JHHE v3n1 Spring 2017 Singles

Journal of Health and
Human Experience
Volume III, Number 1 Spring 2017
Reform and Renewal

The Human Face of Health Care
Journal
of
Health and Human
Experience
The Journal of Health and Human Experience is published by The Semper Vi Foundation.
Journal of Health and Human Experience Volume I, No. 2

Journal
Preface of Health and Human Experience
General Information
The Journal of Health and Human Experience is published by The Semper Vi Foundation,
a 501(c)(3) public charity. The Journal is designed to benefit international academic and
professional inquiry regarding total holistic health, the arts and sciences, human development,
human rights, and social justice. The Journal promotes unprecedented interdisciplinary
scholarship and academic excellence through explorations of classical areas of interest and
emerging horizons of multicultural and global significance. ISSN 2377-1577 (online).
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ii Volume III, No. 1 Journal of Health and Human Experience

Journal of Health and Human Experience
Preface
Library of Congress Registration
January 27, 2015
ISSN 2377-1577 (online)
The Journal of Health and Human Experience is published by The Semper Vi Foundation.
The Journal is an interdisciplinary, academic, peer reviewed international publication. Its
mission is to explore the full expanse of holistic and integrated health within the nature and
meaning of human experience. Its scholarly and professional explorations richly convene all
possible areas within the arts/humanities and the sciences, cultural and social concerns, diverse
technologies, ethics, law, civil rights, social justice, and human rights. The Journal invites the
reader into the fullness of our human nature, our history, and the expanding futures before us.
The Editorial Leadership enthusiastically welcomes academic and research investigations,
reviews, commentaries, creative writing such as poetry/short stories, new and emerging scholar
submissions, and other possibilities.
The Journal makes use of a highly innovative four-stage academic mentoring review process
that was created by members of the Journal leadership beginning in 2006 with their service for
another publication.
A full description of the Journal’s mission, expanse, leadership, author requirements and
additional general information can be obtained at: http://JHHE.sempervifoundation.org
For direct contact, email Journal leadership via: JHHE@sempervifoundation.org.
Journal of Health and Human Experience Volume III, No. 1 iii

Prepared by Graphic Arts and Publishing Services at
The Henry M. Jackson Foundation
for the Advancement of Military Medicine, Inc.
Table of Contents
Preface
Mission: Semper Vi Foundation.................................................................1
Journal Editorial Board.................................................................................5
Journal Gold Patrons....................................................................................9
Author Biosketches.....................................................................................13
From the Editor-In-Chief

Meaning’s Mirror: The Impressionistic Journey ...........................................19
Edward F. Gabriele
Articles & Commentaries

Starting From Zero: An Exploration of Contemporary Issues in Haiti...........25
Tod Schneider, James Shraiky, Wendy Patchin
The Transformative Richness of Puerto Rican and Caribbean Cultural
Diversity in Health Care and Spirituality.......................................................40
Héctor E. López-Sierra
Knowledge, Attitude and Practice of Cervical Cancer Screening
Services among Rural Women in Ohaukwu Local Government Area
of Ebonyi State, Nigeria................................................................................52
Kelechi Johnmary Ani, Rita Ihuoma Anaba, Peter Chukwunwendu Okeke
Zika Virus: Challenges and Considerations..................................................62
Christie Joya
Empathy and Dedication: Hospital Corpsmen to Physician Assistants
– A Wasted Talent Pool in a Time of Need ...................................................77
David Lash
An Inquiry into the Compliance of Construction to Health and Safety
Regulations in Imo State, Nigeria.................................................................90
Emmanuel Ifeanyichukwu Nkeleme, Andrew Obinna Nwaubani,
Ijeoma Genevieve Anikelechi
Anthropological Synthesis of Spirituality and Pain Management: How
Spirituality Affects Pain Outcomes and Copings .......................................103
Andrew A. Ovienloba
A Clamor in the Market Place: Meaning and Discourse in the
Commerce of Healthcare and Research Institutions .................................115
Edward F. Gabriele
(cont.)
Journal of Health and Human Experience Volume III, No. 1 v

Table of Contents
Preface
Vignettes
Healing Hands ...........................................................................................127
Michelle Savaunah Zirkel Marcum
The Art of Diagnosis...................................................................................130
Bruce R. Boynton
Time for Prayerful Rounds..........................................................................131
Charmagne G. Beckett
Mumbo-Jumbo............................................................................................133
Jesse Eugene Hoover
Profiles in Courage: The Next Chapter

“Dr. Schweitzer, I Presume?” The Life and Times of Fergus
and Ruth Pope............................................................................................139
Jan Herman
The Critic’s Choice

Book Review: Musicophilia: Tales of Music and the Brain .........................151
Nathan Carberry, Mill Etienne
Book Review: Just Mercy. A Story of Justice and Redemption .................157
Nickolas L. Rapley
Under City Lights

Poem and Reflection: Graduation..............................................................165
Gregory C. Mabry
Short Story: The Ticket Taker.....................................................................169
Katherine L. Sparrow
A Parable: “Honk….if you love”..................................................................173
Edward F. Gabriele
vi Volume III, No. 1 Journal of Health and Human Experience

MISSION
Mission
Preface
The Semper Vi Foundation
“From Victim to Survivor to Victor”

Mission: The Semper Vi Foundation is a 501(c)(3) tax exempt public charity dedicated
to the design, development, implementation, and promotion of social justice and human
rights resources, programs, and diverse opportunities in education, publishing, research, and
services that help the suffering find healing and meaning in their lives. Of particular interest
for the Foundation’s mission is Wounded Warrior Care and, equally, the care of all those who
suffer in our wounded world.
Vision: Semper Vi reaches out to all who have known the many forms of life’s suffering
and tragedy. Semper Vi activities and opportunities seek to help all those who suffer, not
only to survive, but also to become victorious so that their wounds become sources of healing
for others. Semper Vi assists those who have benefited from our programs and activities to
help others in need. Some of those who benefit from Semper Vi’s humanitarian and relief
commitments include our Wounded Warriors and their families, as well as individuals and
communities who have experienced violence and terrorism, victims of assault and destruction,
those who have suffered discrimination and the loss of their human or civil rights due to
religion and values systems, race, gender, sexual orientation, socio-economic status, national
origin and ethnicity.
Values: Those who become involved with Semper Vi programs practice the Foundation’s
three core values: Learning, Healing, and Serving. Foundation participants seek to show those
who have suffered that healing can be theirs especially when their stories and experiences
become sources of comfort and care for others
Programs: Semper Vi Foundation activities are organized into four programs.
Education: The Semper Vi Foundation convenes a community of international,
interdisciplinary scholars and professionals who develop and promote a wide range
of educational programs and resources for enrichment in the humanities, health and
healthcare, the physical and social sciences, human development and human rights
Journal of Health and Human Experience Volume III, No. 1 1

Mission
Preface
across the globe. This Founation designs and provides workshops, seminars, webinars,
podcasts, full conferences and continuing education courses at various international
locations. Depending on resources, events are filmed and posted on the website.
Publication: The Semper Vi Press publishes the Journal of Health and Human
Experience. It also publishes a wide variety of academic and professional books,
periodicals, newsletters, and other resources serving the Foundation’s mission and
constituents.
Research: The Foundation serves as a sponsored projects college for investigators
looking to promote a wide variety of academic and professional domains of inquiry.
The Foundation promotes such programs in collaboration with various global
universities, centers and institutes.
Social Justice Services: The Foundation serves as a gathering point for individuals
and communities who design and promote diverse social justice services and resources
supporting human and civil rights. The Foundation supports already existing
approaches and promotes the invention and launching of new services to meet
emerging social justice needs across the globe.
Reflection: Tales of heroes abound throughout world literature. Our attention is always
captured by the stories of those who accomplish great deeds that benefit others and the world.
Yet what is it that we mean by the term, “hero?” When is something “heroic?” A hero is one
who, despite danger and weakness, musters the courage to sacrifice herself or himself for the
needs of others. Sometimes this comes at the price of the hero’s life. However, in all instances,
the hero vanquishes the danger and rises above it as victor. Yet there is another nuance. The
work of the hero often goes deeper. In many tales, the hero not only fights the oppressor, but
also suffers grievous wounds in doing so. The hero embodies the suffering and takes it into
her or him self. The hero endures and survives. Yet even more amazingly, in these stories the
suffering and pain are transformed from curse to blessing. The hero matures from victim to
survivor to victor! The hero becomes “semper victorius!” Always the victor!
Invitation: Join us as we build Communities of Victors, for today and tomorrow!
2 Volume III, No. 1 Journal of Health and Human Experience

JOURNAL EDITORIAL
BOARD and
GOLD PATRONS
Journal EditorialPreface
Board
Editor-in-Chief and Executive Director
Edward Gabriele, MDiv, DrMin
Humanities, Education, Research Ethics & Human Research Protections, Academic Theology,
Organizational Development & Strategic Planning
Former Ethicist to the Surgeon General of the US Navy
Editor
Bruce Boynton, MD, MPH, FAAP
Neonatology, Correctional Health, Global Public Health
State Medical Director
Centurion of Mississippi
Senior Associate Editor
Charmagne Beckett, MD, MPH, FACP
Internal Medicine, Infectious Diseases
Uniformed Services University of the Health Sciences
General Counsel
J. Michael Slocum, JD
Slocum & Boddie, PC
Global Outreach, Opportunities & Development Committee

“The GOOD”
Chair
Tony Bennae Richard, MS, MEd
The Bennae Group, LLC
Project Managers Senior Executive Advisors
Joseph Menna, AIHM, MEd Louis Guarini, BA, MS
Brandywine School District of Delaware President/CEO, L.J. Guarini and Associates, LLC
Shane Nicholas, AIHM Anthony Panto, BA, ABA
Westat, Inc. President, Panto Wealth Strategies
Melina L. Frame, AIHM, BA/BS, MA (cand) Nickolas L. Rapley, MBA
AIHM Social Justice Community Department of Defense
Information Technology
Computer Scientist & Webmaster
Zachary Slocum, BS
Higher Ed Growth
Special Sections Editors

Jan Herman, MA De Fischler Herman, BS, RP, SD
History Healthcare Chaplaincy, Spiritual Direction
Navy Medical History Department (retired) Capital Caring Hospice of Washington, DC
(cont.)

Journal
Preface Editorial Board
Associate Editors
Yolanda Amerson, MSW, LSW, PsyD (cand) Ruth Perot, MAT
Social Work, Psychology, Human Development Education, Integrated/Holistic Health
& Humanities Social Justice, Human Rights
Huntington Disease Society of America Summit Health Institute for Research
& Education
Vaughan Caines, MSc, MA in Law (UK)
Forensic Science, Human Rights Law & Clydette Powell, MD, MPH, FAAP
Criminal Law Pediatrics, Neurology, Global Public Health
Marc Geoffrey Barristers & Attorneys, Ltd & Human Rights
George Washington University School of
Patrick DeLeon, PhD, MPH, JD Medicine & Health Sciences
Public Health Policy, Psychological Health
Uniformed Services University of the Dale Smith, PhD
Health Sciences Medical History
Uniformed Services University of the
Exnevia Gomo, PhD Health Sciences
Immunology, HIV, Research Administration
University of Zimbabwe College of Lorenzo York, MDiv, DMin
Health Sciences Pastoral Care & Counseling, Non-Profits,
Business & Strategic Planning,
Elizabeth Holmes, PhD, ABPP Project Management
Psychology, Ethics, Leadership Science Department of the Navy
Stockdale Center for Ethical Leadership
United States Naval Academy Julie Zadinsky, PhD, RN
Pediatric Nursing, Research Ethics,
Ibrahim Abdel-Messih Khalil, MD, MPH Education Research, Qualitative Research
Global Health, Enterology, Infectious Diseases Augusta University
University of Washington
Mildred Huff Ofosu, PhD

Biological Sciences, Immunogenetics,
Sponsored Research
Morgan State University

Journal EditorialPreface
Board
Academic Review Committee
Chair Gordon K. Jones, DDS, MS
Thomas J. Roberts, MPA, EdD Dentistry
Educational Leadership, Higher Education Lovell Federal Health Care Center
Administration, Public Administration
Florida Gulf Coast University Patricia Watts Kelley, MS, PhD, RN, FNP, GNP
Family & Gerontological Nursing Science
Members Duquesne University
Shaun Baker, PhD, MA
Philosophy, Ethics Deborah J. Kenny, PhD, RN, FAAN
United States Naval Academy Women Veterans, Nursing Research, Qualitative
Research Interpretive Phenomenology
Ben J. Balough, MD Beth El College of Nursing and Health Sciences
Otology, Neurotology
The Permanente Medical Group of Frederick Luthardt, MA, MA
Sacramento, California Bioethics, Research Ethics, Human
Research Protections
Cedric M. Bright, MD, FACP Johns Hopkins University
Internal, Community, & Family Medicine,
Health Equity Charles MacKay, PhD
University of North Carolina, Chapel Hill Philosophy, Research Protections
112th President, National Medical Association Independent Health Care Consultancy
Donna Burge, PhD, BC-APRN, CNS Sharon McCarl, MBA, CRA

Orthopedic Surgery and Psychiatric Nursing Finance, Business Administration
USN Nurse Corps Reserves Carnegie Mellon University
Bruce A. Cohen, MD, MPH Victoria Molfese, PhD

Family Practice, Occupational Medicine, Developmental Psychology; Child, Youth &
Undersea/Hyperbaric Medicine, Global Family Studies
Public Health University of Nebraska Lincoln
Old Dominion University James C. Rapley, MD, FAPA
Federal Bureau of Investigation Psychiatry, Mental Health
Mill Etienne, MD, MPH Department of Defense
Neurology, Public Health Nickolas L. Rapley, MBA
Bon Secours Health System Business Administration, Strategic Planning,
New York Medical College Leadership
Jayasri Majumdar Hart, MFA Department of Defense
Cinema/Radio Production/Direction, Bruce Steinert, PhD, CCRA
Humanities, Crosscultural Affairs Pathology, Biochemistry, Clinical Trials
Hartfilms, Inc. Cancer Treatment Centers of America
Jan Herman, MA John Winters, PhD
History Health, Leisure & Human Performance
Navy Medical History Department (retired) Bacone College

Journal
Preface Editorial Board
Manuscript Editing Committee
Chair Joseph Menna, AIHM, MEd
Linda Youngman, MS, PhD STEM Education, Humanities
Biochemistry, Epidemiology, Clinical Trials Brandywine School District of Delaware
SAMHSA, Department of Health and
Human Services Bryan Murphy, MBA, PE
Environmental Engineering
Members United States Fleet Forces Command
Pamela B. Berkowsky, MALD
International Affairs, Government & Anne Marie Regan, MSOD
Non-Profit Administration Organizational Development and Innovation
Blue Sapphire Strategies Walter Reed Military Medical Center
American University
Jere M. Boyer, PhD, CIM, CIP, CCRP
D(ABB, Microbiol) Joseph Thomas, MSSc, MSS, PhD
Clinical Microbiology, Molecular Biology & Leadership Science and Public Policy
Immunology, Infectious Diseases, United States Naval Academy
Tropical Medicine Shelby Tudor, BA
Clinical Research Management, Inc. Communications, Literary Composition,
Dee Dee Chavers, MSM Political Science
Management Science Social Justice Services
Department of Veterans Affairs Pamela Vargas, MBA
Darlene Gilson, BA, CTESL Education and Research Administration
English Literature, Language Education Southeast Missouri State University
Carleton University Marianne Ward, BS, CRA
Joseph L. Malone, MD Research Administration
Infectious Diseases, Internal Medicine, Tropical Duke University
& Travel Medicine Franklin Eric Wester, MDiv, ThM, MSS
Uniformed Services University of the Ethics, Professional Identity, Just War, and
Health Sciences Spiritual Resilience
Evangelical Lutheran Church in America

Special Gold Patrons
Preface
Special Gold Patrons
2016-2017
We give special thanks to the following national academic leaders whose generous support and insight have
guaranteed the continued presence of the Journal for the enrichment of health and humanistic scholarship.
Susan Arjmand Mark Frankel Lisa Osborne
Charmagne & Damian Beckett Shirley Godwin Clydette Powell
Pamela Berkowsky Louis Guarini Ann Marie Regan
Jere Boyer De & Jan Herman Sharon Sloane &
Bruce Boynton Elizabeth Holmes & WILL Interactive
Cedric Bright John Mateczun Sandra Titus
George Ceremuga Patricia Kelley Jennifer Vedral-Baron
Thomas Michael Corrigan Anthony Kerlavage & Marianne Ward
Barbara Harner Michael Washington
Annette Debisette
David Lash Andrew Young &
Arnold & Sandy Farley
Frederick Luthardt John Blair
Karen Flaherty-Oxler
James Martin Julie Zadinsky
Paul Finch
Bryan Murphy

AUTHOR
BIOSKETCHES
Preface
Author Biosketches
Rita Ihuoma Anaba, BSc, PDNE, BSns, holds a Bachelor of Science degree in Nursing
Administration from Imo State University, Owerri as well as another Bachelor’s degree in
Nursing Science and a Professional Diploma in Nursing Education. She is currently doing a
master’s of science in Health Policy and Health Systems Research at the Ebonyi State
University, Abakaliki.
Johnmary Kelechi Ani, BA, PGDE, MA holds a Bachelor of Arts Degree in History and
International Relations from Ebonyi State University, Abakaliki as well as a Post Graduate
Diploma in Education. He proceeded to University of Maiduguri, where he bagged a Master’s
Degree in International History and Diplomacy before proceeding to North West University,
Mafikeng, South Africa, where he is a doctoral candidate in Peace Studies.
Ijeoma Genevieve Anikelechi, B.Engg, PGDE is a graduate of Civil and Water Resources
Engineering from University of Maiduguri, Borno State. She has a Post Graduate Diploma
in Education and is currently a master’s degree student in Science Education at the National
Open University of Nigeria. Her areas of research interest include environmental engineering,
engineering safety and science education.
Charmagne Beckett, MD, MPH, FACP is a U.S. Navy medical officer. She primarily serves as
the Officer-in-Charge, Navy Bloodborne Infection Management Center in Bethesda, Maryland
which reports to the Navy and Marine Corps Public Health Center. Dr. Beckett serves as staff
physician (Internal Medicine/Infectious Diseases) at Walter Reed National Military Medical
Center and Associate Professor of Medicine at the Uniformed Services University of the
Health Sciences.
Bruce R. Boynton, MD, MPH, FAAP is Editor of the Journal of Health and Human
Experience. Dr. Boynton has had a distinguished career as a Naval Officer, pediatrician,
researcher, educator, and hospital administrator. He was Executive Officer, Naval Hospital
Sigonella, Italy; Commanding Officer, Naval Medical Research Unit 3, Cairo, Egypt; and
Commanding Officer, Medical Treatment Facility aboard USNS Comfort, a 1,000 bed hospital
ship. He is currently the Statewide Medical Director for Centurion of New Mexico.
Nathan Carberry, BSE is a fourth-year Medical Student at the New York Medical College. He
has a degree in Bioengineering from the University of Pennsylvania, and is pursuing an academic
career in Neurology with plans for research, education, and patient care.
Mill Etienne, MD, MPH, FAAN, a neurologist specializing in epilepsy and brain injury
medicine, is Director of Epilepsy with Bon Secours Charity Health System, member of the
Westchester Medical Center Health Network. He was Founding Director of the Epilepsy
Center at Walter Reed National Military Medical Center. Dr. Etienne is assistant professor of
neurology, advisory dean of students, and faculty in the first and second year medical student
ethics course at New York Medical College.

Preface
Edward F. Gabriele, DrMin is Distinguished Professor (adj), Graduate School of Nursing,
Uniformed Services University. He is President & Chief Executive Officer of the Semper
Vi Foundation and the Journal’s Editor-in-Chief. An educator for over four decades in the
humanities, he has held several senior executive positions in ethics, including service as Special
Assistant to the Navy Surgeon General for Ethics and Professional Integrity. Dr. Gabriele is
extensively published and is an international visiting scholar.
Jan Herman, MA holds the Master’s in History from the University of New Hampshire where
he also held a Ford Foundation Teaching Fellowship. He is the retired Special Assistant to
the Navy Surgeon General for Medical History and Archivist. He has produced many Navy
Medicine historical documentaries including “The Lucky Few” premiered at the Smithsonian
in 2010. He is the 2015 recipient of the lifetime achievement Forrest C. Pogue Award for
Excellence in Oral History.
Jesse Eugene Hoover, DOM, MS, Dipl.OM is a Doctor of Oriental Medicine specialized
in Chinese internal medicine. He has been an instructor and clinical supervisor at Southwest
Acupuncture College and has served on the board of trustees at Southwestern College. He
provides acupuncture and custom-compounded Chinese herbal formulas. Dr. Hoover has been
independently licensed since 2007 and practices in Santa Fe, NM.
Christie Joya, DO is an Infectious Disease Fellow at Walter Reed National Military Medical
Center in Bethesda, Maryland. Dr. Joya works in HIV research and in clinical care. She is also
an instructor in medicine at the Uniformed Services University for the Health Sciences.
David J. Lash, MPAS, PA-C is the Acting Director of the VA’s Intermediate Care Technician
Program. LCDR (ret) Lash has served as the Acting Executive Officer of the Naval School of
Health Sciences, the Director of the Navy’s Phase II PA Program, and the Navy’s only Surface
Force Independent Duty Corpsman School. LCDR (ret) Lash is an Assistant Professor, has
presented Continuing Medical Education lectures, and has been published in medical journals
and textbooks.
Héctor E. López-Sierra, PhD, LP is Professor of Sociology at the Department of Social

Sciences of the Metropolitan Campus, Inter American University of Puerto Rico and also a
Licensed Psychologist at The Commonwealth of Puerto Rico. Dr. López-Sierra has held a
distinguished record of teaching, research and publishing in the fields of human sciences, and
in sociology and psychology of religions. He serves the university as a Social Sciences and
Humanities online courses developer.
Gregory C. Mabry Jr., PsyD, LCSW, BCD currently serves as the Deputy Chief of Behavioral
Health for Blanchfield Army Community Hospital (BACH), Fort Campbell, Kentucky.
Dr. Mabry is an Army Major and Licensed Clinical Social Worker, whose research interests
include internet and online video game addiction amongst service members.
Michele Savaunah Zirkle Marcum, MA is the author of Rain No Evil, a novel based on true
events. She hosts Life Speaks on Appalachian Independent Radio and writes a weekly column for
Ohio Valley Publishing. Michele is a graduate of Concord College and Marshall Graduate School.
After teaching high school for twenty years, she resigned to follow her passion for writing.

Preface
Andrew Obinna Nwaubani, BSc is a graduate with a second class upper in building technology
from the Federal University Of Technology Owerri (FUTO), Nigeria. He is the pioneer
president of the National Association of Building Student (NAOBS) FUTO Chapter, Owerri.
He is a thorough scholar.
Emmanuel Ifeanyichukwu Nkeleme, BSc, PDE, MSc is Lecturer in the Department of

Building, Federal University of Technology Owerri (FUTO). He acquired a master’s degree in
building services) and his first class honors degree in building from Ahmadu Bello University,
Nigeria. He also acquired a professional diploma with distinction in education. He is currently
directing a PhD programme in Construction Management with UNIZIK Nigeria and serves as
a member of the Research Committee in FUTO.
Peter Chukwunwendu Okeke, BSc, MPhil, holds a First Class degree in Parasitology
and Entomology from Nnamdi Azikiwe University, Awka, Nigeria as well as a Master’s in
Entomology from the African Regional Postgraduate Programme in Insect Science (ARPPIS),
University of Ghana, Legon. His areas of research interest include public health, entomology
and parasitology. He participates in health based volunteer programmes for the control of
tropical diseases of public health importance in Nigeria.
Andrew A. Ovienloba, MA DIR, MA, PhD is President of the School of The Faith and
Leadership in Benin City, Nigeria. He previously was an Interfaith Conflict and Crisis
Interventionist Practitioner at Children’s Hospital Montefiore Medical Center, and an adjunct
Instructor of Religion and Human Experience at Columbia College of Missouri. Dr. Ovienloba
is well published in theological and cultural studies.
Wendy Patchin, MA is Director of Global Missions at Foundation for Peace (FFP), a non-
profit international mission organization serving in the Dominican Republic, Haiti and Kenya.
Ms. Patchin had a distinguished and varied career in the public-school system for 25 years.
Serving with FFP since 2004 she has helped to lead the expansion in mission programs and
community initiatives, provide training seminars with local partners, prepare leaders of mission
teams and develop effective cross-cultural practices.
Nickolas L. Rapley, MBA is Special Assistant for Acquisition, Technology, and Logistics in
the Office of the Assistant Secretary of Defense for Legislative Affairs. A native of Southern
California, he was commissioned in the Navy Supply Corps after graduating cum laude from
Norwich University with a bachelor’s in economics. Captain Rapley holds his master’s from
University of Georgia and attended the Stanford Graduate School of Business Executive
Program in Strategy and Organization.
Tod Schneider, MS is a private consultant on safe, healthy and positive environmental design,
and an international researcher/writer with the Interprofessional Studio for Complexity
Thinking (InterSCT), based in the USA. He served for 30 years as a police department crime
prevention specialist, coordinated Eugene, Oregon’s homeless veterans project, and currently
serves on the board of Community Supported Shelters. He consults, writes, presents and
advocates on such topics as schools, shelters, homelessness, personal safety and refugees.

Preface
James Shraiky, MARCH is the founder and director of InterSCT–The Interprofessional
Studio for Complexity Thinking - a research-based studio that explores systematic solutions
to current and complex social issues. Prior to creating InterSCT, he was a professor and
the director of the healthcare initiative at Arizona State University. Currently, InterSCT is
investigating projects that address Syrian refugee issues around the world, wellness concepts in
Haiti, and environmental factors to combat PTSD among wounded veterans.
Katharine L. Sparrow, MSW graduated from the Boston College clinical social work program
and has worked in the mental health field on the South Shore and Cape Cod. She has been
writing poetry for seven years and was named Poet Laureate for 2015 on AllPoetry, the largest
poetry-sharing forum on the internet. Her next project is to follow her passion for genealogy
and obtain certification in genealogical research from Boston University.

FROM THE
EDITOR-IN-CHIEF
From the Editor-in-Chief
Preface
Meaning’s Mirror:
The Impressionistic Journey
Dr. Edward Gabriele
Editor-in-Chief and Executive Director,
President and Chief Executive Officer,
Tel: (301) 792-7823
Email: egabriele@mac.com
For most of us, our childhood early reading and film experiences were enriched by so many
wonderful artistic cartoonic presentations. One which has been very popular for young children
has been the Lewis Carroll work, “Through the Looking Glass,” published in the late 19th
century. As we know, this is the sequel to his earlier popular work known as “Alice’s Adventures
in Wonderland.” Truly a magnificent tale of the discovery of all things different and wonderful!
From a hookah-smoking caterpillar on a mushroom head to monarchical chess pieces, Carroll’s
work and the eventual Disney animation allow a young child to enter a world that is truly
fantastic. In one respect, it has huge importance because it is an early introduction for children
to see how the young have to deal with things that seem like they should be known but are not.
Carroll’s wonderland and my love of it is summed up rather particularly in the scene where
Alice finds a book in which is a very strange poem. The poem is written backwards and needs
to be read in a mirror. Yet once she sees it “correctly,” the words and images and theme remain
“fantastical.” This is the poem “Jabberwocky” the first two stanzas of which follow:
‘Twas brillig, and the slithy toves
Did gyre and gimble in the wabe;
All mimsy were the borogoves,
And the mome raths outgrabe.
“Beware the Jabberwock, my son!
The jaws that bite, the claws that catch!
Beware the Jubjub bird, and shun
The frumious Bandersnatch!”
What an amazing intentional clash of words and images fashioned into a dynamic
children’s poem about the titanic fight between what seems to be a young heroic warrior and
a monster. Alice reads the entire poem. She is then very puzzled and wondering. She says after
completing her reading:
“Somehow it seems to fill my head with ideas—only I don’t exactly know what they are!”
What a wonderful response. Alice reads images and hears words melted together most
peculiarly. She is left with deep impressions that make her think. Yet she is not quite sure what it
all means. What is she to make of it? Interesting……seeing images and hearing words that seem
to be different from one another yet somehow are melted and melded.

Preface
What does it all mean?
In a very powerful way, this experience of Alice’s and her response have crashed into my
own awareness very much in these past months and heading into 2017 as it unfolds. In the
past year, we have been saddened greatly by the death of phenomenal scholars, leaders, artists,
actors, athletes, government figures, and scientists. For example, among many in so many diverse
fields we lost Astronomer Veronica Rubin, Astronauts John Glenn and Gene Cernan, nursing
hero Faye G. Abdellah, and Holocaust survivor and Human Rights hero Elie Wiesel. From
the journalism world, we lost award-winning PBS news anchor Gwen Ifill and famed British
journalist Clare Hollingworth who died at 105. In the arts, we have been very saddened by the
losses of many gifted actors including Tony Burton, Doris Roberts, Robin Williams, Debbie
Reynolds and Carrie Fisher, Miguel Ferrer, John Hurt, Mary Tyler Moore, and many more.
For many of us even more personally, we lost the legendary and phenomenal historical
figure of Ruth Pope who survived so much. With her husband they helped untold numbers of
the poor and destitute here in the United States building upon their former works in Africa
with Dr. Albert Schweitzer until his death.
Beyond these human losses we were enriched by the opening of the new movie, “Hidden
Figures.” This film recently won the Screen Actors Guild 2017 Best Film Award. Monumentally,
it revealed the untold and too often shelved story of the three black women engineers who were
responsible at NASA for the success of John Glenn with his American first space orbit around
our planet: Katherine G. Johnson, Dorothy Vaughan, and Mary Jackson. Indeed, a true story in
American history hidden far too long.
We also have in the current year the continuing 70th anniversary of the Doctors’ Trial at
Nuremberg when our world discovered the horrific nightmares from the Holocaust how power
and domination can corrupt even healthcare to make human beings into experimental non-
humans. This deepens our understanding of the horrors that our Jewish sisters and brothers
endured in the Holocaust, as well as others such as the Roma, LGBTQ individuals, the
diversely-abled, and others hated and tortured and murdered by the Nazis because they did not
believe they were truly human.
In addition, this year we also will remember the 500th anniversary of the start of the
Reformation with Martin Luther’s nailing his 95 theses to the door of the bishop’s residence in
Wittenberg on October 31, 1517. What a profound rallying image in opposition to what we
remember this year in the Holocaust and the Doctors’ Trial. Yes, this year we are warned, with
these anniversaries in mind, of all of the ways in which hate and terror can invade the human
experience unless we are ever vigilant. Yes, we are called this year to see what we need to reform
and renew --- and to put our hands to the plough and bring it all about.
But why? Why today?

Preface
Today we have been horrified in the wake of all types of terrorism, some of which are new
and even more frightening. We have seen renewed, even violent, waves of discrimination and
prejudice regarding race, religion, ethnicity, national origin, gender, sexual orientation, age,
employment, and socio-economic status. We see prejudices in the workplace against individuals
based on power, politics and personality. Homelessness and poverty continue to rise at alarming
rates even among those for whom we would never dream this could happen, such as our
veterans. We continue to be embattled against all manner of diseases both new and older. We
have seen the rise of sex trafficking of children and of women. Rebel groups have taken over
national lands and murdered poor citizens so as to claim dominance. Indeed, these are times in
which we look into a mirror that seems shattered by hate and the complete loss of our human
reflection of self.
Realizing all of this, and of particularly powerful importance for us Americans, this
coming April 4th will be the beginning of a year of vigil. This will be the year to prepare for the
remembrance in 2018 of the 50th anniversary of the assassination of Dr. Martin Luther King, Jr.
Indeed, we must prepare ourselves to dispel the nightmare and keep the Dream alive!
As these and many other current happenings break into my imagination, I feel very much
like Alice. Perhaps we all do. We all should. Like a powerful impressionistic painting, the
individual events seem to be like singular brushstrokes creating a portrait that both fascinates
and yet terrifies. Standing before them and looking at them, like Alice, perhaps all of us ask
again her one singular question: What does it all mean?
In a certain respect, these events and this one question bring us to a point where what we
are looking into is a type of human mirror in which we are seeing many disparate items. Some
are magical. Some are terrifying and horrific. Yet they are all connected because they are – us!
The response that would seem to be most critically needed at this time is for us, like Alice,
to wonder and be prepared to engage and react as to what all this means about us as human
persons, about our world, and about how we are called to bring about change and newness so
as to secure, as Aristotle taught us long ago, the One, the True, the Beautiful, and the Good.
With all this in mind, this year’s two editions of the Journal of Health and Human Experience
are dedicated to, not a theme precisely, but an opening Alice-like metaphoric door, if you will.
Above the door is carved the living metaphor: “Reform and Renewal.”
In the first instance, both of our editions will move us to ask what we need to change and
correct in ourselves as persons, in our communities, our nation, and our world. In the second
instance, our many published articles and literary pieces will challenge us to open ourselves to
the unseen possibilities of all that might be the Needed New. Yes, our works will look at holistic
health and healthcare as usual. They will also lead us to consider the reform and renewal needed
in our human experience. Most of all, it is our hope that your journey into the following pages of
this edition and the next will be again a type of mirrored doorway…..an impressionistic journey
into The Possible so that we all become committed with one another.
But for what?

Preface
…..To lock arms to raise up those who are bowed down, to defend those who cannot defend
themselves, to break open the bread of field and heart to those who hunger most, and to provide
meaning to those whose lives have been shattered by the Jabberwocks of life against whom today
we must beware and be ready to fight!
Get ready for the mirror. More like Alice’s door, enter it. It just might beckon you toward
The Truth we all need to understand anew in ways so needed in our times today.

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Articles
Starting From Zero:
An Exploration of Contemporary Issues in Haiti
Tod Schneider, MS
Director, Safe School Design
894 W. 4th Avenue
Eugene, OR 97402
Tel: (541) 543-1774
Email: Todschneider@hotmail.com
James Shraiky, MARCH

Director, InterSCT - The Interprofessional Studio for Complexity Thinking
1705 E. Pebble Beach Dr.
Tempe, AZ 85282
Tel: (602) 740-7887
Email: james.shraiky@gmail.com

Wendy Patchin, MA
Director of Global Missions, Foundation for Peace
PO Box 424
Ironia, NJ 07845
Tel: (973) 219-9306
Email: wendy@foundationforpeace.org
Author Note
This research was supported by the following organizations, Safe School Design, InterSCT,
CHAMPS, Foundation for Peace, and Luke 101. The content of this article is the responsibility
of the authors; the content of the research was developed by the following team members:
Tod Schneider, James Shraiky, Kay Anderson, Wendy Patchin, Wendy Zehner, Dawn Bauman,
Jessica Wheeler, Michel Valentin, and Stacy Trainer. Human subject approval was received from
the Arizona State University Institutional Review Board on August, 28, 2014. The application
included consent forms, users’ recruitment letters and interview questions. There are no
financial interests or conflicts.
Abstract
Haitians have been battered from all sides for centuries, almost without respite, with horrors
ranging from slavery to extortion, widespread corruption, a cholera epidemic, abject poverty,
crumbling infrastructure, hurricanes, and massive earthquakes. Especially when building
on rubble, and with needs far outweighing funding, both immediate crises and long term
challenges can be overwhelming. Under such circumstances, how can the international
community plant seeds of sustainable reconstruction? This exploratory study employs an

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interprofessional qualitative research model and the National Health Service (NHS) Institute
for Innovation and Improvement’s Experience-Based Design template to identify obstacles
facing health and education sectors as well as opportunities for Haiti’s long term improvement.
Resulting hypotheses support multi-faceted, inclusive planning and service delivery options
with an emphasis on quality and sustainability.
Keywords: Haiti, education, healthcare, exploratory study, interprofessional research
Introduction
The streets of Port au Prince present a microcosm of the nation as a whole -- a sensory
explosion of color, sights and sounds, equally enriching and overwhelming, hopeful and
daunting. The roads teem with noisy traffic, including brightly painted tap-tap pickups
overloaded with riders and bouncing over ruts. A gauntlet of ramshackle booths lines both sides
of the street, piled high with plantains, boots, lumber, sausages, plates, and motor oil. Goats
work their way through piles of trash. Pedestrians stumble through patches of rubble and dust,
looking for opportunities to earn a few coins. Typically, they earn $2.75 per day. Children
make a game of heading for school, laughing. Little girls stand out with their hair in meticulous
braids, their school uniforms carefully cleaned and pressed. They take school very seriously,
seeing it for the rare gift that it is, a possible route out of poverty. That assumes they can dodge
everything from malaria to cholera in the years to come, long enough to reach adulthood. More
than 1 out of 10 Haitian children will likely die before the age of five.
Haitians are primarily of Afro-Caribbean descent, tracing back to hundreds of thousands

of slaves brought in from Africa in the sixteenth to eighteenth century. The nation has struggled
with the horrors, not only of slavery, but with severe corruption, repression (infamously under
the “Papa Doc” and “Baby Doc” Duvalier regimes from 1957-1986), and dire poverty ever since.
Haiti has also suffered through more than its fair share of natural disasters, with two devastating
earthquakes in the 1700s that cost tens of thousands of lives, and a massive tornado in 2008.
The 2010 earthquake killed 200,000 and left millions homeless. Six years later, Hurricane
Matthew struck, flooding entire communities, devastating tens of thousands of families and
killing at least one thousand Haitians (BBC, 2016; Human Rights Watch, 2015).
Haiti is a remarkable country, rightfully proud of its history, with notable achievements
including liberating itself from France and ending slavery in 1804, enduring an American
occupation from 1915-1934, overthrowing the Duvaliers in 1986, and surviving a variety of
overlords in between. But while Haiti is extraordinary for its sheer capacity for survival, it is
terribly poor by almost any other measure. Each consecutive ruling power looted the Haitian
treasury as a parting insult during points of transition, leaving the country financially strapped
and dependent on continuing foreign investment ever since. Concrete rubble is the most
common landscape feature visible throughout Port au Prince today. Schools, literacy training,
career development, roads, healthcare, housing, sanitation, drinking water, employment
opportunities, utilities, forestry, basic agriculture, the justice system and infrastructure overall
are all woefully inadequate (The World Bank, 2016). Peter Beaumont, writing for the Guardian
in 2010, observed, “If the country was at zero on 11 January, it is at less-than-zero now”
(Beaumont, 2010). If Haiti is not quite a failed state, it is remarkably close to it.

