Conference of the inaugural ceremony of the «X International Symposium of Ischemic Heart Disease,» organized by the Section of Ischemic Heart Disease and Coronary Units of the SEC. Bilbao, 22 May 2002.
Esteemed Mr. president, authorities, ladies, gentlemen, cardiologists, and patients of cardiologists, if there are any present...
They are present.
I am a cardiology patient and it is precisely for that reason that I want to reflect on the relation between physicians and the rest of us, the potential patients who have had to accommodate their relation to witchdoctors throughout the conscious history of humanity. The physician and the priest have been the intermediaries between life and death, that is to say, before what was once conceived as the mystery, a word whose use that has fallen into frank decadence as science has relegated it. Engels wrote that science is the history of its decreasing errors. Perhaps the loss of shamanism in the roles of the priest and physician and the understanding of their greater or lesser functionality have been the foundation for constructing the critical reasoning that is indispensable for understanding the meaning of life without resorting to supernatural explanations, with the word supernatural acquiring its significance as a concession from our knowledge of the natural world.
I am a heart patient and in this inaugural act I feel that I have the role of the pig in the novel by Kazantzakis, Zorba the Greek. I do not want to offend anyone, but I suppose that persons like yourselves, who have been seasoned by operating rooms, will not faint at the story of a castrated pig that enters the kitchen where Alexis and his friends are eating its testicles, prepared according to an excellent Cretan recipe. The invasion of the animal can be seen as a mere protest or it may be more cultural; it demands that the dish at least should be excellent, because cuisine masks the fact that we kill to eat. However, I believe that a cardiological patient among cardiologists has a task similar to that of the reader in relation to the writer, in the way that Goethe claimed that every literary work was the fruit of complicity between two creative subjects, one who writes and one who reads. With my three bypasses I have become your accomplice and I try to analyze the relation between a patient and his «life-fixers,» who are none other than «death-delayers.»
It is difficult to establish a natural relation between one who knows and one who does not. For years I have maintained that we all must have a basic understanding of that which subjects us, that which obliges us to submit to our condition as subjects. An understanding of the rules of health and social communication is among the most important sort of knowledge, since it is the very material of alienation in the first degree: that which derives from the physical limitations of conduct and that which is inculcated by a system of information over which the receptors have no control.
From the 1960s to 1975, under the auspices of countercultural impulses, the current of participatory knowledge and, ultimately, co-responsibility or empowerment began to flow, fundamentally in relation to the health-care system in what was then known as the West and now might be called the North. Information was then considered a system designed for the dissemination of untruths. Ivan Illich developed a hypothesis about the expropriation of health that he presented in Medical Nemesis (1975), which was an accusation against the official health system. Hans Magnus Enzensberger was one of the most unerring critics of the information system that was dominated by commercial interests or controlled by the lords of the Cold War. Both Illich´s writings against the health establishment and those of Enzensberger on information are based on the idea of the participation of the receptor of health care or news. At the same time (1965-1975), the antipsychiatry alternative came into being as an accusation against the ankylosis of psychiatric practice and as a proposal for another way to perceive the disease of the so-called mentally ill or socially alienated person. An important perspective of antipsychiatry was the role of language as a fundamental instrument, which I examine in my novel The Strangler, in which a mentally disturbed person seized on the language of the psychiatrist and eventually ended up dictating reports, including reports on himself as a patient.
Don´t worry, if I were to dare to steal the psychoanalytic or Lacanian language from the Gods to give to men, I would not think of doing so in a field like cardiology, where disease takes the shape of deficits in corporal matter rather than in a polysemic conjunction of words. But it would be advisable to instigate behavioral habits targeting the inner enemies of the human body, which are part of the human body, as part of our earliest education. Children of my age grew up with the idea that our diseases were tuberculosis and cancer, whereas cardiovascular diseases were eminently American and, like everything else made in the USA, concluded in a happy ending.
In my postwar childhood, tuberculosis was in fashion as a result of hunger and poor hygiene and health. Tuberculosis had been a snobbish disease of musicians and writers and a harsh plague cutting through the popular classes, which in no way prevented the rise of certain banal social initiatives in the 1940s, such as Campaigns for Beds for the Tuberculous Poor, just as you hear it, or juvenile transgressions like the song that we shouted out as we ran down the stairs of school when released. This song was of anonymous origin and sung to the tune of an American hymn from a cinema production, in technicolor, of course:
[We are TB carriers
We have fun, we have fun all day
And every time we meet
We cough it up, cough it up and spit.]
