Search Results for: Medicine

Doctors Without Patients: The Eritrean Physicians Stuck in American Licensing Limbo

Illustration by Carolyn Wells

Shoshana Akabas | Longreads | October 2021 | 16 minutes (4,762 words)

*Haben Araya was working in the local hospital when a farmer came in, bleeding from his gums. He was suffering from a snakebite — a case she’d seen many times.

*At the request of the doctors involved, some names have been changed.

Before Araya sought asylum in the United States, before she helplessly watched the COVID-19 pandemic tear across the country, and before she learned about what doctors must go through to relicense in America, she worked as one of a handful of physicians on staff at a local hospital in her home country of Eritrea. She was a general practitioner, responsible for everything from pediatric preventative medicine to minor surgeries and gynecology. She served as the regional appointed physician for malaria case management and the hospital’s Director for Tuberculosis Control. If a patient needed to be transferred to another hospital, she had to write the referral. Call the ambulance. Make sure the ambulance has enough gas. Find someone to fill up the tank.

Snakebite cases were heartbreaking for Araya because she knew the medication was prohibitively expensive: 840 Eritrean Nakfa for a single vial (about 56 USD). Sometimes four or five vials were required, costing more than many farmers would earn in a year.

The hospital insisted on taking some sort of collateral until the bill was paid, but Araya knew the farmers were good for the money. She also knew that they would likely sell their goats or sheep — whatever animals they relied on for their livelihoods — to pay for the treatment. And then, she knew, they and their children would return in a few months’ time with severe cases of malnutrition and a host of consequent health issues.

A nearby military clinic, where there was no on-site physician, had a stock of antivenom. In exchange for a free supply for her patients, Araya told the administrator of the unit that she would provide medical consultation and training. It was not a perfect solution, Araya admits, but her job was to do anything she could for her patients. “We have to do our best with what we know,” she says. “Every day we had to be more than a doctor.”

***

Doctors trained in resource-limited environments possess a unique skill set. They’re adaptable, creative, and work well under pressure. Yet, upon arriving in the U.S., internationally trained physicians like Araya must go through a licensing process so arduous it can take nearly ten years to complete. There are currently an estimated 165,000 internationally trained medical professionals living in the United States and underutilizing their skills. Many, like Araya, are sitting on crisis management experience the United States never thought they would need — until the pandemic hit.


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Eritrea has a single medical school: the Orotta College of Medicine and Health Sciences, offering a six-year medical program. With only 30 to 40 spots in each graduating class, the nationwide competition was fierce. “When I applied to medical school, my dad always tried to impress on me that I need to have Plan B and Plan C,” says Lily Yemane, an expat Eritrean physician like Araya.  But she couldn’t think of any other job she wanted to do.

In the United States, the pandemic forced many doctors who had never experienced shortages to make life-or-death choices about who would be given oxygen, but for Araya and Yemane, that kind of challenge was part of their regular work as physicians. “You have an idea of how a certain patient can be helped, but you don’t have the resources,” explains Yemane. “Two or three patients need a medication, and you have to decide who to give it to.” With only one or two ambulances per hospital, she often fought to convince the administration to deploy their ambulance for her patients.

Resource scarcity wasn’t the only issue. Living under the oppressive regime in Eritrea bled into every aspect of their personal and professional lives. “We don’t choose where we work, we don’t negotiate our salaries,” says Araya. “The government, basically they put our names in a fishbowl.”

Since President Isais Afwerki came to power following the country’s independence in 1993, freedom has been stifled. Afwerki’s extrajudicial executions, imprisonment of journalists and religious minorities, indefinite forced labor sentences, and other human rights violations have been documented by the United Nations Human Rights Council. Reporters Without Borders, on its World Press Freedom Index this year, ranked Eritrea last, below North Korea. There have been no presidential elections held in the country’s 28-year history. “ … You don’t get any say, you don’t vote. We’ve never voted in our entire life,” says Yemane.

When political prisoners were brought to the hospital for care — often for tuberculosis or scabies, the result of years in captivity — doctors were forced to defer to a system they vehemently opposed. Some prisoners were journalists; others had been caught at the border, trying to flee the country. “You almost never ask why,” says Yemane. “You don’t want to know.”

Each time a prisoner was brought for treatment, Yemane had to convince the guards to admit the patient to the hospital for necessary care, raising suspicions that she was on the prisoner’s side. Except once: Yemane supervised the care of a prisoner with kidney failure. When she went to check on him in the recovery facility, she was surprised to find the patient with his family, and the guards nowhere to be found. “He was free,” she says, “but they only let him go because they thought he was dying.”

There was no single moment that pushed Yemane or Araya to leave and follow their family and friends who had already fled to the US. Instead, the burden of oppression and persecution simply grew until they felt they had no choice. “My rights as a human being were being violated,” says Araya. “I did not have the freedom — that basic, basic freedom … we all deserve as human beings.”

 ***

Yemane did not arrive in the United States naive to American culture or to the challenge ahead. She’d read plenty of English literature and loved watching Oscar-nominated movies, from My Fair Lady to La La Land. But still, the culture shock was real. While waiting the nine months for her work permit to be approved, she lived with a family member and took an anatomy course at the local public college, working towards a physician assistant’s degree in case she couldn’t relicense. Eager to resume medical practice, she also began volunteering at a free clinic, which helped her to feel more at home as she gradually met more like-minded people.

Reporters Without Borders, on its World Press Freedom Index this year, ranked Eritrea last, below North Korea. There have been no presidential elections held in the country’s 28-year history.

When Araya reached the United States the following year, more than a dozen Eritrean doctors like Yemane — who’d fled in the months before her — warned her of the difficult road ahead. She’d have to have her credentials verified before she could sit for the three intensive U.S. medical licensing exams (USMLE) and apply for a residency program to repeat her training — the last step before finally being able to practice on her own.

For most refugees arriving with few resources, the financial cost — of translating educational records into English, covering the exam fees (nearly $1,000 each), and working a clinical internship (often unpaid) to help get a residency — is prohibitive. And the Eritrean doctors were struggling to get past the very first step in the process. For their primary source verification, authorized representatives from the Eritrean medical school would need to confirm that their documents, including their diploma and transcript, were authentic.

They’d contacted the Educational Commission for Foreign Medical Graduates (ECFMG), a non-governmental, non-profit agency, responsible for primary source verification. Of roughly 3,500 operational institutions in the World Directory of Medical Schools, ECFMG accepts credentials from approximately three-quarters — including the medical school in Eritrea. But when Araya and Yemane’s colleagues applied for verification, the Eritrean administrators wouldn’t respond to ECFMG’s inquiries.

The medical school and placement system in Eritrea, like many countries, is controlled by the government, which has the power to withhold the records of anyone they don’t want to assist. “In the eyes of the government,” says Yemane, “we are traitors — which is not true. We served our country when we were there. I worked with very little pay, like everybody else in the country, for four years, outside of my hometown. And we did serve the people. We did our best. But the government was not understanding of that. So when we left, we were considered traitors.”

Kara Oleyn, Vice President for Programs and Services at ECFMG, was assigned to their case. ECFMG sees 20,000 applications each year, and Oleyn was no stranger to verification challenges. When ISIS infiltrated Iraq and medical school officials fled to the south, Oleyn’s team worked with the Iraqi Ministry of Health to track them down, so they could provide verification for their former students. In Crimea, where both the Russian and Ukrainian governments claimed the medical university, they had to determine who was actually authorized to verify credentials. “We do need to assure the public that the individuals who are going to be laying hands on them have the appropriate credentials,” says Oleyn, “and primary source verification is a big part of that.”

But Araya’s and Yemane’s cases — and the cases of their Eritrean colleagues — stumped Oleyn. “There was absolutely no information coming out of Eritrea,” she says.

Araya and her peers were devastated. “The fact that the government I left was able to affect me here — it was just heartbreaking,” says Araya. “America, they gave me protection to stay here, but the [Eritrean] government was able to retaliate and hold me hostage, even when I’m here.”

In rare cases where verification couldn’t be obtained — often for political asylees — the ECFMG used an alternate process: having three U.S.-licensed physicians who attended the same international school swear on their medical license that they have personal knowledge that the individual graduated from medical school. Unfortunately, the Eritrean medical school, founded less than 20 years ago, had no prior graduates working in the United States to provide testimony.

Oleyn’s three-person team relentlessly contacted any sources they thought might be able to share information. “We were trying to triangulate exams that we knew they took in Sudan with Sudanese officials, and we couldn’t get anywhere,” she says. Even the US Department of State couldn’t offer any contacts in Eritrea besides those already refusing to cooperate. Instead, the State Department confirmed what she recalled the Eritrean applicants had already told her: “They’re not going to reply to you, because they don’t want their physicians … their young, bright, educated people to leave their country.”

Yemane and Araya’s feeling of helplessness intensified as the pandemic rolled through their new homeland, and they watched as the news quickly became saturated with reports of hospitals running out of beds and doctors to care for COVID patients. When Eritrea went into lockdown, they feared for their friends and family left behind. Yemane would close her eyes and remember the limited number of beds in the hospital’s ICU, imagining them all filled. The staff was already underpaid and overworked before the pandemic.

