Applied Medical Anthropology in Northern European Setting (Estonia)
What is hidden behind the words Medical and Anthropology, which sound more academic than operative?
Kart gave us a reason to understand how many social and emotional dynamics influence the psychosocial efforts done by her, the family, the doctors and the nurses. Medical Anthropologist ameliorates the comprehension of the “hospital life”. Aiming to spread the gynaecological prevention, we hope that the following lines can contribute to keep alive the memory of Kart among us.
Medical Anthropology’s Closet
One thing that can surprise a Medical Anthropologist during his first experience with a patient is the immediate acceptance of his role as a “sensitive person” on a stage where there seems to be only hasty doctors and careless nurses. The authority that is conferred to me by my bourgeois outfit in the middle of a swamp of white coats is a new experience for me and it is characterised by politeness. This is the same politeness that freed me from embarrassment when the Doctor told me about a young patient who speaks my same language, Italian, in the centre of the Estonian capital. Determined to do my best, even if I would not expect a similar “case” on my first operative day, I wait for the Doctor to present me to the patient, and with her ok I enter the room.
Kart’s bed lies besides that of a robust and tired grandmother. Kart is a girl slimmed down by the long recovery and laid down like a feather on the white sheets. Her pale face is marked by two evanescent cheeks, a typical characteristic of Estonian women, which makes it even more incredible that we share a language which is neither Estonian, Russian nor English. This normally happens only if you frequent the clubs sited in the Old Town, where you can easily meet foreigners.
I tremble, I have just crossed the threshold of the room and I stand in front of two creatures so different but profoundly bonded by a mutual presentiment. I present myself and sit down mechanically. I was sure I would make a bad impression, if Kart’s weakness had not forced me to speak slowly, detecting the subtlety of her movements, and to read the meaning on her lips and through her whispers. I behave as if I feel the same struggle to talk. I am propelled by my hidden discomfort. I ask her name, lingering on some details of her frail body, I think of how the ovarian cancer has made her live her whole life in just a few months; she looks like an old lady with the skin of a child.
We exchanged few words that afternoon, but those we did say were intense. As the grandmother gazed outside through the window, at who knows which lost point of the city, I asked Kart if she needed anything. I had noticed some water and fruit juice bottles discarded on the small side table, the majority of which were empty but had not been thrown away. I remember her answer perfectly: “fresh water”. I went to the cafeteria to buy a bottle of water and when I came back I could hear the hoarse and determined voice of Kart’s grandmother reading her a fairy-tale. I knocked, and after I gave her the bottle of water I received two “thank you”s that never I will forget, one in Estonian and one in Italian.
I returned the next day, after hardly sleeping due to a painful stomach ache. I found her there, alone and even weaker than the day before. I understood that the right thing to do was to talk about rest and calmness, and to relax. I could feel that these words were suited to her, but not to me, as I would desire to hear her her opinion on everyone and everything. In the time it took her to respond “yes”, I had already forgotten the question I had asked her. Then someone knocks at the door. A man, roughly thirty years old, walks through the doorway and shakes my hand. After a few moments of hesitation there is a mutual understanding, and I leave them alone in the room. After few minutes he walks out of the room and comes towards me, where I am leaned against a blue stretcher in the corridor. He starts to talk to me as if we were two people who had just met on the street. He asks my occupation, but it was just an excuse for him to start talking about himself. He says that he has taken temporary leave from his optical company, where Kart worked. He felt obliged to be here with her, and told me about the problems he had had with hospitals in Italy; some had asked for 150.000€ for an operation with an uncertain rate of success. He does not talk about his misfortune, adversity, or destiny; Bruno is a rational man who deals in the reality of facts. He decides to bring Kart back to her mother country on Christmas Eve. When everyone was worrying about the Christmas preparations, he was planning a last minute flight.
Just briefly reading “Cattiva’s Closet”, Kart’s blog, is enough to understand that Kart unabashedly taken control of her life. When once sunny pictures and confessions in her mother tongue dominate the blog’s pages, the following keywords now prevail: cancer, surgery and chemotherapy. Bruno remarks the difference between this and a blog that before was followed for keywords like: boots, fashion, and tagliatelle.
Meanwhile Bruno sits with dignity, attempting to rationalise what is happening. I try to cheer him up with a tit-for-tat, which seems to comfort his forced silence, enforced by his lonely nights in an empty, central apartment with few evening distractions. Kart’s grandmother comes out and take’s Bruno’s place as he goes in, then comes Kart’s brother and a friend to whom she does not like to show herself. I listen more than I talk, and when I can I reply with moral words of encouragement that I am not sure I could ever truly apply. I begin to understand more, and I can see from the conversation a man who seeks encouragement, with sense slowly returning to his life. He seems take much from me and to reassure himself with that. I cannot give him more than my phone number so he can call me when he needs me.
