One of the big catchphrases passed around the medical community now is cultural competence, referring to the need to understand the beliefs and principles guiding patients and their life choices. Cultural competence is usually used in the context of mainstream American physicians serving ethnic and racial minorities. It occurred to me recently that I also belong to a cultural minority that has its own “eccentricities” and difficulties: New Orleans natives. During the past year, the city of New Orleans and its current and former residents have received a lot of media attention. For perhaps the first time, a great exodus of New Orleanians brought this city’s residents all across the country as refugees from one of the most severe natural disasters in recent history. Of course, this event may not compare to natural disasters elsewhere such as the tsunami that occurred not long before, but it was remarkable for many reasons, if only for the fact that America as a nation was once again faced with the opportunity to witness true suffering on its doorstep. Did we respond appropriately, and with enough compassion? Those are goals for any physician: to respond appropriately, and with compassion. As a nation, it’s easy to state comfortably that we did so in the wake of the September 11, 2001 terrorist attacks. I think the case is much harder to make with respect to Hurricane Katrina and its aftermath.
I don’t mean to point fingers or write at length about the many instances where we, as a people, failed. I do believe, however, that I have something meaningful to convey in speaking to fellow physicians-in-training like me: physicians must be individuals with great emotional wealth, both in capacity and generosity. We must use this ability to understand the suffering of others, to help ease that suffering, and perhaps even to help abolish that suffering altogether so that all that remains is the memory, hopefully one that can be erased with future happiness. I know that many of my readers are classmates of mine here in the city of New Orleans, and others are fellow physicians-in-training who are friends of mine who know how much this city has played a role in my life. To those of you, it should seem apparent why it would be important to know the character of the suffering of our patients. To others, this account might help remind you of the depth of suffering many around the world face every day, as well as the great opportunities that we as physicians will have to address this pain.
Here is my attempt at (as brief) an explanation (as possible) of how these people have suffered, and how this affects and reflects who these people are – my people, the people of New Orleans. I can’t offer any accounts of a miserable week in the Superdome, of rowing in a boat to help rescue fellow New Orleanians on their rooftops, or of experiencing the cold reception of Houston residents as a Katrina refugee. I can, however, offer a little perspective on how people think, what they believe, and how we can help ease their suffering.
New Orleans may be seen as a city of the decadent, the lazy, and the destitute. It may also be noted for its great socioeconomic and racial disparities, its poor potential for economic growth, and its remarkably high murder rate and gang violence, all of which are intimately intertwined and codependent. It is an imperfect city, and so accordingly, are the people who call it home. They eat, drink, and party excessively, often with little thought for the future. And yet, despite all of this, why would I be fond enough of this place to call it home and these people to think of them as my extended family? I do none of these things in excess, nor am I fond of this city’s vices. I am, however, a person guided by love, and in my travels and my experiences from living in four different cities, I have found few other places in this world where the people live their lives so full of the energy generated by the love of a place, the love of a way of life, and the love of those around you willing to share this life with you. I’m not referring to decadence or lack of ambition or “the big easy” lifestyle that people associate with this place: instead, I find that as a whole, people here are more willing to find friendship and good in those around them, be they friends, neighbors, or new people in their lives, most of whom become fast friends. When people came back to New Orleans, against their “better judgment” and logical economic sense, it wasn’t because New Orleans is a great cultural center or an important port for Gulf trade and industry. These are all just excuses to be made to those who don’t understand. It wasn’t for these things that people came back: it’s for love, of the place and of one’s own people.
I went to college with three friends from high school. Although we were friends previously, we had our separate groups of friends in college and didn’t spend much time together. However, after Hurricane Katrina, when we resumed our undergraduate studies, we inexplicably gravitated towards one another. Without any word spoken, it rapidly became aware to us that there was so much we shared in common with one another, and there was little that we wanted more than just to be with others who understand what we’ve just been through. While others would ask us “Is your family ok? Did you lose anything in The Storm?”, it’s difficult for us to believe that any of them can really empathize with us and what we had been through. Though we asked the same questions to each other, it had a different meaning: we knew that we could understand one another because we spoke a common language and shared a common identity through the experience of having lived in New Orleans. It wasn’t exactly insulting to have others presume that they could possibly understand what we went through, but it was awkward and alienating, as though we were the new “Exhibit A” to be talked about but not touched. Others around us could show a degree of sympathy, but not empathy. Nonetheless, by most measures, we made it out well: two of my friends and I had minor damage to our houses, one of my friends lost his house due to flooding, and my father lost his job (placing my family in a very unstable financial state until he found a new one more than a year later). However, we were alive, none of us lost family members, and we have great prospects for resuming our lives with minimal impacts of the storm on our educations, careers, and social lives.
