Why Are You Here?
I started medical school expecting to become a research scientist. While still in college, I had joined a professor in his efforts to study biological membranes using a then-new technique called magnetic resonance imaging (now referred to by its acronym, MRI). As a member of his research team, I was named as a co-author of a paper he published on the work, and I imagine my acceptance into Stanford in the early 1970s was based partly on my participation in this new line of research. Indeed, I soon found a professor in my new California home with whom I intended to continue these studies. What I never expected was to become a clinician, focused less on research than on seeing patients.
At Stanford I actually started clinical work immediately. I had pushed myself to finish high school before turning sixteen, and as an undergraduate at Indiana University I had persuaded professors to let me take medical and graduate school biochemistry courses. These gave me advanced standing when I entered Stanford at age eighteen. As long as I took a necessary pharmacology course concurrently, I was ready to start seeing patients on clinical rotations. I was on track to finish medical school in June of 1975, with the required nine-quarter minimum. A decade later I learned I was Stanford's youngest ever peacetime graduate, at twenty-one years of age.
The challenging part for me was not in learning about pharmacology and anatomy but in understanding other doctors. There were numbing lists to memorize, of course, of nerves, muscles, bones, blood vessels, symptoms, diseases, drugs, and side effects; but compared with the knottier puzzles of philosophy or higher mathematics, nothing taught was all that difficult. There was plenty to memorize, but all memorization takes is time. The problem for me was that my interpersonal skills had languished in my race through high school and college. Thankfully, I had a new wife to coach me in the car on the way to dinner parties and social events. Professionally, though, I was on my own.
Medical students on clinical rotations were expected to examine patients and entertain a diagnosis. We would discuss our potential diagnoses, and the treatments and medications they implied, with the faculty physician. The challenge was to show that we had considered every possible diagnosis and had either ruled it out or planned the necessary tests to confirm or disconfirm its existence. Although most patients suffer from common diseases, we relished considering all the outlandish possibilities. First prize went to those who, in the end, turned in exactly the diagnosis our faculty physician had already reached -- we had to learn his or her style and mimic it. At nineteen, much to my own detriment, I was still young enough to be idealistic. I thought it was more important to think for myself than to try to think like someone else.
I also thought other doctors shared my own ideal of medicine: that its purpose was to restore unwell persons to health. Imagine my surprise on hearing a renowned professor of internal medicine begin a lecture by noting that the physician's job lay in "slowing and making less painful the patient's inexorable and inevitable progression toward death and decay."
Despite this my first rotation -- three months in neurosurgery -- was challenging and rewarding. I had already done work in college on the neural functions of rats. I was studying a particular brain rhythm, hoping to show that a molecule called serotonin triggered it. To do this, I implanted electrodes into rats' brains, then measured what happened when I introduced serotonin to different sites of their limbic systems. If the rhythm was produced by the serotonin, I would have strong evidence that serotonin was a neurotransmitter -- a message sent by a nerve to the cells in the vicinity. Neurotransmitter molecules are the only verbs a nerve has at its command; which molecules are produced, and how many, determine a message's content. At the time, scientists were certain of only two neurotransmitters; we have since identified twenty-six. These few molecules and the simple messages they carry from one to another of our three billion brain cells are the vital chemistry behind human thought.
Although this wasn't the concern at the outset, neurotransmitter research eventually had the practical yield of all sorts of drugs. Now we know, for instance, that serotonin depletion often accompanies depression. Drugs that increase the availability of serotonin, like Prozac, are common treatments for depression. Prozac, which belongs to a class of drugs known as serotonin reuptake inhibitors, works by blocking the enzymes that cause serotonin to be reabsorbed.
I found that rat brains produced the theta rhythm I was interested in when serotonin was introduced to certain sites "upstream" of the hippocampus -- which, in plain language, meant that serotonin was indeed a neurotransmitter, at least for rats. This was a publishable result. With my professor's advice and assistance, I finished my first solo paper and published it in a neurosurgery journal. I was very proud to become a part of a centuries-old tradition of expanding the known limits of scientific knowledge.
Since I already loved research, it was no surprise to find the data-gathering aspect of the neurosurgery rotation appealing. But I was unprepared to find how much I enjoyed simply working with people, practicing clinical medicine. Even if I was still more comfortable in a lab than on a ward, two months into the rotation I was starting to consider a career that wasn't pure research but combined research with clinical work. Perhaps I would become a pediatric neurosurgeon. Three months later I was on my second rotation, in urology, about to meet the four very sick men who would challenge my career plans even more profoundly.
It was a foggy April morning outside the renal room of the Intensive Care Unit at San Mateo County Medical Center (SMCMC), a major teaching hospital of Stanford University. A nurse introduced me in a perfunctory manner to the first three of the four men inside. There was little hope for them. The fourth man -- whom I will call Juan Martinez -- had a chance to survive. He was a forty-two-year-old carpenter from Los Gatos, in the foothills of the Santa Cruz Mountains. He had lost one of his kidneys in a San Jose hospital. After the operation, his remaining kidney had stopped working. When Señor Martinez's twenty-three-year-old daughter offered him one of her healthy kidneys, he had been transferred to SMCMC's renal room to be evaluated for a transplant.
My job was to begin a pre-transplant evaluation of Sr. Martinez to decide if there was any reason not to proceed with the surgery. I wondered what had happened to the man before he lost his kidney -- what had brought him here. I started by asking when he had last been well. We had to speak up to be heard over the bustling doctors, the efficient nurses, the constant drone of the voice of the paging operator (these were the days before beepers). Only his three drugged roommates were quiet.
The carpenter was lying on his back, holding himself perfectly still, looking more like a quadriplegic than a dialysis patient. His face had the texture of an onion skin. His muscled arms lay uselessly on the sheets. He took longer to answer than I expected; he seemed to be searching for an answer to a question much bigger than mine. Finally he said, "I was never sick."
"What do you mean?" I asked. He was avoiding looking at me, focusing instead on the grains in the ceiling panels overhead.
"There was nothing wrong with me," Sr. Martinez said flatly. His usually dark Hispanic complexion was blushing ocher, and he began to cry quietly. His jaw continued working after he spoke, as if there were more to say but no words with which to say it. I glanced out the window. The morning's fog had dissolved into a light rain, unusual weather for April in San Mateo. Water ran slowly in crazy currents down the window panes. I found myself shivering.
"What do you mean, there was nothing wrong with you?" I asked when it was clear that the carpenter wasn't going to go on. He was clutching the bedsheet.
"They said I had protein in my urine -- but I didn't feel bad or nothing," the man said without emotion. His face was expressionless except for the silent tears in the corners of his eyes.
"They ran some tests. Then more tests. They took a biopsy of my kidney, and I got this infection that almost killed me." The man gazed down the length of his sheet-covered body. "It did kill my kidneys," he said. His jaw stopped working and his lips began to quiver. Our conference was interrupted by an officious nurse who had come to change his IV. Feeling worried and confused about what had happened to her charge, I left her to the task.
Later that morning I read his chart in the conference room behind the nurses' station. Just a few months earlier, he had been framing houses in the canyons outside San Jose. On weekends he went hunting and fishing in the northern California wilderness. His doctor had discovered the traces of protein in his urine during a routine insurance physical. Proteinuria can be a normal enough finding in a person who has been exercising strenuously, but it can also be an early sign of serious kidney ailments and autoimmune diseases.
Although Sr. Martinez had no symptoms of any of these problems, his internist ordered a full workup. A series of ordinarily innocuous medical procedures had led, for Martinez, to the worst possible complications. After his doctors biopsied a kidney, Martinez got an infection, then began to hemorrhage. His doctors repaired that damage by removing the injured left kidney; Martinez's right kidney responded by shutting down. He developed sepsis, an infection of the blood that can spread anywhere in the body. Doctors at SMCMC managed to clear up the infection but couldn't get the right kidney working again. Martinez's best hope now was a new kidney. As for the biopsy that had kicked off the whole process, it had been inconclusive. Nobody had any idea why Martinez had once had traces of protein in his urine, and now nobody was trying to find out. That problem -- if it had ever been a problem -- no longer seemed important.
