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VOLUME 2 | ISSUE 4 | WINTER 2013

OBLITERANTS H U M A N I T I E S A N D S O C I A L S C I E N C E S I N M E D I C I N E A N D P U B L I C H E A LT H

DIVERSITY OBLITERANTS | WINTER 2013

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OBLITERANTS VOLUME 2 | ISSUE 4 | WINTER 2013

JOURNAL OF THE HUMANITIES AND SOCIAL SCIENCES IN MEDICINE AND PUBLIC HEALTH

EDITORS Myra Jon Aquino Joanne Duara Mary Lan Alexandra Levitt Mairaj Uddin

EDITORIAL ADVISOR Gauri Agarwal, MD Assistant Regional Dean for Medical Curriculum

FRONT/REAR ARTWORK Front and Back Cover Photo by Larissa Lester

LETTER FROM THE Editors Welcome to the Obliterants Diversity Issue! This has been our most ambitious issue yet. We’re excited to share with you articles ranging from diversity in Miami, to health disparities, to religion, and even to interests like wrestling. In keeping with the principles of diversity and inclusion, we’re very fortunate to include in this issue articles written by individuals from the UM School of Nursing, School of Law, Department of Creative Writing, and the Department of Epidemiology and Public Health. In order to advance discourse on medicine and public health, it is necessary to view important issues in frameworks that go beyond those two fields. As a journal, we seek to be that conduit for fresh, provocative input and perspective. In the future, we aim for Obliterants to not only publish pieces from people all over UM, but also from other community members and leaders within and outside of Miami.

LAYOUT DESIGN Myra Jon Aquino

ABOUT OBLITERANTS Obliterants is a journal published by students, faculty, and staff of the University of Miami Miller School of Medicine. Its mission is to publish writings and artwork that promote the humanities and social sciences in medicine and public health. Obliterants is not an official publication of the University of Miami School of Medicine. Expressed written opinions are solely those of the authors and artists and do not necessarily represent those of the University of Miami, the School of Medicine, or the Department of Epidemiology and Public Health.

SUBMISSIONS Obliterants is published quarterly. Faculty, staff, and students are invited to e-mail their submissions to

obliterants@gmail.com

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We also seek to cover diversity within our own school, and with this issue we hope that you can get a chance to get to know more about your peers through their unique stories. We are so fortunate to be immersed in such a diverse group of students and to learn from each other. There are many misconceptions that we hope to shed light on, and opportunities for learning with every article and artwork that is being shared here. Discourse about diversity can sometimes be a touchy issue. Just as it’s easier to swallow a pill by drinking water, you will have a more powerful and enjoyable experience if you read this issue with an open mind. And as always, you can submit comments, concerns, and submissions to us at obliterants@gmail. com. Enjoy! Sincerely, Obliterants Team


CONTENTS

“I’ve always felt that it is impossible to engage properly with a place or a person without engaging with all of the stories of that place and that person. The consequence of the single story is this: it robs people of dignity. It makes our recognition of our equal humanity difficult. It emphasizes how we are different, rather than how we are similar.” - Chimamanda Ngozi Adichie, Nigerian Author TED Talk, “The Danger of a Single Story”

FEATURED ARTICLES

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DIVERSITY IN MIAMI

34

CLOSING THE DOOR ON LGBT-CENTERED DISPARITIES

14

RENEWING OUR GOAL TO REDUCE HEALTH DISPARITIES

46

IN DEFENSE OF WRESTLING

EDITORIAL 8

Diversity In Miami: Where Do We Fit In A City Of Fragments? Myra Jon Aquino

DIVERSITY IN MIAMI AND BEYOND 14 Renewing Our Goal To Reduce Health Disparities Nilda Peragallo 19 Reports from the Public Health Student Association Yasmin Dias-Guichot 22

I Came To Serve You Caitlin Hodge

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Talk About Something Else. Kelly Jean Grannan

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Establishing Time-Share Surgical Centers in the Caribbean Jason Frederick Emert

29

The Androgenization of Mary Brickell R. Rammy Assaf

30

Pesticides and Silent Spring, 50 Years Later Eric Hecht, Yasmin Dias-Guichot

DIVERSITY IN MEDICINE 32

The Danger of Culture Rob Fell

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Helping People Feel Like People: Closing The Door On Lgbt-Centered Health Disparities B. Adam Crosland

38

Do No Harm Melissa Stone

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Diversity Driven By Faith Gerard Smith

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41

Being A Mormon In Medical School Christian Blake Morris

43

Celebrations Mairaj Uddin and other students

S Caring HeARTS KEEP AN EYE OUT

SPECIAL INTEREST 46

In Defense Of Wrestling David Haverman

49

Fan Ye Fan Alexander Kaplan

AT THE BEDSIDE 50

Pharmaceutical Couplets Peter Schmitt

51 Tracheotomy Chris Joyner 51

Destruction of the Temple Meredith Camel

52

Don’t Rely On Miracles Zachery Hickman

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Things I Wrote In My Notebook At A Clinic In Guam Myra Jon Aquino

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The Patient Is Discharged Gauri Agarwal

EDUCATION 62

The Surgeon Artist Ekaterina Kostioukhina

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Conversations on the Social Network Mary Lan

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Anatomical Landmarks R. Rammy Assaf

64 Mnemonic Shari Seidman 65

House of Medicine Brett Van Leer-Greenberg

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Ode To Paul Shari Seidman

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In this issue, we feature artwork by children who participated in last December’s MedPals/Caring HeARTs event. Keep an eye out for these “hidden” treasures throughout the issue!

Special Thanks There were many people who were instrumental in bringing this issue together. Without them, many of the articles here would have never gotten to Obliterants to be published. • • • • • • • • • • • •

Sandra Abraham of the Interdisciplinary Programs and Initiatives, UM School of Law Courtney Avery of Cooking Canes Renee Dickens Callan of the UM Office of Multicultural Student Affairs Aliza Epstein of the Jewish Medical Students Association M. Evelina Galang of the UM Dept of Creative Writing Shekeab Jauhari of the Islamic Society of UM Jamal Jones of the UM Jay Weiss Center Linda Li and Christine Pao of Caring HeARTs and MedPals Maria Padron of the UM School of Nursing and Health Sciences Alejandro Portes of the UM Department of Sociology and School of Law Joseph Sollecito of the UM Regional Medical Campus Nanette Vega, Dr. Stephen Symes, and Dr. Stefanie Brown of the UMMSM Office of Diversity and Multicultural Affairs


CONTRIBUTORS As part of our diversity issue, we’re proud to feature ideas on medicine and public health from students, faculty, and staff hailing from various schools and departments at the University of Miami. In the future, we aim to continue to promote interdisplinary, innovative, and provocative discourse on medicine and public health through Obliterants.

Nilda Peragallo, DrPH, RN, FAAN CONTRIBUTING WRITER

Jason Frederick Emert

CONTRIBUTING WRITER

Nilda (Nena) Peragallo Montano is Dean and Professor, University of Miami School of Nursing and Health Studies. She has devoted her 35+ year research and academic career to improving the health status of minorities and other medically underserved populations.

Originally from Knoxville, Tennessee, Jason is in his final year at the University of Miami School of Law. Prior to attending law school he worked for a distributorship representing Medtronic Spine & Biologics and has maintained a strong interest in healthcare law and global development in medicine.

Renewing Our Goal to Reduce Health Disparities, page 14

Physician-Centered Medical Tourism in the Caribbean, page 24

Gauri Agarwal, MD CONTRIBUTING WRITER, OBLITERANTS EDITORIAL ADVISOR

Meredith Camel

Dr. Gauri Agarwal is the Assistant Regional Dean for Medical Curriculum. She lives in Boca Raton with her husband Anurag and their four children Ojas (8), Martand (7), Saranya (21 months), and Sitara (21 months). The Patient Is Discharged, page 61

CONTRIBUTING WRITER Meredith Camel, M.F.A. ’12, is editorial director in the Office of Communications and Marketing at UM. She is a recipient of the Alfred Boas Prize of the American Academy of Poets. Her work has appeared in Reconstruction: Studies in Contemporary Culture, Floorboard Review, CaKe: the Literary Journal of Florida A&M University, Gertrude Press, and The Whistling Fire. Destruction of the Temple, page 51

Eric Hecht, MD, MSPH CONTRIBUTING WRITER

Chris Joyner

Eric Hecht is a Voluntary Associate Professor in the Department of Epidemiology whose current area of research regards the chronic health effects of low dose environmental toxicant exposure.

Chris Joyner is currently an MFA candidate at the University of Miami, but his heart resides in Virginia. His work has appeared or is forthcoming in Penduline Press, Winning Writers, Brusque, Fiddleblack, the Barely South Review, and elsewhere.

Pesticides and Silent Spring, 50 Years Later, page 30

CONTRIBUTING WRITER

Tracheotomy, page 51

Yasmin Dias-Guichot

Peter Schmitt

Yasmin Dias-Guichot is currently pursuing her MPH at UM. Previously, she completed her Master of Life Sciences at the University of Maastricht in The Netherlands. Due to her international exposure she is interested in global health. She is the current VP of the Public Health Students Association.

Peter Schmitt is the author of five collections of poems and the 2012 winner of The Julia Peterkin Award in Poetry from Converse College. He has taught creative writing and literature at The University of Miami since 1986.

CONTRIBUTING WRITER

CONTRIBUTING WRITER

Pharmaceutical Couplets, page 50

Reports from PHSA, page 19 Pesticides and Silent Spring, 50 Years Later, page 30

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Zachery Hickman

Rob Fell

Zachery Hickman received an MFA from UM in 2003 where he was a James A. Michener Fellow, and currently is a Senior Lecturer/Managing Editor of Mangrove, the University of Miami's literary journal. His poetry attempts to forge the gap between idealism and reality, between the lyrical and the narrative. He is currently working on his first full length collection of poetry.

Rob Fell has lived various places including Montana, Japan, Boston, Bolivia, Germany and Miami. He likes eating cereal and sometimes yogurt. He is currently studying medicine and public health at the University of Miami Miller School of Medicine

CONTRIBUTING WRITER

CONTRIBUTING WRITER AND PHOTOGRAPHER

The Danger of Culture, page 32 Photography on pages 8, 30

Don’t Rely on Miracles, page 52

Gerard Smith

B. Adam Crosland

Gerard Smith is a second year medical student at UM. He graduated with a B.S. in Psychology from Virginia Commonwealth University in Richmond, Virginia. He was born in Miami and enjoys to travel, cook, and play sports.

Adam Crosland (MD/MPH 2nd Yr) is really enjoying spending a lot of his free time cooking and gardening. Dancing is his artistic outlet of choice and he can’t imagine his future without it.

CONTRIBUTING WRITER

CONTRIBUTING WRITER

Diversity Driven By Faith, page 40

Helping People Feel Like People: Closing the Door on LGBT-Centered Disparities, page 34

David Haverman

Brett Van Leer-Greenberg

Dave Haverman is a lifelong wrestling fan with nerdy tendencies. Former chemist, referee, and stock boy, and current medical student.  He has no idea what he wants to be when he grows up.

Brett Van Leer-Greenberg is from ‘Belle Harbor, New York’ and is the first in the past four generations of his family to foray into medicine instead of law. His interests in medicine include cardiology, hematology and medical ethics. Outside of medicine, his hobbies include collecting jazz and blues on vinyl, playing guitar, cooking and bicycling.

CONTRIBUTING WRITER

In Defense of Wrestling, page 46

CONTRIBUTING WRITER

House of Medicine, page 65

Melissa Stone

Alexander Kaplan

Melissa Stone is a 2nd Yr M.D. candidate at UMMSM and interested in pursuing a career in pediatrics and medical journalism. She has a strong interest in medical ethics, humanities, and history. She loves to write and her writings can be found in the Yale Scientific Magazine, UMMSM’s Humanities in Medicine Journal, and The Medical I.B.I.S.

Alexander Kaplan originates from Land O Lakes, FL where he enjoyed the works of Southern and Latino poets. Since then, his interest has expanded and he has decided to try his quite amateur hand at the written word.

CONTRIBUTING WRITER

CONTRIBUTING WRITER

Fan Ye Fan, page 49

Do No Harm, page 38

R. Rammy Assaf

Christian Blake Morris

Rammy is a strong believer in the saying, “Home is where the heart is”. If you ask him, he’d tell you Los Angeles, San Diego, Geneva, and Beirut are all his places of inspiration and close ties. Wherever the surroundings, Rammy finds tranquility and little bits of joy in creating objects around the house and exploring themes in the city.

Christian hails from Alpine, Utah. He enjoys outdoor activities such as soccer, skiing (snow and water) and plans on learning how to paddle board.

CONTRIBUTING WRITER

The Androgenization of Brickell, pg 29; Anatomical Landmarks, pg 64

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CONTRIBUTING WRITER

Being A Mormon In Medical School, page 41


Jennifer Schwenk ARTIST

Jen was selected for the “Advanced” Art class in middle school and since then has considered herself qualified to produce paintings. She loves to travel, take pictures, and then paint them. It’s cheaper than buying souvenirs, but more time consuming. Please don’t ask her to paint a human, only landscapes and architecture in her wheelhouse.

Shari Seidman

CONTRIBUTING WRITER AND ARTIST Shari Seidman is a 2nd year MD/ MPH candidate. She went to the University of Miami for undergrad where she graduated with a BA in Creative Writing. Mnemonic, page 64 Ode to Paul, page 67 First Year, page 66

Sunset, page 61

Ekaterina Kostioukhina

Myra Jon Aquino

Ekaterina Kostioukhina is a 4th yr medical student at the UMMSM Regional Campus with career interests in diabetes and obesity. “I discovered painting as a way of escaping into a world of color and imagination. A world where I can create and capture my experiences in medicine and make them into a painting of vibrant oil colors and strong contrast.”

Myra calls Guam and the Philippines home and when she isn’t studying medicine, she’s out watching movies, sneaking into non-medicine related classes at UM, or looking for the next best coffee shop/cupcake. She’s interested in incorporating storytelling, media, game design into studies/ career in medicine/public health.

ARTIST

EDITOR, LAYOUT DESIGN

The Surgeon Artist, page 62

Diversity in Miami, page 8 Guam, page 56

Carly Rivet

Mairaj Uddin

Carly Rivet grew up in Key West, FL and attended the University of Florida for undergrad where she studied biology. She loves being outdoors, especially out on the ocean. She likes black and white photography and hopes to pick up photography as a hobby again soon.

Mairaj Uddin is a first-year MDMPH candidate who graduated from the University of Notre Dame with a degree in Pre-Professional Studies and Arabic Language. He is interested in pursuing a career in international public health.

PHOTOGRAPHER

Ft. Zach Beach, page 27

EDITOR

Celebrations, page 43

Kyle Amber

Mary Lan

Kyle Amber is a 3rd yr MD student at UMMSM. He is a music composer, poet, and graphic artist whose works are often inspired by his medical experiences. Though the medical humanities make up a large portion of Kyle’s interests, he is additionally passionate about clinical research, especially health care utilization and skin cancers.

Mary Lan was born and raised in San Francisco, California. She attended the University of California Santa Barbara and will honestly try anything once.

