After my first year of medical school, I spent the summer working in a hospital in rural South Africa. It was during the waning days of apartheid, not long before Nelson Mandela was released from prison. I actually did very little work, because I knew little of practical use. Instead I trailed after a missionary orthopedic surgeon and tried to think of questions to impress him, since at the time I was vaguely considering a residency in orthopedics. I am ill suited to orthopedics, which I believe I knew even then; but that didn’t stop me from peering through anatomy textbooks in the evenings so that I might be ready for the questions he’d throw my way in the operating room—What is that muscle, Mr. Huyler? The biceps? Yes. And where does it attach? I’d hold my retractor, stare down into the rust-colored muscle and gray-white bone of the wound, and try to answer him.
The doctor was a Scotsman in his mid-50s whose prematurely white hair made him look distinctly senatorial. He was mostly distant and quiet, and I never got to know him very well. He said little about God, and he never went to church when I was there. He was the only certified orthopedic surgeon in a tribal homeland of six million people, and the kind of missionary who did his proselytizing in the operating room.
His patients were always black and always poor. Few whites lived in the homeland, and those who did were all in the capital city, where they had a tennis club, a school, and a few leafy green suburban streets with walls around their comfortable houses. But if there was tension in the air, I didn’t feel it. The pace was leisurely and the atmosphere was calm; even the crimes reported in the local paper—murders and burglaries and rapes—had an oddly casual quality about them.
The doctor and his family lived in a small house on a ragged hill, just a five-minute walk from the hospital and nowhere near the white enclave. I stayed in their spare room—a hut in the back yard. In the evenings, from the porch of the hut, the faint glow of white South Africa was clearly visible on the horizon.
The doctor did all kinds of orthopedic surgery, but his specialty was treating tuberculosis of the spine. Each week emaciated, paralyzed figures arrived from all over the homeland. Their relatives brought them out of the bush to the city, carrying them in the backs of pickups or holding them upright on crowded buses. I watched the doctor expose spine after spine and drain abscess after abscess—tuberculous pus, buttery yellow and white. Cockroaches sometimes streaked across the operating room floor and over our feet. Many of his patients died, but many also lived. Some even walked again.
He worked six days a week, 12 hours a day, and he got up in the middle of the night when someone knocked on his door. Every summer, though, he took a brief vacation. A wealthy white South African friend owned a house and a deep-sea fishing boat on a remote coast a few hours’ drive to the east. The doctor was a fisherman and took his family there each year. He invited me along, because he didn’t know what else to do with me.
On the day we were leaving for the coast, he asked me to check on some things in the morning and then drive down by myself in his other car. The servants would meet me there.
So a few hours after the doctor and his family had packed up their van and departed and I had completed my assigned duties, I took his Opel and followed his directions east to the Indian Ocean. I drove nervously, on the left side of the road, without a valid license. The road turned to dirt at the edge of town, and soon the land around me was barren reds and browns, dotted with herds of thin cattle and the round thatched huts of rural Africa. The road grew steadily worse. As was customary, people tried to flag me down, and finally, reluctantly, I stopped for a young woman with a baby. Her face was a mask of tribal scars, and she sat in the back with her child, head bowed, for miles. She spoke only once, asking to be let off. The child made no sound at all.
It was afternoon when I reached the river. The road, now a dirt track, simply came to an end by a hut in a dusty yard, the wide brown river flowing by. To my great relief, I saw the doctor’s van in the corner of the yard, and the boy who came trotting out of the hut seemed to be expecting me. He held up both hands, the gesture plain—Wait. Then he jogged away from me down the path along the bank.
Nearly an hour passed. It was hot and quiet. I wandered around the empty yard and then walked down to the river. I could faintly hear an outboard motor in the distance. It grew louder, and suddenly a speedboat rocketed around the bend, turned hard, and sent a long tail of spray into the grass on the bank. A small blond boy stood behind the wheel, grinning, and his even smaller brother scrambled up to the bow and threw me a line. These were the doctor’s youngest sons.
The sea was a couple of miles down the river. As we left the confines of the mangrove trees and moved into the wide salt flats of the estuary stretched out on either side, I saw the whitewashed mansion high on a hill, the deep, radiant blue of the Indian Ocean beyond it. It was the only visible building, with a red roof and terraces and a thin line of wooden stairs leading down to the dock by the river’s edge.
The dock was modern, all new concrete. When I jumped out of the boat, I realized that the boys had no intention of stopping for more than a moment. They simply left me standing there at the foot of a hundred steps and roared off again. Fishing, they had said, was boring, and I watched them go, cutting bright arabesques and sending up sheets of spray. Before I’d climbed halfway to the house, several servants had converged, smiling, for my bag.