I sat in the conference room looking out the hospital's narrow windows at the rain and thinking about the man in the room on the other side of the nurses' station. His old charts and records were heaped on the table before me. I thought of the dark forests of northern California, where Sr. Martinez had hunted, of the deep lakes the forests held, of the ancient trails that led up past the timberline into a world of rock and ice and snow -- a world Juan Martinez might never see again. Then I reread his chart, hoping for some clue to his predicament.
I was still searching when a resident in urology, Musaf Habra, walked in and set two Styrofoam cups of tea on the table. Dr. Habra was a Saudi general practitioner who wanted to teach at the Saudi Medical Center in Riyadh after he finished training as a urologist at SMCMC He was the sort of gentle man whose constitutional kindness can be mistaken for weakness. He had won my admiration at a recent party, where he played the violin with a sensitivity that was anything but weak.
"Reviewing Señor Martinez's case?" he asked, nodding at the charts on the table.
"Trying to make sense of it," I said.
"Sense?" Dr. Habra gave me a quizzical look. "What 'sense' are you looking for?"
"I'm not sure," I said. "The logic behind the biopsy, I suppose. I'm trying to understand how this could have happened."
He shrugged and pushed one of the cups of tea toward me. "His doctor wanted to know what was causing his proteinuria," Habra said in a matter-of-fact tone that served to mask what he thought about the whole thing.
"But he says he wasn't sick," I countered. "And I can't find anything in his chart that indicates any other symptoms or diseases."
"He didn't have symptoms. He had proteinuria..." Habra thought a moment and lowered his already quiet voice. "And he had the 'advantage' of the best preventive health care in the world."
"You wouldn't have biopsied him in Saudi Arabia?"
"I wouldn't have biopsied him here," Habra replied. He raised his eyebrows. "But you Americans are so much more advanced than we Saudi." He winked. "Wanting to know the answers to everything can be deadly." He parodied his own accent a little, lending it a playful hint of intrigue.
I agreed with Habra's critique but was hurt to be included by him among "you Americans." Of course I was one, but I didn't identify at all with the culture that lay behind the unnecessary renal biopsy that had destroyed the carpenter's health. I wanted Habra to see me as something more than just another American. I was a Native American, for one thing, and I hoped that somehow made me different.
It seemed to me my medical student friends and I were more like Habra than he knew. A small group of us were naturally drawn together -- Native Americans, Hispanics, and Asians -- because we all had different cultural perspectives from those prevalent at Stanford. Though we didn't have strong social ties, we did hang out together in school. It took the edge off our feeling of not belonging. Some of my fellows had come to Stanford straight from their reservations and found themselves in an entirely new, often incomprehensible culture. Spurred by my new friendships, I began to reconsider my own Native American heritage, which my mother had long ago turned her back on.
While I was thinking about what Dr. Habra had said, David Vickory breezed into the conference room. Dr. Vickory was a decisive, energetic man with an encyclopedic knowledge of kidneys. In his late thirties, Vickory was juggling two ambitious careers, running a busy research lab and simultaneously winning a reputation as one of the best nephrologist -- kidney specialists -- in the country.
"Well, boys," he said, rubbing his hands together as if they were cold, "what do you think of my man, Martinez -- is he a good candidate for transplant, or what?"
Dr. Habra thought for a moment. "There is the matter of his infection --" he started.
"We've licked the infection," Dr. Vickory interjected. "His fever has long since lifted. He's ready for the knife. Unless..." He turned a chair backward and straddled it. "Unless you've found something I missed." His tone was challenging. He waited barely an instant and turned toward me. "You look troubled, Dr." -- he glanced at my name tag -- "Mehl. Did you find something I missed?
"I told him I hadn't.
"And yet," he continued in his light, teasing tone, "you do look troubled. Our man is stable. We've cleared his infection. We've got a kidney standing by. And still something worries you."
"Actually," I said slowly, "I'm struggling to understand how he got here in the first place."
Vickory's face went blank for a moment, and his cheerful demeanor vanished. "You have a question about how patients get infections?"
On one level, it would be a ridiculous question for a medical student to ask: even premeds know that microbes cause infection. But on another level, the question was worth pondering. Why did this particular patient succumb to microbes when most others do not? The first question would be too basic and the second too philosophical to warrant discussion in the urology conference room. Vickory was trying to figure out which of these transgressions I had made.
I saved him the trouble. "Of course I know what causes infection. I was wondering why we did a renal biopsy on a healthy man."
"He wasn't healthy," Vickory corrected. "He had proteinuria. That's something we work up. It's the standard of care, as you know -- or should know." He could probably see the beads of sweat on my forehead starting to form. I hadn't started out to challenge his authority, but I could see Vickory was thinking I had.
"His proteinuria wasn't causing him any problems," I countered. I could see Habra pursing his lips and shaking his head, but I couldn't understand this taboo on discussing the biopsy. Vickory, after all, was not the one who'd ordered it, so even if it had been a mistake, it wasn't his. "It just seems like they could have waited to see if there were any real problems before going for a piece of the guy's kidney."
"Is that the way it seems to you, Dr. Mehl?" Vickory asked. "Well, maybe..." He stroked his chin with his thumb and forefinger and pretended to think about it for just an instant. "But those of us who study kidneys for a living have found that guys who have protein in their urine usually do have a real problem. Maybe someday you'll show us how to identify the lucky ones who don't. Until then, we're just going to have to stumble along doing biopsies. We know from experience that we'll find a lot of renal disease that way. We also know that in a few cases -- not many, but a few -- there'll be infection." His voice was intentionally slow and flat. "It's unfortunate, but it's life. And it's irrelevant to the business at hand -- which is whether or not to give Martinez a new kidney. That's the question on the table this morning," he said, rapping hard on its Formica surface with two fingers. "So you let me know if you see any reason we shouldn't transplant this guy. Until then, Dr. Mehl --" Vickory nodded dismissively and walked out of the room.
I felt stunned and embarrassed. My heart had hammered through every long second of his speech; I wasn't used to conflict, and it frightened me. I was young, I worried what people might think of my youth, and I wanted desperately to do well to compensate. I was scared of Vickory. How could I have had the audacity to challenge him?
"Be careful," said Habra. "If you keep acting like that, you'll never graduate." I was surprised to hear no trace of sympathy in his voice. Although I had not expected him to stick his neck out to defend me from Vickory, I thought at least he would be a confederate afterward. He shook his head as he gathered up the charts. "You might consider which you want to do, debate the philosophy of medicine or become a doctor anytime soon."
"I want to do both," I muttered in a voice barely audible over the background noise of the hospital.
"Good luck," he said without inflection. It was hard to tell whether he meant what he said or precisely the opposite.
When Habra and I went back to see Señor Martinez later that day, we found him lying deathly still on his back, moving only his eyes -- from Habra to me and back again. He looked bewildered while Habra spoke to him.
"We can give you a transplant," Habra told him, "if that is what you truly want. But I insist that your daughter talk to the psychiatrist. She must know what she's risking. She must know what the chances are that you'll reject her kidney. She must know what she's getting into, and I must know that she knows or I would never forgive myself."
Habra had surprised me again. In the few months I'd spent on rotations, I hadn't come across any other doctors who would consider holding this kind of conversation with a patient, acknowledging that it was possible for the physician to be emotionally affected by a treatment's outcome. But if Martinez was surprised or moved by hearing a doctor mention his own feelings of guilt or responsibility, he didn't show it. His eyes continued to float like the bubbles in his leveling tool, looking for a spot on the ceiling to comfort him.
"Tell your daughter to give me a call," Dr. Habra said, placing one of his cards on the bedside table. He searched the corners of the room for clues about how to proceed. "I am sorry for your misfortune," he told the carpenter shortly, standing up from the bedside chair. "We will see you in the morning and talk again then." Martinez managed a nod.
