Despite Virginia Woolf’s (12) famous proclamation that a “poverty of the language” exists in the description of illness, the most common form of pathographies is likely literature. Woolf’s essay On Being Ill argues that illness, compared to topics such as grief and love, remains rarely written into narratives due to the vocabulary itself. Yet, Carel’s work focuses on a more acute limitation. Language in books inherently offers limited bearing on temporality and pacing. While it is true that skilled authors can decide the pace of paragraphs, quickening tension with staccato and parataxis, the reader is ultimately given control regardless. As Roland Barthes (11) writes in The Pleasure of Text, “the author cannot predict tmesis: he cannot choose to write what will not be read.” In other words, the writer’s intentions matter little if a reader decides to skim over what they deem to be unimportant. Thus, the act of writing itself involves a willful relinquishment to the reader, and this act of surrender betrays a core tenet of the illness-experience: removal from control, particularly over time and space.

Video games complicate this dynamic, since some strip the very control Barthes describes back out of the player’s hands. Perhaps no game better exemplifies this removal of player control, especially over time, to depict illness than Before Your Eyes., released in 2021 by GoodbyeWorld Games. Before Your Eyes is not a typical video game. At no point does the player use their hands to control the game. Rather, the opening minutes require the player to set up an eye-tracking system, which lends itself to a simple conceit: with each blink in real life, once a metronome-object appears, time passes rapidly within the video game.

The first half of the game acts as a type of memory play. The main character, Benjamin, whose eyes the player inhabits, awaits judgment after death and must recount their life story to a mythical Ferryman to continue to the afterlife. The scenes begin playing out. Blink – Benjamin, as a baby, playing with rubber ducks. The scene plays out, then a metronome begins ticking down. Blink – watching parents argue about money. Blink – a piano recital. Blink – nervousness about talking to a crush. Evoking how memories work in real-life, each of these moments has a fleeting quality to them, as these scenes can only last if the player does not blink. Life goes by in a blink of an eye, literally.

While this perspective on memory alone makes Before Your Eyes an intriguing musing on memory, the second half of the game recontextualizes what comes before it in the context of medical humanities. As the scenes continue to play out, eventually Benjamin becomes a highly successful musician and artist, garnering worldwide acclaim. Yet, the story increasingly becomes fantastical, until it’s revealed that the story up to this point has been false. Rather, Benjamin died at 12 years old due to an unspecified terminal illness. The game plays out again; this time, the scenes are of Benjamin confined to his hospital bed. Blink – a growing illness. Blink – his parents visiting him at the hospital. Blink – dreaming of playing the piano. Blink – a fading interaction. In this second half, the scenes become ever more fleeting as the metronome signaling the scene is ready to pass appears more rapidly, triggering in the player a desire to avoid blinking. Often, before a moment can conclude, one blinks; time progresses, closer to death.

Before Your Eyes demonstrates the ability of other mediums, particularly video games, to use interactivity to disrupt typical temporality. This technique is not unique to Before Your Eyes by any means; the works of Samuel Beckett employ a similar technique of stripping audience control to simulate the constricted present Carel describes. For example, Beckett’s Not I (1972) features a disembodied mouth that delivers a fragmented monologue about past trauma at a pace too fast for an audience to fully process, let alone control. In video games, Red Dead Redemption 2’s protagonist, Arthur Morgan, develops tuberculosis over the game’s final chapters, which alters gameplay mechanics, including reducing stamina. As Marshall McLuhan famously argued, a medium’s structure shapes the way it delivers experience, independent of its content. Removing description of illness in favor of depicting its phenomenology, whether that is through Beckett’s compression of time or Red Dead Redemption 2’s diminishing of gameplay abilities, aims to cause the audience to experience illness. Before Your Eyes heightens both of these experiences, for time and space are tied to the player’s physical body, as occurs in sickness. In binding the passage of time to the player’s own involuntary blinking, the player’s body becomes a mechanism of failure. Thus, the player is made to inhabit Carel’s claim that illness is lived from within the body rather than observed from outside it. While literature can recapitulate the experience of symptoms, it cannot impose the conditions of it. Before Your Eyes suggests that the truest representation of illness may not be a representation at all, but an imposition of the phenomenological conditions of illness.

References:

Barthes, Roland. The Pleasure of the Text. Macmillan, 1975.

Carel, Havi. Phenomenology of Illness. Oxford University Press, 2016. Silverchair,
https://doi.org/10.1093/acprof:oso/9780199669653.001.0001.

McLuhan, Marshall. Understanding Media: The Extensions of Man. MIT press, 1994. Google Scholar,
https://scholar.google.com/scholar?cluster=4603169387763961023&hl=en&oi=scholarr.

Woolf, Virginia. “On Being Ill.” Family Business Review, vol. 6, no. 2, June 1993, pp. 199–201. SAGE Journals,
https://doi.org/10.1111/j.1741-6248.1993.00199.x.

Web image by medhum.org

The book became, unwittingly it seems, the first of a trilogy ultimately concerned with what conscious is and does. The second book, This is Your Mind on Plants (2021), extends Pollan’s project to three mind-altering compounds found in plants: opium, caffeine, and mescaline, and the third, A World Appears (2026), is his attempt to discern consciousness itself. Here I cover Pollan’s investigation into consciousness across the three books, the results of which frustrated him and required a reconciliation.

The Trips Begin

In How to Change Your Mind, Pollan gives a brief summary of the bumpy history of psychedelics. He recounts how the intense and well-supported interest in them as therapeutic agents during the 1950s was almost completely snuffed out in the 1960s when “a moral panic about LSD engulfed America, and virtually all psychedelic research and therapy were either halted or driven underground” (p. 185). The panic reached its apogee when counterculture movements and their leaders, among them Timothy Leary of “turn on, tune in, drop out” fame, were seen as threats to mainstream society in general. The few remaining embers, though, reignited in the 1990s and by 2006 serious interest in psychedelics revived and research into clinical use resumed through legal means. Structures were in place allowing psychedelic use for specific purposes, opening the way for Pollan’s investigation.

Pollan arranged three separate “trips,” one each for the psychedelics LSD, psilocybin, and 5-MeO-DMT (i.e., “The Toad”). He carefully chose a tour guide for each one. He came through these sessions with what he interpreted as a dissolution of his ego, which made more room for his consciousness: “I was present to reality but as something other than my self” (p. 264). After these experiences and interviews with many scientists, psychologists, counselors, and users, Pollan constructed an argument about how the altered consciousness states psychedelics produce can offer benefits to individuals who are healthy or sick, and to societies that are stable or fractious, by sending “a life or culture down a new path” (p. 407). He is inspiring, vague, and fantastical at times; he gets more so in his follow-up book, Your Mind on Plants.

There’s No Place Like Home

Pollan expands his investigation of consciousness-altering substances by marrying it with his passion for plants and gardening. Therefore, he need not look further than his kitchen and garden for sources serving his interest at this stage: opium (poppy), caffeine (coffee and tea), and mescaline (San Pedro cacti). He explained his rationale for choosing these three mind-altering agents:

Taken together, these three plant drugs cover much of the spectrum of the human experience of psychoactive substances, from the everyday use of caffeine, the most popular psychoactive drug on the planet; to the ceremonial use of mescaline by Indigenous peoples; to the age-old use of opiates to relieve pain. (p. 4)

Pollan received guidance and supervision for his trials of opium and mescaline. As a self-described “heavy caffeine user,” he withdrew from it by giving up coffee and tea, thinking he could make inferences about caffeine effects through reverse engineering the experience.