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A rough tour of Port au Prince speaks volumes, both in terms of determination and in
terms of devastation. While the third world is ripe with dire poverty, Haiti stands out for a
number of reasons. It was the first country in the world in which an enslaved population rose
up to overcome oppression and became its own nation. Unfortunately, this came with being
plundered along the way--what remains is the broken shell of a country. Local forests have
been largely clear-cut, and local agriculture replaced with agribusiness designed for export. As
if the extreme poverty was not bad enough, the 2010 earthquake leveled a large proportion
of the country’s already crumbling infrastructure, leaving endless concrete rubble in place of
roads, schools, homes and hospitals (Sontag, 2012). Interventions that have occurred since the
earthquake have provided excellent examples of both successes and failures--a road map of what
shows promise and what does not. Lessons learned can be applied in order to build on successes
for greater impact, as discussed in the framework for study discussed below.
One question that arises is, where should we begin? Dr. Paul Farmer urges organizations “...
to keep the attention on Haiti,” as the country has not recovered yet (Partners in Health, 2010).
USAID recommends a focus on education because the “education sector in Haiti lacks the
quality and access necessary for sustained social and economic development… These issues put
a generation of Haitian youth at risk of not receiving the knowledge and basic skills necessary
to succeed in the labor force” (USAID, 2016). In their report, “Haiti: URGENT REQUEST
FOR HUMANITARIAN FUNDING,” UNICEF calls for “US$25.5 million to respond
to the most urgent humanitarian needs,” as Haiti continues to face deteriorating healthcare
services, food security, and disaster preparedness (USAID, 2016).
The purpose of this exploratory study is to examine the current state of civil infrastructure
as expressed by diverse vulnerable demographics as well as by aid providers in Haiti. More
specifically, this study aims to describe contemporary issues or obstacles facing individuals,
institutions, and aid organizations in healthcare and education sectors. Ultimately, the goal is to
propose guiding principles, as expressed by stakeholders, and to overcome these challenges.
Current State of Haiti

Haitian individuals, as well as the national government on a larger scale, value education
highly, but face considerable, formidable obstacles in pursuing and developing educational
infrastructure and opportunities.
There have been several education initiatives undertaken by the Haitian government with
outside help, and the situation is improving. While the overall literacy rate is around 60%, some
estimate that young men 15-24 have a literacy rate of about 75%; the rate for young women
approaches 70%. Overall rates still fall far below other Latin American countries, which have
literacy rates closer to 90% (UNICEF, 2013).
Still, most major initiatives over the past 4 decades, including developing a standard
curriculum, teaching younger children in Kreyol, abandoning the extra year after 12th grade to
graduate from high school, lengthening the school day, and providing nutrition, have not been
implemented widely (Columbia University, 2011). Given the lack of funds and the abundance
of natural disasters, including the Earthquake of 2010 and Hurricane Matthew in 2016, it is not
surprising that Haitian educational reform has been difficult.

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While schooling through grade 6 has recently been made compulsory, the public-school
system at the primary level accounts for less than 10% of schools in the country. Most schools
are private and religious, and the quality varies widely. Some estimate that nearly half of teachers
in primary schools have not graduated from high school themselves, let alone had any teacher
training (USAID, 2016). For those who have managed that, the passing rate in Haiti is 50% or
above. This does little to increase confidence in the quality of the teaching provided. Despite
several attempts to promote change, all state assessment is done in French. Haitians speak
Kreyol at home and unless they are taught in Kreyol at school initially, few have opportunities
to become literate in their first tongue. This is one factor leading to children finishing second
grade without having developed reading abilities (USAID, 2016). Receiving instruction
in a language not spoken until they become school age is a barrier to mastery. Outside of
school, speaking French is a prestigious skill and one that separates the educated from the rest
(Columbia University, 2011).
Even getting access to education, as poor quality as it might be, is very difficult. 200,000
students still do not attend school. All students must have uniforms. They must purchase all their
own books and supplies, and they must pay tuition. Parents have traditionally sacrificed a great
deal toward this end, the average cost being $130 a year for people who generally earn less than $3
a day. School expenses are heavily dependent on largesse from outside agencies, but funds received
don’t come close to meeting the needs; 200,000 students still do not attend school.
Poor physical health and nonexistent follow-up care are the norm for a significant portion
of the population. Health care deficits are evident at all levels, across the entire continuum
from prenatal to elder care. Challenges include malnutrition, lack of access to potable drinking
water, a general lack of preventive care, malaria and other mosquito borne illnesses, HIV-
related illnesses, cholera (brought to Haiti by UN peacekeepers after the earthquake), lack
of access to medication in general, lack of access to medical professionals, lack of preventive
health education, undiagnosed mental illness and earthquake-related issues ranging from Post-
Traumatic Stress to loss of limbs (WHO, 2016).
It is often difficult to maintain good health while living in Haiti. Lack of education
perpetuates incorrect beliefs that hamper health. Lack of infrastructure, sanitation, funds for
medical care and vaccines, isolated communities, along with antiquated equipment, all prevent
people from accessing necessary health care. Insufficient nourishment (30% of children are
malnourished) and inadequate access to clean water further compromise health (WHO, 2016).
Haiti’s health system, already inadequate, was weakened further by the loss of 50 health clinics
and damage to both its primary teaching hospital and the Ministry of Health, in the 2010
earthquake. The cholera epidemic which has waxed and waned, and then the devastation of
Hurricane Matthew, have exacerbated the problems (WHO, 2016).
Haiti ranks in the bottom third of all countries in terms of the maternal mortality rate, the
infant mortality rate, life expectancy, and the HIV/AID prevalence rate. Less than half of all
children under the age of two are fully vaccinated, and one out of five are stunted in growth. The
risk of infectious disease is rated as very high (Central Intelligence Agency, 2017). Despite all this,
there are some indicators of progress in infectious disease control. Haiti is close to eradicating
malaria and has made strides with reducing the rate of HIV/Aids (Country Meter, 2017).

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Framework and Methodology
Two models were used to identify contemporary issues facing health and education sectors
in Haiti. The first guided the selection of the research team, the details of the exploratory study,
and the collaborative process. The second guided research methods and models.
The First Model

An interprofessional research model was used as a platform for investigating the challenges
facing healthcare and educational infrastructures in Haiti. Interprofessional collaboration is
an important vehicle for developing new and innovative solutions to complex problems. The
practice often unites individuals who represent diverse disciplines and encourages exploration
and development of new frameworks and methodologies for solving seemingly unsolvable,
multidimensional problems (Burning et al., 2009). Focusing too narrowly on only one aspect
of a complex problem often fails to recognize root causes. As a result, proposed solutions can be
too narrow in perspective, may have little or no impact, or may lack sustainability.
A clinical examination of past, failed projects provides helpful clues regarding where things
have gone wrong. Key blunders have included: Defining problems without first consulting
resident Haitians, local service providers or other experts for clarification, or following up
with these groups for constructive feedback; Crafting solutions, again without the necessary
consultations and feedback sessions; Failing to earn local credibility or local investment,
psychological or otherwise, in proposed solutions; and failing to make arrangements for long
term sustainability.
The 2015 research team included: Tod Schneider representing Safe School Design, Kay
Anderson, Jessica Wheeler, and Dawn Bauman representing CHAMPS, Wendy Patchin
and Michel Valentin representing Foundation for Peace, Wendy Zehner and Stacy Trainer,
representing Luke 101, and James Shraiky representing the Interprofessional Studio for
Complexity Thinking (InterSCT).
Safe School Design is a private consulting firm specializing in Crime Prevention through
Environmental Design (CPTED), and Safe Healthy and Positive Environmental Design
(SHAPED) for schools and other environments (Safe School Design, 2017 ). Foundation
for Peace is a 501(c)(3) not-for-profit organization dedicated to working hand-in-hand with
people in materially impoverished communities in the Dominican Republic, Haiti and Kenya
to provide educational support, health care access, economic opportunity and hope. They
work together as long-term partners in solidarity to enable personal success and community
achievement. They believe this will result in sustainable and successful initiatives that relieve
the effects of poverty, encourage personal growth, and overcome injustice (Foundation for
Peace, 2017 ). CHAMPs, “Connecting Hope and Medicine to People in Haiti, “is a non-profit
charitable foundation reaching out to meet the needs of the underserved, bringing Hope and
Medicine to Haitians (CHAMPS, 2017 ).
InterSCT: The Interprofessional Studio for Complexity Thinking, is a not-for-profit

design and research firm that explores complex health and social issues. Our approach is an
inclusive one, bringing together diverse experts and stakeholders, as well as people in need,
in search of creative, systemic and multidimensional solutions to a wide variety of complex

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problems. Past projects have addressed everything from homelessness and healthcare to
earthquakes, poverty and refugees. Our work has taken us around the globe, with projects in
the U.S., Haiti, the Middle East, Australia, Rwanda, China and points in between (InterSCT,
2017). Luke101 is a 501(c)(3) not-for-profit organization that exists to support groups that
are on the ground in Haiti, Brazil and India working on behalf of at risk people. Their work in
Haiti includes supporting organizations serving families and communities that are assisting the
aging. Haiti’s lack of training, infrastructure and funding has left this at-risk population mired
in poverty, with little hope of extrication. Skilled nursing care, rehabilitation services and a long
list of fundamental resources are in short supply. Luke101 works to connect, train and provide
for groups which otherwise have little to no resources (Luke101, 2017 )
The Second Model

The model developed is based on the National Health Service (NHS) Institute for
Innovation and Improvement’s Experience-Based Design template and is distinctive in
its collaborative research and design efforts involving diverse stakeholders. There are four
distinct phases to the EBD methodology: (1) capturing the experience; (2) understanding the
experience; (3) improving the experience; and, (4) measuring the improvement (NHS Institute
for Innovation and Improvement, 2010). The following sections describe each phase and outline
our application in the study:
Capturing the Experience

This step covers the research formation and planning as well as the data collection.
During a previous medical mission trip lead by CHAMPS in 2015, we made preliminary
observations regarding disparities in Haiti. These observations were then attended to in several
brainstorming sessions to plan for further research. A cross-sectional, exploratory study design
was used to explore perceptions and experiences of contemporary issues impacting health and
educational infrastructure in Haiti. Eligible stakeholders, including educators, students, health
care providers and patients over the age of 18 were interviewed. Stakeholders were recruited
within the context of a Port au Prince home for the aged (Asile Communal), Partners in Health
hospital (HUM, Hôpital Universitaire de Mirebalais), and three area schools (Complexe
Educatif Men Nan Men, La Reference and Universite), a deportee camp (in Fond-Baillard on
Malpasse Road), a Cultural Center (MUPANAH, Musée du Pantheon National Haitien), the
mayor’s office, and orphanages (CAD, Center d’Action pour le Développement). IRB approval
for this study was obtained. All stakeholders underwent informed consent procedures in
English and provided written consent.
Study procedures in this phase included face-to-face semi-structured interviews, behavioral

observations, and focus groups. The duration of the interviews was approximately 45 minutes
for individual interviews and 90 minutes for focus groups. Researchers spent 4 hours per day
conducting observations. Interview questions were adapted according to the type of service
line and stakeholders’ demographics starting with their experiences, and continued with their
perceptions of obstacles facing civil sectors. Examples of questions include: “Can you describe
your healthcare experiences?” “Can you identify issues you faced during clinical experiences?”
Can you describe your educational experiences?” “What is needed to improve the overall
educational outcome?” and “What are the contemporary issues facing health and education in

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Haiti?” Similar questions were asked in the focus groups. The interviewers invited participants
to add and build on each other’s feedback. Service providers were asked about challenges they
had encountered, particularly in terms of barriers to delivering services. Examples of questions
include: “What is the purpose of your organization?” “What types of services do you provide?”
“What are the challenges you face?” and “What are the top issues facing the sector you serve?”.
Follow-up questions explored the impact of policies, culture, community, and poverty.
Understanding the Experience

This step involves the analysis of the data and insights gathered in the first step to identify
issues and themes, and to ensure that subsequent planning is in synchrony with the needs of
individuals on the front lines.
For this step, interviews and focus groups were transcribed verbatim. Pseudonyms were
substituted for names and all identifying information was removed from the transcripts.
Analysis procedures outlined by Krippendorff (1980) were applied to classify codes and then
themes. Each source was open-coded by members of the team. Individual words, parts of
sentences and/or sentences and groups of sentences were the source of new codes. Definitions
for each code were discussed and refined through constant comparison of narrative examples
and review of the transcripts.
Researchers utilized multiple strategies to assure trustworthiness in the data analysis

process (Lincoln & Guba, 1985; Miles & Huberman, 1994). Researchers and authors spent
considerable time discussing and documenting assumptions to address confirmability. We kept
an extensive record of our coding decisions for repeated review and validation. We sought
feedback from Luke101, CHAMPS, and Foundation for Peace to support the reliability of our
analysis and results. We also validated our analysis with the existing body of research.
The Third stage, Improving the Experience, involves applying the first two steps to an
actual product. InterSCT and Safe School Design will collaborate with CHAMPS, LUKE
101, and Foundation for Peace on grant funding to explore specific projects in healthcare and
education that pertain to each organization’s goals and expertise. The final stage, Measuring the
Improvement, will involve rapid-cycling improvement for future projects’ processes as well as
developing an outcome-measurement tool for short, mid, and long term results. Ultimately, the
goal is to measure the intended outcomes after implementing the projects.
Results
Insights gathered through initial research contributed to an extensive list of obstacles that can
be clustered into three broad categories: individual, institutional and NGO obstacles, as follows:
Individual Obstacles
Individual obstacles included poverty, poor physical health, transportation, educational
and vocational challenges, personal safety concerns and the overwhelming cumulative impact of
all of these obstacles.

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Grinding poverty is one of the most overt obstacles confronting this population. The vast
majority of the population lives in chronic, abject poverty. Unemployment is rampant, and
those who do find work are usually paid less than $3 per day. Even college graduates, when asked
“what kind of work would you like to do?” responded, “Any job at all.”
Poor physical health and nonexistent follow-up care was the norm for a significant portion
of the population. Health care deficits were evident at all levels, across the entire continuum
from prenatal to elder care. Challenges included malnutrition, lack of access to potable drinking
water, a general lack of preventive care, malaria and other mosquito borne illnesses, HIV-
related illnesses, cholera (brought to Haiti by UN peacekeepers after the earthquake), lack
of access to medication in general, lack of access to medical professionals, lack of preventive
health education, undiagnosed mental illness and earthquake-related issues ranging from Post-
Traumatic Stress to loss of limbs.
Emergency and trauma care are sadly lacking. Hospitals/clinics are commonly closed on
weekends, inconveniently located or just too far away. There are now 50 emergency vehicles
in Haiti—an improvement over earlier conditions, but far from sufficient for a population of
nearly 11 million (Hadden, 2014). One student even reported needing to hunt for a neighbor
with a car to transport her to the hospital when her appendix burst. Other interviewees told
stories of loved ones dying because they could not get access to facilities that did exist. Many
reported depending on others with motorcycles or cars to get them to health care facilities,
only to be turned away upon arrival if they could not pay. Others reported paying money for
upcoming surgeries only to find there were no records of the payments when they arrived.
Consequently, the surgeries were not done. It is not just the patients who suffer financially--the
underpayment of medical professionals led to an extended strike in 2016 which had profound
health effects. Doctors had been making just $120 a month (NPR, 2016).
The transportation system and infrastructure are rudimentary at best, relying on

improvised pickup truck taxis (tap-taps), buses and private vehicles, all sharing overcrowded,
pitted, inner city roads in extreme disrepair. Although there are some new, smooth and
functional roadways that were built after the 2010 earthquake, leading off into the outskirts or
rural areas, travel within Port au Prince, where most Haitians live, is slow at best, with traffic
jams being the norm. Many students reported walking miles to school for lack of better options.
The lack of uniform, quality educational or vocational training opportunities was another
major obstacle, made clear repeatedly by interviewees. For those who could obtain training
there were few opportunities to apply their new skills in related jobs. We heard no reports of
opportunities for internships or participatory training of any kind, leaving moot the question of
whether such positions held promise of leading to employment. Access to essential training tools
and materials, including books, computers or internet access, was also a common challenge.
Students reported a further common dilemma--needing to drop out of school to take care of
sick family members or to seek work in order to pay the bills. Those who were determined to
attend school often went hungry. Interviewees shared two Haitian proverbs underscoring the
difficulty of learning under such circumstances: “empty stomach, empty mind,” and “hungry
bellies have no ears.”
General economic desperation and an inadequate criminal justice system contribute to

a steady undercurrent of personal and property crime or fear of crime as givens—the topic

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rarely came up in conversation without prodding, and documentation was difficult to obtain.
But as is common in many less developed nations, most homes and institutions were boxed in
by tall concrete walls topped with broken glass. The criminal justice system by most accounts
was considered unreliable, fractured and corrupt. Although hard data is nearly impossible to
come by, given the state of Haitian government, there are strong indications that crimes against
women and children are commonplace. A GSDRC overview report states, “The incidence
of violence against women was high in the pre-earthquake period, but there is widespread
consensus that it has increased since. This correlates with the insecurity, displacement, poverty,
lack of adequate access to basic resources, and loss of livelihoods associated with the disaster”
(Mcloughlin, 2013).
All of these individual obstacles have a cumulative impact. Maintaining good health and
safety, taking care of family members, finding a means by which to pay for food, medicine,
tuition or jobs, or transportation to sources for all of the latter, leave much of the population
feeling overwhelmed, helpless, hopeless, and lacking in self-confidence.
Institutional Obstacles
With few exceptions, the norm for institutions visited was to be in a state of disrepair.
Their overall physical infrastructure, the lack of essential operational supplies and an overall lack
of sustainability were readily apparent. Observed physical infrastructure challenges included
half-built or deteriorating classrooms, clinics and sleeping quarters, with inadequate water
quality, plumbing, sanitary facilities, electrical wiring or reliable access to electrical power.
There were obvious shortages of medical equipment, basic office supplies and electronic
gear that would be considered essential by developed world standards for both educational and
medical facilities. With inadequate funds to address immediate, short-term needs, such as the
need for consistent, quality staffing and a lack of basic supplies, there was even less evidence of
a path to sustainability. Institutions were clearly struggling just to cover expenses day to day,
let alone become self-supporting, and they certainly were in no position to invest in long term
planning. As a consequence, in both medical and educational arenas, many services tended to be
fragmented, with little evidence that a continuous thread might exist for receiving or delivering
essentials. Even an excellent medical hospital inspected lacked adequate aftercare services--by
doctors’ accounts, patients were usually sent prematurely home from the hospital, with no follow-
up facilities or in-home care services to draw on. We further found no evidence of substantial data
gathering, let alone management. There was no reliable shared system for tracking which patients
received treatment where, whether it was effective, or whether issues were isolated cases or
indications of more widespread problems. Again, with very few exceptions, all of this contributed
to an inconsistent quality and quantity of staff, operations and services.
Although many teachers and medical professionals appeared to be doing outstanding work,
interviews left us with the impression that they were more likely the exceptions, rather than the
norm. Many staff, according to the interviews, were poorly trained, poorly paid, rarely paid on
time, and sometimes not paid at all. Cardiologists and orthopedists were reportedly hard to find
in Haiti. Social workers were only found in private hospitals, and anesthesiologists were not
well paid. Patients who needed urology-related surgery generally headed for Cuba if they could
afford it. Facilities were often unsanitary, unsafe or dysfunctional. For example, water fountains

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in a nursing home did not work, and cross-support beams in classrooms were poorly patched
together, in a manner unlikely to survive future earthquakes. Schools relied on primitive
outhouses with inadequate or nonexistent handwashing facilities. Where computers did exist
they were generally second rate, with unreliable internet access. Lack of safety and security were
particularly apparent at one nursing home, where internal and external theft was reported by
residents as being rampant, to the point where medications and food donated for the residents
commonly were intercepted by staff who either sold the items or kept them for their own use.
Staff attitudes varied considerably from site to site. Staff appeared to be deeply committed
and competent in the K12 facilities visited such as La Reference School, which appeared to be
successful largely due to strong commitments from teachers. Their commitment appears to have
been matched by a similar level of commitment from students. Unfortunately, there was no
indication that this was true across the board at other schools, and in fact it was often suggested
by those individuals interviewed that La Reference was an aberration rather than a good
indicator of the educational system. Many individuals interviewed at the higher educational and
nursing home levels commonly suggested that there was a serious lack of coordination, customer
orientation, compassion, care, commitment, or passion for the work by staff at the institutions
they had attended. (Men nan Men was the exception in this case, receiving high praise from staff
and students.) Feedback regarding most schools indicated great room for improvement both
internally and externally in terms of people working together to maximize effectiveness.
There was no reason to expect consistent quality, content or outcome at various schools or
medical facilities, as there seemed to be little in the way of incentives or mechanisms for sharing
knowledge, resources or best practices. Apparently, data are not gathered or shared for mutual
benefit. Autopsies are not commonly conducted in Haiti, for example, making it difficult to
gather important epidemiological information. There was an absence of community outreach to
provide services or education, or to overcome obstacles at home that might impede learning or
recovery from illnesses. As a basic example, a child might receive treatment for lice at a clinic or
school, but without adequate follow-up at home would likely become reinfected.
Students and staff alike reported inadequate Continuing Education opportunities, and
nonexistent incentives for competent staff to stay. Pay was meager and unreliable. Students
complained of a lack of opportunities for hands-on, interactive, on-the-job internships,
mentorships or training. There was little evidence of any cross-training for front line workers
on root causes or broader issues, or to develop leadership skills. (For example, teachers were not
trained to detect basic health problems, or hearing or vision deficits.)
In addition to a lack of safe, reliable transportation for students, patients, and staff in
general, access for the disabled was essentially non-existent. Roads were in such disrepair, and
traffic so bad, that even when vehicles were available trips were lengthy and unpredictable. Even
where the site itself was reachable, the internal infrastructure appeared unreliable in terms of
access for the disabled.
In medical facilities, a lack of more appropriate services appeared to be driving desperate

patients to whatever facility was available, despite its official function--in the same way in which
many impoverished Americans use emergency rooms due to lack of access to primary care
services. Particularly of note was that seniors who could have been served more effectively if

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home health care had been available, were often left at a bare-bones state nursing home that was
in severe disrepair.
NGO Challenges
NGOs in Haiti are diverse in terms of resources, effectiveness and reach. Many do
outstanding work, but reportedly many also show room for improvement. (Deficits were, in
the most part, not observed first-hand by our team, but were relayed secondhand as issues seen
with other projects.) There was a widespread local perception that NGOs did a poor job of
pursuing local input, priorities, emotional investment, or commitment, leading to frequent
project-failures. When project funders and organizers departed, the projects fell apart. In the
case of a Canadian orphanage, an initial, overly optimistic assumption that locals could take
over management of sophisticated projects drove the project to the edge of collapse--no one had
taken the time to assess the skill set of local staff, or to provide training. (Fortunately, the NGO
recognized the error in time to return to the site with highly trained Canadian staff, who have
run this model orphanage effectively ever since.)
Inadequate NGO awareness of, or sensitivity to, local realities or politics was often
mentioned, including simple miscalculations regarding local worker skills or attitudes. This
resulted in problems ranging from the theft of goods to the breaking of political promises or
withdrawal of permissions or support. Governmental intransigence reportedly stopped many
projects in their tracks. On a related note, the distinctions between legitimate taxation or fees,
versus opportunistic shakedowns or bribery, were very difficult to discern.
NGOs also sometimes failed to grasp local cultural factors, such as widespread belief in
voodoo, which can restrict where tribesmen can travel, or their interpretation of problems such
as mental illness. Many Haitians reportedly do not believe in psychology.
A further obstacle was a tendency by NGOs to keep projects siloed, with turf-oriented
or competitive approaches undermining cooperation. Insufficient integration with other
service projects meant missed opportunities to fill holes in what could have been more
comprehensive networking, or which could have helped avoid duplication, or otherwise
maximize impact or effectiveness.
Solutions and Next Steps

Insights gathered through the initial research helped us identify the significant Individual,
Institutional and NGO challenges described above, all pertaining to the fields of health
care and education. They can be further distilled as four overlapping, cross-cutting guiding
principles for future proposed solutions: touching on quality, sustainability, complexity, and
leadership principles.
Quality
Whatever products are intended for delivery--food, health care, equipment, medicine or
education--should be of as high quality as possible. Food needs to be of high nutritional quality
as well as of adequate quantity; medical care, classroom education or teacher training are of
limited value unless they’re at very least competently delivered, and ideally should be top notch.

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Boosting quality can also include addressing attitudes towards service, respect and connectivity,
concepts of leadership and openness to transformation.
Longevity and Sustainability

Longevity and Sustainability go hand in hand with systems thinking, but with an emphasis
on longevity rather than only on cohesiveness. To a large extent this boils down to the need for
mechanisms by which projects can ensure better odds of survival on into the future, years after
the initial funders have departed. This may rely on ongoing donations from afar, but ideally
should involve a plan for pursuing a self-sustaining approach. Institutions that can move from
a crisis footing to a long term one are in much better positions to invest time in long term
planning. Flexibility and adaptability are also key factors in longevity and sustainability.
Complexity and Systems Thinking

Within and between the fields of both education and healthcare, as well as between
myriad NGOs, fragmentation appears as a common theme. On a national scale, a lack of shared
data collection, and access to information, appear to undermine Haiti’s ability to see what it is
doing, how effectively, in order to plan improvements or prioritize projects. On a smaller scale,
hospitals that fail to network with other local providers, or to provide home health visits, or
to survey neighborhoods for public health issues, are put at a disadvantage in terms of doing
any comprehensive public health planning. Schools can enhance their effectiveness if they
track individual student success in detail, and if they can then craft grade-wide or individual
educational plans more strategically and effectively. Efforts to develop more cohesive service
development and delivery hold potential for boosting efficiency and effectiveness. Systems
thinking includes coordination and capitalization between the government and NGOs. A
great deal of effort appears to be wasted on politics and competition. Government resistance to
projects or imposition of taxes and fees along the way, along with NGOs’ independence from
each other, undermine the potential for greater accomplishments regardless of the size of the
various budgets involved.
Leadership
Leadership deficits further suggest the need for appropriate interventions. For any of the
preceding cross-cutting themes, without sufficient in-country, on-site vision, understanding and
commitment, the likelihood of success is moderately poor.
Overall Considerations
As with so many expansive projects, the devil is in the details—how can our broad
prescriptions be translated into more specific actions? Consider the following:
Projects need funding, supplies, facilities and appropriately skilled participants in order to
function. The first three are fairly straight-forward needs that can be met by writing a check.
Skill development is more nuanced. Every project is different, and while some skills may transfer
across sectors or cultures, others are distinct. School and hospital bookkeeping, housekeeping,
management or construction may have some commonalities, but to paint with too broad a
brush could lead to dysfunctional buildings or programs. Necessary skills can involve anything
from backhoe operation to math instruction, but they can also require an awareness of local
materials and expertise, or an understanding of local customs and politics, that are unfamiliar to

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expert consultants brought in from afar. Once these specific nuances are identified they can be
revisited at some point down the road to determine if they’ve been adequately developed, taught
and applied. Hindsight may also help in determining what skillsets were missed. These new
skills can then be integrated into ongoing future trainings. In this way, training effectiveness can
be measured, mentoring nurtured, and local, sustainable expertise developed.
Consultants (including the co-authors of this paper) can undoubtedly be useful in providing
some momentum and an outside perspective for problem identification and solution planning,
but in order to develop functioning, sustainable schools, hospitals or other infrastructure,
collaboration with local players, including potential clients, employees, NGOs and government
officials, is essential. For example, school projects must begin by asking local students, teachers
and administrators not only what they need, but what they have to offer, and what they want to
learn. Facility construction must begin by asking about space needs and concerns.
Effective projects also must take care to avoid the stove-piping so commonly found with
NGOs, operating in a vacuum and then wondering why they have failed. This involves not
only the NGOs, but local institutions as well, including schools, hospitals and governments.
Identifying and seeking input from all involved parties builds partnerships, improving the
likelihood of joint ownership and commitment.
Mutually agreed upon metrics at periodic intervals can help keep projects on track,
establish some accountability, and contribute to a framework for identifying weaknesses needing
attention as projects move forward. Periodic assessments while under construction, and look-
backs farther down the road can also provide opportunities for reflection on project successes
and failures, intended and unintended consequences, and lessons learned that can be applied to
future projects.
No matter what interventions we suggest, it is critical that we integrate each of our four
overarching themes--quality, sustainability, complexity and leadership. From an accountability
perspective, implemented effectively, the results should at the least meet identified goals, as
tracked through appropriate, carefully determined outcome measurement tools. But setting
our sights even higher, interventions should be transformational. If we propose building
clinics, we must explore their roles not only in terms of meeting acute medical needs, but in
reducing health disparities, addressing broad public health issues, providing patient-empowering
preventive health care education, and training staff to a level that can transform health
outcomes. If we build schools, our aims should include going beyond delivering academic basics;
we should be empowering school communities to train, support and inspire future leaders and
to become agents of cultural transformation far into the future.

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The Transformative Richness of Puerto Rican and
Caribbean Cultural Diversity in Health Care and Spirituality
Héctor E. López-Sierra, PhD, LP
Professor of Social Sciences
Department of Social Sciences
College of Humanities
Metropolitan Campus
Road 1, Km 16.3 Corner
Francisco Seín Street, Río Piedras, PR 00919
PO BOX 191293, San Juan, P.R. 00919-1293
Inter American University of Puerto Rico
Tel: (787) 250-1912 Ext. 2383
Email: hlopez@intermetro.edu
Author Note
The author is thankful for the critical review of this manuscript provided by his doctoral
dissertation advisor and mentor in the field of practical theology, Jesús Rodríguez-Sanchéz,
PhD, Professor of Pastoral Theology at Inter American University of Puerto Rico. The author is
solely responsible for the contents of this article and the views expressed are those of the author
and do not necessarily reflect the official opinion of the Inter American University of Puerto
Rico. The author has no conflicts of interest.
Abstract
Behavioral, cognitive, psychosocial sciences and practical theological studies suggest a
relationship between spirituality, religion, health care services (S/RHCS) and cultural
diversity. That relationship is not monolithic for they always manifest themselves in diverse
cultural settings. Cases in point are the studies on Western S/RHCS addressing spiritual and
religious health care receivers (S/RHCR) in Hispanic/Latinos communities. In spite of their
common values (such as Spanish language, the centrality of family and religion, and importance
community), they are not a homogeneous culture, and thus a uniform style of communication
does not exist in their cultural spectrum. They often differ across social, political, economic,
cultural, religious, spiritual and symbolic dimensions. As Hispanic/Latinos and Caribbean
subjects, the Puerto Rican community in Puerto Rico (PR) and in the United States of America
(USA), share particular spiritual, religious, cultural/symbolic linguistic, communication and
experience related to patterns of a coloniality of power. These patterns underline their attitudes,
values and belief systems, socioeconomic, racial attitudes, mostly stemming from their colonial
and legal condition. This theoretical article argues in favor of a transformative and post-colonial
Puerto Rican and Caribbean richness that is trans-pastoral and trans-popular. It therefore
promotes a spirituality and religious (CPS/R) approach to Puerto Ricans as a culturally
different S/RHCR.
Keywords: Puerto Rican, health care services, health care receiver/giver, cultural diversity,
religion, spirituality, popular religion, Diaspora, trans-pastoral

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Introduction
Behavioral, cognitive and psychosocial sciences suggest a relationship between spirituality,
religion, health care services (S/RHCS) and cultural diversity. That relationship is not a
monolithic experience for they always manifest themselves in diverse cultural settings. Academic
literature on human, spiritual and religious health care services oriented towards Puerto Rican
clients in PR and the USA suggest that their socio-psychological and cultural-ideological
orientation to health services and its use and expectations are seen as relatively different from
that of the typical middle-class USA client (Rosaldo, 1980).
In spite of common values shared by many Hispanic/Latinos (such as Spanish language,

the centrality of family and religion, and the importance community), Hispanic/Latinos
from diverse regions and countries are not a monolithic culture and, thus, a uniform style
of communication does not exist in their cultural spectrum. They often differ across social,
political, economic and cultural, religious, spiritual and symbolic dimensions (Garcia, 1997;
Rodríguez, 1999).
Current evidence shows that spirituality and religion (S/R) evokes in health care receivers
the sources to find the necessary inner strengths including perspective thinking, rituals for
transcending immediate physical condition, and modalities of coping with their illnesses (López-
Sierra & Rodríguez Sánchez, 2015). However S/R are not a homogeneous experience for it always
manifests itself in diverse cultural and political settings. As such, S/R provide the individual and
their families with a practical context and social memory, which includes traditions and social/
family practices for maintaining meaning and wellbeing (López-Sierra, 2014). Hence, it can be
argued that to understand these dynamics, a postcolonial trans-pastoral and CPS/R may be the
best approach to Puerto Rican communities as a culturally different S/RHCR.
Method and Conceptual Definitions

A simple systematic search of academic literature published in standard databases (i.e.
Medline, EBSCO, PsycINFO (OVID), ATLA Religion Database and Google Scholar) was
undertaken using a combination of relevant terms. The search was limited to articles and books
published in English and Spanish. The literature was selected after applied recognition of
significant terms approach to academic literature abstracts and conclusions.
The theoretical and empirical analysis academic literature was examined thru a systematic
review and content analysis. Systematic reviews summarize in an explicit way what is known
and not known about a specific practice related question (Cook, Mulrow & Haynes, 1997).
Content analysis is a systematic technique used for analyzing different types of texts by coding
the texts according to explicit rules. It is a technique for making inferences by objectively and
systematically identifying specified characteristics of messages (Titscher et al., 2000; Roberts
Ed., 1997). This technique allows researchers to find out and explain the focal point of the
study (Weber, 1990). The main conceptual definitions are:
1. Cultural diversity can be understood as the embodiment of uniqueness and plurality
of identities and worldviews of groups and societies making up humankind.
(López-Sierra, 2014).

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2. Spirituality and Religion (S/R) can be understood as a fundamental human potential
as well as a need for meaning and value and the disposition for relationship with a
transcendent power and values that may or may not be expressed in terms of a specific
religious tradition, belief and rituals. (Schipani & Bueckert, 2009).
3. CPS/R can be understood as a spiritual and religious bloc providing an alternative style
of human-divine relationship, primarily, through S/R subaltern subjects, worldviews and
practices of CPS/R. These S/R subaltern subjects raise ironic syncretic voices and actions
deconstructing the dominant Iberian-European and North American hegemonic culture
and Anglo-Eurocentric God-Talk. From a critical hybrid, and syncretic rhetoric, S/R
subaltern subjects subvert the institutionalized story of official Christianity. From a counter
hegemonic perspective the S/R subaltern subjects appropriate from dominant culture those
customs and practices which can contribute to the wellbeing of communities. (Cardoza-
Orlandi, 1995; Westhelle & Götz, 1995; Parker, 1996).
4. S/RHCS is an extensive ongoing care process, developed mostly in Western countries, of
active professional listening, counseling and summarizing a client’s story, spiritual strengths,
needs, hopes and coping strategies as they emerge over time. More recently, it occurs in the
context of an interfaith organizational and intercultural community-life, in which ongoing
assessment and inter-professional interventions occur in order to help meet a holistic
process to health, wellness needs and client goals (Schipani & Bueckert, 2009; Schott &
Henley 1999).
5. Postcolonial trans-pastoral is understood as a collaborative and liberation discourse and
practices which promote wholeness health in body-mind-soul-community-earth for-all
in the context of cultural diversity and religious pluralism. This discourse and practices
is critical to coloniality of power from a liberation and psychosocial standpoint (López-
Sierra, 2007). Postcolonial as such, is the situation in which Anglo Eurocentric colonialism
is called to account, questioned, challenged and critiqued (Lartley, 2001, 2006). In
term o method, it demand more than a mono-disciplinary or even a multidisciplinary
approach. It require to go throughout, and beyond fragmentation of Anglo-Eurocentric
knowledge and practices (an interdisciplinary and transdisciplinary perspective) (López
Sierra, 2007). An interdisciplinary and transdisciplinary knowledge which liberate S/R
discourses and practice from only one particular theory and practice. Postcolonial trans-
pastoral methodological goal, avoid reductionism and construct holistic integration with
psychological, sociological, anthropological, political and S/R knowledges and practices
(Furniss, 1994).
6. Coloniality of power constitutes a matrix that operates through control, hegemony and
subjugation of political sphere, production and exploitation, personal life and reproduction,
world-view and interpretive perspective (Quijano, 1999; López-Sierra, 2007).
Puerto Rican Communities and Cultural Identity Traits Tendency

Puerto Ricans in the USA and the Island have created eclectic, liminal or hybrid cultural
identity traits that are manifested in their socio-cultural struggles and survivor strategies.
Characteristic of their identity is a constant mode of coping, dealing and resolving. A strong
sense of cultural identity, different from the American identity, unites Puerto Ricans regardless
of their ideological, economic, and social differences (Diaz Quiñones, 2006). The effort to

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preserve that identity surpasses the limits of political rivalries and the circumstances of socio-
economic migratory movements and demographic transformations (Falcón, (1993).
They have constructed an identity in a social condition in which colonial and counter-
cultural power-discourses and practices coexist and are central to their social and cultural
transnational context. Such identity is rooted in indigenous, African and Spanish heritage and
is often manifested during festivities, which are commonly used as survival strategies to disguise
social and material scarcity. Puerto Rican nationals in the USA display cultural practices that
show their hybrid identity, including the use of salsa music and reggaeton music and Spanglish,
which is the mixture of Spanish and English language, as a way of symbolic socio-cultural
resistance strategies (López-Sierra, 2007, 2014; Flores, 1993; Rivera, Marshall & Pacini-
Hernéndez, 2009).
Scholars studying the Puerto Rican community migration and socio-cultural patterns
suggest that in the context of cultural identity traits, Puerto Ricans demonstrate expressiveness
to strangers, warmth and a sense of hospitality in which respect for the family is critical; mothers
and elders are venerated along with a strong sense of duty towards the family, including the
extended family. They also show a one-dimensional manifestation of masculinity expressed as a
form of machismo as a critical element of Puerto Rican identity. Beliefs in the intrinsic merit of
humanity may be a protective factor and a source of strength. Individuals may avoid discussing
problems that compromise dignity. Dissent may be communicated indirectly (e.g., a nod as if in
tacit agreement). Elders may not make eye contact, while younger Puerto Ricans and those born
in the USA prefer eye contact (Acosta, Belen & Santiago, 2006; Garcia, 1997).
Research on cultural and moral dimension of dignity and respect reveal that those are
main cultural values that lay emphasis on bonds, mutuality and faithfulness to family members
beyond the limits of the nuclear family. Individuals may place family concerns above individual
needs. Individuals may prefer or expect a close relationship once truthful relationships are
established. Children and parents may continue a dependence relationship into adulthood.
Parents may leave children with grandparents as they establish financial stability in the US
(Garcia, 1997).
A one-dimensional masculinity tendency, expressed as a form of machismo, acknowledges

both negative and positive aspects of culturally sanctioned ideas about the expression of male
identity. Private decision-making tends to be shared by husband and wife, though publicly men
may appear to have the final word. Men may believe strongly in their fiscal and moral duties
to their family. They may be judged by their ability to make sacrifices for their family, hesitate
to discuss problems that reveal personal weaknesses, may perceive a fatalistic acceptance of
problems as a courageous attitude, and may be vigilant over matters of dignity and respect
(Rosaldo, 1980).
Puerto Rican General Demographics: The Island and Its Diaspora

In the case of the Puerto Rican population, as a result of a long historical process
of colonialism and massive migrations, they have become what anthropologists, socio-
demographers and migration researchers call a nation on the move, a transnational reality and a
divided nation (Duany, 2003). According to the 2010 Puerto Rican Diaspora Atlas version, and

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the 2010 Pew Research Center’s Hispanic Trends Project, “Hispanics of Puerto Rican Origin in
the United States” statistical profile report, by 2010 there were approximately 4.6 million people
of Puerto Rican origins living in the United States.
This group represents about 9.2% of the Hispanic population in the United States of
America (Motel & Patten, 2013). In contrast, only 3.7 million individuals were living in Puerto
Rico (PR), nearly 1 million less than in the US. Both groups manifest a strong sense of cultural
identity, different from the American identity, regardless of their ideological, economic, and
social differences (Rodriguez-Ayuso, Geerman-Santana & Marazzi-Santiago, 2013).
Puerto Rican Communities: Cultural and Religious Traits