“In a perfect world, when this happens, what do you do? You just go home and you help, and then you come back,” says Yemane. “We could not go back home, even to help, even to contribute.” And in America, she couldn’t help either. “… Imagine sitting with the capacity to do something but not being able to do anything … What was the whole point of your training if you cannot do something, even in a pandemic?”

Many internationally trained doctors have valuable experience working in the thick of SARS and Ebola epidemics, conflict zones, and other limited-resource conditions — not unlike the conditions faced by hospitals across the United States, as doctors scrambled for personal protective equipment. “When you have a shortage in supplies all the time, you get creative,” Yemane explains. “When we didn’t have ventilators, we could make CPAPs out of things that you can access at the hospital. So we have that kind of mindset.”

Jina Krause-Vilmar, the president and CEO of Upwardly Global, a nonprofit organization that provides career services to immigrants and refugees (including several interviewed for this story), says that, despite knowing the risks of COVID-19, their clients were anxious to help and “in tears about the idea that they were standing on the sidelines at a time when their communities were suffering.”

Unable to assist medical efforts directly, Yemane volunteered for a mutual aid society to help with cooking and delivering food to a local homeless encampment, but she wished she could do more. At the height of the pandemic, “that’s when it was most painful,” she says. “You see the hospitals running low on supplies, on skill[ed workers], and you’re sitting at home doing nothing when you could have been out there helping people.”

Yemane would close her eyes and remember the limited number of beds in the hospital’s ICU, imagining them all filled.

In a few select states, desperation finally bred change, and internationally trained physicians were given the opportunity to contribute. New York (home to roughly 13,000 foreign-trained medical professionals not able to make full use of their skills) joined New Jersey, Massachusetts, Nevada, and Colorado in adapting licensing guidelines to allow foreign-trained physicians to help with COVID efforts at various levels — but with limited success.

For some, the application was too difficult. Upwardly Global heard that in one state Russian applicants were deterred because the drop-down menu on the online application accidentally omitted “Russia” as an option for country of origin. Some, like Yemane, applied to the NJ licensing program but never heard back.

“These were emergency policies that were designed and implemented at a time of unprecedented need and at a time when states were trying to mount a response to a public health crisis like no other,” says Jacki Esposito, director of U.S. Policy and Advocacy for World Education Services Global Talent Bridge, a non-profit dedicated to helping international students, immigrants, and refugees achieve their educational and career goals. “So just by virtue of the fact that they were designed and implemented very quickly, there wasn’t the time and the space to consult all of the various stakeholders that would be consulted in a permanent reform process.”

For example, according to Esposito, some states require applicants to have active, valid licenses in another country, but many people — refugees especially — let their licenses lapse to avoid yearly fees and continuing education requirements. Esposito says the application could have required that a foreign license was in good standing when it was last active to accomplish the same goal — of weeding out those applicants with disciplinary actions on their record. “It really was a mix of getting the eligibility requirements right so that they maintain health and safety standards, but at the same time are accessible for applicants,” says Esposito. “Eligibility requirements must be workable for these policies to be effective.”

Without the time to be more intentional about the design of the application process, inform employers about the policy, or conduct outreach to applicants, the opportunity went underutilized. By the end of 2020, the New Jersey Board of Medical Examiners, which operated the most robust program for applicants without residency experience, had received approximately 1,100 applications for temporary medical licenses, but, according to a spokesperson at the New Jersey Division of Consumer Affairs, they issued emergency licenses to only 35 individuals. And according to Gothamist, not all who received emergency licenses were able to secure positions. Many applicants who were eligible for similar programs across the country didn’t know where to look for jobs, and hospitals weren’t sure they were allowed to accept internationally trained applicants — or just thought it was easier to not employ them.

“When push came to shove, the hospitals would rather repurpose a plastic surgeon,” says Tamar Frolichstein-Appel, a senior employment services associate at Upwardly Global, who believes better outcomes could be achieved if healthcare employers, legislators, and NGOs work in partnership. Without buy-in from employers who are willing to hire from this talent pool, a license doesn’t make much of a difference. “It’s a missed opportunity that we have not, as a country, leveraged the immense talent that immigrant and refugee doctors and other healthcare workers offer,” says Esposito.

Amid the crisis, a door was cracked open for a select few. But, by and large, doctors like Araya and Yemane watched the pandemic unfold, stuck outside of a system they desperately wanted to be part of. “We got so antsy to do something,” Yemane says. “It’s a privilege to be able to help in that time, and we didn’t have that.”

***

As more time passed without any news of progress from ECFMG, the persistent uncertainty began to take a toll on the Eritrean doctors stuck in limbo. “A few of us went back to medical school again. But to go to medical school twice in one lifetime — it’s a lot to ask,” says Yemane.

After fleeing Eritrea, another doctor, Abraham Solomon, chose this option to avoid being at the mercy of a stalled bureaucratic process. But he couldn’t simply repeat medical school; he had to go back even further and complete up to 90 credits of undergraduate pre-med requirements before even taking the Medical College Admission Test (MCAT). As he sat through freshman seminars for the second time in his life, he had a strong sense that this situation wasn’t fair, but he had to make peace with it. “What [I] had to do was more important than getting lost in the emotions,” says Solomon, who worked in customer service to pay for school. “At that point, you understand this is something you can’t control.”

Mohamed Khalif, who left Somalia as a refugee when he was two years old, moved around the world with his family before graduating medical school in China. While studying for the USMLE in Washington State, he worked as a security guard and then took night shifts at a pie factory so he could volunteer at a medical clinic. Khalif has valuable skills and is fluent in five languages, including Urdu and  Mandarin, but even after he passed the USMLE he failed to match with a residency program. The screening for residency programs filters out candidates without “hands-on” clinical experience in the United States: few applicants can afford unpaid internships, and few institutions are willing to take them on over U.S. medical students. The applications cost Khalif more than $6,000 each year, in addition to flights and hotels for interviews. After four years, he decided he had to go in another direction.

As the founder of the nonprofit Washington Academy for International Medical Graduates (WAIMG), he now advocates for those who face the same challenges and offers professional development opportunities through his organization. Through this work, he met folks with similar stories, like a Japanese neurosurgeon who married an American and moved to the U.S., but, even after passing the USMLE, was still working at Starbucks because she couldn’t match into a residency program. Khalif’s organization hired her for a job that would count as “hands-on” clinical experience to improve her prospects.

“Once she found this job,” says Khalif, “she actually cried. And I felt that. Because that’s what I’ve been through — those kinds of odd jobs — and I cried with her.” These stories keep him hopeful, even though he’s not able to practice: the fact that he’s making it possible for so many others.

 ***

The matching process is a major concern for Araya, Yemane, and their peers — not having their official transcripts or diplomas will likely pose problems during the difficult process of applying to residencies — once they even reach that stage. This year, only 55 percent of immigrant international medical graduates who applied for residency were matched to first-year positions, compared to 93 percent of U.S. graduates.

And every year Araya and Yemane have spent fighting for the right to even sit the exams has cost them: The more time that passes after a candidate’s graduation year, the harder it can be to secure a residency match.

“When you only consider somebody’s graduating year as a criteria and not know the story behind that, it hurts a lot of people. It hurts a lot of people who are really passionate,” says Araya. “To come here to fight for all these years to go back into your profession — that tells a lot about the persistence and the passion that person has for medicine.”

Amid the crisis, a door was cracked open for a select few. But, by and large, doctors like Araya and Yemane watched the pandemic unfold, stuck outside of a system they desperately wanted to be part of.

Khalif began to look for a solution that wouldn’t require physicians to repeat their entire residency. “Legislators did not know about this match process and this residency process,” says Khalif. “They thought people could apply for residency through Indeed Job Search or something.”

Members from Khalif’s non-profit met with legislators and eventually started gaining traction. “COVID really changed people’s minds,” says Khalif, and in May 2021, Washington Governor Jay Inslee signed into law SHB 1129, which allows limited licenses to be granted to internationally trained doctors in Washington who have completed their USMLE, without requiring residency to be repeated in the U.S. “Once you pass all your exams now, you don’t have to settle for an odd job, or leave the profession like I did,” says Khalif. “You can qualify for a license and work under the supervision of a physician, and you can take care of patients.”

The bill was overwhelmingly supported on both sides. Republican representative Mary Dye says that her small county of Garfield, with only a handful of doctors, has benefited from internationally trained physicians from Bangladesh and South Korea, who can work without the equipment, facilities, and large medical teams that most U.S. doctors rely on. “In rural America, we need people that have different experiences,” Dye explained. “We’re grateful to have … people that are capable of serving in these remote locations, under challenging conditions, with lots of limitations, and still provide wonderful medical care for our community.”

From the rural healthcare crisis to expanding medical access for at-risk populations, advocates believe internationally trained physicians could be part of the solution if given the opportunity. “I think they have a huge role to play in terms of health equity access, because of that cultural language fluency,” says Krause-Vilmar.

“We need to re-envision what the process is for licensure for doctors in the United States,” says Esposito, “so that we are not leaving out people who have 20 years of experience in a field where we know that we need more doctors.”