They gave me a deck chair on the terrace in the sun, and a thin, angular man of indeterminate age brought me a drink. The doctor, he said, would not be back for hours. Are you comfortable, sir? Would you like something to eat?
The terrace was warm and peaceful. I could see for miles—the ocean, the glittering estuary, the clear blue sky. It was a beautiful place, the kind of house that would have cost millions anywhere in the Western world. It was furnished plainly, though, with old couches and comfortable chairs, and decorated mostly with photographs of the owner’s family—a lovely young woman, a couple of handsome children. The man I assumed to be the owner was much older than his wife. He was fat and bald with a kindly face. In the photographs they all looked happy.
There seemed to be at least a half-dozen servants in the house. I could hear their voices downstairs, and the smell of cooking rose to the terrace. The servant who brought my drink pointed out the doctor’s cabin cruiser a mile or so offshore in the open sea. A figure stood in the tower, just visible, looking, I realized, for the flutter of schools on the surface.
I lay back in the sun on the terrace, sipping the cold gin, and after a while I dozed off. I don’t know how long I slept—maybe only a few minutes—before the outboard woke me up, and the older boy raced up the stairs at a speed that, for a 12-year-old, suggested news.
“There’s a dead body,” he said, breathing hard, barefoot and small, in pale green shorts. “They want a doctor. Are you a doctor?”
“Sort of,” I said, though of course I wasn’t at all.
The body lay face down in the mud a few hundred yards up the river, invisible from a distance—we had unknowingly passed right by it only a short while ago. Two of the servants were already there when the boys and I arrived. As we watched, they turned the body over.
He was perhaps 16. He was very cold and very black, like a stump carried and left by floodwater. Rushes had drawn a fine tracery like a watermark on his belly. I knelt beside him. He had no pulse. The whites of his eyes were red, his pupils dark and empty. His blue nylon shorts were wet completely through and clung to the exact outline of his legs. The doctor’s sons stood wide-eyed and quiet and kept their distance. I looked up at them.
“It’s the cook’s son,” one of the boys said. “We know him. He has epilepsy.”
“He shook,” one of the servants said, pointing to the body.
The man did an imitation of a seizure, shaking his arms, contorting his face. A bamboo fishing pole lay half in the water, its restless float trailing out into the current.
“He was fishing on the riverbank?” I asked.
“Yes,” he said, smiling quickly. “Fishing.”
He lit a cigarette, and the smoke rose around his face, lit up by the afternoon sun. The man’s pants were dark to the knee, already drying.
“He did not come back,” he said. “We searched for him.”
I looked at the boys, the servants, all of them clearly expecting me to do something. But the cook’s son was dead, drowned in a foot of water.
“Let’s move him up on the bank,” I finally said to the boys. “We’ll have to wait back at the house for your father. They can stay here with him.”
The servants nodded, lifting the body by the arms and legs, head lolling, mouth agape. It was an effort for them to carry him to the deeper grass.
Nearly two hours passed before the doctor guided the gleaming new cabin cruiser up the river mouth to the dock. We waited on the terrace—the boys, the half-dozen servants, and the cook. Only the cook was crying.
She was the tall thin woman leaning against the wall, and her tears tumbled down the tribal scars on her cheeks like clear, discrete ornaments. Sometimes one would catch the track of a scar and follow it, inward toward her mouth, before dropping off into the blue expanse of her dress.
As the boat approached, I followed the servants down the stairs.
“So you made it, eh?” the doctor called, over the burbling motor as the boat eased up to the dock. He threw the bowline to the servants, then moved nimbly down the deck to the stern. He was sunburned and shirtless, he looked relaxed and content, and his tennis shoes were covered with fish scales—some clung to the hair on his legs, some to his socks. When he was on the dock, I told him.
“Good Lord,” he said, shaking his head, squinting against the brightness of the sun, silent for a moment.
A woman spoke behind me. It was the cook, the last down the stairs, asking the doctor to take her son to the mortuary.
“Please, sir,” she said.
“Of course,” he replied, looking at her, reaching out to touch her on the shoulder as she began to cry again. There was a silence, all of us staring at our feet.
“Do you want to come with us?” the doctor asked as she wiped her eyes with the back of her hand. But she shook her head.
“I cannot bear to,” she said, like an Englishwoman.
A crowd had gathered by the time we reached the body. A village was nearby, invisible from the river, and the news had traveled fast. The men and women stood in separate groups, talking quietly. By then it was twilight.
The two servants met the boat, held the line, and then stood in the shallows as the doctor and I lifted the body and carried it down to them. We had an audience, and we tried to do it well, but the body was loose and heavy, soaking our hands as we struggled through the high grass. Getting it into the boat was more difficult still. One of the servants stood in the boat, his arms wrapped around the body’s chest, grunting with effort as we held the legs. Finally we slid the body, as cold as a wet mattress, up and over the gunwale.