While Pollan describes the effects these three agents had on his consciousness, he went further morphing from his role as an investigative journalist into roles of historian and anthropologist. Pollan covers how opium, caffeine, and mescaline altered the consciousness of millions of people through the millennia, and in doing so, says they figure in world history and human development, often in rather breathtaking terms. Opium spurred “the Romantic revolution in poetry” (p. 31). “Caffeine was the perfect drug not only for the age of reason and the Enlightenment but for the rise of capitalism, too” (p. 119). “The sins of slavery and imperialism, in a global system of production…could only have been fueled by caffeine” (p. 138).

While he does not credit mescaline with having contributed to human progress in such grand scales, Pollan speaks of its power in healing the most devastating wounds. But insofar as affecting consciousness, for him, mescaline does “what all psychedelics do—not so much change how we feel inside as imbue the world around us with never-before-appreciated qualities” (p. 217).

Pollan may have imbibed too much caffeine while writing this book judging from some of the conclusions he makes, but it may have fueled his subsequent quest to understand just what consciousness is rather than just what it does to his mind and its impact on world history. What he found on this quest, or more appropriately, what he didn’t find, became the basis for his next book, A World Appears.

Pollan Trips into a Cave

If psychedelics and mind-altering plants can change consciousness, then, as Pollan surmises in describing his objective with A World Appears, “consciousness is, at its core, a material phenomenon…[or there is] at least some credence to the idea” (p. xx). So off he goes on more trips, this time to experts working on finding a discernible form of consciousness, a trip that in the end fails, but still produces some value towards the way we think about artificial intelligence.

Pollan’s trips takes him to four ports of call, or “four different dimensions of consciousness” (p. xxxi). His first stop is “sentience,” which refers to consciousness as where in living beings sensations are perceived and responses to them generated. The next stop is “feelings,” the awareness of biological phenomena, the communication link between the body and the mind, serving homeostasis, for example. “Thought” is Pollan’s third stop, accounting for “the stream of thoughts that all of us experience every waking moment” (p. xxxii). His trip ends at “self,” or the ’I’ that takes in all of our experiences.

Each trip constitutes a chapter comprising what is known about consciousness from a particular dimension. Pollan describes and evaluates them with the help of people involved in their development. Across the four dimensions, he consults or references a wide range of experts including among others: neuroscientists, physicists, biologists, philosophers, psychologists, screenwriters, novelists, poets, and Buddhists. He combs through their theories, constructs, data, analogies, stories, and metaphors. Pollan, nevertheless, comes up empty, and is “abashed to say I know less now than I did when, naively, I set out to unravel the mystery of consciousness” (p. 225). It took several days in a cave at a Buddhist retreat high in the mountains of New Mexico for Pollan to reconcile with this outcome, “to let go into not-knowing.” He wound up accepting consciousness “as less a scientific or philosophical puzzle to be solved and more as a practice…Consciousness is a miracle, truly, and remains the deepest of mysteries” (p. 239).

So be it, but what then are we to make of the artificial intelligence industries’ determined attempts to integrate or discern consciousness in their machines? Pollan might say they will need a miracle.

Citations:
Pollan M. How to Change Your Mind. Penguin Books; 2019. 464 pages
Pollan M. This Is Your Mind on Plants. Penguin Press; 2021. 288 pages
Pollan M. A World Appears: A Journey into Consciousness. Penguin Press; 2026. 320 pages

Links:
My blog post elaborating on Pollan’s How to Change Your Mind is here, and on Your Mind on Plants is here.

Along with cohost, Dan Albrant, here’s a link to our podcast episode in which we focus on: consciousness, spirituality, and mysticism as what is at work in the effects psychedelics produce, and how they may delineate limits to biomedicine (rational or not), that is, how they brighten or blur the line between classic biomedicine and whatever isn’t. 

Edited by Lucy Bruell.
Web Image: Cave Man, Tim Brown, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The hand’s importance in daily activities is often overlooked even as I look down at my fingers typing these very words. Rudimentary at first glance, the expansive nature of the hand is as complicated as its anatomy and not in the palm reader sense. Its complexity manifests in the intricate duties it performs when acted upon by the user’s brain, and yet there is so much to learn by its simple examination in its resting splendor. The beautiful dichotomy of the hand is illustrated in the simple gesture of hand-holding, a parent’s single finger grasped in their infant’s small palm contrasted with the loose grip of the dying parent with their child. It is in the soft caress that hands are capable of, but also the solid fist of a hard punch, and the complexity of playing instruments, weaving, programming AI and painting.

My office visits begin and end with a post-COVID handshake if the patient is agreeable. The essential job of the clinician begins with listening followed by thorough examination. For it is in examination that the patient map unfurls. From the initial handshake, to how one holds their hands during the visit, little clues are imperceptibly directed at me. The wringing of the patients’ hands is the tip off for anxiety, along with tightly picked nails or scars. The slight hand tremor can be the giveaway of Parkinson’s disease, alcohol withdrawal or thyrotoxicosis. Then there is the yellow-stained thumb and index finger of the habitual smoker. The tiny muscle fasciculations below the skin are the tip off for advanced carpal tunnel syndrome, advanced neck arthritis, amyloidosis or the more devastating amyotrophic lateral sclerosis. The feel and look of the callus distribution on the palm of the construction worker as opposed to the soft and supple feel of the secretary’s palm or those of the computer programmer are all documented subconsciously, while noting the fissuring and hyperkeratotic papules and scale of the mechanic’s hand, or the similar changes on the non-mechanic’s hand suggesting dermatomyositis or anti-synthetase syndrome. Tell me how AI could perceive most of this without the input of touch and observation?

Whether in the office, grocery store or at dinner, examination proceeds whether the person is willing or not, or even aware. Examining the hand is like picking up an oak leaf in the fall with its midrib, venules and variegation all telling you about the health of the tree from which it has fallen. We won’t discuss ornaments that adorn the hands such as rings or nail paintings as this is quite illustrative in and of itself. Rather, I am more interested in scars, irregularities and deformities. Each small finger joint so intricate and important in function, working simultaneously together like the worker bees in a hive or an orchestra.

From the fingertip alone, Terry’s nail, with its loss of the crescent half-moon, ground glass white appearance, and the darker line at the very tip of the nail, suggests underlying liver issues. Move that line of demarcation proximally to affect half of the nail, it transitions into Lindsay’s nail and communicates underlying kidney dysfunction. Should that half-moon crescent change to a blue tinge or even completely change to blue, the patient may be being slowly poisoned by silver or copper. The pale nail bed alone is a tip-off for anemia. A murky longitudinal dark stain, like a comet and its tail tracing from the cuticle to the free nail edge, can be the forewarning of a melanoma. Smaller dark stripes distributed throughout the nail are the potential signs of endocarditis, lupus or vasculitis. Should the patients’ nails look like a pock-marked battlefield, the likelihood of psoriasis as a verdict is greater, especially if they are accompanied by joint aches or a reddish-silver raised skin rash. If the same patient did not choose to paint their nails yellow, and it spontaneously occurred, my pondering moves to lung pathology or autoimmune issues. Lastly, horizontal linear grooves on the nail, named after our friend Joseph Beau, tells me the patient is zinc deficient or enduring chemotherapy. While AI can certainly catalogue each of these physical exam signs and what they indicate, my examination can transpire on a soccer field, train or exam room and without the need for a computer.

