Tuberculosis Week

by Joel Bradley, SOM ’12

First Prize 2010 Gerald F. Berlin Creative Writing Award

Introduction

Because tonight does not include enough time for the whole story you will soon hear a piece of, some background is deserved. It is a weird story, and I struggled with that in the writing – for though fiction is an open invitation to strangeness, I wanted the tale to walk that delicate line between incredulity and the believable. I wanted it to be an improbable – but suspiciously possible – extreme of real life.

It turns out that I lacked the agility as a writer to pull it off as believably as I had hoped, and in that sense it isn’t quite finished, despite the large junkyard of drafts. Exams were approaching I didn’t have much of a choice. So it is the impression of incompleteness that justifies telling the brief story of this story (though ironically enough that means you’ll hear even less of it).

Save a tussle with meningitis at three months old, I have never been extremely ill, and perhaps for that reason, it is possible for me to enjoy being a patient. Especially as a medical student, it is fascinating to observe how people take care of me: where they succeed and fail in addressing my concerns, answering my questions, and explaining the science of the body. To see how they surprise me. I trust this isn’t so strange. We all like – and will at turns need – to be taken care of, even if not by someone in a cheap white cotton coat or the pajamas we call scrubs. It is an unavoidably central theme of our lives.

Now, turn that around. Next year it will be me under scrutiny. How can you ask me to take care of a woman in labor when I don’t know – and will never know – what that is like? How can I understand the fear and doubt that comes of awaiting surgery, a struggle with severe mental illness, or feeling the effects of 90 years of life from a hospital bed? You don’t really know until you’ve lived it, right?

I haven’t lived any of it. In the second year of medical school, every day we talk at a distance from the terrible illnesses that reflect that chance, inscrutable indifference of nature we don’t like to talk about too much: rare diseases, horrific infections, strange and unexplained afflictions. If early medical education was intended to inspire a real appreciation for those perspectives, it has not succeeded. I have only the tattered luggage of a young life. I can’t do much more than imagine those illnesses, and I feel completely unequipped to do anything other than listen to the recounting of those experiences, offering reassurance and teaching as much as my knowledge allows. I am not quite convinced that is going to be enough.

But what if a medical school taught us to be doctors by making us sick – by using illness as education – to give intimate human context to the diseases we study, as a way of scaffolding all the knowledge, and refining our ability to care compassionately for our patients? To help us relate. Maybe “relation” isn’t necessary – but I wonder if really knowing illness might bring us closer to the poise and wisdom we will need to care for people who are ill. Yet, you can’t live everything.

This story – “Tuberculosis Week” – attempts to conjure that medical school, its founder, and its students in the moment before they prepare to spend a week with tuberculosis, getting sick and healing from it. It does not provide any especially good answers, but attempts to ask after what might be gained and lost by bringing students of medicine that much closer – frighteningly close – to the vast, unruly and yet-unanswerable work of medicine…which I have come to believe is an impossible profession, but in a good way. I will read briefly from the beginning of the story.

Tuberculosis Week

ONE

He steadied his blue-gloved hands, flicking a bubble to the top of the well. As the point entered, her skin inflected under the pressure, the periphery welling up in an even rim of flesh. It reminded him of the way water climbs the walls of a glass, reaching for its unspoken compromise between electricity and gravity. But he knew how few laws were in place to govern this first inoculation, and that it was everything but ordinary. Fluidly he pulled back to confirm the flash, snapped off the blue tourniquet, and pushed in enough saline to clear the delicate tube that now entered her pale arm. He looked up to meet her glance for a moment before sealing the IV with a strip of white tape, twisting off the well, and replacing it with one containing an opaque grey fluid. The last twist, slow plunge, untwist were crescendo to a closing act: a choreographed rehearsal of fingers that made a single uninterrupted motion. It ended with him looking straight into her eyes.

David Collins had injected her with tuberculosis.

She looked up into the camera flashes and then back to him, willing a tense smile, as if surprised how long she had been holding her breath. “I’m not in love with sharp things,” she said, trying to fill the silence with a tinny mixture of humor and apology. Collins laughed, full and generous and grateful all at once, as though she had flipped the lid on a screaming kettle at boil, bringing relief to both of them. “Anne, I’m with you on that – after a lifetime of this crazy work, I am still looking for someone who is,” he said, chuckling, dropping the used kit into a red container, his mouth-corners upturned, the wrinkles showing to the sides of his mask.

His mind was in a state of combustion. One hundred years ago this might have been a death sentence, and even in his own work, he had seen people stricken violently with this disease, their lungs ablaze, their bodies horrifically overcome. He struggled to hold down those images as he looked at her, trying desperately to unsee them, frustrated at the impossibility. He felt almost nauseated at the paradoxes of his career’s singular premise, the tenet that had built this school and lifted it to greatness – that this was the way to create an empathetic, insightful doctor of medicine – through illness. That to make a doctor a patient would make a doctor’s patients better. That this was the only way to return compassion to a medical system rotten with dispassionate technological distance.