Latino spiritual traditions based on indigenous and African origins are not often clear
to Western S/RHCS, for they tend to remain hidden from their influences. Hence, while
many Latinos migrating to the USA and Canada can easily adopt at a surface level to Western
religious customs, in private, they usually continue to practice their religious spiritual traditions.
(Fernández Olmos & Paravisini-Gebert, 2011).
Academic literature concerning S/RHCS points to the fact that Puerto Ricans are part of
the Latino community in the Island and in the USA. It suggests that key cultural Puerto Rican
traditions emphasize national identity, collectivism, interdependence, and cooperation. Some
manifestation of such customs is the use of their native language when talking about emotional
expression to minimize possible defensiveness. Those socio-cultural behaviors were found to
be involved in the differential psycho-cultural orientation to human health services therapy for
Puerto Rican clients (López-Sierra, 2014; Ramirez, Guarnaccia, Canino & Bird, 2011).
Puerto Rico and its Diaspora are part of a syncretic or hybrid Caribbean religious and
spiritual cultural identity. What is characteristic among this population is a constant mode of
coping, dealing, resolving, and surviving, and a shared constructed identity in a social context
in which colonial and counter-cultural power-discourses and practices coexist (Rodríguez
Sánchez, 2009).
As main Puerto Rican religious studies and social scientists of religions suggest, CPS/R
should be understood as base in a dialectical relationship between the material world and
spiritual world in which one world can affect and shape the other. (Quintero Rivera, 1998;
López Sierra, 2007).
CPS/R plays an important role as part the Puerto Rican culture. That type of religiosity
and spirituality is rooted in a syncretism, produced by a dynamic amalgamation of Roman
Catholicism with religious practice of the indigenous habitants of the Caribbean and the
enslaved population of the sixteenth century slave-trade of Black Africans brought to the
Americas and the Caribbean Islands. Popular religions and spiritualties play a significant role in
the everyday life of Puerto Ricans.
Practicing religious rites, praying and keeping religious artifacts and erecting small home-
altars are some common religious practices (Stevens-Arroyo, & Pérez y Mena, 1995). A more
recent emergent Pentecostal faith and spirituality has become a growing manifestation of a

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popular evangelical religious and spiritual practice between Puerto Ricans of the Island and
the Diaspora (Cruz, 2005). This understanding provides an alternative style of human-divine
relationship, primarily in confrontation with the dominant culture, but flexible enough to
appropriate from that culture the customs and practices which contribute to the nature of
healing of diseases and well-being of the community, and create a different force for struggle.
This sustains, at a conscious or unconscious level, an attitude of resistance against psychosocial
oppression, dysfunctions and diseases (Núñez Molina, 2001).
S/RHCS to Puerto Rican Communities:

A Postcolonial Trans-Pastoral and CPS/R Perspective
Most Latino human services studies indicate Puerto Ricans as an ethnic group expect
therapy to be directive, and actually prefer family or group therapy. Those studies also suggest
that Puerto Ricans often underutilize mental health services and express pain through somatic
symptoms. They turn to their families in their neighborhood for support (Alegría, et al., 2002;
Andrés-Hyman, Ortiz, Añez, Paris, & Davidson, 2006; Canabal & Quiles, 1995).
Key ethnographic and theoretical research has noted that Puerto Ricans may equally seek
help from a physician as well as a popular spiritualist/religious healer. Because indigenous-and
African-based traditions and Spiritism exist as CPS/R expressions in the Caribbean, all focus
on transforming the immediate circumstances of their adherents. Each offers healing potential.
In most cases, this potential emerges within a working relationship with a spiritual leader from
the tradition. During some sort of divination ritual, spiritual leaders usually identify the causes
of the individual’s suffering and prescribe steps to redress these difficulties (Comas-Díaz, 2012;
Cros-Sandoval, 1979).
Herein lie two significant differences from Western forms of therapy. 1) Although some
difficulties are conceived to be the result of natural causes, many are thought to be spiritual
in origin. 2) Similarly, although most Western therapies emphasize inner processes and their
transformation, many of these religious traditions offer ways to externalize the suffering and
attribute it to other causes than to the self.
To engage these traditions usefully, it may be necessary for Western therapists and
counselors to learn to appreciate the symbolic aspects of these externalizations and their effects.
As a result of that learning process, one of the main objectives of this approach is to overcome
a coloniality of power perspective, embracing the community healers not as exotic others, but as
partners in a caring and holistic liberation process with individuals, families and communities
(Comas-Díaz, 1981; Núñez Molina, 1990). A practice in which a postcolonial trans-pastoral
and CPS/R perspective is critical to coloniality of power.
The postcolonial trans-pastoral and CPS/R perspective is a discourse and practice in

which Eurocentric colonialism, in its different manifestation, is called to account, questioned,
challenged and critically reviewed. Coloniality of power constitutes a matrix that operates
through control, hegemony and subjugation of political sphere, production and exploitation,
personal life and reproduction, worldview and interpretive perspective. Eurocentrism functions
as the ideological valorization of Euro-American society as superior, progressive, and universal,

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though it really represents white supremacy, capitalist profitability, and Euro-Anglo-American
self-universalization (Cardoza-Orlandi, 2001).
One of the key ways in which an S/RHCS with a postcolonial trans-pastoral and CPS/R
perspective will contribute to overcome the oppressions of coloniality of power is caring from a
premeditated and deliberate logic. This includes acts of historical and contemporary subversive
resistance and liberation struggles and negotiations. Latin American sociologist Aníbal Quijano
conceptualizes psychosocial forms of oppression as a historical-structural heterogeneous
totality with a specific power realm that he calls a colonial power matrix. This matrix affects all
dimensions of social existence such as sexuality, authority, subjectivity and labor (Quijano 1999).
Quijano has shown with his criticism toward coloniality of power that we Latin Americans
and Caribbean individuals still live in a colonial world and we need to break from the narrow
ways of thinking about colonial relations in order to accomplish the unfinished and incomplete
20th century dream of decolonization (Quijano, 1999). Living in that kind of state, Latin
Americans and Caribbean spiritual and religious subjects in general, and Puerto Rican
communities as S/RHCR, reinvent themselves. This reinvention occurs as a result of redeeming
autochthonous myths and the repository frame of reference in order to construct their identity
as Afro-Aboriginal-Hispanic, and Anglo-European syncretic faith stories and multiple religious
belongings or affiliations (Maduro, 1996).
As part of this process, our cultural and religious traditional narratives and practices
would have to reconcile our European, Latin American, North American, and Afro-Caribbean
autochthonous heritage in order to survive and avoid subjugation, oppression, homogenization,
exclusion, reductionism and coloniality of power. In this liminal and hybrid betwixt (Van
Gennep, 1960 ; Turner, 1967; Taylor 1992) psycho-social, political and cultural space, Puerto
Ricans have been able to live our subaltern (Gramsci, 1971 and Latin American Subaltern
Studies Group. 1993) and subversives practices of la brega (negotiate), which represent acts of
dissimulation and evasion, i.e. our ability to negotiate without total subjugation or submission
to the beliefs and values system of the imperial colonial psycho-social powers (Diaz Quiñones,
2006). Thus, we avoid a hierarchical and monolithic understanding and perception of reality
based on the coloniality of power.
One of the results of that brega has been to make our myths and customs survive through
the subaltern worldviews and practices of CPS/R subjects. These subjects raise an ironic
syncretic voice that starts with the criticism and deconstruction of the Iberian-European and
North American hegemonic God-Talk and ends subverting the institutionalized story of official
of Christianity from the hybrid and syncretic rhetoric of CPS/R.
The Brazilians religious and Latin American literary scholars Vítor Westhelle and Hanna
Betina Götz, explain the purpose of that popular religious spirituality, and contemporary
socio-cultural knowledge as forms of an ironic voice being addressed from Latin American and
Caribbean Liberation Theology as follows:
[I]rony […] becomes a dialectical pole in the spectrum of re-mythologizing and
deconstruction. [T]heology needs to assert itself by raising another question, the question
of who is the “other” in theological construction. By locating this “other” in the poor
who have been rendered invisible, and by constructing the subjectivity of the non-person,

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theology aims at imploding its own inherited models. And this is the ironic task of
theology within the rhetoric of official Christianity. […] Irony is what calls theology into
the present. It is retrieval, but its function is to unveil the fragmented and fantastic reality
of the present (Westhelle & Götz, 1995, pp. 17-18).
As Westhelle and Betina Götz have stated, the goal of this kind of ironic critical voice
and deconstruction is to re-mythologize reality, and provide wisdom for better living,
justice, empowerment and holistic health. In the case of the Puerto Rican communities the
re-mythologization of reality confronts its quotidian struggle with the complexity of daily
surviving, and achieves community holistic justice and liberation from a CPS/R perspective.
This perspective is accomplished not by negating the institutional ecclesiastical

understanding of the Judeo-Christian story, but at the same time transcending it from a
creative underside of trans-pastoral and practical theology and care that defies and challenges
the exclusiveness, homogeneity, and/or hierarchical authority of the institutional Anglo-
Eurocentric models of S/RHCS and of pastoral and religious care and theologies, and promote
wholeness in body-mind-soul-community-earth. Hence, theologians such as Emmanuel Y.
Lartey, speaking as a pastoral and practical theologian from the African Diaspora, eloquently
describes this perspective as follows:
It had been assumed that counselors of whatever faith tradition would be quite happy
to describe their activities as ‘pastoral’ as a means of articulating their preparedness to
take questions of faith seriously, a situation that had long exercised the minds of pastoral
practitioners, namely the Judeo-Christian captivity of the term ‘pastoral’. […] The reality
of religious pluralism is evident everywhere we turn Hospital chaplaincies, University
chaplaincies, counseling agencies and community mental health facilities all reflect this
plurality. […] Collaborative work with people whose expertise may be ecological, medical,
cultural, economic, political, personal or social – for wholeness in body-mind-soul-
community-earth. Holistic health for-all must be our aim (2006, p.124).
Conclusion:
Puerto Rican and Caribbean Cultural Richness and
Its Transformative Complexity in S/RHCS
Puerto Rican communities in PR and USA, as Hispanic/Latino and Caribbean subjects,
share particular transformative complexities. These are often manifested through common
spiritual, religious, cultural/symbolic, linguistic communication, and coloniality of power
experiences. In this scenario, Puerto Ricans’ spiritual beliefs have been sources of empowerment
for individuals and communities. The interplay between humans, spirits, and access to deities
through ritual, sacrifice, and communication provides them with a strong sense of self-
determination. In other words, when individuals feel they can negotiate with deities and spirits,
they feel they are in control of their destinies and also those divinities and spirits (ancestors) are
part of their own communities.
As S/RHCS seeks to narrow the worldview gaps between Puerto Rican S/RHCR and
a Western S/RHCG, it is important to understand Puerto Ricans’ complexities and colonial
experiences. This means that a S/RHCG needs to recognize the complex realities of Puerto

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Rican S/RHCR S/R, psychosocial and economic oppression, and marginalization as a result
of a power colonial subjugation. To address these differences, Western worldviews of S/RHCG
will benefit from embracing a trans-pastoral and CPS/R approach. As this happens, Puerto
Rican S/RHCG will feel that their Latino Indigenous and African-based beliefs have social
acceptability similar to other, more mainstream religious beliefs, and that their worldviews are
equally validated.
Efforts made by Western S/RHCG to reach and learn about their traditions should result
in a better understanding of Puerto Rican S/RHCR. A Western S/RHCS needs to extend a
respectful attitude toward divergent worldviews, and in many instances, should promote and
develop fruitful collaboration between CPS/R leaders. From this perspective, a Western S/
RHCG with a respectful attitude toward a Puerto Rican S/RHCR recognizes the value of
CPS/R, condemns religious imposition, and sustains religious pluralism. Hence, Western S/
RHCG should be more proactive in exposing themselves to traditions of faith that once were
castaway, stigmatized, condemned and even prohibited in Western Christianity.
After evaluating the importance of Puerto Rican S/RHCR’s situation, the following three
final points need to be underscored and emphasized:
1) Western S/RHCS could further enhance their practical interventions in Puerto Rican
communities by being sensitive and supportive of cultural diversity.
2) Western S/RHCG should consider the value of treatment processes inclusive of CPS/R.
3) S/RHCG should consider adopting a trans-pastoral and CPS/R approach, which may
entail consulting Puerto Rican communities CPS/R practitioners, in a respectful manner
being that these practitioners are usually held in high regard in their communities.

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Articles
Knowledge, Attitude and Practice of Cervical Cancer
Screening Services among Rural Women in Ohaukwu Local
Government Area of Ebonyi State, Nigeria
Kelechi Johnmary Ani, BA, PGDE, MA.
Department of History and Strategic Studies,
Federal University Ndufu-Alike, Ikwo,
P.M.B. 1010 Abakaliki, Ebonyi State, Nigeria
Tel: +234(806)155-2284
Email: kelechi.ani@funai.edu.ng
Rita Ihuoma Anaba, BNSc

National Open University of Nigeria
14/16 Ahmadu Bello Way, Lagos, Nigeria
Tel: +234(908)383-1336
Email: ridon2k3@hotmail.com
Peter Chukwunwendu Okeke, M Phil, BSc

African Regional Postgraduate Programme in Insect Science (ARPPIS)
University of Ghana
P. O. Box LG 25, Legon-Ghana
Tel: +234(703)617-2544
Email: okekepeterc@gmail.com
Author Note
This article presents findings from a public health inquiry into the level of knowledge and
awareness of cervical cancer screening among rural women of south eastern Nigeria, and its effect
on the high incidence of cervical cancer in Nigeria. The initial project upon which this article is
based was a quality improvement initiative for current patients. The initiative was not designed
as a project to contribute to generalizable knowledge. Therefore the original project is not human
subject research as defined by our national regulations. All participants in this patient care study
did so voluntarily. Consequently, the study does not in any way infringe on the university research
guidelines nor breach any ethical requirement for research within the Nigerian university system.
The opinions expressed in this article are those of the authors alone and do not represent those of
the organizations they serve. The authors have no conflicts of interest.
Abstract
Cervical cancer is the second most common preventable cancer and has a major impact on
women globally. It can be prevented by early detection of the premalignant stages of cancer
followed by prompt treatment. The poor participation in routine cervical cancer screening
among women in developing countries has remained a major barrier in the drive towards
reducing the incidence of cervical cancer. Thus, the aim of the study discussed in this article
was to understand the knowledge, attitudes, practice and barriers to cervical cancer screening of

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women in the Ohaukwu Local Government Area of Ebonyi State, Nigeria. A descriptive cross-
sectional study design was adopted with interviewer-administered questionnaires. Participants
were selected using a multi-stage sampling technique. The data collected from the research
population was analysed using descriptive statistical methods (frequency, percentages, mean
and standard deviation). The major factors discovered that constitute barriers to cervical cancer
screening include the poor level of knowledge and awareness (40.5%), the perceived need for
husbands’ consent, the belief that screening is painful and unpleasant, and difficulty in making
time for women to access screening services.
Keywords: cervical cancer, screening, knowledge, attitudes, practice, rural, Nigeria
Introduction
Cervical cancer is the second most common preventable cancer and has a major impact
on women’s lives worldwide (WHO, 2000). In western countries, the incidence and mortality
associated with cervical cancer has been reduced substantially following the introduction of
effective screening programs. This is in contrast to what is found in Africa, including Nigeria,
where cervical cancer screening is rudimentary or non-existent. The awareness and participation
in cervical cancer screening has remained poor in developing countries due to late reporting,
ignorance and cultural issues.
The incidence of cervical cancer increases after age 35, reaching a maximum in women in
their 50s and 60s. The management options include early detection and prompt treatment. This
study sought to explore the present knowledge, attitude toward and practice of cervical cancer
screening among women in the Ohaukwu Local Government Area of Ebonyi State to determine
how to increase screening practice.
In Ebonyi State, screening is as important as in other parts of Nigeria. Screening services

for cervical cancer were introduced in 2010. There are presently two screening centres at the
Federal Teaching Hospital, Abakaliki and National Vesico-vaginal Fistula Centre, Abakaliki.
Despite the awareness promoted through radio/television programs, peer group education
and free cancer screening services in the state, the coverage of the whole state is still very low.
There are many ongoing programs in the state, especially in the urban areas, which are meant
for all the women in Ebonyi State, both urban and rural women. Yet these programs have only
been accessed by a few women in the state’s urban area. Therefore, there is a need to focus on
rural areas where a majority of the women in the state live. There are no ongoing cervical cancer
screening programs in these rural areas, a deficiency that invariably has led to the low utilization
of the screening services.
Cervical cancer can be prevented by early detection of the premalignant stages of cancer
and prompt treatment. Early detection is obtained through routine cervical cancer screening
but there is low participation. Understanding the knowledge, attitude, practice and barriers to
participation in screening services by women in Ohaukwu Local Government Area of Ebonyi
State is very important in developing appropriate intervention.
We have only little information on the knowledge, attitudes and practice about cervical
cancer screening among rural women in Ohaukwu Local Government Area of Ebonyi State.

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Routine cervical cancer screening effectively reduces the incidence of cervical cancer in
developed countries; but in developing countries screening coverage is very low, i.e. it ranges
from 2.0% to 20.5%, in urban areas and 0.4% to 14.0% in rural areas.
In the Abakaliki urban area, where screening has been going on since 2010, only 2,878
women have been screened between 2010-2015 in the Federal Teaching Hospital Abakaliki (one
of the screening centres in the urban area) in a city of over 1.7 million women. Screening coverage
is very low in the rural areas despite all the sensitization that has been attempted via radio,
television, churches, village meetings etc. This results in clients seeking medical attention only
when their disease has reached an advanced stage. This low screening coverage can also be caused
by lack of knowledge concerning cancer of the cervix and the availability of screening services.
The general objective of the study was to assess the knowledge, attitudes, practice and
barriers to the use of cervical cancer screening among rural women aged 18 years and above in
Ohaukwu Local Government Area of Ebonyi State, Nigeria.
Materials and Methods

Study Area, Population and Design
The study was carried out in Ohaukwu Local Government Area of Ebonyi State. It has
an area of 517 km square and a population of 195,555 (Male – 94,479 and Female – 101,076)
as of the 2006 census. The study population included all women aged 18 years and above
in Ohaukwu Local Government Area of Ebonyi State who were sexually active. It is an
uncountable study population. A descriptive cross-sectional study design was adopted with an
interviewer-administered questionnaire.
Sampling Method
A multi-stage sampling technique was employed to select participants. Ohaukwu Local
Government Area was selected using the purposive sampling method because it is one of the
local government areas in Ebonyi state that is close to the urban area where screening for early
detection of cervical cancer is being done. The 15 wards in the Local Government Area were
identified. In stage 2 of the sampling, the 15 wards were subdivided into 5 zones comprising 3
wards in each zone. Using simple random sampling by ballot method, 5 wards (one ward from
each zone) were selected for the study, namely Umuogudu-akpu, Okposi, Wigbeke, Ngbo
and Effium ward 2. In stage 3, the list of all the villages in each ward were obtained from the
National Population Commission (NPC), and two villages were then selected from each of the
selected wards through random sampling. In the final stage, the sampling fraction was used to
determine the number of houses to visit in each of the selected villages. The respondents were
proportionately divided among the 10 selected villages so that each village had 15 respondents.
Hence, a total of 150 respondents were selected for the study.
Data Collection
The instrument for data collection was a structured interviewer-administered questionnaire,
designed to measure the knowledge, attitudes, and practice of respondents towards cervical
cancer screening and also to discover barriers to participation in screening services. The
questionnaires were administered by research assistants trained on the objectives of the study and

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data collection procedures. Proportionate distribution of the questionnaire to the respondents
was done as the socio-demographic characteristics of the respondents in these villages are similar.
The questionnaires were administered to the respondents using the convenience sampling
method. This allowed the researcher to administer the questionnaire to those respondents
that met the desired characteristics and were readily available or happened to be at the selected
houses/place at the time of interview, until the desired sample in that village was obtained. This
helped the researcher obtain a quick result.
Data Analysis
The data collected from the research population was analysed using descriptive statistical
methods (frequency, percentages, mean and standard deviation).
Results
Of the 155 questionnaires administered, 148 were correctly filled and returned, giving a
95.5 % response rate. The majority of the respondents were within the age range of 18 - 27 years
49 (33.1%). Seventy-six (51.4%) of the respondents had a secondary education; 65 (43.9%)
were employed, 104 (70.3%) were married, and 43.9 % had 1 – 4 children. See Table 1 below.
Table 1. Socio-demographic distribution of the characteristics of the participants.

Table 1: Socio-demographic distribution of the characteristics of the participants.
Characteristics Number of
respondents (%)
Age (years)
18-27 49 (33.1)
28-37 47 (31.8)
38-47 7 (18.2)
48-57 14 (9.2)
≥ 58 3 (2.0)
Level of Education
No formal education 9 (6.1)
Primary education 24(16.2)
Secondary education 76 (51.4)
Post-secondary education 35 (23.6)
Occupation
Employed 65 (43.9)
Peasant 19 (12.8)
Housewife 37 (25.0)
Student 25 (16.9)
Marital Status
Single 33 (22.3)
Married 104 (70.3)
Separated 5 (3.4)
Widowed 4 (2.7)
Parity
Nulliparous 35 (22.3)
1 – 4 children 65 (43.9)
5 children and above 22 (14.9)


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Knowledge of cervical cancer screening

Table 2 shows that 58.8% of the respondents had not heard about cervical cancer screening
and the remaining 40.5% who had heard of the screening services did not have positive
knowledge. Of the respondents, 17.6% obtained their information on cervical cancer screening
from health workers, 15.5% from friends and neighbours, 7.4% from the radio, and 6.8% from
family members. The smallest source of information was from religious leaders (6.1%).
The survey showed that 43 (29.1%) of the respondents believed that only women who
have 1-2 children should go for cervical cancer screening; 37 (25.0%) believed that the screening
services was for women who have had 4-6 children; 20 (13.5%) were of the opinion that the
screening services are meant for women who have 7 children and above; 17 (11.5%) were of
the opinion that virgins are the only women that are eligible for screening; 11 (7.4%) believed
that the screening services were meant for prostitutes and elderly women, while 7 (4.7%) of the
respondents believes that cervical cancer screening was meant for all women. Of the respondents,
66.9% thought that cervical cancer screening should be done in the hospital; 18.2% preferred the
maternity home environment; while 8.1% thought that a chemist shop was better.
Table 2: Knowledge
Table 2. Knowledge of respondents
of respondents on cervical
about cervical cancer
cancer screening,
screening, the the source
source of their
of their
information,
information, who be
who should should be screened
screened and where
and where the cervical
the cervical cancercancer screening
screening shouldshould be
be done.
done.
Knowledge of cervical cancer screening Number of respondents (%)
Yes 60 (40.5)
No 87 (58.8)
Source
Family 10 (6.8)
Friends 23 (15.5)
Neighbours 23 (15.5)
Religious leaders 9 (6.1)
Radio 11 (7.4)
Health worker 26 (17.6)
Those eligible for cervical cancer screening
Virgin 17 (11.5)
Women who have 1 – 2 children 43 (29.1)
Women who have 4 – 6 children 37 (25.0)
Women have 7 or more children 20 (13.5)
Prostitute 11(7.4)
Elderly women 11 (7.4)
All of the above 7 (4.7)
Where screening should be done
Hospital 99 (66.9)
Chemist shop 12 (8.1)
Maternity home 27 (18.2)
Attitude towards and practice of cervical cancer screening

From the study, 75 (50.7%) of the respondents were of the opinion that cervical cancer
screening is not necessary, especially when there are no signs and symptoms suggesting disease.
Alternatively, 69 (46.6%) believed that it is necessary, with or without signs and symptoms.

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Table 3 shows that 84 (56.8%) respondents strongly agreed, 19 (12.8%) respondents
agreed, 18 (12.2%) respondents neither agreed nor disagreed, and 9 (6.1%) respondents
disagreed, while 8 (5.4%) of respondents strongly disagreed that cervical cancer screening can
help in the prevention of cervical cancer. Sixty-six (44.6%) respondents strongly agreed, 19
(12.8%) respondents agreed, 19 (12.8%) respondents neither agreed nor disagreed, and 16
(10.8%) disagreed while 19 (12.8%) strongly disagreed that cervical cancer screening can harm
clients. Eighty-three (56.1%) respondents strongly agreed, 21 (14.2%) respondents agreed, 17
(11.5%) respondents neither agreed nor disagreed, and 7 (4.7%) respondents disagreed, while
8 (5.4%) strongly disagreed that cervical cancer screening can help women to live a healthy life.
Table 3. Attitude towards cervical cancer screening.

Table 3: Attitude towards cervical cancer screening
Questions regarding attitudes Number of response (%)
To what extent do you agree that cervical
cancer screening helps in the prevention of
cancer of the cervix?
Strongly disagree 8 (5.4)
Disagree 9 (6.1)
Neither disagree nor agree 18 (12.2)
Agree 19 (12.8)
Strongly agree 84 (56.8)
Mean ± SD 4.17±1.23
cancer screening causes no harm to the
client?
Disagree 16 (10.8)
Agree 19 (12.8)
Mean ± SD 3.70±1.50
cancer screening helps women to live
healthy lives?
Disagree 7 (4.7)
Agree 21 (14.9)
Mean ± SD 4.21±1.20
cancer screening is
unpleasant/embarrassing?
Disagree 32 (21.6)
Agree 22 (14.9)
Mean ± SD 2.82±1.52

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The table also shows that 31 (20.9%) respondents strongly agreed, 22 (14.9%) respondents
agreed, 19 (12.8%) respondents neither agreed nor disagreed, and 32 (21.6%) respondents
disagreed, while 39 (26.4%) of respondents strongly disagreed that cervical cancer screening is
unpleasant and embarrassing to the client.
Twenty-one (14.2%) of the respondents had been screened once for cervical cancer, 14
(9.5%) of respondents had cervical cancer screening more than once, while 113 (76.4%) had
never been screened for cervical cancer. Sixty-two (41.9%) respondents felt that cervical cancer
screening should be done every year; 31 (20.9%) felt it should be done every two years; and 17
(11.5%) felt it should be every three years, while 17 (11.5%) felt that the screening should be
done every five years. With respect to when respondents had cervical cancer screening last, 20
(13.5%) the respondents had been screened within the last three years while 8 (5.4%) had not
been screened for over three years.
Factors that affect participation in cervical cancer screening

Sixty-eight (45.9%) of the respondents did not know the facility where cervical cancer
screening was being conducted, while 64 (43.2%) had good knowledge of the location of the
screening centre. Eighty-eight (59.5%) of the respondents described the distance from their
village to the screening centre as very far, while 37 (25.0%) felt that the distance was not far.
Although 95 (64.2%) of the respondents believed that the distance of the screening centre
should not be a barrier to going for screening, 35 (23.6%) considered the distance to the
screening centre to be a barrier.
Of the respondents, 51 (35.1%) felt that the screening services were not expensive; 45
(30.4%) considered the screening services to be very expensive; 18 (12.2%) felt that the services
were almost free, while 20 (13.5%) considered the services to be reasonably priced. Hence, 89
(60.1%) of the respondents felt that the cost of the screening services was not a barrier, while
45 (30.4%) felt it was. Sixty-eight (45.9%) of the respondents held that the screening involves a
painful procedure, while 62 (41.9%) of the respondents felt that the screening was not painful.
The inability of the respondents to create time from their schedules in order to go for cervical
cancer screening is a barrier to women wishing to access this service.
Ninety-six (64.9%) of the respondents considered the method used in cervical screening to
be culturally acceptable, while 38 (25.7%) of the respondents did not. Ninety-six (64.9%) of the
respondents required their husband’s consent before accessing cervical cancer screening services,
while 39 (26.4%) of the respondents believed that they could go for screening without their
husband’s consent.
Fifty-five (37.2%) of the respondents agreed that anxiety over the expected outcome of the
screening made them reluctant to go for screening, while 76 (51.4%) were not deterred by the
possible outcome.
The study showed other reasons why respondents had not gone for screening: some were
shy (10.8%), some felt they were healthy (18.9%), some were uninformed (41.2%), and some
others were still undecided (16.2%).

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Discussion
As only 40.5% of the respondents had heard about cervical screening, the study showed
a low level of knowledge and awareness of cervical cancer screening among the women. A
low level of awareness has been recorded in a similar study in Enugu, southeast Nigeria,
where only 15.5% of the women were aware of the availability of cervical cancer screening
services (Nwankwo et al., 2011). These findings buttress the theory that lack of awareness and
knowledge of cervical cancer and screening remains the most important barrier to cervical
screening, as observed in various other studies (Fort et al., 2011; Abiodun et al., 2014).
Despite the fact that 56% of the respondents strongly agreed that cervical cancer screening
can help in the prevention of cervical cancer, the majority of the respondents (56.8%) did not
see the need for cervical cancer screening when there were no signs and symptoms of cancer.
This attitude has hampered screening programs and delayed the much-needed decline in the
incidence of cervical cancer in Nigeria.
The low level of awareness and knowledge about cervical cancer screening is a major barrier
to participation in screening programs, as only 10% of the respondents disagreed that cervical
cancer screening can cause harm to clients.
Perhaps this explains why as many as 76.4% of the respondents had never been screened for
cervical cancer. Another study also observed a high percentage of respondents (98%) who had
not been screened (Ogunbode & Ayinde, 2005). Their findings corroborate the observation
that in most developing countries, only 5% of the women undergo any screening for cervical
cancer (WHO, 2000). This is in line with the observation that the screening coverage levels in
Nigeria and most sub-Saharan African countries ranges below 10% (Ayissi et al., 2012).
The study showed that the cost of the screening services and fear of positive results were
not barriers to accessing cervical cancer screening services. However, this is contrary to the
findings of Were et al. (2011) who opined that lack of finances to buy the services, and fear of
a positive result, among other things, constitute a barrier to accessing cervical cancer screenig
services. Of the respondents, 18.9% were reluctant about accessing the cervical cancer screening
service because they believed they had no medical problems. This was also observed in a study
by Nwankwo et al. (2011), who observed that 32.0% of respondents did not assess the cervical
cancer screening because they felt they had no medical problems. This study also observed that
fear of pain, lack of time (Arulogun & Maxwell, 2012) and the need for consent from their
husbands are other barriers to participation in cervical cancer screening in Ohaukwu Local
Government Area of Ebonyi State, south-east Nigeria.

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Conclusion
The major finding in this study is the widespread lack of knowledge about cervical cancer
screening. Although some women believed that screening could prevent cervical cancer, there
are still those who believe cervical cancer screening is potentially harmful. This misconception
needs to be addressed. Some women had no idea at all about their level of susceptibility and
the risks to developing cervical cancer. These women need to become better informed and
educated. Few in our sample had had cervical cancer screening, but a majority of those who did
had been screened only once. Most preferred a female provider to conduct the screening test.
They also preferred a hospital for their test and to receive results face to face.
Therefore, the poor level of knowledge, the distance of the screening centre, the cost of
screening, husband consent, the perception of pain, and the unpleasantness of the screening
procedure and difficulty in making time from the office are seen as key issues.
These key issues must be addressed to increase needed access to cervical cancer screening
services for women.

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References
Abiodun, O. A., Olu-Abiodun, O. O., Sotunsa, J. O., & Oluwole, F. A. (2014). Impact of
health education intervention on knowledge and perception of cervical cancer and cervical
screening uptake among adult women in rural communities in Nigeria. BMC Public
Health, 14, 814. https://doi.org/10.1186/1471-2458-14-814
Anantharaman, V. V., Sudharshini, S., & Chitra, A. (2013). A cross-sectional study on

knowledge , attitude , and practice on cervical cancer and screening among female health
care providers of Chennai corporation, 2013. Journal of Academy of Medical Sciences, 2(4),
124–128. https://doi.org/10.4103/2249-4855.141132
Arulogun, O. S., & Maxwell, O. O. (2012). Perception and utilization of cervical cancer
screening services among female nurses in University College Hospital, Ibadan, Nigeria.
Pan African Medical Journal, 11, 69. https://doi.org/10.4314/pamj.v11i1.
Ayissi, C. A., Wamai, R. G., Oduwo, G. O., Perlman, S., Welty, E., Welty, T., … Ogembo, J. G.
(2012). Awareness, acceptability and uptake of human papilloma virus vaccine among
Cameroonian School-attending female adolescents. Journal of Community Health, 37(6),
1127–1135. https://doi.org/10.1007/s10900-012-9554-z
Fort, V. K., Makin, M. S., Siegler, A. J., Ault, K., & Rochat, R. (2011). Barriers to cervical cancer
screening in Mulanje, Malawi: A qualitative study. Patient Preference and Adherence, 5,
125–131. https://doi.org/10.2147/PPA.S17317
Nwankwo, K. C., Aniebue, U. U., Aguwa, E. N., Anarado, A. N., & Agunwah, E. (2011).
Knowledge attitudes and practices of cervical cancer screening among urban and rural
Nigerian women: A call for education and mass screening. European Journal of Cancer
Care, 20(3), 362–367. https://doi.org/10.1111/j.1365-2354.2009.01175.x
Ogunbode, O. O., & Ayinde, O. A. (2005). Awareness of cervical cancer and screening in a
Nigerian female market population. Annals of African Medicine, 4(4), 160–163. Retrieved
from http://www.embase.com/search/results?subaction=viewrecord&from=export&i
d=L43905432\nhttp://www.bioline.org.br/pdf ?am05040\nhttp://vb3lk7eb4t.search.
serialssolutions.com/?sid=EMBASE&issn=15963519&id=doi:&atitle=Awareness+of+ce
rvical+cancer+and+screening+in
Were, E., Nyaberi, Z., & Buziba, N. (2011). Perceptions of risk and barriers to cervical cancer
screening at Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. African Health
Sciences, 11(1), 58–64.
World Health Organization. (2000). The world health report 2000 - Health systems: improving
performance. Bulletin of the World Health Organization (Vol. 78).

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Zika Virus: Challenges and Considerations
Christie Joya, DO
Fellow, Infectious Disease
Walter Reed National Military Medical Center
8901 Wisconsin Avenue
Bethesda, Maryland 20889
Telephone: (301) 295-6400
Fax: (301) 295-6175
Email: Christie.joya@gmail.com
Editor’s Note
This article is the first of two concerning the Zika virus being published in this year’s
editions of the Journal of Health and Human Experience. This first article introduces
readers to the disease itself and its eruption from the perspective of the physician-clinician.
Author Note
The contents of this publication are the sole responsibility of the author and do not necessarily
reflect the views, opinions or policies of the Department of Defense (DoD), or the Departments
of the Army, Navy, or Air Force. Mention of trade names, commercial products, or organizations
does not imply endorsement by the U.S. Government. The author has no conflicts of interest.
Abstract
The Zika virus (ZIKV) is a new and imminent public health concern primarily due to concerns
about microcephaly, in addition to other congenital effects and Guillian-Barre’ syndrome. A
causative relationship between ZIKV and microcephaly has been determined by the Centers for
Disease Control. However, apart from being advised to avoid getting bitten and using barrier
precautions for sexual contact, little has been done to prevent and treat illness.
Keywords: Zika virus, microcephaly, emerging infectious disease
Introduction
Over the last year Zika virus (ZIKV) has changed from a relatively obscure virus, thought
to cause mild illness and be otherwise inconsequential, into an illness that has been prevalent
on the nightly news. The amount of information learned has been enormous and public health
officials’ actions have been swift. By January 2016 the United States Centers for Disease Control
and Prevention (CDC) issued interim travel guidance for pregnant women and, with mounting
evidence of the gravity of the infection, the World Health Organization (WHO) declared a
Public Health Emergency of International Concern in February of 2016 (Kindhauser, Allen,
Frank, Santhana, & Dye, 2016).