Without any change in legislation in California, the current residency hurdles are still daunting for Araya and Yemane, who hope that, when the time comes, institutions will consider their circumstances and give them a chance to prove themselves. “We are all a loss for our country,” Araya says. “I hope we’re not a loss here.”

 ***

One night, more than a year into the investigation process, Oleyn was working late in her Philadelphia office when she received a call from one of the Eritrean applicants. She detailed everything her team had tried — most recently, reaching out to the medical school in Cuba that had a partnership with the Eritrean medical school. But it was another dead end.

“Anything you can think of,” she asked on the phone that night. Anything at all.

In an attempt to leave no stone unturned, the applicants submitted lists of people they’d come into contact with during medical school — in the hope of providing a useful connection. As Oleyn’s team searched for leads through the lists of names, they found that one was a dean at a U.S. medical school. It turned out that a small number of U.S. physicians — faculty members of American medical schools like George Washington University — helped establish the school in Eritrea. The connection provided a glimmer of hope after months of coming up empty-handed.

A caseworker from Oleyn’s team contacted the dean; he didn’t remember the specific students but put them in touch with other American faculty members who had taught or helped design the post-graduate training curriculum in Eritrea. Oleyn’s team asked those physicians to verify the information about the applicants: the courses they took, which textbooks were used, and their graduation dates. They responded enthusiastically about the qualifications of each applicant and eagerly asked how they could help.

The alternate form of verification — with all the supporting evidence they had amassed — was presented to the ECFMG’s board of trustees, which finally granted approval in summer 2020. Araya and Yemane could move forward to the exam stage. When Yemane heard the news, she felt like she’d finally gotten her life back. “There was a time when I was too scared to be hopeful about that because I didn’t want to be disappointed,” she says.

Solomon had just finished a year of intro courses — Biology, Chemistry, and Physics — when the decision was released. He no longer had to repeat the rest of the prerequisite courses and medical school, and he was thankful to finally have some control over the next steps. “This is a challenge I can overcome,” he says. “An exam is just an exam. You study. You prepare.”

“It’s a good thing that we’re doing this exam,” Yemane says. “It’s a good way to revisit the basic sciences and to familiarize ourselves with what’s most important and most common in this country.”

The Eritrean physicians continue to stay in touch through their Whatsapp group, meeting occasionally, sharing job opportunities, and cheering each other on. Araya says she won’t stop rooting for their success. “Passing the exam, getting matched [with a residency program] has become more than even being a doctor: Just proving that the government back home, the school — whoever could not give us our certificates, credentials — that actually, there is justice in the world, and they could not dictate our professional pathways.”

This year, only 55 percent of immigrant international medical graduates who applied for residency were matched to first-year positions, compared to 93 percent of U.S. graduates.

In a thank you note Oleyn received an Eritrean physician wrote: “This shall also afford every graduate the privilege to revisit his/her oath to humanity, to summon his/her medical expertise, and to engage hereafter in the honored service of the people of the United States of America.”

It remains the most gratifying case Oleyn has seen in her 22 years at ECFMG.

 ***

On a warm Thursday in June 2021, Yemane traveled to San Jose to take her first exam. She hadn’t slept well the night before. Kept awake by nerves, she’d scrolled through Reddit, where other nervous exam-takers shared their anxieties. But in the morning, she pretended she’d had the best sleep of her life. “I think that worked,” she laughs. “I think I fooled my brain.”

The test center was familiar because she’d paid $75 to take a practice exam there earlier that week, but it was nerve-wracking all the same. “There was a lot of pressure on me, because I’m one of the first people taking the exam from my country,” she says. “And we begged for three years for this opportunity.”

She reminded herself that she was prepared. She’d done over 7,000 practice questions. She thought about a text her friend sent, telling her that the test outcome would not change her identity. She imagined her father and mother telling her, “You were created for this.”

When she finished the eight-hour exam, a sense of relief washed over her. This was the hardest test for her; the next one focuses on clinical skills, and she hopes to sit for it in spring 2022. After that, she will take the third and final test. The next challenge — applying for residencies — will be the final step in the long and expensive licensing process.

For now, though, she’s taking one step at a time. As she anxiously awaits the results, she knows that even if she doesn’t get the score she’s hoping for, she was brave just to take the exam after everything she’s been through. “That’s what I’m doing right now,” she says. “I’m celebrating the bravery.”

Shoshana Akabas is a writer and teacher based in New York. She primarily writes fiction and reports on refugee policy and issues of forced migration. 

* * *

Editor: Carolyn Wells 
Fact checker: Nora Belblidia

The Heavy Burden of Breasts

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A psychiatrist told Daniel Valter Jensen that “you can’t live like a something in between,” yet that is precisely what he had been doing for many years, waiting for the top surgery he needed to continue his transformation to male from the female body he was born into. In this searing account for Information, Line Vaaben explores the 10 years Daniel spent in limbo waiting for surgery — years spent struggling with addiction and homelessness. Daniel lives in Denmark, where transgender acceptance has increased in recent years, along with a corresponding rise in inquiries about surgery: “In 2013 at Rigshospitalet, 65 people were referred for examination. By 2019 the figure had climbed 600 percent.” However, in the years prior, many trans people were denied surgery, and in 2010 Daniel was one of them. After being turned down for gender transition, Daniel located a doctor willing to prescribe testosterone for trans women, not caring that it wasn’t legal.

A four-milliliter bottle of testosterone costs 1200 Danish kroner – about 200 dollars. Daniel gently draws the small bottle from his backpack and places it on the table in the doctor’s waiting room. He calls it »my elixir« and gets the injections from his GP every three months. If he delays, he becomes teary and his period returns. He’s had to delay buying his antidepressant and blood pressure medicine, and even skimping on cat food to afford testosterone.

But recently his application for free medicine was approved and he felt greatly relieved.

»Daniel?«

An elderly man in jeans, shirt and Birkenstock sandals summons Daniel into the consulting room. That’s Daniel’s doctor, Jesper Nielsen, who holds up syringe and bottle and draws back the plunger. Daniel lies on the examining table, his striped boxer shorts down, exposing his right buttock. The doctor pierces the skin with the needle and slowly injects the liquid, then pats on a small band aid.

Daniel is finally scheduled to have his top surgery in January 2020, and his excitement is palpable, despite being unable to stick to his doctor’s prerequisite to give up smoking: “There is always a risk of the nipples being lost … And smoking is especially damaging to the nipples.” Sigrid Nygaard documents the surgical process alongside Vaaben’s words with incredibly powerful, honest, and sometimes graphic photographs. After the surgery Daniel, finally, feels on the road to becoming “just a normal guy.”

Hours pass. His head clears. He texts a few friends. He texts his supervisor from The Homeless Unit. And a lot of hearts and smiley tumble back at him. Four years earlier, when he was homeless, he’d felt completely alone in the world. But now he feels the love and care of so many people.

He’s still feeling the anesthetic, so everything makes him cry: When another text message dings. When the nurse carries in a plate of meatballs. When he hears Bee Gees’ ’To Love Somebody’ in the background of a car commercial on television.

He’s not sad. Simply overwhelmed. It’s been a long time since he’s cried that much. Years come to think of it. Perhaps it’s release from the frustrations of a lifetime that now flow out of him. Again and again, he pats his hands along his chest. The breasts are gone! He’d had to wait so many years and then, it only took an hour-and-a-half.

Read the story

The Geography Closest In

Photo by Mats Silvan/Getty Images. Edit by Cheri Lucas Rowlands.

Miranda Ward | Adrift | Weidenfeld & Nicolson | January 2021 | 15 minutes (4,339 words)

The bald conclusiveness of a positive pregnancy test draws a clear line between yes/no, this/that, knowing/not-­knowing. For a moment at least it clarifies everything, or distils it, into a single and irrefutable piece of knowledge. This certainty, when it comes to the body, is rare (later a doctor will tell me: if everything in medicine were as reliable as a pregnancy test, my job would be a lot easier), so I hold on to that piece of knowledge, which is proof of my own productivity, for as long as I can.

But doubt, worry, have a way of threading their way through even the solidest conviction. Threat is everywhere: a light fever, an undercooked egg. Indeed the more I read the more I realise how fragile a pregnancy is, how it isn’t as simple as a positive test and a baby nine months later, which is something I suppose I always knew in the abstract but never had any real frame of reference for before. I was aware that some of my friends and acquaintances, for example, had had miscarriages, but I had not until now really understood what it meant, in both practical and emotional terms, to have to hold an awareness of this terrible possibility always alongside a hope, a longing, for it not to happen to you. Most of what I know about pregnancy, in fact, comes from fiction, from books, films, TV: the way certain signifiers – wooziness, weakness, nausea – are used to suggest a pregnancy before it is confirmed; the way, once it is confirmed, a woman must somehow both alter her behaviour drastically and hardly at all, vomiting copiously into a bin at work seconds before giving a presentation just as if nothing is amiss, but studiously avoiding, suddenly, a whole litany of food and drink; most of all the way a baby is almost always the inevitable result of a pregnancy. The plain fact of it – that at least one in four pregnancies end in miscarriage, perhaps more, since sometimes a woman might miscarry before she even knows she’s pregnant – had somehow eluded me, or else I had somehow failed to think of it in tangible terms.

