Physician, Heal Thyself

“I’m stepping out for a smoke,”I said to a fellow medical student during our first week of class in New York. “Want to join?” I’ll never forget the look he gave me. Like I had asked if he wanted to murder a puppy with me. He not-so-politely declined, and I walked out of the hospital alone looking for the smoker’s corner. There had to be one. I had learned to recognise those long, grey poles that stretch down and flare into cylindrical bases storing thousands of squashed cigarette butts. Those poles, repulsive as their contents were, signalled a safe space for me. “You are welcome here,” I imagined they would say if they could talk.

I scanned the pavement that skirted the hospital but there were no smoking poles. Instead there were signs with a cigarette in the middle of a red ring and a diagonal red line going through it. As per hospital policy, in order to smoke one had to cross the street to the next block. I entered the park. Kids played on a swing set, a homeless man sat next to his shopping cart, and I lit up in the corner. I inhaled deeper than usual and felt briefly lightheaded before my thoughts brightened. Before it became bearable to think again.

Growing up in Zimbabwe, I knew many doctors who smoked. I remember waiting for my father at his lengthy appointments with our family doctor. After a punctilious physical exam where the doctor listened to my dad’s heart and lungs, tapped on his belly, felt his thyroid, made him say, “Ah,” the two would step into the adjacent courtyard and have a cigarette while they reminisced about their school days. It was part of the service. “What a great doc,” my dad would always say as we walked out, the familiar fatherly smell of a just-smoked cigarette lingering on his sweater.

In medical school we learned about “the addicted brain”. About how substances such as cocaine and nicotine increase neurotransmitters in our brain’s reward circuitry to make us feel good. In our textbooks, we saw pictures of neurons with long, thin axons ending in purple tendrils that spew magic chemicals such as serotonin, acetylcholine and, of course, dopamine. A jolt of pleasure. Over time, as we use addictive substances, our neurons themselves begin to change. They require more drug to achieve diminishing effects. A dribble of pleasure. After a while, even a photograph of lines of cocaine makes the same parts of our brain light up as when we take the actual substance. A longing for pleasure.

But addictive substances are more than just chemicals; they are woven into our society. The sociologist Pierre Bourdieu posited the idea of habitus – that the daily practices through which we take our body, such as brushing our teeth, sitting down to family dinner and even smoking, are shaped by social forces including history and class. “The habitus,” writes Bourdieu, “a product of history... ensures the active presence of past experiences which, deposited in each organism in the form of schemes of perception, thought and action, tend to guarantee the ‘correctness’ of practices and their constancy over time.”1
I reflect on the “correctness” of my smoking rhythm: wake up, coffee plus cigarette, shower, cigarette, breakfast, cigarette. I wonder how much of that rhythm was to blame for my individual failings – my “addicted brain” – and how much was shaped by the history behind it all.

When the British colonised Zimbabwe in the late 1800s, they realised its tobacco-growing potential. The British South Africa Company, with Cecil John Rhodes at its helm, seized indigenous land and used locals as indentured servants to build a tobacco industry modelled on American tobacco farms in Virginia. The crop was the country’s top export; Zimbabwe became Africa’s foremost tobacco producer and one of the world’s leaders in tobacco.

Tobacco was Zimbabwe’s treasure. At school we went on trips to tobacco farms owned by the parents of white kids in my class. They walked us with pride through the lush fields and into barns brimming with dried tobacco. The golden bunches of toasted leaves hung from the ceilings like the foot-long traditional brooms made of straw that Zimbabwean women stoop over to sweep the floors. I’ll never forget the sweet scent inside those barns. Even today, an olfactory piece of my childhood pokes through in my preference for candles with notes of tobacco laced into the wax.

That leathery fragrance transports me back to the tobacco auctions where white farmers sold their crops to the highest bidder. I sat and waited while my father, an Indian sound engineer, worked late to make sure that his microphones amplified those white voices to the corners of the vast warehouse. As he amplified their voices, he amplified their profits.

