Donohoe MT. “Exploring the human condition: literature and public health issues,” in Teaching
Literature and Medicine, AH Hawkins and MC McEntyre editors (New York: Modern Language
Association, 2000).
Exploring the Human Condition:
Using Non-Medical Literature to Teach Students
About Important Public Health Issues
Martin T. Donohoe, MD
Oregon Health Sciences University
Division of General Internal Medicine
Exploring the Human Condition
Exploring the Human Condition:
Using Non-Medical Literature to Teach Students
About Important Issues in Public Health
In this paper, I describe a novel approach to teaching concepts in public health, using nonmedical literature as a vehicle for vicarious experience and a catalyst for discussion of the social,
cultural, and economic determinants of the health of individuals and populations.1 Despite the
amazing technological advances of American medicine, the U.S. has indicators of community
health, morbidity, and mortality similar to or worse than other countries which spend far less per
capita on health care. Many feel that medical education fails to address adequately the
socioeconomic, cultural, occupational, environmental, and psychological contributions to
individual illness and community health problems. In response, reformers in medical education
are calling for increased emphasis on topics traditionally associated more with the field of public
health than with scientific or clinical medicine. Moreover, the Association of American Medical
Colleges, the American Board of Internal Medicine, and other groups have recommended that
curricula be population-based and adjusted toward societal needs, and that physicians be
encouraged to act as agents of social change.
As a physician concerned about these issues, I have addressed this need, by designing a
course that combines literature (short stories, essays, and novellas) with articles from
contemporary medical periodicals to promote discussion about the social, economic, and cultural
determinants of illness. Literature, medicine, and public health share a fundamental concern with
the human condition. Through literature, readers can vicariously experience new situations,
explore diverse philosophies, and develop empathy with and respect for others whose place in
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Exploring the Human Condition
society may be very different from their own. Reading about the experiences of those who suffer
the consequences of poverty, racism, stigmatization, and impaired access to health care can help
medical students to identify more closely with their patients, whose complex lives they glimpse
only during periodic clinic visits.
The course is an elective, weekly, small group seminar for medical students offered over
10 to 20 weeks. For each two hour session, students read prose selections, along with selected
research and review articles. The stories vividly describe such experiences as homelessness, or
being a victim of domestic violence, or finding oneself a stigmatized patient with a disfiguring or
contagious illness. Occasionally, participants read actual case histories. The journal articles
augment the literary selections by providing background on the issues raised in the stories and by
suggesting areas for discussion, debate, research, intervention, and physician activism. The
purpose of the course is to expose students to the instructive and evocative powers of literature; to
introduce basic principles of social medicine and community health; to facilitate discussion
between students regarding the social determinants of illness, the health of populations, and the
public health responsibilities of physicians; to increase empathy, understanding, and appreciation
of alternative viewpoints; and to encourage students to undertake further studies and/or research
in public health, and to publicly work towards solutions to sociomedical problems.
Each week the seminar focuses on a different topic, with complementary stories and
articles serving as catalysts for discussion. For the session on stigmatization, we read John
Updike’s “From the Diary of a Leper,” in which the afflicted narrator describes how his
relationship with his girlfriend, the quality of his art, and the reactions of society change during
the course of his outwardly successful ultraviolet light treatment for disfiguring psoriasis.
Students examine why Updike’s psoriasis victim seeks empathy and wants society to see beyond
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Exploring the Human Condition
his disfigured exterior yet, as he recovers, becomes hypercritical of his girlfriend’s imperfections.
They comment on how Updike’s victim invests the ultraviolet light therapy chamber with
mysterious, near supernatural powers and how this mirrors society’s desire for high-technology
interventions, which may not always be as beneficial or cost effective as less glamorous
preventive measures.
Updike’s fictional account is complemented by a study by I.H. Ginsburg examining
the psychological consequences of rejection and stigma in psoriasis patients. This serves as a
springboard for the examination of stigmatization of AIDS patients. Students read an article by B.
Gerbert et al. documenting physicians’ attitudes toward caring for patients with AIDS. They are
troubled by the results of a survey of health professionals asking if they would eat cookies
prepared by an AIDS patient or a leukemia patient (and if not, why not), and by a report by M.
Ragg on the Australian government’s controversial plan to compensate only those AIDS patients
who acquired the disease via blood transfusion.
Some students candidly share their fears of needlestick injuries from caring for
patients with AIDS and hepatitis, though they also acknowledge that occupational infectious
diseases among physicians were much higher in the past (e.g. bubonic plague, secondary syphilis
before the discovery of penicillin). They realize that if physicians cannot overcome irrational
fears about HIV transmission, that they won’t be able to persuade the public at large to overcome
its superstitions.
We usually also discuss the degree of blame physicians associate with different
afflictions, from alcoholism and obesity (where genetic disorders or character flaws can be judged
as intemperance or gluttony) to childhood leukemia (which afflicts “blameless innocents”), and
how blaming patients for their diseases can compromise one’s compassion for their suffering. I
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Exploring the Human Condition
ask students to construct a scale of blame for various diseases: they debate where to place not
only alcoholism and obesity, but also lung cancer and multifactorial conditions such as coronary
artery disease and adult-onset diabetes mellitus.