Ascending from the fingertips, I look at the profile of the fingers. Do they keep their standard characteristic orientation, straight as an arrow or do they angle? Simply the direction of that angle can tell me so much, as the rearrangement of the interphalangeal joints offers countless clues. Should the patient get angry at all the meddling with his finger and point that finger at me, does his finger hyperextend backwards from the middle joint while the fingertip itself bends forward? Quickly I am carried pondside to see the swan neck of rheumatoid arthritis, lupus or scleroderma. However, should that fingertip hyperextend while the middle joint flexes, this represents the boutonniere deformity of injury or other connective tissue disorders. Moving from the quaint pondside to the opera house, I consider the shortened collapsing finger joints crumpling in a telescoping manner like an erstwhile opera-glass. This is the finger joint destruction of arthritis mutilans or advanced psoriatic arthritis. Now envision that same finger, fat and round like a sausage, and you have the less than delectable exemplar of dactylitis, which may be another sequelae of psoriatic arthritis, lupus or even tuberculosis.

Lest we forget the palm, it can serve as a mirror into superficial and deeper matters both physically and professionally. If there are a collection of cords slowly stealing a digit’s extension, you’ll find the fascial condensations of Dupuytren’s contracture. This patient has either had a long career of intense work with their hands or has been long afflicted with diabetes or may just have one more thing to thank a parent for. Should one of the fingers flex and become locked, trigger finger is now the diagnosis, although no marksmanship is required.

Both AI and I could go on for pages with the exam findings of the hand if necessary, particularly if we wanted to discuss congenital hand deformities or telltale characteristic findings on x-rays such as the appropriately named boxer’s fracture or the hand surgeon’s bane of the scaphoid given its peculiar blood supply. Oh, the many amusing mnemonics to remember the bones of the wrist can be quickly recited, both from AI and by the medical student! Ultimately, the power of observation is vital and a trusted companion of the doctor alone. The world is the clinician’s exam room and once one puts on these glasses and truly observes, it is hard to unsee the pathology vexing us humans. So, I say go forth and learn. Always start with a handshake as this key unlocks so much during the visit and then sit and watch. We physicians are a fortunate few beholden in full to our patients, who are granted access to this vast vocational milieu and this is what sets us apart from machines.

Web image by Medhum.org

Two hidden stories by two famed authors written decades apart in two countries eventually became widely known. One, Anton Chekhov’s, At the Pharmacy, was translated into English in 1998, about one-hundred years after it was published in Russia. The other, Raymond Chandler’s, It’s Alright–He Only Died, was unearthed from its unpublished state by Strand Magazine in 2018, about sixty years after it was written. Though written in different times, and using different scenarios, both stories warn of the barrier money creates to urgent and necessary health care, and of the corrosion in professionalism it causes in providers. They tell of what was to become a defeating feature of Western health care because of financial incentives, social prejudices, and human folly.

Six Kopecks or Your Life

Peter Constantine reached back from the 1990s into the 1880s to assemble a translated anthology of some Chekhov short stories not available to English-speaking audiences. Among the chosen stories in The Undiscovered Chekhov: Thirty-Eight New Stories, is At the Pharmacy.

The story begins when Egor Alexeyitch Svoykin becomes sick. His physician prescribes medicine that a pharmacy would need to prepare. Svoykin felt some relief being in a large Russian city during the late nineteenth century that would have pharmacies he could count on. This feeling of relief dissipated just after entering the pharmacy and coming before the imperious pharmacist there. 

The pharmacist eventually raises his head from a newspaper, looks at the prescription, shouts instructions to his assistants, and then returns his gaze to the newspaper while at the same time informing Svoykin the prescription will be ready in an hour. Svoykin is the only person waiting at such a late hour as it was, and he was deteriorating.

His mouth was on fire; there was a drawn-out pain in his arms and legs; foggy images tumbled about like clouds and shrouded human figures in his heavy head. He looked as if through a veil at the pharmacist, the shelves of jars, the gas burners, and the cabinets. The monotonous pounding in the marble mortar, and the slow ticking of the clock seemed to him to be coming not from the outside but from inside his head. (p. 129)

When Svoykin reports to the pharmacist that he is becoming feverish and feeling weaker, “the pharmacist “remained stock-still and, leaning his head farther back, kept on reading his newspaper. He didn’t respond to Svoykin with word or movement—it was if he hadn’t heard him.” (p. 130) When Svoykin subsequently approaches the pharmacist pleading with him to hurry the prescription, the pharmacist again brushes him off saying, “It’ll be ready soon enough…excuse me, but there’s no leaning on the counter.” (p. 131)

The next half hour was “unbearable” before the prescription came and then made more so by the dubious rituals the pharmacist performed in adorning the prescription container. The pharmacist charged one ruble and six kopecks, but Svoykin was short the six kopecks. 

Under the circumstances…I would be grateful if you would let me bring you, or maybe send you, the six kopecks tomorrow…

I’m sorry, we don’t accept credit here.

What am I supposed to do?

Go home, get the six kopecks, and then you can have your medicine.

But…I’m having difficulty walking, and I don’t have anyone I can send…

That’s your problem.

pp. 132-133

Svoykin returned home, though with difficulty. The Kopecks were there on the table, but his illness kept him from returning to the pharmacy.

Just Drunk

Strand Magazine is a source for “unpublished works by literary masters.” The October-February (2017-2018) issue includes an unpublished Raymond Chandler short story. Chandler wrote crime fiction for the most part, and the stories usually involved the fictional detective, Phillip Marlowe. This story, however, written between 1956 and 1958, is about a person brought to a hospital emergency room and denied service for financial and social reasons.

As the story opens, a man who has been hit by a truck is brought into the emergency department at General Hospital. He arrives just before shift change and so the admitting clerk is already annoyed about having to assess him. The clerk checks the patient’s pockets for the required $50 deposit and finds nothing, so she could now send the patient to the county hospital, and that would be that. But, before she initiates the transfer, she asks a passing private attending physician to look at the patient. He sees that the patient is dirty, smells of alcohol, and would cost a lot to work up. Mindful of an admonition from a major donor that the “hospital is not run for charity,” the physician surmises the patient is “just drunk,” and agrees the patient should be moved to the county hospital. Off the patient goes.   

The next day, the same admitting clerk at General Hospital gets a call from the county hospital. She’s informed that the patient they transferred had a head injury requiring surgery, and that the patient had $4,000 in a money belt inside his undershirt. The patient couldn’t be saved, however, because of the delay involved in the transfer to the county hospital. “It’s all right—he only died.”

Fast Forward

If they could have foreseen the current time when they wrote these stories, 140 years ago for Chekhov and 70 years ago for Chandler, they would have realized that the scenarios they created became commonplace and institutionalized in many ways.

Pharmacists may not go unseen behind a newspaper as Chekhov’s pharmacist did, but they may be buried under insurance company paperwork or piles of prescriptions needing to be filled. And certainly in a few situations, perhaps only independents, do pharmacists have ways to cover costs when patients are short on cash, credit, or insurance coverage. They are very likely to send patients away to get money even when they are very sick.

Hospital personnel do not now actually reach into the pockets of unconscious patients to see if there’s enough cash for admission as Chandler conjures in his story, but he would see them still check for money in the form of insurance cards or proof of sufficient financial means. He would also see that the scenario he described in which patients without money get transferred to county hospitals had progressed to a degree that people are moved around among different health care providers based on health care insurance plan coverage or lack thereof. But the poor treatment of patients in need of emergency care can even occur in the “right” hospitals when they are held for hours to days in hallways or holding wards for beds to become available.