Habra rubbed his eyes as we made our way to the next bed, where lay Dr. Jackson, a forty-eight-year-old professor of English from the University of California at Santa Cruz. His story was nearly identical to his neighbor's, beginning with proteinuria and ending with two useless kidneys. Dr. Jackson's infection, however, was out of control, and dialysis was failing to cleanse his blood adequately. Habra and I had been asked to determine if surgical removal of his kidneys and debridement of the region (cleaning out the infected tissue) might help. It might, we decided, and should be tried, because it was his only chance to beat the infection. But even this radical treatment might fail. Unless our debridement was accompanied by a miracle, Dr. Jackson did not have a very good chance of leaving the hospital alive.
Neither did a fifty-one-year-old store clerk, Mr. Brasher, nor a thirty-seven-year-old postal worker, Mr. Brown -- two more men who had begun with protein in their urine and no other symptoms, who had run the gamut from biopsy to infection to the loss of kidney function. We trudged past their beds, murmuring short greetings and shorter good-byes.
When we finished rounds, we ducked into the cafeteria. Habra bought himself a Coke. "What are the odds," he said, "that in any one morning we would do four such similar consults, that four men who had been well before visiting their physicians would all be lying in the same room together?"
"I don't know," I responded carefully. I wanted to know what Habra thought, but after the episode with Vickory, I was reluctant to set anybody else off. "It seems like something must be wrong with three people dying because of their physicians' best efforts."
Habra nodded. The rain had stopped and the sun was starting to shine. We walked outside. "But what exactly went wrong?" Habra asked. "No one amputated the wrong leg or prescribed incorrectly. No one missed a disease or made the wrong diagnosis. Perhaps Vickory is right -- perhaps this is the price we pay for good preventive health care."
"You don't believe that," I ventured. The chairs were still too wet for us to sit down.
"No," Habra said, "but you can't quote me. Anyway, my opinion carries no weight."
"But why is Dr. Vickory so defensive?" I asked. "He didn't make any mistakes."
"He has to defend his colleagues," Habra suggested. "After all, they were faithfully following the guidelines of our profession." We were leaning against the rough concrete walls of the building. We could see planes landing and taking off through the mist covering the San Francisco Bay.
"But is this what good care is?" I asked, genuinely agonized. "If you kill the patient, can you call the operation successful?" I finished my tea. Squirrels were climbing up and down the trees, and birds squawked overhead.
"Who can say?" Habra said as he opened the door to the hospital. "Maybe Vickory's right. Maybe finding the treatable cases justifies the losses, maybe those men we saw today are a statistical anomaly. We are simple soldiers on one battlefield. Maybe we cannot understand the war?"
"Like hell," I shot back, smiling.
"At least you're in a better mood," he said. "There's nothing I hate worse than a mopey intern."
My great-grandmother was a traditional healer in a rural area of Kentucky. I carry vivid memories of her but not of her theories and practices, since she died when I was five. I wish now I could ask her all kinds of questions that I wasn't concerned with then. What I do remember seeing was a number of very sick people coming to her to be healed. When I was older, I watched healings led by the local Christian snake handlers. I didn't know what magic these writhing, agile beasts worked. But magic it was, as far as I could tell.
At the time I was never much interested in the cause-and-effect relationships of anyone's "miracle" recovery. Nor was anyone else I knew. Where I came from, faith healings were accepted as natural occurrences -- nothing to arouse either doubt or skepticism. Later, my curiosity would come to rest in the concept of human transcendence, in the movement beyond illness that healing occasions. I would learn that healing sometimes calls for people to ascend the greatest heights they are capable of reaching. And then sometimes healing seems as natural and commonplace as weeds in a garden.
Before a person can be healed, one medicine man told me years after medical school, he or she must answer three simple questions: "Who are you?" "Where did you come from?" and "Why are you here?" This California elder believed that anyone who could give clear answers to these three questions would be well.
The third question seemed easiest to answer -- Why was I at SMCMC? I knew that the study of medicine would allow me to pursue my interests in biology, physiology, and psychology. So far these expectations were satisfied. I was only surprised to find, in medical school, that few shared the awareness and acceptance of healing I had known in Kentucky. Why could faith healing occur in the hills of my youth but not in a progressive hospital? I took it for granted that there was a spiritual component to illness, and wellness too, and that doctors would respect it. But I had no thought at that point of integrating my interests, of using the healing traditions of people like my great-grandmother alongside the scientific approach of modern medicine.
It wasn't until I experienced the shock of seeing four devastated but previously healthy men together in the same renal room that I began to think the healing traditions of my childhood might have something to offer the professors of Stanford. There must be an alternative, I thought. I was too naive to recognize that even the idea of healing -- without drugs, surgery, or other invasive care -- was considered déclassé and counter to the conventions of medical school.
Now, sometimes invasive procedures are entirely appropriate. But they aren't always. Too many of the doctors I was encountering lacked the critical insight of the healers I was later to meet, that a disease may bring balance to an otherwise untenable situation. Medicine people are careful not to act until they are certain of the consequences of their actions. Disturbing the body's balance without forethought can have disastrous consequences, as Martinez was learning, whether or not his doctor ever did. The true healer recognizes that every action produces a result, and that a patient's own intentions, conscious or not, can determine the direction of the result.
It seemed only by coincidence that I was even in a position to learn from this unfortunate convention of renal failures. During my first rotation as a medical student, in neurosurgery, I befriended a surgical intern, whose next rotation was to be in urology. The illness and subsequent death of a family member required his presence at home, leaving his position vacant. Asked to fill his spot, I was promoted to acting intern for the month, after only four months of clinical training. This was fine with me, but a few eyebrows were raised in the emergency room the first time I showed up in response to a call for a stat urology consult.
Now that I am more fully immersed in Native American spirituality, I recognize that my being made acting intern was no coincidence. I was learning firsthand that most doctors rarely consider the larger, encompassing questions about the body, mind, and spirit that medicine people address. And I was learning this at a young enough age not to dismiss it; a few years later, I might have ignored things that disturbed me in the interest of getting ahead.
The great thrill for most of my teachers was in diagnosis. As one neurology professor said, "Most patients are very boring. What is interesting is what they might have and making sure they don't have it. What is left after that -- the treatment and so on -- is either boring or difficult. Few diseases respond in the textbook manner to the drugs we offer them. Some diseases respond to no drugs. Invariably, patients never do exactly as they are told. Patients have the pesky habit of doing what they want, regardless of our advice." At Stanford, I learned a term for this phenomenon, too: doctors call it "noncompliance."
Throughout that April day I found myself wondering just how many treatable cases are revealed by those invasive biopsies, and how many biopsies it would take to justify what we had done to Señor Martinez and what we were preparing to do to his daughter. After all, removing a kidney is no piece of cake. She could develop an infection herself, even die. How many successes justify a loss? Who decides such things? I knew better than to talk to Vickory again. Habra was less than three months from graduating and returning to Riyadh, so I couldn't count on his sympathies, but maybe Friday night after rounds, when the urology department retreated to the Stanford Coffeehouse, I could talk with him over a beer.
As it turned out, I didn't have to wait long to hear the question debated. A little before eight o'clock the next morning, we gathered in the urology conference room for our weekly discussion of transplant candidates. Because this was a teaching hospital, senior physicians sometimes expounded on the more interesting cases. When I slid into my chair across from Dr. Habra and saw that Sr. Martinez was scheduled for discussion, I wondered if anyone would point out that his own doctor had caused his illness. Doctors have a word for that occurrence too, a long, Latinate word that allows us to distance ourselves from the truth of the idea. We doctors call a disease caused by one of our own "iatrogenic." Now I just call it bad medicine.
Vickory sailed in at 7:59, took a seat at a table at the front of the room, and gave a "You're on" signal to his resident. This businesslike young woman shuffled her pages of notes and then began to tell the gathering of physicians and students about the patient.
"Juan Martinez is a forty-two-year-old, married carpenter from Los Gatos," the resident began. Her hair was black and curly and seemed still damp from her morning shower. Perhaps she had been on call all night at the hospital. "He is status post treatment for sepsis and perinephric abscess with renal failure on the basis of acute tubular necrosis from sepsis." The resident moved crisply through her presentation. She talked about the removal of Martinez's left kidney in San Jose and worked forward from there, never mentioning how he had found his way into the world of nephrologists in the first place. "It has been determined that his renal function will probably not return. His daughter offers him a kidney, and we wish to proceed with transplant."