In the session on homelessness, Doris Lessing’s “An Old Woman and Her Cat”
provides a moving fictional entrée into the world of society’s dispossessed. This short story
details the struggles of two unwanted creatures, an aged gypsy and her adopted alley cat, trying to
cope with the daily struggles of life on the streets of London. When the woman becomes ill with
pneumonia, she takes refuge in a dilapidated, condemned house. She feeds on pigeons, caught by
her cat, which she roasts on rotting floorboards, until she succumbs to a lonely, isolated death.
Students discuss the reasons behind the woman’s progression from the disordered thinking
associated with mild dementia, to stubbornness and an unwillingness to accept solutions
proferred by social service agencies - as when, for instance, she refuses housing because no pets
are allowed in the building.
While some students initially express incredulity that the woman would rather starve
to death in a hovel than accept charity, most come to appreciate her pride in not wanting to accept
handouts, her desire for independence, and her loyalty to the pet who has been her only solace in
a world where the human beings she encounters ignore or even scorn her. An epidemiological
study by B.G. Link of the lifetime prevalence of homelessness alerts students to the dimensions of
the problem, and a clinical review by Usatine et al. describes the health problems commonly
experienced by homeless individuals. Through discussing the story and the article, students gain a
greater appreciation of the survival skills necessitated by a life on the streets and come to
appreciate why the homeless have lower rates of preventive care and medication compliance, and
are more likely to visit emergency rooms for their primary care.
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Exploring the Human Condition
In the session on family issues, we read Grace Paley’s “An Interest in Life,” a single
mother’s somewhat tongue-in-cheek story of searching for companionship, trying to raise her
children, and navigating through the often-illogical vagaries of the welfare system after her
husband leaves her. Students identify with the difficulties the mother faces and confront some of
society’s (and their own) stereotypes about “welfare mothers.” Many struggle with whether or
not to sympathize with the woman, who, despite being taken advantage of by her ex-husband and
a friend, continues to turn to them for emotional support and sexual solace. Articles cover the
economics of welfare, profile the American family, and discuss child care and parental leave.
For the session on race and health care, we read “The Sky is Gray,” Ernest J. Gaines’
story of a poor, single, African-American farm mother trying to obtain dental care for her ill
child. Students share in their struggle to overcome both overt and subtle racism. An essay by
Todd Savitt on pre-civil war medical care for slaves provides background on the origins of the
two-tiered medical system portrayed in the story, and an overview by the AMA’s Council on
Ethical and Judicial Affairs of current black-white disparities in health care illustrates that much
progress still needs to be made in improving health care for these minorities. We also discuss the
de facto segregation of health care that continues to exist due to socioeconomic differences in
access to care and the diminishing funding for inner city public hospitals, despite the fact that
suburban facilities have an excess of MRI scanners and other high technology equipment.
Students wonder about their own roles in both perpetuating and responding to the two-tiered U.S.
system of medical care.
After a brief introduction to different systems of health care delivery, from single
payer, to fee-for-service, to capitation and managed care, I encourage students to voice their
concerns about the future of medicine. They almost never worry about their future incomes, but
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Exploring the Human Condition
rather, speak passionately about the primacy of the doctor-patient relationship. Many worry that
increasing demands to see more patients in less time will prevent them from getting to know their
patients intimately and from addressing socioeconomic and psychological contributors to illness.
They worry that the corporatization of medicine will erode the bond of trust between physician
and patient so critical to healing.
Another meeting covers domestic violence, including child and spousal abuse and the
physician’s response to victims. In William Carlos Williams’ “The Insane,” a young pediatrician
shares with his physician-father his frustration at the long-term effects on a child’s mental health
of witnessing violence and of emotional neglect. In Michael LaCombe’s “Playing God,” a rural
doctor covers up a woman’s shooting of her alcoholic, physically-abusive husband. Students
interpret these short stories from the points of view of the abusers, the victims, and the
physicians. While it is hard to garner sympathy for the abusers, students recognize the roles
played by histories of child abuse, alcoholism, financial stressors, and many cultures’ acceptance
of male dominance within marriage, which all provide fertile ground for the development of an
abusive personality. And, while they grieve for Lacombe’s victim, they show frustration at her
unwillingness or inability to follow the physician’s repeated advice to extricate herself from the
relationship. In our accompanying discussion of a review by Hyman, et al. we discuss the pros
and cons of mandatory reporting laws: should physicians be required to report suspected cases of
violence against women, with the hope that, as with the early debate over required reporting of
child abuse, formal recognition of this offense will in time diminish its occurrence? Or does
mandated reporting, particularly when unaccompanied by measures to protect women from
retributive violence and to assist them in exploring housing and economic opportunities, place
them in acute danger and augment their sense of powerlessness? Interestingly, female students
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Exploring the Human Condition
have been more likely to agree that Lacombe’s physician did the right thing in covering up the
woman’s shooting her husband, whereas male students were more often troubled by the doctor’s
extrajudicially handling what many would consider murder.