I did not want to intrude on such a delicate and definitive moment. I have had experiences similar to this but never as stranger, as a professional. He calls to update me, saying that her grandmother is breaking down and he does not ask me to come. I assure him that the next morning I will reach the hospital at 9.00, and he thanks me.
Honestly, the most intense moment of my life is contained in less than one minute of that surreal conversation. Indeed, at a certain moment Bruno asks me how he should behave with Kart, whether he should talk about the disease or not, and what else? I tell him that is better to avoid the topic, that touching and looking at her are less helpful now. When a person is dying the most important thing is whispered and slow speech, hypnotizing her with ancient, profound words such as peace, rest and relax. I assure him that it will help him to accompany her her to a serene death; that his words will hold her hand.
I will never think back to where these words came from, nor their truth or anthropological effectiveness, without remembering his silence as he took in what I said. That unconditional loving gesture was so beautiful; I could see that it will stay with Kart forever.
Medical Anthropology as a bridge can treat the pain of the patient as well as that of their relatives, linking their lives inside and outside the hospital. It suggests the best ways to communicate with the patient on a case-by-case basis. I consider it useful to continue in this direction, anticipating the progression of the illness and medical protocols. These protocols are responsible for the data and information, as well as taking advantage of its detachment from the patient. The Medical Anthropologist, informed by both the doctor and the patient about the clinical progress, accounts for both perspectives showing themselves as a sensitive interpreter of the different backgrounds, all of them necessary throughout the therapy and for its success.
Saturday was the third day I spent with Bruno and Kart. The rhythm of the hospital conveys a quiet atmosphere, slowed down by the absence of weekday technicians, doctors and some discharged patients – often coincident with the lack of beds.
At 9.00 I meet Bruno on the same shaky public transport, and we get off near the hospital. Our conversation covers diverse topics. That morning, the discussion of Kart’s disease was brief, with the exception of some talk about what had happened over the last month. Other topics prevailed; stimulated by the fact that Kart was more present and serene than the day before. She gazed upon us with her eyes, a gesture made even more profound by her bodily immobility; she seemed to be looking for answers, but not to questions about her health. Numbed by drugs, she asked Bruno something about a celebration of marriage – who knows if it was a dream, or perhaps a desire for happiness. Beside her he tried to behave as if everything was be normal- he even found the time and the clarity to comment on my dear Medical Anthropology (he had done some research on it the night before), as “an important discipline which aims to supervise and improve the quality of the healing assistance”.
It was hopeful morning, made slightly surreal by the empty spaces surrounding us, which were vaguely filled with young and careful nurses in transit, who always seem to have something different to do. Only Kart spread hope, concentrated and vigilant on her last moments of contact with the world. She looked like a sultan in her pyjamas, royally ruminating upon the riches of the world before leaving them to those around her. I felt more and more involved, and more and more aware of the fact that my participation was based on detachment, reciprocity and solidarity, words that should be rediscovered without allusion to their commercialised meanings. I accepted Bruno’s tentative of friendship without any hesitation That morning I left Kart beside her grandmother, who talked to her with the same tenderness that is normally reserved for children. Although it was an uncharacteristic way to speak to a grown woman, it seemed to give Bruno a feeling of freedom and help him understand himself, and he went alone to find the cafeteria. As he departed, he told me some friendly suggestions and jokes. He seemed enchanted that Saturday, with a frail enthusiasm and hope in his eyes.
As the sun set Bruno called to update me. He told me that I should work with others tomorrow, as I had helped he, Kart and her grandmother enormously. He also said that he hoped that I could spread my role throughout other hospitals, and I garner the same hope – our role is necessary in the medical system.
Often, and I am certainly not the first to support this thesis, it is helpful to tell people in a calm way, with slow phrases and pauses, to help the listener to maintain steady nerves. The patient is very sensitive to the mood of the person beside them, and when their condition worsens, due to the familiarity of their expressions and slow, calm breathing, she is able to stay calm.
That afternoon we move from the Chinese rural terracing, Ikea meatballs and business management to the inevitable Italian politics break. We speak of the culture, given that we are both foreigners in Estonia, made to feel even more foreign in the hospital. Although it is Sunday, there are few visitors, and the emptiness of the ward would effortlessly destroy even the unconditional joy of a child. Her grandmother had spent the whole day beside Kart, who seems to have recovered from her panic in the morning , closed in the room that will stay in her memory. I pass some time in conversation with Bruno; he gets excited showing me pictures from a trip they took to Asia. He says he has no regrets in the time he spent with Kart. He is a man who understands happiness. He has learnt how avoid getting angry, interpreting anger as a weakness,, a Chinese tradition. I use my common sense when we no longer have mutual topics to talk about. I like listening to him, lingering on his soft blue eyes. It’s as if he has just returned from a long voyage, full of stories of adventure and conquest. Then, Kart’s brother arrives. He is, like many of the locals, blond and masculine. He stands quietly in the doorway, ready to pick up his grandmother. I can see that Bruno is surprised by the fact that her brother can behave so coldly, seeing his own sister lying weak and weary on the cold hospital bed. Her brother is not stupid, he seems to quickly realise that the norm in Italy is to enter the hospital rooms animatedly, talking and energized, even if the patient is almost unconscious. It is obvious that our country is very far from here.