Vickory asked for questions. There was a brief discussion of the blood urea nitrogen and the creatinine, which serve as markers of renal function. That discussion ended quickly with the conclusion that Martinez's one kidney was not working. Then came a lull, the usual signal to move on to the next case.
I glanced around the room. Dr. Habra was shaking his head at me ever so slightly. But his warning wasn't necessary; I had learned my lesson the previous morning. I would not give Vickory a second chance to mock me. I had given up hoping that anyone else would see anything remarkable about Martinez's case when Robert Upton, the chief of our renal transplant service, spoke up.
"Hey, Dave," he said. Given his status as a transplant surgeon, Upton could call anyone by first name, including Vickory. "What was wrong with this guy before his abscess? Any idea how he got sick?"
"Complication of renal biopsy," Vickory said dryly, closing Martinez's chart.
"But what was wrong with him before that?" Upton asked. "Why was he biopsied?"
"Proteinuria," Vickory said with finality, looking around the room, hoping for other questions.
"Caused by what?" Upton persisted.
While Vickory hesitated, I glanced at Habra; he was sitting forward in his seat as well. Outside our door a cart of breakfast trays clattered by.
Vickory thought an instant more, scowled, and admitted, "We don't know." His resident quickly opened her files and wrote some frantic notes to herself. She had already become skilled at appearing not to notice anything potentially embarrassing to her attending physician.
"You want us to transplant this guy and you don't know what was killing his kidneys in the first place?" Upton said, making a show of being amazed.
It was a legitimate question. Unless the disease that destroyed the original kidneys was identified and controlled, transplantation was pointless because the new kidney could be attacked and destroyed in the same manner as the old one. In Martinez's case, however, the kidneys had not been originally under attack, and Vickory had no choice now but to say so.
"There was nothing wrong with his kidneys," Vickory said impatiently. Seeming to realize where that left him, he lowered his voice and said, "He had protein in his urine. Everything else was fine."
"How much protein?" Upton asked.
"A little," Vickory said quietly. "Consistently one to two plus on urinalysis."
"That's it?" Upton asked incredulously.
Upton let loose his trademark laugh. This abrupt, barking sound was feared throughout the hospital -- Upton was not afraid of making enemies. "Ya gotta love this," he said, speaking to the ceiling but clearly addressing the students present. "We'll never be out of a job. When there's not enough real disease out there, we make some."
Vickory glared at Upton, considering a retort. He cleared his throat. In the official hierarchy of the hospital, these two men were equals. But there was a second hierarchy at play, and everybody in the room knew its unofficial and unspoken rules. Upton generated enormous revenue for the hospital and the university. For institutional physicians, money equals power. Vickory said nothing. No doubt he would remember the incident. One day, sitting on some committee or other, he might find a reason to put the scalpel to Upton on another pretext. But that permissible revenge of the academic physician would have to wait.
Everyone had a good laugh at Vickory's expense, leaving the real question of why we do what we do unanswered. The day before, I had seen four men, healthy until our profession stepped in. We could justify what we had done by arguing that the early detection of disease across a population is worth the occasional harm that preventive care inflicts upon an individual. But try telling that to the four individuals in question, or to their families. Why was amusement at Vickory's position the only emotion provoked by the meeting? Why weren't we shocked and outraged at what we had done?
Other questions of importance to me, had I asked them, were even more likely to infuriate my assembled colleagues. Why was Sr. Martinez recovering while the other three men were slowly dying? Martinez wasn't well, but he was well enough to be discussed as a candidate for transplant. What factors had healed his infection? He was a Mexican Catholic. Had he been supported by the power of prayer? Were supernatural forces real and present for him? What about the other men -- had anyone prayed for them? Did they believe spirits or guardian angels were helping them?
Together Vickory and Upton knew as much about kidneys as any two people on earth. Surely they had some thoughts worth hearing about intervention versus a wait-and-see approach. And Habra was about as gentle and sensitive a doctor as you could hope to meet; he must have had opinions about the delicate task of treating people whose illnesses are due to their physicians. These were the sorts of ideas I was interested in hearing discussed. Instead, we talked of blood and urine and dysfunctional kidneys until precisely nine o'clock, when the conference ended. Notebooks snapped shut, chairs scraped back, and private conversations started as people milled around the door.
I stayed behind a moment after the conference was over. I was impressed that Upton had challenged Vickory and the standard of care as well. But it didn't seem to affect others in the same way; they were more amused by the power dynamic that was expressed than by the ideas behind it. And unfortunately Upton was probably more concerned with letting the students know his station than he was with Martinez's well-being. This was not what I had thought becoming a doctor was all about. I hated to think the profession might one day require such a performance of me. I hoped, if it did, I would have the strength to resist giving one.
I got up to walk to a window. It looked across a concrete courtyard on to another brick-and-cement wing of the building. The window was shut tight. Air was controlled at this institution. My great-grandmother would have been appalled by a building without working windows, shut up tight as a Tupperware container. She would never have attempted a healing in a room shut off from the rich resources of heaven, earth, and sky. She was a gardener as well as a healer. Besides medicinal herbs, she grew tobacco, marigolds and watermelon, beans, squash, tomatoes, and heavily plumed stalks of corn. The composition of her garden was a measure of her mood.
My Cherokee grandfather, Archie, would have been unable to pray in a room in which his tobacco smoke could not rise to the heavens to summon and greet the spirits he communed with. Archie's cigars -- or smoke sticks, as he preferred to call them -- would have succeeded only in activating the smoke detectors and summoning the fire marshal. Archie would have wondered how people could get well without feeling the healing powers of the sun on their skin.
What a vast difference between the hermetically sealed hospital and the ramshackle Kentucky church where the snake handler's congregation gathered. The brightly lit, sterile rooms of Western medicine couldn't have been further removed from the darkly mysterious sweat lodges where, I had been reading, my Native American ancestors held their healing ceremonies.
The academic world had met my thirst for knowledge throughout high school and college -- but it had proven to be as spiritually barren as it was intellectually bracing. Now my spiritual desires, which had never been well addressed by the tidy theologies my mother favored, were demanding my attention. I stood with my back to the window, looking over the empty conference room, listening to the echoes of the hour-long discussion of transplant candidates, waiting while two lessons emerged. Neither had anything to do with kidneys; both, I realized, had been part of my curriculum from my first day at SMCMC.
The first was a lesson about patients. From a modern doctor's perspective, a patient is a bundle of biological matter, a collection of tissues to be rolled in and out of treatment, X-ray, and operating rooms. A doctor needs to know nothing about the soul wrapped in those tissues. In fact, we were taught that the less we knew, the better -- the more objective we could be.
I started wondering about Juan Martinez. A forty-two-year-old carpenter from Los Gatos. I bet his parents had come from Mexico when he was still a child. Perhaps they were looking for the good life in America. They traded the long traditions of a life in Mexico for the orange groves of San Jose -- now plowed under, replaced by homes, malls, and parking lots. Juan's health had gone the way of the orchards. Until recently Juan was dying; now, for a while, he was not.
We had no idea why Juan had been one of the relatively rare casualties of renal biopsy, or why he had been granted a reprieve. Nor were we particularly interested in finding out. We didn't know anything about his relationship with his wife or his daughter. In fact, if by accident we had seen anything telling when his family visited, or caught some sense of their feelings in their glances and questions, we actively tried to forget it.
We didn't know about his anger at us or how it might affect the course of his disease. About his faith, if he had any. About what he believed had caused his illness. Was it El Destino, the fate Mexican-Americans are said to believe in? What did he believe was the meaning of his life? How had this illness altered that? I wondered what he might have told us about his illness and his recovery if we had only listened more and measured less. Or what we might have learned about the three dying patients who shared his room, whose only hope now lay in miracles, and for whom we therefore had no hope.
