Consumption (59 page)

And so medicine has intellectual shortcuts: intuitions and platitudes and rules of thumb. These are called heuristics: “Never let the sun set on an abscess” (operate early when you find one, antibiotics don’t work well on walled-off infections) or “until proven otherwise, painless third-trimester vaginal bleeding is placenta-previa” (an imminent obstetrical catastrophe) or on a more particular note: “Gerald hasn’t looked right for months now, this isn’t just a cold.”

The feeling, the art, is precisely what is appealing about medicine, for doctors. It is personal and warm, and dramatic pithy platitudes about the indications for surgery are easier to remember and more satisfying to cite than the constantly changing and dry data on outcomes. And the art
is
necessary. But in the end, the art is simply what one wants it to be. And if one simply feels that blood transfusions are good for people with pneumonia, should that be enough reason to transfuse them?

The answer has always been, pretty much, yes. Clinical impressions do matter and ought to be taken seriously. When an experienced neonatology nurse doesn’t like the look of an infant, for instance, a paediatrician takes that very seriously, or quickly learns to. Even if there is no fever, or abnormal lab tests. It sounds a little like magic, this art. And once you believe a little in magic, it’s hard to imagine there’s anything it can’t do. Hence the over-reliance on clinical impressions and on intuition. And the suddenly dead cardiac patients.

Ours is a less heroic age. The dramatic cures in medicine have stopped coming. Penicillin for meningitis, streptomycin for tuberculosis, Salk and polio,
survivable operations for appendicitis and infected gallbladders: what those days must have been like, with self-evident cures trotting forth regularly for all the old killers. Everyone used to die of this, now almost everyone recovers—the only trick is in making the diagnosis. How satisfying it must have been, how easy to feel potent.

Now we die of things like congestive heart failure: diseases that haven’t submitted to easy, magic-bullet cures and have the habit of announcing their presence quietly, when they are already well advanced. These are pared away incrementally, the mortality rate decreased by a few percentage points with this manoeuvre, a few more with that one. A number of things help a bit, nothing helps a lot. If there were single simple answers to be deduced from clues in the disease’s nature, they probably would have been found by now. Or they have been.

So the warriors are being replaced by the accountants. The 28 per cent response rate is traded for the 31 per cent response rate; differences in effectiveness that are too subtle to be noticed by an individual practitioner justify ongoing refinements in therapy. The numbers dictate the changes and each year the outlook is slightly better. Each decade, substantially better.

The wariness of medicine testifies to its recent maturity. Confident bravado was a useful trait for a time, but this a different age now, and the derring-do of trauma surgeons is less useful generally than the methodical fastidiousness of bookkeepers who are suspicious of eureka moments and the impression that a phenomenon is known. It is much less romantic, this approach to problem solving, and this is appropriate for our much less romantic time. We have won the dramatic fights. The predators hanging out just past the light of the campfire are all dead. We are rich and resourceful. What we struggle with now are our self-injuries.

devotion

(i) to the community

L’Hôpital Sainte-Thérèse in Chesterfield Inlet stands out as an anachronism among the younger buildings all around it. It towers above the hamlet of four hundred Inuit, and from its top storey the floe edge may be glimpsed even in late winter, miles from the shore of Hudson Bay. It is the oldest building there and is constructed of thick wooden beams the size of ship timbers and has nearly cubic proportions, jutting three storeys high into the arctic wind. The buildings that surround it, the new houses and the interlocking government buildings, were shipped here prefabricated from Montreal or, by train and barge, from Winnipeg. They sit upon poured concrete pilings, and line the rock face of the coastline like aluminum-sided molluscs. When the wind blows very hard the new buildings all rattle and the snow blows right under the floors, between the pilings. In the morning, even with carpeting, it is necessary to wear shoes while dressing because of the cold seeping in from beneath. The old hospital, on the other hand, is like a hollow tree. It is imposing and resolute and of a time when the Church was considered above suspicion, and when the idea of missionary work among indigenous peoples was not itself suspect. It was erected when such structures were built in the place they were meant to stand, of heavy timber and with thousands of man-hours worth of labour.

It is the only building with a basement in the community. The permafrost and the rock face do not normally permit them. The priests that built the old
hospital were wedded to temperate-climate architectures, however, and dug through the shallow soil to bedrock to lay the foundation of the hospital. In the basement is a bread oven that has not been used since the Oblate fathers, and the doctors they employed, left in the late 1960s. There is also an old workshop with a dusty lathe and drill press. A small room and a narrow cot lay off to one corner—presumably for the baking priest’s use—but is unused.

Once, there was an old priest visiting the hospital and he died in his sleep in that bed. The last nun with medical training—my friend Sister Isabelle, who kept the place going until her death—used to tell this story with a conspiratorial gleam. You thought, Next she’s going to tell the story about the monkey’s claw. But she didn’t. She just walked on through the corridors of the former hospital, reeling off the outlines of anecdotes like forgotten genealogies. These things happened. These people existed. There was no attempt to impress, and anyway it was all being forgotten. On the moment of her death, in 1999, a whole history vanished.

The bread oven in the basement and the obsolete surgical equipment seen lying about in odd corners are dusty and corroded. They have been unused since the mid-1960s, when the federal government assumed responsibility for health care in the Arctic, and the Church was eased aside. The old hospital, the only one ever to function in the Kivalliq District, stopped performing surgery then and stopped treating emergencies or providing any sort of acute care; anyone requiring hospital admission was flown instead to the hospital in Churchill, by this time a booming Canadian and American army town of five thousand. There were military physicians there, with specialist surgeons and anaesthetists. It was probably a reasonable decision at the time. The military’s interest in the Arctic looked to be long-lasting and anyway, there is a rail line to Churchill; shipping supplies and people there is possible all year long and is vastly less expensive.

