Search Results for: health

Making Health Care Better

Longreads Pick

When I have asked them whether they have any hope that medicine will change, they have tended to say yes. When I have asked them whether anybody has already begun to succeed, they have tended to mention the same name: Brent James.

Published: Nov 3, 2009
Length: 34 minutes (8,636 words)

You Have No Idea What Health Costs

Longreads Pick

If You Did, You Might Just Want Real Reform

Author: Ezra Klein
Source: Washington Post
Published: Sep 20, 2009
Length: 5 minutes (1,448 words)

Did Warren Burger Create the Health Care Mess?

Longreads Pick

The 1975 antitrust decision that gave you physician-owned hospitals.

Source: Slate
Published: Jul 29, 2009
Length: 6 minutes (1,660 words)

The Health-Care Wimps

Longreads Pick

Obama may be impervious to the demons of 1994, but his party is still haunted by the failure of Hillarycare.

Source: Daily Beast
Published: Jul 20, 2009
Length: 4 minutes (1,087 words)

How I lost my health insurance at the hairstylist’s

Longreads Pick
Author: Downtowner
Source: Daily Kos
Published: Jul 7, 2009
Length: 11 minutes (2,862 words)

The Coming Age of Climate Trauma

Longreads Pick

“What should a mental health response look like in the wake of a climate disaster? How can we better prepare communities for the moment when they are forced to confront climate change?”

Published: Oct 27, 2021
Length: 23 minutes (5,841 words)

Curator Spotlight: Robert Sanchez on Highlighting Notable Storytelling from City Magazines Across the U.S.

By Cheri Lucas Rowlands

Related reading: Elaine Godfrey on the death of a local newspaper in Iowa and Nickolas Butler on the power of community journalism in Wisconsin.

Last week, the Black Mountain Institute announced that The Believer, the literary and culture magazine founded in 2003, will publish its final issue in spring 2022. It’s yet another blow to the world of print media, and reminded me of the other dismal headlines I’ve read this month lamenting the decline of small-town newspapers — and the ultimate cost to the communities they serve.

In a time when publications and newsrooms continue to struggle, Robert Sanchez’s tightly curated City Reads account is a beacon on Twitter. City Reads tweets the best writing from city magazines across the U.S., shining a light on local and regional stories that I might otherwise miss. Sanchez is a senior staff writer for 5280, Denver’s award-winning magazine, and has written many longreads we’ve read and enjoyed over the years. I chatted with him via email last week about the process of curation, the importance of amplifying city journalism, and his recent 5280 story on sifting through and reading the 8,500+ letters and postcards mailed to Colorado Governor Jared Polis, demanding justice in the Elijah McClain case. Read more…

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 Mysterious Case of Mr. X

Ben Jones for The Atavist Magazine

Laura Todd Carns| The Atavist Magazine | September 2021 | 7 minutes (1,935 words)

This is an excerpt from The Atavist‘s issue no. 119, “Searching for Mr. X,” written by Laura Todd Carns and illustrated by Ben Jones.

 

On a summer day in 1931, a man was found wandering South State Street in Jackson, Mississippi. He appeared to be lost. He was white, with gray hair and a thin, angular face. His clothes were worn and rumpled, but on his feet were a pair of tan Borden low-quarter dress shoes, the kind that sold for more than ten dollars at S. P. McRae’s department store on West Capitol Street. He had shell-rimmed eyeglasses and a belt buckle with the letter L on it. In his pocket was a cheap watch and a single penny.

The Atavist, our sister publication, publishes one deeply reported, elegantly designed story each month. Support The Atavist by becoming a member.

When police questioned him, the man seemed dazed. He was unable to supply his name, his address, or an explanation for why he was in Jackson. He was arrested for vagrancy. After a few days, he was placed in the custody of Dr. C. D. Mitchell, superintendent of the Mississippi State Hospital. Upon his arrival at the facility, the man, who was estimated to be about sixty, was entered into the patient ledger as “Mr. X.”

Who was he? Where had he come from? How did he wind up alone on a street in the Deep South, at the beginning of the Great Depression, without his memory? Months passed, then years. Mr. X remained at the hospital, and the mystery of his identity lingered. For reasons no one could discern, his past was beyond his reach.

Formerly known as the Mississippi State Lunatic Asylum, in 1931 the hospital was a warren of overcrowded barracks so decrepit that patients kept getting injured by pieces of plaster that fell from crumbling ceilings. Worse yet, the hospital was a firetrap—its buildings were full of mattresses, linens, and other combustible material. One blaze after another destroyed parts of the facility, necessitating reconstruction.