The second lesson was a vision of ourselves as doctors. We were being taught to do no more than diagnose disease and manage conditions -- including those which arose from our own interventions. But we were not to be embarrassed by our own impotence; we were to accept it gracefully. We were learning to deny our ignorance of the mysteries of health and disease. We were well on our way to becoming not just doctors but paragons of "scientific objectivity," holding sacred hard numbers and physical data instead of subjective world views. Only the foreign doctors like Habra could see through the smoke screen of omniscience we used to obscure the things we did not know.
We viewed ourselves as having the only possible answers to health and disease. Didn't royalty from Saudi Arabia fly all the way to California to be treated by our professors? Wouldn't we soon be the colleagues and equals of these "learned" teachers? Our confidence in our world view was not diminished by the death of a patient, so long as we measured the process and documented it thoroughly. Even if we were able to save just one of four patients who came to us with severe kidney infections, we could walk away from the working day believing we had done all there was to do.
I loved science. I still do. Of course, in my college years I had encountered many people who were of the opinion that scientific discoveries precluded the possibility of a spiritual realm. But I didn't agree, and I had inspiring models to follow. Sir John Eccles, a Nobel laureate for his work on adrenaline and its role in the nervous system, was a visiting lecturer at Indiana University while I was an undergraduate there. He believed that science gave proof of God and the soul. Many of my professors thought he was a crackpot; I never missed a lecture.
Two months after meeting Señor Martinez I was bumping along in the back of a pickup truck toward the Wind River Reservation in Wyoming. I squinted my eyes against the bright sunlight to watch the gentle hills and prairies roll by. I had finished my urology rotation without getting into any more dangerous philosophical discussions, but I had also firmly resolved to pursue the magical world of Native American medicine I had been reading about. I didn't know how exactly to go about pursuing it, or where it would lead me, but I could feel in my heart that I was bound to try.
There weren't many people to whom I could talk about this desire and the conflicts surrounding it. I needed a mentor, someone who could help me discover a path toward spiritual medicine. I was lucky to find the friend I needed. Eddie, an Arapaho-Shoshone medical student, hailed from the Wind River Reservation I was now heading toward.
Like other universities in the early 1970s, Stanford was actively recruiting minority students. Our class of one hundred students included three other Native Americans. Counting the classes ahead, there were nine of us. Most were full-blooded and had grown up on reservations, but a few others were of mixed blood, including a blond Comanche woman. We all hung out together, and I first met Eddie through this informal support group.
All of us had in common cultural values that were at odds with expectations at Stanford. We were more inclined to cooperate than compete. We froze before the rapid-fire question-and-answer sessions on ward rounds, which medical students call "pimping." Our group never tried to make someone look bad on rounds -- though others did that to us, behaving viciously one moment, then good-naturedly thumping us on the back when the resident was gone.
Many behavioral habits confused us. We weren't used to people who were unwilling to sit in silence, who sought constant eye contact, who had a general lack of respect for illness, death, and dying. The two Dineh students from northern Arizona had it worst -- their sacred laws concerning death and dying were continually being violated. But we all felt a culture gap to some degree, and took comfort in each other's company.
One day, during my third rotation, Eddie sought me out in the pediatrics ward. He told me he would soon be going home to attend a healing ceremony for one of his relatives. I was thrilled and terrified when he invited me to come. Although I very much wanted to participate in a Native American rite, I was afraid to be found lacking, to be rejected for being a half-breed, for not speaking their language, or for committing some awful faux pas during the ceremony.
Native American religion was illegal at the time, having been outlawed by an act of Congress in 1895. Although schoolchildren learn that the Constitution protects freedom of religion, Native Americans were long denied the right to practice theirs. We were forbidden from congregating. We were not allowed to keep sacred objects, including pipes and eagle feathers. Eventually the injustice was recognized, and our right to practice our religions was restored by Congress in 1975. But the old laws were still on the books in 1973 when Eddie's family brought Nelson, a medicine man, down from Lame Deer, Montana, to treat their uncle, Jimmie Left Hand. His chest pains had gotten so bad that Jimmie couldn't meet the demands of his job, driving a delivery truck. The Indian Health Service doctor had diagnosed angina (chest pain caused by an insufficient supply of blood to the heart muscle) and wanted Jimmie to go to a hospital in Caspar for more tests, but Jimmie wanted to try a healing ceremony first.
If the local police discovered the ceremony, Eddie explained, the participants could be jailed and their sacred objects destroyed. These threats were real in Wyoming, where some of the police were fundamentalist Christians intent on routing paganism from the reservation. Other local cops were less diligent, especially those who were Arapaho or Shoshone, who participated in the traditional ceremonies themselves. One interesting character was the local Catholic priest, Father Stone -- he attended the clandestine meetings and sat ready to declare them orthodox Catholic rituals should any fundamentalist cops burst in. "The way he figures it, we all pray to the same God anyway," Eddie told me.
We were headed west from Caspar along U.S. 20-26, toward Riverton, a small city in west-central Wyoming at the edge of the reservation. The same highway took tourists to the ramparts of Yellowstone National Park and the Grand Tetons. From Riverton they turned north through Thermopolis. Devil's Tower was in the opposite direction.
Eddie and l leaned against the bales of hay in the back of the truck with his older cousin Kiefer. Eddie or Kiefer would sometimes chant a song as we watched the rocky hills roll by. Sometimes the sound of the rushing wind was too loud for me to make out their words. Kiefer's mother was Kiowa, from Oklahoma. "Kiowa like to make up legends," Kiefer said. "We got here late, only two centuries ago, so we had to work hard to make up as many as the other tribes around here already had." He laughed.
Before making this trip, I had begun struggling to remember my early childhood. Much of it seemed as far away from me as the legends Kiefer was spinning out for my benefit. In fact, I had been using stories to get back episodes from these times, writing out short pieces in an effort to recall long-forgotten memories. On visits home I would grill Archie about my past and his. I would talk to my grandmother Hazel, his wife, while she was cooking corn bread, greens, and bacon. I bought the few books then in print about Native American traditions, especially those of Vinson Brown, and read them avidly. In fact, I was so distracted by these pursuits that I had failed the anatomy section of my National Board exams. While passing overall, I still faced having to study anatomy again all summer long -- Stanford students are required to pass each section, not just the exam as a whole.
But the wind in my hair and the late afternoon sun on my face were working to remove my current worries about medical school. Cresting the top of a hill, the truck frightened a herd of pronghorn antelope, which bounded away from the road, leapt over the sharp angles of a rocky hillside, and disappeared behind a stone escarpment. Under scrub sage and tumbleweed the brown earth hid its unlovely past -- the bones of settlers and Indians who had slain one another, the carcasses of the buffalo herds massacred after the building of the railroads. For as far as the eye could see, nothing stood taller than two feet except the rocks that marked the graves of some long-forgotten men.
"We have a few trees on the reservation," Eddie promised, winking.
We stopped for a milkshake at Yellowstone Drug in Shoshoni, a two-street town just before Riverton that catered to tourists on their way to the park. At Yellowstone Drug they counted every milkshake they sold. If your receipt number matched the last three digits of the total they had sold so far that year (by July, the total was up over twenty thousand), you won something. We didn't win anything material that day, but while we slurped our shakes Kiefer had the time to tell us a story about Devil's Tower he had heard from his Kiowa grandmother.
"Eight kids were playing there," he said. "Seven sisters and their brother. They came too close to a sacred place. Suddenly the boy was struck mute. He couldn't say a word. He shook all over and got down on all fours. His fingers became claws and fur grew over his skin. Before long he was a bear. He scared his sisters. They ran from him in terror. He chased them, thinking he was still a boy, running after his sisters. He didn't know what was happening to him. He had no way of knowing yet that he was a bear. Probably he was just as scared as the girls. He chased them to the stump of a Great Tree, which is now called Devil's Tower. The Great Tree told the girls they should climb all the way to his top. The bear tried to follow them. Maybe he was just lonely, or maybe he was scared because his sisters were running away from something and he wanted to run away from it too. But however deeply he sank his claws into the bark, he kept slipping back down the Great Tree. When the girls reached the top, they kept going. No one knows how or why they did that. It was probably the magic of that sacred place. The bear kept trying to get to them, and he scratched the Great Tree's bark on every side. The seven sisters stayed in the sky. They became the Big Dipper."