Susan Sontag in Illness as Metaphor (1978) parted from the hypothesis that tuberculosis benefited from a romanticized idea of the disease, as if it had been a diagnosis made to measure for Chopin, with his pneumothorax scars, while cancer was at the service of a simplistic philosophy of the world, in which there was a Manichean division into malignant and benign cancers. «Perhaps right-wing groups,» wrote Sontag, «are the main organized support for quack cures like Laetrile because they also share a paranoid view of the world.» Once tuberculosis was controlled, cancer suddenly appeared as a plague of growth and modernity, a disease so uncontrollable as to seem to surge from the deepest wells of impotence or human punishment. We have invented language in order to grasp a sense of things and defend ourselves against them, as if by naming them out loud we could cast a metabolizing spell: earth, air, water, and fire. But when the threat of the Other is too terrible, language does not help to create even an illusion of possession and defense. For that reason, the popular classes decades ago refused to name cancer and the redundant expression «bad disease» was used to avoid the words «incurable» and «uncontrollable.»
No longer present on front pages, although not for that reason to be considered eradicated, cancer gave way to AIDS as an item of privileged information merchandise, due to its condition as a symbolically punitive illness that appeared to condemn a humanity capable of inventing the miniskirt and birth control pill.
Observe that after a decade of renewed expectations of a liberalization like the one we saw from 1965 to 1975, when carnations could be placed in gun muzzles, brains turned into flower vases, revolutions were characterized as velvet, and sexuality was free, the seventies brought the extermination of the left in the southern cone of Latin America, the petroleum crisis, the decree of zero development, panic in the work market and, finally, AIDS. Words like «hope» or «future» disappeared from vocabularies and we were all crushed by what Leonardo Sciascia called the «present as Inquisition.» Susan Sontag emerged again in 1988 with AIDS and Its Metaphors to denounce that AIDS had been characterized as a plague worthy of a sinful humanity and to thus accentuate the idea of an Apocalyptic end to the century, end to the millenium, end to a paralyzing History of the dialectic sense of the political and the historical. We cloaked ourselves with postmodernism after destroying the fundamental ideas of progress, whether they came from capitalist optimism or Marxist optimism, and distrust of progress meant an entrenchment in the cynicism of determinist survivors, brains and stomachs caught between gratitude for the scraps and panic about announced shortages.
AIDS has now been relegated to fifth or sixth-page merchandise. It should be noted that when trendy diseases lose their media status, the heart reappears as a focal point for concern. Evidence of the heart and brain as elements of a vital axis is reaffirmed, and the heart is now cast as an organ threatened by the idea of progress as conspicuous consumption and a straying from recommended guidelines for the life of the body and spirit. If it is possible to reach a point where globalization can be criticized from the perspective of the globalizee rather than the globalizer, then perhaps cardiologists, along with the other proprietors of knowledge fundamental for life, should become sociologists critical of the organization of production and that relations between humans and Nature that leave the heart alone to confront danger and in the hands of the statistics that emanate from clinics, where we, the patients of cardiologists, go in search of a moratorium, since a full amendment seems out of the question.
The statistics tell us that more than 40% of the deaths that occur in Spain are due to cardiovascular disease, without clarifying whether this very high percentage corresponds to persons who were not expected to suffer heart disease or to persons in biological decline, who have to die of something. Nutritionists have placed the Mediterranean or low-fat diet in counterposition to a diet based on fast foods that favors heart disease. The fight against smoking is dictated in part by an intention to improve health and by in part as a cost-cutting measure for public health services that must deal with the consequences of diseases caused by tobacco.
I seem to perceive in the manner of some physicians a certain ethical puritanism that incites them to treat patients like sinful laymen who have fallen into improper excesses for creatures of such a precarious nature, in view of the fact that the six days of creation of the world were insufficient to guarantee the absence of cholesterol. Some physicians, fortunately still few, have eyes of exterminators, eyes too theological or agnostic to understand that we must have been brought into this world both to imbibe whisky now and then, preferably a thirty-year-old Springbanck, and to suffer cholesterol in the same way that we suffer the brevity of human life, as a biological swindle. In all human knowledge and its application, a balance must be reached between geometry and compassion, between super-rationality and sympathy for the losers.
