November 26, 2006
A Parable To Help Make Sense Of Iraq
Tale of a doctor, a patient and hope
By Col. S. Ward Casscells
Those of us struggling to help Iraqis rebuild their health system are often asked about the ancient and bitter hatreds, the poverty, corruption and lack of technology — this in the land which gave birth to writing, the wheel, Hammurabi's laws, three great religions, algebra, and the discoveries of Ibn Sina, who dwarfed the physicians and scientists of medieval Europe. "How can Iraq be understood, so that our efforts do some good, or at least no more harm? Is it time to give up?"
I ask these questioners to picture a young man in a poor country, walking home one evening, when he is robbed, beaten and left for dead. Two days later, he is found and taken to the hospital, where a doctor finds him delirious with fever and combative. The doctor advises urgent surgery, but the patient is unable to give (or refuse) informed consent, and family members, not all of whom are present, cannot agree. The hospital asks a local court to intervene. The doctor recalls the Hippocratic aphorism chiseled in the granite at his medical school, "Ars longa, vita brevis, occasio praeceps, experimentum periculosum, iudicium difficile" ("the art (of medicine) is long, life is short, the occasion instant, experiment dangerous, judgment difficult").
Before the court decides, the laboratory informs the doctor that the patient has a drug-resistant and highly contagious lung infection. The patient is now in shock, so the doctor operates, draining the patient's abscesses to try to save his life, and prevent the infection from spreading through the hospital.
In surgery the doctor discovers tuberculosis of the lung, and a lung cancer, which is removed. The postoperative course is stormy because of the patient's poor nutrition, heavy smoking and several medical errors (a transfusion reaction, failure to order ulcer-prevention medication and a bed sore).
Even the family members who approved of the operation are now angry. Some of the doctor's colleagues mutter, "Primum non nocere" ("First, do no harm"). Others say the decision to operate without the court order will harm his career.
The doctor ponders the ancient French teaching, "Guerir quelquefois, soulager souvent, consoler toujours" ("Cure sometimes, relieve often, comfort always"). He presses on.
Over a year, the man recovers. Though he walks with a limp for the rest of his life, he returns to work, marries and raises a family. The story of his recovery is one that is told by friends and neighbors, who credit his courage and will to live, and their own support of him through his ordeal.
The man himself recalls only some of his illness, but he recounts the hospital adventures and misadventures, tasteless food, the kindness of the nurses, the consolation of the chaplain and the mysteries of medical machines and jargon.
His wife is now the head of volunteers at the hospital, his daughter is a microbiologist and his son works in the ministry of transportation, fighting for better and safer roads. None is a smoker.
The doctor, now old, is asked what credit he deserves for the gratifying turn of events. He smiles at the memory of the case that nearly ruined his reputation, and observes, "As Ambrose Pare said, 500 years ago, 'I dress the wound; God heals it.' "
Dr. Casscells is serving in Baghdad with Multinational Force — Iraq. The views expressed are not necessarily those of the U.S. Army, Multinational Force — Iraq, the U.S. Department of Defense, the State Department or the University of Texas in Houston, where he is professor of medicine and public health.