Scenarios such as these can and have been addressed to varying degrees through government welfare programs, regulatory requirements, technology advances, and professional practice standards among other responses. The two stories, though, also expose human folly not so amenable to these actions. What can be done about the pharmacist who won’t put the newspaper down to address the needs of a person seeking help for an acute illness? What can be done about the physician who after a cursory evaluation brushes off an unconscious patient as “just drunk?”

Chandler makes an attempt at addressing the human folly he and Chekhov reveal by describing how it fails humanity on both professional and personal levels, and in shaming the character, who is ostensibly standing in for those behaving as this doctor in the story did.

All he had done was disgrace himself as a person, as a healer, as a saviour of life, as a man required by his profession never to turn aside from anyone his long–acquired skill might help or save…Why should a doctor in such circumstances be better than other men? The answer is simply, that if he isn’t, he is not a doctor. The $4,000 would have made quite a difference in this case, wouldn’t it?  Should it?  

Chekhov and Chandler are perhaps hoping that those in the care of others will exhibit more humane and professional behaviors when they ask themselves many decades later: “Am I a doctor?”“Am I a pharmacist?” “Am I a human being?” Would it make a difference? Should it?

Notes

Title image:
A young girl waiting for a pharmacist to make up a prescription.
Photogravure, 1912, after J. Jendrassik, 1896
Licensed under the Creative Commons Attribution 4.0 International

End image:
Nurse Aide Rocky FordHospital CO
Mennonite Church USA Archives, No restrictions, via Wikimedia Commons

Daudet tried all sorts of therapy, including mashed bulls’ testicles and elixir of guinea pig. Nothing worked, with the exception of large quantities of morphine and chloral hydrate, which made his life bearable. Daudet also coped with his intractable pain by writing about it. He planned to write a complete memoir of his life with pain, but by the time of his death in 1897, he hadn’t gotten farther than 60-odd pages of notes and reflections. About twenty-five years ago, the English author Julian Barnes translated and collected these fragments into a small jewel of a book called In the Land of Pain.¹

The title is illustrative. Those who suffer from chronic pain live in a different country from the healthy, and they gradually find themselves speaking a language that others don’t understand. At first, Daudet introduces details of his discomfort into conversation but soon realizes how repetitive and boring this is to his friends. “Pain is always new to the sufferer,” he writes, “but loses its originality for those around him. Everyone will get used to it, except me.” (p. 19) Daudet finds himself living in a land where suffering is pervasive, “Pain finds its way everywhere, into my vision, my feelings, my sense of judgment; it’s an infiltration.” (p.23) Toward the end he writes, “I’ve passed the stage where illness brings any advantage or helps you understand things; also, the stage where it sours your life, puts a harshness in your voice, makes every cogwheel shriek.” (p. 65)

Although Daudet was not known as a poet, many of these presumably random notes are, in fact, miniature poems. Consider this example: “In the dining room: the man who quite suddenly finds himself unable to read the menu. His wife bursts into tears and leaves the table…” (p. 63) And here is another: “The hotel. The bell-board. The bath times. / Solitude. / Encroaching darkness.” (p. 65)

One of the more depressing aspects of medicine today is the fact that many doctors are still “very poor at discerning things,” at least when it comes to pain. I get a knot in the pit of my stomach whenever I hear a resident discussing whether a patient’s pain is “real” or “imaginary,” or making a cynical comment about drug seeking behavior, especially when the resident herself has prescribed a grossly inadequate course of analgesia. Some of my colleagues believe that a person has to be visibly anguished before they take seriously his reported experience of severe pain. And others get exasperated with patients who describe having more pain than their condition (according to the doctor) warrants, and tell them, “You’re overreacting,” or “It’s all in your head.” When I hear this, I want to shake the physician by their shoulders and yell, “Of course it is! All pain, no matter what causes it, exists in the head. Where else could the experience be generated?”

In the Land of Pain illustrates that chronic pain sufferers can live calm, productive lives despite constant agony. Daudet continued writing, publishing, and socializing until the end of his life, even though he wrote, near the beginning of his journal, “My friends, the ship is sinking, I’m going down, holed below the water line.” (p.7) At the same time, the author’s strength, compassion, and humor illuminate his little book. He emerges as a generous person, who was well loved by his contemporaries. If you were his physician, what would your assessment be?

Would you accuse him of exaggerating his pain because he doesn’t appear desperate?

Daudet refers to his pain as an “unwanted guest,” to whom he intends to give “no special attention.” (p. 79) At another point he reflects on “the ingenious efforts a disease makes in order to survive.” (p. 26) The writer never questions his enemy’s ultimate victory, but neither does he turn in upon himself. He remains a source of joy to others, especially his family, as indicated in this note: “I only know one thing, and that is to shout to my children, ‘Long live life!’ But it’s hard to do so while I am ripped apart by pain.” (p.49)

Chronic pain remains challenging for doctors to treat. One set of barriers are the moral and legal concerns about overuse of opioid analgesics. Questions about the threat of addiction, or the possibility of being manipulated, favor resisting the patient’s suffering, rather than responding with compassion. Many are uncertain about how to proceed because they lack knowledge of treatment protocols that include nonpharmacologic modalities, or referral to pain control clinics for invasive procedures. Alphonse Daudet’s little book invites us to imagine ourselves living, at least for a little while, in the land of pain.

1. Daudet A. In the Land of Pain. Edited and translated by Julian Barnes. New York, Alfred K. Knopf, 2002. (page numbers indicated in the text).

Photo of Alphonse Daudet from Wikicommons.

A Most Unexpected Path Laid by a Most Unexpected Disease

Dr. Ross Slotten chose family medicine to serve patients from cradle to grave. But, as he was entering practice, the AIDS virus was entering the community where his practice was situated, and he found himself serving patients much closer to the grave than the cradle. 

In June 1981, a few weeks before I began my internship in family practice [at Saint Joseph Hospital in Chicago], the Center for Disease Control in Atlanta had published the first report of a strange lethal infection among a cohort of gay men in Los Angeles. I had no clue then that the disease would soon kill friends, former lovers, colleagues, and patients; devastate tens of millions of people and their families worldwide; and consume my entire professional life and more than half my chronological one. (p.14)

From both the circumstance of time and place he found himself in, and the sense of necessity and compassion that claimed him, Slotten’s professional trajectory unexpectedly shifted away from traditional family medicine towards specializing in AIDS. His interest in AIDS, however, extended to personal considerations, because as a gay man, he was part of the population at risk, and harbored the same anxieties and fears he saw in his patients and throughout his social circles. His patients were principally gay men because of his geographic location in an established gay community and the resulting referral patterns. The book chronicles both his experiences as a physician taking care of gay men with AIDS, and his experiences as a gay man at risk for AIDS. For Slotten, these experiences were not independent of one another, which makes for rich insights on the complexities of both. 

Slotten spent a lot of time at Saint Joseph Hospital because his patients required intense medical support and specialized services. He tells how he and his practice partner pushed for establishing a specialized AIDS unit in the hospital. They bumped up against usual bureaucratic obstacles, plus a few more concerning issues specific to AIDS patients, but they ultimately prevailed. Slotten “was to spend the next fifteen years there, often heartbroken, occasionally inspired.” (p. 109) In contrast to his commitment, he recounts how some specialists he called for help with particular patients refused when told they had AIDS. Those occurrences stuck with him: “I couldn’t forgive those other physicians for abandoning me and my patients in the hours of our greatest need.” (p. 108)

With whatever little time he had left for volunteer and advocacy work, Slotten stayed local. He talks about the volunteer-run health clinics where he worked (e.g., the famed Howard Brown Clinic), and the housing facility he helped set up for homeless people with AIDS. He left protesting at the Food and Drug Administration, the National Institutes of Health, and the annual International AIDS Conference to others while he focused on his patients, his studies, his volunteer work, and his own safety.