In 1935, four years after Mr. X’s arrival, the institution moved to a brand-new campus about 15 miles outside Jackson. It was built on the site of a former penal farm and dubbed Whitfield, in honor of the governor—Henry L. Whitfield—who approved the construction. Over the course of several days, patients in Jackson were loaded onto buses in groups. They traveled along Highway 80 before turning onto a long gravel drive lined with young trees and freshly planted flower beds. Some 70 redbrick buildings with white columns were nestled on Whitfield’s green lawns and connected by paved walking paths. A visitor, taking in the manmade lake and the wide porches on the buildings, might have thought the place a summer camp or a university.

Over the previous century, patients in mental hospitals were often written off as subhuman and kept in barbaric conditions; by the 1940s, mental health care began shifting toward new treatment models, some with real potential to help people (psychiatric pharmacology), and some that could only do harm (lobotomy). Mr. X’s time in state care fell between these two eras, at an institution flush with the spirit in which it was built. Whitfield’s superintendent, Dr. Mitchell, designed the campus in line with the latest scientific understanding of psychiatry. The physical environs were intended to be peaceful and pleasing to the eye. Patients attended weekly dances and movie nights. On Sundays, patients and staff alike worshipped in the campus chapel. Orchards, fields, and a dairy farm provided Whitfield’s food. Able-bodied patients sewed overalls in the occupational therapy workshop; others milked cows or repaired fences. Mitchell believed in giving residents the opportunity to contribute to their community, because the dignity of honest work could be a salve to a troubled spirit. It also helped stretch the institution’s meager budget.

For some patients weathering a temporary crisis, the restful environment was all the treatment they needed, and they left after a short stay. For those suffering from more severe or chronic disorders, the hospital offered comfort and stability. The focus of treatment was on easing symptoms and providing structures that kept patients safe.

By all accounts, Mr. X thrived at Whitfield. He worked in the hospital’s greenhouse, tending to plants and flowers, and he revealed a surprising store of botanical knowledge. In his downtime he played cards with other patients and with staff. He had a knack for complicated games like bridge.

Knowing the names of things is semantic knowledge; knowing how to do things is procedural knowledge. These parts of Mr. X’s mental functioning were intact. What was missing were his autobiographical memories. And without them, who was he? A skilled bridge player who couldn’t remember how or when he’d learned the game; a gardener with no recollection of who’d taught him the names of flowers or which varieties grew in his mother’s yard.

Mr. X spent hours in the hospital’s library, reading every newspaper and magazine he could get his hands on. He told his doctors that he was looking for something that might jog his memory, something that felt familiar. Nothing ever did. He spoke with a genteel Southern accent, which suggested that he’d had some education in his life, or at least had grown up among educated people. Those people—his people—could tell Mr. X who he was. But no one came to Whitfield to claim him.

 

We’re not the only ones who carry our memories. The people around us, who share in our experiences, have their own version of events saved away. And when we tell a story to a loved one, we’re giving them a piece of our lives. We scatter memories like seeds, letting them take root in the people who care enough to listen.

One day in the late 1990s, I sat cross-legged on the cool tile floor of my grandmother’s sunroom in Florida, listening. I had a cheap spiral notebook in my lap where I scribbled down the scraps of memory she shared. My grandmother had always been reticent to talk about her upbringing in Mississippi, but as she spoke, her initial hesitance burned away like a fog dissolving in sunshine.

As she described her childhood, she dwelled for a while on a woman named Ligon Smith Forbes, her aunt on her mother’s side. Ligon—pronounced with a short i and a hard g—died well before I was born, but as my grandmother spoke, a lively, unconventional woman took shape in my mind. “She was a feminist divorcée suffragette journalist alcoholic lesbian rabble-rouser,” my grandmother said, tapping a manicured finger against her ultra-slim cigarette. “You would have loved her!”

Ligon was a tall, striking woman, and by the time she was in her fifties, her lined face had a rosy glow—the complexion of a heavy drinker. She was married briefly, retaining nothing from the union but the title “Mrs.” and a new last name. Ligon worked all her life, and she held a wide variety of jobs. She tried teaching, then managed a stationery and newspaper shop. She dabbled in real estate and in the insurance business. She got into journalism and road-tripped with Eleanor Roosevelt to report on conditions in the rural South for the Emergency Relief Administration. She also started the first advertising agency in Mississippi. Her cofounder was her longtime “companion,” a woman named Earlene White.