PHOTOGRAPHER

EDITOR, ARTIST

Conversations On The Social Network, page 63

Photo, page 22 Spectrum of Equal Glasses, page 50

Larissa Lester

Kelly Jean Grannan

Larissa Lester is a second year MD/MPH student at the Miller School of Medicine. She is interested in health disparities and relationship-based community development. She loves photography because it is a powerful way to engage with people and tell their stories.

Kelly is a 2nd year MD/MPH candidate with a bachelor’s in Spanish from Ohio State University. She is grateful to Myra Aquino, the lovely, magnificent Obliterants editor, for accepting her late submission.

PHOTOGRAPHER

CONTRIBUTING WRITER

Talk About Something Else, page 23

Front and back cover photo Candles, page 40

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EDITORIAL

DIVERSITY IN

MIAMI WHERE DO WE FIT IN A CITY OF FRAGMENTS? In the collective American mind, Miami is a gorgeous city with an edgy reputation. But Miami is more multifaceted than popular media suggests, and it is only through an accounting of the city’s relatively short history and its diversity that we can begin to understand why Miami is fascinating to study. The question, however, still remains: Where do we belong in a city where there are so many opportunities to contribute to its growth?

WORDS BY Myra Aquino PHOTOGRAPHY BY Rob Fell, Alexandra Levitt, Myra Aquino

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Miami is remarkable in that it can be a very different city to different people. It’s a beach destination

and a cosmopolitan playground for the elite, but it’s also a second home for immigrants, and a place of refuge for many individuals who are fleeing violence and instability in their country of origin. Everyone carries different perceptions of Miami, and after having lived here for almost two years, I’ve come to liken the city to an iridescent iceberg: It emits different colors depending on how you look at it from the outside, with far more complex activities going on beneath the surface— beyond what meets the eye.

When it comes to Miami,

however, I can’t speak for the experiences of others—I can only speak for myself, and what this city has come to mean to me. As a Filipino American, much of my life is spent interacting with aspects of the Filipino diaspora, and examining how cultural assimilation and integration has affected my family and the people around me. Second generation Filipino Americans (and I suspect, other American ethnics) are raised to accept multiple realities and to perceive culture as a social construct that is modifiable— beliefs and values that are an unquestioned certainty to others have been cultural assumptions to us since we were young. Accepting this way of thinking is necessary if we are to integrate our parents’ cultures and values into our present-day “American” realities. It is a never-ending process of attempted cultural reconciliation that, at its best, can create new and transformative multicultural communities. But at its worst, it can lead to self-destructive identity crises and heartbreak. Somehow, re-acknowl-

edging this struck a chord in me as I began to see Miami through this lens— as a city that is, in part, comprised of ethnic enclaves and molded by waves of immigrants, each of whom carry with them the vivid, untold stories of their home countries and of the city they now live in. As students, we are given many opportunities to get involved in public health projects and clinics that serve different communities in Miami, and I am always struck by how every community I enter has its own distinct character, with its own collective sets of fears, hopes, and dreams. For individuals such as ourselves who are involved in medicine and public health and are continuously engaged with members of different populations, how do we go about genuinely engaging with such a diverse city? Answering this question requires a revisit to the concept of diversity. Difference, inclusion, variety. Diversity elicits different definitions, and it is a loaded word, a term that I fear has lost the power it once had. It’s important, however, to note that diversity isn’t merely a matter of demographics,

or a tiresome exercise in didacticism—it involves examining the politics of difference and inclusion in our cities and in our institutions. How does diversity within our own student body and within our own school manifest itself externally as well through our interactions with our patients, our communities, and with other sectors of society? These were all aspects of diversity that I was interested in investigating further within the context of Miami, a multicultural city with a complex history. At times, Miami doesn’t seem to be a “traditional American city” and this, along with many other reasons, makes it a fascinating place to study. One sociological framework has been proposed and it is based on the idea that social structures in Miami are constructed differently compared to other cities in the United States. The city has largely been influenced by Latin American and Caribbean geopolitics; successive waves of immigration literally mold the city into various shapes and sizes, each rendering more indistinct than the last. Because of this, a true under-

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MYRA AQUINO

Race Relations 101

A Skim Through The Glossary All terms and definitions taken directly from Introduction to Race Relations, by Ellis Cashmore and Barry Troyna

INSTITUTIONAL RACISM The policies of institutions that work to perpetuate racial inequality without acknowledging that fact. Douglas Glasgow refers to this as camouflage racism, meaning that it is not open and visible but is concealed in the routine practices and procedures of organizations such as industries, political parties, and schools.

CULTURAL DEFICIT Often, when victims of racism and various other forms of oppression continue to suffer across space and time, explanations are sought in their culture. In other words, they are not blamed as individuals, but neither is the society in which they live. It is the culture to which they belong that is seen as somehow flawed and inferior. So, according to this interpretation, their culture is identified as the main contributory factor to the oppression because of its (alleged) deficiency.

THE NUMBERS GAME Refers to the belief that the starting point for the debate about race relations is the absolute numbers of immigrants entering and settling in the host countries, their fertility rate, number of relations, etc. It avoids paying attention to the actual quality of relationships between different groups by concentrating only on numerical features of their presence.

SELF-IMAGE The conception persons have of themselves; their sense of identity. In race relations, the negative self-image of migrants (and their children) is often invoked to explain the lack of militancy or challenge to subordination. Briefly, this means that the migrant accepts what seems to be a prevalent definition of him or herself; if the rest of society believes all blacks to be inferior and suited for degrading work, it may well be that the immigrant comes to accept this negative image and settles quite happily for degrading work.

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I’ve come to liken the city to an iridescent iceberg: It emits different colors depending on how you look at it from the outside, with far more complex activities going on beneath the surface— beyond what meets the eye. standing of the city can only arise from knowing how it grew to be the way it is today. Though oftentimes newly arrived immigrants to the United States are faced with a culture to assimilate into, this doesn’t seem to be the primary case in Miami. In this city, there is “acculturation in reverse” where, to a certain extent, some immigrant cultures have exerted their own influence on the native population in Miami. Therefore, instead of being a city where different communities are incorporated under a single “dominant” culture, Miami has grown to be comprised of multiple parallel sociocultural structures, each of which represent communities that have established their own institutions, hierarchies, and cultural life within the city. As medical and public health students, where do we fit in this kind of sociocultural structure? How does it affect the way we communicate with different commu-

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nities in our public health projects and in the clinics that we serve? Does this kind of structure produce disparities in accessing health care in Miami? Secondly, Miami’s past and current socioeconomic structure can affect the political agency of its communities. In the first half of the century, Miami was dominated by the “Miami Anglos”, whose intention was to set Miami up as a prime tourist destination and as a major city for export. In the latter half of the century, waves of immigration significantly transformed the local economy, which in part led to the production of “enclave economies” (an ethnic economy of substantial scale). Different groups were affected in different ways by these socioeconomic changes, yielding narratives of success and upward mobility for some communities, while producing further neglect and disenfranchisement for others. These aspects of the lived


POPULATION BY RACE AND ETHNICITY Miami-Dade County, 2011

Miami, 1950

Florida, 2011 Non-white persons, 16.3% Black persons, 16.5%

Black persons, 19.3%

Persons of Hispanic or Latino origin, 64.5%

White persons not Hispanic, 57.5%

White persons, 83.7%

White persons not Hispanic, 16.0%

Persons of Hispanic or Latino origin, 22.9%

Asian persons, 1.7% Persons reporting two or more races, 1.2% Native Hawaiian and Other Pacific Islander persons, 0.1% American Indian and Alaska Native persons, 0.3%

Language other than English spoken at home, 2007-2011

Foreign Born Persons, 2007-2011 51.2%

Miami-Dade County Florida

19.2%

Miami-Dade County Florida

72.3%

27.0% Source: United States Census Bureau

experiences of members of different cultural communities in Miami mark historical periods that are long gone, but some of the same themes remain. It’s important to note that institutions in society have ways of preserving oppressive structures without realizing it, producing unseen and unjust consequences on communities as a whole. Gaining access to the economic core of a city is a very serious issue for any community in the United States. If a community faces significant barriers to job opportunities and housing, and cannot summon enough economic clout

to stake a place in the higher rungs of the social order, then they have little political agency. And without political agency, the community’s agenda will be overlooked, their concerns denied legitimacy. These are all very important considerations when taking into account the social and economic determinants of health in Miami’s communities. Do we have a responsibility to address economic concerns in the development of public health programs? Can our projects and programs exploit a community in ways that we ourselves cannot recognize? What priv-

ileges—socioeconomic, political, or otherwise— do we unconsciously exert that could alter the way we relate to these communities? History cannot be unseen. There is much that we can see through Miami’s history that has implications on how we view and engage with the city today. Miami is evolving into a global, modernized city where the future of many of its ethnic communities can, at times, seem a little unclear. In the midst of all this, where do medical and public health students fit in this discourse? What role do they play in Miami?

In this city, there is “acculturation in reverse” where, to a certain extent, some immigrant cultures have exerted their own influence on the native population in Miami. As a result, the city has grown to be composed of multiple parallel sociocultural structures, each of which represent communities that have established their own institutions, hierarchies, and cultural life within the city.

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“You have to live in Miami, sleep in it each day, to really know how it is and how it has forged the profile it has. It isn’t easy without a long historical accounting to understand the roots of so much incomprehension.”

INTRODUCTION

- Heberto Padilla, Cuban poet

ALEXANDRA LEVITT The answer is complex. Different issues arise when diversity is being addressed internally. Although the Coral Gables campus houses a diverse student population, it was explained to me by Renee Dickens Callan, director of the UM Office of Multicultural Student Affairs, that some students have problems connecting to the city. Furthermore, some students of color at UM don’t see race the same way previous generations saw it. “These students are thinking ‘I don’t have the same issues my parents had. I’m doing okay.’ For them,” Callan said, “the fight is not the same.” There’s a fake sense of racism ‘being in the past’—even though racism is still alive and well. This has implications on how students interact with each other. As students, are we still facing the same problems our families and communities used to face decades ago? Do we really live in a post-racial world? When I discussed diversi-

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ty in medical education in Miami with Director Nanette Vega, Dr. Stephen Symes, and Dr. Stefanie Brown, who currently lead the UMMSM Office of Diversity and Multicultural Affairs, Dr. Symes replied that “it’s a very complex situation.” Although UMMSM does actively recruit historically underrepresented medical school applicants through pipeline programs and minority pre-medical associations, the school loses some of these students to other medical schools due to UMMSM’s limited financial capacity to provide scholarships. This is changing, however, due to the Dr. Astrid Mack Diversity Endowment Fund, which is being developed to support the many diversity-promoting activities that the office facilitates. Additionally, they did mention that retention is better for medical residents who transplant to Miami. Some of these doctors saw an opportunity to care for individuals whose background may not be the same as

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themselves. This type of perception sets a strong foundation for them to connect to communities in the city. Diversity is not only an administrative issue, but one that manifests in the daily lives of students. For example, students may not see eye-to-eye on a certain controversial health issue, or a person may make a well-meaning but offensive statement, and be oblivious to its racist or sexist undertones. Conversely, however, classmates are in a position to educate each other about their own backgrounds, and to engage with each other for mutual insight and appreciation. The thing about diversity is that your front cover picture on a university brochure of a multicultural group of smiling students can either say a lot or say very little about what diversity is actually like at that institution. The term “diversity” can be a smokescreen that can obscure unvoiced and unacknowledged tensions arising from multiculturalism. I personally


UMMSM Office of Diversity and Multicultural Affairs A GLIMPSE

INITIATIVE

Program (MSHCMP), and the MCAT Preparation Program.

DID YOU KNOW

The objective of the Miami Model is to prepare high school and college students from disadvantaged backgrounds to successfully pursue a broad array of healthcare professions, including becoming a physician. This is carried out through programs such as the Summer Science Enrichment Program (SSEP), Students Training in Research (STIR), High School Careers in Medicine Workshop (HSCMW), Minority Students in Health Careers Motivation

FUNDRAISING

The Office of Diversity and Multicultural Affairs is open to medical students who seek guidance and social support. Drop by the Faculty Affairs office (D2-6), Park Plaza West Garage, Suite J (near main entrance to Jackson Memorial Hospital beside SunTrust Bank and across from the Latin Cafe) or email Nanette Vega at NVega@med. miami.edu.

wonder if the term “diversity” has lost the transformative power it once had, as if we have assumed long ago that “diversity” as an ideal has been reached, and that there is no longer any need to strive for a spirit of collectivism and activism in our universities. In my interview with Callan, she stated that the American spirit has become very individualistic, and that it is a barrier that gets in the way of community engagement. “At some point, you can’t always ask the victims to be the voice,” she said. “Who is fighting for others to get a piece of the pie?” Miami is many things— unique, intriguing, multifaceted, and it is a city that is continuing to grow into a future that isn’t quite clear, at least not yet. Regardless, let’s push the dialogue forward and ask ourselves: Why not stand, instead, for the possibility that Miami

can be not only a great city, but a great city for everyone? It’s difficult—but it’s possible. At the risk of this piece being ironically didactic, the bottom line is that before we can stand for the transformation of Miami, we have to first stand for transformation from within. Learn to distrust your surface assumptions about people and the communities to which they belong, and listen instead for the rich, complex stories they have to tell. Acknowledge the fact that racism and discrimination of any kind occurs despite good intentions, and that we currently live in a society where our entitlements can take away those of others in very insidious ways. Read Miami through its history and learn to recognize oppression and disenfranchisement, even in the smallest ways. Understand and become skilled in examining how economic, cultural,

Miami Model Program

Dr. Astrid Mack Diversity Endowment Fund Created to help support diversity initiatives in the Office of Diversity and Multicultural Affairs, including the Miami Model program, and scholarships for underrepresented groups pursuing medical school.

Guidance and Support

and sociopolitical problems in a community can serve as barriers to the success of public health projects. Recognizing and acknowledging problems for what they are, and collectively designing solutions that work for everyone are some of the first steps to creating a more just world. And I would argue that Miami is not so much an anomaly as it is a unique microcosm of the world with its many disparate backgrounds and cultures. How we engage with Miami now will shape our interactions with different communities in the future. All over the globe, metropolises are asking themselves the same question: “How do we all live and grow with difference?” The answer varies from city to city, from person to person. What is our answer for Miami? n

Miami is many things— unique, intriguing, multifaceted, and it is continuing to grow into a future that isn’t quite clear, at least not yet. Regardless, let’s push the dialogue forward and ask ourselves: Why not stand, instead, for the possibility that Miami can be not only a great city, but a great city for everyone?

For a list of acknowledgments, and of the resources used in this article, turn to page 60

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DIVERSITY IN MIAMI AND BEYOND

FEATURED ARTICLE

RENEWING OUR GOAL TO REDUCE HEALTH DISPARITIES WORDS BY Nilda Peragallo, DrPH, RN, FAAN Dean and Professor at the University of Miami School of Nursing and Health Studies

PHOTOGRAPHY BY Andrew Innerarity

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NEARLY 30 YEARS AGO, AN ENCOUNTER WITH A PATIENT CHANGED THE COURSE OF MY CAREER. In the early 1980s, I had just earned my doctorate in public health and was teaching and advising public health nursing students at the University of Central Florida in Orlando. One day, I was at the hospital with my senior nursing students doing clinical rounds. There was one room on the unit that no one wanted to enter. Since I had assigned one of the nursing students to the man in this room, we went in. When we entered we found trays all over the room, the curtains were down, and the aura of isolation could be sensed. This man had AIDS. Nobody wanted to enter that room because, at that time, none of us, not even healthcare professionals, knew what AIDS really was. This episode affected me to the point where I designed and implemented a study on nurses’ knowledge and attitudes towards HIV/AIDS patients. That study found a significant connection

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between lack of knowledge regarding HIV/AIDS and bias and discrimination against patients suffering from the disease. The results of that study changed state of Florida policy to require HIV/AIDS education as a pre-requisite for nursing license renewals. That man, alone in that room, propelled me in the direction of HIV/AIDS risk reduction and prevention research, with a focus on Latino populations.