Collins shuffled with the equipment on the burnished metal cart beside him, pushing the reporters and rows of expectant students out of his consciousness. When he had the respirator ready, he gestured with an awkward ‘thumbs up’ to several other doctors in gowns and masks who had been waiting against a far wall – a signal to begin administering the treatment to the rest of the students.

Slowly – as if in ceremony – he handed Anne the mask that would now fill her lungs with the disease that was already spreading through her body. The faculty knew this was not the typical way of acquiring the disease, but its slow natural course did not suit the academic calendar, which was forever pressed for time, and could not wait. This was the fastest way to an experience they needed to have: disease to cure in one week.

Anne had offered to be the first student to be infected with the scourge that had begun its devastation with pharaohs and made its way through centuries of unforgettable minds before ending here with an accidental new molecule in a forgettable decade. A new antibiotic had made tuberculosis curable if caught early its course, and that discovery, tethered to the ongoing controversy of Darrvah School of Medicine’s incendiary educational ideas, made this story irresistible.

Collins hated that part – just enough scandal mixed in with humanitarian appeal to attract the mindless vultures. Every major paper and news station wanted coverage, and the press cameras were splashing lightning in frenzied intervals on the bustling scene, hungry for their newest banquet of history. He knew how few people understood the method or appreciated the message of this institution. He was naked here, reminded of the public’s scrutiny in the recent wake of Andrew’s death, flowing together with his own regrets, the blame, and a guilt he could not turn away. The memory came with a flash of anger – he had resisted the inclusion of the press ferociously throughout his meetings with the administration. But in the end, the nectar of prestige had overcome his appeals to prevent a curriculum he believed in from becoming a spectacle: they had been invited here to celebrate the defiance of a modern science trumpeting its victory, at a school trying to cement its legitimacy. It had not helped that one of Darrvah’s scientists had patented the drug. Collins felt it had become a public execution: a grotesque call to the hanging of a disease that had taken part in shaping the world.

Taking the mask from his hand, Anne held it to her mouth and inhaled deeply: her eyes looked so intensely in return that David Collins felt them penetrate like accusation. But he recognized in them something even more threatening, if he proved wrong: faith in the principle that had made this risk worth taking. He wondered which of the two the public would recognize in those first photographs, if they looked carefully enough.

“Anne.”

“Yes?”

“Be well. Good luck. Study carefully. We’ll be here when you need us.” Collins pressed his hand to her shoulder, met her eyes with his, smiled a moment longer than was required by formality, and moved on.

TWO

It was “TB week,” and we sat on folding chairs in a long rectangular room that bespoke the humdrum elegance of collegiate wealth – broad high windows, slate floors, wood panels, and a row of expectant faces waiting for wisdom from the belly of a syringe. Ordinarily we would give the shots to one another, but Collins had come out to partake personally in the ceremonial breach of medical history, giving us these inoculations as he had given us our first over a year and a half ago now. I had a habit of mistrust with ceremonial figures, but with Collins there was something beneath the polish that was real – he listened, cared, remembered, and believed with a huge rugged faith in the importance of submitting us to this ordeal.

It was on account of his conviction that I had come here: I had once believed that this was the only way to understand illness.

Anne’s inoculation was an eternity. I was sitting just far enough away that I couldn’t hear them speaking, and during the injection, several leaning heads blocked my view, and stayed that way. I took instead to eyeing the reporters with a steadily fraying sense of calm – they fiddled nervously with their masks, looking like low-grade TV astronauts who had absentmindedly traded helmets for shower caps. One of them – a squat fellow with a thick neck beard – even had the mask upside-down, which ordinarily would have been funny, but it wasn’t under the circumstances. The absence of humor was among the most disconcerting features of this entire gathering. The students seemed lethargic, even tranquilized, and no one even seemed to be fiddling with their phones, checking e-mail, whispering – just necks craning to see through an atmosphere thick with waiting.

Andrew had died four weeks ago. I hadn’t been close to him, but I was there to see chance deliver him into a tragedy that by equal chance – and without explanation – I escaped. Unexpectedly, we had both gotten very sick, and since it seemed arbitrary that only I had come through it, the event was still playing tricks on my dreams. In fact, dreaming was the only disproof of my conviction that I hadn’t slept since.

For months our class had been “trying on” microbiology, as we quipped, wading through the encyclopedia of infectious disease like a twelve-year old trying on every single item in a department store, regardless of size, shape, or practicality. Two feet of snow on the ground and we were in bed trying to get rid of tropical worm infections.

We would learn about a disease in lecture on Friday, knowing that by Monday we’d be enjoying the experience firsthand. It had gotten to the point that an evening fever, aches and chills were no longer an impediment to studying late, and a morning sore throat was only an anticipated bend in the day. We got by fine on little sleep – sometimes even without getting sick. It was remarkable what we could get used to, though at times we joked that walking to manhood by way of a fiery bed of coals seemed the preferable anthropological rite, because you would only have to do it once, and you wouldn’t get sick of it.