Zimbabwe’s tobacco industry made smoking ubiquitous. As a child my favourite candies were Arenel sweet cigarettes, which came in green and white boxes similar to Everests – my grandmother’s cigarette of choice. Inside were white, cylindrical candies with glowing red tips. I would hold the long, thin sticks between my index and middle fingers and fake inhale, puffing my cheeks out the way my mother did when she smoked, before a long, fake, feminine exhale. By the time I lit my first cigarette aged 12, the motions were natural for me. It took a while longer to get used to the burn of the smoke filling my innocent lungs.

Smoking brought my family closer to whiteness. It was phony, but it’s why we all started. When my ancestors, farmers and cobblers from rural India, arrived in Rhodesia in the 1800s, they believed that inching closer to the colonial apparatus would improve their lives. Over four generations we accumulated hobbies such as cricket and tennis, held dinner parties with sticky toffee pudding and Pimm’s, and smoked fags the way white people did.

Even though my mother, father and sister all smoked, it was taboo in our Indian home for children to do it in front of elders. That was where we drew the line between us and white people. So I spent my days at my friend’s house. Her family were white tobacco farmers; smoking was acceptable at all ages. Most whites at school wouldn’t invite me into their houses so I felt lucky to be with this white farmer family. We sat on the couch and passed lighters and packs of Newburys back and forth, taking deep drags, sometimes blowing circles, smoking until it hurt.

Later, during my first week in medical school, I had a routine visit at the student health clinic to receive vaccines and ensure I was fit to train as a physician. In the waiting room I completed a form that asked questions about my health. Then I saw it:

“Do you smoke? (within the last five years)”

I was nervous after my experience earlier in the week trying to find a smoking partner. “Doctors are professionals, right?” I told myself as I checked the box, semi-confident in the stethoscope-bearing creatures whose ranks I’d soon join.

I waited in the clinic room, then an oddity with its antiseptic smell and jars of tongue depressors and cotton balls, now my familiar home. The crisp sheet of translucent paper on the exam table crinkled underneath my bottom. The doctor, a white man in his thirties or early forties entered, sat down on a swivel stool and wheeled himself over to me.

“This form says you’re a smoker.” He looked confused or concerned, it was hard to tell which.

I felt a knot form in my stomach. How would I explain making it this far, all the way to medical school, with this flaw? Would he tell my dean? Would I lose my scholarship?

“I smoked in college,” I said.

“How much?” the doctor asked.

I felt cornered.

“I had a few cigarettes at parties,” I lied.

I lied because I felt that the doctor had power over me and that my medical career was at stake. I also lied because it was too difficult to describe why I smoked in the first place or how I had struggled. I didn’t think I could convey any nuance around something as abhorrent as smoking. I couldn’t pull the doctor aside and say, “This, doctor, was my habitus, formed gradually over time by those around me and those that came before them.” I couldn’t explain that in some places smoking was the cultural norm, and that in those places the culture is defined by an industry run by people that looked just like he did, or that that was why I had started, to try to look like he did.

Doctors oversimplify health and use their authority to dictate what people do to their own bodies. Never drink again. Quit smoking. In this absolutism we avoid the complexity of patients’ circumstances, the raw messiness of it all. We say to our patients that we are morally superior and can resist the forces of history that make them smokers, the racism and capitalism that give them diabetes, the loneliness that makes them drink.

Maybe it’s because we’re exhausted or because we weren’t trained to address these forces in medical school. Maybe it’s because blaming our patients makes our impossible jobs slightly easier. But maybe it’s because the same forces that make smokers smoke – colonialism, racism, capitalism – also prop doctors up. Maybe we’re really not resisting the forces of history at all because, just maybe, we are these forces.

“Oh! Don’t worry about a few cigarettes at parties,” said the doctor. “We’ll change this form.” His eyes softened and a little grin crept onto his face; he seemed relieved. Then a little grin crept onto my face. I was relieved, too.

PHYSICIAN, HEAL THYSELF

PHYSICIAN,
HEAL THYSELF