Like many healthcare professionals in the 80s, I had been watching the HIV statistics from the CDC. The number of Latino women with HIV was steadily increasing. I wondered what was causing the disparity between Latinas and other groups, and, more importantly, whether something could be done about it. These questions led me to develop an HIV/AIDS intervention for low-income, inner-city Latinas. This intervention was the first R01 grant funded by the National Institutes of Health/National Institute on Nursing Research to a Latina nurse.

THE ESTABLISHMENT OF EL CENTRO I have tried to bring this commitment to reduce health disparities among minorities to my position as dean of the UM School of Nursing and HeaStudies. When I arrived in 2003, I enlisted the help of my colleagues in envisioning a

When we entered we found trays all over the room, the curtains were down, and the aura of isolation could be sensed. This man had AIDS. Nobody wanted to enter that room because, at that time, none of us, not even healthcare professionals, knew what AIDS really was.

first-class research center dedicated to understanding and addressing health disparities— the first of its kind to be housed in a school of nursing and health studies. In 2007, we were awarded $7 million in NIH funding to establish El Centro – the Center of Excellence for Health Disparities Research. El Centro’s ultimate goal is to eliminate the health disparities that affect Latinos, African Americans, Caribbean Americans, and sexual minorities. That original funding allowed us to develop our infrastructure, build and sustain community and academic alliances, expand our health disparities research training, and conduct innovative research studies to improve minority health. Every day at El Centro, our researchers are expanding the state of the science regarding how to address health and social problems that disproportionately affect minorities – HIV/AIDS and other sexually transmitted infections, substance abuse, family and intimate partner violence, and related mental and physical health conditions. We are developing interventions to prevent and treat these problems, while ensuring the approaches are

IN SUMMARY

EL CENTRO GOAL To eliminate the health disparities that affect Latinos, African Americans, Caribbean Americans, and sexual minorities.

PROGRAMS Reducing the incidence of HIV, STIs, and domestic violence among Latinas in Miami Assisting mothers in the recovery stage of substance abuse treatment Family-oriented mental health and drug use treatment for Hispanic adolescents Cultural factors and risk behaviors of Hispanic men who have sex with men and health risks of transgender women Family intervention study with Hispanic 9th grade students to prevent adolescent violence

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Through El Centro, Dr. Rosa Gonzalez-Guarda leads Juntos Oppuestos a la Violencia Entre Novios (JOVEN, “Together Against Dating Violence”), a teen dating violence prevention program that targets 9th graders. The program is guided by the principles of communitybased participatory research, and based on findings from a community forum, the program found that the Hispanic community in South Florida perceived domestic violence prevention as a high priority, especially for youth.

tailored to the cultural values and needs of each group. We are then putting these interventions to the test in the real world of community-based programs. In the process, El Centro investigators are working closely with students in interdisciplinary teams, thus educating the next generation of health disparities researchers. This work has paid off in the form of a second $7 million NH grant 5 years later, which ensures El Centro’s research will continue through 2017. This award will allow us to continue building a program that serves our University, as well as our local and global com-

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munity, in advancing the science of eliminating health disparities. The new funding will allow El Centro to conduct two new randomized trials that will test evidence-based interventions in real-world community settings.

REDUCING THE INCIDENCE OF HIV, SEXUALLY TRANSMITTED INFECTIONS, AND DOMESTIC VIOLENCE AMONG LATINAS IN MIAMI I am Principal Investigator of one of these trials— SEPA III (Salud, Educación, Prevención, y Autocuidado / Health, Education,

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Prevention, and Self-Care). This trial focuses on testing the effectiveness of the SEPA intervention in reducing the incidence of HIV, sexually transmitted infections, and domestic violence among Latinas. Our intervention is the first culturally specific HIV prevention program known to reduce intimate partner violence and to address multiple and interrelated health disparities experienced by Hispanic women. Addressing the interrelationship between violence and HIV/ STI health disparities is critical because the two conditions often co-occur and have common root causes. We are studying the impact


We’re very much interested in HIV prevention, but we’re not convinced the answer is just providing information about safer sex and condom use. We are interested in researching how mental health factors such as depression, low self-esteem, and substance abuse may influence high-risk sexual behaviors.

of cultural factors, such as acculturative stress, partner communication, and health knowledge, on this interrelationship.

ASSISTING MOTHERS WHO ARE IN THE RECOVERY STAGE OF SUBSTANCE ABUSE TREATMENT The other new study is “Healthy Home” (Victoria Mitrani, Ph.D., Principal Investigator), which aims to prevent relapse in mothers who are in substance abuse treatment and improve the health of their children by enlisting the entire family in the recovery process. The idea behind the project is to help mothers who are in the recovery stage of substance abuse treatment, as well as their families. Our intervention is an extension of that treatment, and it will involve nurses visiting patients’ homes and meeting with them and their families. The commitment of substance-abuse treatment can interfere with time and energy that a mother devotes to her family. Sometimes families put pressure on

the other to give them more time. We want families to understand that if they support the mother in her recovery, then this will have a positive impact throughout the family – on the health of the mother, the health of the children, and how the children do in school.

FAMILY-ORIENTED MENTAL HEALTH AND DRUG USE TREATMENT FOR HISPANIC ADOLESCENTS The new NIH funding will also provide continued support to El Centro’s CIFTA (Culturally Informed Family Therapy for Adolescents; Daniel Santisteban, Ph.D., P.I.) study, which has a focus on family-oriented mental health and drug use treatment for Hispanic adolescents. Our research shows considerable overlap between adolescent behavioral issues, such as violence and drug use, and mental health issues, such as depression. With a substance-abusing child, for example, it’s highly probable that there are underlying psychiatric symptoms. Family intervention appears to be the most effective approach,

but even the most successful treatments work very well only about half the time. Much of our work targets Hispanic adolescents-- because their rate of drug use in middle school is so high. The trick is to figure out the cultural nuances that can impact treatment and improve outcomes.

CULTURAL FACTORS AND RISK BEHAVIORS OF HISPANIC MEN WHO HAVE SEX WITH MEN AND HEALTH RISKS OF TRANSGENDER WOMEN Two other health disparities research projects currently underway are “Cultural Factors and Risk Behaviors of Hispanic Men Who Have Sex with Men (MSM) and “Health Risks of Transgender Women”, both directed by our faculty member Dr. Joseph De Santis. We call the first one “the men’s study” and we’re very much interested in HIV prevention, but we’re not convinced the answer is just providing information about safer sex and condom use. We

Caring HeARTS

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DIVERSITY IN MIAMI AND BEYOND

Nursing has tremendous potential to lead the reduction of health disparities. With more than 3.1 million registered nurses, the nursing workforce is the largest among the U.S. healthcare professions.

are interested in researching how mental health factors such as depression, low self-esteem, and substance abuse may influence high-risk sexual behaviors. The transgender-women study is also about mental health factors that influence risky sexual behavior, but it includes psychosocial aspects such as gender reassignment surgery, employment issues, discrimination, and marginalization. The men and women in both studies have immigration issues that make gaining employment a challenge. The women, however, are more likely to end up doing commercial sex work to earn money. Ideally, we would like to develop HIV-prevention interventions for both groups based on their unique mental health needs.

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FAMILY INTERVENTION STUDY WITH HISPANIC NINTH GRADE STUDENTS TO PREVENT ADOLESCENT VIOLENCE Our family intervention study with Hispanic ninth grade students to prevent adolescent violence is led by faculty member Dr. Rosa Gonzalez-Guarda. Our goal is to develop a teen-dating violence-prevention program that can be implemented in schools that have a majority Hispanic student body. Prior community-based participatory research has identified Hispanic youth as a priority group to address through domestic violence prevention efforts. This finding is supported by data demonstrating that Hispanic youth report dating violence victimization more frequently than non-Hispanic white youth. We will be working with ninth-graders because they are

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entering high school and beginning new relationships. This entrance also carries potential for highrisk situations such as dating and exposure to drugs at parties. Through the end of the school year, we will be working with students, their parents, and school personnel to increase their capacity to promote healthy teen dating relationships and to intervene when there are signs that abusive relationships exist. Nursing has tremendous potential to lead the reduction of health disparities. With more than 3.1 million registered nurses, the nursing workforce is the largest among the U.S. healthcare professions. Given the size of the workforce, their close proximity to patients, and their expertise in the science of caring for vulnerable populations, nurses have an excellent opportunity to make a real difference. n


ARTICLE

REPORTS FROM THE PUBLIC HEALTH STUDENT ASSOCIATION

WORDS BY Yasmin Dias-Guichot

THE PUBLIC HEALTH STUDENTS ASSOCIATION AT THE UNIVERSITY OF MIAMI MILLER SCHOOL OF MEDICINE IS DEDICATED TO THEIR LOCAL COMMUNITY. Overtown is an

underprivileged neighborhood next to the medical school campus where they implement their public health community outreach projects, primarily focused on nutrition and well-being. These include healthy cooking classes at the local high school, a community garden, and a yearly public health fair. They are determined to address these local issues by expanding these projects to create sustainable and widespread community health initiatives.

e

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e 1

Push Ups for PHSA

We had the Push-Ups for PHSA where we raised over $1,500! All of these proceeds went towards supplies and teaching materials for the Cooking Canes program at Booker T. Washington High School. Teams collaborated together and had a pushup competition that combined the efforts of students, faculty, and staff!

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01 02 03

Group M&Ms Team Aviators Team Ninja Turtles 03

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Cooking Canes

Overtown is an area that currently faces many health disparities stemming from underprivileged education, high crime, and overall low socioeconomic status. This neighborhood currently has one of the highest rates of mortality from chronic diseases in Miami-Dade County. Our focus is to provide programs that will increase health, well-being, and nutritional awareness. Our goal is to increase health education, and empower a community to take control of their own well-being by linking them with available resources. Our role as the PHSA will be to unify and overlap our programs to teach the community as a whole. We target youth after school in the garden, high schoolers in the cooking program, and families of all ages at the health fair.

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Grow To Grow Community Garden

Caring HeARTS

We will use the produce from our cultivated garden in the cooking class, the cookbook from the class at the health fair, and the teachers from garden programs in the health fair, etc. Our goals are to create a self-sustaining program that benefits the entire community. During the school year, we increase involvement through a solidified partnership with the high school and increased awareness in the study body. A holistic approach to the prevention of ill-health educates people on topics which include fitness, disease prevention, hygiene, dental, women’s, sexual, and environmental health. Our health fair address many of the community’s health concerns such as diabetes, cholesterol, obesity, heart conditions, skin lesions, STIs, etc. If any evidence of a condition is found, the appropriate referral service can be provided through the University of Miami’s programs or the Miami-Dade County Public Health Department. We are hosting regular information sessions along with fitness classes providing people of all ages with the opportunity to gain world-class knowledge in their own backyard. n

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KYLE AMBER

POETRY

Experiences from the Lotus House Shelter

I CAME TO SERVE YOU WORDS BY Caitlin Hodge I came to serve you. I brought my black bag full of tools, To poke and prod and figure out what’s wrong. You’ll feel better soon. I have all the tools to bandage all your wounds. My inspection couldn’t reveal the battles behind your scars. My test tubes couldn’t collect the spirit that flows through your veins. My stethoscope couldn’t hear the love and faith that fill your heart.

I came to see, to find, to fix, and yet I missed so much. But today, today is different. Today I left my tools at home. You invited me in, and I brought only myself, to see, to feel, to hear. I see your self-worth, hard-earned against the harshness of your life. I feel your love for each other, the sisterhood that fills this space. I hear the praise free-flowing from your heart, a faith I’ve never seen before.

I came to serve you, But I leave with more gifts than I brought. You showed me strength, beauty, a little glimpse into your world. I am leaving here with the teaching that only you could give.

The Lotus House Shelter is a unique resource center and residential facility serving homeless women and infants in the heart of the historic African American district of Overtown, Miami.

lotushouseshelter.org

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ESSAY

TALK ABOUT SOMETHING ELSE. WORDS BY Kelly Jean Grannan TAKING A PATIENT HISTORY IS AN ODD AND FARCICAL WAY TO INTERACT WITH ANOTHER HUMAN BEING. It involves asking a series of

progressively more probing questions of the patient while sharing nothing from the position of the provider. Imagine some of these questions out of context; “Hi, are you our new neighbors? How many sexual partners have you had in the past 12 months?”, “I’m so glad you could fix the cable. Do you ever have difficulty or pain with urination?” Clearly the roles we take in these situations are not clinical, but we have often spent much less time with a patient than we might with a neighbor or cable repair person. Getting information about a person is not the same as getting to know them. With this in mind, the student leaders in AMWA and the Lotus House DOCS clinic worked together to throw a holiday

cookie party. The idea was simple: To provide a setting where shelter guests and medical students could spend time together acting as nothing more than themselves. I met a woman whose apartment had caught fire and was working to get back on her feet. Another had lived where I studied abroad, and we shared stories about how to pick a coconut. Students, staff, and guests each mentioned that they felt more comfortable here than they had with each other in the clinic. Our patients are often very different from us. They come from different backgrounds and our everyday lives bear little resemblance to each other. Their story is never fully encompassed by their clinical history, and ours doesn’t begin and end with being a medical student. We ask for clinical information for a reason, and we should. Sometimes, however, we should talk about something else. n

Members of Lotus House Department of Community Service (DOCS) Clinic and student leaders of the UMMSM Chapter of the American Medical Womens Association (AMWA) pose for a photo at Lotus House.

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ESSAY

ESTABLISHING TIME-SHARE SURGICAL CENTERS IN THE CARIBBEAN There is a breadth of scholarship on patients seeking health and economic advantages to treat their ailments in the burgeoning medical tourism industry. While there is an advantage for patients in a purely economic sense, there is a tremendous opportunity for U.S. licensed physicians to treat patients in offshore medical centers. WORDS BY Jason Frederick Emert

THE WORLD CONTINUES TO GET FLATTER AND MORE CONNECTED.

For better or worse that is reality. It is a reality that all industries must recognize and corporations and individuals alike must adapt. The medical industry is no different. There has been a tremendous growth of patients seeking medical treatment at offshore medical centers across the world seeking shorter wait times and lower costs. Thus, the medical tourism industry has exploded into the lexicon of foreign governments seeking ways to bolster their treasuries during this period of great economic upheaval. According to the World Travel & Tourism Council (WTTC), in 2011, the total impact of the

University of Miami School of Law, 3L The Chrissie Tomlinson Memorial Hospital is a private, for-profit hospital in the Cayman Islands dedicated to providing exceptional health care to the Cayman Islands.