The 2020s are approaching when Slotten writes about the preceding three-and-a-half decades. As he finishes the book he is still caring for people with HIV, but the horrible complications of AIDS are now infrequent since the availability of effective medications. His practice had been reliably stable and predictable for some time, a circumstance he could only dream of when he first started. That dream ended abruptly just as the book was released on July 15, 2020: Covid was surging.

Moments of Horror, Relief, Calm, and Then…

Slotten’s perspectives correspond with the trajectory of AIDS over the thirty-five years his memoir spans. Particular periods are discernable, beginning when gay men were presenting with illnesses associated with profound immunodeficiency of unknown cause. Another is the time of peak AIDS death and destruction represented by the moment in 1992 when Slotten hears from the Chicago Board of Health, “that no one had signed more death certificates in Chicago than I had.” (p. 122) The next moment arrives at the turning point when highly active antiretroviral treatment (HAART) became available, transforming HIV/AIDS for him “from a universally fatal disease…into a chronic one like diabetes…it was almost beyond belief.” (p. 186) Then the prolonged period of relative calm when AIDS became controllable—even preventable—with Slotten noting during a moment in 2016 that, “It had been almost a decade since I’d cared for someone with advanced HIV infection, and I hadn’t lost a patient to AIDS since 2004.” (p. 202)

The AIDS epidemic is known for and measured by the number of deaths that occurred. Slotten wants us to remember the misery the disease causes.

For those who didn’t experience that terrible time, or who’ve forgotten how terrible it was, let my chapters serve as a warning to the complacent and the ignorant: untreated HIV is as ruthless as any terrorist and as destructive as a nuclear device. (p. 3)

He drives this point home when he recounts the stories of individual patients tortured by Pneumocystis carinii pneumonia, Kaposi’s sarcoma, cytomegalovirus retinitis, herpes simplex infections, cryptosporidium dysentery, AIDS wasting syndrome, AIDS dementia complex, and progressive multifocal leukoencephalopathy among other medical horrors, and who often suffer many at the same time. And, all the while, he had little to offer but his wits and his compassion. 

Both attributes would be called upon again in 2020 as Covid struck. Though those with Covid did not produce nearly the fatality rate of AIDS, not nearly the severe comorbidities of AIDS, not nearly the stigma and prejudice as AIDS, and not any of the governmental insouciance seen with AIDS, it still caused a lot of death, suffering, grief, and misinformation at a time when only supportive care was available. Like AIDS, though, the Covid pandemic was transformed into a manageable syndrome with the availability of an effective vaccine, new antiviral agents, and better clinical management regimens.

Complacency remains a threat to the reemergence of any infectious disease. Indeed, AIDS is reportedly rising in poor and developing countries in 2026 as funding for AIDS treatment and prevention programs has been withdrawn from donor countries, mostly that from the United States. Lessons from Slotten’s book may thus be called upon again.

Notes

Book citation:
Slotten, Ross A. Plague Years: A Doctor’s Journey through the AIDS Crisis. University of Chicago Press, 2020. 224 pages

Plague Years is a good companion to the documentary film, 5B, which reports on how San Francisco General Hospital coped during the early years of the AIDS epidemic, and Rebecca Makkai’s novel, The Great Believers which features the stories of a group of gay men in Chicago also during the early years of the AIDS epidemic.

Dr. Slotten was a guest on an episode of The Clinic & The Person podcast to discuss his experiences during AIDS epidemic as he reported them in his book, and how well they match up with what we see in 5B and read in The Great Believers.

Web image by Medhum.org

Although Stevenson’s fieldwork was unusually thorough, mainstream scientists rejected reincarnation as a viable explanation and instead focused on potential methodological weaknesses such as retrospective testimony, cultural influence, and the difficulty of ruling out information leakage. Stevenson described the cases as “suggestive,” but he made clear that reincarnation—or at least the survival and transfer of some aspect of personality—was, in his view, the most plausible interpretation.

The twenty cases in the 1966 volume represented only a fraction of the material Stevenson had been collecting since 1960. His early publications had attracted the attention of Chester Carlson, the inventor of the Xerox process, who left a bequest of one million dollars to the University of Virginia upon his death in 1968. The Department of Psychiatry used the gift to establish the Division of Perceptual Studies (DOPS), with Stevenson as its founding director. The name provided an academically respectable umbrella for research that included, but did not explicitly advertise, the study of children’s past-life memories.

Over the next three and a half decades, Stevenson and his colleagues expanded their investigations across Asia, the Middle East, Africa, Europe, and the Americas. By the time of his death in 2007, Stevenson had published twelve additional books and more than three hundred papers, documenting over 2,000 cases. In 1999, journalist Tom Shroder’s detailed investigation, Old Souls. The Scientific Evidence for Past Lives offered an intimate portrait of Stevenson’s fieldwork and helped bring the research to wider public attention.²

Leadership of the program passed to child psychiatrist Jim Tucker in 2002, when Stevenson retired.³ Tucker became Director of DOPS in 2014 and, in 2021, published Before, an updated synthesis of his own two earlier books. ⁴ Tucker reports that the DOPS database now includes more than 2,500 cases worldwide, including many from North America. Only a minority—roughly 15–25 percent—qualify as “strong cases,” meaning that the child’s statements were independently verified as matching a specific deceased individual.

The strongest cases share several converging features: verified statements about the previous life, verified identification of the deceased individual, physical correspondences such as birthmarks or birth defects, behavioral continuities, and early onset of statements. One of Stevenson’s most striking findings involved physical correspondences. By 1997, he had documented 210 cases in which a child had a birthmark or birth defect corresponding to a wound on the deceased individual, and in 49 of these, he obtained autopsy reports confirming the precise wound locations.⁵ These findings were presented in detail in Where Reincarnation and Biology Intersect and in his massive two-volume monograph Reincarnation and Biology.⁶

Here is an example of one of Ian Stevenson’s earlier strong cases. When Swarnlata Mishra was three years old, she began singing unfamiliar songs and performing dance steps her family had never seen, dances from a region of India more than a hundred miles from the family’s home. Soon she was describing a former life as a woman named Biya Pathak, recalling the layout of Biya’s house, the names of her children, and even a stash of money hidden in a wall. Stevenson documented her statements before any contact with the Pathak family, and when they eventually visited, Swarnlata greeted them with an ease and specificity that startled everyone present. She correctly identified family members, teased one man with a childhood nickname only Biya had used, and pointed out a brother’s limp. The encounter had the uncanny feel of a reunion rather than an interview, and for Stevenson it became one of the clearest examples of a case where detailed memories, personality traits, and verifiable facts converged before any possibility of normal information transfer.