But the cynical fun ended when we ended up in the hospital together. That Monday, we had both woken up with delirious fevers that had tumbled wildly into sepsis. The school’s emergency team had responded promptly, and we had both gotten antibiotics quickly…but with him, they must have missed something, because after a few hours of getting better, he took a long, unbearable slide, his organs failing one after the other. It was terrible to lie there in the same room, separated by a curtain brushed constantly with the fleeting impressions of living bodies, overhearing the worry in the doctors’ voices, hearing his mother and father cry as their son’s last hours ticked by on a wall clock I could see from my bed, the slowest in the world.

At one point, an attendant offered to move me out. I refused. By the end everyone in the room was sobbing, and my mom held me so hard she accidentally tore the IV out of my forearm. Andrew’s ten year-old sister was the only one that noticed the large puddle expanding across the tiled floor.

That day, exhausted and numb, I was transferred out, stable. Two days later I was allowed to go back home.

I kept replaying the conversations of the few hours we had been conscious neighbors, our parents there, the administrators stopping in with cards and flowers. That was the first time I had met Collins in person. Our parents had gone to pick up lunch, and naturally, we were in the middle of surmising how Collins might be covering his ass, concocting an elaborate story – with elements of subterfuge and gun-point coercion – when he knocked on the open door. We both flushed: always embarrassing to have that sort of thing overheard. He had laughed, and said: “Actually, gentlemen, you were pretty close.” He asked if he could visit. We said sure.

He wheeled aside the monitors to sit between our beds on a low plastic chair. For over an hour he listened as we spoke about the experience: the fear, the panicky, desperate feeling of not knowing what was next, the oddity of coming in and out of consciousness. He listened intently, letting us talk, filling the pauses with careful questions that seemed to pull us constantly but imperceptibly in a direction he had chosen. We did not resist because we both wanted to go there, to be heard, to hold his audience as long as we could.

Finally he offered us what we hadn’t been willing to ask of him: for justification of our presence here, sick and groggy with drugs, sidelined from our work, our obligations, our families and friends. We wanted him to account for this fracturing of expectations – that we were expected to learn from being sick, while sickness kept us from learning what was expected. Afterward I could not recall exactly what he had said, only how he has said it – and what it was like to listen for the first time to the way brilliance sounds in the thrall of absolute conviction. His voice folded over us in smooth waves, and we lost track of everything, listening as he named our doubts, conjured our anxieties, and left us with a rising, weightless pang of hope.

When Collins had left, after a silence, I said: “Whoa. That guy is intense.” I had meant it, but hated to hear my voice break the reverberant silence he had left. Andrew agreed: he had restored in minutes faith we had shed over months, the fraying clothes of a certainty we had brought here in our suitcases, the feeling of absolute assurance that we had chosen correctly, taking a vital and singular path.

Six hours later, Andrew died.

THREE

Collins was just starting to turn toward me when my hand reached his shoulder, asking for audience, derailing his ministrations with the IV kit. He looked up at me and stopped, waiting. I could hear my heart muscling away inside my stomach.

“Dr. Collins, no. Please; I’m tired of being sick.”

I had the impression of hearing myself speak too long after I mouthed the words, as though they had been dubbed. I thought I saw Collins brace, as if conscious of containing the physical blow of my denial – but his masked face and brown eyes conveyed nothing but searing attention. The cameras, which had tired of the whole enterprise soon after Anne’s debut, abandoned their coffee cups and began flashing again in earnest. It was obvious that they had been hoping for something like this.

“This scene really scares me. Illness is our recreation, and this week it’s TB; tomorrow it will be the next thing we couldn’t cure yesterday. We expect it. We’ve bought in. It doesn’t even surprise us anymore – not the way lung cancer surprises a forty-something family man who has never smoked. We know it is coming, we study what to look for, how to plan for the complications, where to get help.”

“Andrew’s mother sobbed on my shoulder after her son had died, last month. I didn’t need to almost die beside him to understand that I’d never get at what his mother felt. I knew I could only shut up and stay there, holding on and trying not to break down. It was her husband who had died of lung cancer, Andrew’s dad. So I want to ask you something right now in a setting where you have to answer me: how much suffering will make us ready to be doctors? Once we’ve had every disease, lived through every treatment – after we have forgotten what it is like to be normal? You are asking us to live every form and angle of life before we begin our lives as doctors, so that nothing surprises us, there’s nothing we’re not ready and able to understand, identify, name. I just wonder how much of ourselves we’ll lose on the way to finding out how impossible that really is.”

Collins paused for a long time before answering. “Jamie…you’ll take care of me, then.” It was said as an order and as a question, and it was punctuated by a sleeve pulled up, a sweep of disinfectant, and a needle entering his own skin, the liquid collapsing, the motions automatic. A moment later Collins clapped the mask to his mouth and inhaled. He removed it, and looked at me, waiting.