What does that statistic actually mean, practically speaking? It means that nothing is a given. It means that there are people – a lot of people – for whom the result of a pregnancy is not a baby. It means that even the purest elation is often shaded, especially in the early weeks, when miscarriage is most likely, with fear.

I develop a set of superstitions for protection; certain shirts for luck, certain routes home from the library or the grocery store, certain songs skipped or repeated. An aping at control. And for a while everything is normal, in the sense that nothing is normal, in the sense that I feel slightly ill, weary, a little as if I am not myself. My overriding emotion is happiness, but there is also a part of me that feels as if I have become separated somehow from my body, as if it is acting of its own accord, and the thinking part of me is just along for the ride. There are psychological adjustments to make – I have to play the phrase I’m pregnant over and over to myself to believe it; I have to think about what is good for me not in terms of my body only, but also in terms of the invisible body-­to­-be inside me. There are physical symptoms, too, though they are mild (another thing I didn’t realise: that while some pregnant women are indeed debilitated by illness or weariness, not everyone is). I am never actually sick, though I am dogged by a whisper of nausea that asserts itself at odd times and leads me to keep a pack of digest­ives on my bedside table. I can feel a largeness, a tenderness, to my breasts, and although I know it’s far too early for the pregnancy itself to show I feel fuller somehow, heavier than I was before I knew, as if the knowledge itself has some weight or substance to it.

This is not an unpleasant feeling – because it is a novelty, and because the pregnancy is so unequivocally desired – but it is hard to escape a sense of uneasiness, too. I find myself tracing familiar routes around Oxford, where I’ve lived for years, ever since I moved to the UK after university; I know the roads well, and yet I feel every encounter between feet and pavement to be different now, because I am differently bodied. What I have is a sense, visceral and unignor­able, that my body no longer belongs wholly to me – and in a way it doesn’t. As I walk I feel not exactly a ‘we’, but a blooming plurality, an ‘I and…’, perhaps, the assertion of a possibility taking physical form. Where once I occupied my mind during walks with long, elaborate daydreams, there now seems to be no room for anything other than the immediacy of experience and the planning and execution of the tasks of my own daily life. I take to listening to radio shows and podcasts, tuning out my external surroundings and internal circumstances, focusing on the minute details of, say, a true crime story, losing myself in the voice of the presenter.

* * *

Geographers write about the inseparability of the body from our experience of place: we sense places, are bodily present in them, see them, hear them, smell them, move within them. How else do we know a favourite room or city or mountain trail? The body, as Tim Edensor writes, is the means through which we experience and feel the world.

To which he adds: bodies are not only written upon but also write their own feelings upon a space in a process of continual remaking.

What I am struck by in the delicate earliest weeks of pregnancy is that I am being both made and unmade; rewritten. The pregnancy is largely unspoken of: we have told our doctor, and our parents, which perhaps lends it a weight in the world that it wouldn’t yet have had we not told anyone, but day to day I move through the hours without anyone but us knowing, because the pregnancy is still invisible. When I stand in front of the mirror I see nothing different, but nothing the same, either. When I go to the swimming pool, as I do most mornings, an almost religious habit, the place of it has shifted, though the change is microscopic, under the surface. On a quiet morning I watch the play of sunlight on the bottom of the pool and I am in a foreign country. In the changing room, pulling off my wet suit after a shower, I am self­-conscious for the first time – can they tell? But I want them to tell, even though there’s no way they possibly could, even though when I think of it I have the sense not so much of the world tilting on its axis but of the axis itself having drifted elsewhere. I smile knowingly at a visibly pregnant woman undressing and she looks away, uncomprehending or embarrassed or both. I am the foreign country, or else I have lost the map of this place. Walking home, along the same roads I have always taken, the green of the trees fading into yellow, I feel somehow both lonely and plural.

* * *

And then.

One morning, a few weeks after that first definitive, positive test, I wake up and feel my old self again – that is to say, not ill, not weary, not plural or novel – and that evening I experience some mild pain, a quick gush of blood which soon slows to an ambiguous but ominous trickle, and a sense of doom. I am not sure what the appropriate reaction is: denial? Despair? I cannot summon the energy to cook or even to eat dinner; although it is still early I retire to bed, lying on top of the duvet, curled into a question mark. Alexander lies down next to me, his body settling around mine. He tells me the things I both want and don’t want to hear: that it’s OK, that we don’t know for sure that anything’s wrong yet, that he loves me. He’s meant to be playing football in twenty minutes. Do you want me to stay? he says. I’ll stay with you. No, I say vehemently, as if this is in fact an uncharitable suggestion, you should go, you should play, what can you do at this point, what can I do? Nothing. Even after he’s pulled his socks over his shinpads, laced up his boots, he hesitates at the door: are you sure you don’t want me to stay? I don’t want you to stay, I say emphatically. If I were being honest – with him, with myself – I’d say exactly the opposite: stay, please. Instead I lie back and stare at the wall for an hour until he gets home and we go to sleep.

The next morning I call my GP, who arranges an emergency scan for me at the hospital. The soonest the scan can be done is in two days, so in the interim period I carry on as usual: I go to meetings, answer emails, run errands. It’s not as hard to do this as I would have imagined it would be, and after all, what choice do I have? But it’s also indicative of the ongoingness that will characterise much of the next two months.

I cannot summon the energy to cook or even to eat dinner; although it is still early I retire to bed, lying on top of the duvet, curled into a question mark.

I would have imagined, too, that a miscarriage was a definite thing – yes/no, this/that, knowing/not­-knowing – a neatly shaped happening with a beginning, a middle, a definitive end, each closely following the other. Women say, ‘I had a miscar­riage’, and until now I have always heard their experience as being something contained, even while brutally uncontrollable: all those stories of blood-­drenched bathroom floors, of unimag­inable agony, of horror and shock, of sadness and then resolution (often in the form of a baby arriving a year or two on, as if some consolation must always be offered): what I understand now, of course, is that these stories are told retrospectively, packaged in the way that all stories, to some extent, must be. But when I phone the doctor I’m unsure, grammatically speaking, how to phrase my concern: do I say to him that I have had a miscarriage, that I’m having one, that I’m worried I might have one in the future? The idea of the miscarriage in progress perplexes the part of me that imagined that this is a thing that can only happen privately, violently, suddenly, because it is a thing that is happening without much noise at all, and meanwhile here I am transcribing an interview, here I am meeting with a freelance client, wearing a new skirt I bought yesterday from the charity shop, here I am buying groceries and planning dinner, with nothing but a question mark inside me.

Alexander and I take a taxi to the hospital for the scan; it’s early morning and the driver is playing loud Pakistani pop, which is somehow soothing, and drowns out my own thoughts. In the waiting room Alexander scrolls restlessly through his phone. A little plastic radio on a cabinet in the corner of the room is pumping out cheerful tunes punctuated by cheerful radio host banter. I take my book from my handbag and lay it on my knees, open at my marked place. Knausgaard, A Death in the Family. In his younger-­self narrative, the author’s father has just died, while in his current­-self narrative, his partner is heavily pregnant, lumbering around, practically bursting with new life. But I cannot read on. I become fixated on a single paragraph, a description of a piece of artwork, which strikes me as incomprehensible. I read it over and over again until my name is called.

The scan reveals an embryo with no heartbeat. I lie on the bed, naked from the waist down, a blue plastic sheet draped over my legs. Alexander holds my hand while the ultrasound technician swirls a wand around inside me, talking us through the image of my uterus on the screen. It is illegible to me – darkness, light, hazy shapes – but to her the meaning is crystal clear. I’m so sorry it’s not the news you were hoping for, she says. She gives me a wad of tissue to wipe myself with before leaving the room to let me get dressed. She leads us back to the waiting room, which is fuller now, no one making eye contact, the radio still humming; a doctor will see you soon, she says, to talk to you about what happens next. ‘Soon’ is an ambiguous word, and time becomes difficult to perceive; we are there for what feels like both an eternity and an instant. I take my book out again, stare again at that same page; Alexander unlocks his phone, moves his finger across the screen in a kind of robotic motion.

What I am struck by in the delicate earliest weeks of pregnancy is that I am being both made and unmade; rewritten.

Sometimes these things resolve naturally, the doctor says when we are finally called in to see her; sometimes intervention becomes necessary, or desirable. She schedules me for another scan the following week, so we can monitor whether there’s been any change: in other words, whether the products of conception, as the embryo is now known, have been partially or even wholly expelled. After the scan, she says, we can decide how to proceed; you don’t need to make any decisions now. Good, I think, though I’m a little hazy on exactly what kind of decision I might be called upon to make; she has described the various forms of intervention but I can’t quite situate them in relation to my own body, my own products of conception.

She is very young, the doctor, soft-­spoken, apologetic. She says to call if anything changes before my next appointment, if I have any concerns. She gives me a business card, circles a phone number that’s operational 24/7. To minimise the risk of infection, she adds, seemingly as an afterthought, you shouldn’t take baths or swim.

