies her daily life, it is not enough merely to give her food, clothes, and medicine. Reorienting one’s self to the possibility that we can learn from Fatima and not just treat – that her current situation is dictated by a cruel pragmatism that elevates politics, benefit, and economic gain for some and leaves nothing for others, is at the very heart of what Gutiérrez demands of us. Solidarity and social justice, therefore, aren’t just words to throw around when we agitate for equal rights or when we advocate for our patients, but emphasizes an actual philosophical stance, one that Scorsese, via Kazantzakis, urges us to think about in the form of film. Though I know I will see Fatima again in the near future, her life, to me, is one that requires a “thick description,” to paraphrase Clifford Geertz, in order to understand the inadequacies of my actions and to rectify them for our benefit. In essence, to advocate for change that will meaningfully impact the lives of patients like Fatima, I need to look beyond the material that my training in medicine will give me, and look to what she, like any other person, can teach me about the logic of insecurity and violence that strangles the ability of those deprived and disinherited – whether Lebanese, Palestinian, Syrian, or American – to exist securely and happily.

** for those curious regarding the developments surrounding providing housing to victims of the storms I wrote about a week ago, please see: http://www.dailystar.com.lb/News/Local-News/2013/Jan-12/201927-state-to-cover-housing-for-homeless-storm-victims.ashx#axzz2HmNfnTuu

[1] The Beka’a valley, known as the “breadbasket of Lebanon,” is a major area of agriculture in the area. Many famous wineries, such as Ksara and Kefraya, are located in and around Zahleh, making the area a destination for many tourists.

[2] I think of a story one of our deans at BUSM, Dr. Bob Witzburg, told our group about social determinants of healthcare. While working as an attending at Boston City Hospital at the height of the HIV/AIDS epidemic in the 1980’s, he was confronted with a case of full-blown AIDS in a young woman, currently admitted for therapy. At this time, antiretrovirals were not available, and patients were treated only for opportunistic infections that they may either have or carry the risk of contracting, based on CD4 count (pneumocystis carinii pneumonia (PCP), cerebral toxoplasmosis, mycobacterium-avium complex pneumonia, and the like). She had not been taking her medications, and Dr. Witzburg and the care team were about to go into the room and have a discussion regarding medication compliance. After they finished speaking, the woman said, “Doctor, AIDS is not the biggest issue in my life right now.” Stunned, the entire team fell silent as the patient recounted her issues surrounding housing and poverty, and how these issues, and not her life-threatening illness, were more important.

[3] For purposes of confidentiality, I’ve changed the patient’s name and omitted some of her history.

[4] Drawing on history, there is a long and convoluted relationship among the governments of Lebanon and Syria, and the Palestinian cause. Widely considered a major player in Lebanese politics, both past and present, Syria has funded multiple milita groups during and after the civil war and has played a key role in many of the fractures that plagued the PLO (Palestinian Liberation Organization) after its exile from Beirut in 1982 and, indirectly, in the “Battle of the Camps” during the end stages of the Lebanese civil war. Though both pro- and anti-Syrian movements are present in Lebanon, as exemplified most strikingly in recent history in the 2005 Cedars’ Revolution, there are wild speculations within and outside of the camps regarding the influx of Syrian refugees into Beirut (for new numbers of refugees and accounts of violence towards them, see: http://www.dailystar.com.lb/News/Local-News/2013/Jan-19/202866-un-8000-new-refugees-registered-this-week.ashx#axzz2IVx0Cv6y). Moreover, with stories in the press regarding suicides and deaths of Syrians (see: http://www.dailystar.com.lb/News/Local-News/2013/Jan-17/202550-palestinian-refugee-from-syria-commits-suicide-in-ain-al-hilweh.ashx#axzz2IVx0Cv6y), there is a general air of distrust and worry among Syrians in general.  For more information about Syria’s relationship with Lebanon, see Rosemary Sayigh’s Too Many Enemies (1994), Sayigh’s essay “Palestinians in Lebanon: Harsh Present, Uncertain Future” (1995), and Richard Norton’s Hezbollah: A Short History (2009).

[5] Though a multitude of NGOs work in Shatila, the primary caregiver of services and support, UNRWA (the United Nations Relief Works’ Agency for Refugees in the Near East) has been consistently underfunded for projects in Lebanon, despite the country housing the majority of Palestinian refugees outside of the Occupied Territories. Sayigh pinpoints this underfunding to the issues surrounding the Oslo Accords of 1993, wherein Yasser Arafat negotiated with Israel for the creation of the Palestinian Authority, seen by many critics as an appeasement strategy and a so-called “sell-out” of the Palestinian cause. See Sayigh 1995, cited in [7].

[6] Here, I think on Aesop Rock’s simple, yet poignant, lyrics for a similarly titled song – “Food, clothes, medicine/’cause hungry, naked, sick sucks.” See “Food, Clothes, Medicine,” off of Aesop Rock’s Fast Cars, Danger, Fire, & Knives [EP] (2005)

[7] See Michel Foucault’s The Birth of the Clinic (1963) and Beverly Davenport’s “Witnessing and the Medical Gaze: How Medical Students Learn to See at a Free Clinic for the Homeless” (2000).

[8] See Philippe Bourgois’s “Recognizing Invisible Violence: A Thirty-Year Ethnographic Retrospective” In Global Health in Times of Violence, Barbara Rylko-Bauer, Linda Whiteford, and Paul Farmer, eds. Santa Fe, NM: School for Advanced Research Press. Pp. 17-40. (see: http://www.philippebourgois.net/Edited%20Farmer%20et%20al%20Violence%202010.pdf)

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One response to “replacing the romans

  1. Very interesting comments, and capturing of the many different groups who flee to Lebanon for refuge. I am glad you were able to witness and report back eloquently as always.

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