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History of Zika Virus
Zika virus is a flavivirus that is primarily transmitted by mosquitos of the genus Aedes. It
was first described in a captive rhesus monkey in the canopy of the Zika Forest in Uganda in
1947 and from Aedes africanus in 1948 (Dick, 1952). It was not until 1964 that it was described
in humans as a mild febrile illness with maculopapular rash (Simpson, 1964). From that time,
until 2009 when the New England Journal of Medicine published the first documented outbreak
that took place on Yap Island in 2007, there were only 14 documented cases of ZIKV infections
(Duffy et al., 2009).
The initial infections were all documented in Africa and Asia. The outbreak on Yap Island
and then in French Polynesia in 2013 were the first to show transmission of the virus moving
across the Pacific (V.-M. Cao-Lormeau et al., 2014). Subsequent to the outbreak in French
Polynesia there was noted to be an increase in the number of cases of Guilliain-Barre’ syndrome
(GBS) (V. M. Cao-Lormeau et al., 2016).
The first reports of ZIKV infection in the Americas were from March of 2015 from the
northeastern states of Brazil and, by October of 2015, there is a noted increase in the number of
infants born with microcephaly. By December of 2015 thirteen countries in Central and South
America and the Caribbean had documented cases of local ZIKV acquisition. As anticipated, in
July of 2016 there was the first documented case in the continental United States (Kindhauser
et al., 2016).
Consequences of Zika Virus Infection

Prior to the 2007 Yap Island outbreak ZIKV was not known to cause outbreaks, only
sporadic cases of infection, and was considered to be mild illness without significant sequelae.
In fact, 80% of infections appear to be asymptomatic (Duffy et al., 2009). However, as the
outbreak in French Polynesia and the Americas progressed, new correlations between ZIKV
and fetal abnormalities (microcephaly, brain calcifications, chorioretinitis, deafness, and fetal
demise) and GBS became apparent.
Microcephaly
Microcephaly is defined at a head circumference that is greater than 2 standard deviations
below the mean for age and sex. In November 2015 the Brazilian government declared a
national public health emergency due to the increased cases of microcephaly. The prevalence
of microcephaly by December of 2015 was 99.7/100,000 live births versus 5.5/100,000 in
2000 and 5.7/100,000 in 2010 (“Increase of microcephaly in the northeast of Brazil,” 2015).
The majority of these were in Pernambuco in northeastern Brazil where there was increased
reporting of ZIKV. Case reports showed fetal malformations with brain tissue positive for ZIKV
(Mlakar et al., 2016).
A small cohort study was published by Brasil, et al. showing that women with positive
ZIKV by PCR in blood or urine were more likely to have fetal abnormalities seen on ultrasound
than those who were ZIKV negative (29% versus 0%) and of the babies that were born at the
time of publishing the paper the ultrasound abnormalities were confirmed at birth (Brasil et

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al., 2016). In addition, another case report was published of a women infected with ZIKV
during her eleventh week of gestation whose fetus showed evidence of microcephaly at 20
weeks gestation and pregnancy was terminated at 21 weeks gestation. Post-mortem, high
concentrations of ZIKV were found in the fetal brain, with ZIKV RNA in the placenta, fetal
membrane, umbilical cord, muscle, liver, lung, spleen, and amniotic fluid (Driggers et al., 2016).
In addition a retrospective analysis from the French Polynesian outbreak showed increased
microcephaly as well (Cauchemez et al., 2016).
The case for a causative relationship was building, and in May of 2016, the U.S. CDC
determined that ZIKV causes microcephaly based on Shepard’s criteria and Bradford Hill
criteria, although they were unable to fulfill all of Koch’s postulates. In their report they state
that there is no other plausible explanation for the increased reports of microcephaly and that
further research should be focused on better understanding of congenital ZIKV infection,
determining the absolute and relative risk, and identifying other factors that may modify the
risk of ZIKV infection during pregnancy (Rasmussen, Jamieson, Honein, & Petersen, 2016).
To date congenital Zika syndrome has been diagnosed in 19 countries and territories in the
Americas, and more than 168,000 cases (“Zika cases and congential syndrome associated with
Zika virus reported by countries and territories in the Americas, 2015-2016,” 2016).
Guillain-Barre’ Syndrome
Guillain-Barre’ syndrome (GBS) is a severe immune-mediated neurologic illness presenting
with ascending paralysis that is known to have several viral triggers, including: influenza, human
immunodeficiency virus, cytomegalovirus, and Epstein-Barr virus. After the French Polynesian
outbreak in 2013 and 2014 there was noted to be increased incidence of GBS. A case-control
study was published in Lancet in April 2009 showing that all of the patients diagnosed in the
study period had neutralizing antibodies to ZIKV compared with only 56% in the control
group. The majority of the patients (88%) with GBS reported symptoms consistent with a
ZIKV infection in the 6 days prior to onset (V. M. Cao-Lormeau et al., 2016). Given the size of
the outbreak, this was calculated to be 0.24 cases of GBS per 1000 ZIKV infections. The data
from this paper were then analyzed by Yung & Thoon who calculated an estimated attributable
risk of 0.39 per 1000 person-years, a 21-fold increased incidence (Yung & Thoon, 2016).
According to the WHO Situation report published August 4, 2016 Brazil, Columbia,
the Dominican Republic, El Salvador, French Guiana, French Polynesia, Honduras, Jamaica,
Martinique, Suriname, and Venezuela all report increased incidence of GBS (“Situation Report:
Zika virus, microcephaly, Guillain-Barre syndrome,” 2016). Given that many of these countries
are in the developing world, there may not be adequate intensive care units to support the
increase in GBS patients.
Diagnostic Considerations
The diagnosis of ZIKV infection is not straight forward. ZIKV infection has many
overlapping clinical features of other viral illnesses, including dengue, chikungunya, and
parvovirus. The most common clinical features as noted during the Yap Island outbreak were
maculopapular rash (90% of patients), fever (65%), arthralgias, (65%), conjunctivitis (55%), and

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myalgias (48%) (Duffy et al., 2009). Symptoms were generally mild and self-limited. However,
given the severity of impact, especially in pregnant women and persons of child bearing age
there is often a need for confirmatory diagnosis. Currently the U.S CDC recommends testing
pregnant women exposed to ZIKV, infants with abnormalities of congenital ZIKV infection,
infants whose mothers tested positive for ZIKV, and women and men of childbearing age with
ZIKV exposure who are symptomatic (“Zika Virus: Clinical Guidance,” 2016).
Testing for ZIKV is most often through state labs or the U.S. CDC. If a patient presents
within 2 weeks of having signs and symptoms of ZIKV infection it is recommended that he/
she be tested using real-time reverse transcription polymerase chain reaction (rRT-PCR) of
serum and urine. A positive PCR is diagnostic, although a negative PCR does not mean that
the person does not have ZIKV infection. PCR testing is also recommended for asymptomatic
pregnant women who have positive ZIKV IgM within 2 weeks of exposure. ZIKV IgM serology
should be offered to all pregnant women between 2 to 12 weeks after exposure. If the pregnant
woman lives in an area of ongoing ZIKV transmission rRT-PCR should be part of routine
obstetric care in the first and second trimesters (Oduyebo et al., 2016).
Interpreting the results of serology is not straightforward due to how closely related ZIKV
is to other viruses like dengue, yellow fever, West Nile, and Japanese encephalitis. ZIKV IgM
testing is by enzyme-linked immunosorbent assay (ELISA) and not uncommonly can have
false positive results owing to the cross-reactivity between ZIKV and other flaviviruses, either
due to prior infection or vaccination. When a patient has a positive ELISA, this is termed a
“presumptive positive;” the serum is then sent for plaque reduction neutralization test (PRNT).
This test is performed against ZIKV and other related flaviviruses to increase the specificity
of ZIKV testing. The test measures specific neutralizing antibodies to help determine the
infecting virus. If this is the person’s first flavivirus infection the PRNT of that virus should be
the only one with neutralizing antibodies. However, in patients that have had prior flavivirus
infections or vaccination against a flavivirus there may be neutralizing antibodies against more
than one flavivirus. In the past if a neutralizing antibody for one virus was more than four times
higher than that of another virus, the higher titer virus was determined to be the source of the
infection. With the ZIKV outbreak the CDC has decided that “[b]ased on earlier flavivirus
research and limited preliminary data specific to [ZIKV], the historical use of a 4-fold higher
titer by PRNT might not discriminate between anti-Zika virus antibodies and cross-reacting
antibodies in all persons who have been previously infected with or vaccinated against a related
flavivirus (i.e., secondary flavivirus infection). Because of the importance of appropriate clinical
management of [ZIKV] and dengue virus infections, and the risk for adverse pregnancy
outcomes in women infected with [ZIKV] during pregnancy, a conservative approach to the
interpretation of antibody test results is now recommended to reduce the possibility of missing
the diagnosis of either infection (Rabe et al., 2016).
Given the similar vector, geographic distribution, and seasonality of dengue and ZIKV, it is
very common to have patients that have PRNTs that are positive for more than one virus. In the
cases seen in my clinic both have had positive PRNTs for more than one flavivirus. One of these
patients was actively trying to conceive, which made counseling more difficult as there was no
definitive diagnosis.

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Zika, Birth Control, and Abortions
Many of the countries affected by ZIKV are overwhelmingly catholic and, per catholic
doctrine, neither birth control nor abortion are allowed. In light of the ZIKV outbreak Pope
Frances stated, “Avoiding a pregnancy is not an absolute evil (Pulliam Baily & Boorstein, 2016).”
In most of Latin America and the Caribbean abortions are illegal or restricted. There are
seven countries in which abortions are illegal (Chile, Dominican Republic, El Salvador, Haiti,
Honduras, Nicaragua, and Suriname) and four countries where there are no restrictions on
abortion (Cuba, Guyana, Puerto Rico, and Uruguay). The other countries fall somewhere in
between usually allowing abortions in cases of rape, incest, or to save the life of the mother
(“The World’s Abortion Laws 2016,” 2016). In El Salvador induced or even spontaneous
abortion can even lead to charges and prosecutions for homicide or aggravated homicide, and
sentences of up to 50 years in prison (“El Salvador’s Total Ban on Abortion: The Facts,” 2015).
With the known severe complications of congenital ZIKV infection, the United Nations High
Commissioner for Human Rights, Zeid Ra’ad Al Hussein, called for pulling back on restrictions
to access to birth control. He stated, “[c]learly, managing the spread of Zika is a major challenge
to the governments in Latin America. However, the advice of some governments to women to
delay getting pregnant, ignores the reality that many women and girls simply cannot exercise
control over whether or when or under what circumstances they become pregnant, especially
in an environment where sexual violence is so common (“Upholding women’s human rights
essential to Zika response - Zeid,” 2016).”
In November 2015, the Pan American Health Organization (PAHO) issued an

Epidemiologic Alert stating that there was concern for ZIKV causing microcephaly and in
suit several countries issued advisories or states of emergency about this concern. Investigators
from the U.S. and Europe evaluated whether these advisories and concern for ZIKV led to an
increased rate of abortions. Due to the legal restrictions in many of these countries, it would
be difficult to determine the true incidence, but they were able to evaluate abortion requests
made through the non-profit organization, Women on Web, which provides medical abortions
through the internet. They found that in countries where there is ZIKV transmission there was
a significant increase in the number of requests for abortions in all countries, except Jamaica
(Aiken et al., 2016). In Brazil, concern over the ZIKV is increasing the debate over reproductive
rights and abortions.
Besides limited access to abortions for women concerned about congenital Zika syndrome,
there is also generally a lack of reproductive education and limited access to contraception that
has historically resulted in 56% of pregnancies being unintended, despite Columbia, Ecuador,
El Salvador, and Jamaica all recommending that women delay pregnancies (Sedgh, 2014;
“Zika virus triggers pregnancy delay calls,” 2016). Further evidence of this was reported by The
Henry J. Kaiser Family Foundation, which showed that five countries (Dominican Republic,
El Salvador, Guatemala, Haiti, and Honduras) did not have a sufficient stock of contraceptives
(Kates, Michaud, & Valentine, 2016). In addition, many of the medications that can be bought
in country may be ineffective. A study looking at emergency contraception sold in Peru showed
that 7 out of 25 batches did not have the drug availability advertised and likely only 72% of
samples would have provided the expected level of contraception (Monge et al., 2014).

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Unique Modes of Transmission
Sexual Transmission
Although the primary means of ZIKV transmission is through bites from Aedes aegypti,
there have been several reports of disease transmission by sexual contact. ZIKV has been known
to exist in sperm since the outbreak in French Polynesia, during which a Tahitian man was
evaluated for hematospermia two weeks after a likely ZIKV infection. Interestingly, the viral
load in the semen was 100,000 times the level usually detected in the blood (D. R. Musso, C.
Robin, E. Nhan T. Teissier, A. Cao-Lormeau, V.M., 2015). There was report of a man returning
to Colorado after working in Senegal who developed a symptomatic ZIKV infection and
transmitted ZIKV to his wife presumably by sexual contact (Foy et al., 2011). Since then, there
have been several more reports of transmission, including female to male, male to male, oral
sex and asymptomatic male to female sexual transmission (Brooks et al., 2016; D’Ortenzio et
al., 2016; Davidson, Slavinski, Komoto, Rakeman, & Weiss, 2016; Deckard et al., 2016). The
longest period of latency between ZIKV disease before transmission is 41 days (Turmel et al.,
2016). ZIKV has been documented in semen, and this has been seen in multiple other reports.
The longest time after ZIKV infection that ZIKV PCR has remained positive in the semen is
188 days (Nicastri et al., 2016), although the longest that ZIKV has remained culturable in the
semen is 24 days (D’Ortenzio et al., 2016). ZIKV has also been found in the female genital tract
(Prisant et al., 2016).
Based on this evidence, the U.S. CDC and WHO have recommended safe sex for anyone
of child bearing age who visits an area of ZIKV transmission or with concern for sexual
exposure. The U.S. CDC states that women who have possibly been exposed to ZIKV should
wait eight weeks from last possible exposure before attempting conception, while men should
wait six months (“Zika Virus: Clinical Guidance,” 2016). WHO recommends six months of
abstinence or safe sex for six months after exposure (“Prevention of sexual transmission of Zika
Virus, Interim Guidance Update,” 2016). Both groups recommend that if the sexual partner of
a pregnant woman has concern for exposure to ZIKV safe sex or abstinence should be practiced
for the duration of the pregnancy (E. E. Petersen et al., 2016).
For people of childbearing age who live in a ZIKV transmission area the advice from
the WHO is to educate people on ZIKV and contraception, as well as stating the emergency
contraception should be available to women (“Prevention of sexual transmission of Zika Virus,
Interim Guidance Update,” 2016). The U.S. CDC recommends a multifactorial approach
to discussing the best timing for conception taking into account other factors of ZIKV and
condition of the mother (E. E. Petersen et al., 2016).
Blood-Borne Transmission
Other arboviruses have been transmitted through blood transfusion (L. R. Petersen &
Busch, 2010). During the 2013-2014 ZIKV outbreak in French Polynesia a study showed that
of 1,505 asymptomatic blood donors 42 (2.8%) of samples tested positive for ZIKV RNA and
another study in Puerto Rico showed 1.1% of asymptomatic donor blood had ZIKV RNA
(Kuehnert et al., 2016; D. Musso et al., 2014). The first reports of blood transfusion associated
ZIKV infection were out of Brazil in which two patients in March of 2015 in which the two
recipients of blood from a single donor had an identical virus to the blood donor (“Brazil

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reports Zika infection from blood transfusion “, 2016). There have been other reports of
probable transmission of ZIKV reported (Barjas-Castro et al., 2016). In addition, there has been
probable ZIKV transmission with platelet transfusion (Motta et al., 2016). These last cases were
discovered due to the donor calling shortly after donation to report symptoms consistent with
ZIKV and investigation into the recipients. None of the recipients displayed signs or symptoms
of ZIKV infection.
The Food and Drug Administration’s (FDA) Revised Recommendations for Reducing the
Risk of Zika Virus Transmission by Blood and Blood Components state that, “ZIKV is likely
cleared by the existing viral inactivation and removal methods that are currently used to clear
viruses in the manufacturing processes for plasma-derived products.” These methods are heat,
solvent/detergent, and incubation at low pH. There are also FDA approved pathogen reduction
devices that use amotosalen and UV light to reduce ZIKV as well as other flaviviruses for
platelets and plasma (Aubry, Richard, Green, Broult, & Musso, 2016; Revised Recommendations
for Reducing the Risk of Zika Virus Transmission by Blood and Blood Components, 2016).
The FDA has not approved a nucleic acid test (NAT) for the detection of ZIKA for
screening, but one is available by the Investigational New Drug (IND) program (Revised
Recommendations for Reducing the Risk of Zika Virus Transmission by Blood and Blood
Components, 2016). This test is currently being used in Puerto Rico and areas of the USA at risk
for ZIKV vector transmission (Kuehnert et al., 2016). The FDA recommends that all blood
donated in the United States and its territories are tested for ZIKV or use a pathogen reduction
technology for platelets and plasma (Revised Recommendations for Reducing the Risk of Zika
Virus Transmission by Blood and Blood Components, 2016).
Travel Advisories
In January 2016, the U.S. CDC issued a Health Advisory stating that pregnant women
should “consider postponing travel (“Recognizing, Managing, and Reporting Zika Virus
Infections in Travelers Returning from Central America, South America, the Caribbean,
and Mexico,” 2016).” As the evidence mounted for severe teratogenicity of ZIKV, the
recommendation advised pregnant women to avoid all non-essential travel to ZIKV transmission
and avoid conception for 6 months. There are now travel notices for Central America (Belize,
Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, and Panama), South America
(Argentina, Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Paraguay, Peru,
Suriname, Venezuela), Mexico, Cape Verde, Pacific Islands (American Samoa, Fiji, Marshall
Islands, Micronesia, New Caledonia, Papua New Guinea, Samoa, Tonga), Singapore, and
the Caribbean (Anguilla, Antigua and Barbuda, Aruba, Bahamas, Barbados, Bonaire, Virgin
Islands, Cayman, Cuba, Curacao, Dominica, Dominican Republic, Grenada, Guadeloupe, Haiti,
Jamaica, Martinique, Puerto Rico, Saba, Saint Barthelme, Saint Kitts and Nevis, Saint Lucia,
Saint Martin, Saint Vincent and the Grenadines, Sint Eustatius, Sint Maarten, Trinidad and
Tobago, Turks and Caicos). When the outbreak occurred in Florida, Miami was also included on
this list, but has since been dropped (“Zika Travel Information,” 2016).
In addition, there is concern for travel to areas that are endemic for ZIKV and pregnant
women should talk to their physicians prior to travel to these areas. These include Brunei,
Burma, Cambodia, Indonesia, Laos, Malaysia, Maldives, Philippines, Thailand, Timor-Leste,

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and Vietnam. Other areas known to be endemic with ZIKV such as Africa and parts of Asia
are thought to be less risky, but pre-travel counseling is still recommended (“Zika Travel
Information,” 2016).
Combatting the Zika Virus

Zika Virus Vaccine
Currently there is no vaccine for the prevention of ZIKV. However, there is optimism
about its development as there have been successful vaccines developed for other flaviviruses
(yellow fever, Japanese encephalitis, and tick-borne encephalitis). In addition, early studies of
non-human primates have shown immunity after ZIKV infection (Dudley et al., 2016). At
this time, there are clinical investigations underway into several different types of vaccines. The
National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of
Health (NIH) is currently working in collaboration with several other groups on several types of
vaccines including a DNA-vaccine similar to West Nile virus vaccine, a live attenuated vaccine
related to dengue virus vaccine, a version of vesicular stomatitis virus used in investigational
Ebola vaccine, and a whole-particle vaccine similar to the Japanese Encephalitis vaccine (“Zika
Virus Vaccines,” 2016). While these vaccines have some initial successes it will likely take several
years for them to become widely available.
There are also many other considerations to take into account when developing a ZIKV
vaccine as little is known about the pathogenicity of the virus. Dengue (a closely related
flavivirus) displays antibody dependent enhancement leading to more severe disease when a
person has been exposed to a different serotype. Reactions such as these are unknown in ZIKV.
Also, particular attention needs to be paid to the neurologic outcomes after vaccination as we
have seen that a patient’s immune response to infection can lead to GBS.
Mosquito Control Programs

In order to control the mosquito population, it is generally advised to get rid of standing
water so that mosquitos will not have a place to lay their eggs. Although this may be helpful, an
integrated approach is needed for vector control. This includes the above, along with mosquito
surveillance and insecticides. Mosquito surveillance is done by public health departments in
order to know where adult mosquitos and larvae are located, what diseases they may be carrying,
and whether they harbor insecticide resistance (“Integrated Mosquito Management for Aedes
aegypti and Aedes albopictus mosquitos,” 2016).
Fifty years ago, due to the threat of yellow fever, there were massive mosquito
eradication programs to eliminate Aedes aegypti in places like Brazil by using
dichlorodiphenyltrichloroethane (DDT). However, this method became unfavorable after the
publication of Silent Spring by Rachael Carson due to DDT’s environmental impact. Other
insecticides remain in use. In Miami, Florida the insecticide Naled was used for aerial spraying in
September 2016 amid a great deal of controversy. Naled is safe according to the Environmental
Protection Agency and the CDC, although a product of its breakdown is dichlorvos (DDVP)
which has been shown to cause health problems in humans. It was used in 2014 for mosquito
control to spray 6 million acres in Florida and on average it is used on 16 million acres annually
in the United States (CDC Information on aerial spraying 2016). In addition to aerial spraying

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the CDC recommends targeted outdoor residual spraying around buildings and plants, and
indoor residual spraying for homes without adequate screens or air conditioning.
Mosquito larvae can also be targeted with larvacides that are applied to breeding sites that
cannot be drained. In Florida, Bti was used during the summer. Bti is Bacillus thuringiensis
subspecies israelensis. This is a toxin-producing soil bacterium whose toxin kills mosquito
larvae and larvae of some other insects. It is applied by spraying areas from trucks into
neighborhoods and is considered non-toxic to humans and animals. A list of insecticides and
larvacides currently approved for use can be found on the U.S. CDC website (“Interim CDC
Recommendations for Zika Vector Control in the Continental United States “, 2016).
Wolbachia is an obligate intracellular bacterium that naturally infects many insects. Once
the mosquito is infected, Wolbachia prevents the replication of viruses such as dengue and ZIKV
(Dutra et al., 2016). Infected mosquito embryos pass the infection from the adult female to her
offspring and Wolbachia remains in the Aedes population. Wolbachia infected Aedes mosquitos
have been used to combat dengue in several areas including Australia and Southeast Asia
(Enserink, 2010).
Genetically modified Aedes aegypti have also been developed to combat ZIKV and other
mosquito-borne illnesses. OX513A modified mosquitos carry a gene that prevents their
offspring from maturing in order to reduce the mosquito population. Release of the OX513A
was done in the Cayman Islands in 2010, leading to a decrease of Aedes aegypti by 80% and in
a suburb of area of Brazil by 95% (Carvalho et al., 2015). Another similar method is to release
male mosquitos that have been sterilized through radiation such as was used to control the
medfly population in the United States (Calla, Hall, Hou, & Geib, 2014).
Fish can also be used for mosquito larva control. There are several species that are
larvivorous and eat mosquito larvae. They have been used successfully to help manage malaria
in several Middle Eastern countries (“Use of fish for mosquito control,”). This method has also
been of use in the United States for the control of mosquitos carrying West Nile virus. They are
placed in unused swimming pools, watering troughs, and ornamental ponds.

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Conclusion
The ZIKV and congenital Zika syndrome at one time seemed to only be concerning
for those who traveled to Latin America; however now with increased visibility, ongoing
infections continue to occur in Africa and Asia as well. The outbreak that reached Puerto Rico
in December 2015 and Miami in July 2016 brings concerns closer to home. The primary vector
at this time is Aedes aegypti, which has a distribution closer to the equator; more worrisome,
ZIKV has been found in Aedes albopictus whose range goes much farther north into most of
the northeastern and central United States. Vaccine development continues to be a goal of
many researchers and public health officials and there are several promising candidate vaccines
undergoing clinical trials. The United States Congress passed $1.1 billion in federal funding
in order to combat the ZIKV in September of 2016, eight months after it had initially been
requested. This money should help with further vaccine development and the majority of it will
be distributed by the CDC.
Despite rapid gain in our knowledge of ZIKV there are still many things that need to
be investigated. Namely, are there patient characteristics that make some individuals more
susceptible to passing this infection to a fetus or to developing GBS? Is there an interaction
between ZIKV and other viruses such as dengue that cause people to have worse outcomes? Are
there good management tools to decrease the population of Aedes aegypti without endangering
people or the environment? Also, in regards to public health resources, will babies born with
congenital zika syndrome have the support needed, especially those born in resource-poor areas,
as the lifetime estimated cost to treat a child with microcephaly is more than $10 million dollars
according to the March of Dimes? Can reproductive rights change in these areas? These are all
questions that hopefully will soon have answers, because ZIKV will likely become endemic to
the Americas.

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Breaking News…..
Empathy and Dedication:

Hospital Corpsmen to Physician Assistants -
A Wasted Talent Pool in a Time of Need
David Lash, MPAS

Physician Assistant
Veterans Health Administration
Captain James A. Lovell Federal Health Care Center
3001 Green Bay Road
North Chicago, Illinois 60064
Email: doclash@outlook.com
Author Note
This article provides an important insight into the critical role of physician assistants for
American health care. The article makes use of a creative combination of academic reflections
combined with historical experiences (see below “newscasts”) from the lives of those in this
health care service. The author acknowledges the contributions of the Navy physician assistants
who shared their personal experiences to make this creative article a possibility. The author is
solely responsible for the contents of this article. The contents do not reflect the policy of the
Veterans Health Administration. The images used are from the Department of Defense and
therefore are in the public domain. All correspondence should be directed to the author. The
author has no financial conflicts of interest.
Abstract
Navy hospital corpsmen are relied upon to make life and death decisions when treating the
combat injuries of the Marines and other military members to whom they are assigned to serve.
They provide hemorrhage control, airway reestablishment and support, cardiac support, and
pain control, as well as treating whatever injury their patients have suffered. The corpsmen
stabilize the patients for transport to the shock trauma units and then other corpsmen assistant
the doctors, physician assistants (PA), and nurses with the combat treatment provided in these
more advanced treatment areas. Many of these hospital corpsmen pursue further careers as
physician assistants, both in and out of the Navy. Unfortunately, the civilian community largely
ignores the medical skills they developed and honed in combat once these sailors leave the navy.
Keywords: Physician assistants, hospital corpsmen, workforce shortage, primary care, veterans,
Veterans Affairs

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Introduction
The United States health care system is facing a decline in the primary care workforce
and access to primary care as physicians increasingly seek specialty positions or retire from
clinical medicine. The U.S. is projected to have more than 130,000 fewer healthcare providers
than needed by 2025. One in five (i.e. 60 million) Americans currently lacks adequate access
to primary care due to the health care provider shortage. This shortage coincides with an
increasing demand for primary care practitioners in rural and underserved communities, an
increase of required primary care services defined through the Affordable Care Act, an aging
population, and an increase of 123,000 service men and women being discharged from the
Armed Forces over the next 3-4 years. According to a recent USA Today report 50% of critical
VA health care positions remain unfilled. (USA Today, 2015; Becker’s Hospital Review, 2014;
AAMC projections, 2015; Conde Nast 2016; HRSA Health Workforce Reports, 2013; Health
Affairs, 2013)
The VA operates one of the largest health care delivery systems in the nation, consisting
of 150 medical centers and over 800 community-based outpatient clinics. Since 2001 and the
start of the Global War on Terrorism enrollment in the VA health care system has increased
significantly as well. (GAO’s 2015 High Risk Report)
Physician Assistants, the Corpsman and VA Connection
Newscast 1
A SEAL Team Medic, deployed in support of the Global War on Terror, provides
emergency first aid to one of his SEAL Teammates. He stabilizes his fellow SEAL and
the sailor is picked up by a medivac, surviving the battle injuries. The Corpsman later
teaches trauma and long-term medical care to fellow Special Operations Corpsmen and
Medics. After becoming a Physician Assistant (PA), he is the lead provider on a mobile
trauma team in Helmand Province, Afghanistan. His team deploys on missions outside
of the desired medivac flight time/distance perimeter to provide a more vigorous medical
response to allied forces engaged in battle. He is now the Senior Provider and Medical
Department Head of a Special Operations Team. This PA saved countless lives in the worst
of conditions, and through the skills of those he teaches and leads he is still saving lives.
The physician assistant (PA) profession was established in 1965 to address the shortage of
physicians in the U.S. The first class of physician assistants was composed of former U.S. Navy
Hospital Corpsmen. The program’s intent was to take advantage of the combat healthcare
experience of Vietnam era military trained medics and corpsmen to fill the workforce shortages
in medical primary care that existed in the 1960s. The curriculum for the first PA program was
based on the fast-track training of medical doctors during World War II. (Wikipedia, 2016;
Journal of Physician Assistant Education, 2007).

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Heroic military medical personnel rescuing the wounded in World War II on Normandy.
Newscast 2
A Navy corpsman providing medical support to the Marines during the battle of Fallujah
is promoted for saving the lives of Marines while under enemy fire. During a subsequent
deployment to earthquake ravaged Haiti he coordinated the evacuation of 133 critically
injured patients and assisted military surgeons in the surgical and postsurgical care of
earthquake survivors requiring amputations. His dedication to his Marines and his empathy
for human suffering serve him well as the surgical PA that he is today.
In 1967, the first employer of PAs was the then-Veterans Administration (VA), now
known as the Department of Veterans Affairs. Currently the VA is the largest single employer
of PAs, employing around 2,000 PAs. Over the next 3-4 years employment opportunities for
PAs is expected to increase at a steady rate of 38%, much faster than the average for all other
occupations. The PA occupation has been named as the single best master’s degree for the
several years. The National Commission on Certification of Physician Assistants reports that
78% of recent PA program graduates are receiving multiple job offers, with 52% entertaining
three or more offers. (Wikipedia, 2016; Forbes, 2014)

Articles
Newscast 3
A Navy corpsman serving as a Combat Medic and heavy weapons gunner on a Special
Operations (SPECOPS) boat crew in Iraq earned a Bronze Star with Valor for his actions
under fire, providing medical care to wounded Marines calling out for his assistance while
being targeted himself by the well entrenched enemy. He was awarded a purple heart for the
injuries he received while attending to the wounds of “his” Marines. Later, while assigned as
a SPECOPS Combat Medic Instructor, he attended college classes at night to qualify for
PA school. After graduating as a PA he was subsequently assigned as a Battalion Medical
Officer with the 3rd Battalion Marines and deployed back to the warzone as a Medical
Officer. The faces of his Marines had changed but the severity of their injuries were known
to him. His experience as that SPECOP Corpsman was key to his expertise in treating yet
another cadre of his Marine Corps family suffering from the injuries inflicted during service
to their country.
The Need is Expanding and Increasingly Complicated

Today’s Veterans have been exposed to a multitude of often complex physical and/
or mental invasions of their well-being. They were required to leave their loved ones for
agonizingly prolonged periods of time. They have been forced to live in harsh conditions where
many around them were actively trying to kill them. For months at a time, from the time that
they get up in the morning until the time that they go to bed at night, every single day they
are not sure that they will still be alive at the end of that day. They are sure that some of their
adopted family members, and their team “IS” their family, will not be alive at the end of the
day. Imagine getting out of bed every day knowing that someone in your family would be killed
before the day is over. You hope that it will not be you. You are relieved when it is not you; and
that is closely followed by the guilt that it was another family member instead of you.
According to a Gallup poll taken in 2014 after the incident published concerning the
VA Medical Center in Arizona, Veterans continued to prefer that more of their medical needs
be met by the VA. The poll demonstrated that Veterans favor an expansive role for the VA in
meeting Veterans’ care over a more limited one. Fixty-six percent say the VA should care for all
Veterans’ medical needs for the duration of their lives, while 38% believe the VA should only
care for those medical issues related to the Veterans’ military service. (Gallop poll, 2014)
In 1991 22% of all PAs were employed by the federal government. That percentage
dropped to 9% by 2008, where it remains today. In 2014 PAs had the highest total loss rate
(10%) in the VA, more than any of the other top ten VA occupations deemed difficult to
recruit. A recent VA OIG report determined that PAs were third when compared to all other
VA occupations with the largest staffing shortages. In 2016, 37% of VA PAs were eligible
to retire. That is an approximate loss of 600 PAs. That workforce loss will result in a loss of
approximately 1.15 million Veteran-eligible patient care appointments. By 2021 an additional
48% of VA PAs will be eligible to retire. (AAPA report, 2015)

Articles
Newscast 4 & 5
A Navy corpsman assigned as a Search and Rescue Aircrewman participates in 49 helicopter
rescues. These rescues were executed in nearly inaccessible canyons, on treacherous
shore cliffs, and on steep rock canyon walls. He repelled down from the helicopter to
injured people, stabilized their vital signs, applied lifesaving first aid, placed the injured
into stretchers and hoisted the patients to hovering helicopters. His duties also involved
accessing aircraft mishaps in remote or hard to reach locations, stabilizing and evacuating
survivors, as well as retrieving the remains of those who did not survive. This corpsman
was ultimately accepted to PA educational programs/institutions. As a PA, the now Naval
Officer was assigned as the Officer-in-Charge of a Shock Trauma Platoon in the war zone
of Afghanistan. His platoon was the primary casualty treatment and stabilization/transport
facility for American war casualties and Afghan civilians overwhelmed by the war being
fought all around them in the Afghan province. One Afghan family’s survivors transported
their severely injured loved ones 10 miles, through mountainous and desert terrain, bullets
and explosions everywhere, even in wheel barrels, to request treatment in the American
medical “facility.” Unfortunately the treatment was too late.
In yet another war zone deployment a combat hardened PA was assigned as the Lead
Advisor to the Afghan Surgeon General. Assistance provided included advice on the day
to day operations of medical departments. Medical clinic organization, administration,
staffing, logistics and finance were also provided. The PA was a key element in the planning
for the reestablishment of Afghan medical schools and medical training pipelines. The PA
is currently providing leadership to U.S. sailors and providing orthopedic medical care to
military members and their families.

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Military medical personnel bringing humanitarian aid and healthcare to the poor of other
countries including children and those most wounded.

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Wasted and Ignored Skills
Newscast 6 & 7
A Navy corpsman spends years training with and providing medical care to the U.S. Marines
and is then selected for and subsequently provides medical care to a SEAL Team. He then
gets selected for PA school. The corpsman melds those many years of experience as an
operational hospital corpsman with his new PA education. He reports to the war zone to
provide medical care to a combat support base that included up to 10,000 U.S. and allied
military forces, and support civilians. While serving there, the PA provided combat casualty
life saver training to allied forces from Japan, Jordan, Saudi Arabia, Kuwait, and Oman. He
was ultimately promoted into the medical unit’s leadership position.
Another PA who is a prior corpsman deploys to Iraq in a Shock Trauma Platoon treating
numerous severe combat casualties and saving many lives. The PA subsequently deploys
to Iraq in a Forward Surgical Team and once again assists in saving the lives of American
and Allied Marines and Soldiers injured while fighting alongside Iraqi government troops.
Called upon to deploy once again, the PA reported to Afghanistan as the Medical Officer
with a Provincial Reconstruction Team. The PA provided advice and guidance on recreating
medical infrastructure and supervised medical care to the team. The PA later deployed to
both Qatar and Jordan as the Medical Officer-in-Charge with Combined Forces Special
Operations Command. The PA is currently a primary care provider taking care of military
personnel and their families.
On a yearly basis around eleven thousand former military corpsmen and medics leave the
service. The unemployment rate for Veterans aged 34 and younger, the age group encompassing
the majority of discharged Veterans, is consistently higher when compared with their peers
who did not serve in the military. Military corpsman and medics are trained to manage pain,
including administering narcotics. They treat life-threatening battlefield injuries, stabilizing
their comrades until their medical support can arrive, or their patient can be evacuated from
the battlefield. They perform intubations and IV administration, treat colds, stomachaches,
and other common primary care complaints. They prescribe and distribute medications on the
battlefields, on the ships in the fleet, and on the military installations of all of the U.S. Armed
Forces. These corpsmen have saved the lives of many of their Marine Corps family members, in
horrific combat situations, under lethal enemy fire, bullets zipping by within earshot, explosions
all around them, Marines are heard always calling for “DOC,” who are many times wounded
themselves, and with medical backup hours away.(EMS1 News, 2012)
Civilian EMTs are certified at the basic level and are not allowed to perform the basic level
of medical care routinely provided by military corpsmen and medics who are not deployed
in combat. Even with the military corpsmen’s and medic’s superior training and experience, a
comment made by an official of the National Registry of EMTs printed in EMS1 News SEP
in 2012 stated that “Veterans should complete the full range of paramedic courses through
CIVILIAN schools, no matter their experience level.” (Capitalization mine). Perhaps this
“official” needs to be deployed to the war zone and see if s/he can manage the mayhem on the

Articles
battlefield, and perhaps s/he can at least stay out of the way as the corpsmen and/or medics
around him/her save countless lives. According to the statement made by a U.S. Congressman,
also printed in EMS1 News in September, 2012, “Many Veterans use federal benefits to pay for
civilian schooling in skills they’ve already mastered. We are literally wasting millions of tax payer
dollars requiring someone to attend training they have already completed, which could be spent
on more advanced qualifications.” (EMS1 News 2012)
Newscast 8
After 16 years providing medical support to the U.S. Naval fleet, a Hospital Corpsman
is accepted to PA school. Subsequent to graduating from PA school and receiving a
commission as a Naval Officer, she reported to a Naval Health Clinic and was soon
promoted to the Senior Medical Officer position (Senior Health Care Provider). Not
accustomed to sitting on the sidelines, the PA volunteered for deployment into the war
zone and was assigned as the Executive Officer of a Shock Trauma Platoon and Forward
Resuscitative Surgical Suite at a Combat Outpost in Iraq. The PA and her medical team
treated the injuries and saved the lives of numerous combat casualties. After a brief time
back in the U.S. she deployed as the Regimental Surgeon (Senior Health Care provider to a
Marine Regiment) responsible for the health care of 2,500 sailors and marines. When not
treating combat casualties and administering the medical department she found the time
to earn the Plans, Operation, and Medical Intelligence subspecialty. This PA implemented
the Medical Home concept in the regiment, significantly improving access to medical care,
keeping the maximum number of Marines combat ready at any given time. She was always
looking for ways to improve the lives of those around her and authored both the “Going
Green (USMC)-A Naval Officer’s Toolkit” and the Navy’s Emergency Medicine Physician
Assistant Fellowship Program. This prior corpsman, now a PA, went on to complete a
Congressional Legislative Fellowship, advising a Congressman on national security, foreign
relations, and Veterans Affairs. She is now serving as a Legislative Liaison to the Navy
Surgeon General.

Articles
Prior Corpsmen and Physician Assistants Can Fill the Need
An article appearing in the Journal of Health Affairs in 2013, discussing the primary care
workforce gap in the U.S., notes that research has determined that physician assistants can safely
perform many aspects of the primary care previously performed only by physicians. The article
continues to recommend further that a “primary care extender” could be established along the
model of the Emergency Medical Services Technicians (EMTs). As it states:
EMS is almost entirely delivered by EMTs and paramedics. EMTs extricate people
from car crashes, control bleeding, splint fractures, and provide basic life support.
Paramedics conduct detailed patient assessments, insert intravenous lines, administer a
wide range of oral and prenatal drugs, and perform certain lifesaving procedures. EMS
professionals practice under the license and supervision of a physician medical director.
Because EMS professionals work in the field, their actions are largely guided by clinical
protocols and standing orders. However, they can obtain medical direction by radio
or telephone if this is required. This approach enables a small number of physicians to
meet the pre-hospital care needs of the United States. ( Journal of Health Affairs, 2013).
Always prepared. Ever serving.

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Newscast 9
A Navy corpsman is “baptized” into combat during Operation Desert Storm with the
Marines. The combat experience included seeing the charred remains of numerous
Iraqi soldiers who had been incinerated by Coalition ground and air forces. Undeterred
by this horrific battlefield experience, following the deployment, the corpsman began
taking nighttime college classes after putting in a full day in an operating room. He made
numerous additional deployments with the Marines on routine training and deployment
exercises around the world, before being accepted into PA school. Then came the Global
war on Terror. The PA was deployed with the Marines to Camp Fallujah Iraq during some
of the most intense fighting of the entire Iraqi war. He was kept extremely busy treating and
tracking the casualties from three separate Marine Corps infantry battalions. The fighting
was fierce, the injuries were graphic, and yet countless lives were saved through his efforts
and those of his team.
After a rest (from combat) back to the U.S. the PA was deployed to a reconstruction
team in Khost, Afghanistan, serving as the U.S. medical representative to the Afghan
Provincial Government, and as the Provincial Public Health Officer. The PA supervised
the rebuilding of health clinics to give the local Afghan population access to basic health
care. He supervised the procuring and providing of medical supplies and equipment for the
clinic. He established a children’s nutritional supplement program to address the endemic
malnutrition, purchased clean water treatment units to give the population a source of
uncontaminated drinking and cooking water, and purchased garbage incinerators to dispose
of the numerous disease causing piles of refuse that littered the area. This PA’s efforts
provided a safer and more humane environment for the Afghan population in the province.
The PA and his medical team were the first responders after an infamous suicide bomb
attack on a nearby CIA compound. Their efforts saved the lives of six severely wounded
U.S. personnel, however nine others could not be saved. He served out his time in the U.S.
Navy and is now a Family Medicine PA in a U.S. community utilizing his skills to protect
the health of the next generation of potential veterans.