The doctor sat in the bow, with the boy’s exposed face between his feet, and we went off down the river toward the cars. The two servants cupped their cigarettes in their palms, the doctor’s white hair rose up, our shirts flapped around our ribs, and it got cold quickly. The presence at my feet seemed immense.
No one was in the yard to watch us, so we simply dragged the legs through the shallows to get to the cars. The back seat of the van folded down neatly, and we laid him there. The men walked back and forth through the headlights, mooring the boat, and the doctor wiped the mud from the boy’s face, his bare legs and feet, then threw the towel down toward the boat in the darkness.
There was an old green bedspread in the back of the van. We used it to cover him.
“I knew him his whole life,” the doctor said, shortly, as I watched him. Then he shook his head, got in the van, and started the engine.
It was a long drive, well over an hour. The men sat cross-legged in the back and gave us directions. The body shook and leapt on the rough dirt road, sliding into them, and they struggled to hold it still. The headlights were mostly full of dust. Occasionally, the men in back said something to one another, but the doctor and I didn’t speak. It was warm with the heater on.
The hospital was a small mud building—a clinic, really—but it was open, and a radio played somewhere as I walked in alone. Only one nurse was on duty; I found her folding sheets, loading them into a cabinet.
“Excuse me,” I said, and she turned around. “We’ve brought a body for the mortuary.”
“A body here?”
“Yes,” I said. “For the mortuary.”
“Do you have a death certificate?”
“No, the boy has just died.”
She studied me. “You need a death certificate,” she said. “I can’t admit the body without a death certificate.”
“I can certify that the boy is dead.”
“It doesn’t matter. You need the proper form.”
“Where can I get the proper form?”
“You have to wait until tomorrow.”
“Wait a minute, please,” I said. “I’ll be right back.”
As I stepped out into the dirt yard, one of our companions stood in the headlights, urinating a long bright arc into the darkness beyond. The doctor regarded him impassively from the driver’s seat, listening to me and watching the pale stream of urine in front of him.
“I’ll go in and see what I can do,” he said. “Why don’t you wait here.”
I nodded, and watched his erect figure disappear into the bright square of the hospital door. He came out a few minutes later.
“It’s taken care of,” he said. “I gave her some money.”
The morgue was an outbuilding in the corner of the yard. It was filled with stainless steel rows of drawers, refrigerated, with dials; it was cool and odorless, astonishingly modern, like the clean innards of a dairy.
We carried him on the hospital’s stretcher, wrapped in the green bedspread, through the lights to his drawer. As he lay there, stiffening now, the nurse entered the room. She held a Polaroid camera in her hand and bent over the boy, focusing on his face. Then the flash, reflecting off the metal cabinets, and then the drawer, closing very quietly and smoothly.
“For our records,” she said, and we watched as the image rose out of the black film, his face taking shape, the corners of his mouth and half-open eyes, his white teeth, his hair dark against the sheet.
We climbed back into the van, and she followed, casually, waving the photograph in her hand to dry it. We watched her through the windows as she crossed the yard and entered the door, then closed it behind her.
“At least he was saved,” the doctor said. “At least there’s that.”
“If he had been standing two feet back, it would only have been a seizure,” I said.
He nodded and didn’t answer, and I remember wishing I hadn’t spoken. The men in the back were quiet, the road was clear, and for a few minutes the doctor drove fast, taking the curves with a shudder. But after a while he slowed down again.
“Sorry about all this,” he said, as if somehow he were to blame.
We settled into an uneasy silence, with only the sound of tires on the washboards, the occasional hiss of a match striking behind us. The van was full of smoke, but dust poured in the windows if we opened them.
Nearly home, we came to a gentle stop as a small herd of cows, looking very white in the headlights, drifted out into the road and turned their slow heads toward us. I remember this clearly: the doctor didn’t blow the horn, but merely waited as the engine ticked over, and a few dim sounds from the fields came up, and then the cows continued across the road and disappeared.
Fifteen years have passed since then. I’ve never been back to Africa, and I long ago lost touch with the doctor. He would be in his 70s by now, and the boys in the motorboat would be nearly 30. I didn’t become an orthopedist. I became an ER doctor, and since people with epilepsy often come to the emergency room, I’ve seen many seizures over the years.
For a second it’s not clear what’s happening to them. They look off into space. Sometimes they cry out. Then an arm or a leg starts to twitch, and suddenly it’s all over them, dark and otherworldly. After a minute or two it stops, and they go limp. It takes many minutes for them to wake up. This is when, I’m sure, the cook’s son drowned—not during the seizure, but in the aftermath.