No swimming. Of course. But I am thrown by the thought of this: the removal of the most obvious physical coping mechanism I have for dealing with what is essentially an entirely uncontrollable physical situation. I realise I’ve said this out loud without really meaning to. A silence falls, either respectful or uncomfortable.

I’m a swimmer too, the doctor says suddenly, as I’m standing to leave, abandoning, briefly, her professional distance. I’d hate not to be able to do it.

After the appointment we walk to a Starbucks near the hospital. It’s dark and anonymous inside, and smells of sweet pastries and wee. I order a latte, two shots, why not, and we sit at a counter at the window, watching buses trundle by. It’s mid­-morning and the place is full of new mothers and their prams, though occasionally someone in scrubs or a suit hurries in and then out again. Alexander texts his boss to say he won’t be coming in to work today. Not just the day but the month, the year, stretches out before us, suddenly open. What will we do with it? What can we do? The coffee is too hot, tasteless, the milk burned, but I suck it down in a rush, turning the inside of my mouth furry. Before all this, the test, the pregnancy, the ungrowing embryo, we were planning a wedding; we had set the date, hired a venue, made arrangements with the registrar. We should have cancelled everything – my due date was too close to the wedding date – but we never did; too superstitious, or preoccupied, or both. Now, of course, I say, devastated, amused, we won’t need to change the date. We can simply pick up where we left off. I feel myself begin to rewrite the map again, to slip in and out of familiarity with myself and my surroundings. There’s a simplicity to it all, underneath the ambiguity, the anguish, that makes me almost giddy: for what is this but a reversion to my natural state, a return to old routines?

A thought – terrible, comforting – hits me square in the face then, that there’s relief to be felt. The awful thing, the dreaded thing, has happened, and I need no longer fear it. I hate myself for feeling this but can’t let go of it, either, because I think it’s a way forward, a way out, a small tremble of light.

* * *

The second scan is no more or less enlightening than the first: there is still an embryo, there is still no heartbeat. No change, in other words: an unwanted stillness.

The doctor gives me a leaflet, which outlines in clinical language the three ways of managing a miscarriage when preg­nancy tissue remains in the womb: expectant, medical, surgical. The first is the wait-­and-­see approach, taken on the assumption that the tissue will pass naturally out of the womb with time. The second involves taking a course of medication to stimulate the passing of the tissue out of the womb: a potentially painful, lengthy, and often messy process, not always entirely effective, sometimes necessitating the third approach anyhow, which involves surgical removal of the tissue.

I still don’t know how to decide what to do, so I put it off: if nothing’s happened in a few weeks I’ll opt for some kind of intervention. I want above all to trust my body to do whatever needs doing, but already it’s betrayed me once, so what do I know?

Still no swimming, obviously, the doctor says sadly. Other­wise, proceed as normal.

As normal. Nothing is normal, I start to think – but then again, in a kind of terrible way, everything is normal again, isn’t it?

* * *

The present­-tenseness of the event, the miscarriage, which is not so much an event as a continual unfolding of uncharted territory, a vast grey area, makes it virtually impossible to talk about in any way that makes sense of what is actually happening. I don’t know what to tell people because the language I have is not elastic enough to encompass something which is past, present and future all at once. So I do what the doctor suggests: I proceed more or less as normal, going to meetings, going to the supermarket, scrolling mindlessly through Twitter, doing the laundry, eating, sleeping, working. I let myself lose track of time. At one point, in a notebook, next to a to-­do list, I write: The calendar is a kind of enemy, reminding me of the facts of things, the time it is actively taking to go through this process of miscarriage. I take to walking – long, slow strolls at the very edge of dusk, through parks and quiet suburban neighbourhoods that smell of woodsmoke and exhaust fumes. I feel my muscles going slack, and an irrational fear grows daily: what will my body become while I can’t swim?

My fear is really a form of vanity. I know that with each day or week that passes without a swim my body will start to look subtly different. I’ll lose, am losing, the public indicators of my fitness – the muscle, the shape of my arms and legs, the things that say to other people that I’m disciplined, that my body is under control. And I don’t want them to see what I know: that nothing is under control, that this body is not working properly, that athletically, reproductively, it is not doing at all what it’s supposed to do.

Mostly, though, if we’re honest, it’s the changes in our bodies that are in control of us, not the other way round.

Words come to me on my walks, as they used to on my swims. Some of them are obvious. Why is this happening to me? I think selfishly, inevitably, as I climb the hill to the park on a soft bed of wet leaves, fresh-­fallen after a night of howling wind. But other things, too, drifting like the smoke and the fumes. Disobedience. Betrayal. Softening, slackening, slowing. Undisciplined. Back at home, in my notebook, I write: I guess I feel disconnected from a part of myself. Not that I’m not still the same person or can’t be again, but that for a while I and some other part of me are not quite coinciding. I’m talking about the swimming, not the miscarriage, or at least ostensibly I am. I have a deep sense of geographical dissonance, like a dream of a familiar place in which the location of everything is slightly wrong, so that you round the corner and suddenly come upon a street that should be miles away, or discover that all along there has been an extra room in your house.

One Sunday afternoon, sitting in a booth at my local pub, I see a woman I used to see most weekday mornings at the pool; she always wore a bright pink cap, a navy swimsuit. She’s about my age, sitting with a friend, eating lunch. Perhaps it’s her local too, I think, for the first time realising, stupid as it sounds, that these people I’ve been brushing up against at the pool are people with lives outside that context, just like me.

Occasionally I log on to Facebook and check the page for the triathlon club I belong to. I look through the list of times from a recent 400-­metre time trial, spotting familiar names, noting the improvements, and wonder how much I, too, could have improved by now. For a moment I’m gripped by something which feels a little like jealousy but isn’t quite – desire, perhaps, something almost carnal. But then the desire, or whatever it is, fades: I’m here now, and maybe, if I can admit it to myself, I’m actually a little relieved that I’m not sweating away in a pool, that I don’t have to worry about how fast or smoothly I can cut through the water, how hungry I’ll be later, how tired.

* * *

The poles of the earth have wandered, the journalist John McPhee once wrote: even that which seems most permanent and solid is, in its own way, shifting. It’s true literally – think for example of the tectonic plates, the movement of the continents, which still, on average, drift a few centimetres a year apart, about the rate at which our fingernails grow, as the geographer Doreen Massey frames it, a reminder that the body is never in stasis either. In other words the whole world is a continual work in progress; the present is not some kind of achieved terminus, Massey writes. To underline this idea, she describes the slow movement of what she calls the ‘migrant rocks’ that came, over the course of millions of years, to form Skiddaw in the Lake District. Solid and eternal as it seems, she says, the mountain is not timeless. Like she and her sister, staying in a hotel in Keswick, it’s just passing through. It was once elsewhere. It will be elsewhere again someday.

It’s easy to lose your footing here, to feel that nothing is solid, but I’ve always found something comforting about this idea that place is essentially unfixed. The rigidity of permanence would be too much to bear, surely: who wants to be stuck in the same place forever? Who can know and love anywhere and not see that a point on a map is one thing, a living, breathing place quite another?

It’s a concept that scales well – if the world is a work in progress, then so too is a city or a street or a swimming pool. So too is the body, which is, after all, as the poet Adrienne Rich puts it, the geography closest in; it’s the first place, the place we must make peace with – subject, like all places, to the pressures of time, of external rhythms and events, changing from moment to moment, year to year, getting older, bigger, smaller, more or less capable of performing certain tasks, more or less like it was at the beginning.

There’s a simplicity to it all, underneath the ambiguity, the anguish, that makes me almost giddy: for what is this but a reversion to my natural state, a return to old routines?

Sometimes we’re in control of that change, or we think we are. Exercise in particular gives us the illusion of power over our own physical futures. Take your recommended thirty minutes of activity a day and stave off all kinds of bodily evil. Lose a bit of weight, add a bit of muscle, establish a routine, live forever, or longer, anyway. The geographer John Bale wrote of exercise as a literal form of recreation: through time, repeated action, the body is re-­created so that it works better. It incorporates knowledge, becomes stronger, fitter. Progress. Maybe next week, or the week after, I’ll be faster than I was last week. All it takes is discipline, resolve, another few thousand metres racked up. Most of all denial: of the body that wants, of the possibility of vulnerability or limitation. A few years ago, I remember, I became obsessed with watching Olympic swimming races; I trawled YouTube, read interviews with the athletes, fascinated by all their talk of sacrifice and discipline. And isn’t this why I watched in the first place? To see what happens when we write certain kinds of want out of our body, and one singular, possessive, demanding want into it: to be the best, the fastest, the one standing on the highest platform of the podium?

Mostly, though, if we’re honest, it’s the changes in our bodies that are in control of us, not the other way round. The fact of the matter is that not that long ago, my body was capable of run­ning 13.1 miles, of swimming 3,000 metres without complaint; not that long ago, my body was actually hosting another body, or the beginnings of one.

And now everything is different, and everything will be different again someday, and different again, and different again.

This excerpt has been lightly adapted for publication on Longreads.

* * *

Miranda Ward is a freelance writer, editor, and lecturer. Her memoir Adrift: Fieldnotes from Almost-Motherhood is published by Weidenfeld & Nicolson in the UK. She grew up on a cattle ranch in California and now lives in Oxford.