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There should be a venue for physicians wanting to provide their patients with lower surgical costs or proven, but unapproved procedures log-jammed in government bureaucracy for the treatment of aggressive ailments. This surgical center... would act as a time-share for U.S. physicians with investment from the host country.

BY THE NUMBERS

MEDICAL TOURISM IN 2011

255 million jobs worldwide 9%

of the global GDP contributed by medical tourism

BY 2022 medical tourism industry contributed 9% of global GDP (over $6 trillion USD) and accounted for 255 million jobs. In the next decade, medical tourism is expected to grow by an average yearly of 4%, contributing up to 10% of future global GDP ($10 trillion USD). Eventually by 2022, it is estimated that 328 million jobs will be created in the medical tourism industry: equal to 10% of jobs in the world. The economic benefits alone of medical tourism to patients and doctors should warrant a serious look at providing care outside the United States. Not to mention the aesthetic reasons for choosing to offer treatment at an offshore medical center which are typically in some of the most beautiful locations in the world. The following is a list of the top-10 countries for medical tourism and the percentage lower of costs compared to the U.S.: Brazil (25%-40%), Costa Rica (40%-65%), India (65%-90%), South Korea (30%-45%), Malaysia (65%-80%), Mexico (40%-65%), Singapore (30%-45%), Taiwan (40%-55%), Thailand (50%-70%) and Turkey (50%-65%). Addi-

tionally, Patients Beyond Borders estimates that medical tourism is growing at 25% - 35% per year setting the stage for growth in new regions. Not one Caribbean nation is listed above. How could a region that educates so many American doctors be left out of the top-10?

THE CARIBBEAN: THE REGION THAT STANDS TO BENEFIT THE MOST Thus, the region that will benefit the most from the cultivation of a robust medical tourism market is the Caribbean. Many people are familiar with Caribbean medical schools. There are 27 medical schools in the English-speaking countries of the Caribbean, however; only five schools are accredited by the internationally recognized Caribbean Accreditation Authority for Education in Medicine and Other Health Professions (CAAMHP). Although more will likely seek and achieve accreditation in the coming years due to the recent Educational Commission

328 million jobs worldwide 1 out of 10 qqqqqqqqqq of the jobs in the world will be in the medical tourism industry

COUNTRIES FOR MEDICAL TOURISM: TOP 10 COUNTDOWN 10 Turkey 9 Thailand 8 Taiwan 7 Singapore 6 Mexico 5 Malaysia 4 South Korea 3 India 2 Costa Rica 1 Brazil

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for Foreign Medical Graduates (ECFMG) rule requiring international medical graduates (IMGs) to graduate from a school with an ECFMG Certification in order to apply and obtained an unrestricted medical license to practice medicine in the United State from the United States Medical Licensing Examination (USMLE). Thus, the Caribbean should work with doctors, hospital groups, and insurance providers to develop a system that benefits the patient and the physician: bringing in top surgeons with lower costs to the patient while providing a much needed economic boost to the often cash-strapped islands. And while there are well-documented instances of poor treatment in certain offshore medical centers, they rarely employ U.S. licensed physicians. Therefore, there is an opportunity to balance care and cost. The ability to provide quality care at lower rates and fewer government restrictions as to the use of proven medical technologies, hospitals and physicians should jump at the opportunity to create a surgical center meeting the demands of the global medi-

cal marketplace. However, U.S. licensed physicians should have the opportunity to practice in these offshore medical destination without having to uproot their practice, lives, and family; at least not in its inception. Thus, why not develop an offshore surgery center operated similar to a time-share?

TIME-SHARE: A MODEL FOR MEDICAL TOURISM The centers would be designed after the traditional time-share or fractional ownership model many are familiar with in vacation accommodations or private jets. Doctors would have an allotted week or month to run an operating room for their patients who opt for treatment not available or too expensive in the United States. While this tactic will not work everywhere in the world it could work in regions closest to the United States given the rate of patients seeking treatment outside the United States. Accordingly, Caribbean destinations are positioned to prosper the most from the creation of surgical time-share centers.

Caring HeARTS The Caribbean could capitalize on this burgeoning industry and familiar relationship between the U.S. medical industry and the Caribbean, as medical tourism becomes a reputable alternative to the already high and continually rising costs of American healthcare. The offshore medical centers would be an extension of a physician’s

Thus, the Caribbean should work with doctors, hospital groups, and insurance providers to develop a system that benefits the patient and the physician: bringing in top surgeons with lower costs to the patient while providing a much needed economic boost to the often cashstrapped islands.

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CARLY RIVET practice at home; saving costly, experimental, and/or non-FDA approved surgical procedures for medical tourism destinations while providing the high quality of care patients have come to expect from physicians in the United States.

JAMAICA’S ENTRY INTO MEDICAL TOURISM Recently, Jamaica decided to expand into the medical tourism market. Given its proximity to the United States and the beauty of the island, Jamaica is a natural fit to benefit from U.S. surgeons and patients flying down for surgery. If Ja-

maica chooses to develop a system of healthcare time-share centers, they will meet fit the mission of becoming a medical tourist destination by boosting the economy and raising the international profile of the island. Plus, Jamaica will differentiate the nation as an industry leader and premier offshore medical destination with the capabilities of hosting U.S. licensed physicians year-round. The Jamaican investment and promotion agency, JAMPRO, estimates the average medical tourist spends $5,000, which is double the amount of the current average tourist. Now, imagine if you add the amount of money brought in

by patients to what physicians will spend is a considerable amount of money generated for the nation. Additionally, physicians will more than likely bring their families along as well. Furthermore, there would be a permanent support staff of hospital personnel making higher wages that will also add to the national coffer. As medical tourism grows more Americans will seek treatment abroad. It is imperative that patients are protected from poor treatment, scams, and unlicensed doctors. Establishing surgical centers with American board certified surgeons provides patients the same assuredness they demand at home

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DIVERSITY IN MIAMI AND BEYOND

ALEXANDRA LEVITT

The creation of an offshore surgical center should not be a way to circumvent the laws of the United States and the accountability of physicians, hospitals, and insurance providers. Quite the contrary, it should strengthen patients’ rights around the world, not just in the Caribbean, by expediting a more uniformed medical approach and higher treatment expectations whether you are in Tennessee, Jamaica, or Malaysia. with greater economic advantages and treatment opportunities abroad. However, the creation of an offshore surgical center should not be a way to circumvent the laws of the United States and the accountability of physicians, hospitals, and insurance providers. Quite the contrary, it should strengthen patients’ rights around the world, not just in the Caribbean, by expediting a more uniformed medical approach and higher treatment expectations whether you are in Tennessee, Jamaica, or Malaysia. In developing this concept

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there is much to balance: law and ethics, international standards, government regulations, and bi-lateral medical and malpractice trade agreements to safeguard patients who may want to seek indemnification for a procedure gone array. Nevertheless, in a time of great economic uncertainty bold moves will determine which nations will succeed, although nations do not have to try to re-invent the wheel in order to do so. For the Caribbean, the medical foundation and familiarity is already in place. All that is needed is an evolution of its purpose to meet the demands and

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expectations of medicine today. The United States healthcare industry with the Caribbean medical education establishment, coupled with the beauty and ease of travel to the region, would develop a partnership structured to lead the global healthcare industry providing unparalleled access to great medicine in some of the world’s most unequal destinations. n If you would like to provide input or feedback to this article, contact Jason at jfemert@gmail.com


PHOTO ESSAY

THE ANDROGENIZATION OF MARY BRICKELL Who, or what, is the face of Brickell? WORDS AND PHOTOGRAPHY BY R. Rammy Assaf

BRICKELL SPACE IS ONE CONSISTENTLY IN FLUX.

The way it looks today is radically different from just five years ago. Rapid change seems to be the one constant, with new condos coming up on every corner and fluxes of students, families, and young professionals moving in and out of the area.

Amongst the movement and insatiable expansion, the question of identity becomes shrouded. Who, or what, is the face of Brickell? Nestled under a tree in a center lane divider on Brickell Avenue, you’ll find the bust of Mrs. Mary Brickell, one of Miami’s first prominent real estate developers and managers. While her body is absent, developers and artists have freely structured their own representations of the human form

throughout the city. Through a gendered lens, however, the result reveals distinct patterns. An idealized form of the male, with a torso resembling forged Roman armor, is repeated time and again in popular sites around the city, in shopping centers, bridges, parks, condo fronts, even replicated in street signs. Sirs Ponce de Leon and Simon Bolivar stand proud on the waterfront, each fathers of their own respective lands and discoveries. Constructed representations of the woman reveal another theme - one that is hidden. Her body is overcast by that of the marksman on the bridge, almost formless in other locations off the main roads. Though each statue carries its own aesthetic and symbolic meaning, my concern is not with art, per se, but with message - patterns and representations in an inhabited space that has yet to define itself or its future. n

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FIFTY YEARS AGO, RACHEL CARSON RELEASED HER SEMINAL WORK, “SILENT SPRING.” THE PUBLICATION OF THIS BOOK BEGAN THE MOST SIGNIFICANT ENVIRONMENTAL MOVEMENT EVER SEEN IN THE US.

FEATURED ARTICLE WORDS BY Eric Hecht, MD, MSPH and Yasmin Dias-Guichot

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Carson warned of future health problems due to organophosphate pesticides, substances first developed as chemical nerve gas weapons around the time of WWII, which today amass to over 2.5 million tons sold annually. Globally, pesticide exposure is a common source of acute poisoning with an estimated 25 million poisonings and 200,000 deaths in the developing world each year. Equally concerning are the chronic effects of pesticide exposure. At the time of her writing, Carson had documented the adverse effects of pesticides in the ecosystems of birds and other animals. Carson interpreted the use of pesticides as a chemical war against nature. “Man is a part of nature … his war against nature is inevitably a war against himself.”

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ROB FELL

PESTICIDES AND SILENT SPRING, 50 YEARS LATER


If alive today, Carson would likely continue to question the wisdom of the unbridled usage of pesticides. She would likely continue to insist that society find more sensible alternatives. Pesticide residues remain on food and are often resistant to washing. Following the ingestion of pesticide contaminated food, the pesticides store in human fat, and the brain, often for long periods of time. Recently, the CDC began to measure these chemical residues left in the body, and found 13 different pesticides in the urine or blood serum of over 70% of Americans (including children). What makes pesticide residues retained in the body so concerning, is their possible linkage to many varied health problems including childhood cancers, leukemia, breast cancer, lymphoma, diabetes, obesity, Parkinson’s disease, birth defects, autism, and infertility. Dr. Carson commented in Silent Spring, “It is ironic to think that man might determine his own future by something as seemingly trivial as the choice of an insect spray.” Eight years after the publication of “Silent Spring”, and to some extent, in response to “Silent Spring”, the US Environmental Protection Agency (EPA) was formed. Shortly after its formation, the EPA banned DDT, the major culprit Dr. Carson highlighted in her book. The EPA was convinced by Dr. Carson’s argument that the domestic use of DDT posed unacceptable risks to the environment and potential harm to human health. Unfortunately, the export of the toxicant to developing countries was still deemed acceptable and

continues to this day. Scientists have since learned that atmospheric wind patterns often bring this banned substance back into our backyard. The ubiquitous usage and easy availability of pesticides to consumers suggests a measure of safety that is often untrue. Unfortunately, proving safety is not required before a pesticide is allowed to reach the market. When it comes to pesticides, history teaches us that what is sought is evidence of harm years and often decades after product introduction. Only then, and often with significant industry resistance is a ban on a harmful pesticide imposed. Dr. Carson endorsed a philosophy that is today called the precautionary principle. This principle places the burden of “proof of harmlessness” onto the manufacturer. Carson believed that precautionary principles should be imposed when harm was suspected even without definitive proof; plausibility of harm was itself sufficient to keep a product off the market. Outside the US, the ideas behind the precautionary principles are accepted and in fact, such principles are explicitly incorporated into The Maastricht Treaty of the European Union in 1992. Today, the precautionary principle could not be more relevant as local health authorities weigh the risks and benefits of spraying pesticides over local communities in order to diminish

mosquito populations that carry concerning infectious diseases. These vectors are anticipated to become an increasing problem as global warming changes the survival characteristics of mosquitos. Illnesses due to the West Nile virus, Dengue, and perhaps Malaria are predicted to increase in the United States. Should our approach to these potential problems rely upon airplanes spraying pesticides onto our communities? While newer classes of pesticides are likely less toxic to humans than those banned in prior years, all pesticides have adverse effects on ecology and aquatic life and effects on human health cannot be ruled out. For example, several epidemiological studies now suggest that exposure to a class of presumably safer pesticides (Pyrethroids) may in fact have adverse effects on the intellectual development of children. If alive today, Carson would likely continue to question the wisdom of the unbridled usage of pesticides. She would likely continue to insist that society find more sensible alternatives. n

Eric Hecht MD, MSPH is a voluntary associate professor in the department of epidemiology at the Miller School of Medicine at the University of Miami. Yasmin Dias-Guichot MS, is obtaining her master’s degree in public health at the University of Miami.

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DIVERSITY IN MEDICINE

ESSAY

THE DANGER OF CULTURE WORDS BY Rob Fell

“In the conflicts between man and man, between group and group, between nation and nation, the loneliness of the seeker for community is sometimes unendurable. . . He will know that for all men to be alike is the death of life in man, and yet perceive harmony that transcends all diversities and in which diversity finds its richness and significance.” - HOWARD THURMAN

HUMANS USE “GROUPS” TO ORGANIZE CHAOTIC DIVERSITY. I have Japanese friends, I have Muslim friends, I

have Lutheran friends. We all have subconscious and/or conscious ideas about what each of those groups of friends may be like. Some of our ideas may be accurate, some may not. Although my groups of friends are extremely diverse within themselves, it is often practical for the sake of cognitive organization to use broadly defined categories, most notably cultural and religious categories. It seems to be basic human tendency to segregate into groups based on some degree of shared similarity. The community produced by faith-based or culture-based groups can greatly benefit those involved by providing a social circle that shares one’s most fundamental views on the world and life. My growing concern, however, is the “thickness” of the boundaries between groups. Thick boundaries can become barriers. The classic example is language. Perpetual exposure to only one language grad-

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What can we as future physicians do to ensure boundaries do not become barriers? It may start with ventures outside one’s own group. Pay attention to subtleties, understand a friend’s belief system, gain insight into a dissimilar political perspective.

ually shapes thought and speech into a function of that language. But even when the classic barriers of language are not present, thick cultural or religious boundaries can impede the flow of effective communication, leaving only blank stares, moving lips, mumbled jargon. The practice of medicine inherently crosses these human boundaries. Future physicians who aspire to barricade their practice into their own monolithic culture seem to be an exception. Most of us will handle endless encounters

in which a “boundary” must be crossed—language, cultural, religious—for the benefit of an individual’s health. What can we as future physicians do to ensure boundaries do not become barriers? It may start with ventures outside one’s own group. Pay attention to subtleties, understand a friend’s belief system, gain insight into a dissimilar political perspective. It is important to ensure our own boundaries do not grow “too thick” to the point we use only one language. I believe the more culturally adept we are, the

less limiting these human boundaries will be. Finally, I believe the micromechanism of cultural competence is friendship. Come share with us your thoughts on barriers, culture, religion, faith, spirituality and medicine at the new MultiFaith Society at the University of Miami School of Medicine! n

Multifaith Society

at the University of Miami School of Medicine STATEMENT OF PURPOSE

SYNOPSIS

This group encourages discussion of religion and spirituality for the development of cultural competency, especially as applied to the medical setting.