Before she leaves, Kart’s grandmother stops in the corridor to speak with a nurse that is around her age. She needs to share her feelings with someone with whom she can connect. “Perhaps you see something similar in me”, I suggest to Bruno, who is lost in self-destructive theories concerning Kart’s grandmother, who will become sad and suffer, no matter what she does. Ages, cultures, different lives.
Meanwhile, Kart is waiting for a glass of fresh water, which is being brought to her by Bruno.
Basically, the problem was grounded in the grandmother’s pain; the cancer moved from the patient’s body to the bodies of those around her. Gently I explained to Bruno that it is currently more important to try and understand the suffering of the grandmother. Bruno and the grandmother have the same basic need: to accompany Kart to her destination. They are, however, using different means of transport, the first one through emotion, and the second with nervous tension. It is unlikely they will understand each other without a common language; they have just their gestures, gazes, emotions. He has the strength to succeed, and only with an intense discussion, as foreigners we are able to infiltrate layer that is surrounding Kart, to revaluate ways of thinking and talking about death, and tie everything together. Above all, the empathy in the Kart’s eyes, in which she can clearly see the end now. She is no longer focussed on the problems of the others in the room, yet she is aware of their importance. I hope that my next chat with Bruno will be more decisive.
The ovarian cancer is colloquially called “silent killer”; you do not know to have it, unless you get a transvaginal ultrasound to diagnose the disease. Kart’s blog can become a helpful medical tool, where young women are encouraged to talk about their personal problems and worries and to visit the gynaecologist. But at the moment those pages just motivate Kart, full of the sentiment to “never give up”.
The following Monday does not call fond memories to my mind. My wake up was psychologically and physically dull, and the news of Kart’s move worried me. It was as if I imagined that everything would be finished or eternally stay forever on that seventh floor. I thought that I had not completely managed Bruno’s anxiety, and was trying to figure out another way I could help him. Actually, the only effective support that I could give him was to listen. We were stuck in vortices of sharp reflections, of recriminations based on his, our Italian heritage, which often he compared with the different cultural identity locals. I wanted to interrupt him, as friends lost in a conversation usually do, but I stopped myself, imagining the following mental connections of such a curious man. I tried to imagine how he would behave beside Kart, how they enjoyed trips and dreams together. Little by little, every mosaic tile was finding its slot. It was not easy now to take care of Kart. I thought that separating them from each other with our chats would be mutually beneficial for them. Bruno had found the way to rouse Kart from her rest, with short sentences and soft, gentle “sì”s.
I remember that I was totally unaware of how long Kart would be able to fight the disease. I imagined that the move from the hospital to the hospice would tire her, and I was worried that her life hung by a thread. Bruno had much more confidence than me in that circumstance, and his drug of choice became spirituality, he would retreat to “Bruno’s closet”. He told me how she gave strength to the dreams of many young Estonians, with her ability to leave a small country like Estonia to find happiness somewhere else. We sipped a cappuccino and caffé latte, after his habitual cigarette smoked under the covered perimeter between the hospital exit and the cafeteria. It started to snow. As we spoke about stereotypes and the necessity to continue to encourage Kart, his eyes began to glisten. As usual, we said hello with a handshake; through her illness Kart allowed our friendship to be borne.
Kind and meticulous nurses do exist, and one in particular supported Bruno a lot during that anxious Tuesday. I would like to know how it feels to be someone constantly in the ward, to give her a voice. .
On Wednesday morning I opened facebook to find her gaze: the small nose, the lipstick and these lines: “Today Kart left this life. Her soul, her positivity will remain forever in our hearts. Please like to say goodbye”. There were already 300 likes at 10.00. Two hours later more than 1.500 thumbs-up, and roughly 400 comments. This shows how a gaze, a small nose and a lipstick can inspire hope in many young and varied Estonians. Bruno says that the majority of them do not live in Tallinn; it would be interesting to speak to them and to know their stories.
We recognise in Kart a magically spread luminosity, like the candle turned on by Bruno on that last night, we cannot forget the real love of this man and her grandmother. The only people who stayed beside her.Bruno asked me to give to the Doctor some words of gratitude from him. All in all, it seems that this part of my mission is complete. I thank Bruno, and await news about Kart’s funeral.
I believe that the real first tale of Medical Anthropology should end before the last goodbye to Kart. So that at least this fruitful experience of professional solidarity stays with us.
“The family of Kart authorizes the publication of this article”