I loved the storytelling, but it also provoked my fears. Fears of rejection, and of failing to understand things others took for granted. I didn't really know what Kiefer meant by his story -- if he meant anything. Was it just a kid's tale, or was it a coded message I ought to understand? I nodded sagely when Kiefer finished, and hoped I looked convincing.
I was afraid, too, of mystical powers in the night that would turn on me, perhaps kill me. I had been told that we would be going straight into a sweat lodge. While I had read about lodges, I had never been to one. Eddie had kidded me the whole way to Caspar about how hot it would be and how disgraceful it would be if I had to leave. He told me that future fathers-in-law tested potential sons-in-law by taking them into the sweat lodge. If they made it through, they could marry the daughter. If they shamed themselves and their families by fleeing from the heat, that was the end of the courtship.
I was terrified of how the heat would affect me. I had never even taken a sauna or gone into a steam room. I preferred the cool fog of the Pacific Coast to the humid heat of Kentucky, Ohio, and Indiana, where I had grown up. Also, my childhood fear of the dark still lingered. When I was very young, Hazel would tell gruesome stories about the evil spirits and escaped convicts that lurked in the dark of night to eat little children. During my later childhood, I cringed in terror when my stepfather asked me to go to the barn after dark by myself. When he made me go down into the basement at night to put coal into the furnace, I would cover my head with a sweatshirt and peer out of the tiniest opening, thinking that somehow this would protect me.
Eddie had told me that the sweat lodge was absolutely dark inside. And hot. Yet the stakes were high. My acceptance hinged on my behavior in that lodge. The closer we got, the more frightened I became. The sweat lodge had taken on an importance beyond anything else I had done or had yet to do. In fact, I felt like my whole life, my soul and my being, would be tried that afternoon in the lodge.
I felt something crawling on my neck and almost jumped out of my skin. It wasn't a bug, though; it was a piece of hay Kiefer was playing with. Eddie and Kiefer were laughing at my nervousness, trying to tease me out of it.
I was worried about being a half-breed, about not looking the way I should. Eddie and Kiefer looked the way most people expect an Indian to look. My own appearance is typical for a Cherokee; I'm often mistaken for a southern European (most usually a Yugoslav, for some reason). Like many members of the related Iroquois tribes, the Cherokee are not a very dark-skinned people. Some Cherokee are even fair-skinned. I'm a little more olive than fair. My skin can turn really brown in the sun, but I hadn't been outside much since starting med school.
"What's the problem?" Eddie asked, interrupting my ruminations.
"Nothing. Well, worrying," I answered distractedly.
"About the sweat lodge."
"That and everything else."
"I'm sorry," he said. "We'd better stop teasing you. Let me make sure you know what will happen."
One of Eddie's uncles was driving the pickup, with his big black Stetson on the seat beside him. Rifles filled the gun rack. Eddie moved closer to me so he could speak over the roar of the wind and the road.
"They've been heating the stones already," he said. "My brother Floyd is the firekeeper. He builds the fire and gets it just right. He prays over it and with it, helps it to burn strong in the four directions, and makes sure it stays sacred. When it's ready, he places the stones onto the fire, piles wood around them, and keeps them covered until it's time for them to come into the lodge. Then he'll carry them in with a pitchfork."
"When we get there, the men will be ready to go in. They've planned to wait for us. Nelson will lead the lodge. We'll all follow him inside. He doesn't do mixed lodges, so if the women were planning to sweat, they'll have already done so. It'll just be the men of my family and Nelson and you, and any old men that Nelson has invited, and any singers he's brought down from Lame Deer to help."
"What about Jimmie Left Hand?" I asked.
"You'll meet him this evening. This afternoon's sweat is to purify those of us who will be there tonight to pray for Jimmie. He's probably too ill to join us in the lodge right now." Eddie bowed his head thoughtfully before continuing. "Nelson will fill his sacred pipe and put it on the altar outside. Then he'll have Floyd bring in the first bunch of stones. Then we'll close the door and he'll start to sing. Like I said, he'll probably have a singer with him to help."
"I don't know any of the songs."
"Sit next to me in the lodge," Eddie said. "Hum along with me. You'll catch some words right away. Kiefer and I will keep singing some like we've been doing, so you won't be hearing these songs for the first time."
"When does he open the door?"
"A day later." Eddie laughed. "Just kidding. After the songs are done for the first round. We usually sing the directions song, and a pipe song, and a prayer song, and maybe an eagle song for the first round. But if you get scared or are too hot, tell him and he'll open the door early."
"Never," I hissed, thinking I'd rather die of heat exhaustion than embarrass myself in front of Eddie, Eddie's family, and Nelson, the great medicine man.
"That's the spirit." Eddie clapped me on the back. "Keep thinking like that and you'll do fine." He wore jeans today, and a denim jacket. Eddie's jet-black hair -- short on top and long in the back -- danced in the wind. His skin was richly dark despite his year under the fluorescent lights of the hospital. I thought how natural and self-assured he looked here, compared to how nervous and out-of-place he looked in his white lab coat back at school.
"No one back at Stanford would believe what we're doing," I said to Eddie.
"You think anyone on the rez would believe what happens there?" We were inside the reservation grounds now, bouncing along a dirt road. The sun was setting over the high peaks of the Continental Divide. Long shadows were growing from the rocky hills around us.
Eddie continued explaining the sweat lodge to me, how it was built, what would happen. "It's supposed to symbolize the whole world," he said. "Also the womb of Mother Earth. Even though it's a half sphere above ground, you're supposed to think of it as a whole sphere going down inside the earth as far as it stands above the earth. The pit in the middle of the lodge is where they put the stones. Think of those as your placenta. You're returning to the womb of Mother Earth. The placenta is there to doctor you and to take away the wastes and the toxins that you no longer need. You're going to sweat them out. The stone people get filled up with the energy of the sun when the wood is burned. Then they give that energy back to you. That is the medicine." He paused a moment. "We cover the lodge with canvas and plastic tarps. Once, we used to cover it with skins, but no one can afford that now."
We passed a small crossroads with a store, a gas station, and a church. Several dilapidated houses were standing by faith alone on either side of the road. Dogs scurried off the highway at the sound of our approach. Old men sat on the store's porch. Shortly afterward we turned onto a very rough dirt road. We must have continued on that road half an hour, bouncing past jackrabbits and scrub sage, washes and hills. "It's more fun to ride out here on a horse," Eddie said, after a particularly rough bump.
When the truck stopped, I could see smoke coming from a fire just over the next ridge. Someone hollered from the top of the ridge in a language I didn't recognize. "Hurry," Eddie said. "They're ready to start."
We ran up the ridge. A short way down the other side sat the most beautiful simple structure I had ever seen, a half sphere covered with a dull green army-surplus canvas. The door faced west, and before it was the fire, glowing bright hot. Eddie's brother stood bare-chested beside it, soaked with sweat, leaning on his pitchfork. Before I knew it, we were standing beside the lodge, shucking our clothes down to our underwear. Eddie's father had towels for both of us. The other men were already inside. I was terribly conscious of my too-white skin. Nevertheless, I hastily pulled off my T-shirt, dropped my jeans, and tied a towel around my waist, just as Eddie was doing. We each draped another towel around our shoulders; I was glad to cover my paleness. Then we bent down and went inside.
Eddie said something as he entered. I mumbled something similar, trying to sound just like him. Twelve men were sitting around the circle. My heart was beating in my throat; my moment of reckoning was at hand. I followed Eddie to the back of the lodge. He spread his towel on the ground and sat on it. I did the same. As soon as we were seated, Nelson yelled something out the door. There was a flurry of sound, and Floyd appeared with a red-hot stone on his pitchfork. He put it down just inside the door. Nelson took an incredibly long, beautiful pipe and touched the pipestone bowl to the stone. He said some words; then two men lifted the stone with deer antlers and placed it in the westernmost part of the pit as Nelson spoke again. He was speaking Northern Cheyenne, which I had heard before only in audiotapes of peyote rituals. He sprinkled sage over the rock. The sage promptly burst into flames. I was already too hot.