Culture and religion are foundational to an individual’s identity. As future physicians, we believe attentiveness to various cultural and religious persuasions is a vital attribute. We believe friendship and spiritual discussion with individuals from different cultural and religious backgrounds promote cultural competency and avert formulaic generalizations. This group encourages discussion of religion and spirituality for the development of cultural competency, especially as applied to the medical setting.

Contact Rob at rbfell@hotmail.com for more information about the organization.

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FEATURED ARTICLE

HELPING PEOPLE FEEL LIKE PEOPLE Closing The Door On LGBT-Centered Disparities WORDS BY Adam Crosland

“WE TREAT EVERYONE THE SAME HERE.” When I was reading this statement for the first time, it did not strike me as non-inclusive or discriminating at all; in fact, it sounded like it was attempting to make a point to provide equality. This statement was presented in the Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community from The Joint Commission. This specific issue focuses on the

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power we have as providers to create a patient-centered approach to healthcare as it continues to evolve. As we strive to meet the individual needs of every patient, we must utilize concepts that focus on effective communication, cultural competence, and sensitivity to issues that many members of the lesbian, gay, bisexual, and transgender (LGBT) community face at some point in their life. Therefore, the needs of the LGBT community, some being shared with other minority groups and some being unique, must be considered in the provision of care, treatment, and services. The quoted statement I began with can now be viewed differently. It is a common statement that does not necessarily indicate inclusivity in regards to treatments and services concerning LGBT patients and their loved ones. To an extent, it can imply that there is no need to acknowledge individual differences. I think it is important to include statements like the aforementioned to let patients know that they can expect to be treated with-

out discrimination. However, there is a call-to-action to also have their individuality (i.e. sexual orientation and gender identity) taken into account within the healthcare system.

HEALTHCARE CONCERNS OF THE LGBT COMMUNITY In order for someone to acknowledge and handle disparities appropriately, it is important to become informed and educated. In general, the LGBT community disproportionately experiences: less access to insurance and health care services, including preventive care (such as cancer screenings), lower overall health status, higher rates of smoking, alcohol, and substance abuse, higher risk for mental health illnesses (such as anxiety and depression), higher rates of sexually transmitted diseases, including HIV infection, and an increased incidence of some cancers1-3. We unfortunately need even further considerations for specific age groups. For example, LGBT youth might experience outright rejection from trusted individuals (i.e. coach-

es, teachers, friends, family, etc.) on top of the common challenges teenagers experience. According to the Institute of Medicine Report, LGBT elders statistically have fewer children than heterosexual couples. Therefore, when considering the longevity of care, they may have higher rates of isolation due to lack of family or social support. Social Security and many private pension plans do not provide partner or spousal survival benefits to legally unwed couples; the disability or death of a loved one can thus threaten the economic security of the surviving partner4. This was not meant to be an exhaustive list of issues, simply an introduction that could shed some light on specific examples.

ACTIONS TO TAKE TO IMPROVE HEALTH CARE DELIVERY TO THE LGBT COMMUNITY In regards to what has been said, as professional students who are constantly learning, working long hours, and seemingly expected

In general, the LGBT community disproportionately experiences: less access to insurance and health care services, including preventive care (such as cancer screenings), lower overall health status, higher rates of smoking, alcohol, and substance abuse, higher risk for mental health illnesses (such as anxiety and depression), higher rates of sexually transmitted diseases, including HIV infection, and an increased incidence of some cancers. Previous Page: (Left to right) UMMSM 2nd year MD/MPH students Krishna Rao (MedicOUT Treasurer), Ryan Reusche, Elan Horesh (MedicOUT Communication Vice President), and Adam Crosland (author of the article and MedicOUT Co-President) in front of the Ferry Building in San Francisco, CA, where they attended the 30th Annual Gay and Lesbian Medical Association (GLMA) Conference.

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REMEMBER THIS

1-800-246-PRIDE GLBT National Youth Talkline

A free and confidential service you can direct LGBT patients to that offers counseling on a variety of LGBT issues

‘to know it all’, it can seem daunting and near impossible to focus on a patient’s individuality. There are some simple actions that are not revolutionary or extraordinary but can make all the difference in the world to a patient in terms of their perception on the delivery of their health care. For example, smoking cessation information and resource guidance can be found with a simple telephone number. Becoming familiar with one or two local or online resources for LGBT patients can help alleviate the burden that you must be an ‘all-knowing expert’ on LGBT issues. The GLBT National Youth Talkline is 1-800-246-PRIDE (7743), a free and confidential service offering counseling from trained personnel on coming-out issues, relationship concerns, parent issues, school problems, HIV/AIDS anxiety and safer-sex information, and lots more. The degree of safety, comfort, openness, and respect that LGBTQ youth patients, in particular, feel often has an impact on their future access to health care, risk reduction, and help-seeking behaviors5. The 2011 Joint Commission Field Guide also talks about the importance of listening to and reflecting the patient’s use of language when they describe their relationships, in any capacity, and in regards to how they like to identify their sexual orientation. This is an easy method that only requires the listener to provide a welcoming environment in which the patient

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feels comfortable enough to discuss these topics. Patients, like everyone, will vary on their comfort level with different subjects, this too is something to remember; not every patient is comfortable even disclosing that they are a member of the LGBT community. Therefore, understanding that self-identification might not always align with behavior is crucial. Patients might be currently dealing with emotions and feelings that they cannot themselves even fully comprehend or express. Hopefully, illustrating compassion and understanding at the bedside can minimize the anxiety or frustration some patients might have in expressing their feelings. Most importantly, as continuing research furthers our understanding of healthcare-related and non-healthcare-related issues concerning the LGBT community, staying informed and up to date on these topics can only help providers stay appropriately knowledgeable

and equipped to more effectively deliver patient-centered care. At the heart of the matter, we are all human beings and it is very natural for a person to want to feel listened to and understood. However, there sometimes is a rift between providers and patients when one of these members feels uncomfortable or nervous for any number of reasons. It is therefore easy to understand why a highly charged and sometimes scary medical visit can be further confounded by insensitivity and lead to a less than ideal patient-physician relationship. Inadequate healthcare provision then becomes a very probable outcome in this scenario. Personally, I feel that when two individuals are being sensitive to one another, it does not necessarily mean that the two must be agreeing with each other. This world is made up of many different people with many different beliefs. We use sensitivity in the healthcare setting

As continuing research furthers our understanding of healthcare-related and non-healthcare-related issues concerning the LGBT community, staying informed and up to date on these topics can only help providers stay appropriately knowledgeable and equipped to more effectively deliver patient-centered care.

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to try and better understand why a person acts the way they do and to hopefully provide medical guidance and treatment plans that will be most beneficial to all facets that are encompassed under the umbrella term of health.

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01 (L-R) Ryan Reusche, Adam Crosland, Shane Snowdon (founding Director of the UCSF Center for LGBT Health & Equi ty), and Elan Horesh at the GLMA confer ence. 02 Adam Crosland with Chad Parvis at the first MedicOUT social 03 Hansel Tookes III, Brooke Honeycutt, Erryn Tappy, and Adam Crosland with Dr. José Szapocznik, Ph.D. (Chair, Department of Epidemiology and Public Health) 04

Kelly Grannan with Hannah Wallace (MedicOUT Co-President)

MedicOUT: LGBT AND ALLY STUDENT GROUP MedicOUT is the LGBT and ally student group at the University of Miami Miller School of Medicine. This group has been diligently working to provide educational avenues for students, physicians, and faculty to learn more about LGBT health issues. Four MD/MPH students in MedicOUT, Adam Crosland, Elan Horesh, Krishna Rao, and Ryan Reusche, traveled to San Francisco, CA for the 30th Annual Gay and Lesbian Medical Association (GLMA) Conference this past year. For more than a decade, GLMA has tackled many initiatives and projects. In its infancy, GLMA focused on HIV/ AIDS and the many issues faced by physicians coming out at work. As the climate

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and culture have been changing, GLMA continues to be a leader in public policy advocacy related to LGBT health. These dedicated student attendees presented some of the most current research topics being discussed at the national conference at the medical school’s first LGBT Health Symposium, hosted by MedicOUT. As the student organization strives to increase awareness of LGBT health- and non-health related issues at the Miller School of Medicine, it hopes to create sustainable change among not only the student body, but also faculty and administration alike. As our healthcare system continues to develop and evolve, we, as professional students, can make a direct impact on the delivery of services and care. By staying informed on current research, illustrating compassion, and practicing medicine with sensitivity, we can help usher in a new era of physicians by remaining accountable for our actions and work environment. Sustainable LGBT-sensitive care will have to come from the medical community; it will fail if it’s being supported by only one type of provider. Being a known role model and a voice for LGBT health can help implement the change that is necessary and long overdue in the healthcare environment. n For a list of the resources used in this article, turn to page 60

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DO NO HARM ESSAY

WORDS BY Melissa Stone

EDITED BY Brett Van Leer-Greenberg

THE OTHER DAY, I WALKED ONTO THE METRO AND SAT NEXT TO THIS YOUNG, GOOD-LOOKING MAN.

He was wearing teal scrubs and was entranced by the racing game on his iPhone. I then noticed the small swastika tattooed between his thumb and pointer finger. In disbelief, I glanced at his hand again, and about ten more times after that during the eight-minute ride. The year was 2012 – was I sure this was a swastika? I checked again and clearly saw the four lines intersecting at their center. Seventy years ago, a similar scene would have been commonplace. Boarding the German Rail, I would have sat next to a man proudly displaying his swastika, a symbol of his allegiance to the National Socialist German Workers’ Party led by Adolf Hitler, while I would have a yellow patch with the Star of David pinned to my sweater. But unlike today, many Jews, like myself, would be taken prisoner by the Nazis and held in concentration camps. Some of these prisoners would be forced into painful experimentation until their disfigurement and disability rendered them no longer useful or death brought them peace.

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JOANNE DUARA


With all that has changed since the Holocaust, what remnants of the past still remain? ... a Jew might be denied health insurance due to a BRCA1 mutation for breast cancer. A Jewish couple might choose to adopt a child after discovering both are carriers for Tay-Sachs. And, a young Jewish girl might beg her parents for a rhinoplasty for her sixteenth birthday present. Nuremberg Code delineated the principles of informed consent and beneficence that we, as medical students, are taught today. With all that has changed since the Holocaust, what remnants of the past still remain? While the Jewish people are certainly no longer forced into gas chambers ‘til their lungs collapse and their hearts stop beating, a Jew might be denied health insurance due to a BRCA1 mutation for breast cancer. A Jewish couple might choose to adopt a child after discovering both are carriers for Tay-Sachs. And, a young Jewish girl might beg her parents for a rhinoplasty for her sixteenth birthday present. As Jewish people, we inherently possess attributes outside the norm. A small tribe of Jewish people thousands of years ago are the ancestors of millions of Jews around the globe, and many of us have bred with descendants of those ancestors ever since. Consequently, our genes are different – with a higher proportion of risks for breast cancer, the Tay-Sachs gene, and a deviated nasal septum. Although many years have passed While acknowledging since the Holocaust, the phrases these differences, and even embracing the ignored by the physicians of the technology used to concentration camps – “the good identify or augment of my patients” and “never do them, as a society, we must remember what harm to anyone” – still resonate these differences meant These experiments were performed by physicians who graduated from medical school and similar to students of modern day, likely turned their tassels to transform into newly minted physicians as they uttered the Oath of Hippocrates. Serving as steadfast pillars of a moral code, these precepts are the ethical foundations of our profession. How did these doctors once proclaim, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone,” and then perform such horrendous actions at the camps? The world watched the ‘Doctor’s Trial’ at Nuremberg, United States of America vs. Karl Brandt, as these physicians were convicted of moral atrocities conducted in the name of science. From these ashes came new doctrines of medical practice and research ethics. This trial sent the message to the world that the title “Dr.” embodies respect, altruism, and knowledge, and the subsequent

with many Jewish people.

to our great-grandparents. We must keep the eugenics movement of the Nazis in mind as we enter a world of personalized medicine and genomics. I do not know why that man on the metro had a swastika on his hand. I do not know how it got there or what that symbol represents to him, and I do not want to make assumptions about his circumstances. But I do know what that swastika on a medical personnel means to me. Although many years have passed since the Holocaust, the phrases ignored by the physicians of the concentration camps – “the good of my patients” and “never do harm to anyone” – still resonate with many Jewish people. Knowing the torments that medicine can bring, we cannot know what lies ahead. But I do know that as a future Jewish physician, I will never forget the sufferings in the camps, and will strive to always practice medicine with no harm. n

This article was written by Melissa Stone, a second year medical student at the University of Miami Miller School of Medicine (UMMSM) and member of the Jewish Medical Student’s Association (JMSA), and edited by Brett VanLeer Greenberg, a third year medical student at UMMSM and former President of JMSA.

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ESSAY

DIVERSITY DRIVEN BY FAITH WORDS BY Gerard Smith

AS AN AFRICANAMERICAN MUSLIM IN MEDICINE, I MEET SEVERAL QUOTAS FOR DIVERSITY. One of the biggest

stereotypes that people around the world have about Muslims is that you can tell a Muslim from non-Muslim based off physical appearance, ignoring the true emphasis that Islam places on values and intentions. Quite frankly, I experience this stereotype regularly when people find out I am Muslim for the first time and I receive the question: “But how?” What many fail to realize is that Islam is a way of life, and what is inside a person. Islam for me shapes a large part of who I am and what I do and was a great factor in me choosing medicine. Being Muslim means being of service to your community and to the world. One of the 5 ‘pillars’ of Islam is Zakah (charity) and along with that we also have a term Sadaqah, which refers to voluntary acts of giving. Sadaqah can be manifested in many ways such as holding a door open, making someone smile, or helping to improve someone’s quality of life (i.e.

LARISSA LESTER

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In my case my diversity is not something that can be seen on a physical level, but rather is manifested in actions and values as it relates to my faith.

doctor). Providing a service for others was one of the components I desired most when I was choosing

a career path and I feel extremely blessed to be able to incorporate this component of my faith into my work. I mentioned earlier that simple acts such as making another person smile are key components of Islam. Along with this, positive interactions with people are another example of influence I try to incorporate from my faith into the workplace. Although I have many shortcomings in achievement, one of my consistent objectives in life is to always be a person that brightens a room and leaves a person/place in better condition than when I

found it. In medical school this can present in many fashions: Contributing knowledge in a small group learning session, being a person that classmates always feel that they can talk to, and helping care for a patient in the hospital while simultaneously making them smile/ laugh are all exemplary. So it may be obvious how my faith plays a role in my passion and practice of medicine. And in my case my diversity is not something that can be seen on a physical level, but rather is manifested in actions and values as it relates to my faith. n

ESSAY

BEING A MORMON IN MEDICAL SCHOOL WORDS BY Christian Blake Morris

Famous Mormons: Steve Young, Gladys Knight, Kaskade, John Heder, Yukihiro Matsumoto

I WAS ASKED TO WRITE ABOUT BEING A MORMON IN MEDICAL SCHOOL. I

must say that I am not writing this as a spokesperson for my church but rather as a member of this church in medical school. I was

hesitant to write this at first because I felt that my experience in medical school is probably very similar to the experiences of most other medical students and was not very interesting. Also, I am a very open person about my religion but am somewhat fastidious about my

spirituality. I decided to write this in order to give my perspective as well as redress a few misconceptions surrounding Mormonism.