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And finally…..
A Navy Corpsman gets accepted to a PA school, and upon graduation is deployed to Iraq.
The PA worked in a Shock Trauma Platoon treating the casualties of the U.S. Marines and
allied forces fighting for Iraqi freedom. He later was assigned to a SEAL Team and deployed
to the warzone in support of the Team’s combat operations. He is now the head of a Naval
medical clinic providing medical care to U.S. Sailors, Marines, and their family members.
A PA joins the Navy and is deployed with a Marine Corps Air Wing Support Squadron in
the Iraqi warzone. She provided essential medical and casualty support to the Marine Corps
pilots supporting America’s war on Global Terrorism. Her experience has enabled her to
progress into leadership roles in the Navy.
Another Navy corpsman is commissioned as a PA. After additional training as an Aerospace

Physiologist she served as the Operational Officer at the Navy’s busiest Aviation Survival
Training Center overseeing the high-risk water survival and altitude chamber training of
aircrew and SPECOPS personnel deploying in support of the Global War on Terror.
Conclusion
Health care provider shortages is the root cause of the problem of Veteran’s access to
health care in the VHA. Use of “primary care extenders” in the model of the EMTs would allow
credentialed health care providers to focus on the diagnosis and treatment of patients. Using all
members of the health care team to the optimum extent of their capabilities would give physicians
more time to address the more serious or more challenging patients that only physicians can treat.
According to the VA Office of Inspector General (OIG) Report of January 2015, the five
VHA occupations with the largest staffing shortages were Medical Officer (physician), Nurse,
Physician Assistant, Physical Therapist, and Psychologist.
The VA is traditionally a draw for former service members seeking employment. Veterans
trained as medics and corpsman may once again offer a solution to the primary care shortages.
In the past, medics and corpsmen were considered exceedingly able candidates for primary
care work and as rural providers. Their broad training was considered an untapped reservoir of
needed attributes and clinical skills.
Many former corpsmen and medics choose the PA profession as an avenue to increase their
medical knowledge and to utilize their acquired medical skills, while acquiring even greater
medical skills as PAs. Historically, the very first PAs were all employed by the VHA. Many other
corpsman and medic veterans choose the nursing profession. The current generation of former
corpsman and medic veterans would likely follow the historical pathways and choose the VHA
if given the opportunity. (Wikipedia, 2016)
The vastly untapped talent pool of prior corpsmen and medics should once again be
pursued and utilized by the VHA. In addition, the VHA needs to increase targeted recruitment
and retention initiatives towards physicians, nurses, and PAs (VA OIG, 2015).

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Even with additional targeting towards physicians, the declining pool of available
primary care physicians will require the VHA to rely more heavily on PAs. To attract more
of the extremely talented and experienced PAs leaving the U.S. military, as well as others, the
VHA must pay competitive salaries to PAs when compared to the salaries paid in the civilian
community. In addition the VA should grant full practice authority to PAs throughout the
VHA regardless of the opposition of other health care professionals. PAs have been and do
provide fully independent practice throughout the armed forces, on the battlefield, and in
remote and inaccessible locations, and have been doing so since the late 1990s. Outdated
beliefs and fears by others will cause the continued lack of veteran access to the healthcare
that the veterans unquestionably have earned. The VHA is the largest medical system in the
world and should be on the cutting edge of medical practice in this country. The VA must
seize the opportunity to employ prior corpsman and medic veterans, and to utilize all medical
professionals to the full extent of their training and experience. To do any less is to ignore their
sacrifices --- sacrifices that were given freely in the blood, gore, and mayhem of combat.
Failure of our commitment to our Veterans is never an option!
Health care --- truly human care

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References
American Academy of Physician Assistants (2015, March). Report to the House Committee
On Veterans’ Affairs, AAPA.
Bloomberg, S. (2012, September). Combat medics betrayed by civilian job market, EMS1 News.
Colver, J., Blessing, J. & Hinojosa, J. (2007). Military physician assistants: Their background
and education, The Journal of Physician Assistant Education, 18(3).
Dall, T., West, T., Chakrabarti, R. & Iacobucci, W. (2015, March). The Complexities of
Physician Supply & Demand, Projections from 2013-2015, Center for Workforce
Studies of the Association of American Medical Colleges.
Dill, K. (2014, June). The best and the worst master’s degrees for jobs in 2014, Leadership, Forbes.
Government Accounting Office (2015). Managing Risks and Improving VA Health Care, High
Risk Report.
Grounder, C. (2013, January). The case for changing how doctors work, Conde Nast.
Hoyer, M. (2015, August 20). Half of critical positions open at some VA hospitals, USA Today.
Jones, J. (2014, July). Majority of U.S. veterans say access to VA care difficult, Gallop poll,
Gallop World Headquarters.
Kellerman, A., Saultz, J., Mehrotra, A., Jones, S. & Dalal, S. (2013). Primary care technicians: A
solution to the primary care workforce gap, Health Affairs.
National Commission on Certification of Physician Assistants (2013), Statistical profile of

Physician Assistants.
Punke, H. ( Jan 2014). 8 Physician Shortage Statistics. Becker’s Hospital Review, Integration &
Physician Issues.
U.S. Dept. of Health and Human Services, Health Resources and Services Administration
(HRSA), Bureau of Health Workforce Analysis. (2013, November). National and
Regional Projections of Supply and Demand for Primary Care Practitioners 2013-2015.
U.S. Dept. of Veteran’s Affairs. (2015, January) Determination of Veterans Health

Administration’s Occupational Staffing Shortages.
Wikipedia (May 2016). Physician Assistant, Healthcare occupations, Wikimedia Foundation, Inc.

Articles
An Inquiry into the Compliance of Construction with Health
and Safety Regulations in Imo State, Nigeria
Emmanuel Ifeanyichukwu Nkeleme, BSc, PDE, MSc
Department of Building,
Federal University of Technology
Owerri, Imo State, Nigeria
Tel: +234 (806) 077-2657
Email:bishopeio@yahoo.com
Andrew Obinna Nwaubani, BSc

Department of Building,
Federal University of Technology
Owerri, Imo State, Nigeria
Tel: +234 (813) 218-2080
Email:cuteobiano4real@gmail.com
Ijeoma Genevieve Anikelechi, B.Engg, PGDE

Department of Science Education,
National Open University of Nigeria,
Abakaliki,
Tel: +234 (806)616-3785
Email: ijeomakc@gmail.com
Author Note
This article presents findings from a professional public service inquiry needed to assess and
improve public safety standards in construction in the country of Nigeria. The purpose was
to provide quality improvement for current construction practices. The initial project, upon
which this article is based, was a quality improvement initiative for construction workers. The
initiative was not designed as a project to contribute to generalizable knowledge. The original
project therefore is not human subject research as defined by Nigerian national regulations. All
participants in this construction company study did so voluntarily. Consequently, the study
does not in any way infringe on the National Open University of Nigeria (NOUN) research
guideline nor breach any ethical requirement for research within the Nigerian university system.
The authors have no conflicts of interest.

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Abstract
Health and safety of Nigerian construction firms have long been an issue because of reports
of accidents during construction work. This study aims to “assess the adherence of Health
and Safety Requirements in construction firms in Orlu, Okigwe and Owerri Municipal of
Imo State.” To achieve this aim, 138 copies of questionnaires were administered to workers on
site in four randomly selected building construction companies. Of these, 112 copies of the
questionnaire (81.2 %) were returned and analyzed using descriptive statistics. Data from the
questionnaires were analyzed by simple frequency and presented by percentage. Respondents
noted that a major cause of accidents was non-compliance with health and safety requirements
by construction companies It is recommended that appropriate legislation on construction
health and safety requirements be addressed urgently by the Government.
Introduction
The construction industry is an important part of the economy in many countries and is
often seen as a driver of economic growth, especially in developing countries. Construction
sites are still among the most dangerous workplaces because of the high incidence of accidents
(Egbokhare, et al., 2002). The construction industry is characterized by its fragmented structure
in the production phase and its needs for coordination of different interdependent trades and
operations. The nature of construction work is inherently dangerous. Hence safety and health
issues must be considered and advocated so that the safety and health of persons are protected
and safety regulations are enforced, not as a luxury but as a necessity (Tam, et al., 2004).
The output of industry in Nigeria accounts for over 70% of the gross domestic product
[GDP] (Mbachu, 1998), and therefore is a stimulator of the national economy. It is against
this background that the construction industry has been recognized concurrently as a major
economic force, yet one of the more hazardous industries. The importance of the construction
industry in the national development cannot be overemphasized considering the fact that at
least 50% of the investments in various development plans is primarily in construction. In
underdeveloped countries it is the next employer of labor after agriculture (Diugwu, et al, 2012).
However many construction activities contain inherent health and safety risks, such as
working at height, working underground, working in confined spaces and close proximity to
falling materials, handling loads manually, handling hazardous substances, noises, dusts, using
plant equipment, fire, exposure to live electrical cables, poor housekeeping and ergonomics.
This article seeks to identify the requirements and the factors affecting health and safety
compliance in the construction companies in Imo State with the following identified problems:
1. The high level of exposure of construction workers to occupational hazards in
construction sites.
2. The lack of attention given to health and safety practices to reduce occupational hazards.
3. The non-compliance of construction companies to occupational health and safety practices.

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Objectives
The aim of this quality improvement project was to assess the compliance of construction
companies with Health and Safety regulations in construction sites. The following are the
objectives of the project:
1. To identify the Health and Safety regulations that construction companies must meet in
construction sites.
2. To assess the factors affecting compliance with Health and Safety requirements in
construction sites.
3. To recommend ways to implement Health and Safety regulations more effectively.
Scope
The study is limited to assessing the compliance of small and medium size construction
companies with health and safety regulations in construction sites in the Owerri, Orlu and
Okigwe zones of Imo State. The results of this project are also limited to the opinions of skilled
and unskilled construction workers of the studied companies. The scope is necessarily centered
on quality improvements needed for safety in the local geographic areas detailed. Therefore, the
scope is not necessarily applicable to generalizable knowledge or universal applicability.
Construction Health and Safety Scenario in Nigeria

Construction in developing countries, such as Nigeria, Pakistan and India, is more labor
intensive than in the developed areas of the globe, involving 2.5-10 times as many workers per
activity (Farooqu, 2008).
Typically, workers tend to be unskilled and migrate in a group, with or without their
families, throughout the country in search of employment. In fact, they are usually divided
into various factions. Communication problems related to differences in language, relation and
culture tend to inhibit safety on the work site.
In Nigeria, there is a significant difference between large and small contractors. Most
large firms do have a safety policy on paper, but employees in general are not aware of its
existence. Nevertheless, a number of major constructions companies do exhibit a concern for
safety and have established various safety procedures. They also provide training for workers
and hire professional safety personnel. In many developing countries the legislation governing
occupational safety and health (OHS) is significantly limited when compared with developed
countries. Unsafe conditions exist on many sites, both large and small, and laborers are subjected
to numerous hazards (Fung, et al, 2005)

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Health and Safety Requirements in Construction Sites

The following are areas covered by standard health and safety requirements for
construction sites:
1. Site Layout and Planning
2. Personal Protective Equipment (PPE)
3. First Aid Kits and Accident Reporting
4. Health and Safety Warning Signs
5. Welfare Facilities
6. Safety Training
7. Emergency Routes and Exits(Idubor and Oisamoje, 2013)
Methodology
With the aim of achieving the above objectives, this project was carried out via an appraisal
of literature in the areas of interest; and, with the use of a well structured questionnaire in view,
to obtain the opinion of both skilled and unskilled workers on the compliance of construction
companies with health and safety regulations in Imo State. The target population for this
project included the following:
1. Skilled workers (i.e. Artisans)
2. Unskilled workers (i.e. Labourers)
Voluntary random sampling was adopted so that all workers had equal opportunity to
participate. With regards to the sampling size in the distribution of the questionnaire, the
sampling size was determined based on the formula below considering the fact that the targeted
population was unknown.
n= (z2pq)/d2
Where:
n = the desired sample size
z = the ordinate on the Normal curve corresponding to α or the standard normal deviate,
usually any of the following determined based on the ‘margin error formula.’
1) A 90% level of confidence has α = 0.10 and critical value of zα/2 = 1.64.
4) A 99.5% level of confidence has α = 0.005 and critical value of zα/2 = 2.81.
p = the proportion in the target population estimated to have particular
characteristic (normally between the range of 0.1 – 0.5)
q= 1.0-p
d= degree of accuracy corresponding to the confidence level and Z selected.
For the purpose of this study, a confidence level of 95% was adopted in an attempt
to gain a reliable data collection. The sample size was thus determined as,
Z= 1.96, d= 0.05, where p= 0.1, q= 0.9
n= (1.962X0.1X0.9)/ (0.05)2= 138

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It therefore means that a total of 138 questionnaires (respondents) were sampled in the
area using random sampling technique. A well-structured questionnaire was employed and
administered to the workers to ascertain their assessment on the compliance of construction
companies to health and safety regulations. The questions were a mixture of open-ended and
close-ended questions that allowed for either Nil (N), Low (L), Moderate (M), High (H) or
Very High (VH) responses from respondents, especially where the opinion of the respondents
were to be ranked. The questionnaires were self administered, i.e. they were hand delivered to
the respondents, who were instructed to complete the questionnaires themselves.
Data Analysis Procedure

Responses from skilled and unskilled workers were collected and analyzed using descriptive
statistical methods. The results of the analysis were presented in simple percentages and tables.
The descriptive statistics method was used to evaluate the relative ranking of those factors
that affects the compliance of construction companies with health and safety regulations. The
results were transformed to relative importance indices based on the Likert Scale, to determine
the relative ranking of the factors. These scores were then transformed to a Relative Importance
Index (RII).
∑w 5n5 + 4n4 + 3n3 + 2n2 + 1n1
R11 = =
AN 5N
Where;
n1 = number of respondents for option designated as 1
N = total number of samples
Data Presentation and Analysis

This section presents and analyzes the data collected from the questionnaires in a statistical
form on the assessment of the compliance of construction companies with health and safety
regulations in Imo State. The analysis of the responses from the questionnaire is presented in
simple percentages to represent the opinion of the respondents to the questions asked.
Percentage Responses
Table 1.1 shows a summary of the percentage responses to the administered questionnaires.
The table shows that out of the 138 questionnaires distributed among the workers of the
four different construction companies in the three areas studied, a total of 112 (81.2%) were
successfully filled and returned. However, 18.8% (i.e. 26) of the questionnaires were not
returned as shown in the following tables.

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Table 1.1 Percentage Response
Questionnaires Frequency Percentage (%) Cumulative (%)
Questionnaire returned 112 81.2 81.2
Questionnaire Not returned 26 18.8 100
Total Questionnaire Administered 138 100
Source: Survey (2015)
Table 1.2 below shows the profile of the respondents to whom questionnaires were
administered. From the table it can be deduced that 71.0% of the respondents were male
compared with 29.0% female. Also, 30.0% were single and 70.0% were married. The educational
qualification shows that 32.0% of the respondents have only first learning certificate, 42.0%
with O’level certificate and 26.0% Ordinary National Diploma (O.N.D). The working
experience of the respondents indicates that 40.2% have 1-3 years experience, 39.3% have 4-6
years experience, 13.4% have 7-9 years experience and 7.10% have over 10 years experience.
Table 1.2 Respondent’s Profile:

S/N OPTION FREQUENCY %
i Gender A- Male 80 71.0
B- Female 32 29.0
Total 112 100

ii Marital Status A- Single 34 30.0
B- Married 78 70.0
Total 112 100

iii Educational A- First leaving certificate 36 32.0
Qualification B- O’level certificate 47 42.0
C- O.N.D 29 26.0
Total 112 100

iv Working A- 1 – 3 years 45 40.2
Experience B- 4- 6 years 44 39.3
C- 7 – 9 years 15 13.4
D- Over 10 years 8 7.10
Total 112 100


Factors Affecting Health and Safety Compliance

Table 1.3 below, shows the ranking of factors affecting Health and Safety Compliance.
From the table, it can be deduced that the respondents’ three most important factors were:
inadequate legislation, lack of health and safety inspectors in construction site due to insecurity/
dogmatic attitude of workers, and poor enforcement of health and safety laws. The two least
factors that affect health and safety compliance are: complexity of design and discrepancy.

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Table 1.3: Ranking of the Factors Affecting Health and Safety Compliance
S/N Factors Affecting Health 1 2 3 4 5 Ef Efx Mean Rii Rank
And Safety Compliance
1 Bribery and Corruption 17 21 26 24 24 112 353 3.15 0.63 7th
2 Discrepancy 12 40 32 20 8 112 308 2.75 0.55 14th
3 Political influence 10 30 30 30 12 112 340 3.04 0.60 9th
4 Severity of Penalties 15 28 39 18 12 112 320 2.86 0.57 12th
5 Lack of awareness of 19 20 23 35 15 112 343 3.06 0.61 9th
contractors on the
advantages of applying
health and safety
requirements
6 Procurements system 18 23 37 21 13 112 324 2.90 0.58 11th
7 Poor enforcement of health 10 26 28 20 28 112 366 3.27 0.65 4th
and safety laws
8 Inadequate legislation 9 13 37 27 26 112 384 3.43 0.69 1st
9 Management commitment 16 16 34 26 20 112 354 3.16 0.63 5th
and attitude to health and
safety requirements
10 Lack of health and safety 9 18 32 35 18 112 371 3.31 0.66 2nd
inspectors in construction
site due to insecurity
11 Lack of health and safety 12 21 26 39 14 112 358 3.20 0.64 5th
inspectors due to inadequate
funding
12 Dock mantic attitude of 10 15 41 22 24 112 371 3.31 0.66 2nd
workers
13 Complexity of design 18 26 38 20 10 112 314 2.80 0.56 13th
14 Lack of skilled person 12 24 33 28 15 112 346 3.09 0.62 8th
power
Legend: 1 = Nil, 2 = Low, 3 = Moderate, 4 = High, 5 = Very high.

Provisional Health and Safety Requirements on Site

Table 1.4 shows the ranking of Health and Safety Requirements on site. From the table it
can be deduced that the three most important health and safety requirements that topped the
rank in occurrence are: proper handling and storage of materials, explosives and combustibles,
adequate site layout/general site cleanliness, and suitable measures to prevent or reduce
exposure to dust. In the opinion of the respondents, the three least important health and safety
requirements were: back filling of hole and trenches properly and promptly to prevent falls,
appropriate safety signs in place, and provision of emergency routes and exits.

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Table 1.4 Health and Safety Requirements
S/N Health And Safety 1 2 3 4 5 Ef Efx Mean Rii Rank
Requirements
1 Adequate site layout 11 16 47 19 19 112 355 3.17 0.63 2nd
2 Properly 12 20 46 23 11 112 337 3.01 0.60 7th
maintained/
adequate scaffolding
3 Availability of 14 32 32 20 14 112 324 2.90 0.58 11th
Personal
Protective
equipment(PPE)
4 First Aid 9 30 40 23 10 112 331 2.95 0.59 9th
arrangement
5 Proper handling and 4 30 23 40 15 112 368 3.29 0.66 1st
storage of materials,
explosives and
combustible
6 General site 7 28 35 27 15 112 351 3.13 0.63 2nd
cleanliness
7 Back filling of holes 24 28 30 23 7 112 297 2.65 0.53 12th
and trenches
properly and
promptly to prevent
falls
8 Appropriate safety 22 31 31 21 7 112 296 2.64 0.53 12th
signs in place
9 Provision of 31 19 36 19 7 112 288 2.36 0.47 14th
emergency routes
and exits
10 Regular workers’ 17 23 31 29 12 112 332 2.96 0.59 9th
safety training
11 Adequate fire 16 17 39 28 12 112 339 3.03 0.61 5th
precautions in place
12 Adequate 13 15 46 28 10 112 343 3.06 0.61 5th
maintenance of
electrical systems in
safe condition
13 Suitable measures to 17 23 30 14 28 112 349 3.11 0.62 4th
prevent or reduce
exposure to dust
14 Properly shored 14 17 48 20 13 112 337 3.01 0.60 7th
excavation
Legend: 1 = Very low, 2 = Low, 3 = Average, 4 = High, 5 = Very high.


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Enforcement of Health and Safety Requirements
Table 1.5 below shows the ranking, according to the perception of the respondents, of the
measures suitable to the enforcement of health and safety requirements. The ranking based
on the Relative Importance Index establishes that the three most important measures for the
enforcement of health and safety requirements are: enforcement of occupational safety at local
levels, recruitment and training of enforcement officers by the enforcement authority, and
making provisions for adequate occupational safety and health information. The two lowest
ranking measures to enforce health and safety requirements are: the adoption of self-regulatory
style of enforcement by organizations, and updating and revising occupational safety and health
regulations as required by relevant authorities.
Table 1.5 Ranking of Measures to Enforce Health and Safety Requirements

S/N Measures To Enforce 1 2 3 4 5 Ef Efx Mean Rii Rank
Health And Safety
Requirements
1 Recruitment and training of 12 13 29 25 33 112 390 3.48 0.70 2nd
enforcement officers by
enforcement authority
2 Adoption of self-regulatory 9 16 35 31 21 112 375 3.35 0.67 5th
style of enforcement by
organizations
3 Enforcement of occupational 2 18 36 30 26 112 396 3.54 0.71 1st
safety at local level
4 Making provisions for 12 11 31 34 24 112 383 3.42 0.70 2nd
adequate occupational safety
and health information
5 Development and adoption 9 14 34 35 20 112 379 3.38 0.68 4th
of Approved Code of
Practice
6 Updating and revising 15 15 25 34 23 112 371 3.31 0.66 6th
occupational safety and
health regulations as
required by relevant
authorities
Legend: 1 = Nil, 2 = Low, 3 = Moderate, 4 = High, 5 = Very high.


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Summary of Findings
The results of this project revealed that lack of appropriate legislation is the major factor in
the non-compliance with health and safety requirements by construction companies. This lack
must be addressed urgently by the government if companies are to adhere strictly to health and
safety regulations.
Other factors revealed that account for non-compliance include:

1. Lack of health and safety inspectors in construction sites due to insecurity: High level of
insecurity characterizes Nigeria, e.g., bomb explosions and kidnapping. As a result, the
security of enforcement officers is questionable.
2. Dogmatic attitude of workers: Most workers, due to their long stay in the construction
industry, tend to have deaf ears to health and safety rules. Their familiarity with
construction activities makes them susceptible to not obeying health and safety rules and
thereby endangering lives from occupational hazards.
3. Poor enforcement of health and safety laws due to bribery and corruption: The corruption
level in Nigeria is high as Transparency International (2012) ranks Nigeria 139 out of 176
in terms of corruption perception index. Surely, this may hinder effective enforcement in
the country as the activities of authorities responsible for enforcing the laws are seen as
questionable. Nevertheless, whether the rationale for enforcing OSH regulations is for
selfish financial reasons or to achieve the aims of the regulations, the facts are that the
efficacy of OHS regulations enforcement is poor, corruption and bribery hinder effective
enforcement of regulations, and the authorities that tackle corruption in Nigeria appear not
to be doing enough.
4. Management commitment and attitude to health and safety.
Conclusion
The assessment of the compliance of construction companies with health and safety
requirements in this project indicate that most construction companies in the study areas fail to
comply with Occupational Safety and Health Association (OHSA) regulatory requirements.
Other aspects assessed included the factors that affect non-compliance by construction
companies with OHSA regulations, the health and safety requirements available at the site,
and the measures taken to enforce these OHSA regulatory requirements. The main reason for
non-compliance with health and safety regulations is the lack of the government’s health and
safety legislation being required of mostly smaller construction companies, sub-contractors and
site operatives. However, it emerged from the study that contractors benefit from a safe work
environment with increased levels of compliance with OHSA requirements. This suggests that,
although complying with the OHSA regulations involves upfront costs, these costs saved health
and lives. Preventing potential accidents outweighs the cost of non-compliance. It is, however,
hoped that the results of this project’s study will form the basis of a more inclusive survey of
Health and Safety in the Nigerian construction industry in the future.

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Recommendations
Based on the findings of this project, the following are the recommendations that will help
to resolve the existing situation.
1. Workers with moderate or high levels of educational qualification and work experience
should be considered for employment so as to have easy communication with safety
supervisors on safety issues.
2. Lack of appropriate legislation on construction health and safety, a requirement that is seen
as the major cause of non-compliance to health and safety requirements by construction
companies as noted by the respondents, needs to be addressed urgently by the government.
The efforts of the government in addressing these lapses are not impressive. The Factories
Act of 1987 (now known as Factories Act of 1990) does not address factory hygiene issues,
which recognize workplace serious health issues and does not require the use of Personal
Protective Equipment (PPE) in the construction industry.
3. Emergency routes and exits should be provided in every construction site to enable workers
to have access to a safe place in order not to be caught up in an unforeseen disaster that
might occur during construction work. Muster points should be located on site for workers
to gather in during hazards so that the number of saved workers can be ascertained. Also
there should be an adequate site layout and general site cleanliness at all times.
4. Enforcement of health and safety requirements is the key to the oversight and correction
of the majority of construction companies that fail to comply with health and safety
regulations. Therefore, enforcement of occupational health and safety regulations at the
local level should be enforced effectively. Also, adequate occupational safety and health
information and recruitment and training of enforcement officers by the enforcement
authority are vital.

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Anthropological Synthesis of Spirituality and Pain
Management: How Spirituality Affects Pain Outcomes
and Copings
Andrew A. Ovienloba, MA, DIR, MA, PhD
President, School of The Faith and Leadership
Benin City, Nigeria
Email: vavandy@icloud.com
Author Note
The content of this article was originally presented at the Montefiore Third Annual Pain
Symposium on November 5, 2013 at the Montefiore Medical Center Bronx, New York. The
content represents the research and scholarly opinions of the author and does not represent the
official positions of the organizations he has served. The author has no conflicts of interest.
Abstract
Sickness and pain more often than not redefine the dignity and individuality of persons. They
reorient the way individuals see themselves, others, and God in their lives. Religion and science
oftentimes have been perceived and treated as incompatible entities whose realities conflict or
operate at cross-purposes. As true as this assumption may be in some cognitive parlance, the
concept of religion and the language of religion that is “spirituality,” remain one essential coping
mechanism to which the human person often makes recourse under the yoke of excruciating
physiological and psychosomatic pain. How these realities coordinate science and religion
to meet a desired goal remains a complex but evolving field for research study. This article
therefore, attempts to look at the various synergistic opportunities that individuals utilize to
familiarize and coordinate their experience of faith and medicine from an anthropological
perspective. Tapping on the different spiritual realities of Islam, Judaism, Christianity, Oriental
Religion, and African Traditional Religion, this article precisely analyzes how a patient’s
spirituality effectively impacts pain and coping mechanisms in oncological settings and how
caregivers can utilize such opportunities.
Keywords: Spirituality, pain management, human needs, Christianity, Islam, Hinduism, African
Traditional Religion, death and dying
Introduction
It was about 2:30 pm. My beeper rings. It was a call from the Hematology/Oncology
department. A family wanted to see the Chaplain urgently. I rushed down the elevator, got to
the room packed with friends and family members but was stunned by the birthday decorations.
Then a gentleman walked to my side and said to me; “Do whatever you can for my daughter,
Father. She is in great pain and we are all in an unbelievable pain.” I walked closer to the bedside
and realized it was “Zeda” (pseudonym), a patient who had never wanted to speak with me for
the few months she had been in the hospital. She grabbed my hands, looked straight into my
eyes and said to me, “I do not want to die, Father!” After she said this, tears flowed down her

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cheeks profusely and her friends in the room joined her in a river of tears, as if to drown the
dance they dreaded to dance all along. It was Zeda’s birthday and it had become quite obvious
to Zeda, her friends, and family that the battle for Zeda’s life had shifted to an obvious negative
position. The energy in the room was fully charged with hopelessness and helplessness. Fear
of the unknown shot pain through the emotional veins not only of Zeda, but also all involved.
I watched Zeda progress from anger and denial, through resentment to gradual acceptance/
reluctant surrender, spiritual resolve, and peaceful transition. But the synthetic layers of pain
in the life of Zeda, her friends, and her family were better observed than described. This is my
experience of pain with patients in the hospital.
The dream of every human person, as in the case of Zeda, is to live a life free from pain or
at least with minimal pain of any sort. Yet grasping the unkind hands of pain is inevitable in life.
As Peterson and Mutter state:
Pain is ubiquitous, and occurs in varying domains including emotional and mental anguish,
with intensities that vary from mild to debilitating, and roles such as interpersonal or
spiritual distress. The way patients and caregivers cope with pain may be adaptive or
maladaptive depending on the nature of the pain (Peterson & Mutter, 2010, p.182).
In the above case of Zeda, I witnessed the reality of maladaption, rejection, and reluctant
adaptive submissiveness. But in her adaptive phase, prayer and spirituality became her source
of peace and connection with the outside world. Before she died she was determined to be
baptized and practiced daily communion. I was amazed at how Zeda and her family found
peace with the beaconing reality of death through a deep romance with spirituality. At this
point, I came to the realization that the varieties of pains there are reflect the complexities of the
human person in search of meaningful response to embodied threat or an existential desire for
a comprehensive life of peace and tranquility. Reasoning from the case study above, my attempt
in this article will be to explain how spirituality and religious beliefs serve as a useful resource
in coping and managing pain. Additionally, the article will argue that these tools are deeply
important for dealing with patients and their needs.
What is Spirituality and What is Pain?

Because of the different ways people conceptualize their sense of spiritual self, spirituality
is a very difficult concept to define. Nonetheless, a clear understanding of religious practices can
help to clarify what is spiritual. Different scholars at different points in history have attempted
to define religion and religious practices based on their theological backgrounds. For example,
in the Anatomy of the Sacred, Livingston (2009) presented a catalogue of various attempt at
defining the concept of religion.
Religion is the belief in an ever-living God, that is, in a Divine Mind and Will ruling the
Universe and holding moral relations with mankind. [ James Martineau]. 2) The essence
of Religion consists in the feeling of an absolute dependence. [Friedrich Schleiermacher].
3) Religion is that which grows out of, and gives expression to, experience of the holy in
its various aspects. [Rudolf Otto]. 4.) The religious is any activity pursued in behalf of an
ideal end against obstacles and in spite of threats of personal loss because of its general and
enduring value. [ John Dewey]. 5.) Religion is the state of being grasped by an ultimate
concern, a concern, which qualifies all other, concerns as preliminary and which itself

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contains the answer to question of meaning of our life. [Paul Tillich]. 6.) Religion centers
upon an awareness and response to a reality that transcends our world and us whether the
‘direction’ of transcendence be beyond or within or both...this object is characterized more
generally as a cosmic power, or more specifically as a personal God [ John Hick] (Levinson,
2009, in Amazon Kindle Edition).
These definitions typify the various ways people often conceptualize their sense of religion
as either social or cultic. Thus each of the above opinions grounds its logic and philosophy
in a different school of thought. On a personal note, this author sees religion from an
anthropological perspective. Religion could better be understood within the meaning of culture
and cultural values. What is culture? Culture resonates as the sum total of the life experience,
beliefs, values, and the way of life of a living people. In the language of Augsburger (1992),
“culture embodies the authenticity and unique purposes of each community.... Each culture
seeks to express a people’s values, sensitivity, and spirituality” (p.7).
From this perspective, religion is a subdivision of culture that helps maintain philosophical
balance for those who live and believe in that cultural space. Religion creates sanity for
individuals who crave meaning regarding the myths and mysteries of daily life; and without
which chaos and anarchy will pervade the human experience. Religion can be organized or
unorganized but it nevertheless represents our individual or collective articulation of a sense
of the non-corporeal as we experience it. The language of that cultic articulation of the non-
corporeal but pervasive presence in the human psyche is what is often termed as spirituality. As
this author has stated previously:
Religion is an intrinsic part of culture that responds to people’s questions about life, death
and the afterlife by restoring hope and replacing fear and anxiety with the presence of a
divine comfort that soothes human needs. Spirituality, on the other hand, is the language
religion uses to express itself. This linguistic provision could be verbal or non-verbal or
even just a feeling of satisfaction communicated from an unexplainable source (Ovienloba,
2012, p.116).
Thus the experience of the inner serenity and resilient assurance from within, as seen in
the Zeda story above, is an expression of an inner sense of the divine that dignifies, and gives
meaningful assent to our sense of self and dignified identity. Everyone connects with this inner
call of search for Who am I? Where did I come from? and Where am I going from here? There
can be no better time to be forced to respond to this innate search for destiny than when our
existence is threatened. For example, what Zeda’s maladjusted phase suggests is a deep feeling
of threat to her identity and her dream of a blossoming life. But once she was able to journey
through this phase through some personal connection with her spiritual self, her fear became
her strength. Essentially then, spirituality is our language of search for meaning in life. For the
most part, it serves as a non-verbal companion on the road less travelled by those in pain, as they
search for meaningful ways to understand their new phase of life.
During those moments of silence in the void of seeming hopelessness, and the crisis of
faith in one’s self and the institutions, spirituality creates an assurance that in the stillness
of our lives there is a hand that truly cares and understands our pain even when the voice
is not forthcoming. It is an inner experience that affirms and supports the individual in
differentiating his or her personal identity as distinct from and deeper than the disease they

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suffer. For example, for as long as Zeda personified the disease, her emotions were filled with
anger, resentment, rejection, and fear. But once I was able to help her separate herself from the
disease, a transformation occurred. This is where the Latin definition of religio, which means to
rebind, becomes a reality. Our inner spirit aids us towards a self-reconstruction away from the
helplessness of the uneventful circumstance in the human existential journey. The stronger our
connection with this inner resource, the better we fare. This is where the value of institutional
religious groupings holds rich promise because of their potential to hone people’s abilities to use
these innate skills.
Pain: What is Pain and How Do We Describe Pain?

There are several definitions and analyses regarding the concept of pain. In this article
I would like to speak of pain as “A complex experience consisting of a physiological (bodily)
response to a noxious stimulus followed by an affective (emotional) response to that event”
(http://www.pain-management-info.com/definition-of-pain.htm ). While the physiological
(bodily) response to noxious stimuli is often easily responded to through a pharmacological
approach, the healing science of psychotherapy has often been charged with the care of the
affective (emotional) dimension of pain.
While these approaches have worked with tremendous results over the years, affective
pain demands more than acquiring a new occupational skill. Affective pain speaks to the heart
of spiritual pain. Spiritual pain raises question about guilt regarding the source of the pain,
anxiety about the ends of the pain, and pertinent questions about the ultimate meaning of life
and death. Spiritual pain grips the psychosocial and psychological fabric of the entire person
and resonates in the physiological balance of the individual as chronic or enduring suffering
and pain. This could be the product of what Ranney, in the “Anatomy of Pain” described as the
“emotional consequences and behavioral responses to the cognitive and emotional aspects of
pain” (Ranney, Ibid).
For example, when I had the opportunity to enter into personal discussion with Zeda, and
she became emotionally open to me, her first statement was ‘I am afraid about where I am going
and what happens to my family.’ Fear was a very strong and powerful element in the pain that
Zeda embodied. How do you medicate that? Her response to that was to shut everyone out of
her emotional space because she felt no one understood and, even if they did, they could not
help her. It needed more than a sympathetic affinity prayer or kind words. What she needed
was an inner assurance of security that would humanize and affirm her identity beyond her
visible reality through a spiritual presence. And this is where spiritual empathy comes along as a
professional, emotional healing tool.
One study that further contributes to the understanding of the complexities of pain
was conducted by Melzack and Wall (1965 &1970). In their study the authors proposed
the “conceptualization of pain as a sensory phenomenon with a multidimensional construct
that integrates motivational–affective and cognitive–evaluative components with sensory–
physiologic ones” (Melzack & Wall, 1965 & 1970). This conceptualization of pain mediates
the reflexive and ontological dimension of pain as an evolutionary process of being. The
International Association for the Study of Pain defined pain as “an unpleasant sensory and
emotional experience associated with actual or potential tissue damage and described in terms of
such damage” (Mako, Galek, & Poppito 2006).

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Once more we are called to some ontological questioning on behalf of those populations
who experience pain without tissue damage or any likely pathophysiologic cause, suggesting
that such pain may have psychological roots (Ibid.). In other words, pain is more than tissue
damage shown on an MRI. Some studies have shown that there are some varied experiences
of pain that do not register in diagnostic imaging of neurophysiologic instruments. Such
pains that redound on the entire body from an unexplainable source resonate as spiritual pain
requiring a multi-disciplinary and multidimensional approach. This includes pharmacological,
psychotherapeutic and cultural spiritual approaches to pain management. Cultural spiritual
approaches here would include a treatment plan that integrates the perspective of an individual’s
sense of self and belief. This approach honors individuals as human beings with identity, cultural
beliefs/meanings, and purpose beyond the disease.
The Anthropology of Spirituality and Pain Response

Cultural behavior regarding sickness and pain management varies from place to place
and from person to person. What may seem culturally and spiritually acceptable to one may
be an aberration to another. The variation in peoples’ beliefs is equally transported into how
they respond to the management of their pain and sickness. In some parts of the world as in
Africa, the Caribbean, Asia, and perhaps among cultural Indians, sickness and pain is a spiritual
matter. In some cases, it is a private affair because of the cultural beliefs that come with the
state of illness. In some cultures people include spiritual rituals to satisfy the gods of their land
and thereby hope to alleviate the pain or ensure hope for a cure. Aside from the rituals, marks
are engraved on the skin of the sick person. Charms and amulets are equally and often worn
either as waistband or wristband to ward off evil spirits believed to be inflicting pain on the
sick. People are shaped to a great extent by what they come to believe and often engage their life
journeys through the lens of their faith or belief system. In Man, Medicine, and Environment,
Dubos (1968, in Ovienloba 2012, p. 117) opined,
Throughout history and whatever the level of civilization, the structure of medicine has been
determined not only by the state of science but also by religious and philosophical beliefs.
This is just as true of the most evolved urban and industrialized societies as it is of the most
primitive populations. Like his Stone Age ancestors, modern man lives by myth (p.255).
It is these myths of life and survival that are reflected and codified in the various rituals
and religious documents many use as guiding principles in their lives. The Holy Quran for
example indicates to its believers the divine imprint of Allah on pain and sickness. It states that
only Allah can take away pain and sickness (Holy Quran, Surah 6:7, 26:80, 10:47, and 17:82).
Islamic medicine combines faith and divine ethics to attain harmony and universal equilibrium.
Illness is a vehicle for cleansing and knowledge of Allah. Furthermore, it is firmly held that
Believers can seek help but within the ethics of faith and Islamic practice (Rassool, 2000). In
the Hindu and Buddhist cultural religions, pain and suffering are not negative phenomena.
Pain and suffering are linked to the laws of Karma, life process, and rebirth. Thus it ought to
be perceived as a purifying call in the life of those who suffer pain and illness of any kind. For
persons in these religious traditions, pain and suffering ought to be embraced with a sense
of liberative-ritual spirituality, detachment, and acceptance (Morse, p.212, Fadiman, 1997,
Ashima, 2007, Pp.29 (1); 29-32).