More than half a century later, Jim Tucker encountered a very similar pattern in the case of “Ryan,” a young boy from the American Midwest. At age four, Ryan began speaking urgently about a previous life in Hollywood—describing movie sets, agents, and a bustling life in Los Angeles. His parents, who had no interest in reincarnation, tried to reassure him, but the boy’s distress grew until Tucker became involved. Using Ryan’s spontaneous statements, Tucker and the family identified a long-forgotten bit-part actor and Hollywood extra from the 1930s and 40s. Ryan had given more than fifty details about this man’s life, including the street he lived on, the name of a restaurant he frequented, and the fact that he had danced on Broadway before moving west. Many of these details were later verified in archives and autobiographical sources unavailable to the family. What made the case especially compelling to Tucker was not only the accuracy of the statements but the emotional tone: Ryan spoke of the former life with longing and confusion, as if caught between two identities, until the memories gradually faded around age six.

Here is an example of a case in which the child had birthmarks corresponding to the deceased person’s wounds. In rural Burma, a young boy began speaking at age three about having been a man who was shot from behind while walking along a road. His parents were startled not only by the specificity of his statements but by his two unusual birthmarks: a small, round mark on his chest and a larger, irregular one on his back. When Stevenson later investigated, he found that the boy’s descriptions matched the death of a man from a nearby village who had been killed by a close-range gunshot. Eyewitness accounts and medical documentation confirmed the wound pattern, which corresponded closely to the boy’s birthmarks. The child also showed a deep, visceral fear of guns and loud noises, reacting with panic in ways that seemed disproportionate to anything in his current environment. The case combined early and detailed verbal statements, independently verifiable information about a violent death, and physical marks on the child’s body that mirrored the trauma he described.

Stevenson’s long-term research program—and Tucker’s continuation of it—poses a direct challenge to the assumption that consciousness is wholly generated by the brain. Across more than 2,500 investigated cases, they documented young children who spontaneously described memories, behaviors, and emotional dispositions corresponding to identifiable deceased individuals. While most cases are incomplete or ambiguous, a substantial minority meet stringent evidential criteria, and more than two hundred combine multiple independent lines of evidence: verified statements, behavioral continuities, and physical correspondences. Critics have proposed cultural contamination, suggestion, fraud, or loose investigative methods, but none of these explanations plausibly account for the best-documented cases, especially those with medical records, multiple independent witnesses, and physical anomalies. Even the most skeptical reviewers have struggled to articulate a coherent alternative hypothesis that explains the full pattern of data.⁷

For more than sixty years, however, mainstream scientists have dismissed the research. Critics argue that the stories of past lives are most likely due to coincidence, misinterpretation, parental influence, observer bias, or other sources of error. They emphasize the complexities of contextualizing and translating these “memories,” especially in cultures with strong beliefs in reincarnation.⁷ Yet critics rarely engage with the case narratives themselves; instead, they rely on hypothetical sources of error. To attribute all of these cases solely to flawed methodology would require assuming that Stevenson, Tucker, and DOPS have repeatedly committed the same errors for six decades despite their detailed rebuttals of such claims.

The deeper criticism, however, is philosophical. Although surveys show that most Americans and physicians believe in a soul or spirit, most philosophers and neuroscientists endorse a materialist-reductionist view: the brain creates the mind through electrochemical activity, and consciousness ends with the death of the body. Clinically, there is ample evidence that consciousness depends on a functioning brain—brain injuries and diseases clearly alter mental states, and imaging techniques reveal neural pathways associated with various emotions and thoughts. For clinical purposes, consciousness appears entirely dependent on the physical brain.

Yet this dependence does not settle the metaphysical question of what consciousness is. Critics of Stevenson and Tucker often assume, without argument, that the physical world as described by contemporary physics is the totality of what exists, and that consciousness must therefore be a byproduct of physical interactions. But subjective experience—the interior world of personal identity—does not obviously follow from any known property of quarks, electrons, photons, neutrinos, or the forces that govern them. The gap between third-person description and first-person experience is conceptually radical. No arrangement of particles, however complex, seems to entail subjectivity, i.e. interior life, in the way that arrangements of particles entail objects, organisms, or chemical bonding. To assume that this gap will close through further study of neural circuitry is to smuggle in a metaphysical conclusion under the guise of scientific optimism.

The quantum world is exceptionally weird – in many ways it violates common sense. Particles are also waves and waves are particles. An electron can be in multiple places at once. The behavior of one particle may determine the behavior of another, even though they are too far apart for a message to pass between them. Particles can tunnel through barriers apparently without having enough energy to do so. However, none of this weirdness suggests that large accumulations of particles (e.g. atoms, molecules, brains) could generate an interior world of personal identity There must be a deeper, more complete, theory of what exists in the universe that does account for the generation of consciousness; a quantum of subjectivity, if you will. As science writer Jim Holt summarized in Why Does the World Exist?, “The properties of a complex system like the brain don’t just pop into existence from nowhere; they must derive from the properties of the system’s ultimate constituents. Those ultimate constituents must therefore have subjective features themselves.”⁸

This is why the possibility that consciousness has a fundamental place in the universe is not mystical speculation but a legitimate philosophical alternative. Some philosophers and neuroscientists propose that consciousness may be an intrinsic aspect of matter, or that the universe contains a fundamental “interior” dimension alongside its measurable exterior. Panpsychism—the view that consciousness is woven into the structure of matter—is endorsed by a small, but growing, minority of philosophers, including David Chalmers⁹, Philip Goff¹⁰, and Galen Strawson.¹¹ Another group, notably Thomas Nagel¹² and John Searle¹³, acknowledge that our current physical ontology is incomplete, although not fully endorsing panpsychism. Physics has repeatedly revised its understanding of matter; it is not unreasonable to suspect that consciousness may require a similarly deep revision. To quote Thomas Nagel, “Consciousness is the most conspicuous obstacle to a comprehensive naturalism that relies only on the resources of physical science. The existence of consciousness seems to imply that the physical description of the universe, despite its richness and explanatory power, is only part of the truth.”¹²

Given these considerations, the continuation of consciousness, at least in some form, after death seems at least a possibility. Stevenson and Tucker’s work may well represent the identification of a previously unknown natural phenomenon, perhaps analogous to reported near-death experiences — well-documented yet difficult to explain. To my mind, this conclusion is more likely than is six decades of repeated errors.

However, that doesn’t mean the “former lives” data necessarily support a traditional doctrine of reincarnation, in which a unitary soul passes from one body to another. If a psychic dimension of the cosmos exists, a one-to-one transmission of “mind-stuff” to a newborn baby in the same country and culture seems overly simplistic, more in line with supernatural beliefs than with an unknown natural phenomenon. It is notable that the phenomenon is rare and the memories transient and strongly associated with traumatic death. Could it be that, under certain conditions, a “package” of psychic impressions may transfer from a dying person to a newborn, occasionally even influencing the child’s body? This, like any other scenario, is speculative, given our ignorance of the origin and meaning of consciousness in the physical world.

The broader point is that most philosophers and neuroscientists begin with an unexamined premise: that everything real must be physical in the sense described by current physics. But consciousness—the one phenomenon we know from the inside—does not obviously fit within that framework. Before declaring that mind must be reducible to matter, we should ensure that our conception of matter is adequate to account for mind at all. Consequently, Stevenson’s and Tucker’s six-decade quest to understand the experience of children who report having lived former lives should, if anything, leave us wondering whether we really know what we think we know about the way the universe works.

