The New England winter is frigid, and we try to rush it on. Before it got unseasonably warm this weekend, it was inhumanely cold, and I was crossing the street, hopping across puddles of crosswalk sleet. As everyone rushed to cross in the biting cold, I saw someone walking very slowly, an abstract expression on his face. More surprisingly still, he had only one shoe on, and the other foot exposed, and out of where his toes began, there emerged a large, bulbous, shiny snowglobe of flesh and skin. It looked like a tennis ball squeezed under the taut knuckles of the foot. It made me pause on the crosswalk.

Is someone treating his gout? I thought. I watched him cross with slight consternation.

I happened to be on my way to my biochemistry class, where we had just learned about the disease of gout the previous week. Biochemistry was a blur of crisscrossing arrows, Mike&Ike shaped receptors, Pacman enzymes, and muscle cells drawn with Microsoft paint. It was a mashup of alphas and deltas and gammas, of function and dysfunction, and of enzyme names with letters enough to surpass “antidisestablishmentariasm” by a long shot. It was only on third or fourth look that I would appreciate the exquisite and beautiful nature of biochemical pathways. And it was only on physically seeing—and recognizing—this man’s gout that it hit me how illness can visibly grow.

Gout is an accumulation of too much uric acid in the blood, which then deposits in the joints. The uric acid crystallizes in the joint, like sharp microscopic needle. It happens when there is too much breakdown in your body of purines, which are the A and G nucleic acids in DNA. Purines come inherently from your body as well as some foods, like certain meats or vegetables (like mushrooms). Gout is believed to be mostly hereditary and predominates in men: in the U.S., 6% of men and 2% of women have it.[1]

In class, we saw a picture of a vivisected foot from a sufferer of gout. It was like white snow piled into the foot. When I saw this man’s foot, crossing the street in the subzero weather, I thought about how incomparable the cold outside was to the striking pain he must have been feeling in his joints, inside. I also thought of the treatment we had learned about in biochem: allopurinol, a drug that slows the rate of making uric acid by blocking a specific enzyme, as well as strict dietary control. His gout seemed untreated, based on its size. His matted hair, overcoat, and many bags suggested to me that he didn’ t have a place to stay; I turned around and he was already seated on the bench across from CVS, with a look of it being his final destination. Maybe it wasn’t. Maybe his gout had flared up that evening, he couldn’t fit into his nice shoes, and he was waiting for a doctor’s appointment the very next day. Maybe he was resting for a bit before going into CVS to pick up an allopurinol prescription, and all would be well. Maybe it wasn’t gout.

But maybe not. Maybe he didn’t have nice shoes.

Amidst the pathways of biology we don’t see the people, but conversely, amidst the people we don’t see the pathways if we haven’t learned about them. Science is slowly teaching me about the emergencies that exist before eyes—what I would call the “slow” emergencies. The fast ones are the ones we learned about in EMT class: the car accidents, the ectopic pregnancies, the diabetic coma. But the slow ones are insidious. The slow ones fester, a nightmare deferred, within our bodies. Certain people have the privilege—health insurance, doctors, and money–to try to make it stop while others fall on the fringes or outside of a system that could help them. Reading this article on the large racial gap between breast cancer screening and survival rates made me wonder how slow and silent these emergencies are. A lump may grow in the breast of a woman while her stomach grows small, twisted by hunger. There are these other slow emergencies—poverty, distrust of the system, pessimism—that aggravate the medically recognizable ones.

The scary thing about knowledge is wondering whether you’ll be able to use it to help everyone you want to help. I don’t presume that a single 10-minute portion of a biochemistry lecture would justify me attempting to help this man with his gout. But maybe one day, as a doctor, I would know all I need to know to help. But would I stop at the crosswalk, turn around and presume to help a stranger on the street who didn’t ask for my help, who might not want it, who might find me condescending to randomly offer it—and how? Maybe the real question, how do you deal with the guilt that might come with your knowledge?

I’m not sure. But hopefully, with healthcare reform giving people with pre-existing conditions access to healthcare, the man gets 2014 insurance this week. And hopefully he’ll see a doctor soon. And then the knowledge pre-meds, medical students, residents, and attendings cultivate will be even more worth it, and even more powerful.

 

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