Maybe it was the exotic location, the depth of the contrasts, my own odd position, my youth, the strangely aesthetic quality of that day—I don’t know. But few things in my life have stayed with me in the way that experience has. I can’t really make sense of it. The rational mind can worry at events like this, get some purchase here or there, but ultimately the central core of mystery remains untouched and sails along undisturbed. I’m not any closer to understanding this experience than I was on the morning after it happened.
A big event like the boy’s drowning is really a cascade of tiny incidents: what seems singular is manifold, each small thing making its little dark contribution to the larger whole. These small events are occurring all the time, but more often than not, something goes wrong—or right—and the moment of synthesis never arrives. The boy goes fishing, and he has a seizure, but he’s standing on the bank and falls into the grass, or he falls backward instead of forward in the water and keeps breathing, or whatever drew him down to the water’s edge—something he saw, perhaps, out in the current—never appears. Or he’s not alone. Think of the orchestration required, the intricacy of timing—the seizure occurring precisely at that moment when he was most vulnerable and could do nothing to save himself. So many small chances, falling one after another so perfectly against him, as if by design. It was a seemingly random event, but it was also full of immense order and precision. We tend to think of such happenings as forms of entropy, but in a way they are simply competing forms of order. In rational terms, that’s about as far as I can get.
Maybe this is profound, or maybe it’s just obvious, but one of the major difficulties of medical practice, at least for me, has little to do with the long irregular hours or the daily frustrations. Instead, it has to do with questions like why did that boy fall forward instead of backward. These questions are everywhere in medicine and go entirely unaddressed in any kind of formal way. Their effect is cumulative and insidious. It was such a short distance between the water’s edge and the bank, the kind of distance that we always expect to be able to cross. The orthopedic surgeon whom I followed around had seen many things like that, and though he was clearly disturbed by the experience, he had his faith tucked neatly in his back pocket. I had youth and the sense of personal safety that youth affords. But now, as I get older, that sense of distance is eroding away. In large part I think this is because clinical distance is not the same as honesty, though the two are often confused, nor is it the same as intellectual or spiritual courage. Ultimately, it’s a form of pretense, a useful tool to get on with the work at hand. There are lessons to be learned from the medical literature where vast human struggles—five-year survivals, prognoses, side effects, and complications—are numbered so exactly. But on some level, it’s also important to remember that the unstinting eye is also a dishonest eye, because it fails to acknowledge that the perceiver is also a participant, that we are all caught up in these forces, and that no amount of rigor, or intelligence, or clinical distance, or professional accomplishment can save us from them.
Soon enough, one realizes that one is never going to understand these things at all. The question then becomes not so much how to understand the vagaries of this world, but what to do when you recognize that you don’t. One or two events like the boy’s drowning can be shrugged off. As the years pass, however, these events accumulate, they do not recede. And it’s precisely the accumulation of these events that leads us to ask the kinds of questions about our own lives and futures and the lives and futures of our loved ones that cannot be answered by the rational mind. For many, like the Scottish orthopedist, the answer is faith. But what is left for the skeptics among us?
Richard Selzer, one of the finest physician writers of the 20th century, has spent his literary career considering exactly these questions. Selzer, now in his late 70s, practiced surgery at Yale for some 40 years. In one of his stories, he describes meeting a boy in the lobby of the Yale University hospital. The boy is undergoing chemotherapy and is near death. Selzer doesn’t need to be there at all—he’s been retired for many years. He’s become one of those forgotten old men, common in blue-chip law firms and places like Yale, who formally haunt their own pasts. Selzer describes the boy as follows:
He is bald; his lips are crusted, and with a sore at either corner of the mouth. An intravenous drips into his left arm. Perhaps he weighs 80 pounds. The bottle hangs from a metal pole attached to the wheelchair over his head. In his lap, a plastic bottle of water with a straw. He looks to be about 10 years old. His head is all eyes and ears. He seems to be studying me, with great interest, and without any restraint. The expression on his face is one of glacial intelligence.
They strike up a conversation. At first, it’s pleasantries. But soon enough it becomes clear that the boy is more than just a boy. He’s many things—a mythic figure, a death’s head, a deity of one kind or another, and ultimately Selzer himself. The rest of the story revolves around a simple question the boy asks: What will you do on your last day on earth?
It’s not a simple question. The story itself quickly becomes a kind of dreamscape narrative, an odd synthesis of past and future, where the solutions are inconclusive, aesthetic, suggested rather than claimed, and approached obliquely. Somewhere, though, despite all the darkness of the story, there is the distinct whiff of comfort, a kind of Keatsian negative capability that, Selzer implies, can be hoped for and perhaps even found.