References 

1. Stevenson, Ian Twenty Cases Suggestive of Reincarnation, University of Virginia Press, 1980 [First published in 1966] 
2. Schroder, Tom. Old Souls. The Scientific Evidence for Past Lives. New York, Simon & Schuster, 1999 
3. Tucker, Jim B. Ian Stevenson and Cases of the Reincarnation Type, Journal of Scientific Exploration. 2008; 22: 36-43 
4. Tucker, Jim. B. Before: Children’s Memories of Previous Lives, St. Martin’s Press, 2021 
5. Stevenson, Ian. Where Reincarnation and Biology Intersect. Westport. Praeger, 1997 
6. Stevenson, Ian. Reincarnation and Biology: A Contribution to the Etiology of Birthmarks and Birth Defects, Westport, Praeger, 1997 [Two volumes] 
7. Matlock, J. G. ‘Reincarnation Case Studies: Criticisms’. Psi Encyclopedia. London: The Society for Psychical Research. <https://psi-encyclopedia.spr.ac.uk/articles/criticisms-reincarnation-case-studies/>. (2022, retrieved 24 March 2026) 
8. Holt, Jim. Why Does the World Exist? London, W. W. Norton & Company, 2012, p. 194 
9. Chalmers, David J. The Conscious Mind: In Search of a Fundamental Theory. Oxford University Press, 1997 
10. Goff, Philip. Galileo’s Error. Foundations for a New Science of Consciousness. New York, Pantheon Books, 2019 
11. Strawson, Galen. Consciousness and Its Place in Nature, Imprint Academic, 2024 
12. Nagel, Thomas. Mind & Cosmos. New York, Oxford University Press, 2012, p. 35 
13. Searle, John. Mind: A Brief Introduction, Oxford University Press, 2005 

Web image by Medhum.org

In the throes of the early AIDS crisis, people began stitching panels to remember their loved ones. The panels were joined in quilts, and the quilts were joined with each other until they became bigger than a tennis court, bigger than a football field. So unwieldy it became, the giant quilt had to be broken into pieces in order to be manipulated. Chunks would tour on display. It now has a virtual existence too and is curated by the National AIDS Memorial.

In 1989, Robert Epstein and Jeffrey Friedman made Common Threads, a 79-minute documentary, narrated by Dustin Hoffman. Based on the AIDS Memorial Quilt, their film traced the stories of five people who had died through the words of their grief-stricken friends and family. The survivors describe the solace that they had derived from quilting memorial panels for their loved ones. They also refer to milestones in the disease history: the president who would not utter the word; the movie star who acknowledged his own disease only after 15,000 had already died. The five divergent tales serve to emphasize the awesome scope of the tragedy: each panel and each name must recall an equally unique and cherished life cut short. In their final scene, the AIDS quilt lies on the Mall in Washington as names of hundreds of loved ones are read by grieving families and friends.

As the drone-less but steady camera slowly pulls back high above the patches of color in the evening light, I was reminded of the famous, expanding scene midway through, Gone with the Wind, as Scarlet O’Hara picks her way through the waste of Civil War wounded and dead. Common Threads is equally political, and it too is a love story. It won the 1989 Academy Award for Best Feature Documentary. I cannot help but imagine that the quilt and the film helped to generate the protections against discrimination of people living with HIV/AIDS provided by the Americans with Disabilities Act, signed into law in 1990.

Stitchery, knitting, embroidery, macramé and crochet have long been significant components of occupational and art therapy for mental and physical health (Leone 2021; Youngson 2019). But they have been marshalled into numerous anti-war, anti-discrimination, pro-environment causes with remarkable aplomb, talent, and humor. Remember the pink Pussyhats from the Women’s March in 2017? Patterns for them still abound on the web. The possibly antediluvian origins of crafting protest are featured in history and fiction: recall Charles Dickens’s knitters at the foot of the guillotine (Tale of Two Cities, 1859); or Margaret Atwood’s Zillah who makes art from dryer fluff, calling it “naive surrealism with a twist of feminist lemon” (Cat’s Eye, 1988); or even Peggy Erhart’s more frivolous parking-meter protest in small-town America (A Dark and Stormy Knit, 2024).

Self-described “craft nerd,” Betsy Greer coined the word “craftivism” in 2003. She wrote Knitting for Good (Roost Books, 2008) and edited an anthology that goes well beyond knitting to other techniques and contexts (Craftivism, Arsenal Pulp Press, 2014). Scholars have noticed (e.g., Moreshead and Salter, 2023; Vachhani et al, 2025). The diffuse movement has even found critics who challenge its “white, feminist appropriation of graffiti,” and seek to empower it to “evolve and become a more intersectional” practice (Close, 2018).

References 
Close, Samantha. Knitting activism, knitting gender, knitting race. International Journal of Communication 12 (2018): 23-23. 
Leone, Lauren. Craft in Art Therapy. Routledge, New York and London, 2021 
Moreshead, Abigail, and Anastasia Salter. Knitting the in-visible: data-driven craftivism as feminist resistance. Journal of Gender Studies 32.8 (2023), 875–886.
Vachhani, Sheena J., Emma Bell, and Alexandra Bristow. The Affective Micropolitics of Craftivism: Organizing social change through the minor gesture. Organization Studies 46.4 (2025): 525-547. 
Youngson, Bel. Craftivism for occupational therapists: finding our political voice. British Journal of Occupational Therapy 82.6 (2019): 383-385. 

Web image by Medhum.org

If there was ever an ironic title for a book about the best ways of achieving a long and healthy life, it’s this one: Eat Your Ice Cream. That’s because a major conceit of the book is that if we are to incorporate all the recommendations for achieving good health into our lives, some balance—tradeoffs—will be necessary. Eating ice cream exemplifies that balance: when consumed in moderate amounts, it offers some nutrients and a lot of happiness.  

The author, Dr. Ezekiel Emanuel, known to all in his many circles by the mononym “Zeke” (think: Sting, Prince, Oprah), points to a couple of motivations for writing the book. One is in the service of his life-long quest to “improve Americans’ health.” (p. 11) He has gone about this in many ways including his service as a medical oncologist, chief of the National Institutes of Health Bioethics department, medical school professor, health policy researcher, author of many books and articles on a range of health care subjects, and as an architect of the Affordable Care Act (aka, “Obamacare”). His other motivation arises from his view that current wellness advice makes it “nearly impossible to differentiate the valid, reliable, and effective from the speculative, deceptive and just plain stupid.” (p. 4). His aim, then, is to “provide a concise, clear, and authoritative synopsis of what health experts know works best to bring the biggest health benefits—without extraneous, speculative, or absurd additions.” (p. 11) 

Getting a Six Pack 

Running through the book is Zeke’s insistence that wellness behaviors and practices will be most effective when they become part of daily life and not something separate or extracurricular, and as such wellness rules “become an invisible part of lifestyle, sustained by habit.” (p. 10) He gives himself the task of cutting through the jungle of wellness advice and providing “a distillation of the evidence to simplify doing the right thing” for a healthy life. (p. 9) 

In keeping with his theme of simplicity, he breaks down wellness advice into “the six wellness behaviors that yield the maximum benefits with the least work.” (p. 9) They are: 1) avoid self-destructive behavior; 2) cultivate family, friends, and other social relations; 3) stay mentally healthy; 4) consume healthy food and drink; 5) exercise well and regularly; and 6) get the rest you need. He hastens to add that these six behavior categories reflect the thinking of ancient times among Greeks, Chinese, and Indians.  

Each of the wellness behavior categories constitutes individual chapters. In each, Zeke covers both obstacles to attaining good health (e.g., heavy alcohol consumption) and practices that facilitate attaining good health (e.g., getting vaccinated). His recommendations are based on evidence from credible sources and are time tested. He presents them in more of a conversational form in plain language and not much in the way of strict protocols or mechanical algorithms.  