Nelson repeated this process six more times as Floyd kept appearing with stones, each one seemingly larger and hotter than the one before it. After the seventh stone had been laid out, Nelson handed Floyd his pipe. Floyd leaned it against a wood frame on the altar. Nelson said something else and Floyd grunted. It was intimidating not to understand a word.
"Ten more stones," Eddie whispered to me, interpreting what had been said. Oh my God, I thought, my heart sinking. I suddenly felt weak and light-headed. I was already overheated and the door hadn't even been closed yet. What is happening to me? I wondered in a panic; then I thought of the boy in Kiefer's story, who had turned into a bear and couldn't understand that either. I found the story oddly comforting as I too felt the rumbling beginnings of a deep inner change, one over which I had no control. A sweat lodge can make you feel as helpless as a baby, dependent on Mother Earth for survival.
Once the seventeen stones were all arranged, Nelson spoke again and Floyd closed the door. It wasn't dark, though -- I decided Eddie had only been teasing. The reddish glow from the stones filled the inside of the lodge. I began rocking back and forth. Nelson started shaking a bear-claw rattle. His singer began the Four Directions song and everyone joined in but me. I started humming along as Eddie had suggested, catching a few words here and there. Sweat poured into my eyes. My heart was racing. I could hardly catch my breath. I felt as if I was going to die from the heat. I tried to remember the symptoms of heat exhaustion, but my mind just wouldn't work. I couldn't stay focused on anything. Great, I thought, I'm getting delirious.
The sounds comforted me, however, and carried me along. I wrapped myself in my towel to keep the searing steam from burning my skin. I made a little opening in the towel to breathe through, as I had done years before with my protective sweatshirt. I put my head low to find air, any air, anywhere.
Just when I thought I couldn't take another moment, Nelson called out and the singing stopped. The door opened. I tried to look cool despite my panic. Eddie looked me over. "You know, you're sitting in the hottest spot," he said, laughing. "You're doing good." I groaned. No, I hadn't known. Yes, Eddie had sat me there on purpose.
Nelson chatted with everyone while we cooled off. I must have been a sight -- filthy head to toe, from rubbing dirt on my sweaty skin to stop the burning; hair disheveled, hanging stringily down to my shoulders. I couldn't see Nelson all that clearly because the light was poor and I'd left my glasses outside the sweat lodge. Now I saw what Eddie meant -- things got darker as the stones cooled. Eddie said something and pointed at me. Nelson looked me over. "Welcome," he said finally, in English.
Before the door closed again, Floyd brought in ten more stones. It got hotter and hotter. This time the song was a prayer song. Suffering greatly, I hummed along. I had made it through one round, I would make it through another. I remembered swimming two miles at a Boy Scout camp. I had thought I would drown before I finished, but here I was today. I remembered running so hard once in high school football practice that I threw up afterward. And I had gotten through that. I used to give every ounce of energy I had during football games, and then find some more when the two-minute warning sounded. I would convince myself that I could do anything for two minutes. The problem was different now, though, as I didn't know how many minutes stretched before me.
We started praying when the song ended. The singer prayed first. Then came the man on his left. Each man prayed in his own language. The sounds were beautiful. Just when I felt I was adjusting to the heat, Nelson poured more water on the rocks; the steam was cooking my nostrils, I was sure. Finally it was my turn to pray. I prayed in English, the only language I knew. I felt I stood out speaking that way. Nevertheless, I tried to pray sincerely and intensely. I tried to remember how Archie had prayed, and I did it that way. Occasionally one of the men grunted or said "Hau." Obviously they understood me, even though I did not understand them. I felt small and insignificant in that lodge just then. I was a nobody among men of power.
Finally Nelson prayed. Suddenly he stopped himself, then continued in English. I was grateful, and embarrassed, too, knowing it was for my benefit. When he finished, the door opened. I felt the heat pouring out. I was ready to collapse, and we were only half done. To my relief, Nelson called for water. He was speaking English now. "Drink this," he said. "It has been blessed. This water is now the blood of Mother Earth, the life of the stone. Drink it and you will be healed."
Slowly Nelson passed a dipper of water to each person. The full dipper traveled clockwise, the empty dipper returned counterclockwise. "It is this way," Nelson told us, "because all fullness travels the way of the sun and emptiness in the opposite manner." I prayed my thanks when the water reached me. Never had I been so grateful for water. Never had it tasted so good. It filled every cell, every pore of my body, with sustenance. The water came around a second time and many men splashed themselves with it, pouring some over their heads. I followed their lead; the shock of the cold water on my hot scalp was intense. It awoke me from my delirium. I was alert again, if absolutely exhausted. Eddie gave me the thumbs-up sign. Ten more stones were brought in, and the ordeal began again.
The third round involved more prayer songs. Then came a quiet passage when Nelson invited us all to cry out to the spirits for a vision. Did I have a vision? Not while I was struggling just to survive. The most I hoped for was to be able to walk out of the lodge later, rather than be carried out. One good thing was, I was too exhausted now to be afraid. I slouched down to the floor. Soon the door opened. "Sit up," Eddie said sharply. "Be alert. The pipe is entering."
I struggled to sit straight. Floyd entered the lodge with the pipe. I tried hard to coordinate my muscles enough to wipe the dirt and sweat off my face and hands, as the other men were doing.
Nelson lit the pipe, and his singer took the first puff. Slowly the pipe went around the circle. The tobacco was both sweet and harsh. I puffed carefully -- Eddie had warned me not to let the pipe go out.
"Think of your prayers," Nelson said. "As you smoke and the smoke goes skyward, it goes all the way to the Lodge of the Creator. There your prayers will be heard and answered."
When the pipe had made its way around the circle, Nelson finished the tobacco. He returned the pipe to Floyd, who put it on the altar. "We're almost done," Eddie whispered. "This is the last round." Then Floyd fetched ten more stones and closed the door.
"Rejoice," Nelson said. "Your prayers have already been answered. You have been purified. Now we will celebrate. Each of you take your privilege. Tell us something good. Tell us a story, sing us a song, say another prayer. Whatever you wish to do, that is your privilege." Each man took his turn. One told about a cousin who had been cured of cancer by Nelson. Another told of a relative whose depression had lifted. Another sang a song. When it was my turn, I thanked them all for letting me participate. Then Eddie talked about medical school, and how hard it was for him. He said I had been his friend and made it that much easier. Other men thanked me for that.
There's something, I thought to myself. I had been so wrapped up in what I needed from Eddie, I hadn't thought about what our friendship might hold for him. Perhaps, part of the magic of the sweat lodge was to be found in just this, getting the chance to say something simple but important to a family member or a friend.
Finally it was Nelson's turn. "Open the door," he said. I really rejoiced at that; I had made it through the ordeal without disgracing myself. "I have a story for you."
And the story he told went something like this:
Imagine a young man who has distinguished himself as a great hunter. The coyotes follow him to pick over what he leaves behind. Behind them come crows and vultures. When people are hungry, they count on this young man to find the buffalo on the great plains. He always finds the herds and gets their meat, so the people can survive another winter. He is careful when he hunts to follow the sacred traditions of praying and thanking the buffalo for the girl of their meat for the people to eat.
One August morning, the young man comes to a place by a stream where he knows the buffalo will come to drink. He waits with his bow ready. Butterflies and dragonflies buzz around him excitedly, knowing what is going to happen. He sees a buffalo cow coming toward him, and he draws back his arrow. But before he can let it go, something magical happens. He doesn't know if he fell asleep or if the world turned upside down. A beautiful young woman steps from the weeds to the pebbles at the edge of the stream and takes a drink from a buffalo horn. He stands up and walks toward her. Her hair is wild and tangled. She smells of wild sage and prairie flowers. In less than a moment he knows he loves her. He stands before her unable to speak.