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Among the Tribal Nations in Canada and the United States, sickness and pain are also
approached with a spiritual investigative dialogue with nature. A craving for balance between
the spiritual and physical is highly prized. Thus “Aboriginal healing practices explore the
spiritual along with the physical, using rituals and ceremony to heal a person’s entire being.
With Aboriginal methods, healing ...is a journey and a process that is just as spiritually based
as it is physically based” (McKenna, 2012, p.66). Within this context, “spirituality is that vital,
intangible aspect of life that attempts to meaningfully clarify and preserve the wealth of our
cultural heritage” plundered by illness (Ovienloba, 2012). Interestingly, among traditional
Africans, the herbalist who doubles as a native doctor employs the help of the gods of the land
to attain cutting edge treatments. Oracles are consulted for directions while they enter into
open conversation with plants and healing trees in the middle of the night at a specified spot in
the forest to get the right root herbs for treatment. Like Robert Boyle once noted, doctors are
perceived within these cultures as priests of nature.
Additionally, the Judeo-Christian Tradition adopts an inclusive approach to science and

faith. In the book of Sirach 38:1-2, believers are enjoined to “honor physicians for their services,
for the Lord created them, for their gift of healing comes from the Most High.” Thus Judeo-
Christian theology approaches sickness from a psychosomatic perspective. It holds that physical
illness goes beyond the visible to reflect a spiritual and mental state of being. Christian theology
on sickness is incarnational and cultic. It builds on the Letter of St. James 5:13-20 that calls for
confession of sins and ministry by the priest for redemptive healing and union with Christ the
Eternal Physician. The Catechism of the Roman Catholic Church equally holds sickness and
pain as a call to a new way of being, or an invitation to conversion and personal union with God
who is the healer (CCC art, 5). The difference between the Judaic and Christian perspectives is
the presence of the Christ figure who is seen as defining the incarnational substance of Christian
theology of pain, sickness and wholeness. The Judaic perspective is creational and thus God,
the Creator of the Universe, who chose Israel as his own people, is the Healer of all sickness
and pain as he promised (Ex. 15:26, Is. 33:24). The prayer for the sick in cultural Judaism and
Kaddish, recited at funerals, reflects this belief. Notably, Christians and Jews often use the same
Hebrew Biblical sources to justify their theological claims for the healing power of their faith.
How Spirituality Affects Pain Outcomes and Coping

Scientific studies and theories grounding understanding of how spirituality affects pain
outcomes and copings are still in their infancy. The limitation in the availability of robust
theories and studies, in spite of the pervasive presence of religion and spirituality in human
history, is largely based on the over-sensitized suspicion of the negative effect of religion
among some medical scholars. This began in the late 19th century when major breakthroughs
came with the discoveries of efficient and effective vaccines and treatment options. Worries
of some medical scientists were analyzed on the basis of looking at religion through the lens
of laboratory/empirical equivocations of correlating cause and effect. Additionally, other
associative conjectures, such as anxiety producing elements of fear of divine retribution and past
institutional overbearing control of organized religion, historically stifled freedom of research
and practice (e.g. Consider Galileo Galilei’s experience.). These fears are real and may have
some merit, but nonetheless, they are often overblown in contemporary experience by some
overzealous scientists who create unnecessary tension between faith and reason (Pope John Paul
II, 1998, Fides et Ratio). Religion and medicine ultimately have the same goal of health and
wellbeing. However, their methods and focus in reaching that goal differ. While science and

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medicine focus on disease control and cure as a way of caring for the human person, religion
and spiritual care adopt a holistic human-spiritual approach that responds to both physical and
emotional/spiritual pains that cannot be medicated to attain optimum health and wellbeing.
This realization in recent time may explain the re-valuation of the speculative dismissive tension
between the disciplines over the last decades. For example, medical schools are now evolving
courses such as in culture and health or epidemiology of spirituality etc. Also, in the last twenty
years there has been an ever-increasing scientific body of statistical evidence demonstrating
correlating effects of religious beliefs and practices on human health.
Recent studies that have attempted to demonstrate how spirituality affects pain outcomes
and coping include one conducted by Kapogiannis and colleagues (2009). These scholars
…..conducted functional magnetic resonance imaging (fMRI) studies to learn how

religious beliefs are processed in the brain.... Inzlicht and colleagues (2009) equally
discovered that religious convictions had an anti-anxiety effect for the persons who held
them.... ( Johnson, 2010, In Ovienloba, 2012, p.116).
Kapogiannis and colleagues’ research discovery echoes social cognitive theory. “Social
cognitive theory states that personal factors (beliefs and other cognitions) and environmental
factors (physical and social) interact to influence behavior [and emotions]” (Harvey, 2008).
Spiritual care combines social cognitive and resilience theory to impact positively
the self-efficacy of individuals in pain through pastoral presence and support. In Assessing
self- management and spirituality practices among older women, Harvey (2008) indicated the
increasing beneficial use of spirituality as a coping tool for persons dealing with chronic pain
and disease. Young (In Harvey 2008) conducted a qualitative interviewing of 12 adults.
These adults indicated that their spirituality gave them a feeling of well-being, which
emanated from the belief that God knew their needs and empowered them to continue to
survive through difficult times. In a correlative study, Pressman (25) showed that among
elderly women hospitalized for hip fractures (n = 30), those with stronger spirituality had
a better ambulation status at discharge (F = 12.15, df = 1.26, P<0.002). Samuel-Hodge
(26) used a focus group to study the influences of spirituality on self-management among
70 diabetic African American women. Informants articulated that spirituality was an
important factor in the self-management of their diabetes (Harvey, 2008).
Puchalsky (2001) observed that patients explore the tool of spirituality to manage their
pain in three different forms namely: mortality, coping and recovery. Observational study
conducted by Strawbridge, Cohen and Kaplan (1998) hypothesized the relationship between
longevity and regular attendance of religious services. Spiritual practice and belonging to a
religious group creates a systemic coping mechanism for pain patients. It does this by positively
insulating them from the feeling of isolation and loss of self-actualization. Pain resulting from
a life threatening illness more often than not creates a sense of vulnerability. These life feelings
oftentimes come with a soul-searching experience of guilt, as well as uncertainty about the
past, present, and future. Guilt often comes with self-scapegoating. Self-scapegoating includes
a feeling that portrays pain and chronic illness as possible punishment for past life wrongdoing
occurring in the present with less hope for the future. This in turn leads to suffering that
can exacerbate pain. Certainly we are aware that morphine and Tylenol attend to disease’s

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pains, but the suffering involved with this type of pain needs a different medication entirely.
What spirituality and spiritual beliefs do at this point is provide the needed ware for resilient
assurance. Dr. Jeff Levin (2001) in “God, Faith, and Health: Exploring the Spirituality-Healing
Connection,” indicated in his seven researched analytical principles that:
Religious affiliation and membership benefit health by promoting healthy behavioral

lifestyles. 2.) Regular religious fellowship benefits health by offering support that buffers
the effects of stress and isolation. 3.) Participation in worship and prayer benefits health
through the physiological effects of positive emotions, 4.) Religious beliefs benefit health
by their similarity to health-promoting beliefs and personality styles. 5.) Simple faith
benefits health by leading to thoughts of hope, optimism, and positive expectation. 6.)
Mystical experiences benefits health by activating a healing bioenergy or life force or altered
state of consciousness. 7.) Absent prayer for others is capable of healing paranormal means or
by divine intervention (Levin, 2001, Pp. 13-14).
Seybold and Hill, (2001) in The Role of Religion and Spirituality in Mental and Physical
Health, seem to support Levin (2001). Seybold and Hill’s research noted that spiritual
and religious practice through its hope reinforcing synergies affects “various physiological
mechanisms involved in health (Larson et al., 1998).” For these scholars,
Positive emotions (e.g., forgiveness, hope, contentment, love) might benefit the
individual through their impact on neural pathways that connect to the endocrine and
immune systems. Negative emotional states (e.g., anger and fear) can lead to arousal
of the sympathetic nervous system (SNS) and the hypothalamic-pituitary adrenal axis
(HPA), systems involved in mobilizing the body’s energy during stressful situations. Such
excitability can produce a stress response in the body? .... The stress response, in turn, can
lead over time to inhibition of the immune system, increased risk of infection, increased
blood pressure, impaired healing response, and increased risk of stroke and heart attack.
Meditation, forgiveness, and certain religious and spiritual thoughts might reduce the
arousal in the SNS and HPA (Thoresen, 1999), increasing immune competence and
restoring physiological stability (Seybold and Hill 2001, p. 23).
The impact of spirituality in pain management can further be understood through identity
and Abraham Maslow’s human needs theories. Human needs and the hierarchy of needs theory
holds that individuals are born with certain innate needs that include the physiological, safety,
belongingness, and love, esteem and self-actualization. According to Maslow, these needs are
attained based on priorities. However, prioritization of these needs could be offset by social
events or other unforeseen circumstance, such as sickness and pain that can reorder levels of
prioritizations (Schultz & Schultz, 2013, PP246-247).
In the case for individuals dealing with chronic delimitating pain the priority of needs are
definitely altered. What spirituality does here is to boost the safety needs (assurance of divine
security), belongingness (responding to social isolation needs through participation in religious
services), and esteem (reinforcing the sense of self through affirmative non-discriminating
acceptance in the group). Underwood and Teresi (2002) in their research observed that certain
feelings tapped by their Daily Spiritual Experiences Scale (DSES), such as experiences of God’s
presence and guidance,

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…..may reduce feelings of psychological stress, thereby moderating the link between social
stressors and health and well-being. Additionally, the experiences of comfort, love, and
spiritual peace may reduce feelings of anxiety and depression, and may elevate mood and
promote optimism and self- esteem (Underwood & Teresi, 2002; Lawler & Younge, 2002;
Ellison & Fan, 2008, p. 249; Amoah, 2011).
Furthermore, a feeling of vulnerability could lead to identity challenges and threats often
attributed to limitations caused by the presence of pain. For example, this identity challenges
were visible in the life of Zeda especially when her chemotherapy started taking toll on her
appearance. While individual identity is socially constructed, “psychological states of challenges
and threat can be faced through changes in physiological responses that are concomitant with
[circumstantial] experiences” (Inzlicht & Schmader, 2012, p.56). Specifically,
…..challenges and threat theory maintains that responses to stressful situations are a
combination of individuals’ assessment of available resources relative to task demands:
when resources are higher than demands, individuals are more likely to experience
challenge, whereas when demands exceed resources, individuals experience threat (Ibid).
Given the fact that chronic pain, especially in a palliative situation, may give a glimpse of
death; there is the possibility of a feeling of sense of helplessness or resignation to fate due to
a cognitive assessment that the resources available fall short compared to the demands of the
pervasive pain condition. In this case, religious service provides an affirmative reason to forge
ahead with faith, hope, and love.
Different studies, including results from a pain questionnaire distributed by the American
Pain Society to hospitalized patients, indicated that patients with strong spiritual beliefs tend to
cope better than those with none in dealing with their symptoms and pains. They were observed
to live happier with better stress management skills. Personal prayer was especially reflected
as the most common non-clinical tool patients used to manage their pain and symptoms
(Puchalsky, 2001, p.353; Seybold & Hill, 2001). Another research study with individuals
with sickle cell disease showed “frequent attendance at church was related to lower sensory
and affective experiences of pain, as well as fewer symptoms of somatization, depression, and
anxiety (Harrison et al. 2005)” (Wachholtz, Pearce, & Koenig, 2007, p.313). In the same study
regular attendance at church service was also linked to lower self-report of pain intensity among
individuals in the same group. Seybold and Hill, (2001) observed that religious beliefs and
practices engender certain behavioral changes that necessarily impact the health and wellbeing
of individuals. Moreover, individuals with strong beliefs and attachment to their religious
sentiments are more inclined to behavioral modifications in favor of a healthy lifestyle than
those without faith group associations.
Essentially, spirituality attempts to respond to the issues of suffering connected with human
needs in pain management. Additionally, pastoral care investigates and responds to questions
such as: What are the fears, worries, uncertainty or mental state about the present condition?
Are there questions as to whether one’s pain is a punishment for sin or one’s lacks? Spirituality is
extremely valued and needed to assist those who are suffering such matters in times of pain.

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Conclusion
Sickness and pain more often than not redefine the dignity and individuality of persons.
They reorient the way individuals see themselves, others, and God in their lives. This experience
is more than a physiological or pharmacological need. It is a spiritual experience that comes
from the core of what it means to be human. The healing and management service that pastoral
care brings to the table is an attempt to underscore a person’s experience of illness of any sort,
as a journey that requires faith, hope, and serenity in order to experience physical, spiritual,
and emotional healing. Thus chaplains mostly pray with patients and for the patients as fellow
human beings on a unique self-revealing and enriching journey. Prayer brings in that language of
“I care” to assist and bring care to the troubled identity and self-actualization questions hidden
in the rubbled quarries of what is going on with one’s body and when or where will the pain
end? Spirituality attends to those fears, improves hope, and minimizes the feeling of helplessness
that feed into the various veins and neurons of pain. It therefore is a most needed compliment
to all the medications patients take. Yates et al’s (1981) research findings supports this prospect
when it indicated that religious activities improve moods, elevate pain tolerance, reduce anxiety,
facilitate relaxation and thus allow for blood flow the absence of which would otherwise
intensify pain (Yates et.al. 1981 in Wachholtz, Pearce, & Koenig, 2007, p.313).
Finally, different studies have indicated that most patients would rather trust a physician
who inquires about their beliefs and faith over DNR and DNI, especially during life threatening
illness. A pulmonary outpatient study from the University of Pennsylvania and a report from the
USA Weekend Faith and Health poll indicated 65-94% for whom spirituality was important
wanted their doctor to address issues about their spiritual beliefs during a visit. Fifty percent for
whom spirituality was not important thought it was important still for their physician to address
their spiritual needs. Sixty-six percent agreed that a physician’s inquiry about their spiritual beliefs
would strengthen their trust in the physician (Puchalski, 2001, p.354). The reasons for this desire
are quite obvious: Spirituality humanizes the person, and helps to heal the potential problem that
a patient might be objectified as the disease to be treated.
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Academic Commentary
A Clamor in the Market Place:

Meaning and Discourse in the Commerce
of Healthcare and Research Institutions
Dr. Edward Gabriele
President and Executive Director
Semper Vi Foundation
Author Note
This article is a revised and updated version of an academic presentation made by the author in
1999. The author is the copyright owner of the original material. The opinions reflected in this
article are those of the author and do not reflect the official policy of any institutions the author
assists. The author has no conflicts of interest.
Abstract
Language both expresses and forms identity as a developmental phenomenon for individuals
and human organizations. Language is one of the most powerful acts of performative
meaning in personal, cultural and professional life. The ability to reflect critically upon often
subconscious choices of language and linguistic patterns is essential to gaining extremely
valuable insight into the unarticulated but overwhelmingly powerful paradigms of meaning
central to the self-conception of individuals and organizations as well as to the interaction or
mission which individuals and organizations cultivate with the wider expanse of the world.
Healers, healthcare leaders, researchers, related institutions and executives adopt concepts and
language patterns to describe who they are and what they do. As in the current ambivalent use
of the terms “customer” and “client” to describe those that many institutions serve, linguistic
patterns are not always chosen with sufficient and insightful precision, thus leaving doors
open for the incursion of less than desirable self-understandings and professional patterns of
behavioral interaction. Healthcare and research leaders are best served when they critique with
care the implications of institutional choices in professional discourse to describe “who we are”
and “what we do” to ourselves, to our wider communities, and to those whose needs we serve.
Keywords: Language, linguistics, performative meaning, ritual processes, leadership formation

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Introduction:
The Clamor of the Healthcare and Research Marketplace
In the last many years, I have attended any number of meetings, the purpose of which was
to discuss emergent management styles and practices for strategic organizational reshaping of
healthcare and research. During the course of these meetings various seminar leaders and guest
lecturers consistently, and rather persuasively, proposed the integration of current American
industry-concepts into the self-understanding of healthcare and research institutions associated
with universities and federal agencies. Some of these included concepts such as “team building,”
“delegation of authority,” “metrics of success for product development and attainment of
goals,” “differentiating macro and micro management,” and “customer service.” I remember
with some vividness how the term “customer service” made me distinctly uneasy. At first I
could not understand my lack of comfort with the term. However, the more I have attended
these meetings and engaged in subsequent conversations with those who seemed favorably
inclined toward such terminology, the more my discomfort has grown. As often as I heard
the term “customer service,” the more the images of bargain basement let-downs in discount
super-stores began rising up in my imagination. As often as seminar leaders kept reminding
us that our institutions had to develop “good customer service strategies,” I kept thinking
about how I felt when having to head toward a customer service desk in a department store to
exchange an item, question when a particular item would arrive on the shelves, or lodge the
occasional complaint at how I was treated by a “service representative.” In short, my persistent
reaction today to the clamor of “customer service” terminology in the healthcare and research
marketplace is proportional to the impatience I feel at being placed on “hold” during a home
phone call to a utility company waiting for fifteen or twenty minutes until a “customer service
representative” picks up the line, quickly asks for my account information and last four digits of
my social security number, and then just as quickly dispatches our connection with a polite but
perfunctory “Have a nice day.”
Today, the language of customer service and other current business phrases and concepts
has made its way into organizational manuals for research institutions and standard operating
procedure documents for health and research endeavors. In a far too easy fashion, these
linguistic constructions and their underlying paradigms seem to have become the most current
way of expressing and understanding who we are as healers, scientists or administrators and the
giftedness that we bring to the table of American genius. However, as with all other emerging
vocabularies and linguistic patterns, one has to wonder if those currently shaping the design
of our organizations have clearly explored the implications of such linguistic and conceptual
patterns of self-understanding and on-going institutional formation.
In addition, I have found it curious that, when discussing the integration of customer
service and other fashionable concepts and vocabularies into contemporary healthcare and
research life, almost immediately my colleagues from a wide variety of institutions add how
much their respective communities have changed in these last decades as the language of
American business has been assimilated by institutions dedicated to biomedical endeavors.
In these informal conversations, any number of topics have emerged with varying degrees of
evaluation: the problem of sharp funding cuts resulting in program survivalism and the erosion
of morale, the decline of the journal club or academic seminar as a regular forum for professional
stimulation and intellectual growth, the demise in the laboratory of the days of the “gentleman
scientist” and the emergence of the “successful business person,” an increasing tension between

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the goals of the health and research endeavors and the business paradigm etc. In addition, other
related tensions also arise in these dialogues especially that fear and critique the never ending
rise of a produce or perish culture for research and the need to see the most patients in the least
amount of time in hospitals and clinics. For my part, I have found it more than passingly curious
that these and other related patterns of behavior are co-terminus with the continuing mad rush
toward industry new-speak and seemingly fashionable currents that have the character of the
organizational equivalent of popular but naïve self-help programs.
I am neither a natural scientist nor a certified regular healthcare professional per se. My
original professional involvements in education and social services did not include much of
what we call today American industrial practices. My doctoral background is in areas of inquiry
aimed at behavioral analysis and philosophical speculation. My academic training is to look
for questions and only slowly come to emerging answers, indeed if answers come at all. It is my
penchant to look at personal or institutional behaviors and wonder what they all mean. Hence,
as I continue to hear the clamor of the industrial marketplace edging its way into the healthcare
and research forums, I wonder as to what we are saying about our mission, our future, and
ourselves. I wonder if we realize that, despite all of its ease-of-use, a wholesale bartering for the
incorporation of industry-language in our self-understanding (such as “customer service”) may
be symbolic of a darker side with radical implications for the unfolding future of who we are
becoming and the fulfillment of the responsibilities which are ours for the advancement of the
public good, especially the care of those most in need.
To understand more precisely the phenomenon of industry-language, the “clamor,” and its
implications for the commerce of our research marketplace, it will be necessary to explore briefly
two matters: 1) the nature and power of language itself; and, 2) the foundational character of
the acts of healthcare and research, including their mission. Having explored these matters, it
will be possible to suggest that there is a discontinuity between contemporary industrial new-
speak and the classical identity and life of the healing and research communities, and that this
discontinuity is a highly creative tension which can assist the evolving foundation and character
of who we are and what we do.
The Performative Nature of the Linguistic Ritual

Since the nineteenth century, linguistics has emerged as an important science. Over the
years, linguists have struggled with language theory and have yet to be able to formulate a
precise hypothesis as to the origins of language. However, they have been able to posit why
it emerged. The human animal, born as an independent entity but essentially incomplete in
personality and being, has an inner need to be in communication with others. From the time
that we are born into the world, we are bombarded by innumerable stimuli arising from within
ourselves and from without. Language is the bridge that allows us to negotiate and understand,
to express and formulate our grasp of reality such as it becomes part of our experience, our
consciousness, our worldview, our daily living, indeed our very selves.
More deeply than the particular linguistic grammar we speak, be it English or Dutch or
Arabic, there is the inner construct of our language that is the actual bridge between thought
and grammar, between ideation or concepts and specific words or phrases. In a sense, between
the act of knowing or perceiving and the act of speaking or writing, there is an internal linguistic

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matrix or paradigm which orders our experiences, stimuli and thoughts while making use of
referents of past experiences and past conceptualizations which have been given to us by others.
It may be helpful to entertain that this inner matrix is more a process than a “thing.” It is this
process that shapes the way we think and the way we finally articulate, evaluate and order our
experiences in the world. As such, the linguistic matrix is the seedbed from which our language
emerges as part of the larger part of human symbolic processes which have been referred to
as “ritual:” organized patterns of behavior to express meaning. As scholars have reminded us,
all of ritual is a performative act whereby what we “mean” is both expressed and formed for
ourselves and for others. All human rituals are instruments through which human societies and
individuals “act out” identity, pathologies, fears and hopes, relationships whole and broken,
and finally mission and meaning. Realizing that our external, behavioral language-rituals reveal
and form our internal self-conception has enormous consequences for our understanding of
the power of the linguistic rituals and constructs we use to express who we are as persons and as
professionals in the acts of healthcare, research and their executive administration.
Our internal linguistic matrix and our external linguistic rituals are some of the most
powerful tools we have as human animals. The dynamic linguistic process, i.e. the fluid and
sometimes colliding even explosive interaction between internal linguistic matrix and the
external ritual of language, is what shapes our relationships with others, with the world and
with the self. It is the means by which we grow and develop. It is the means by which we
grow as members of a variety of human associations including family, friends, schools, local
communities, nation, industry, commerce, and finally the global village itself. Formed as persons
by all of these entities but gifted as individual members of a species capable of transcending
traditional categories in the act of insight, our language ritual is a performative act of meaning
by which we both express and form our identities whether as individuals or as organizations.
One of the aspects of the linguistic process that increases its sense of power is the
absorbent nature of the language ritual itself. Language is a connotational reality. Words are
many-meaninged (i.e. polyvalent or tensive). As our personal or global human histories have
evolved, the ritual of words we use and the inner linguistic matrix itself take on shades of
differentiation. Sometimes they even reverse themselves from original descriptions such as in
the case of the term “awful” (which once meant to be full of gratuitous awe but today connotes
something horrible). Part of the connotational properties of human language is the ability of
words to signal radically diverse realities at precisely the same moment whether these realities be
conscious or not. Sometimes the connotational power of language can bring to birth unforeseen
and unintended results. Hence, our interaction with others in the linguistic ritual is critically
important to ascertain the positive or negative potential of linguistic constructs, grammars and
vocabularies. In short, human societies require time for the prudent testing and evaluation of the
appropriateness of self-expressions which could irrevocably change, alter or mutate one’s original
vision of self and mission.
Therefore, given the powerful nature of the linguistic ritual and the power of articulated
language itself, the words we use to describe who we are and what we do in personal life, in
society, and in industry are enormously important for our identity, our mission and our future.
In a certain respect, we need to observe from the vantage point of relatively dispassionate
scientific scrutiny and reflection the choices of language-ritual we make to express and form our
identity as healthcare providers, researchers, executives, and our various institutions.

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Identity, Mission and Language in the
Commerce of Healthcare and Research Institutions
From the moment of our existence, the human family has always been aware of the reality
of sickness, injury, demise, and death. As such we have always been on the road to trying to
discover how to live healthy and long. Additionally, ever since the first humans lashed stones
to wooden sticks and discovered that the rudimentary axe was a more efficient way to dig for
roots than the human hand, research has been at the very center of the same discovery process.
Over the centuries, the processes of healing, healthcare, and research have changed and altered
due to a variety of factors --- some systematic, others more accidental. These milieu has evolved
greatly from the days of medieval alchemy. However, the telos, i.e. its philosophical end for
the advancement of human health and knowledge and social progress, is essentially still the
same. However, this is not to say that the history of healthcare and research has been a smooth
continuity uninterrupted by problematic variants. We may wish to entertain that there are two
caricatures under which we can reflect upon the historical problematics in the identity, mission
and commerce of healthcare and research. It may be helpful to see them as two extreme end
points along a pendulum: theoreticalism and utilitarianism.
Today we define research as a systematic investigation for the purpose of generalizable

knowledge. We understand healthcare and systematic and tactical processes that both maintain
and restore health during the experience of illness. We also understand healthcare as the means
to palliative humane care as we approach the passing over from this life to the beyond. Within
all of these areas, we realize that there is a definitive value in the engagement of learning for the
sake of learning itself. In a contemporary world which too often seems to excoriate educational
learning in the face of the need for simple and easy utility, there is a distinct value in holding up
generalizable and more intricate knowledge as a critical part of the processes of healthcare and
research themselves. For the moment, permit me to use my background in biomedical research
administration to underscore all of this. The development, testing and evaluation of healthcare
research projects cannot take place responsibly without the critical labor of intelligent
consideration of theory and hypothesis on all levels including the most elemental. The human
animal is not just a “using” reality. We are not defined as “homo faciens” but rather as “homo
sapiens.” However, the “sapiens” part of our genus and species definition is not just about
knowledge but about wisdom. Intelligent healthcare research does not remain on the part of the
solely theoretical. It has to have some place in the wider stream of human knowing and human
progress. Hence, there is an ever-present danger in research whereby we can become too easily
satisfied with mere cogitation even when it becomes eminently clear that our speculation has
no merit or usefulness. The danger of remaining on the level of “theoreticalism” poses the equal
dangers of the waste of intelligence, personnel, finances and the delay of discoveries that are
essential to human welfare. Obvious, this affects healthcare and healing themselves. In addition,
we can adapt my comments here to the reduction of healing and healthcare into impersonal
and inhumane productivity interactions in hospitals and clinics or in physician offices. Just as
research knowledge must be discovered within the paradigmatic matrix of wisdom, so healthcare
must be provided within the unquestionably needed paradigmatic matrix of humane and
patient-centered healing. Research must become part of our journey to Wisdom. Healthcare
must be conducted within the unqualified practice of Presence.

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On the other side of the pendulum, beginning with the rampant hunger of alchemists for
gold and emerging into our own age with the frantic scramble of scientists for new discoveries
that would increase the political power of demagogues, there is the temptation of concentrating
solely on the utility of research and “productive, metrified” healthcare for immediate, and
sometimes unethical, gains. We have seen in the last hundred years loud and deserved criticism
of American industries that have turned production factories into sweatshops and intelligent
designers into automatons. Our history is replete with examples of the problems that develop
when prestige, political or personal power and greed have become the “telos” for utility. The
acquiescence of healthcare practices or research to mere utilitarianism, without a commitment
to the search for knowledge and the advancement of the good, is the very seedbed that has
allowed mad political leaders to order medical experiments for the discovery of a master race or
laboratory efforts for the development of genocidal biological and chemical weaponry. It is the
same that has led us to value the healthcare of individuals only on their ability to pay and to be
present only so quickly so as to make room for more “customers” to come with their insurance
cards into the appointment line.
It is probably best to understand that the healthcare and research acts are themselves a
conversation between knowledge and human commitment for the humane care and progress of
peoples. Theory and utility are equal discussants in the conversation of healthcare and research
and, when partnered under the search for humane progress of peoples, become ethical critiques
of one another. In the end, it is important that our consideration of who we are and what we do
in the acts of healthcare and research must take into account the full panorama of our identity,
our mission, our raison d’etre, our telos. And it is when we realize that we must be committed to
on-going reform and revision of our identity and practices that we are better able to evaluate and
make responsible choices for the myriad ways by which we express and form ourselves and the
mission that is given to us as individuals and as professionals called to bring healing, knowledge,
wisdom, and life to all those we serve.
Conclusion:
The Leadership of Healthcare and Research Leaders
In the light of the above reflections, we need to observe and evaluate with extreme care the
grasping of our healthcare and research institutions today for linguistic rituals of commerce and
their underlying linguistic matrices. We may find current public relations language or advertising
constructs to be fashionable and convenient. Perhaps they are much too convenient for our
on-going search to understand our identity and the commerce of our marketplace. As posited in
the beginning of this article, the use of popular terms such as “customer service” may be, in the
end, just too popular. Teachers have students, lawyers have clients, pastors have parishioners. But
what do researchers and research administrators have? Do healthcare providers have patients ---
or do they have “customers?”
To quote the poet, what’s in a name? Perhaps nothing; or perhaps more than we are willing
to admit or realize. Our choices in this regard do not just shape how we relate to those who
come to us. Our choices shape how we understand ourselves and what we do in the acts of
healthcare and research. Are we, in fact, a perfunctory agency stocking the shelves with just the
newest plethora of products or treating our patients as the same when we call them “metrics of

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productivity” or “relative value units?” Do we conceive of ourselves and behave organizationally
as a consumerist, self-perpetuating financial entity, the worst of all business stereotypes? Are we
allowing ourselves to become a bargain basement let down in a superstore?
Given the divergent realities of our endeavors, it may be impossible to find that precise term
which captures those we serve and the professional relationship we share with them. Perhaps it
is itself too painful or personally inconvenient for some providers to remember that the term
“patient” comes from the Latin patior meaning “to suffer with.” We may never be able to fashion
a language that arises truly from within the healthcare and research experiences themselves or
allows us to feel deeply the meaning of serving patients’ needs.
Short of developing a “meta-language,” i.e. a language beyond language, we may be forced

to choose from a wide variety of terms to describe who we are, what we do, who we serve. In
the final analysis, however, we are strongly cautioned to consider very carefully the implications
of whatever discourse and linguistic rituals we choose with their concomitant underlying
constructs, paradigms and matrices by which we order our identity, our mission and our
service in research and healthcare. This demands that we develop an internal ability to allow
the clamor of the marketplace to be raised up courageously to intelligent critique and mature
reflective consideration.
In the end, much of this requires the virtue of prudence and the service of prudent leaders
in our communities of inquiry. Our executive leaders have a particular responsibility within our
communities for evoking and facilitating creative questions however tense. As the executives
with the responsibility for the function of administrative oversight and policy for much of
the larger context of our mission and activities, our leaders are situated at a particular vantage
point whereby important questions of identity and mission can be articulated. By raising to
consciousness the implications of the discourse by which we advertise ourselves, our executives
and other leaders can help our communities to understand what pathways of self-expression and
self-understanding we are pursuing as we engage in systematic and individual services for both
generalizable knowledge and human healing.
We need to provide leadership that is strong, dedicated, prudent and wise for our
communities to engage in a critically essential reflection upon the clamor, the linguistic ritual,
of our market place and ask the hardest questions ever thrown down like a gauntlet before that
discursive and self-conscious creature called “homo sapiens:” Who are we? What do we “mean”
in the course of things? Who are we presenting ourselves to be? How are we shaping our identity
and our service for others? What is the quality of our self-expression and what are its implications
for how we are perceived and sought out? In short, beneath the cares of commerce and cost
accounting, there is a far deeper responsibility for healers and researchers to be a bit like the good
philosopher whose role in society always has been to raise far more questions than answers.

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For Further Reading
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Augustine of Hippo. (1991). The Confessions, A new translation by Henry Chadwick. New York:
Oxford University Press.
Barnes, MH. (2006). In the Presence of Mystery. Fourth printing of revised edition. New
London: Twenty Third Publications.
Bellah, R., Madsen, R., Sullivan, W., Swidler, A., Tipton, S. (1996). Habits of the Heart:
Individualism and Commitment in American Life. 2007 Edition. Los Angeles, CA:
University of California Press.
Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Educating Nurses. A Call for Radical
Transformation. San Francisco. The Carnegie Foundation for the Advancement of
Teaching. New Jersey: Jossey-Bass.
Berdyaev, N. (1962). Dream and reality. New York, New York: Collier Books.
Berdyaev, N. (1947). Solitude and society. London: Geoffrey Bles: The Centenary Press.
Berdyaev, N. (1957). The beginning and the end. New York, New York: Harper & Bros.
Berdyaev, N. (1960). The destiny of man. New York, New York: Harper & Rowe.
Bertrand, Y. (1998). The Ordinary Hero. Madison: Atwood Publishing.
Bush. V. (1944). Science – The Endless Frontier. A Report to the President on a Program for
Postwar Scientific Research. Reprinted May 1980. Washington, DC: National Science
Foundation.
Beauchamp, T., & Childress, J. (2001). Principles of biomedical ethics (5th ed.). Oxford, UK:
Oxford University Press.
Bureau of Medicine and Surgery. (2009). Bureau of Medicine and Surgery Instruction 6500.3:
Research integrity, responsible conduct of research education, and research misconduct.
Washington, DC: Department of the Navy.
Bureau of Medicine and Surgery. (2010). Bureau of Medicine and Surgery Instruction 6010.25A:
Healthcare ethics committees. Washington, DC: Department of the Navy.
Coles, R. (2000). Lives of Moral Leadership: Men and Women Who Have Made A Difference.
New York: Random House.
Cooke, M., Irby, D., O’Brien, B. (2010) Educating Physicians. A Call for Reform of Medical
School and Residency. San Francisco. The Carnegie Foundation for the Advancement of

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Crawley, R. (2007). The diversity of health research ethics in Europe. Proceedings of the Institute
of Clinical Research Annual Conference, 17-28.
Foster, C., Dahill, L., Golemon, L., Tolentino, BW. (2006) Educating Clergy. Teaching Practices
and Pastoral Imagination. San Francisco. The Carnegie Foundation for the Advancement of
Fowler, J. (1981). Stages of Faith. The Psychology of Human Development and the Quest for
Meaning. San Francisco: Harper and Row.
Gabriele, E. (2007). Stretching wide the boundaries within. Proceedings of the Institute of
Clinical Research Annual Conference, 1-16.
Gabriele, E. (2009). Centers of care: A suggested plan of action for establishing the palliation
paradigm. Washington, DC: US Navy Bureau of Medicine and Surgery.
Gabriele, E., Caines, V. (2013). LeaderBeing: Critical Reflections on Context, Character and
Challenge in the Culture of Research and Its Administration. Research Management
Review. 20(1). As found at: http://files.eric.ed.gov/fulltext/EJ1022034.pdf
Gabriele, E. (2009). Palliation and palliative healthcare: Academic reflections on a future

paradigm. Washington, DC: US Navy Bureau of Medicine and Surgery.
Gabriele, E. F. (2015). Rising from the Ashes: Strategic Approaches for Reclaiming Healthcare
and Research as a Culture of Innovative Care. Research Management Review. 20(2). As
found at: http://eric.ed.gov/?id=EJ1063993
Gusmer, C. (1984). And you visited me. Collegeville, MN: Pueblo Publishing.
Holmes, E. (2010). Character, leadership, and the healthcare professions. International

Ethics Conference Proceedings, The University of Botswana. The Journal of Research
Administration, 41(2), 47-54.
Holmes, U. (2002). Spirituality for ministry. Harrisburg, PA: Morehouse Publishing.
Institute of Medicine. (2002). Integrity in scientific research: Creating an environment that

promotes responsible conduct. Washington, DC: National Academies Press.
Institute of Medicine. (2003). Responsible research: A systems approach to protecting research

participants. Washington, DC: National Academies Press.
Institute of Medicine. (2003). The future of the public’s health in the 21st century. Washington,
DC: The National Academies Press.
Institute of Medicine (2009). On being a scientist (3rd edition). Washington, DC: National
Academies Press.

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Jecker, N.S., Jonsen, A., & Pearlman, R. (Eds.). (2007). Bioethics: An introduction to the history,
methods, and practice. Sudbury, MA: Jones and Bartlett.
Kuhn, T. (1962). The Structure of Scientific Revolutions. Chicago: University of Chicago Press.
Lakoff, G., Johnson, M. (1980). Metaphors We Live By. Chicago: University of Chicago Press.
Lambert, L. et. Al. (2002) The Constructivist Leader. Second Edition. New York, NY: Teachers
College Press.
Lisin, D. (1995). Philosopher of freedom. Available at http://vis-www.cs.umass.edu/~dima/

mytexts/suff.html.
May, G. (1988). Addiction and Grace. New York: Harper and Row.
Pence, G. (2004). Classic cases in medical ethics. New York, NY: McGraw-Hill.
Petersen, C., Seligman, M. (2004). Character Strengths and Virtues. A Handbook and
Classification. American Psychological Association. New York: Oxford University Press.
Presidential Commission for the Study of Bioethical Issues. (2011). Moral science. A Report
of the Presidential Commission, Washington, DC: Department of Health and Human
Services.
Rosenbach, W., Taylor, R. (eds). (2006). Contemporary Issues in Leadership. (6th Edition).
Boulder, CO: Westview Press.
Schon, D. (1983). The Reflective Practitioner. USA: Basic Books, Inc.
The Belmont Report. (1979). Prepared by the National Commission for the Protection of
Human Subjects of Biomedical and Behavioral Research. Washington, DC: Department of
Health, Education and Welfare.
Turner. V. (1969). The Ritual Process. Structure and Anti-Structure. 2007 Edition. New Jersey:
AldineTransaction.
Whitehead, A.N. (1929). Process and Reality. 1979 Corrected Edition. Griffin D. and
Sherburne, D. (eds). New York: The Free Press.

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Healing Hands
Michele Savaunah Zirkle Marcum, BS, MA
1304 Forsyth LN
Galena, OH 43021
Tel: (614) 270-8436
E-mail: zirksquirks@yahoo.com
The walls of the room where I am lying are lined with symbols I have never seen. They
remind me of Egyptian hieroglyphics, but they are different, more like squiggles and zigzags.
I’m only here because I don’t know where else to turn for help. I don’t even know what is
wrong with me. I just know I’m not happy. A friend recommended I see Jeanie, who is not only
a Reiki Master; but a homeopathic doctor who graduated Magna Cum Laude from Midwest
University. My friend told me Jeanie is a lightworker and uses a form of energy healing similar
to Reiki.
It sounded harmless, but now that I’m on a bed in her basement office, it’s a bit spooky.
Jeanie clicks on a CD, a mix of Gregorian chants and nature sounds which relaxes me a bit.
She tells me she’ll be working on my auric field that’s just above my physical body. She will
stop if I am uncomfortable. She’ll be able to sense areas in my body where energy is stagnant.
Stagnant energy causes disease. She will channel energy from the Divine to me and the infusion
will heal my cells.
Jeanie places my right hand on my belly and tells me I can keep my eyes open or close them.
I choose the former.
She wedges her left hand under my sacrum and with her right, makes loops in the air like
she is writing an invisible message. I wonder if she is signing the same symbols that are plastered
on the walls.
I’m seriously questioning my decision to trust this lady when she tells me that there
are angels present and that I can pray while she works on me. I quickly take her up on that
suggestion.
For several minutes her right hand hovers over my right hand that’s still on my stomach.
Slowly the lightworker raises and lowers her hands several feet above me as if she were
smoothing the air with a rolling pin.
She repeats this several times, rolls behind me and cups her hands around my head. I feel
like I have static in my hair and I’m dizzy, but I don’t dare tell Jeanie. I don’t want her to stop. I
want this to work.

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She continues down the left side of my body. It must be fifteen minutes into the session.
My head is spinning like it’s in a dryer. I focus on a long shadow on the ceiling in an attempt to
make the spinning stop.
Jeanie asks if I’m okay. I’m tingling from my earlobes to my toes and I feel like my head is
going to whirl right off of my shoulders, but I tell her I’m fine.
I close my eyes and press my head deep, trying to anchor it into the pillow beneath it.
Suddenly I hear angry voices above me. “You shouldn’t have come here!” I look up, but there’s
no one there. Again I hear several voices talking over one another, “Shouldn’t have come! Told
you—shouldn’t have come.” I scan the room, but the only person in the room besides me is Jeanie.
I succumb to the sensation of being sucked into a black hole.
The next thing I know, Jeanie’s patting my face with a cool cloth.
I push my elbows into the bed in an effort to sit up, but have no strength and collapse back
onto the pillow.
Jeanie’s hand softens to my wrist that’s searching for leverage. “Easy, there. No rush.”
“I’m so weak,” I say.
Jeanie strokes my forehead. “I know, honey.”
I feel really stupid—tired and confused and stupid. Jeanie offers her arm so I grab hold and
attempt to swing my legs off of the bed, but they barely budge.
With her free hand, Jeanie slides my legs till they dangle off the edge. With her assistance, I
settle into a rocking chair.
“Do you remember anything?” Jeanie asks, her soft blue eyes practically propping me up
from across her desk.
“My head spinning and growling voices. They didn’t want me here.”
“You were under attack from negative influences and had a seizure.”
She explained that several negative entities were attached to my auric field and had been
influencing my moods and behaviors.
In the ensuing days Jeanie taught me that we each perceive the world in our own way and
have the ability to change our perception. With Jeanie’s prompting, I began identifying life-
enhancing circumstances and self-defeating ones. I began looking at myself as self-reliant and
found joy in just being alive. I began to love myself.