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THE MISCONCEPTIONS 1

The name of the church is the “Mormon Church”. False, the name of the church is “The Church of Jesus Christ of Latter Day Saints” and as the name reflects we believe that Jesus Christ has re-established his church in modern times.

2

Mormon men have multiple wives. False, I can barely get a girlfriend much less a few wives.

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All Mormons are Republicans. False, there are many Democrat as well as Independent Mormons, the most prominent being Harry Reid who is the Senate Majority leader.

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Mormons aren’t Christian and don’t believe in the bible. False, Jesus Christ is central to all our teachings and we believe in the bible but only as far as it is translated correctly. Most misconceptions can be cleared up by simply going to www.Mormon.org and perusing the website.

MY PERSPECTIVE AND OPINIONS Central to Mormon theology is the belief that God’s greatest gift to human beings is the ability to choose our own paths and make lucid decisions. It is part of the reason that Mormons are taught to abstain from things such as alcohol, tobacco and pretty much any addictive substance or behavior. At times it can be very difficult but I have gained great amounts of discipline in adhering to these principles. As far-fetched and naïve as it sounds, imagine healthcare in world where people simply abstain from consuming harmful substances. Having a science background and having loved “the sciences” my whole life, it would seem a bit hypocritical and inconsistent to deny evolution based on my religious beliefs. Fortunately, I don’t have to do that. I believe in a divine origin and accept evolution

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as a scientific reality. I do not believe them to be mutually exclusive. Furthermore, I do not believe that any amount of science can prove or disprove the existence of a divine being. Families are forever. Mormonism teaches that families can be sealed together for eternity and that the bonds of marriage and family persist into the next life. This teaching, I feel, has given me a broad perspective on life as well as less fear surrounding death. The Book of Mormon. Probably the most stark difference between mainstream Christianity and Mormonism is the belief in continued revelation and scripture. We believe that God continues to speak to us through prophets. Joseph Smith founded the church and there has been a succession of prophets and there is a prophet today by the name of Thomas S. Monson. I hope I have given a glimpse into Mormonism as well as

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some perspective into parts of the Mormon thought process. I would like to end by telling you a little bit about how Mormonism has influenced me into choosing the field of medicine. I will start with a quote by Marianne Williamson: “Our deepest fear is not that we are inadequate. Our deepest fear is that we are powerful beyond measure. It is our light, not our darkness that most frightens us.’ We ask ourselves, Who am I to be brilliant, gorgeous, talented, and fabulous? Actually, who are you not to be? You are a child of God. Your playing small does not serve the world. There’s nothing enlightened about shrinking so that other people won’t feel insecure around you. We are all meant to shine, as children do. We were born to make manifest the glory of God that is within us. It’s not just in some of us; it’s in everyone and as we let our own light shine, we unconsciously give others permission to do the same. As we are liberated from our own fear, our presence automatically liberates others.” I believe that every one of us is a child of God and as such has infinite power to make our world a better place. I believe that each person is gifted and talented in a unique way and can contribute greatly to the overall well-being of our society. I thrive on human interactions and the opportunity to do something of worth in someone’s life is my raison d’etre. “You have not lived today until you have done something for someone who can never repay you.” n

I have greatly appreciated learning from all of you and appreciate any and all feedback: Christianblake.morris@gmail.com. I have a fairly thick skin so don’t hesitate.


PHOTO ALBUM

CELEBRATIONS

New Year Celebrations

COMPILED BY Mairaj Uddin and Myra Aquino

The New Year of the lunar calendar has been celebrated by many people around the globe throughout time. In the Hebrew Calendar, it is Rosh Hoshanah, literally meaning “head of the year.” The Islamic Calendar is observed mostly in South Asia and the Middle East, with the ushering in of the first month of Muharram. While the Persian calendar was once originally lunar, the Persian New year is Nowruz, known for its elaborate decorations and traditions. The Chinese calendar, which is a mix of lunar and solar calendar, is celebrated across Asia and integrated into many government systems in Southeast Asia. As in any new year’s celebration, whether based on the lunar or solar calendar, a wish for a year of continuing goodness and success is common among all.

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Lunar New Year and Thanksgiving, Mairaj Uddin For my family and me, thanksgiving fell during a special time this year. It was the beginning of the Lunar Calendar on November 4th, 2012. Since the lunar calendar is shorter than the International Gregorian Calendar, this New Year date changes approximately 11 days from year to year. However, as in typical Indian sub-culture, the date may change but celebration stays the same—food—lots and lots of food. As in every of our thanksgivings, there are two turkeys that are made. One made the good ol’ American way, which serves as the first course, and of course the second turkey marinated in all the Indian masalas, chutneys, and garnishes that make for a night filled with stories from the elders and everything associated with food coma.

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Rob Fell Robert “Phantom” Fell relaxes with friends and family after a long year. As an MD/MPH1, kicking back in the hot tub in Dallas, Texas proves to be a much needed respite after a long semester of studying.

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Rob Fell Whether in the hot tub, or in the snows of North Dakota, spending time with friends is always fun!

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Diana Byrnes Byrnes siblings on the rooftop of the Barcelona Cathedral

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Diana Byrnes Casa Batlló located on the Passeig de Gràcia, one of Antoni Gaudí’s Modernisme masterpieces

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Nicholas Cortolillo Me and Anne Kimball doing a waterfall hike in the Blue Ridge Mountains of Georgia.

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07-09 Jennifer auf der Springe Spending the holidays with my entire family back in Washington state. 10

Jennifer Schwenk Kayaking the Panama Canal

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Ryan Reusche During the holidays, I had an opportunity to go to the backstage of Cirque Del Soleil’s Mystere. Big pic is empty auditorium, small pics include a dressing room, view from catwalk where they harness to drop from the ceiling, and one of the medical therapy rooms where they have a doctor on call 24/7.

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Jennifer Schwenk Three-Toed Sloth

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Caring HeARTS


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Chanelle Diaz This was taken in Praia de Pipa, Brazil, one of the best beaches in northeast Brazil, known for its surfing.

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This was taken after midnight at New Years Eve on a beach in Natal, Brazil. It’s tradition to wear white and to go out to the water to make an offering (such as flowers) to lemanja or to jump the waves for good luck.

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My New Years’ Celebrations are usually noisy, bright, and filled with smoke.

Xavier’s and my feet after we jumped the waves.

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Pandan-flavored sago’t gulaman, a common Filipino refreshment consisting of gulaman cubes (basically jello) suspended in milk, and flavored with pandan leaves.

Myra Aquino No Filpino Christmas is complete without lechon-- which is roasted suckling pig, cuisine brought over by the Spaniards during the country’s colonization era.

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SPECIAL INTEREST

FEATURED ARTICLE

IN DEFENSE OF

FIRST, LET ME START THIS ESSAY BY SAYING THAT I AM A FAIRLY WELL ADJUSTED 24-YEAR OLD MALE WITH AN ACTIVE SOCIAL LIFE AND NORMAL INTERESTS.

I, however, am also a wrestling fan. Not an Olympic wrestling fan, but a sports entertainment fan. Watching World Wrestling Entertainment (WWE) is my not-so-guilty pleasure. Whenever I tell people that, I get a mixture of scorn, disdain, and confusion. People cannot understand why someone over the age of 12 would want to watch the WWE. But, if you will indulge me, I will explain why I still watch it. When anyone thinks of the WWE, they think of the Attitude Era. The time in the 1990s where wrestlers like the Rock, ‘Stone Cold’ Steve Austin, and Triple H were at the peak of their powers. People think of these larger than life personalities and remember the ‘fake’ fighting that takes place in the ring. People say, “How can you watch that, its so obviously fake?!” Well, yes-- yes it is. But that isn’t a problem. How many times have you turned off a sitcom or a TV

WRESTLING WORDS BY David Haverman ARTWORK BY Mary Lan

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People say, “How can you watch that, its so obviously fake?!” Well, yes-- yes it is. But that isn’t a problem. How many times have you turned off a sitcom or a TV drama because it was ‘so obviously fake’? The realism argument has no merit here. drama because it was ‘so obviously fake’? The realism argument has no merit here. As a 24-year old I have been aware that the actual wrestling is fake, but that doesn’t make the athleticism any less entertaining. The wrestlers spend many years perfecting their craft so that what they do looks as real as possible. There is a term in wrestling, called kayfabe which, translated roughly from Japanese, means the suspension of reality. In wrestling it applies to the willful suspension of disbelief. Just like any TV show, movie or even Broadway play, one must suspend disbelief in order to appreciate the product. Wrestling is an entertainment product; with roots all the way back to Vaudeville. And kayfabe has been the modus operandi for many years, ever since WWE

CEO Vince McMahon declared publically in 1994 that wrestling is fake. But this, as I keep saying, does not detract from the entertainment value. The show that the ‘superstars’ and ‘divas’ put on in the ring is impressive if you think about the athleticism involved. To see a 350-pound man lift another 300-pound man over his head and slam him onto his neck without injuring him is extremely exciting to see. If the wrestlers are good at what they do in the ring, you find yourself subconsciously getting invested in the match. Without even realizing it, you care about who wins, you are concerned for the safety of the performers, and you are being entertained. Getting hit with a chair hurts, even if you know how to mitigate the blow. But the in-ring product is not the primary draw for me. It is

everything that happens outside the ring that keeps me coming back. When the superstars address the crowd, they call it cutting a promo, and it is in my opinion the most entertaining part of the show. For me the entertainment value comes from the speaker’s ability to work the crowd. It is not easy to give a speech in front of a crowd, let alone one with 20,000 screaming fans. The speakers have to further the story while engaging the crowd. Whether a wrestler is a good guy (baby-face) or a bad guy (heel), they need to get a crowd response. There is a saying in the business that it does not matter if the crowd cheers or boos you, just that they respond to you. The ability of the better performers to cut promos is truly mesmerizing. One cannot help but be impressed by a person who

But the in-ring product is not the primary draw for me. It is everything that happens outside the ring that keeps me coming back. CM Punk and Dwayne “The Rock” Johnson in a face-off. Recruited by the University of Miami to play football, The Rock graduated from UM in 1995 with a Bachelor of General Studies in Criminology and Physiology.

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CM Punk, sitting cross-legged at the top of the stage, delivered a scathing commentary on the state of the wrestling business, and more notably on the McMahon family, which made everyone watching think, “Wait, is this real?!” speaks for four minutes and can completely manipulate the emotions of 20,000 people. Some do it based on reputation, like wrestler-turned-movie star, The Rock. Because of his reputation, and considerable mic skills, he can get a crowd of 80,000 people to chant “Rock-y, Rock-y” just by raising an eyebrow. Some do it based on skill. The best example of this is current WWE champion, CM Punk. CM Punk is currently my favorite wrestler, and the favorite of many fans like myself. He is great in the ring and even better on the microphone. CM Punk will be the longest-reigning WWE champion of the modern era in just a few short weeks. This achievement in the era of ADD and rapid story progression is extremely impressive and speaks to his skills as a wrestler. To be the champion for this long, one has to continually evolve and keep the crowd entertained. The writers will keep you champ as long as you can continue keep the crowd entertained. On June 27, 2011, Punk cut a promo that shifted the paradigm of the WWE universe. His promo, a ‘worked shoot,’ which is where the writers give freedom to the performer to speak the truth and break the fourth wall, ushered in the current Reality Era of the WWE. CM Punk, sitting cross-

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legged at the top of the stage, delivered a scathing commentary on the state of the wrestling business, and more notably on the McMahon family, made everyone watching think, “ Wait, is this real?!” The line of kayfabe had been blurred. This blurring of reality in the wrestling world is a welcome change for older fans like myself. From the ashes of the PG-- or “parental guidance suggested”-- Era where the WWE catered to its younger fans, this new era has arisen. While they still maintain the PG rating, and haven’t quite returned to the brash TV-14 antics of the Attitude Era, the reality provides a much-needed reprieve. It is a more ‘self-aware’ WWE now. One where the writers, or bookers, can use the desire of older ‘smart’ fans for reality to manipulate us into more traditional fans or ‘marks’. The few moments where I turn from a smart to a mark are always supremely entertaining. Moments, like the aforementioned CM Punk promo, where I wonder if what I’m seeing is actually true, despite the fact that I know it’s fake, is what keeps me coming back. Because of this, the so-called insiders have created a new term for fans like me, a ‘smark’. I am a fan who knows how the industry works, and understands the intricacies of kayfabe, but I am not above completely

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becoming engrossed by the story. The WWE has toed the line between reality and kayfabe amazingly well over the last few years. There is also an element of nostalgia that keeps me watching. I remember watching wrestling in my youth and watching with my father. My father grew up a wrestling fan and was a smart fan back in the days when I still thought it was real. When I came to the realization that it was fake, we watched together to see the finer points of the business. Our favorite wrestlers are not necessarily the good guys that the business promotes. We like the wrestlers that keep us entertained. Wrestling for me has a special place in my heart and was a great part of my youth. So, I have said a lot about the merits of today’s WWE and sports entertainment as a whole. But my closing statements to you the skeptical reader is simple. If you go into wrestling with the idea that it is entertainment and not real, you will enjoy it. If you try to watch with an open mind and not just assume that it is stupid, you will enjoy it. If you cannot subscribe to kayfabe, then watch for the skill of the performers and the level at which the good ones perform. Give it an honest chance and I promise you, you will enjoy it. n

Caring HeARTS


MYRA AQUINO

POETRY

FAN YE FAN WORDS BY Alexander Kaplan

the child born in the East discovered by a lone wise man he brings not gold nor frankincense nor myrrh for gold softens, frankincense and myrrh combust what he offers is too vast to bring manchurian girl, born of horse and grass finds herself strapped to a strange man’s chest expressing a jumbled language through olive eyes Extraordinary the girl undertakes a lengthy journey she naps on the hump of a camel and cries in the viscera of a flying machine message manifest a boy a girl a woman greet the strange man who is no longer so strange and embrace the child with limbic flush and racing heart Extraordinary

skin caught on bone a grotesque brachial scar legacy of an ignorant herbalist she becomes the boy’s first patient fed on familiar jello and some vegetables she won’t eat meat but grows Extraordinary fed on attention and a swing and a slide she thrives when blood is given from one to another whose blood is it? It matters not Extraordinary this blood has no lifespan love transplanted in a vigorous child it is neither mine nor hers

love’s triumph is that it could not exist without mind as body body as mind Extraordinary without love a great divide like the century’s wasting of Alsace love creates an omniscient union with invisible stitches a family Extraordinary the boy has changed like a leaf turning towards the sun the ocean reflects sky and he sees himself in her and her in him Fan Ye Fan sinocryptic linguistics a name meaning Extraordinary

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AT THE BEDSIDE POETRY

PHARMACEUTICAL COUPLETS WORDS BY Peter Schmitt Second honeymoon at Niagara? Better pack the Viagra. Kind of your joy's Lo-Jack we might call Prozac. Potato chip? Cheese spread? Dip it more! After all, you're on Lipitor. Reflux isn't sexy, hon; I'm recommending Nexium. There's just no quit in him-since starting Ritalin. Assistance at the urinal? Don't ask-unless it's from Flomax. If you're down to Plan X, you're ready for Xanax. Feeling Zombian? Get some shut-eye with Ambien. PHOTO

SPECTRUM OF EQUAL GLASSES by Kyle Amber

“Spectrum of Equal Glasses” came about during the aftermath of hurricane Sandy. Though my patio furniture had somehow endured storms of greater magnitude, it had finally met its match. As I was about to discard of the large mounds of broken glass, I began to appreciate the aesthetics of this pile. Once organized pieces of glass were now broken into unequal crystals. Each one on its own refracted light differently, but in my eyes, each individual piece was equally beautiful and perhaps more beautiful than my once sturdy and faithful table. My table’s destruction and subsequent discovery of this broken glass occurred during one of the most unpleasant times to watch the television: the election season. Saturated with comments about the role of law in allowing or retracting the rights of many people whom are close to me, I sought to demonstrate the equal beauty of the individual as a protest to the political stance of depriving individuals of their rights.