Editor: Cheri Lucas Rowlands

The Household Covid Budget

Full length of young female friends using smart phones while relaxing on bed at home during slumber party

Since the arrival of Covid-19 even popping to the shop for some milk has become a risk — and if you live with people, it is also a risk for them. In a shared housing situation figuring out what is acceptable behavior has become harder, and even the clearest advice “doesn’t address many of the subtle situations in which we find ourselves.” Gregory Barber asks in Wired what to do if you are a group of six people, including polyamorous members, living together in a house share? For such a group in San Francisco, the answer lay in maths — they came up with a calculator to work out risk, giving each other a points budget to use each week. 

Some activities were trickier to translate into points. First dates, in particular, would trigger a reversion to what Olsson calls a “one-off person-risk estimate.” The fact-finding missions these estimates required were a little strange and intrusive. The housemates wanted to know how often a new person shopped for groceries, who they lived with. Were they a gym rat? An ER doctor? Bachar found these interrogations uncomfortable. It felt as if she was implying that her friends were behaving badly. But others felt the questions were a reasonable concession to the pandemic. Dobro says that polyamory had prepared her for these awkward conversations around trade-offs. “We’re used to having conversations that are linked to risk,” she says. If you choose to be indoors with someone, the roommates agreed, make it count. Make it a deep conversation. Make it sex.

This was a house share better suited to calculating risk than most — Olsson works for a Silicon Valley foundation on projects that seek to mitigate the potentially catastrophic effects of advanced AI — and the other residents, to various degrees, are adherents to “rationalist modes of thinking.” The calculator this particular house came up with has now been used around the world — including by Bob Wachter, the chair of internal medicine at UC San Francisco and a frequent public commentator on all matters Covid-19.

Olsson called their risk points microcovids, in a tip of the hat to Howard, and one microcovid equaled a one-in-a-million chance of catching the virus. They pulled epidemiology papers from Google Scholar and gathered around the table in the hearth to go through the data. The first step was to impose a top-line risk budget that would anchor all of their calculations. They debated this question at length. Olsson floated the idea of 10,000 microcovids per person per year—the equivalent of a 1 percent chance of catching Covid. But what was the actual cost of 10,000 microcovids? By their estimations, for people their age, a 1 percent chance of getting sick was about as risky as driving, which was something they did without thinking. And besides, they figured, if other people who could stay home kept to a similar budget, the hospitals would not overflow. The virus might even disappear.

To some extent, governments around the world are using their version of Covid point calculators. It may seem strange that in some areas regulations mean we cannot meet friends while children are still going to school, but it is how risk has been allocated across a community to keep it at an acceptable level. 

This was the initial premise of shutdowns and social distancing and sheltering in place. Our common infection budget was tied to hospital capacity—the number of ICU beds and respirators and medical staff able to respond. For those who could work from home, the task was to contribute as little as possible to the overall sum. This left more points for those who couldn’t. Then, as the first infection curve began to flatten, the foundation of the societal budget seemed to shift. Yes, we still had to worry about public health, but that concern was being stretched by other considerations: business closures, job losses, some ideal of liberty, the desire to eat burritos.

Read the story

I Will Always Love You: A Dolly Parton Reading List

Dolly Parton attends the 61st Annual GRAMMY Awards at the Staples Center on February 10, 2019, in Los Angeles. (Photo by Axelle/Bauer-Griffin/FilmMagic via Getty Images)

Central Florida doesn’t do glamour. I know because I was born and raised in Lakeland, Florida, the birthplace of Publix supermarkets and where Ernest Hemingway’s first wife, Hadley Richardson, died in a nursing home. Growing up, my sister Abby and I had a never-named game where we’d see a figure skater, Vanna White, anyone, wearing a pretty dress on television, and then we’d passionately bicker over who got to have the rhinestoned, beaded, or sequined costume. We knew what glamour looked like, and we wanted it. By the time I’d graduated high school, I knew glamour in real life. I’d seen it in person three times.

My high school band competed in an annual competition up in Gatlinburg, Tennessee. Each year, when the music part of the trip was over, we’d go to Dolly Parton’s dinner theater show one night, and spend a day at her theme park, Dollywood. And inside Dollywood, inside Chasing Rainbows, a museum dedicated to telling Dolly’s life story, was my pilgrimage: a collection of Dolly’s rhinestoned, beaded, and sequined costumes, more beautiful and breathtaking than anything I’d ever bickered over in the never-named game of my childhood.

Two years after high school, I moved to New York City and dug my heels into culture shock. Five years in, I got into a Dolly Parton-themed holiday party put on by a fancy New York PR firm. I glided through the night among the well-dressed and well-heeled. I sipped moonshine and peach iced tea with a party-themed name like it was mother’s milk. I danced to Kylie Minogue performing Dolly covers. And I held my head up high all night because I’d long already seen the installation in the front room, a sparkling display of Dolly’s costumes on loan from Dollywood.

I won’t say Dolly Parton changed my life. I’ve only just read her 1994 memoir “Dolly: My Life and Other Unfinished Business,” loaned it to three people, gave it as a wedding present, and have the first and only edition in paperback and hardcover. I recently got the first Christmas album Dolly recorded with Kenny Rogers, “Once Upon A Christmas.” I’m pretty proud of that. I don’t own any Dolly T-shirts or anything like that (maybe I should), I just think she’s a gift to humanity — a living, breathing embodiment of dreams. Maybe you agree, maybe you don’t. Dolly would say, “It’s hard to be a diamond in a rhinestone world.” Maybe she’s not for you, even though she’s for everyone. But, hey, don’t take my word for it.

1. “Outta That Holler” (Sarah Smarsh, Slate, October 2020)

In this excerpt from her 2020 book, “She Come By It Natural: Dolly Parton and the Women Who Lived Her Songs,” journalist Sarah Smarsh describes Parton’s brand of implicit feminism. By harnessing the value of economic agency and sexual power to overcome the poverty that defined her childhood — born the fourth of 12 children, “wearing dresses made of feed sacks” and “dyeing her lips with iodine from the family medicine cabinet for lack of lipstick” — Parton has shaped the person she is today.

She reminds her audiences that, no matter where they came from, everyone can identify with being shamed one way or another, and no one deserves it. Never be ashamed of your home, your family, yourself, your religion, she says, and adoring crowds applaud. One need look no further than her immense LGBTQ following to know that Parton’s transformation from a slut-shamed, talented teenage bumpkin to entertainment superstar contains a universal struggle that has less to do with being Appalachian than with being human. If her presence and the appreciation it instills in people could be whittled to a phrase, it’s “be what you are.”

2. “The Grit and Glory of Dolly Parton” (Emily Lordi, T: The New York Times Style Magazine, November 2020)

The person and brand that is Dolly Parton did not just happen overnight. Emily Lordi provides an overview of Parton’s decades-long career, illustrating how it’s been furthered not by reinvention, but through the reintroduction of Parton and her music, all while Parton herself engages with the times. Lordi first interviewed Parton over the phone, then in person after providing a negative COVID-19 test.

People want her gifts, her glow, her time; and Parton, who, as she says, “loves everybody and wants everybody to love me,” is often happy to oblige. She can’t sit still anyway — and early on in the pandemic, she decided to keep working, as long as her team could do so safely. Last May, she released “When Life Is Good Again,” a song of reassurance that justifies the journalist Melinda Newman’s claim, in Billboard, that, during the coronavirus crisis, Parton seems to have appointed herself America’s “comforter in chief”: “When everything is on the mend, / I’ll even drink with my old friends, / Sing and play my mandolin … And it’s gonna be good again.”

3. “Dolly Parton Steers Her Empire Through the Pandemic — and Keeps It Growing” (Melinda Newman, Billboard, August 2020)

The daughter of an industrious sharecropper father and a musically inclined mother, Parton is a savvy businesswoman whose earliest and latest decisions in the music industry are only the core of her empire. As Melinda Newman writes, “Her legendary body of music is just the start of what makes her Dolly. …”

She sounds surprisingly giddy as she talks about the next chapter of her career as if it’s her first. “I’m touched and honored that I’m still around and that I’m able to still be important in the business,” she says. “I honestly feel like I’m just getting started. I know that sounds crazy but I really feel like I might have a big music career, record career. Who knows?”

4. “Dolly Parton on How to Be More Like Dolly Parton” (Anna Moeslein, Glamour, November 2019)

In an interview with Parton, Anna Moeslein and Parton review “Heartstrings,” a Netflix series in which each episode is based on a different Parton song. They also discuss emotions and Parton’s position on what people can do to bring “a little Dolly in their own lives,” as well as fashion and beauty.

Well, I think it’s always important for us to be allowed to be who we are, all that we are, and appreciate that. And I know being a woman in this world…I’ve always been proud that I was born a woman, and I’ve joked that if I wasn’t, I would have been a drag queen. That’s my favorite line, but it’s probably true. I love being able to express myself, and I want to be seen and appreciated for who I am. So I’ve always appreciated and loved people for who they are. Because we don’t need to all be the same.

