These are the words you use to map a body: the deep curve of an embryonic tail is caudal, the humped head becoming a nose is rostral. Anterior, posterior. Proximal is for structures nearby
Distal is easy, at first: it is a way to speak about distance, though this is a relative sort of distance. The wrist is distal to the shoulder; in humans, the distance is only about 65 centimeters. Picture the arteries coursing out from the thorax like highways, branching and narrowing until they reach their destinations in the fingertips and toes.
There are the distances in our bodies, and then there are the distances in the world. The room where I write this today is thousands of miles away from a hospital clinic in Bandiagara, Mali, in West Africa. There, nine months ago now, a young woman waited in the dark.
Bandiagara is a small town deep in the Sahel, a semi-arid region south of the Sahara Desert. It is a place where silversmiths work in tiny shops and camels kneel in alleys. I traveled to Bandiagara to assist with malaria research during the summer after my first year of medical school. Our laboratory was based out of the local hospital, a compound of single-story buildings on the edge of town. In the mornings, I accompanied the medical staff on rounds. We moved from bed to bed in the wards, where the shutters were kept shut against the heat and urinary catheters drained into buckets on the floor. Discussions between the doctors and nurses were conducted in a mix of Bambara and French, and vitals were penciled into charts and hung on clipboards on the beds.
It was there that I met the young woman. She was nineteen years old and already ten days blind. She spoke no French. As with all the patients, when the doctors entered the ward, her family quietly left to wait on the veranda outside. She remained on the plastic-coated foam mattress, colorful lengths of wax-printed fabric wrapped around her swollen body. Her kidneys were failing, and her heart and lungs were a riot of noise. For several mornings in a row the medical staff crowded into the room, the family shuffled out, and the young woman slept.
In the face of serious illness and limited resources, it is easy to fix on a point: Get this patient to a doctor. The woman’s family traveled from their remote village to the hospital in Bandiagara, intent on bringing her to a place with medical care. But, though the hospital had doctors, there was no ophthalmoscope, let alone more sophisticated equipment, available to guide her treatment. The doctors called for an ophthalmologist and I found myself thinking, Once he arrives, he will know what to do.
On Friday, the ophthalmologist arrived, and the young woman sat up in bed. He examined her eyes, then passed around his ophthalmoscope. When it was my turn, I touched the woman’s shoulder, lifted her eyelid with my thumb, and leaned in with the borrowed light. She fixed her eyes straight ahead and rested her hands in her lap. I followed the veins until I found the optic disk. Superior to it, a white cloud appeared embedded in the retina. I had no idea what I was seeing; I had never even held up an ophthalmoscope before. I wanted to apologize. Instead, I whispered my thanks in Bambara, and the woman remained still, or perhaps nodded once.
The ophthalmologist left, and the doctors discussed transferring the woman to the hospital in Bamako, ten hours away by road. If only we could get her to Bamako, they will know what to do. Her family hesitated; they had never been to the city before. So she waited, and we waited, and Bamako seemed farther and farther away.
The family must have hoped for a cure. But they came to Bandiagara, where little could be done. The national hospital in the capital, with its steady electricity and teams of physicians, was a dream. The longer we waited, the less likely she was to survive the journey. I began to realize that doctors are not saviors, but servants to an unimaginably complex world.
During rounds on Tuesday morning, the woman leaned on her arms and struggled to breathe. I wasn’t at the hospital when her lungs failed. When I returned late in the afternoon, she was dead and her father was pacing the grounds in his long, loose robes.
It is easy in the developed world to assume that we are the beating heart of the globe. This would make a place like Bandiagara distal to us, the way the hand is distal to the heart. It is not that simple. You can draw your hand up to your heart; the anatomical relationship holds, but the distance is diminished nevertheless.
Humans are not so dissimilar, nor so distant from one another. Bandiagara lacked dialysis equipment and teams of intensive care physicians available to stage miraculous reversals of malignant hypertension. But not everyone is saved in the bright rooms of modern hospitals either. Whatever limits the physician faces, she can be a steward of comfort and compassion, even when she cannot promise a cure. I heard later that the woman’s father expressed gratitude for the care his daughter received. This strikes me as a tremendous acknowledgment of those doctors who offered what they could in a near-impossible situation.
We gain comfort from others as well. On the day the young woman died, I walked home in the orange light of early evening. The streetlamps came on, motorbikes spun dust into the air, and children greeted me and disappeared behind mud walls. Halfway home, a Malian boy with Down syndrome waved to me from across the street, and then joined me to walk together. We shared some words in French, but mostly spent that half-mile in companionable silence, before parting in the dark, down were the main road encircled an unfinished monument.
The Arnold P. Gold Foundation Humanism in Medicine Essay Contest
The Arnold P. Gold Foundation was founded in 1988 with the mission of maintaining the balance between medical science and human needs by ensuring that doctors value and provide patient-centered care that is both compassionate and cutting edge. The Gold Foundation’s annual Humanism in Medicine Essay Contest was launched in 1999 in order to allow medical students to reflect on their experiences through writing.
In 2012, participants were asked to reflect on the words of the Foundation’s founder, Dr. Arnold P. Gold: “You are now a steward of medicine and it is your job to safeguard the profession” What does it mean to you (and your patients) to be a steward of medicine? More than 200 students submitted essays which were reviewed by a distinguished panel of judges ranging from esteemed medical professionals to authors in the field of humanistic medical care.
The top three essays were selected along with ten honorable mentions. Winning essays were published on The Arnold P. Gold Foundation website (www.humanism-in-medicine.org) and will be published in consecutive Fall issues of Academic Medicine.