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Thanks to docs we count on we're well-supplied in Oxycontin. Your stocks aren't rallying? Time for a Valium.

KYLE AMBER


POETRY

TRACHEOTOMY WORDS BY Chris Joyner 4. Heel the boat. When your boat is becalmed, the sails will just sit limp with no shape or form. Sails work like wings and lift translates into propulsion… —“How to Sail in Little to No Wind” It was a strange flute jutting from the throat when breath failed her. It was a flowerless vase, punctured sail, and how the hole clung to dying wind.

POETRY

DESTRUCTION OF THE TEMPLE WORDS BY Meredith Camel

Today I was dumped by my acupuncturist.

What a prick. Oh, how he held my hand three fingers down from the wrist where the lung chi exists

With knees knocked, fingers locked I hoped he’d build something special with me like a stronger spleen.

Defunct spleen can explain poor respiration, profuse perspiration “Gotta Have It!” Cold Stone cravings. I try to B+ It’s in my blood but out of circulation. Meridians transposed like batteries, polarities reversed. Wired when I should be wound down. Tired when I should be upwound. Standing above ground with a sinking feeling that something horrible remains unfound. “Try kinesiology,” he said, pawning me off on some alternative healer. Echinacea, vitamin C zinc and green tea yoga, yogurt and a pomegranate splash—

bathe my tissues My body is the sphere

in your healing solution. where East meets

West.

Needle stick, pinprick or any other probe, pinpoint the place where healing begins.

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DON'T RELY ON MIRACLES WORDS BY Zachery Hickman The poem narrates and reflects on the last few months spent with my brother who was suffering from terminal brain cancer. It comments on lost, unconditional love, the bonds of friendship, the strength of our wills, the fight to remain optimistic in the face of terminal illness, and learning to cope with the emminent decline and death of the people who know us better than ourselves.

I. I used to pray until I found out it didn’t dictate outcomes. My brother suffered from terminal brain cancer, he had a head cast to pinpoint tumors with gamma rays, the cast protecting the rest of his head from radiation. In April and June, his left side paralyzed from a stroke, he could barely put together a sentence, but we still bonded, listening to Marley and Springsteen on his front porch, smoking cigarettes in the same spot we lit up after school during our childhood— the neighborhood boys fresh from their miseducation finding freedom in the stench of nicotine. I had to help him from the hospital bed to the wheelchair and from the wheel chair to the sofa. He slid in sly comments just when everyone thought he was asleep, a rabbit in a vegetable garden. And he slept all day. He shit and pissed in a cold bedpan because he could not get to the toilet in his wheelchair. He called me “Laquesha” and we sang a made up poopy-rain-dance song one morning to relieve his constant constipation, waiting

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JENNIFER SCHWENK, ACRYLIC ON CANVAS

POETRY


for a bowel movement which doesn’t arrive. If a person survives, we call it a miracle, but what do we call it when they die? Watch what God says. Even though his short term memory was gone, we still engaged in the wave of conversations we always did, moving from one subject to the next, the segway unspoken. We spoke in the tongues of brothers. The only miracle was in the way our minds moved in synchrony, our ideas harmonizing. Sleepless nights, rustling on top of the covers in my blue jeans, adopting his rejection of pajamas, I crawled Into the bed we slept in together as young children, playing matchbox cars with flashlights under the covers where the sheets tucked in, watching Ben stare blankly into the ceiling from his motorized bed, willing him to slip into sleep, the only place he looks peaceful during the last months when angels rescue him in his dreams, white noise breaking the quiet.   II. In late July, landing after a late flight to Pittsburg, I drive over the peaks and down through the fog collecting at the bottoms like water to a drain, sucked into the abyss, needing GPS to find the hospital where he is, even though I grew up with him in this town. scorching the night, tempting the possibility of fate, walking the train trestle five stories high, diving into the dirty river. Nine years later, the cancer gripped onto his brain stem like a leach. I didn’t make it in time. He passed before midnight, our favorite time as teenagers, two mountain boys pondering our escape from what we knew, life manifested in the oppression of each millisecond. His parents and sister left just after one a.m. In the airport, on the phone, waiting for mechanical repairs, I told him goodbye, and they asked if I wanted to see the body. I began to shake from my bones, a shuddering slouch I could not hide from the other passengers waiting impatiently.

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53 MYRA AQUINO


I had never seen a dead person outside a grandparent at a funeral. When I finally arrive, two a.m., I walk past the nurse’s station, heading straight for room 310. The nurse realizes who I must be going to see and asks, “Are you sure you can handle this?” I pretend she’s just a tile on the cold floor. I blame her for letting him die even though I recognize she had nothing to do with it. Corridors like walk in freezers, the smells of sterile alcohol and urine, and the chalky taste of meds taken without water crusts around my mouth, pills to flush down the shaking, the doubt, only to return again. The room an igloo, freezing death. Between us, a thin cotton curtain hangs curved around his still, resting body, sheltering his empty vessel. I smell him before I see him, the faint stench of death creeping into the hospital hallway. He looks like Ben, like the purity of darkness, like the cynic behind his laughter, like the intellect he hid from everyone, like the weightlessness of snow, like the dense air of summer, like the pouring rain, and like the wind’s calming whistle. But his smell is gone, flesh rotting as each minute passes, the antique stillness of the last oxygen to leave his lungs. I sit in a chair in the corner, alone. I don’t know what to say then, just as I will be speechless at the funeral, except to read the poem he scribbled in a forgotten notebook, “Self-Pity.” I just stare at his motionless body, again, at rest for the first time in his three year fight. I clean the sticky goo all over his face from the tape holding down all the tubes, black marks on his nose left by what was keeping him alive, a reminder of the mess of an unexpected departure. I kiss him on the forehead and say goodbye. His flesh turning blue. I leave after 15 minutes. I have nothing to say to a dead body. We said what we needed to say to each other always, always a mutual kinship for observing over talking. For action.

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III. Twenty eight years ago, we took pen knives to the back alley under the pines and opened our palms at the same time, placing each of our blades onto soft skin and shutting our fingers into fists. Then, we pulled the blades straight back towards our slim, six year old bodies, slicing twin gashes. As the blood began to squeeze out over our knuckles, we clasped our palms, letting the blood drip onto the sharp sides of the rocks, slipping down into the soil where miracles are grown from effort and care, not hope. Men in jumpsuits will burn his body in an incinerator, turning his flesh, bone, hair, baby blue eyes, pale skin, and cowlicks protruding and intertwined like two hands into gray, flaky ash, into the material I flick from my cigarette butts, reduced to a tin can, propped up as a way to keep remembering he’s dead, rather than celebrating his life by going out to our favorite spot in my Uncle Bull’s woods, which has changed too, timbered by men who need, who need and need, tearing apart the forest like a cancer. I want to wrap him up in his favorite blanket and carry him over those first few ridges, until I find a spot under a tree where the heat of the sun and her close cousin, shade, alternate temperaments. I wanted to dig a grave with my father’s spade. I wished to place him back down into the ground that birthed him, through the fiery core of the earth’s magnetic center, which pulls us in directions we have no choice but to follow. You cannot resist the pull of Mother Nature and her centered role in the energy spawning the earth, galaxy, and universe, a move from the narrow to the broad, a move each person who loses someone has to make, to look out to see the calm ocean past the break. I’ve realized how lonely believing becomes and how faith divides. I cannot believe in anything that provides for some, while not for others. I fall asleep listening to the voicemails I saved before the stroke stole his speech, listening for his words in my head to quell the stress headache caused by memories of the talk of miracles passed down to us. We wrote our own truths, lived and died by them.

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55 MYRA AQUINO


SHORT STORY

THINGS I WROTE IN MY NOTEBOOK AT A CLINIC IN GUAM VIGNETTES FROM A SMALL ISLAND IN THE MIDDLE OF THE PACIFIC OCEAN

WORDS AND SKETCHES BY Myra Jon Aquino All names have been changed to protect the identities of the people in these short stories.

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IT’S THE SUMMER OF 2010. I’M SPENDING MY SUMMER IN GUAM SHADOWING A NUMBER OF DOCTORS AT A PRIVATE PRACTICE. The clinic

is owned by Dr. Perez, who is a general surgeon. He happens to perform many colonoscopy and AV fistula procedures, so I often see anuses and colons in the early morning, and exposed forearms in the afternoon.

STRESS Today, an old Caucasian man named Stuart is in to follow-up on the results of his colonoscopy. During his

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procedure, a hyperplastic polyp was removed. Stuart has a history of colon cancer, which he has recovered from, and he is in for the results of his 3-year follow-up. “I wonder if stress has something to do with it,” he wonders, referring to the polyp. “Stress has something to do with anything— seriously,” Dr. Perez replies. “Routine is what the body craves, but the mind likes variety.” They talk some more, after which Dr. Perez asks, “Your wife’s doing okay?” “Yeah,” Stuart answers. “Lord’s being good to me.” He then points at me. “I see you got a new one,” he says. A new nurse or medical assistant, he means. Dr. Perez introduces me as a pre-medical student.


IN BRIEF

GUAM Source: CIA Factbook

“Myra doesn’t want to be a doctor,” Dr. Perez jokes, “so she’s following me to find out why not.”

ANUSES AND COLONS Maria, an exuberant old Chamorro woman, comes in for a colonoscopy consult, accompanied by her husband. She expresses her worry over the procedure. “I have to get a colonoscopy next month, too,” Dr. Perez says, by way of reassurance. “Really?” she replies. “I didn’t think doctors needed those.” Dr. Perez laughs. “Doctors have anuses and colons, too.” Maria then proceeds to pose to Dr. Perez a series of personal questions— Where are you from? What is your race? What do you do for fun?— and he makes a dry joke at every turn. She continues to regard him solemnly. “You’re so serious,” Dr. Perez says at her expression. “Well, it’s because I’m putting my life in your hands. I wanna know who you are,” she protests. Dr. Perez chuckles. “Oh well, I have no secrets.” Dr. Perez notices a burn scar on her husband’s lower left leg and asks about it. Then Maria and her husband talk briefly about their lives. Fifty one years of marriage. Maria changes the subject back to her colonoscopy procedure. “So when is my thingy?” she asks. “Thingy?” Dr. Perez repeats.

PINSTRIPE PANTS

A young man named Derrick waits in the examination room, and the first thing I see as I walk in the door are

SIZE 544 sq km (roughly the size of San Francisco)

HEALTH CARE CONCERNS Obesity, diabetes, hypertension Medically underserved

ETHNIC GROUPS Chamorro 37.1% Filipino 26.3% Other Pacific Islander 11.3% White 6.9% Other Asian 6.3%

ECONOMY US military spending and tourism POPULATION BELOW POVERTY LINE 23% FACT The military installation is one of the most strategically important bases in the Pacific.

RELIGION Roman Catholic 85%

his pinstripe pants. He’s in the clinic to get a second opinion from Dr. Aguon regarding the dermatitis on his face. This man is all lacquer and polish, with the kind of chic metrosexuality that looks so out of place in the tropical, laid-back atmosphere of Guam. He looks at his reflection in a compact mirror while he talks to Dr. Aguon. The doctor prescribes him hydrocortisone for his skin, and adds a short apology for getting to him later than the scheduled appointment time. Dr. Aguon has a larger load of patients today. “I’m one of his nightmare patients,” Derrick tells me, providing his own explanation. “So he makes me wait. But I’d gladly wait,” he coyly adds. Dr. Aguon, being his normal taciturn self, grunts. He’s a very large man, and makes no effort to make himself appear any less intimidating. James, the OR tech, likes to rhapsodize about the perfection of Dr. Aguon’s reconstructive surgery work (“He may have man fingers— but they are the fingers of an aristocrat.”). Perhaps all his gentleness is reserved for his hands. In the meantime, Derrick continues to chatter away, this time about a previous visit with Dr. Aguon. “He told me I wasn’t getting any younger,” he tells me, “and I was like ‘Shut up!’”

EASY Andres, an old Filipino man, is in the OR for an inguinal hernia repair. A previous attempt was made to repair the inguinal hernia in a hospital in the Philippines, but it was a shoddy job. As Dr. Perez performs the procedure, he tells me a few things. “You see, a lot of surgeries are easy. You need as much dexterity

as cutting steak with a knife. What’s difficult are the complications.” “How often do you get complications in your surgeries?” I ask. I scoff inwardly— disbelievingly. Surgery— easy? “I don’t have complications in my surgeries,” Dr. Perez says. “Spoken like a true surgeon,” Pam, the OR nurse, interjects. Dr. Perez finishes the procedure, thanks everyone, then promptly leaves. Andres is transferred to a gurney and brought to the recovery room. He wakes up some minutes later, quiet and bleary-eyed. When the patient’s daughter comes in, she asks how he feels. “Dizzy,” he says. They dress him out of his robe, and his daughter buttons up his Aloha shirt for him.

CHEESESTICKS Alfonso is a middle-aged man from Saipan, an island that neighbors Guam. Patients from Saipan usually fly to Guam for a procedure, or conversely, doctors from Guam will fly to Saipan. Like Guam, Saipan is medically underserved. Alfonso is mustachioed and portly— I tend to remember patients with mustaches— and is in the clinic for a scheduled lumbar epidural injection to treat lower back pain. Dr. Samson, the chronic pain specialist, feels for the patient’s iliac crest before locating the L4 vertebra. He cleans the injection site with betadine. “Are you allergic to any medications?” Pam asks. “My wife,” John replies. Dr. Samson and Pam are too busy to respond to the patient, but James snickers. “Just keep breathing,” James

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“Do I need a driver?” Isaiah asks. “Yes,” Dr. Perez replies. “My wife doesn’t drive,” he says, looking perturbed. “She only drives the chickens away.”

tells Alfonso. He coaches him while Dr. S proceeds with the injection. “You okay?” Dr. Samson asks Alfonso as he injects the steroids. “Oh yeah.” “You feel it going down your leg?” “Oh YEAH.” Dr. Samson covers the injection site with gauze. “I wanna go get cheese sticks at KMart,” Alfonso exclaims as he’s being taken out on the gurney, looking a lot happier than he did when he came in that morning. “Then go find a restaurant.”