5. “Is Dolly Parton the Voice of America?” (Rachel Riederer, The New Republic, December 2020)

Citing Jad Abumrad’s Radiolab podcast (“Dolly Parton’s America”), Parton’s Netflix series, shoutouts from Nicki Minaj and Drake, and even a history course at the University of Tennessee, Rachel Riederer discusses the latest Dolly Parton renaissance. And, given the political landscape of the U.S., Riederer wonders if there’s a place for Parton’s enduring position to sidestep politics — which Abumrad refers to as “Dollitics.”

You cannot talk about sharecropping without talking about politics, and to say more would not be her style. She was not shy about her desire to sell books or to present her life as a fairy tale, and you sell a fairy tale by focusing on the romance and adventures of the rising princess, not the conditions that made her a scullery maid.

6. “Springtime for the Confederacy” (Aisha Harris, Slate, August 2017)

When I mentioned Dolly’s “dinner theater show” above, I was intentionally vague. Despite my setup, I know Dolly is human. And humans are complicated. Dolly’s dinner show seems complicated, too, but really, it’s not. The show, known until 2018 as “Dolly Parton’s Dixie Stampede,” is performed before an arena split into the “North” versus the “South,” where the audience, feasting on a four-course dinner eaten without cutlery, cheers on white-washed narratives of colonization, then the Antebellum South, then a performance competition between the North and the South. As a high schooler attending the show, I sat and watched from the North side, not fully grasping how problematic the programming was. I suppose I could do what Parton did in the Billboard article above: plead “innocent ignorance.” As an adult, I know better.

The last time I saw the show was in 2006. Aisha Harris reviewed the show in 2017, after watching it the same week as Unite the Right, a white supremacist rally, descended on Charlottesville, Virginia. At the rally, a neo-Nazi intentionally drove into a crowd of counter-protesters, killing an innocent woman, Heather Heyer, and injuring others. (The president notably remarked in the aftermath that there “were very fine people, on both sides.”) Harris recorded the experience of the dinner show from start to finish, without holding back.

While the show makes zero mention of slavery, that’s not to say there were no references to the Civil War. The war was alluded to both in the overarching North-versus-South conceit and through details both subtle (the gray and blue color schemes on each side) and blatant: The racing piglets were named after Abraham Lincoln, Ulysses S. Grant, Robert E. Lee, and Scarlett O’Hara. Dolly says that the show is about bringing back “those good old times,” referring to her childhood, but of course she wasn’t around during the days of Grant and Lee.

Harris wrote a follow-up to this piece after the show responded to her initial review, and again in April 2018, when the show dropped “Dixie” from its name.

7. “Living with Dolly Parton” (Jessica Wilkerson, Longreads, October 2018)

Jessica Wilkerson, who grew up in East Tennessee, where Dollywood is located, confronts the worldviews of her upbringing with those acquired as an adult after moving away from home for graduate school in New York. Weighing the socioeconomic implications of Dollywood’s hiring practices and confronting “Dolly Parton’s blinding, dazzling whiteness,” Wilkerson strikes a reluctant balance, compartmentalizing more than one version of Dolly Parton.

But the aftermath of Dollywood left me low-spirited. I was nestled into a cozy room in the log house my dad built on top of a ridge, where we lived. From the peak of that ridge, I could stand and see the Smoky Mountains, where Dolly Parton grew up and where she built a simulacrum of her mountain childhood. Hers felt more real than mine. I was sad, but jealous, too. I lived in the real world of Appalachia. A world of layaway stores and packaged foods, bleary-eyed workers and stressed-out mothers. I longed for the simulation.

Alison Fishburn is an American writer living in Paris, Ontario.

Is the Cure for Cancer Locked in Shrunken Heads from the Amazon?

Simon Prades

There’s a photo from the 1960s, of a young boy in California holding two shrunken human heads. The boy is the stepfather of writer Steven Lance, and the heads came from a family friend named Wilburn Ferguson. He had gotten them from an Amazonian tribe called the Shuar, who shriveled the heads of their enemies using a fluid derived from jungle plants. Ferguson, a nurse, former religious missionary, and lifelong dreamer who had moved his family to South American in the 1930s to pursue medical research in the Amazon, believed that the fluid could do something else—something life-giving. In his Atavist Magazine* feature “The Secret Formula,” Lance explains the root of Ferguson’s theory, which was shared by his devoted wife, Ruth:

Soldiers who fought the Shuar, according to stories Ferguson heard, might wake up one morning to find a stack of [heads] in their camp, shriveled but still recognizable as those of fallen comrades. It was powerful propaganda, a warning to steer clear. Head shrinking was “the most effective national defense ever devised,” Ferguson wrote.

He suspected that it might be much more than that…. “The thought occurred to me,” Ferguson recalled, “that perhaps the active ingredients of this process could be in some way adapted to shrink, or at least check, the wild growth of cancer cells.”

By that time, as Siddhartha Mukherjee explains in his 2010 book The Emperor of All Maladies: A Biography of Cancer, scourges like smallpox and tuberculosis were yielding to medical advances. “But of all diseases,” Mukherjee writes, “cancer had refused to fall into step in this march of progress.” Cancer is out-of-control division and growth of abnormal cells that can destroy healthy tissue and spread through the body. As Americans escaped other ailments and lived longer, more of them developed the disease. By 1926, it had become the nation’s second leading cause of death.

Long stigmatized and little understood, cancer now drew widespread attention. One senator proposed a $5 million reward for “information leading to the arrest of human cancer.” Americans dreamed of finding what Fortune called a “new principle of treatment.” The Fergusons were caught up in the zeitgeist. The thought inspired by the shriveled head was simple enough: If cancer killed by growing, shrinking was a way to fight it. For the Fergusons to test their theory, they needed access to whatever the Shuar were using on their enemies’ heads.

What followed was a saga spanning several decades and countries, and more disappointments than successes. Ferguson tried to prove his hypothesis, mustering evidence from lab experiments and patients (some consenting, others not). The scientific establishment rejected him. Yet today, more than 20 years after his death, he still has acolytes—people who told Lance that they believe Ferguson discovered something world-changing:

Ferguson wasn’t a snake-oil salesman or a con artist. Outlandish though some of his stories still seem, the details contained within them were consistent. The people I spoke to who knew Ferguson were struck by his sincerity. He could be stubborn and impractical, but as my stepdad recalled, Ferguson was always careful to point out that he hadn’t discovered a silver bullet, merely a promising treatment that needed more study. What he wanted most of all was a real scientific shot.

Ferguson was an outsider his whole life. Like a modern-day Don Quixote, he chased an impossible dream based more on faith than evidence. He wandered the wilderness seeking a miracle. The doctors and scientists who doubted him had every reason to. But what if they missed a bark or root of medical importance? What if Ferguson saw something they couldn’t? What if he was right?

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*The author of this post is the editor in chief of The Atavist, which is Longreads’ sister publication.

The Racist Healthcare System that Failed JaMarcus Crews

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JaMarcus Crews’ mom was diagnosed with Type 2 diabetes while she was pregnant with him, making him more likely to develop the condition himself. As Lizzie Presser reports at ProPublica, he worked hard to manage his health after being diagnosed as a teen. He did everything right, everything they told him to do. He watched what he ate. He exercised. He lost weight. He drove hours and hours, sometimes having to borrow gas money to attend life-saving dialysis after the disease progressed. His only mistake? Putting his trust in a system that was set up to fail him as a Black man with Type 2 diabetes.

A race-adjusted equation was also at play in JaMarcus’ case. The formula calculates kidney function by looking at what’s called “estimated glomerular filtration rate,” or eGFR. Creatinine is plugged into the formula along with age, sex and race. Doctors must note whether their patient is “Black” or not. By design, the equation assigns healthier scores to those who are listed as Black, because at a population level, a few studies found that this was more precise. With little investigation into why this might be the case, it was just accepted. That inflated score can mean a longer wait for a kidney because eGFR must drop to a certain level before you can start accumulating time on the transplant waitlist. The best-case scenario is to get a new kidney before needing dialysis, to avoid weathering the side effects of the machines. But those transplants are given on a first-come, first-served basis, and Black patients are less likely to get one.

The researchers and physicians behind the original formula, developed in 1999, wrote that Black patients had higher creatinine levels because “on average, black persons have higher muscle mass than white persons.” The assertion that Black bodies are different from all other bodies keeps company with generations of racist ideas that have infiltrated medicine, some of which were used to rationalize slavery. Researchers who developed the equation acknowledge that race is an imperfect variable, but even though they have updated the formula, they continue to adjust for race. The vast majority of clinical laboratories in the United States use such formulas today.

Dialysis is corporate healthcare on steroids: For-profit companies dominate the market, reap their revenues from Medicare and lobby hard against government reform. DaVita and Fresenius recently spent over $100 million to fight a ballot initiative in California that would have capped their profits, much of which are derived from taxpayer dollars, arguing that the initiative would lead to a shortage of doctors. They have lower staffing ratios and higher death rates than nonprofit facilities. And studies have found that patients at for-profit clinics are less likely to reach the transplant waiting list; they are 17% less likely to get a kidney from a deceased donor. Purnell, the Johns Hopkins epidemiologist, said the whole system is broken as long as corporate dialysis, which is financially incentivized to keep patients, is in charge of steering them to the better treatment of transplant: “Why would I walk into a Nissan dealership to tell me about a BMW?”