However, when I look upon my medical school classmates, particularly those from other cities and states, I wonder if they can possibly fathom the extent of the suffering that other New Orleanians suffered and still suffer. How can they possibly understand what it would have been like to live for a week in the Superdome: sleeping on the stadium seats, the filthy-beyond-belief bathrooms, and the rumors and possible reality of rape and violence in the absence of order and authority? Struggling to survive in the Convention Center, completely overlooked and forgotten by FEMA’s leadership for several days? Or hitting even closer to home, could they imagine what it would have been like to have stayed at one of the hospitals or medical campuses during that terrible week, waiting desperately for the rescue helicopters to arrive while being shot at constantly by gangs, now equipped with stolen rifles and handguns, trying to break in? To those who don’t believe that Post Traumatic Stress Disorder is a serious medical problem, I invite you to live in a war zone, a world turned upside down, for a week. On top of that, stuck at the edge of existence, imagine hearing that the national government and the rest of the country doesn’t care enough about you to do all they can to help. Instead, they respond with hesitance, judgmental criticism, and half-hearted efforts. Once a city of love, it became a city of hate and hopelessness: hate of the betrayal felt as we were abandoned with our dreams of a beautiful New Orleans broken, and hopelessness as everything we once loved decayed into chaos so rapidly.
These are memories that most people would rather forget: the days when all of the problems we thought we had addressed reared their ugly heads and destroyed the self-image of the city. These are also things that the mass media was urged not to report on extensively, for fear that the rest of the nation would sour to the prospect of helping the people of New Orleans. When we were all in the same boat, how could some of us turn against one another? This was perhaps the most emotionally traumatic consequence of the hurricane, this manifestation of all our vices: having the gang war cycle of violence normally isolated to the gangs suddenly be turned on the rest of the populace in the moment of chaos and uncertainty. In particular, a number of young black men in gangs, having looted guns from a local Walmart, were said to have tried to “take over the city.” Some people might say that these troubled youths were simply gang members, not members of the same family that we belong to. Could that be any further from the truth? I hate the fact that even my mention of the phrase “young black men” automatically causes some people to subconsciously label them as “other.” I once found it remarkable that I had personally experienced more racism in Cambridge, Massachusetts than in New Orleans, Louisiana. I sometimes, perhaps naively, believed that New Orleans was a special place where people were actually trying to ease race tensions on a social level, and hopefully someday, on a socioeconomic level. And yet, race became an apparent issue in the wake of the hurricane, particularly since it became apparent that the relatively peaceful coexistence of races prior to the hurricane was more tenuous than some of us believed: it was dependent on the “good life” and good will of the people of New Orleans, but those suffered greatly. Likewise, the pains of the school system, the lack of stable employment opportunities, and the vicious murder cycle among gangs that were always here blazed brightly before us, now that we were awake from our complacent state.
I consider myself to have a vivid imagination, but even I can’t fully grasp the extent of the suffering felt by New Orleanians who lost homes and family members to the hurricane, let alone the horror faced by many New Orleanians trapped in the city in the wake of the storm. However, even if I can’t know the suffering in full, I can care about it and the people who suffer, with all of my heart, each time I encounter someone who has felt this pain – it comes naturally, because these are my people and I understand them, even if I don’t fully experience their pain.
Hard to Heal
For a long time, I was hesitant and uncertain about the prospect of returning to New Orleans for the first stage of my medical training. The inverted image of my hometown, turned upside down and ravaged, constantly visited me in both my dreams and waking hours, and thousands of miles away from New Orleans, I felt wave upon wave of despair and betrayal. A large part of me didn’t want to come back; it wanted to forget and cut ties and not take up the responsibility of addressing the great suffering I knew existed. Like so many who chose not to return to New Orleans, I didn’t want to face any more pain then I already felt. Furthermore, like many of my classmates, I wondered whether I was making a risky gamble to seek training at a financially-troubled school and in a city with a broken health care system. However, each time I cried myself dry, I knew one thing: that although I don’t expect to live in New Orleans forever, I didn’t want to leave the city with bitterness in my heart. There are some wounds that cannot be easily healed in a convenient context – another time, another place. I came back, with apprehension, but rapidly found many of the things I once loved to be intact. Despite the apparent devastation around us, I found that those who returned (from all walks of life, all socioeconomic classes, all races and creeds) still remembered what it was like to be a family, to have a warm and congenial degree of commonality, and they were also now ready to address those problems that tore our city apart. Each smile and sign of hope I see around me balances out each tear I shed in the days as I waited to hear whether my parents had made it out of the city alive amidst the gunfire, the days when I silently absorbed the vented bitterness and depression of my father, and the days I fought with myself over the prospect of returning to the place I had thought I would never get a chance to see again. I think I’m making good progress so far. I hope I can help others find redemption and healing in a similar way.
What Physicians Can Do
The example of New Orleanians and what they have suffered is a meaningful analogy to the role of physicians in the lives of their patients. We often bemoan the shortening of time given to each patient encounter (especially in private practice), and people often attribute this to a distancing in the doctor-patient relationship. I believe, however, that we can do better, regardless of the amount of time we have. The moment someone tells me they are from New Orleans, there is something I instantly know about them, and my heart immediately opens up to their suffering. I hope that someday I can react this way to the suffering of all of my patients, regardless of their backgrounds and identities. Likewise, I encourage all physicians-in-training to learn how to truly open their hearts and minds fully to the patient sitting before them: to address and treat the suffering as well as the disease, since treating just the disease would mean that we’re only achieving half of our mission. There’s so much to know about another person, but we cannot afford to be overwhelmed to the point of hesitancy, apathy, and inaction. I personally do not belong to any specific faith, but I do believe in a commonality shared by all people: we are a family, and we should try to understand and care about one another as we do with the friends and family we currently recognize as being our own. Perhaps in believing this, I belong to a cultural minority. If so, I hope that all physicians belong to this same group, and that all physicians-in-training aspire to be part of it.