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I’ve been seeing Jeanie for four years now, and I’ve never had another seizure. I feel more
balanced in mind, body and spirit after my monthly treatments with her.
Jeanie’s advice helped me to change my perception.
Would her advice alone have made such a profound impact on my life without the energy
treatments? Perhaps the life-coaching component of Jeanie’s services would have helped, but I
doubt I’d have made such a remarkable transformation. It would have been impossible to live an
authentic and joyous life under the influence of dark forces.
All I know is that something real and substantial happened on Jeanie’s table the day I had that
seizure—something that can’t be calibrated with a gadget of any sort—something I can’t explain
adequately; yet, something so profound that the very nature of who I am believes that I was indeed
healed by the hands of a lightworker, a healer with a heart who helped me to mend mine.
Postscript
The above story is an abridged version of actual events depicted in Zirkle Marcum’s
recently released novel, Rain No Evil, available at Amazon and http://www.rainnoevil.com.

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The Art of Diagnosis
Bruce R. Boynton, MD
Editor, Journal of Health and Human Experience
Chief Medical Officer, Centurion of New Mexico
Tel: (858) 729-3220
Email: bruce.boynton@gmail.com
The Art of Diagnosis demands keen powers of observation and the ability to draw logical
conclusions from an array of apparently unconnected facts. And sometimes the key is a tiny and
seemingly unimportant detail.
Little wonder that Sir Arthur Conan Doyle, the creator of Sherlock Holmes, was himself
a physician and the character of his great detective was drawn from a professor he knew at the
University of Edinburgh.
But the greatest diagnostician I ever encountered was not a professor at a famous
university; in fact, she was not a physician at all. She was a poor woman from the southern
mountains who brought her little boy to see me at the local health department.
“My family thinks I’m crazy,” she said, “But I believe he has something stuck up his nose.”
Such complaints are not unusual in pediatric practice. Toddlers often stick things into their
nostrils and, once discovered, they are fairly easy to remove. The trick is to discover them. Often
the object lies festering for weeks or months, creating a putrid odor and leaving the parents
wondering what is going on.
The child grinned at me. I smiled back and turned to his mother. “What makes you think
he has something in his nose?”
“Because,” she replied, “His nose only runs on one side!” I was impressed.
“Well, let’s have a look.” I tipped the boy’s head over my knee and shined a penlight into
his nose. There it was, a faint white speck, high up in one nostril. I reached in with a pair of
alligator forceps and pulled out a purulent, foul-smelling bit of blood tinged fabric.
“You were right,” I said. I held up the object for the child to see before throwing it in the
trashcan. We chatted for a few minutes and the woman thanked me, gathered up her son and
left the exam room.
As I prepared for the next patient I pondered what had just happened. Here was someone
with little formal education whose powers of observation and deduction were equal to those of
the most highly trained clinician.
Oh, and one more thing. . . she was blind.

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Time for Prayerful Rounds
Charmagne G. Beckett, MD, MPH, FACP
Officer-in-Charge,
Navy Bloodborne Infection Management Center
8901 Wisconsin Ave, Bldg 17, Ste 3G
Bethesda, Maryland 20889
Office: (301) 295-5246
Cell: (301) 919-2350
Email: charbeckett@gmail.com
For most internists and medical sub-specialists, hospital rounds are the focal point of care for
inpatients on the medical wards. During teaching rounds, we thrive on the chance to learn about
and see new patients admitted overnight, often presented in detail by fellows, residents and/or
medical students. This is also a precious time to develop and refine the diagnostic assessment and
treatment plans necessary for healing. Time is a key factor in efficiently completing daily rounds
and keeping patient care on track, while always keeping the discharge plan in mind.
One day, on rounds with my Infectious Diseases Consult team, we started with an activity
that took extra time – prayer. It was not intentional, but we came to visit a new patient at just
the right time. The chaplain stated, “Welcome, we are just about to have a word of prayer. Will
you join us?” As the Attending physician and team leader, I stated “Yes, certainly we can join in.”
After I accepted the prayer invitation on behalf of my team, I thought – ‘Was that the
right thing to do? Was it politically correct? Should I have given my subordinate team members
a chance to opt out? Would anyone feel uncomfortable during the prayer? Was I wasting the
team’s time?’ My mind was flooded with these questions, but the chaplain proceeded as we
stood at the bedside in silence with bowed heads. The prayer lasted about five minutes. For me,
it was an intensely spiritual five minutes. The prayer included prayers for our team and asked
that we be guided in the delivery of patient centered, compassionate care. After the chaplain
concluded he introduced himself, thanked us for ‘all we do’, and then departed the room.
I realized that we had yet to introduce ourselves to the patient. “We’re the Infectious
Diseases Consult Team, and we were asked to help take care of your wound infection.”
The patient was a young, active duty service member with a rectal abscess, presumably
a complication of his severe inflammatory bowel disease. After a medical evacuation from
overseas, he was recovering from surgery and suffering from intense pain. He had multiple
organisms growing from the wound cultures and required intravenous antibiotics. It was likely
that he would not return to his unit for months and face duty limitations. I imagined he’d be the
typical stoic, young guy that I had seen on many occasions in our military setting.
Yet his response to our visit was quite the opposite. He was so thankful that we took the
time for prayer. This five minute investment seemed to help him decide that we were the team
and this was the hospital that he needed to help him heal. He expressed his sincere gratitude

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for the care rendered and felt confident about the road to healing. He smiled despite the pain,
shook our hands and thanked us for evaluating him – and for praying with him.
After our team departed the hospital room, I felt a sense of extreme relief. Prayer during
rounds was the ‘right thing to do’ for this patient; from the patient’s perspective, this extra time
was essential to his treatment plan and healing.

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Mumbo-Jumbo
Jesse Eugene Hoover, DOM, MS, Dipl.OM
Connerly Physical Medicine Group
1892 Plaza Del Sur Drive, A
Santa Fe, NM 87505
Tel: (505) 690-9317
E-mail: jessehoover@cybermesa.com
One of my patients was an academic scientist, and near the end of his career he was
stricken with debilitating joint pain. Eventually the diagnosis of rheumatoid arthritis was
made. Surprisingly, he had actually made his career researching rheumatoid arthritis. He had
spent years of his life researching the very disease he later developed. When one of my students
heard this, he immediately formed some meaning around it, as if this patient’s career had
somehow caused his condition. I admit it made me raise my eyebrows. There seems to be a
human tendency to make something of such facts. They have coincidence and this suggests a
relationship, as if one thing had anything to do with the other. At the very least, they strike one
as interesting.
In general, there are no observable causes for many of our common experiences. I entered
a grocery store the other day and thought of a friend whom I rarely see. Shortly thereafter, I
bumped into him and his wife. After discussing the fact that he had just popped into my head,
we agreed that it did not really mean anything. He concluded, “Of all the thoughts we have,
statistically some of them have to form coincidences.” His wife disagreed and offered some new-
age mumbo-jumbo that the coincidence must have been due to “thought waves.” We rolled our
eyes at her.
After leaving their company, I reflected on the difference in their points of view. Her view
postulates something speculative (thought waves) to make the case that, in coincidence, there
is a cause. It is mumbo-jumbo because her need, most likely derived from her world-view, took
precedence over the absence of evidence to support her claim. On the other hand, her husband
used “coincidence” in a modern sense—as an artifact of two independent processes that happen
to overlap. This is one of the effects of statistics: In examining complex events, causes are often
found wanting. Coincidence does not equal causation. My friend, by the way, is a physicist.
Despite the current prevalence of new-age thought, we live in a scientific society. Everyone
has had some education in the sciences, with most of us getting this education at least
through high school. Non-scientific things sound like mumbo-jumbo, which is precisely why
I have very few patients who are scientists, despite practicing close to Los Alamos National
Laboratory. However, I believe that my medical practice is often undermined without genuine
evidence of its lack of efficacy. My patient with rheumatoid arthritis, who was also a scientist,
took a very long time to schedule his first appointment. Most likely, this was due to his
skepticism. By the time I had any say about his treatment, his condition was debilitating and he
considered himself crippled.

Vignettes
The basic facts of his case are simple. I, or one of my students, gave him acupuncture
weekly for nine months. During that time he also drank custom-compounded Chinese herbal
formulas daily, in a form known as “powdered extracts.” These formulas and his acupuncture
point prescription were modified weekly according to the evaluation of various changes that
were observed or reported. Approximately sixty-percent of his response to treatment occurred
within the first month. By the end of six months he was nearly asymptomatic. Eventually we
stopped making progress, so we discontinued treatment. Rheumatoid arthritis is considered an
autoimmune disorder. He took Methotrexate before and during the first stages of treatment but
discontinued it and started Leflunomide—an immunosuppressant—at month four of treatment.
He continued taking this prescription after the Chinese medicine treatment concluded.
It has been a year since I have seen him. I called him up a few days ago to see how he is
making out. He is doing very well! The arthritis has not progressed and his discomfort has not
returned. He was, though, thinking of stopping the Leflunomide, which was giving him chronic
diarrhea, incontinence, and peripheral neuropathy. He told me that he would call to schedule
an appointment with me if his rheumatoid arthritis symptoms returned. Out of curiosity, I
asked him whether he believed that his successful experience with Chinese medicine could be
explained as a placebo effect. He did not believe so.
The other day, a retired physicist commented to me that he takes “a dim view of things
unscientific.” I said, “Science isn’t the only field that produces good models or good solutions.”
Traditional Chinese medicine has solutions, or partial solutions, for rheumatoid arthritis and
many other illnesses. The problem is this: Much in the way that physicists have been unable to
reconcile particle and wave theories of light, the intellectual structures of modern science and
Chinese medicine are not immediately and obviously integrate-able. It does not help the matter
that scientists and doctors cast a wide net of doubt and so insulate themselves from fields that do
not sound scientific. Their stance overlooks the fact that most of life is not amenable to analysis
with the scientific method. Important theoretical and practical fields like psychology, sociology,
and economics are not wholly scientific, nor could they be. Health, wellbeing, illness and disease
are not the sole province of medical science, nor should they be. As objects of knowledge,
human beings are simply too complex for that.
In general, most of our thoughts are mumbo-jumbo. As Ioannidis (2005) has argued, there
are many more possible, false hypotheses in the world than true ones. He logically showed, in his
seminal paper “Why most published research findings are false,” that we cannot necessarily trust
the results of the research we have conducted. This provides intellectual force to understand
the recent “crisis of irreproducibility” which has begun to plague the medical sciences. I would
add that, of the many hypotheses we do form, we only have the resources to try to test a fraction
of them. However, there is another way to frame the problem: We require means other than
science to identify valid medical treatments.
Fortunately, we have other means and have always had other means. Traditional medicine,
especially when it is captured in a written tradition, was developed over long periods of time.
In studying such a tradition, one can see that successful models and treatments were developed
and maintained, while less successful ones were relegated to antiquity. If this sounds like science,
I believe it is because all serious, practical endeavors proceed in this manner. Good work is
essentially an evolutionary process over a long time frame. In this regard, the contemporary
corpus of Chinese medicine, even as it continues to evolve, is extremely well tested.

Vignettes
Traditional medicine does not generally surprise us the way Leflunomide did (and other
drugs can and have), with side-effects that are intolerable or dangerous. It does surprise us when
it works and especially when it works consistently, as Chinese medicine so often does. As a
scientific society, we just do not expect it. Our skepticism is part of our culture.
I recently took a brief course in philosophy of science. Most of my classmates were

retirees but had been medical doctors or scientists from distinguished institutions. Everyone
there eventually learned that I was an acupuncturist and they reacted in various ways. In their
presence, I felt somewhat abashed to say that I am a Doctor of Oriental Medicine or DOM. That
title I earned through four years of graduate school, a thousand hours of supervised practice,
the passing of state and national boards, and an additional apprenticeship. There has also been
the continued study, practice and teaching that have kept me busy for ten years. What I would
have liked to have said is that traditional Chinese medicine, like other developed disciplines, has
method. It is an independent, coherent and effective medical system. However, while looking
around the table, I suspected they would not believe this. They really thought my experience
was either due to the placebo effect or was, in fact, a long series of coincidences. The theory, the
diagnoses, the method, the medicine was—to them—nothing more than mumbo-jumbo.
Addendum: After some additional time had lapsed, I emailed my patient, curious to know
his progress. After six months off the Leflunomide, his side effects have abated and he is no
worse in terms of discomfort. He describes his joint pain as occasional and mild. He is not
currently in need of treatment.
For Further Reading

Ioannidis, J. P. (2005). Why most published research findings are false. PLoS Med, 2(8), e124.
Lushington, G. H., & Chaguturu, R. (2015). Biomedical research: a house of cards?

Future medicinal chemistry. 8(1). As found at: https://www.researchgate.net/
publication/287805426_Biomedical_research_A_house_of_cards
Kaptchuk, T. J. (1983). The web that has no weaver. London: Rider Books.

PROFILES IN COURAGE:
THE NEXT CHAPTER
Profiles in Courage
Articles
“Dr. Schweitzer, I Presume?”
The Life and Times of Fergus and Ruth Pope
Jan K. Herman, MA
The Historian of Navy Medicine (ret.)
Tel: (202) 431-6901
E-mail: histguy45@yahoo.com
Introduction
This article is the fourth in a special series that regularly appears in the Journal of Health and
Human Experience. “Profiles in Courage: The Next Chapter” highlights individuals of our time who
move us to a greater understanding of the human experience. The articles published in this section
bring to our attention contemporary issues and initiatives that call each of us to be truly healthy.
This article is based upon interviews with Fergus and Ruth Pope. Inspired by Nobel laureate, Dr.
Albert Schweitzer, the Popes dedicated their lives providing medical care and education to needy
communities on two continents.
Mr. Jan Herman is the 2015 Forrest C. Pogue Awardee for Excellence in Oral History. The opinions
in this article are those of the author alone. The author has no financial conflicts of interest.
The photographs in this article were provided courtesy of the Pope Family.
This past year, the humanitarian community suffered the loss of Ruth Pope, one-half of an
extraordinary team. Her husband, Fergus, a dedicated physician, pacifist, environmentalist, and
advocate of human welfare had passed away three years earlier. The hallmark of the Popes’ lives
was their altruistic service to their community and the countless patients they cared for during a
career that spanned more than half a century on two continents. Although I had the privilege of
spending only a short time with them in their western North Carolina home several years ago,
their story thoroughly engrossed me--and has stayed with me for the last several years.
As a young boy, I was captivated by the African continent, an interest sharpened by

National Geographic’s sensational photographs. The story of Henry Morton Stanley’s search
through central Africa for missionary and explorer David Livingstone in 1871 only enhanced
the allure. As an avid reader of Life magazine, several articles and photo essays dedicated to the
legendary Dr. Albert Schweitzer naturally caught my attention. The white-maned icon with
matching mustache had built, starting in 1913, a primitive jungle hospital, which at that time
was located in an area considered “darkest Africa.” He selflessly dedicated the remainder of
his life to treating the sick. For his humanitarian work, he was awarded the Nobel Peace Prize
in 1952. Nearly 60 years later, I interviewed two people who not only knew the fabled Dr.
Schweitzer but who also worked by his side and tended him in his last hours.
***

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Ruth Pope was the product of a renowned Hungarian-born pianist and a wealthy Austrian
mining engineer and businessman. Her mother, Lili Kraus, was considered one of the most
gifted musicians of her generation. As a child prodigy, Lili trained at the Royal Academy of
Music in Budapest, Béla Bartók, the celebrated composer and pianist, being one of her principal
teachers. Lili was especially known for her renditions of Schubert, Haydn, and Mozart. She was
also an occasional actress and linguist, fluent in seven languages. Ruth’s Austrian father, Otto
Mandl, met Lili in Vienna, and they married in 1930. Because Ruth and her brother Michael
were born in Berlin and traveled widely with their peripatetic parents, Ruth always maintained
that she grew up “all over the world.”
When the Germans invaded Austria, resulting in the Anschluss in March 1938, the Mandls
knew what they had to do. Within 24 hours, they fled Vienna. With father Otto in Berlin on
business, Lili gathered her two children and what belongings she could stuff into a few suitcases.
As Ruth remembered, “We left two beautiful Steinway grands, a grand library, beautiful carpets;
you name it. We just took the clothes we had. We met my father on the frontier of Italy and
Switzerland at midnight.”
Taking refuge in Italy, the family lived on Lake Como in northern Italy, safely absent from
what Germany was turning into under Hitler. “My father saw the handwriting on the wall with
the Nazis and he wanted us out of Germany.” Although her parents were Jewish, Ruth never
observed their faith; she and her siblings knew virtually nothing of their heritage. It was not
until 1952 when she was 21 that a relative visiting the family in Paris disclosed this well-guarded
secret in a casual conversation. Ruth recalled him telling her,
“‘It must be have been difficult during the war being Jewish’
I replied, ‘We’re not Jewish.’
He said, ‘Yes, you are and I should know.’
We then confronted my mother, who was recovering from sunstroke at the time. ‘How
come you never told us we were Jewish?’”
Before she could respond from her sickbed, Otto escorted Ruth and Michael from
the room and said, “Lili isn’t Jewish. I’m Jewish.”
But that declaration turned out to be confusingly untrue. A whispered rumor occasionally
circulated that Otto had converted to Catholicism. Even more bewildering was another episode
that occurred six years before. Lili had told her two children that she had a terrible secret that
was weighing her down. “We thought she was going to disclose a rumored affair she was alleged
to have carried on with her long-term violinist-partner, Szymon Goldberg.” But that alleged
affair was not the revelation Lili wanted her children to know about.
Being a Jew in occupied Europe during the war was no recipe for longevity. The
explanation for why her father had earlier denied his wife’s Judaism had nothing to do with
ensuring her safety. Otto felt it would have adversely affected her career. After the secret was out,
Ruth noted, “We never talked about it again.”

Profiles in Courage
Articles
Shortly before the outbreak of World War II, the Mandl family left Italy and moved to
London where Ruth and her brother attended boarding school. Ruth recalled that she was the
only girl in a school with 72 boys. She was 8 years old at the time and that one year of boarding
school was the only formal schooling Ruth ever had. All the rest was “catch-as-catch-can and by
osmosis,” she said.
She learned English in six weeks and over time became fluent in several other languages.
Her father tutored her when he had the time, but his dedication to Lili’s career made those
tutoring sessions few and far between. By this time, Otto had given up his business career to
become his wife’s full-time manager. The couple had always communicated in German but they
now spoke only English in deference to the country that had offered them asylum.
The Mandl’s English sojourn lasted only a year. In 1940 Otto scheduled an international
concert tour for Lili in Holland, the Dutch East Indies, Australia, and New Zealand. After
arriving at their second destination, the family fell in love with the island of Bali, but soon
thereafter the Japanese conquered Singapore and now had the Dutch East Indies in their sights.
And so for the second time in a few short years, the family had to flee tyranny.
Ruth recalled Otto missing an opportunity for the family to escape to New Zealand by ship
and how they ended up as prisoners of the Japanese. Their captors separated the children from
their parents, and for a year the Mandls had no contact with one another. Ruth and her brother
were originally held in Bandung, Java, but were then moved to an internment camp in Batavia,
now Jakarta, Indonesia’s capital.
Even her parents were separated. The Kempeitai ( Japanese secret police) charged Lili with
trying to overthrow the Japanese occupation government, and held her in a women’s camp for
“dangerous” prisoners. Otto was imprisoned in a men’s camp. The children lived in what was
called a “family camp.”
Several days into her incarceration, Lili’s prison commandant, who had listened to her
recordings and was aware of her international reputation, asked if he could do anything to help
her. She asked for a piano and to be reunited with her family. Six months later Lili got the piano.
Six months after getting that piano, the family members were reunited. Although this was a
most happy circumstance, lack of food threatened their survival. “If the war had gone on another
year, all of us would have died,” Ruth pointed out. When hostilities ended in August 1945,
British forces liberated the camp and the Mandls went to Australia and then New Zealand.
***
Fergus Pope was a native of Sausalito, California. He moved to Maplewood, New Jersey
with his mother and older brother after his parents divorced when he was 4 years old. Fergus
came from a Christian Science background and his mother raised him in that tradition. When
he was 12, Fergus informed her that he would no longer attend Sunday school because he didn’t
believe in the Christian Science doctrine. At that point, he became an agnostic, filling the void
with what he called a “humanitarian instinct.”

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After graduating from Colgate University where he majored in literature of the Western
world, he enlisted in the Air Force during the Korean War, was commissioned an officer,
and trained as a bomber pilot. The implications of that duty were not lost on the sensitive
and introspective young man who was leaning increasingly toward pacifism. Risking court
martial, Fergus informed his commanding officer that he was not cut out to be a bomber pilot.
Surprisingly, the sympathetic colonel arranged leave for Fergus so he could reconsider his
decision. Upon returning to duty, Fergus learned of his new assignment--flying observation
aircraft from a base in England, to gather weather information. This arrangement suited him
until he finally left the Air Force in 1954 to ponder an uncertain future.
The young Popes with Fergus in uniform.
A November 1954 Life magazine article, which featured a photo essay about Dr. Albert
Schweitzer, changed his life. “After reading that article, ideas began crystalizing in my head,”
and soon thereafter, Fergus was on his way to Africa to meet the legendary physician. He drove
a rented Land Rover across the Sahara before arriving in Lambaréné, a town in what was then
French Equatorial Africa, now Gabon. Here Albert Schweitzer had established his jungle
hospital in 1913. Caring for the local population, many of whom had never seen a European,
much less a physician, Schweitzer and his wife Helene, an experienced nurse, ran the hospital.
With the assistance of villagers they trained, the Schweitzers treated patients afflicted with
tuberculosis, leprosy, yaws, and tropical diseases endemic to West Africa, such as dysentery,

Profiles in Courage
Articles
sleeping sickness, malaria, elephantiasis, and yellow fever. Schweitzer also performed thousands
of surgeries with Helene who acted as anesthetist.
“I went in the back door of the hospital and met one of the nurses, who introduced me to
Schweitzer,” Fergus recalled.
The renowned physician, at that time a recent Nobel laureate, was less than cordial. Fergus
remembered Albert Schweitzer’s first words to him: “The next time you come, please write first.
I don’t like surprises.”
Fergus added, “Schweitzer had a real temper, although he was as gentle as a lamb with his
patients.”
Fergus was undeterred by the elder’s often irascible manner with staff and strangers. He saw
something both grand and spiritual in the former theologian-organist-philosopher that drew
him to Albert Schweitzer’s lifelong mission. “After about a week, I decided there was a lot I
could learn there and I decided to stay on and do anything.”
Fergus began working around the hospital, doing carpentry and other construction chores.
Much work needed to be done to keep the hospital’s many simply built wooden structures in
good repair. “Schweitzer didn’t believe in plumbing in that kind of climate. There was one two-
holer for men and women,” Fergus pointed out. “I learned pretty quickly the simple things he
Fergus and Schweitzer in jeep.

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wanted done and made peace with Schweitzer’s lack of plumbing and electricity. He had what
he called a ‘disease of construction.’ He was constantly building. Schweitzer obtained some
construction materials, such as corrugated tin for roofs and cinder blocks and then emphasizing
self-sufficiency, he used all his own sand and gravel and local okume hardwood for constructing
his buildings. He was always looking for an excuse to construct a new building.”
With speaking fees, money earned from selling local handicrafts and furniture made on the
premises, and donations from all over the world, Schweitzer increased the size of the hospital to
70 buildings by the early 1960s. The expanded hospital of 350 beds could then hold more than
500 patients in residence, and a facility for lepers that could house an additional 200.
It was not long before Schweitzer told Fergus that he would not be very useful unless he
could speak French. So he taught himself French from available grammar books and learned
everyday usage from French-speaking African patients and staff. Slowly but surely, Fergus
began to realize that he could be far more useful as a doctor than as a carpenter. When he asked
Schweitzer what he thought of the idea, he encouraged Fergus to go to medical school.
Fergus then returned to England to attend St. Bartholomew’s Hospital Medical College
at the University of London. While in London, he met Ruth Mandl at a tea party. He was then
looking for someone who could speak German because he needed some medical texts translated
from English to German for his mentor, Dr. Schweitzer. Since Ruth was fluent in German,
French, English, Italian, and Dutch, she fit the bill not only as a linguist but as a romantic
interest. They married in 1959. Fergus graduated from medical school five years later.
Fergus and Ruth on wedding day.

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After an internship at Monmouth Medical Center in New Jersey, Fergus returned to
Africa with his growing family, not as Mr. Pope but as Dr. Pope, and assumed his medical
duties alongside Dr. Schweitzer, setting up a clinic for infants and a physician’s assistant training
program for Gabonese students. When not caring for their three young children, Ruth helped at
the hospital in any way she could, mainly by working as a translator.
Pope family with Schweitzer.
Fergus’s reunion and collaboration with Albert Schweitzer was short-lived. On September
4, 1965, the 90-year-old doctor died from a stroke. Fergus and Dr. David Miller, an American
cardiologist-epidemiologist, also noted for promoting human welfare and famine relief, cared
for the doctor during that last illness. Miller had come to the Schweitzer Hospital to help direct
a heart disease study and, as with Fergus, had developed a close friendship with Schweitzer.
Fergus, Ruth, and their three children stayed in Lambaréné for several months following
Schweitzer’s death, but an unexpected and shocking episode ended their work in Africa. In
1960, Gabon had achieved independence from France, and the political situation remained
very turbulent as rival factions fought for power. One day, Fergus received an ominous message
that his presence was required in Libreville, Gabon’s capital. When he arrived, he learned that
his association with the minister of education, who was suspected of conspiring against the
government, threatened his status as a guest in the country. Shortly thereafter, all the minister’s
foreign-born friends and colleagues, now branded as enemies of Gabon, were to be expelled

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within two weeks. Fergus was told that when he changed his ideas, he would be welcomed back.
“That’s the first time we knew anything about changing ideas.”
Apparently the continuing political unrest and a recent unsuccessful military coup, as well
as French military intervention, had fanned the flames of political unrest. “My impression at the
time was that this was a country struggling for its independence and not wanting any intrusions
from the outside.” An American physician, who had occasionally expressed liberal and pacifistic
notions, was indeed suspect.
The Popes departed Africa and traveled through Europe for several months before ending
up in 1967 in Rochester, Minnesota, where Fergus completed a pediatric residency at the Mayo
Clinic. During that period, he returned to Africa several times, setting up food and medical
supply distribution systems in Nigeria for aiding victims of the civil war in Biafra.
When he completed his program at the Mayo Clinic, Fergus already knew what his life’s
calling would be. His association with Albert Schweitzer and caring for the poor in primitive
circumstances had determined his fate. Fergus entertained no doubts when he contacted realtors
all over the United States seeking a farm for sale in a needy rural community. He wanted to
serve an area that had little or no access to health care. He, Ruth, and the children decided on
Yancey County, in the western mountains of North Carolina. A 600-acre farm in the small town
of Celo became their home. Fergus set up his first clinic with two exam rooms. Realizing he
would never prosper as a physician, the land was his safety net. When necessary, he sold small
parcels to physicians he had encouraged to move to this area to assist with this community’s
health care needs.
“Back then, the roads were bad, people were scattered all around, and many of the
mountain people didn’t have phones,” daughter Frannie recalled. And since cash was often hard
to come by among his rural patients, barter was necessary. “I remember people paying Dad in
chickens. One patient, who had been injured in an auto accident, brought us three five-gallon
tubs of ice cream after Dad sewed him up in the middle of the night.”
Fergus’s practice soon encompassed a seven-county region of western North Carolina.

He served an estimated population of 150,000, and 40,000 of them were children. To cover
such a large territory, Fergus often made house calls. But he also realized that the health care
requirements were much too great to handle by himself and by his meager staff and volunteers.
He became a fund-raiser, another of his many talents, and helped obtain a $5 million
grant in federal funds through the Appalachian Regional Commission to establish programs in
maternal and child health, environmental services, and community mental health. He continued
to recruit medical students, nurses, and other health care professionals, many of whom moved to
the area. Switching from fund-raising, Fergus founded and directed the region’s first Head Start
program, the Children’s Health Services Council, a Child Development Center serving Yancey
and Mitchell counties, and the Developmental Evaluation Clinic in nearby Boone. He also
created a seven-county program for children with developmental disabilities, and established
North Carolina’s first rural primary care clinics, the Yancey County Health Department, and
the Bakersville Medical Clinic.

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Articles
In the early days at Celo, Ruth had assisted in running the home clinic. Despite her
partnership with Fergus, her many interests soon led in other directions, down her own path
and directly into community life. As with her husband, Ruth had much to give. She longed
to teach others about personal development, including the use of meditation and yoga. After
obtaining her teaching credentials, she organized and ran a Montessori school and also became
an avid proponent of holistic health. She pioneered the teaching of health, nutrition, and fitness
in Yancey and Mitchell counties and taught after-school music classes. Sandwiched in between
this whirlwind of activities, Ruth found time to serve on multiple boards affiliated with cultural
awareness, helping to found the Music in the Mountains program and serve as its president.
In 1982, a phone call from a hospital in Texas suddenly interrupted, or rather uprooted
their frenetic rural life. Fergus and Ruth learned that their son Daniel had been seriously injured
with a vertebral fracture incurred in a diving accident. Early reports suggested he might be
paralyzed for life. The couple flew to Houston to help care for him and ended up moving there
during his long treatment and rehabilitation, which happily proved very successful when Daniel
again regained his ability to walk.
Always quick to turn adversity into something quite the opposite, both Fergus and Ruth
decided to add to their resumes. Building on his pediatric specialty, Fergus completed a two-
year residency in child psychiatry at the University of Houston, and then a three-year residency
in general psychiatry at the University of North Carolina in Chapel Hill. Ruth obtained her
GED, then enrolled at the University of Houston studying psychology, eventually fulfilling
her lifelong dream of having a college education when she graduated from the University of
Asheville in 1990 at age 60. It was quite a triumph for a woman who up until then had but one
year of formal education.
The Popes returned home to North Carolina, where Fergus joined Blue Ridge Mental
Health Center in Asheville as a staff child psychiatrist. While there, he helped obtain a $2
million grant to develop a continuum of mental health services for children and youth in
western North Carolina. But despite a slight change of venue, “Celo Farm” was their permanent
home, the only one Fergus and Ruth had ever known. Fergus spent the last 15 years of his life at
his beloved farm before succumbing to Parkinson’s in 2013 at age 83.
Ruth, always seen as a radiant fixture in their community for her warmth, humor, elegance,
and creativity, decided to leave the farm after Fergus’s death and move to California to be closer
to her daughters, Zazi and Frannie. While visiting Frannie in January 2016, she suffered a
debilitating stroke. But such was her passion for life that Ruth did not count herself out just yet.
Almost immediately, she committed herself to a grueling regimen of physical therapy for the
next seven months. But a week before her 86th birthday, she had a second stroke which proved
fatal. She died on September 15, 2016.
The couple I had met at Celo Farm in 2011 were not only gracious but eager to recount
their stories. Almost 81 years old at the time, but still spry and with a warm smile and wonderful
sense of humor, Ruth spoke animatedly about her larger-than-life mother, Lili, and their
improbable circumstances during harrowing times before and during World War II.

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Although infirm with Parkinson’s, Fergus’s eyes brightened when I inquired about his quest
to meet Dr. Schweitzer and how that relationship forged Fergus’s mission in life. Frannie later
related that the father she had known as a child had transformed himself significantly over time.
“As a young man, he was perceived as being very direct and intimidating. Yet he grew into a
sweet mild-mannered man. He was always compassionate and wanted to do good things.”
The Popes in retirement.
Ruth and Fergus Pope were considered humanitarians by all who knew them personally or
who benefitted from their dedicated and tireless work. The word “humanitarian” is a label and
itself vague and ambiguous. That word cannot possibly do justice to what they, as a couple and
as individuals, achieved and to the people they touched.
If being compassionate and doing good deeds are the hallmarks of a meaningful life, Ruth
and Fergus Pope accomplished that--and much more.

THE CRITIC’S
CHOICE
Reviews
Book Review
Musicophilia: Tales of Music and the Brain
by Oliver Sacks, MD
Vintage Books
Random House, Inc. (2007)
Nathan Carberry, BSE
Medical Student
New York Medical College
Tel: (787) 506-2656
Email: Carberry.Nathan@gmail.com
Mill Etienne, MD, MPH, FAAN

Assistant Professor of Neurology
New York Medical College
Tel: (914) 594-4498
Email: Mill_Etienne@nymc.edu
Author Note
The opinions of this review are those of the authors alone and do not represent the views of
New York Medical College or other institutions or organizations the authors serve. The authors
have no financial conflicts of interest.
Introduction and Background

Music is a human expression, a pattern of sound waves that communicates thoughts and
emotions. Not just noise, music carries meaning as it is conceived, produced, received and
interpreted within the brain. Oliver Sacks explores the neurology of music in Musicophilia as
he shares personal and patient anecdotes and ruminates upon the science behind an art form.
Sacks is a renowned Neurologist and author who found success presenting complex medical
information in an approachable format. In this way, Musicophilia found a large audience primed
by his other popular novels, including Awakenings and The Man Who Mistook His Wife for
a Hat. This review seeks to summarize and reflect upon the book’s salient points within the
categories of musical gifts, musical pathologies, and musical therapies.
Musical Gifts
What constitutes a musical brain? Sacks explains that the corpus callosum, a structure
that connects the left and right hemispheres of the cerebral cortex, is enlarged in musicians.
Made possible by the advent of magnetic resonance imaging (MRI) machines, there is a
notable correlation between musicality and an enlargement of this and other areas of the brain,
particularly when musical training begins early in life. Not everyone is gifted in music from
birth, but inspiration to develop can present at surprising times. Sacks emphasizes this point

Reviews
as he introduces his reader to the connection between music and neurology when a previously
artless surgeon becomes a respected pianist after being struck by lightning.
One of the most popular notions within musical gifts is absolute pitch, which is the ability
to recognize and recreate the identity of any given note without external reference. To help
explain the advantage this gives to musicians, consider an author who can only recognize the
letter “T” if it is seen next to “S” and “U.” Whether this power is congenital or developed with
practice, there is no questioning its physiologic basis: Sacks indicates that MRI morphometry
has enabled correlating absolute pitch with asymmetry in the activity of the right and left
planum temporale.
Even more legendary is the concept of savants, a group of people who have a dramatic
proclivity in specific subjects such as music that sometimes coexists with mental handicap. In
his book, Sacks explains that the left hemisphere of the brain is reserved for logical and verbal
faculties, while the right handles artistic expression and perceptual skills. Not just independent
operators, the two sides of the brain communicate and exact inhibitory influences on each
via callosal connections. Sacks considers that musical savants may have some asymmetric
hyperactivity of the right hemisphere at the expense of the left that can leave them with
increased musical strength. In fact, the author indicates that transcranial magnetic stimulation
(TMS) has unlocked savant-like powers by inhibiting the left cortex “to allow a transient release
of perceptual functions in the right hemisphere” (pg 169).
Another remarkable musical gift is synesthesia, which is the experiencing of two or

more sensations from a single specific stimulus. Sacks describes several examples of musical
synesthesia, such as one painter who saw or perceived color as he listened to music. The patient
enjoyed greater artistic expression within his profession, but was stripped of the ability following
a head injury. This indicates that the phenomenon is grounded in the brain’s physiology, a
theory that is supported by functional brain imaging. As Sacks indicates, these new imaging
tools have provided “unequivocal evidence for the simultaneous activation of two or more
sensory areas of the cerebral cortex in synesthetes” (pg 192). Sacks theorizes that the cross-
activation is a result of abnormal neural connections between otherwise unrelated areas of the
brain. While it is usually a gift, synesthesia can also be a curse. One musician described in the
book developed such intense musical-visual synesthesia after becoming blind that he was no
longer able to perform.
Musical Pathologies
Not always isolated gifts, musical powers can sometimes be the sign of pathology. Oliver
Sacks introduces us to Williams syndrome, a genetic disorder that is classically characterized by
dysmorphic physical features, visual impairment, and cognitive defects, but with an especially
strong relationship with music. As explored in the book, not all patients with the condition are
musically gifted, but almost all are deeply affected by the art form. The brains of such individuals
tend to be twenty percent smaller than average with the majority of diminution in the occipital
and parietal lobes. In fact, the temporal lobes are normal to supernormal in size. As Sacks indicates,
“the devastating impairments of visuospatial sense could be attributed to the underdevelopment
of parietal and occipital areas, while the strong auditory, verbal, and musical abilities could be
attributed to the large size and rich neuronal networks of the temporal lobes” (pg 365).