Articles describing the relevance of domestic violence for health care professionals
(Council on Scientific Affairs, Violence Against Women) and the deleterious effects of witnessing
violence on child development (Groves, et al.) facilitate discussion of possible solutions to the
growing epidemic of violence in our country. These include stronger gun control legislation,
reducing the amount of violence in the media, stricter sentencing and attempted rehabilitation of
violent offenders, and emphasizing violence prevention through educational programs and
peaceful mediation of disputes.
Another course meeting covers poverty and access to care. Readings include “How the
Poor Die,” George Orwell’s timeless essay describing the abysmal conditions in certain public
hospitals; selections from Anton Chekhov’s writings on his journey to Sakhalin, where he
witnessed the detrimental health effects of extreme poverty; and “Phlebitis: At the Public
Hospital,” a chapter from homeless author Lars Eighner’s best seller, Travels with Lizbeth, in
which Eighner provides a scathing, sarcastic account of being treated with derision and suspicion
during his hospitalization for a swollen leg. The articles which complement these writings
examine socioeconomic inequalities in health (Adler, et al.), the costs of caring for the poor
(Epstein, et al.) and the health consequences of economic recessions (Jones). Students become
more attuned to the barriers to care faced by the poor, and learn a little about how medical care
for the indigent is financed.
Nevertheless, the historical pieces have frustrated students, who realize that while the
technology of medicine has developed remarkably, medicine’s approach to the detrimental health
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Exploring the Human Condition
effects of poverty has in some ways changed very little over time. Many of the topics we cover
could lead to a sense of nihilism or inculcate pessimism among the students; on the contrary,
most appreciate having been made more aware of these issues and express a desire for further
exploration of these topics - through the vicarious approach of reading stories, through sharing
their thoughts and experiences with fellow students in a supportive environment, and through
community involvement. Throughout the course, we discuss our roles and responsibilities as
physicians. These include improving our profession’s attention to the socioeconomic
determinants to disease, conducting research on underserved populations and disseminating our
findings to colleagues and policy makers, and volunteerism and service, as well as improving our
understanding of the different cultures we serve (often learning their language) and participating
in organizations fighting violence and international human rights abuses.
It is not clear to what extent this enthusiasm might wane over time. Offering similar
courses to premedical and medical students and physicians at other stages of training may help to
counteract the loss of compassion and jadedness that can afflict medical trainees and practitioners
over time. I have developed an expanded version of this course for fourth year medical students,
and am incorporating poems and brief stories into ward rounds and offering reading seminars for
internal medicine residents. I will be interested to learn how medical trainees respond to this
teaching method at different levels and over time.
The course I have described differs from and goes beyond other literature and medicine
courses in several ways. Though the centrality of a close doctor patient relationship to good
medical care (often the subject of literature and medicine courses) is acknowledged, equal
emphasis is placed upon sociocultural determinants of illness. Our patients’ lives are stories,
hence the usefulness of approaching a sympathetic understanding of their sufferings and
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Exploring the Human Condition
dilemmas through fiction. However, the signs and symptoms of our patients’ illnesses lose
meaning when they are dissected out from the patient’s social context, hence the value of
exploring their sociocultural milieu. The course’s melding of fiction and essays parallels
medicine’s nature as both art and science. Stories can be vehicles for vicarious experience experience that prepares students for the informative background material and fosters their
receptiveness to the suggestions for positive change in the articles. Students are encouraged to
develop the reading habits required for continuous, lifelong learning.
In conclusion, the use of stories coupled with journal articles to facilitate medical
students’ understanding of public health topics is feasible, enjoyable, meets the professed goals of
modern medical education, and should be utilized more frequently as a method of instruction. It
will require both verbal and financial support from deans and department heads; knowledgeable
and enthusiastic faculty; and, adequate curricular time (ideally in both the preclinical and clinical
years, as students’ perspectives develop through increasing exposure to patients). I am convinced
that such teaching can help contribute to the development of empathic, broad-minded clinicians
and policy-makers, sensitive to the social, economic, and cultural determinants of illness.
Through the course’s ecosocial approach, which focuses not just on problems affecting
individuals, but also on the broader determinants of health that can be changed only through
widespread social action, students can grow into strong advocates for the public’s health.2
Notes
1. The author gratefully acknowledges the editorial guidance of Dr. Anne Hunsaker Hawkins and
the support of the Robert Wood Johnson Clinical Scholars Program, the Palo Alto VA Medical
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Center, and Oregon Health Sciences University, and thanks Dr. David B. Wheeler and Susan
Schrag for their excellent technical assistance in the preparation of this manuscript.
2. Other topics in the course include alcoholism and substance abuse, aging and long-term care,
occupational health, and war and human suffereing.
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Public Health and Social Justice Website
http://www.phsj.org
martindonohoe@phsj.org
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