Dialysis facilities are responsible for transplant referrals, according to federal regulations, and JaMarcus’ DaVita social worker was assigned to educate and support him. When he was first assessed, a couple of weeks after he began, she wrote that he was suitable for referral and she would get him one when he got insurance. JaMarcus qualified for Medicare within three months. But more than a year later, he still hadn’t been referred.

By 2015, JaMarcus had a new DaVita social worker, Robbin Oswalt, who attributed the delay to a different prerequisite: “He is interested in getting a transplant referral if the Dr. approves after his wgt loss.” JaMarcus had lost 108 pounds since he started dialysis, and his body mass index had been hovering around the University of Alabama’s limit for months. At the time, he didn’t know that his height had been mistakenly entered into his DaVita records as 5-foot-11 — an inch and a half short of his actual height. Their incorrect number was then used to calculate his BMI, which made it look to his doctor that his weight was disqualifying, when it wasn’t.

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Motherhood on the Line

Migrant women and children, like Fania and her infant son Bilfani, seek care at the Mother and Child Hospital and refuge at the Path of Life (Senda de Vida) shelter, both in Reynosa, Mexico. Photo by Jacky Muniello.

Alice Driver | Longreads | December 2020 | 12 minutes (3,442 words)

 
FANIA*

* Fania’s last name is withheld for privacy.

The doctor made a uterine incision on the woman’s body to extract the fetal arms, then grasped the baby’s feet and pulled him from the womb upside down, delivering him into the era of coronavirus. Fania, 33, had traveled 1,726 miles from Haiti to Reynosa, Mexico. She had not planned to become pregnant nor imagined giving birth during a pandemic. “In my life, I did not want to have children. I was very careful, and I managed for four years with my husband. The idea was not to have a child who is suffering,” she explained.

When Mexican photographer Jacky Muniello and I met Fania on August 3, 2020, in Reynosa, Mexico, her C-section scar was fully healed. Muniello and I had worked together in Reynosa on several projects, and we were familiar with the risks of working in a city controlled by cartels, one whose militarized streets suggested a city at war with itself. This, however, was our first time working in the city during the pandemic, walking its streets in N95 masks. We found citizens wary, on edge, suspicious, anxious, and struggling to process the coronavirus death news cycle alongside the conspiracy theories spreading like wildfire on social media. Read more…

‘Anyone Can Walk in the Woods, But Who Truly Knows Them?’

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Tristan McConnell‘s recent essay at Emergence Magazine just might be the deep breath you need amid your busy week and a chaotic, never-ending cycle of news. In “Illuminating Kirinyaga,” McConnell takes us on a journey into the shrinking forests of Mount Kenya and writes about the land, coexistence, and the people who commune with the trees.

We immediately meet Joseph Mbaya, a man who lives in Kiambogo, a village on the edge of the forest. Mbaya forages for medicine among the trees and finds treatments for everything from arthritis to indigestion; the sap he collects from a red stinkwood tree can help treat an ear infection or a toothache, for example. There’s also Samson Thureinira, an elder living in the foothills, “still strong as a cedar’s trunk,” writes McConnell, and who moves “on a timescale more akin to trees than humans.” The indigenous saplings in Thureinira’s tree nursery are part of a reforestation program led by the Mount Kenya Trust that will, hopefully, help to protect these forests long after he and Mbaya are gone.

They, and other foresters of this landscape, understand that the forest can be used without destroying it.

Mbaya’s visits to the high forests mark him out. While the swirling centrifugal forces of modernity have sucked so many others into a prison of quotidian constraints, Mbaya’s forest walks are a portal to a different, slower, and more meaningful world. Anyone can walk in the woods, but who truly knows them? As we strode, paused, scrambled, and sat, Mbaya painted the forest with his knowledge; trees and plants were illuminated by their names and made more vivid in their value and uses. To see the forest through his eyes— however fleetingly and partially—is to be granted a rare glimpse of an understanding that feels as inaccessible as Mount Kenya’s soaring peaks. But appreciation and preservation of the mountain and its forests is dwindling.

DEEP INSIDE THE fractured forests that still ring the mountain, a hallowed sense of wonder persists. One morning, soon after the sun burns mist from the mountainsides and clouds shroud the peaks, I visit part of the mountain’s few remaining areas of old-growth woodland with a pair of young Kenyan foresters from the Mount Kenya Trust. Marania Forest, on the mountain’s northern fringe, is a revelation: thickly towering trunks of eight-hundred-year-old rosewood reach overhead, the trees’ crowns held up to the light of the canopy, pencil-straight cedar and craggy-barked olive are draped with lichen, and moss carpets the earth, muffling sound to a church-like silence. It is dark, crowded, and otherworldly—the ground soft underfoot, the trunks damp to the touch, the trees centuries old, the sunlight breaking through in narrow shafts. At our feet, fallen trunks breach the understory like shipwrecks, gradually decaying and returning to the soil—to its subterranean fungal networks and the spreading roots of neighboring trees—as food for the rest of the forest. We all smile, the foresters and I. It is a routine venture out for them, and my first to these old forests, and yet our reactions are the same: joy and reverential wonder. We instinctively drop our voices to a whisper. We walk and talk, feet sinking into the damp, spongey soil as the foresters teach me about the trees.

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There She Goes: How to ‘Feminize’ a Face

Morsa Images

When most people think of the medicine of gender reassignment, hormone therapy and genital surgery likely come to mind. In a thoughtfully written feature in The Guardian, journalist Jenny Kleeman describes a new frontier: facial feminization surgery, or FFS. Kleeman introduces readers to trans women who, unsatisfied with — or traumatized by — the way they are perceived physically, visit surgeons who shave jawlines, plump cheeks, lift brow lines, and perform other procedures that can make faces read as more feminine. “I’m not trying to make myself beautiful,” says Sophia Drake, the main subject of the story. “I see testosterone as a poison in my body, a poison that I had to deal with for 20 years. I want to put my face to the way it would have been if testosterone had never been [there].” Her surgeon, Dr. Keith Altman, operated on Drake in October 2019:

There was no more easy chatter between the doctors when Altman returned to the theater to operate on Drake’s brow and forehead. This was the most difficult part of the surgery. It would remove the parts of Drake’s face she thought were most male, the features she hated so much. Altman brushed sterile aqueous iodine over her face and hair, rendering her first rusty red and then yellow. He made an incision into her hairline with a swift, steady hand.

He drew back her skin in either direction from her hairline until it gathered in folds on one side at the tip of her nose, and draped back across her crown on the other. With a tiny steel mallet and a chisel, Altman set to work carefully chipping away her brow bone, before filing it with a tiny drill bit. Then he stopped, and everyone in theatre craned in to see the difference.

When he was satisfied with the result, Altman changed his gloves and turned his attention to her forehead. The MRI on the lightbox showed Drake had a large sinus cavity with a thin wall; the challenge was to saw the bone down without perforating the sinus, and the best way to do this was to remove part of her forehead entirely. Altman drew a 5cm by 3cm rectangle on to her skull with marker pen. He sliced into it with another fine tool, then prized out the section of bone. He held it in his hand as he filed it back, turning a flat plane into a gentle curve. When he put it back in place, he pulled the skin over it, tilting his head to the side to check his work. Finally, the piece of forehead was fixed back in the skull with two 4mm titanium plates, which his trainee, Maini, secured using a tiny screwdriver. Drake’s skin was smoothed back for a last time. “Good,” Altman nodded.

As Kleeman details, FFS raises challenging questions about privilege and beauty standards. The surgery is expensive and not covered by the National Health Service in most of the United Kingdom. According to Juno Roche, author of Trans Power, FFS contributes “a kind of two-tier system where, on the whole, the most successful trans people are beautiful people that pass. People who are proud to be trans, and those people who can’t afford the surgery, fall into a separate category. That’s most people. And we have to create safety for everyone.” Then again, Roche adds, “Trans people deserve an easy life. This is a tough gig.”

For Drake, the results of FFS were life-changing. Kleeman interviewed her two months into post-surgery:

The change was almost imperceptible to me, at first. But I could soon detect a new poise: her face seemed narrower, and strangely her shoulders did, too. Her dimples were more prominent, her eyes looked brighter and more expressive. There was a faint, pale pink sliver of a scar along her hairline, mostly covered by the dark roots of her fringe.

“It was just enough, without being too much,” she told me. “The hairline frames my face better. I find that my eyes aren’t sunken, they’re further out. I feel that I’ve got a lot more expression in my eyebrows now. Other people spot this”—she cupped her hands around her jaw—”more than I do. But when I go back and look at old pictures, I see a massive difference.”

The biggest change was in Drake’s demeanor. She no longer sat with her arms across her chest or played with her jewelry. She was open, at ease, comfortable.

“It’s made me so much happier. Calmer. I can sit and relax in ways I’m not sure I’ve ever been able to,” she said. “I don’t walk around any more worrying that people are looking at me.”

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