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Williams syndrome also causes significant change in the planum temporale within the
superior temporal gyrus, which is known to be associated with absolute pitch. Functional brain
imaging has revealed that patients with Williams syndrome activate a much larger portion of
the brain in response to music than normal listeners, including regions of the cerebellum, brain
stem, and amygdala. The neurologic characterization of Williams syndrome has thus provided
copious information about the physiology of music.
Frontotemporal dementia is another pathology which has enhanced the objective

understanding of music. This condition is associated with atrophy in the frontal and
temporal lobes, and has associated accumulation of tau-positive Pick bodies within neurons.
Besides cognitive deficits and behavioral problems, frontotemporal dementia can also have
accompanying dramatic musicality. Sacks describes one of his patients with this pathology who
had extensive memory loss, but was able to recall any music with ease. For example, he could
not remember the Christmas holiday, but rapidly completed the song “We Wish You a Merry
Christmas” when prompted.
Sacks introduces the famous neurologist Narinder Kapur to explain how increased
musicality can follow brain debilitation. The idea is that neurons can exert inhibitory influences
on one another such that damage to one area of the brain may unlock another. In the case of
frontotemporal dementia, damage to the “anterior temporal lobe of the dominant hemisphere
[may cause] disinhibition or release of the perceptual powers associated with the posterior
parietal and temporal areas of the non-dominant hemisphere” (pg 349).
A similar phenomenon is demonstrated in strokes to the dominant anterior frontotemporal

areas, which Sacks indicates can cause aphasia along with a dramatic augmentation of musicality.
These findings support the theory that the non-dominant hemisphere is a greater home to
artistry and emotionality. Despite the possible ingenuity that can be gained by damage to the
areas within the dominant hemisphere of the cortex, however, Sacks notes that the frontal lobe
must remain intact for performance.
Epilepsy is another pathology that can have an intricate relationship with music. Musical
processing pathways can become activated as a result of temporal lobe epilepsy, and patients
can subsequently hear music when they have seizure activity. On the other hand, music can also
provoke seizures as in the case of musicogenic epilepsy. While patients with this type of epilepsy
often react to different types of music, the seizures usually have the same pathway as they start
in the temporal lobe and distribute throughout the limbic system. It is theorized that the trigger
is related to an emotional or memory aspect of the subject music. One of the authors (ME) had
a patient who was deeply religious and regularly attended church, but had decreased church
attendance because her seizures were provoked by gospel music. In Musicophilia, a patient
avoided treasured family events because she was so affected by the music played in this setting.
Interestingly, the seizures resolved with removal of the brain structures that were causing the
seizures (the epileptogenic zone) and the woman was subsequently able to enjoy her family’s
traditional music.
Another pathology that shares characteristics with epilepsy is musical hallucinations, in

which people will experience internal music endlessly. Sacks makes the point that like a seizure,
this condition has ignition, kindling, and self-perpetuation. In fact, anti-epileptic drugs are

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sometimes used to abort these circuitous episodes. One patient discussed in Musicophilia
began having hallucinatory experiences alongside progressive sensorineural deafness. Sacks
corroborated the classical Konorski hallucination theory, stating that “the conjunction of an
aging brain with hearing impairment… may push a frail balance of inhibition and excitation
towards a pathological activation of the auditory and musical systems of the brain” (pg 73).
Although neurologic disease can enhance the musical experience, there are also conditions
in which artistic ability can be blunted. An example of such a condition is amusia, characterized
by an inability to process pitch to the point that music is perceived as a collection of discordant
sounds. In the words of one of Sacks’ patients, music was described as “pots and pans on the
floor” (pg 112). Amusia can be categorized as melodic or rhythmic, and Sacks explores this
distinction in Musicophilia. He posits that a deficiency of sophisticated melody can result from
isolated right-hemisphere lesions. However, the more primal rhythm is represented robustly
throughout the cortical and subcortical system, and dysfunction thus requires extensive lesions.
Amusia can be congenital, but it may also result from physical damage. In particular, the
cochlea is critical in sound comprehension as it is mapped tonotopically onto the auditory
cortex. As Sacks puts it, the cochlea can be described as a “stringed instrument, differentially
tuned to the frequency of notes” (pg 144). If there is damage to this organ, as with trauma or
in overuse, people can develop the inability to appreciate sounds and music. Sacks considers
one patient who developed harmony deafness after a motor vehicle accident, and had to retire
as a composer because of this deficit. Fortunately, amusia due to cochlear dysfunction can be
improved with therapy, as seen in another of Sacks patients: “Through intensive musical activity,
attention, and will, [the patient’s] brain has literally reshaped itself ” (pg 151).
Musical Therapy
Beyond its scientific merit in terms of musical gifts and pathology, this art form is critical
as a therapeutic tool. Its most obvious application is in mood disorders. Nearly everyone has
utilized music as a solace for life at its most melancholy, including Sacks. In his book, the author
describes his debilitating grief following his mother’s death, and his climactic escape when he
hears the music of Schubert echoing out of a basement window. As music has a power to express
internal states, it relieves its performers and listeners of the burden of encapsulated emotion.
Even chronic psychiatric disorders can be alleviated with music, as Sacks represents with a
patient with bipolar disorder who could modulate his intractable mood by playing piano.
Music has also found home in the therapy for aphasic disorders, in which patients
experience a disconnection between their thoughts and the ability to express them. Sacks
tells the story of a patient who developed severe Broca’s (expressive) aphasia after a stroke.
The patient knew what he wanted to say but could not get the words out. Speech therapy
was discontinued after two years of stagnation, but musical therapy led to dramatic progress.
The book explains that while aphasic patients have defects in the neuronal pathways for
communication, singing uses an alternate route and can be therapeutic for a population
otherwise imprisoned with their own thoughts.
The power of musical therapy is even more dramatically demonstrated in patients who
have had the language centers of their brain completely removed with left hemispheric

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surgeries. Sacks details that it is possible to recover speech by reassigning this faculty to the right
hemisphere using melodic intonation therapy (MIT) as it calls upon the right hemisphere’s
musical skills. While it usually has only rudimentary linguistic capacities, the right hemisphere
“can be turned into a reasonably efficient linguistic organ with less than three months of
[musical therapy]” (pg 242).
Tourette’s syndrome is another pathology that benefits from musical therapy. In this
condition, a patient’s expressions can be halted by uncontrollable outbursts that can be
embarrassing and isolating. Just like stuttering can be remedied with a “singsong manner of
speech” (pg 235). Sacks explains that the pains of this syndrome can be ameliorated with music
as it harnesses the energy of outbursts and organizes them into an orderly flow. Music takes its
effect by reconfiguring brain activity and calming people otherwise distracted by compulsions.
The book emphasizes the power of music by mentioning an esteemed composer with Tourette’s
syndrome named Tobias Picker who uses music to control his pathology.
Musical therapy also has a role in treating other movement disorders like limb paralysis
and Parkinson’s disease who struggle with activities such as maintaining the rhythm of walking.
Keeping time depends on communication between the auditory and dorsal premotor cortex,
and so it follows that music could alleviate gait disorders. The author gives the example of a
patient with a paralyzed leg who found that her limbs could only move when she listened to
Irish jigs, and eventually recovered use by coordinating exercises with music. Another patient
who had lost all spontaneity of movement was able to participate in the dancing and clapping in
a Grateful Dead concert.
Parkinson’s disease is a movement disorder that is caused by an abnormality of a structure

within the brain called the substantia nigra, which is a part of the brain region called the basal
ganglia. The result is the production of classical Parkinsonian signs and symptoms such as low
voice sound, muscular rigidity, slow movement, tremor, and difficulty with walking. Multiple
facets of the disease benefit from musical therapy, including verbal stuttering which responds
to the rhythm and flow of music even if the patient has no familiarity with a given song. Sacks
also tells the story of a musician with Parkinson’s disease who had uncontrollable tremors that
resolved only while playing music. Another patient had difficulty initiating movements unless
she sang, and used a song called “Walkin’ Mama” that enabled her to navigate her house.
Finally, musical therapy is critical in the lives of people with dementia. The connection
between music and memory becomes clear with consideration of an ancient storyteller’s use
of rhythm and rhyme to recite epics like The Iliad and The Odyssey. Patients with Alzheimer’s
disease are gradually stripped of most of their memory faculties as they accumulate plaques and
tangles within their brain. It is in this capacity that music can become critical for functioning
just like a child is reliant on a tune to remember their ABCs. The book mentions the patient
who famously mistook his own wife for a hat who requires song for functionality. As his wife
puts it, if his music is stopped, “he comes to a complete stop, [and] doesn’t know his clothes
or his own body” (pg 258). Another patient with Alzheimer’s disease seemed to emerge from
catatonia with music, and his caretaking wife indicated “she was least sad, least widowed, when
they all sang together” (pg 377). The performances have the same effect on the mood of these
patients, which can outlast the music.

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Beyond what is mentioned in Musicophilia, musical therapy also has applications in
managing the sequelae of war. For example, there was dramatic success in music as treatment
for combat stress reaction following World War I. This condition, formerly referred to as “shell
shock,” is thought to be related to the bombardment of trenches as soldiers suffered through
relentless explosions. The condition left soldiers with a paralyzing panic as well as a thousand-
yard stare that became an iconic symbol for the war that caused it. With minimal successful
treatments, one singer named Paula Lind Ayers was able to alleviate the signs and symptoms
using live performances of familiar music (AE, 2014). Combat stress reaction lives beyond
World War I, and musical therapy can be used for soldiers affected by improvised explosive
devices (IEDs) and other explosives on the modern battlefield.
Musical therapy also has a role in managing post-traumatic stress disorder (PTSD) in
veterans. PTSD is a debilitating condition that can occur after witnessing or experiencing a life-
threatening event in which an individual repeatedly re-experiences the trauma. This condition is
particularly prevalent in soldiers returning from the battlefield, and can impair reentry back into
society due to debilitating depression and social withdrawal. One of the primary treatments for
PTSD is cognitive behavioral therapy (CBT), but group musical therapy has also been shown
to help (Carr C, 2012), likely by enabling formation of social support systems and providing a
means for self-expression. One case report detailed how a torture victim successfully used heavy
metal music to overcome constriction and disconnection associated with PTSD, and relieved
her of the burden of an untold story (Precin, 2011).
Reflection
Oliver Sacks covers significant ground in his Musicophilia. With physiology as complicated
as music itself, the author attempts to document a large breadth of phenomena in the categories
of musical gifts, pathologies, and therapies. While the author excels in amazing his reader with
one curiosity after another, he stops short of exhausting any single subject. This book is far
from a scientific manuscript, but rather is a celebration of the human mind and its relationship
with music. Like an astronomer giving an introductory course to the universe, Sacks leaves the
reader gazing at the stars and conceiving questions. There is a constellation of knowledge to be
explored for each topic covered in this book, and it is up to the reader to decide where to go
next. Let there be no question, however – this is a great place to start.
References
Reschke-Hernandez AE (2014). Paula Lind Ayers: “song-physician” for troops with shell shock
during World War I. J Music Ther, 51(3):276-291.
Carr C, d’Ardenne P, Sloboda A, Scott C, et al (2012). Group music therapy for patients with
persistent post-traumatic stress disorder -- an exploratory randomized controlled trial with
mixed methods evaluation. Psychol Psychother, 85(2):179-202.
Precin P (2011). Occupation as therapy for trauma recovery: A case study. Work, 38(1):77-81.

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Book Review
Just Mercy
A Story of Justice and Redemption
Written by Bryan Stevenson, JD

Equal Justice Initiative
Speigel & Grau
New York
Copyright (2014)
Nickolas L. Rapley, MBA
Captain, Supply Corps, United States Navy
Special Assistant, Legislative Affairs
Office of the Secretary of Defense
The Pentagon
Tel: (770) 855 7342
Email: nrapley@msn.com
Author Note
The opinions in this review are those of the author alone and do not represent the views of the
Department of the Navy, the Department of Defense or other agencies of the United States
Government. The author has no financial conflicts of interest. Please note that the photograph
at the conclusion of this review is an anonymous photograph in the public domain obtained at:
https://pixabay.com/en/homeless-child-b-w-kid-sad-844215/
Introduction
Just Mercy is far more than a casual read. Its origin, its message, and its significance are
profound and life altering. In an extraordinary way, the book embodies the career and passions
of its author. The author, Bryan A. Stevenson, is an American lawyer, social justice activist,
founder and executive director of the Equal Justice Initiative (EJI), and a professor of clinical
law at New York University. Based in Montgomery, Alabama, Stevenson works to challenge bias
against the poor and minorities within the criminal justice system, especially children.
Stevenson had been working on Alabama defense cases since 1989 for the Southern
Center for Human Rights and was director of its center for Alabama operations. The Center
received federal funding to provide legal representation to prisoners on death row until
Congress terminated financing these programs in 1994. Since Alabama is the only state that
does not provide legal assistance to death row prisoners, Stevenson committed himself to their
representation in the absence of necessary state or federal funding.

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Consequently, Stevenson transitioned his Montgomery practice into a non-profit
organization in 1994 by founding the Equal Justice Initiative (EJI), and continues to serve as
the organization’s executive director. EJI “guarantees legal representation to every inmate on the
state’s death row.” The organization has worked to eliminate excessive and unfair sentencing,
exonerate innocent death row prisoners, confront abuse of the incarcerated and the mentally ill,
and aid children prosecuted as adults.
Stevenson helped achieve court decisions that prohibit sentencing children under eighteen
to death, or life imprisonment without parole. He supported cases that saved dozens of prisoners
from the death penalty, advocated for poor people, and developed community-based reform
litigation to improve the administration of criminal justice to all citizens. Without question,
Stevenson’s lifelong commitment to the selfless service of others is impressive and deeply inspiring.
As a military officer, I deal in the undesirable reality of armed conflict; but, what more
noble cause than to save a life, particularly that of a child, or the wrongly accused? Before
summarizing the book below, allow me to share a historical quote that came to mind as I read
and re-read Stevenson’s powerful work.
What is the use of living, if it be not to strive for noble causes and to make this muddled world
a better place for those who will live in it after we are gone? How else can we put ourselves in
harmonious relation with the great verities and consolations of the infinite and the eternal?
And I avow my faith that we are marching towards better days. Humanity will not be cast
down. We are going on swinging bravely forward along the grand high road and already
behind the distant mountains is the promise of the sun.
Winston Churchill, “Unemployment”

A Speech at Kinnaird Hall, Dundee, Scotland
October 10, 1908
As published in Liberalism and the Social Problem (1909)
Brief Summary
Just Mercy begins with Bryan Stevenson’s first interaction, as a young legal intern, with a
Georgia death row inmate named Henry. Stevenson is transfixed by the “astonishing measure
of his humanity” as this condemned man expresses deep gratitude for news that he would
not receive an execution date for another year. Stevenson’s initial experience with death row
situations revealed that some people are treated unfairly; consequently, he sought to understand
how the legal system works relative to socio-economic status.
The book’s introduction provides autobiographical context to Bryan Stevenson’s lifelong

quest to understand this crucial issue and to provide justice for the poor, disenfranchised, and
underrepresented. It details his humble beginnings as the third child of black working class
parents in a segregated rural town in Delaware, as well as his ascent to scholarship education at
Eastern University, Harvard Law School and the Harvard Kennedy School of Government.
Just Mercy recounts the compelling and true story of Walter McMillian, a black man
wrongly accused, and convicted, of killing a beautiful young white woman. Stevenson describes

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how McMillian’s illicit affair with another married white woman led to his implication and
politicized conviction for an improbable crime. As this story unfolds, details of collusion,
corruption and professional misconduct among the state authorities emerge and highlight the
depths of the social, racial and economic inequities as Stevenson works to exonerate Walter.
Stevenson weaves this story with alternating chapters that explore appalling instances of
gaps in the justice system which have led to inappropriate treatment of children, the mentally
disabled, and women. He also details his own personal experiences with racial stereotypes and
treatment under the law.
The book concludes with Walter’s death of natural causes as a free man. It describes
Stevenson’s eulogy, and the insights from years spent working with Walter. His speech
highlights numerous opportunities for (and examples of ) humanity, compassion, revelation,
transformation, and (of course) mercy.
Permit me to share with you some excerpts and key points from the text that have
resonated with a number of scholar commentators as important “take-aways” from this
powerful body of work. The following, along with other points and quotes, are found
originally in the book summary on the James Clear website at: http://jamesclear.com/
book-summaries/just-mercy.
• “Capital punishment means them without the capital get the punishment.”
• “The United States has the highest rate of incarceration in the world.”
• One in three black male babies born today can expect to go to prison.
• Until as recently as 2012, the US was the only country in the world that sentenced children
to life imprisonment without parole.
• “The opposite of poverty is not wealth; the opposite of poverty is justice.”
• “The true measure of our character is how we treat the poor, the disfavored, the accused, the
incarcerated, and the condemned.”
• “Each of us is more than the worst thing we’ve ever done.”
Reflections
As a mixed race, African American and Italian American male who grew up in a violent
gang and crime-ridden area of Southern California, Just Mercy was more than just a captivating
read. It was not just poignant. It was a real challenge --- even a disturbance, but one of great
personal importance. This book made me very uncomfortable, as I was forced to confront
and reconcile certain contending truths. This learning journey so late in my life has been
emotionally and intellectually disruptive as it painfully compels me to reassess my sense of
efficacy and trust in many of the things I take for granted. I naively believed that our justice
system is comprehensive enough to prevent the occurrence of such inexplicable examples of
negligence as those described in Stevenson’s book. Clearly, our laws are no guarantee of justice.
As a typically honest, hard-working American, I regretfully must admit that I spend very
little time considering the rights of the “fringe” of our incarcerated society who are sentenced

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to life imprisonment or death row for violent crimes. My internal prejudices and traumatic
personal experiences have led me to assume that if someone is perceived as a threat to humanity,
they are likely in jail for good reason… so good riddance. I have stubbornly maintained a trust in
our legal system and believe it is written to ensure fair and equitable due process; further, I have
heard very few - or perhaps paid little attention to - exceptions of unjust imprisonment.
But these convenient assumptions have been challenged recently; and very much so now
after reading Just Mercy. It is almost as if the text summarized for me what has been a necessary
collision of my personal biases and misconceptions.
Even if the system is 99% accurate, can we afford the consequence of wrongful
imprisonment of just 1%? In 2016, the Prison Policy Initiative estimated that in the United
States about 2,298,300 people were incarcerated in the United States, one percent equates to
roughly 23,000 citizens.
What is more, the passage of the Anti-Drug Abuse Act in 1986 imposed the same five-year
mandatory sentence on users of crack as on those possessing 100 times as much powder cocaine.
The initiative was meant to stem drug related crime (for which I was personally grateful) but
also had a disproportionate effect on low-level street sellers and users of crack, who were more
commonly poor racial minorities, the young, and women.
But what of the poor, the disfavored, the accused, the incarcerated and the condemned?
Are they all evil… or is there more to their story? Are they anyone we know? The questions
from Just Mercy abound and rightly so. Painful as they are for anyone, they are critical questions
that deepen our sense of compassion and responsibility to -- and for -- one another.
I would not consider my behavior as a youth to be one worthy of emulation; however,

thanks to numerous merciful acts of blind faith in my future potential, I ultimately ascended
to senior ranks as a naval officer. These multiple “second chances” also imbued me with a deep
sense of humility as a leader over the last quarter century of service to my country. Mindful of
the compassion received, I was compelled to lead with a measure of optimism, patience, and an
empathetic desire to learn the rest of the story from our young sailors. Most times, the details
are just not black and white. Military leaders are trained to consider circumstances which drive
various behaviors as we work to elicit the best efforts of our young warfighters and defenders. In
essence, it is necessary to explore and consider the depths of people’s life stories and all of their
varied circumstances. Nothing is ever simple. Just Mercy makes that clear. And it certainly has
challenged me to see beyond the over-simplicity that is often the approach of the uninformed.
As I close my reflections on Just Mercy, I am struck by how much it meant to read of

Stevenson’s work. In fact, delving into this text leads me to contemplate the value of reading.
Certainly, as my young daughters learn to read, they do so for common communication and
understanding. As we grow older, we read to learn about the world around us and become
productive members of society. But as I grow older, works like Stevenson’s Just Mercy remind
me that “reading” at the deepest level is more than an effort to improve my social awareness and
personal knowledge. Now, with the context of a lifetime of observations and experiences, the
most important reads force us to confront and reexamine enduring personal assumptions and
perceptions, as well as one’s sense of humanity and purpose.

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And that is exactly what happens when one reads Just Mercy.
As a young man who was granted more than my fair share of second chances, I find myself
wrestling with a few existential questions after reading this book… and one of them is this:
“Am I more than the worst thing I’ve ever done? “
And what about you? To what personal revelations will your exploration of justice and
mercy lead you?
“Am I more than the worst thing I’ve ever done?”

UNDER CITY
LIGHTS
Under City Lights
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Graduation
A Poem and Reflection
Gregory C. Mabry Jr., PsyD, LCSW, BCD
Major, Army Medical Service Corps
Deputy Chief of Behavioral Health
Blanchfield Army Community Hospital (BACH)
650 Joel Dr.
Fort Campbell, KY 42223
Tel: (270) 798-4097
Email: gregory.mabry@gmail.com
Author Note
The insights or views expressed in this creative reflection are those of the author. They do
not reflect official policy or the position of military medicine, the Department of the Army,
the Department of Defense, or the United States Government. The author has no financial
conflicts of interest.
Graduation
Many healers complete their education and training,
but never graduate…
Many work for corporates or open private practice,

but never really graduate…
Many hang a shingle, prop their feet up on their desk, and release a sigh of satisfaction;
yet never, ever graduate…
To graduate, what then must one do?

…Transcend the knowing
…Go beyond the doing
…Enflesh the time in clinic
…Ignore profit and practice human care
…Hear the cries of those in need
One only really graduates

when one is truly present
when one is really present
with the patient.
Where might one find such an event?

Such a launching into the real?

Under City Lights
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The exceptional clinicians bring altruism to the waiting room.
Absent is the bill of service rendered.
Funding is required to pursue education.
Education in conjunction with experience
are the prerequisites of the helping professional.
The dual relationship.

Money funds education.
The pro bono struggle to reconcile the pledge of charity
within themselves and our profession.
Adequate professors teach.

Good professors teach well.
Great professors mentor.
The next generation waits to be of service

to those who service us.
Who will be the providers
to care for the defenders of justice?
We reply, “Just us.”
On one day of one true graduation…

The battlefield healer is the valedictorian
cap and gown of steel
kevlar-lined loafers dusty with sand
and faded by desert sun.
Pomp and circumstance chime,

but with echoes of shot and shell.
The procession moves ---
bounding, cover, and concealment.
“Congratulations, Graduates!
Now get on a plane; your patients need you.”
Patients whisper with parched throat and cracked lips.

“Doc, I miss my spouse.”
The graduate reflects with furled brow.

“So do I.”
Patients stare at cracked florescent screens.

“Doc, I miss my children.”
The graduate’s cracked lip forms a droplet of blood

and recollects longingly.
“So do I.”

Under City Lights
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Patients hide their face from the sun in the palms of their hands.
“Doc, I just want to be there for my Soldiers and bring them home alive.”
The graduate, once sullen in appearance,

corrects their posture and reestablishes contact.
“So do I.”
Patient’s eyes widen oh so wide, now seeing the face of a brother or a sister.
“You get me, Doc, for real!”
Lifelong family and friends will never attend this ceremony

and the graduate is grateful for their absence.
Ah, the keynoter-patient

giving real guidance to the now real graduate.
Now stars shine brightly.

Every utterance brings smiles, and nods, and agreement.
Now, the valedictorian really stands and utters the challenge:

“I’m ready. Are you?”
Upon Reflection
The battlefield soldier’s expectation of a healthcare provider is elegant in its simplicity:
“Understand me. Heal me.” The holistic approach of treating the mind, body, and spirit is
not compatible with pharmacological interventions alone. To be present in location and
circumstance places the combat clinician on the path to graduation.
Graduation: The act of conferring a title upon conclusion of an academic program or a

training experience. Completion of a formal academic plan is the accepted requirement for
graduation. However, there are differing views of what constitutes graduation. In fact, a new
aspect of graduation needs to be explored and realized. One powerful new aspect needs to be
the ability to be really present to the patient.
Being present is not an academic requirement or a testable skill set, but a powerful inner
realization born of experience. Being present requires the experience of formation as a person,
not just the achievement of skill or intellectual knowledge. The battlefield soldier may not
remember the names of those to whom were provided clinical interventions; however, the
patients definitely remember the feeling of being in the presence of a caring and compassionate
provider – more appropriately named, a healer.
Yes, healthcare from one perspective is a business, a job, and a career. Unfortunately, the
business aspect of healthcare garners the most societal attention in our time. Membership in this
lucrative enterprise becomes the goal for many. The gateway to becoming a healthcare provider
is education via certifications, licenses, and degrees.

Under City Lights
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However, something much deeper is true of healthcare. Healthcare is more than just a
business or a career. It is a universal right for all, and it is most importantly a calling to provide
care for those who suffer. Becoming a healer requires that one understand that healthcare is
human care. And providing such requires that healers learn the art of real presence to patients,
to colleagues, and to the self.
Something therefore is needed in healthcare education. Professors in academic institutions

and medical treatment facilities need to assist students in these powerfully deep foundations of
healthcare and the healing arts and sciences. They need to shape their students accordingly.
The aim? To become effective and compassionate healers who provide the best but who
also know what it means to be really present.

Under City Lights
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Short Story
The Ticket Taker
Katharine L. Sparrow, MSW
Dennis, MA 02660
E-mail: Katesparrow@live.com
Sometimes, a single piece of information can create a massive shift in perception: a DNA
test that proclaims a convicted man’s innocence, a bundle of yellowed love letters discovered in
the attic of an old maid, an act of betrayal by a trusted friend. Once learned, there is no going
back. There is no way to return to the impressions and convictions once held. Everything is
different from that moment forward. With one piece of information, a nobody from the past
might just reach out a hand to gently touch a shoulder and become a somebody.
I grew up in a Leave it to Beaver neighborhood in Malden, Massachusetts, a suburb of

Boston. Malden was the end of the Boston subway’s orange line. It was close enough to spend
a day in the big city without much planning, but far enough away to maintain the small town
feeling of our Malden community.
It was the late 1960’s, and still the days when young children were allowed to wander far
from home without a worry, and my brother and I were wanderers. Malden Square was the best
place to go, if you’d saved your allowance for at least two or three weeks. There was a bowling
alley, Brigham’s ice cream shop for the very best sundaes, Jordan Marsh with four floors of
merchandise, and the Granada Theatre. The Granada was no different from any other cinema
of the day, showing all the new movies that came out to regular crowds of Maldonians. Saturday
afternoon was the kids’ matinee, and my brother and I were frequent patrons.
In good weather, we might walk to the Granada on our own, though it was several miles
from our home. Kids walked a lot more back then and didn’t think anything of it. In winter
Mom would drop us off at the front doors and meet us there when the movie got out, having to
drive around the block several times to avoid a ticket before we would emerge. I remember many
movies that I saw there. Some were new, others older, classic films for children. We saw Lassie
Come Home (I cried), Willie Wonka and the Chocolate Factory, Oliver! and Lady and the
Tramp. We’d join a darkened theater of restless children, munching butter soaked popcorn and
shushing the other kids when they laughed too loud.
And always there was the ticket taker at the Granada Theatre. After buying our tickets
at the window just off the street, we’d enter the ante-lobby area, lining up against the velvet-
covered ropes. Standing by the double glass doors that led into the main lobby was the ticket
taker. It was always the same man and he was there every single time we ever went to see a movie.
My brother and I thought he was ancient, but he was probably somewhere in his seventies.
Beanpole tall and slender, he had a thinning head of what was once red hair, now graying with a
ruddy tinge. He wore a black suit, immaculately pressed, with a white dress shirt and black silk
bow tie. A musty elegance clung to his wiry frame, an air of distinction that seemed left over

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from another era. He seldom met our gaze, but kept his milky blue eyes downcast as he took the
tickets from outstretched hands. I remember how he tore the tickets. Slowly, deliberately, with
the bearing of ceremony he would tear each ticket in two, turn slightly to drop half into the slot
of a box mounted on a chrome pole, and shakily hold the other half out for the child to retrieve.
In all the years that my brother and I saw movies at the Granada Theatre in Malden, we never
heard the ticket taker utter a single word.
When looking back at our time in Malden, years after we had left, my brother and I would
always think of the Granada Theatre and reminisce. On one such trip down memory lane, my
brother said, “Hey, remember the guy who took the tickets? That old guy?” Yes, I did remember,
and I added my own recollections about the ticket taker, how he looked and dressed, and the
S L O W way he would tear the tickets. Neither of us had ever known the man’s name.
From then on we referred to him as “the guy at the theater” and he became an ongoing
joke between my brother and me. We had devised a game called “Who Would You Rather
Marry?” in which one of us would propose two people, usually celebrities but sometimes
people we knew, and the other would have to choose between the two, even if the choices were
both dubious. This game always ended in peals of laughter at the thought of one another in
matrimony with our absurd choice of spouses. Often included in my choices was “the guy at
the theater” and, when faced with a choice between him and some very distasteful character, I
would pick him, much to the delighted crowing of my brother, imagining me waltzing down the
aisle, arm tucked into the black suit of the nameless ticket taker.
Whenever a conversation between my brother and I called for a reference to some random
person, “the guy at the theater” was mentioned with giggles. This private joke carried on into
our adulthood, one of the many slivers of life that close siblings share, like memories that
spontaneously surface when you hear a pop song from decades ago.
Then came the internet. A year or so ago, I joined a group on Facebook. It’s one of the things
I really like about Facebook, which I seldom use for posting anything about myself. A Facebook
group can be found about anything of interest to any user, and the group I joined was called
“Malden Back In The Day”. It is a group of people, mainly my age and older, who lived or still live
in the city of Malden and want to share photos and memories of how the city was in ages past. I
relished the postings of my fellow group members, bringing back memories such as Jimmy the ice
cream man and the hill near the hospital grounds which was the very best for sledding.
One night, after reading a group member’s reminiscence about the Granada Theatre,
it occurred to me that someone might remember our “guy at the theater.” So I posted my
recollections about him and asked if anyone else remembered him or knew his name. Over the
next several weeks I got few responses. Some remembered other Granada employees, one had even
worked there for a short time in the 70’s, but no one seemed to remember the aged ticket taker.
Several months later, I checked my posting again to see if anyone else had responded. Yes!
A group member had posted simply,
“Harold Ray was the ticket taker’s name.”

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I was excited and eager to see what I could find to confirm that this was the right man.
After all these decades, could “the guy at the theater” actually have an identity?
I set to work, scouring the internet for anything I could find about this Harold Ray. The
census wasn’t much help, which surprised me. There were a few Harold Rays who had lived in or
near Malden in the sixties, but the records were sketchy. I turned to the Malden city directories,
which are online up to 1964.
There, in the 1964 Malden directory, was Harold Ray, his occupation listed as “ticket taker
at Granada Theatre”. That was him! The “guy at the theater” had a name. My first impulse was
to call my brother and tell him. He would laugh so hard!
But I delayed that call. I sat there, staring at the listing in the Malden directory. Something
in me slowly turned, like a ferris wheel car gliding haltingly to the ground. Harold Ray was the
ticket taker at the Granada Theatre, so many years ago. Looking more closely I saw that he’d
lived at number 180 Mountain Ave. in Malden. I knew the street. He’d lived there. He’d been
more than just the ticket taker. He’d been a man with a life in the city where I’d once lived. He
was Harold Ray.
I forgot about calling my brother. I needed to know more about Harold. I checked the
listings in some earlier directories and made some discoveries. Not much, really, but enough. He
had worked in the fifties at the Strand theater, another theater in Malden, that met its demise
several decades before the Granada closed. He was listed there as “doorman”.
I noticed there was another Harold Ray who lived just one or two doors down from number
180. He was listed as “salesman”. That was odd. His father, perhaps? I quickly brought up Google
maps and found the address. That house was still there, a large Victorian style with three floors, a
gabled dormer at the top. Must have been a relation, but there was no way of knowing.
Harold’s address on Mountain Ave. revealed an apartment building of red brick with glass
sliding doors on each apartment. It looked too modern to have been the place where Harold had
lived, and when I checked I saw that it had been built in 1968. There must have been another
home there at one time, because the directory listing indicated that Harold had lived on the
second floor in a house with that number. Where had he lived, once the apartments were built
in 1968? Surely his wages as ticket taker would not have allowed him to have moved into one of
the brand new apartments.
I pictured Harold in his second floor room on Mountain Ave., straightening his black bow
tie in a mirror by his door before heading out to catch the bus to the Granada. The directories
give the marital status of each listing, and there was no indication that Harold had ever married.
How had he gotten that first job at the Strand? Did he have siblings? Nieces and nephews?
Friends? Or was he solitary and possibly lonely? When had he died? So many questions… I
wished I knew.
But I did know much more now about the “guy at the theater” than I’d known when I
woke up that morning. He was a single man who had worked all his life in the Malden theaters,

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renting a room on Mountain Avenue. He was someone who had cared about his job, that had
been evident, took pride in his employment and care in performing the tasks required of him.
My life had intersected with his so very tenuously, and I’d known nothing then, hadn’t even
really wondered about him. Throughout my life he’d been the butt of jokes between my brother
and I, a cardboard figure, a nameless nobody.
How many people are like this, really? How many people who come into our lives for a
brief moment do we not notice? How many of them will be remembered by anybody? Will we
be remembered? Will anyone remember us when we are gone, search for us in city directories,
Google the street where we lived? How much does each life really matter, when it comes right
down to it?
I did finally call my brother to tell him the news. The guy at the theater had a name; he was
a somebody. He didn’t laugh as I’d imagined he would. He only said one word.
“Amazing.”

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A Parable
“Honk….if you love…..”
Who we be…..and all we are called to do
Dr. Edward Gabriele
Editor-in-Chief and Executive Director,
President and Chief Executive Officer, The Semper Vi Foundation
Distinguished Professor (adj), Graduate School of Nursing
Uniformed Services University of the Health Sciences
Tel: (301) 792-7823
This reflection was originally written in 2011 when the author was serving as Special Assistant for Ethics
and Professional Integrity to the Surgeon General of the United States Navy. It was inspired by an actual
event during one of the author’s personal visits to what was then called the National Naval Medical
Center in Bethesda, Maryland.
Reflecting…..
Yesterday was one of those days when I needed something different. As some of my friends
and colleagues know, I try on occasion, with my supervisor’s permission, to get myself away for
an hour or so from office and paper and head to one of our hospitals or clinics to walk around
and remember ---- to remember why in the world I am in the job I have anyway. I just walk
around letting the needs of patients and the care given them to soak into me.
It is so easy to get caught up in the noise and crash of policy and politics and personality.
It is too easy to forget that it is really about the call of those who come to us for healing and
for wholeness.
Indeed, yesterday was one of those days. It was really obvious that I needed to shove
myself away from the paper and get myself up to one of our hospitals…..and fast. I needed my
own “retreat time” right away! So I drove onto the property, hid my official badge to be truly
more anonymous; then I parked the car, and went to walk the clinic paths just to drink in the
atmosphere and be soaked in the memory of what is really important in life.
Great medicine for me when I get into “my stuff.”
And then it hit.
As always. Completely unexpected. Comically hysterical.
I looked up to the sky and said: “Go ahead. You’re doing it to me again!”

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I had driven to our hospital in Bethesda. Parked the car. Struggled with my arthritic hip
and leg and foot --- cursing life all the while. Walked the path toward the first open door across
from the parking garages on my left.
And there they were --- calling out.
Two geese.
It was Spring. Mr. and Ms. Goose were waddling about. And amidst the din of all the
construction on the property, the noise and exhaust from cars, of loud conversations of those
coming to and leaving duty --- there Mr. Goose had raised his head, opened his beak, and was
honking as loud as he could --- protecting his Lady Love. He honked above the din, calling
attention to something different, something incongruous and out of place, something far deeper.
Amazing.
Almost with defiance, he was walking up to passersby honking at them and flapping his
wings. He tried, unsuccessfully yet boldly, to step into the street way and stop traffic so his Lady
Love could cross the street in the shadow of his protective waddle.
I just could not move: eyes, body, heart, soul --- all stopped at firm attention. Something
made me look, and stare, and peer, and follow…..and smile. There was something here. Others
saw the two as a curiosity. Something to laugh at and ponder. They continued on. I could not.
There was something really deeper here.
I watched them and I kept smiling. Something cracked inside me as I was standing there
almost incapable of moving. I closed my eyes, felt a swoosh inside me somewhere; and then I
was whisked away centuries ago into an ancient book. A very out of place southern farmer was
somehow moved and journeyed to a northern capital city. There he waddled into the streets.
Saw the privileged lifted up on purple. Saw the never-privileged grovel at the same time on
the sides of streets --- hungry, forgotten, inconvenient. Filled with the incongruity of it all, the
farmer Amos opened his throat in that brash rural sense of Truth-making sound oh so simple.
He honked. “You fattened cows of Bashan......”
A honking --- brash, rural, refreshingly different. It disturbed what my mind normally
judges as the really important things in life --- but really are not.
The goose-honk called me to something far deeper. In fact, the honk was critically
important because it was incredibly inconvenient. Disturbing. Like the brash farmer from the
sticks coming into my oh-so-polished urban and urbane self to grab my face and shove it into
the really important scrub of human life.
The scrub that I am called to love.
To love others whose lives are filled with anything but.

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To love those who themselves are inconvenient.
To love them when others might judge my loving them as something oh so improper.
“Why love the lost and the despised? In fact, why love at all? Just produce. Why not just give
perfunctory care? Hand out a pill and walk away within the proper timeline. Being “present” is
a waste of time, a waste of effort. So inefficient.”
Yet love --- REAL love --- REAL care --- is always present and never counts the cost.
REAL love is truly and always inconvenient. Ask one who left a comfortable job and
confronted harsh powers to lead a small group of workers across a parted sea to freedom.
Ask one who got nailed to a tree because he dared to be present, to love.
Interesting.
People like to use bumper stickers to display what they believe or endorse or find
important.
I remember those that tell other drivers to “Honk if you love......(fill in the blank).”
I wonder.
Mr. Goose and his Lady Love made me think about that bumper and word it slightly
differently.
Honk --- just if you love --- period!
Honk just if you’re capable of REALLY loving..........loving even when it is inconvenient ---
when it calls you deeper than paper and policy and politics.
Mr. Goose honked. His raucous out of place calls rang out to protect the one he loved and
with whom they would create new life.
He reminded me.
Reminded me to listen for the real honks of life. The honking from others in need. The
honking within myself of my own needs but that I would prefer to deny because they remind
me that I too am vulnerable.
Perhaps that is why I try to be deaf to others’ honking --- because it reminds me of my
own needs and incompletion. It is easy to pay attention to paper, to policy, to politics, to
personalities, to productivities. Yet it is inconvenient…but oh so richer…to be present to people.
I owe a lot to Mr. and Mrs. Goose today.

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Perhaps we all do.
They eventually flew off to another place on the property. They probably honked there too.
Now, and always, it is my turn…it is our turn................
Honk!

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Notes
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Notes
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Notes
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Journal of Health and

Reform and Renewal

Journal of Health and Human Experience Volume I, No. 2

Subscriptions, Availability and Resourcing

ii Volume III, No. 1 Journal of Health and Human Experience

Journal of Health and Human Experience Volume III, No. 1 iii

Journal Editorial Board.................................................................................5

Journal Gold Patrons....................................................................................9

From the Editor-In-Chief

Articles & Commentaries

Journal of Health and Human Experience Volume III, No. 1 v

Profiles in Courage: The Next Chapter

The Critic’s Choice

Under City Lights

vi Volume III, No. 1 Journal of Health and Human Experience

“From Victim to Survivor to Victor”

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Global Outreach, Opportunities & Development Committee

Special Sections Editors

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Mildred Huff Ofosu, PhD

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Donna Burge, PhD, BC-APRN, CNS Sharon McCarl, MBA, CRA

Bruce A. Cohen, MD, MPH Victoria Molfese, PhD

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8 Volume III, No. 1 Journal of Health and Human Experience

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Héctor E. López-Sierra, PhD, LP is Professor of Sociology at the Department of Social

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Emmanuel Ifeanyichukwu Nkeleme, BSc, PDE, MSc is Lecturer in the Department of

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16 Volume III, No. 1 Journal of Health and Human Experience

Journal of Health and Human Experience Volume III, No. 1 19

But why? Why today?

20 Volume III, No. 1 Journal of Health and Human Experience

But for what?

Journal of Health and Human Experience Volume III, No. 1 21

22 Volume III, No. 1 Journal of Health and Human Experience

James Shraiky, MARCH

Journal of Health and Human Experience Volume III, No. 1 25

Haitians are primarily of Afro-Caribbean descent, tracing back to hundreds of thousands

26 Volume III, No. 1 Journal of Health and Human Experience

Current State of Haiti

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28 Volume III, No. 1 Journal of Health and Human Experience

The First Model

InterSCT: The Interprofessional Studio for Complexity Thinking, is a not-for-profit

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The Second Model

Capturing the Experience

Study procedures in this phase included face-to-face semi-structured interviews, behavioral

30 Volume III, No. 1 Journal of Health and Human Experience

Understanding the Experience

Researchers utilized multiple strategies to assure trustworthiness in the data analysis

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The transportation system and infrastructure are rudimentary at best, relying on

General economic desperation and an inadequate criminal justice system contribute to

32 Volume III, No. 1 Journal of Health and Human Experience

Journal of Health and Human Experience Volume III, No. 1 33

In medical facilities, a lack of more appropriate services appeared to be driving desperate

34 Volume III, No. 1 Journal of Health and Human Experience