If words like «tuberculosis» or «cancer» terrify humanity, particularly the poor, as metaphors for absolute failure, the word «heart,» that tragic inner friend and foe that allows us to attend congresses like this one, may benefit from its condition as a literary metaphor, as if the ancient idea that life depends exclusively on the heart were capable of inspiring seductions and masochistic torments that other diseases cannot. The use of the word «heart» is common in Literature and omnipresent in what was formerly known as popular music. Heart is the title of a book of pedagogy par excellence that was read between end of the nineteenth century and mid-twentieth century, a work by Edmundo D´Amicis, a patriotic spokesman who attempted to propose a canon for the sentimental and patriotic education of the Italians, who had just come together to become a state. This book was eventually read by children throughout the world. Cuore was part of our sentimental education and retained sufficient relevance to be a topic of analysis by Umberto Eco in his early period as the young cofounder of semiology. Slave to the association of the heart as an organ and sentiment as the material of feeling, the work by D´Amicis deserves analysis by congresses of cardiologists and literary analysts, which result in such a hybrid meeting that it might give rise to unforeseeable conclusions for the history of humanity. I do not know if the heart has served as a symbol for other arts, although it has sometimes appeared as a sculpture or bas-relief [on grave monuments] in American cemeteries. However, it has not attained the same level of conceptual organization as the liver, an organ that motivated the construction of a monument by the first socialist mayor of El Ferrol in the course of the present Spanish democracy.
The heart appears as a metaphor in Heart of Darkness by Conrad, as an image of the core of darkness, or as a simple statement in «heart of stone» or «heart of the matter» or «broken heart,» a less than brilliant reference. However the word is capable of inspiring titles as poetic as El corazón y otros frutos amargos [The Heart and Other Bitter Fruits], by Ignacio Aldecoa, or The Heart is a Lonely Hunter, by Carson McCullers. The first is the title of one of the best short story collections in twentieth-century Spanish literature and the second serves the poetic uses of a story of love and loss of love by the author of The Ballad of the Sad Cafe. For Aldecoa, the heart is a one of the bitter fruits possible and for McCullers, an active, self-absorbed, and solitary hunter, often too hidden to entrap the game sought after. It would be very interesting if you cardiologists would illuminate the use of the term «heart» by Aldecoa and McCullers with your knowledge. Can a motor organ attain the condition of a bitter fruit responsible for sentimental failures? Can the heart be an active subject in the pursuit of love or in the loss of love?
You have not been able to eradicate the metaphoric use of the word «heart,» although scientific discoveries usually condemn emotionally charged words to obsolescence. Ever since the Moon came into the reach of telescopes and cosmonauts, it has lost much of its value as a literary symbol. Nowadays nobody would dare to write songs like La Luna y el toro [The Moon and the Bull] or La Luna se llama Lola [The Moon´s Name is Lola] or La Luna y el Sol [Moon and Sun], nor would they run the risk of characterizing the Moon as a woman, Luna Luna Lunera [Moon, Moon, Lady Moon] or Luna de España [Moon over Spain], always under the watchful eye of the Sun.
[In case the Moon deceives him
Ay! she does deceive him
Every night,
After the Sun retires
The Moon strolls into the street
Swinging her hips like a gypsy.]
Undauntable, the progressive increase in scientific and technical knowledge of the excesses of the heart has not been able to silence authors like Javier Marías, capable of writing a novel like A Heart So White, or the canzonetistas (1) who still conserve the classic conception of heart, soul, and life as the three most important things in a relation between a man and a woman: corazón para quererte, alma para conquistarte y vida para vivirla junto a tí. [A heart to love you, a soul to enrapture you, and all my life to stay at your side.]
Distinguished cardiologists, do we love with our hearts? Our brains? Our memories? Or do we love with our greater or lesser capacity for self-deception? I do not believe that this congress has been convened to take exception to poetry, novels and boleros, because if systematically debunk mystery, we would arrive at a geometrical rationality incapable of compassion. It is good that boleros, in which the heart is characterized as an emotional sponge, can even serve as background music for a cardiology congress dedicated to nothing less than ischemic heart disease.
In the political terrain, I distrust summit meetings, which are so costly for general budgets, because no political summit resolves what has been resolved, or not resolved, by telephone, fax, Internet, or the calculation of probabilities. Political congresses are usually theatrical representations where the audience watches the show and then drops a vote in the hat of the organizer. However, congresses of physicians are meeting places for those who are often lost in thought and distanced from each other to communicate what they have learned. This makes the encounter a crossroads for information and practices that surmounts the obstacles that health industries sometimes erect, dependent as they are on the laws of the market.
From my simple condition as an accomplice, a heart patient, I welcome you to Bilbao, which has been rediscovered by landing of the Guggenheim ship. I urge you to surprise me. On any day at all, surprise me and discover how to revive my dead ventricle or how to make my condition as a heart patient compatible with my predilection for bacalao al pil-pil (2).
In expectation of that soon-to-come future in which we will be able to buy artificial hearts at the end-of-season sales of the El Corte Inglés, Galleries Lafayette or Macy´s, we will hum a cha-cha,
[Heart of melon, heart of melon, melon, melon, melon...]
...hopeful that you will leave this congress wiser than when you entered, and that I will leave it healthier and thus overcome my complex about feeling like the pig in Kazantzakis´ novel. That would certainly help to reconcile me to my three bypasses.