FINGERS A middle-aged Chamorro man named Isaiah is sitting down in the examination room waiting for a colonoscopy consult with Dr. Perez. He tells him that he hasn’t had a colonoscopy yet. “Just had one finger up my anus,” Isaiah says. “Just one finger?” Dr. Perez asks as he sits down in front of the patient. He puts up two fingers. “You didn’t ask for a second opinion?” Isaiah laughs. Dr. Perez performs many AV fistula operations on patients— which is fairly common, given that many locals— not just Chamorros, but any person who happens to love the predominant meatand-rice diet here in the island— are hypertensive, diabetic, and on dialysis. While talking to the patient, Dr. Perez leans forward and feels around Isaiah’s forearm and hand, looking for any abnormalities in his circulation. He checks for this regardless of what his patients come in for, and to me this gentle exploration of a person’s fore-

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arms and hands is a strangely intimate yet comforting ritual. Dr. Perez informs Isaiah that it seems he has a circulation problem with his right hand— a weaker pulse— probably due to atherosclerosis. He lets Isaiah know that while the colonoscopy is being done, he will look at his legs as well. “Clearly it’s not okay,” Dr. Perez tells him. They then talk about the day of the colonoscopy. “Do I need a driver?” Isaiah asks. “Yes,” Dr. Perez replies. “My wife doesn’t drive,” he says, looking perturbed. “She only drives the chickens away.”

JAMES I spend a lot of time in the OR before the actual operations, talking to James— a veteran ER/OR tech— and watching him prep the room for surgery. He also has a mustache. Part of my time with him consists of me pointing to things around the room and asking what they are and what they’re for, but most of the time he shares stories with me. He’s kind of like a cool uncle. He’s full of pithy, humor-tinged advice, and he walks with the kind of stocky build that looks as if he’s about to enter a boxing ring instead of assist in a microvascular operation in a surgical theater. He talks about how he used to smoke pot on the beach with the ER docs back in Maui. This is his way of persuading me to pursue Emergency Medicine. He’s lived all over the Pacific— Maui, Samoa, Tonga, Micronesia, the Marianas Islands, to name a few— and he talks with the kind of easy

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wisdom and worldliness that is a direct contrast to the disposition of other islanders who see Guam— an island just a little bigger than San Francisco— as the only patch of land that exists in the world. He’s done his own rotation as an assistant in various specialities throughout his varied career, and he regales me with tales of his past occupations. This time he talks about how he used to work at a psychiatric ward for a number of years, and we talk about the psychiatric patients he used to assist. A sobering expression covers his usually cheerful face. “The difference between me and them? I have the keys,” he says.

MAROON Pedro, a middle-aged man, comes in to the clinic complaining of pain around his rectum. During the examination, they discover that his jeans have stained brown red. He’s brought to the OR for an emergency incision and drainage, and as his jeans are removed, dark maroon fluid flows down his legs. Dr. Perez washes the area with betadine, then injects Lidocaine into the site. He marks the incision and cuts through the lesion with a 15 blade. Fluid immediately escapes. Lots. Pedro moans.


“Sorry Pedro, you’re doing okay,” Dr. Perez says. He inserts an instrument into the perirectal lesion, and it goes down three to four inches. I feel my eyes go wide. “Ah f---,” Pedro grunts. Dr. Perez packs the wound, and Pam applies the bandage dressing. Pedro returns the next day, and he lies on his stomach on the OR table, his buttocks exposed. “You have a hairy rear end, like I do,” Dr. Perez observes. He takes off the bandage dressing from Pedro’s butt. “We don’t charge for the wax,” he says. Pedro manages to chuckle. Dr. Perez proceeds to remove the packing from the wound, and Pedro groans. “You okay there?” Dr. Perez asks. Pedro mumbles. Dr. Perez inserts an instrument into the four-inch abscess. “Ah f---. F$%&!” Dr. Perez injects lidocaine around the site again. Then he looks at me. “Sometimes you use anesthesia just to be humane,” he says.

LITERARY SOLUTIONS “Hey doc, long time no see.” Dominic, a man in his late thirties, comes in to meet with Dr.

Aguon. He has a large cyst on his left hand, and thick fluid slowly oozes out of the lesion. “I want it out,” Dominic says. “That or I’ll slam it with a book.”

WHIMSY David is a young boy who comes in for a wart removal from the skin near his left eye. He’s accompanied by his father. We wrap a blanket around his body and hold him down while Dr. Aguon does a quick injection at the site. Even with children, Dr. Aguon only talks when necessary, and the room is silent. David is initially quiet, but then he starts to make a bit of noise. “Go ahead and cry,” Dr. Aguon says as he withdraws the needle. The kid takes a deep breath and starts

sobbing. Leslie, the medical assistant, cleans the wound with betadine, and David cries even louder. “Five minutes,” Dr. Aguon says, and he leaves the room. He never lingers while the anesthesia sets in. I don’t know what he does in his office in those five minutes, maybe he writes performance poetry or breezily clicks through the StumbleUpon website. Later, when he walks back into the room, David cries, “What are you going to do to me?” He squirms in the blankets he’s still wrapped in. Dr. Aguon tries to explain what he’s doing and to comfort David while he holds a scalpel and a small pair of scissors in his hands. David continues to cry, and his cheeks are streaked with tears. “We’re going to Whimsy after this, remember?” his father says. Whimsy is a local entertainment center

I asked him what he thought of people who did that kind of work. International medical work in areas of conflict. “Crazy,” he says. “I think they’re running away from something, or have some unresolved issues.”

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Caring HeARTS for kids, like a smaller version of Chuck E. Cheese’s. “Where are you gonna go when you’re in Whimsy?” “To the ball pit,” David replies, whimpering as Dr. Aguon deftly lobs off the wart.

CANDY Danny, a middle-aged man, comes in for an AV fistula creation on his right hand. As the nurses and OR tech busily prepare him for surgery, he lies on the OR table, saying various things until someone responds. “I’m tired already.” “I’m getting the cold sweats.” “Ooh… I’m hungry.” Dr. Perez finally approaches him. “You’re hungry? We’ll feed you some candy through the IV,” he says. During the operation, Dr. Perez talks about the international work he’s done, which he sums up in one word: Frustrating. He tells me that in 1996, he was supposed to go to Rwanda with his wife— another doctor— but she found out she was pregnant, and they both decided not to go. The people who replaced them ended up being killed in the trip. I asked him what he thought of people who did that kind of work. International medical work in areas of conflict. “Crazy,” he says. “I think they’re running away from something, or have some unresolved issues.” Danny snores loudly throughout the whole operation.

STRESS, PART 2 Bi Jung, a middle-aged Korean woman, comes in to follow-up on her colonoscopy results. She’s accompanied by her sister. Dr. Perez shows

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her the snapshots he took of her colon, and informs her that she has moderate chronic gastritis based on the results of the biopsy, and from the observed inflammation in her intestine. There is, however, no infection, and no cancer. The sister of Bi Jung translates all this to her in Korean. Dr. Perez asks further questions that might give clues as to what might cause the presence of the inflammation— what medication she takes, if she drinks or smokes, if she’s stressed. “It’s stress,” her sister exclaims in English. “Stress! She’s very sensitive. Very sensitive.” Bi Jung says something in Korean, looking distressed. Her sister translates: “Maybe because of her daughter-in-law.” They both seem to agree with this explanation. Dr. Perez prescribes Prilosec to Bi Jung, for two months. Looking

worried, she asks for three months. We all laugh, and she smiles. Dr. Perez asks her what the name of her daughter-inlaw is. “Jae Won,” she and her sister both say. “Sounds like trouble,” Dr. Perez says, and the room erupts in laughter.

MACHETE A brown-skinned, portly, middle-aged man named Thomas comes in to the clinic requiring an excision of mass from his back. Mustachioed. Dr. Perez injects the site with anesthesia. “Now all we need is a blunt machete, and we’re good,” Dr. Perez says. While lying on his stomach on the examination table, Thomas asks about me. Dr. Perez tells him I’m a student learning how not to be a doctor. “I’m learning a lot,” I say. Dr. Perez chuckles. “Funny girl.”n

SOURCES CITED Helping People Feel Like People: Closing The Door On LGBT-Centered Disparities, by Adam Crosland 1. Gay and Lesbian Medical Association: Healthy People 2010: Companion Docu`ment for Lesbian, Gay, Bisexual, and Transgender (LGBT) Health. Apr. 2011. http://glma.org/_data/n_0001/resources/live/ HealthyCompanionDoc3.pdf (accessed Dec. 10, 2012). 2. Dean L., et al.: Lesbian, gay, bisexual, and transgender health: Findings and concerns. J Gay Lesbian Med Assoc 4:101–151, Sep. 2000. 3. Krehely J.: How to Close the LGBT Health Disparities Gap. Center for American Progress, Dec. 21, 2009. http://www.americanprogress.org/issues/2009/12/lgbt_health_disparities.html (accessed Dec. 10, 2012). 4. Gay and Lesbian Medical Association: Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients. http://glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf (accessed Sep., 2011). 5. American College of Physicians (ACP): The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender 
Health. Philadelphia: ACP, 2008. Diversity in Miami: Where Do We Fit In A City Of Fragments, by Myra Aquino My special thanks goes out to Renee Dickens Callan of the UM Office of Multicultural Student Affairs, and to Nanette Vega, Dr. Stephen Symes, and Dr. Stefanie Brown of the UMMSM Office of Diversity and Multicultural Affairs for interviewing with me for this article. I’d also like to thank Dr. Gauri Agarwal, Dr. Daniel Lichtstein, Jennifer auf der Springe, Brigitte Frett, and Joseph Choi for their thorough and valuable review and critique of the piece prior to its publication. The sociological history of different communities in Miami was drawn from two books: 1. City On The Edge: The Transformation of Miami by Alejandro Portes and Alex Stepick 2. The Logic of Black Urban Rebellions: Challenging the Dynamics of White Domination in Miami by Daryl B. Harris

WINTER 2013 | OBLITERANTS


JENNIFER SCHWENK, ACRYLIC ON CANVAS

POETRY

THE PATIENT IS DISCHARGED WORDS BY Gauri Agarwal, MD My children gather on the sand Among others The town has come under darkening clouds To witness a return My sons peek under the orange ribbon Through the backs and legs of adults My daughters become impatient And dig for shells Sitara sits in the foam Screaming in delight at an unexpected wave Murmurs begin and cameras emerge She has arrived. She was found injured and alone Gasping in the water With the mark of teeth on her back And limbs that were torn Over months, she was carried and loved

Given sutures and injections Fed honey and water She is ready to return. Her first steps are tentative Her flipper cautiously grazing the water She stands for a moment, gazing at seaweed And the gulls above It appears that she may sag And then, she remembers Those with whom she swam The moonlight when she returned to the beach The eggs that would open with her young And with that, her body submerges The clouds surrender and bathe her My children dance with joy in the rain As her shell darkens into the sea

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EDUCATION

ARTWORK

THE SURGEON ARTIST Oil on canvas with photoenhancement ARTWORK BY Ekaterina Kostioukhina THIS PAINTING IS ABOUT ONE OF MY PRECEPTORS WITH WHOM I HAD THE PRIVILEGE OF WORKING. It is a scene that hopes to portray the contrast between his work as a surgeon and his parallel life as a very talented artist. I didn’t think it was possible to be a successful surgeon and at the same time have that special talent of creating art with paint and brushes. The surgeon with all his precision tools and sterile outfit is highly focused on his work which engages the left side of his brain, but when he is in that state of concentration it becomes an art, like the one he creates with his brushes and paints. The surgical field turns into a canvas and his scalpel into a brush, and that is when magic happens. The right side of his brain brings in the artistic touch to the surgical table. n

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COMICS

CONVERSATIONS ON THE SOCIAL NETWORK ARTWORK BY Mary Lan FEATURING UNIDENTIFIED MEDICAL STUDENTS IN AN UNIDENTIFIED SOCIAL NETWORKING WEBSITE

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POETRY

ANATOMICAL LANDMARKS WORDS BY R. Rammy Assaf Our bodies, they tell a story to the dreamer and realist alike they tell a story. To the scientist an infinite field of discovery To the architect  a structural grid of efficiency To the artist  a flourishing composition of inspiration Like the fascination of flesh to the painters of Rococo    of movement to the Impressionist    of scale to the Minimalist    of truth between David and Michelangelo. Our bodies, they breed dialogue.

MNEMONIC

WHAT DISEASE DOES THIS DRAWING “ILLUSTRATE”? Hint: Refer to the renal module. See bottom of page for answer.

ARTWORK BY Shari Seidman

Answer: Autosomal Dominant Polycystic Kidney Disease (ADPKD)

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HOUSE OF MEDICINE

ESSAY WORDS BY Brett Van Leer-Greenberg EDITED BY Melissa Stone

This edifice never withers and never decays – it just expands. We hold its teaching steadfast until they manifest as clinical findings and surgical techniques. The beauty of medicine is that these discoveries do not exist in a vacuum. Physicians are not docents, polishing exhibits in a museum – but rather, tried and true principles of medicine are passed down from attending to resident, resident to intern, intern to student. The daily practice of medicine unwittingly preserves each fact with the zeal and intrigue for which it was originally discovered.

ORIGINATING IN THE PYRAMIDS WITH THE WISE PROVERBS OF IMHOTEP, THE HOUSE OF MEDICINE HAS BEEN UNDER A CONTINUOUS STATE OF DISCOVERY AND DEVELOPMENT. Our forbearers Hippocrates, Maimonides, and Galen

laid the foundations upon which the likes of Salk, Laennec, and Cushing built great cathedrals of knowledge. The souls and wisdom of these architects have come to dwell in the house they helped to create. Since the first spark of curiosity, medicine has evolved through the pyramids into cathedrals of knowledge and are more recognizable today as the modern hospital. We are steeped in these connected rooms of knowledge because each gives us a deeper understanding on how to treat and cure. The truest practice of the scientific method, as hypotheses mature into observable fact, medicine transforms abstract ideas into physical reality. When physicians and researchers stand on the shoulders of intellectual giants to build their work, existing knowledge serves as our scaffold to foster greater understanding. We have pushed the envelope of knowledge to the molecular level as we now look to the genetics and proteomic details to furnish this house and crystalize our understanding of the human condition. With each innovation, our church of knowledge has taken the shape of a hospital. It is the place where the maladies of our patients and the accumulated knowledge of medicine converge. We are the brokers, keeping

When we put on our white coat and stethoscope, we assume a greater identity. We represent the body of knowledge that defines the profession of medicine. But what do we do with this responsibility?

this knowledge but never possessing it. We use it for the good of our patients; its application pays homage to those great minds that were kind enough to share their discoveries with us. Medical students have the privilege of receiving this knowledge but it comes with an incredible responsibility. It is a responsibility, not only to our patients but also to the physicians who have forged the path before us. When we put on our white coat and stethoscope, we assume a greater identity. We represent the body of knowledge that defines the profession of medicine. But what do we do with this responsibility? Our white coats don’t just symbolize those who came before us but rather they show what we are capable of. They symbolize the privilege of knowledge that has been given us. Much of the house of medicine remains unfinished and unknown; it is our responsibility to build on those foundations and to continue discovery that we will teach to the next generation of doctors. n

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OBLITERANTS

Obliterants Winter 2013  

This is the Winter 2013 issue of Obliterants, a journal for humanities and social sciences in medicine and public health, created by student...

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