When I was last there, the old hospital in Chesterfield Inlet was now home to a dozen handicapped Inuit children. There were eight to twelve patients at any one time. They suffered the sequelae of meningitis, adrenoleukodystrophy, cerebral palsy, and various genetic and idiopathic neuro-degenerative disorders.

It was sad to see them there, as it is to see such children anywhere, but the care they received was extraordinary. Some were fed through surgical feeding tubes; others could be fed orally but only by dint of tremendous patience and affection. Bedsores—a constant problem in the care of such children in most centres—were very uncommon, testimony to the fastidiousness and tenderness with which these children were turned in their beds, and washed each day, and sung to.

They were cared for by a handful of women led by Isabelle, who was then eighty-five years old and had possessed as long as I had known her a vitality and fresh-aired enthusiasm not commonly seen in urban settings except among the deranged. The first time she took me fishing on the ice floes I watched her bounding out over the several-foot-wide leads in the ice like there was no possibility at all of ever slipping or, worse, falling in. I gingerly held a foot out trying to span the gap and she hollered at me from the other side, “You just have to throw yourself across. It’s all about momentum!”

The other women included at any one time at least a few nuns—usually two—and two middle-aged Inuit women who lived in the old hospital on the patient ward, in stark plastered rooms with cots and plain wooden crosses on the wall. Isabelle was one of the last nursing sisters still working anywhere and certainly the only one in this part of the Arctic. The others helped at whatever they could, but the truth is that it was, and had always been, pretty much up to Isabelle.

She knew her children so well that without lab tests, she usually could tell when the anti-convulsant drug levels were too high. The doctors who visited from time to time admired her deeply. We were none of us as dedicated or as selfless as she. She would pass the prescription pad, and as I took dictation, we chatted about her childhood in the Qu’Appelle Valley in Saskatchewan. Her accent was still lyrical and full of long vowels and I could only imagine how isolated her family was, that she did not learn English in 1940s Saskatchewan until late enough in her adolescence that an accent still endured at her age. She told me once how she decided to become a nun, after working outside the home for a year, at a bank, I believe, and she was unhappy and lonely and wanted community. When I first met her, at sixty, she was tall
and thin and disconcertingly beautiful; as a young woman, I think she must have been painful to look upon.

Until very near the end, she walked every day from the old hospital to the airport, ten miles out of town, even on the coldest days, which, on the tundra in January, are a different experience altogether from what is usually meant by the word
cold
, requiring, really, their own term, one that better contains the ideas of unwelcome pain of searing immediacy. The manager of the Co-op store, which buys carvings and furs and sells ammunition and Cheezies, thought that she was insane. He fished and hunted with the old men as avidly as any southerner had, but in January he stayed inside and watched satellite television and worried about her when blizzards blew up quickly. She dismissed his concern with a wave. Or rather, she did until the very end of the millennium. Then she learned that she was very sick and would soon be unable to continue working.

I have not been to Chesterfield Inlet since this terrible news. I can only think that she must have been irritated by the insistent concern of her friends and colleagues. And the manager of the Co-op. I imagine that she was terrified by the question of what would become of her children and the old hospital. This would have weighed on her on her like a clamp. Isabelle was an anachronism as much as the old wooden building is. There are few young nuns, and the initiates no longer often choose to study nursing—that is no longer the province of religious orders, at least in this part of the world. But neither are there nurses who will work here and accept being on duty all the time, and rarely take vacation. Nor are there such doctors, for that matter. There is a nursing station run by the Nunavut government in town, but the nurses there seem to change every six months and nobody knows how to persuade people to stay in that job. Which pays well, and involves holidays.

It seems inevitable that the old hospital will close. The facts of its history are less relevant than the fact of its age, and the extraordinary expense of heating it. Several years ago it was pointed out that there was no sprinkler system in the wooden building and that this was the least that could be expected of a place where handicapped children are cared for. Funds were found somehow.

There are other renovations in its future, to meet future building-code amendments, but buildings may be modified only so much before it becomes more practical to simply build new. This is true in cities and more true in the Arctic, where building supplies are shipped thousands of miles and it would be no more difficult to send up a barge with a new rectangular aluminum-sided building on it. But that part is not the obstacle. The problem is the matter of who would work in the new rectangular box. This problem seems to have no solution.

Selfless devotion to others is not as much seen among my generation as it was among Isabelle’s. None of my doctor and nurse friends are prepared to be on call all the time, except in brief, well-remunerated spurts, and it is unthinkable that any of us would work that hard in anonymity. If any of us want to work for free we will go with Médecins Sans Frontières, to some topical and equatorial disaster, where there will be other concerned Western doctors and nurses and maybe some sort of social life. Nobody I know would go up to the old hospital, over the long run, to replace Isabelle.

There is an idea contained in the massively constructed hospital, of resoluteness and faith, which I admire but do not quite understand. I have no faith myself, have never attended any church, and I find the nostrums of organized religion facile and unpersuasive, mostly based on mind tricks to assuage the fear of death. That’s what I think. But there is something else in there that I wish I had access to. The religious sense of agape, of not just concern for, but of personal obligation—to the point of ongoing sacrifice if necessary—to one’s fellow humans. There is self-righteousness in this, certainly. The evangelical sentiment that lies within most missionary efforts is, faced squarely, fairly repugnant on one level. As if these people didn’t have gods already, and ones better suited to this fierce climate. But whatever the contradictions of the ethos that brought Isabelle to the Arctic and kept her there, it did—and the children she cares for are not anonymous residents of some chronic-care ward on the southern prairie. They live their short lives in the Arctic. And their parents may visit them. It is much better that she was there, that someone did what Isabelle did. She died May 15, 1999, in a convent in St. Boniface, in Winnipeg.