“When I was turning 13, Mama let me take the train to visit Aunt Ligon in the city, to celebrate my birthday,” my grandmother told me, her eyes shining at the glamour of it all. The year was 1931, and the city was Jackson—for a girl from a small, dusty town, the state capital was the height of sophistication. She stayed with Ligon and Earlene in their suite at the Robert E. Lee Hotel.

“Of course, they were lovers,” my grandmother said in a casual aside, “but we didn’t talk about things like that back then.”

Her mother—my great-grandmother, Ligon’s sister—had given her five dollars to buy a dress. “Five dollars was a lot of money,” my grandmother said solemnly, as if she could still feel the weight of it in her patent-leather purse. “Ligon took me shopping, and well….” My grandmother shrugged. “Instead of a dress, I came home with my first pair of high heels.” She grinned with the mischief of a rebellious teenager.

“She worked for the Times-Picayune in New Orleans for a while,” my grandmother said of Ligon, narrowing her eyes in concentration. “Wrote for a bunch of newspapers. Sometimes she sent me cuttings, but I don’t think I saved them. Maybe you could look”—at this my grandmother gestured vaguely toward the sky, indicating technology and its mysteries—“find out something about her work.”

I tried, but searching through old newspapers on library microfiche was a formidable task, and the earliest databases for genealogy research, such as Ancestry.com, were just coming online. The notebook where I’d scribbled my grandmother’s memories soon slid to the bottom of a box. It sat there, unopened, and moved as I did, to new homes, half a dozen times over the years.

When I discovered the notebook again, my grandmother had been dead for a decade. But there were her words on the page, transcribed in my ballpoint-scrawled hand. Outlandish stories of feuds with her older brothers, of the small-town telephone operator who eavesdropped on everyone’s conversations, of the house her lumberman father built, hand-picking every board. And memories of her beloved Aunt Ligon.

I took the fragments my grandmother had given me—the Robert E. Lee Hotel, the Times-Picayune, Earlene—and fed them into search engines. There she was: Ligon Smith Forbes. I discovered facts about my aunt’s life that my grandmother hadn’t shared, perhaps hadn’t even known. Ligon filed a patent in 1920. She worked with Near East Relief, famously the first charity to let donors “adopt” a child by supporting them financially from afar. And at the time of the 1940 census, her residence was listed as the Mississippi State Hospital in Whitfield.

At first I thought Ligon had been a patient. Perhaps she was being treated for alcoholism. But no—I soon learned that Whitfield was another career shift. Ligon was hired in July 1938 as the institution’s public relations director. Previously, administrators or the occasional contractor had handled publicity. But someone convinced the hospital that it could use a dedicated staff member to liaise with the press. In all likelihood that someone was Ligon herself. Creating jobs out of whole cloth was one of her specialties.

Ligon moved into the female staff dorm at Whitfield. Her commute to work was a stroll down landscaped paths, first to the dining hall for breakfast at communal tables, then to the cupola-topped administration building. She had a Rolodex full of contacts at regional newspapers and magazines. She had experience writing copy she knew papers would run. Now all she had to do was scour the hospital for story ideas.

Ligon reached out to the Commercial Appeal, a newspaper in Memphis, Tennessee, that had wide circulation in the South. It was always seeking content for its weekly photo supplement, referred to in the newspaper business as rotogravure. Ligon suggested that the paper do a two-page spread on the state-of-the-art mental hospital where she’d recently started working. She said she would travel to Memphis herself and hand-deliver the photographs. The newspaper, presumably eager for an easy way to fill a couple of pages, agreed.

On the day she would board the train for Memphis, Ligon came across a patient file that roused her journalistic instincts. As topics went, it was far meatier than images of Whitfield, however lovely the campus was. It was the sort of thing the public was hungry for. The stuff of radio melodrama and matinee movies. The kind of story a writer stumbles upon only a handful of times, if ever.

She had discovered Mr. X.

Read the full story at The Atavist

It’s Time for Men to Start Talking About Male Infertility. I’ll Go First.

Longreads Pick

“We can form a whole new language that moves us away from the reductive and sexist tropes tied to infertility, that a woman’s biological clock is the single biggest fertility issue. For one in three heterosexual couples with fertility problems, there are issues with the man and the women, and in a further 8 percent of cases, male fertility issues are the only cause, according to the CDC.”

Source: Inverse
Published: Sep 16, 2021
Length: 9 minutes (2,344 words)