She says, "I come from the buffalo people. My father sent me here because of your good feelings toward all buffalo. The buffalo council knows that you are a good, kind man, so I was sent here to be your wife. So that we can set an example for people of both persuasions -- the stand-upright people and the walk-on-all-fours buffalo people -- of how to live together in peace and harmony."
They get married and live happily for a time. They have a son and name him Calfboy. But you can imagine how it goes in a small village -- people talk. There are some people who don't like this woman because she doesn't comb her hair the right way. She doesn't smell like everyone else or talk like everyone else. She doesn't follow the same customs or eat the same foods. "Where does she come from, anyway?" they ask. "Who does she think she is?"
Pretty soon, people in the village are saying she's an animal and will never be one of them. One day when the young man is out hunting, his relatives get together and tell the woman that she has to leave. They're menacing, so she picks up Calfboy and runs away. When the young man comes back from hunting, he sees his wife and child leaving in the distance and he runs into the village to see what has happened. When he finds out, he's very angry. He sets out right away to bring them back, but they have a head start and are moving quickly.
All day long he follows their trail. When he loses it, the grasshoppers speak to him to tell him which way to go. By evening he reaches a painted tipi. He sees smoke from the cooking fire coming out the top. He sees Calfboy playing outside. When Calfboy sees him, he says, "Come on in, Papa. Mama has dinner ready. She's cooking a good meal." And so the hunter enters the tipi and eats corn and turnips, which is what they would have at that time of year, maybe with wild greens from the trail, flavored with sage and other things like that.
While his wife is feeding him, she says, "I've got to go home to my people. I can't live anymore with your people. You can't follow me because, if you do, my people will kill you. They will be so angry about this whole situation that they'll kill you dead."
And he says, "I don't care if I die. I love you and I'm going to go where you go." Next morning he wakes up and the tipi has disappeared and he is lying there in the grass. He sees a circle of dew around him, so he knows he didn't hallucinate. He sees the tracks of his wife and child leading off and he follows them all day long. Once again at the end of the day he finds the tipi and his son comes out to meet him.
"Mama's going to make it really hard for you to follow us tomorrow, so you won't be killed. She's going to make the rivers run dry. When you're thirsty, look in my tracks and you'll find some water there."
Then his wife comes over. She points out a distant high ridge and says, "My people live over there. You really can't come because they'll be so angry they'll kill you on the spot."
But again he looks at her and says, "It doesn't matter whether I die. Nothing is going to make me turn back. I do this because I love you both." While his wife is asleep that night he buckles his belt through hers, and he wraps her hair around his arm. Still, in the morning he wakes up alone. He sees tracks leading away from where he is, but they are the tracks of a buffalo and a small calf, not a woman and a child. But a flock of ravens comes to tell him that the tracks belong to his family. And they lead up to the high ridge. He follows those tracks across a dry, winding river, and he finds water in Calfboy's tracks, which keeps him going. Finally he gets to the top of the ridge and, from behind a rock, looks out in awe over the whole buffalo nation. There are buffalo everywhere as far as the eye can see.
Calfboy, his son, has been looking out for him. When he spots his father, Calfboy comes running up on all fours and says, "Papa! Go back! They're going to kill you."
The hunter says, "No, son. I came to stay with you. I'm not going anywhere. This is where I belong."
"You'll have to be brave, then," Calfboy warns. "Don't show any fear or my grandfather will kill you. He's the chief of the whole buffalo nation. He's going to ask you to find me and Mama. You'll know it's me because I'll twitch my left ear like a fly is bothering me. You'll know Mama because I'll put a cocklebur on her back. Be alert, Papa, and you'll survive this trial."
And so the hunter comes down off the ridge, and the old buffalo charges him like nothing you ever saw. The old buffalo paws the earth with his hooves and tosses sagebrush with his horns, and still the young man stands his ground. He doesn't flinch. He doesn't move a muscle. He doesn't show any fear. Finally the old buffalo stops and says, "This stand-upright person has a strong heart. He doesn't show any fear. I guess I won't kill him outright."
You can see that his courage saved him. The old buffalo leads him back to the painted tipi in the middle of the buffalo nation. All the buffalo gather to form a circle around them. The little calves are in the inner circle, then the yearlings, then the youngest cows, and all the way out to the oldest bulls, in circles according to age. And the old buffalo says, "If you're so smart, if you're such a good man, show me who your son is."
And so the young man walks around and around until he finally sees a young buffalo with a twitch in his left ear. He says, "This is my son." And all the buffalo are really surprised.
"What a wonderful person," they say. "This guy must be really smart."
The old buffalo says, "Okay, stand-upright person, if you think you're so smart, find your wife for me."
And so the man walks around and around again and finally sees the cocklebur. He says, "This is my wife," as he pats her on the head. The buffalo are amazed. A tear falls from his wife's eye. The old buffalo announces that because this stand-upright person loves his family so much and because he is willing to die for them, they will make him one of the buffalo. And they will have a big ceremony to do this.
The old buffalo says to everyone, "Make a circle around the tipi. We're all going to join in with our thoughts and make him a buffalo." And so they take off all the young man's clothes and cover him with a buffalo robe with horns and hooves attached. Then they put him inside the tipi and tie the door shut. For three days and three nights the buffalo surround the tipi and fill the air with their grunts and bellowings. They sing songs in the buffalo language while they paw at the earth. On the fourth day the oldest buffalo make a sudden rush and push the tipi over. They roll the young man over and over until he's covered with dirt. They squeeze the breath out of his body and breathe new breath into his lungs. They lick him and rub him until all of his human smell is gone. When this is over he tries to stand up, but he can't stand up straight anymore. Finally he struggles to his feet on all fours like a newborn calf. And when they hear him grunting and talking in the buffalo language, everybody makes a big shout and they work even harder, turning him over and over in the grass until he is truly one of them. At last he can stand strong on all four feet.
It was this day that made the buffalo a friend of the human being. Because that brave young man loved his family so much that he was willing to become a buffalo, the buffalo agreed that they would give their flesh to the humans so that little children and unborn babies would have meat to eat to survive the winter. A covenant was created between the people and the buffalo nation.
"That's an ancient story which is considered sacred," Nelson said. "The elders say a story has a spirit of its own. They say that when you retell a story you release the power of its spirit."
Why did Nelson tell this particular story and not another? Medicine people use stories like mirrors, to catch an image of our hearts and minds for us to reflect upon. A story teaches and pleases all at once. At the time I didn't think to question or analyze the story; I was simply caught in its spell. Now I see how, for the sake of love, the hunter in the story is willing to transform himself into something entirely new, something he can't begin to comprehend. He's willing to die to be reborn. This is the essence of what healing requires. Healing will not happen unless you're willing to die for it. If you're not willing to reach into your own depths, at least as deep as your life-threatening problems, then you will not earn the power you need to change them.
The story Nelson told gets to the essence of healing, which is perhaps why he told it. But why tell this story of healing to the men assembled in the sweat lodge, when it was Jimmie Left Hand we had all gathered to heal? Were we being prepared to help him, to be strong ourselves, so we could lend Jimmie our strength? It worked for me. Nelson's story provided a context, a stimulus, and a catalyst for what was going to happen. I was fascinated, even mesmerized, by Nelson. I was ready to open my heart to him because he was so genuine, warm, and caring.
Maybe Nelson didn't choose this story consciously. Maybe it just occurred to him when it came to be his turn. I don't know what the story meant to the other men present. I don't know exactly what the story meant to Eddie, and whether it helped bring peace to him about his struggles at Stanford. I know that the story struck home for me. For not only is it a story about healing and transformation; it is a story about an individual caught between two worlds. And it is a story about a man with a special gift, who discovers why he has been given it -- why he is here.
"We're done," Nelson said. "Follow me out." He went first. The rest of us formed a chain behind him. I was behind Eddie. When I finally made it outside, I collapsed to the ground. I did not have the strength to walk another step.
Eddie knelt before me, smiling. "You're stronger than you think. That much is clear about you." I was glad he thought so, but I couldn't have answered if I tried.
"See you tonight, boys," Nelson said, walking past us.
Copyright © 1997 by Lewis Mehl-Madrona