While Zeke considers all six wellness behavior categories crucial to a healthy and long life, he does not rank them in importance or priority. He does, however, form two groups from them and makes a distinction between the two, noting that “risk management, friendship and social interactions, and mental engagement have a measurably greater impact on your wellness than diet, exercise, and sleep.” (p. 8) This may come as a surprise to hardcore health advocates who put a major emphasis on, if not obsess about, exercise, diet, and sleep. Zeke goes further to say about the zealots: 

They ignore the importance of family, friends, and social relations—the emotional wellness behaviors—which have a remarkable impact on the quality and length of one’s life. And it’s a dangerous fallacy that a deficit of emotional wellness behaviors can be remedied with a surplus of physical wellness behaviors. No amount of kale or number of steps or hours of sleep can replace the importance of building and maintaining good relationships for wellness and longevity.  
(p. 54) 

He comes back repeatedly to the greater importance of social over physical components for good health. He seems a bit obsessed with it, though convincingly so.  

Neither Extremist nor Scold 

Distinguishing this book from others in the field is how Zeke does not scold people to abandon all behaviors that can work against achieving a healthy life, nor does he advocate people push themselves to extreme levels of compliance and sacrifice. Neither is sustainable and both can result in futility and abandonment. He urges us to find the mix of behaviors and levels of commitment that can be woven “into the fabric of your everyday life so they become automatic and easy, not a chore, burden, or all-consuming fixation. (p. 187) 

Zeke offers ways to moderate specific recommendations or to make trade-offs. One example is alcohol consumption. He realizes that although alcohol should be avoided, that’s not likely. When it can’t, he advises that people at least not drink alone because some of the risks of a daily drink “is probably outweighed by the benefits of time with friends.” (p. 34) As another example, Zeke advises that exercise is essential, but when excessive, diminishing returns can result. “Exercising 2 or 3 hours a day will not improve your longevity more than 45 minutes a day.” (p. 164) Furthermore, in this regard, he says, “There’s something to be said for living fully and being present, not constantly monitoring our activity tracker or feeling guilty for not achieving every wellness goal.” (p. 10) Don’t obsess, and toss the wearables.  

So, go ahead, eat your ice cream, but not too much, and do it with family and friends. Then walk home safely and get a good night’s sleep.  

Photo attributions: 

Hubert Opperman eating an ice cream next to a Peter’s Ice Cream Reo truck, 1936 
Sam Hood  
State Library of New South Wales collection, No restrictions, via Wikimedia Commons 

Melba Phillips Eating Ice Cream 
Emilio Segrè Visual Archives  
CC BY-SA 4.0, via Wikimedia Commons 

It seems simple. Ask a few questions, record the answers, job done, move on. But as all doctors know, getting a good history is a defining skill, something that blends medical acumen and astute intuition. When history taking is done properly, it distinguishes adequate physicians from those who are truly exemplary in their ability to diagnose and treat disease. What makes getting an accurate history so challenging? 

This slim but beautiful book by Jane Ziegelman may help answer this question. At first glance, it seems like an unlikely point of departure for a discussion of medical humanities. This elegiac work of history describes the yizkor (memory) books, which were written by survivors of the Holocaust. Their goal was to compile a lasting remembrance of the shtetls (towns/villages) of Eastern Europe, a record of the places where they lived and people among whom they lived for decades before the start of World War II, and that had been totally annihilated by the murderous onslaught of the Nazis. Most of the communities were small, populated by poor artisans and farm laborers who struggled day-to-day to feed and clothe their families. Food was never plentiful and the weekday diet was dominated by potatoes in any shape and animal fat in any form. Rain and snow routinely turned the streets into an unpassable sea of mud. The village square was cluttered with animals, big and little. Only young boys received a regular education and even that was often given by underpaid and underappreciated old men who were just as likely to beat their students as to serve as role models of the good life. Jewish rituals and the holiday calendar served as a sturdy anchor for shtetl life and provided spiritual relief to the townspeople from the quotidian drudgery. In a word, life was hard – a continuous battle to survive the hostile forces of nature and the random antisemitic attacks of their neighbors. 

Yet, the inhabitants of the shtetls that dotted the Eastern European landscape never despaired of life. It is true that escape to America, the goldineh medina (country of gold), the promised land, was a dream for many. At the start of the 20^th century, thousands of shtetl Jews abandoned their hometowns and left their families behind to cross the Atlantic Ocean in hopes of achieving a more prosperous life. But most stayed put and were reconciled to their lives. The steadfastness of shtetl life has been recorded in Jewish history and literature. In the face of hardship on so many levels, these men and women maintained their families, jobs, and, most importantly, their human agency. 

History is the record of many kinds of stories – of people, places, political movements, ideas, war and peace, companies, the natural world, and the creative arts. The trajectories and the lessons to be drawn from historical narratives are as varied as the subjects. The endings can be upbeat and inspiring, or they may culminate in demise and depression.  

Ziegelman’s compilation of shtetl memory books are historical documents of loss. For the writers of these books, the Holocaust had utterly destroyed their world. Everything they knew and held dear was wiped out in a frenzy of hatred and violence. The yizkor books were an effort to bring those vanished worlds back to literary life, to recreate them in full. But pain for the victims who died, regret over decisions made, and nostalgia for a better time inevitably color these tragic tales of loss. Can the testimony of the surviving witnesses be trusted? Are the linguistic pictures they draw true to what life was really like in Luboml, Radin, Lodz, or Kobrin? Was the community ever as unified as described by the yizkor book authors? Were the squabbles quite so divisive? Did everyone really look so angelic as Sabbath arrived at twilight on Friday? Did people really sink up to their knees in the mid-December mud? We are inclined to believe the authors because we empathize with their suffering and loss. But if we are to learn from the past and prevent the destruction of future worlds, we need to be sure we have things right as we look in the rear-view mirror. 

It is reading about this literature of loss that brings us back to the doctor or nurse who is encountering her patient for the first time. These patients – men, women, adolescents, and children — have to recount their stories and explain what it is that brought them to the office or clinic. They are also telling stories of loss – loss of vitality and energy, the ability to think clearly, to climb a flight of stairs without needing to stop to catch their breath, to love passionately, to party with friends and family. For patients, their histories are tales of the world that they have lived in and grown accustomed to but which suddenly seems on the verge of breakup. As we listen, we have to decide. Are they accurate? Are they exaggerating their problems to gain our attention or downplaying them to avoid our interventions? Is their memory dependable about timing, severity, and responses to treatment? How confident are we that we have elicited an accurate story? 

The notion of illness as narrative is widely appreciated in the world of medicine. We are attuned to view our patients as participants in a larger more comprehensive social context in which their illness is but one feature in a multitextured milieu. The initial patient history is our first entry into that world. We should be fully aware that the stories that patients tell us at that initial visit are, like the yizkor books, tales of loss. Hopefully, the medical story will unfold over time. There is no telling at the start how the saga will play out and end. But it always starts as a tale of loss. Just as we aim to combine heartfelt sympathy and clear minded appreciation of the facts as we read the Holocaust survivors’ yizkor stories, we should make sure that, while we are emotionally engaged with their pain and suffering, we are attentive to the facts and nuances as patients first describe their loss of health that prompted them to seek our help in the first place. Getting their history right at the start is the first step to getting patients better.  

Once there was a town: The memory books of a lost Jewish world 
Jane Ziegelman 
St. Martin’s Press, New York, 2026, pp.227 

Web image by Medhum.org

“Once There Was a Town: The Memory Books of a Lost Jewish World” Book Launch