Nobody, it seems, is comfortable with death. In Haiti, where death and life are fluid concepts, where voodoo curses and ghosts are spoken of as fact rather than fiction, death is comfortably present. The dead are buried in mass graves throughout the country, victims of political crime, violence, malnourishment and infectious disease. There, life can be drained from a healthy person in a matter of hours for lack of clean water.
In Haiti, death is a visceral part of life. However, when death is associated with cancer, those who bury their friends and family with tearless stoicism fall silent. The dying, not yet dead, lie without explanation or discussion of the cancer that is consuming the life within.
While working at a hospital in Port-au-Prince, I watched a young man die a slow, painful death from cancer. The patient became weaker and quieter with each day. His gleaming eyes, darting from his sunken visage haunt me. He laid in the setting neon glow of the makeshift ward. The rusted hospital bed cramped amongst the leprosy, typhoid, post-delivery and trauma patients as you would see only in a chaotic, crowded hospital of the developing world.
I was surprised to learn that the patient had not been told he was dying and that the word cancer was one he had yet to hear. A palliative surgery had taken place and afterwards he remained in the unit, breathing the last of life in the humid, stale air of the ward. Meals came and went, the patient being unable to eat much. The shabby, tiled floors were cleaned daily in a Sisyphean fashion, perpetually damp. Haitian nurses assured me that the patient knew he was dying; only the family knew of the shameful diagnosis.
Looking in his eyes I felt, as much as someone can imagine, what the fading moments of life must feel like. I held his hand and it felt cold. Why hadn’t he been told? For a society so comfortable with death, dying, the dead and occasionally, the undead, why was cancer such a dreaded word? I took cultural note and as I had been encouraged, accepted the values and traditions of the society in which I worked. Friday night had just begun in Port-au-Prince and the emergency room was beginning to fill with the consequences of violence and trauma. It was hardly difficult to fill a 2-bed emergency room in a city of a million people. So, I went to the next patient.
A couple of months later I received a call from a friend concerning an elderly relative with whom I was acquainted. At 80, he had been diagnosed with pancreatic cancer. By the time it was discovered, he had been given weeks to live. We discussed the options of palliative surgery, chemotherapy, and quality of life. And then I was made aware that he had not yet been told that the tumor was, in fact, cancer.
“Well”, the friend explained, “we won’t know definitively until we have the final pathology report.” The preliminary report, however, was available as was the radiology reading highly suggestive of metastatic disease. I thought for a moment about the elderly patient, his strength of character, the straightforward and practical approach he took to life, the sense of humor and grit with which he would handle a situation, whatever the size, whatever the diagnosis. I thought about the importance of understanding, of making informed choices, of living with intent and dying with careful respect. I thought he should know everything and the sooner the better.
A moment later, I thought of Haiti. Why is it that both here and there, across the immense social and cultural divide, from a city shrouded in uncertainty, dust and fear to one where life follows the well-lit, straight lines of suburbia and the middle class, cancer still evokes such fear?
Perhaps the histopathological lack of control is what frightens us most. The inexorable growth and invasion of normal tissue somehow makes us feel less human, unable to control the brute, unyielding nature within us. Perhaps the fear of cancer is death, the finality and inevitability of what is to come and the uncomfortable guilt of knowing its means. While taking the life of the patient, cancer assumes an existence of endless propagation. This innate fear of an invasive growth is a part of the collective unconscious, as present in the slums of Port-au-Prince as in a private hospital in well-to-do middle America.
Cancer killed the elderly American as it killed the young Haitian. While the medical truth was initially withheld, the essential nature of their illness was within them. I wonder if each understood the innate taboo without words or final reports. Although their lives bore little resemblance, the word cancer aroused such discomfort within the hearts of their families that it was avoided as long as possible. Unfortunately, I was unable to see the elderly man before he passed but I wonder if his eyes had the same knowing look as the young man in Haiti. A look of understanding, acceptance and peace although the word itself had yet to be spoken.
Elizabeth Horn is a resident physician.