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Books, Journals, New Media
January 19, 2000

Biography: The Scalpel and the Silver Bear

Author Affiliations

Harriet S.MeyerMD, Contributing EditorJonathan D.EldredgeMLS, PhD, Journal Review EditorRobertHoganMD, adviser for new media


Not Available

JAMA. 2000;283(3):405-406. doi:10.1001/jama.283.3.405-JBK0119-3-1

The Scalpel and the Silver Bear is a poignant, fluidly written autobiography of a Navajo woman, tracing her steps from the reservation in Crownpoint, Ariz, where she grew up to the upper echelons of academic medicine at Dartmouth University. In between is a compelling tale of the cultural and psychological hurdles that Native Americans and women face in the world of medicine. And while Arviso's story contains an incisive, critical look at medical education and the culture of modern medicine, it is directed not solely at medical professionals and medical educators. It is also directed toward Navajo girls interested in knowing their options, sick people who hope to see their illness in a new light, and anyone interested in viewing healing in a broader, more holistic sense.

Arviso is a Tsi'naajinii, a black-streaked-wood person from one of the bear clans (hence the reference to the silver bear in the title), but she is also ‘alni, a person from two different cultures. On the paternal side, she is the daughter of Robert Cupp, a full-blooded Navajo who taught Arviso and her sisters to hunt. Although Cupp attended one of the best prep schools in the state and had been an excellent student, he dropped out of college after a couple of years, a decision he regretted deeply and which, apparently, led him to drink excessively. Arviso was also greatly influenced by her paternal grandmother, Grace Cupp, a remarkable woman who received a degree in education from New Mexico University and taught elementary school while helping her husband in different business ventures. Through Grace, Arviso learned the calamitous history of her tribe and was taught to honor Navajo ways. However, neither she nor her sisters were encouraged to speak Navajo, since English was considered the language of opportunity, a message that both Robert and his mother had been given repeatedly throughout their lives.

Arviso's mother, on the other hand, was a bilagaana, a white person, and had a rather marginal place in reservation life. "From my mother," Arviso writes, "I learned what it meant to always be slightly outside a culture . . . this was doubly ironic, because we felt peripheral to a culture that was itself peripheral . . . . We lived on the margin of a margin, which is dangerously close to nowhere at all." However, Arviso's marginality is also an unrecognized or understated source of strength, a limen that enables her to participate effectively in two worlds and to do things that she might otherwise not consider doing, such as attend medical school and write books. In speaking of the contributions that Navajo concepts could make to allopathic medicine, Arviso notes, "in typical Navajo fashion, I did little to promote them. But the outside world was often interested, and in atypical Navajo fashion, I did not turn it away." And it is precisely this conflict between a desire to do things Navajo style, to lead by example, and a recognition that she is atypical that defines the unique quality of the narrative. Arviso does draw attention to herself by writing a book, something notably un-Navajo; however, rather than challenging medicine head-on with statistics and clinical studies to prove her argument (eg, that good rapport and a respectful attitude toward the patient lead to better surgical outcomes), Arviso simply recounts her own positive experiences. And where the reader most expects to encounter acrimonious detail—the treatment of women in surgical residencies—Arviso is brief and surprisingly upbeat. "My colleagues," Arviso writes, "and the attending surgeons didn't treat us any differently from our male counterparts."

However, what really sets this narrative apart from other reform-minded treatises is the author's unapologetic reverence for high-tech medicine. While Arviso does discuss the insensitivity of doctors toward nurses, the lack of esprit de corps, the greed of managed care companies, and the tendency to treat patients as products or outcomes rather than human beings, these sentiments are counterbalanced by a youthful exuberance for modern medicine, especially surgery. Indeed, notwithstanding the fact that surgery is the object of a strong taboo in Navajo culture—no small irony considering that the term Navajo comes from the Spanish term for blade—Arviso describes the movement of a surgical team as a form of choreography and compares gallbladder surgery to expressionist art.

Lit up on the large surgical video monitor, the inside of the body can be exquisite. Sometimes the familiar shapes of the liver's lobes, the gallbladder, the stomach, the spleen, and the pancreas, and the delicate, curving arches of the duodenum, colon and small intestines look strange and surreal, like Expressionist art. If a capillary is cut when the laparoscopic equipment punctures tissues to delve further inside the body, the screen blooms with red lilies of blood. When the gallbladder is punctured, an inky fluid pours out. Whether I was looking at the shiny fascia covering the person's muscles, or the whitish peritoneum that lines some organs and the abdominal cavity like a fine tissue, or a swollen, infected gallbladder or appendix, what I often felt was awe and reverence.

At the same time, however, Arviso highlights the value of Navajo knowledge and memory in solving contemporary medical problems. For example, she recounts that in the early 1990s a mysterious flu appeared on the Crownpoint reservation resulting in the deaths by catastrophic asphyxiation of at least 11 people. The epidemic, affecting otherwise healthy individuals in their 20s and 30s, was so baffling that at one point a dozen or more laboratories were investigating the disease, and medical investigators had proposed theories ranging from Epstein-Barr viral illness to bubonic plague to account for the sudden deaths. Although Arviso was unaware of it at the time, a Navajo physician employed by the Centers for Disease Control and Prevention (CDC) was told by a hataali, a traditional healer, that the epidemic was caused by an increase in rainfall and a huge crop of piñon nuts, occurrences associated with disease in Navajo oral tradition. While the haatali's advice apparently made little sense to the CDC, it was not long before the disease was linked to a hantavirus found in mice, which were in great abundance owing to an oversupply of piñon nuts resulting from unusually wet weather. At this point, the hataali's teachings about the need to maintain balance begin to make sense to Arviso.

While the messages Arviso seeks to convey are simple—get to know your patients, listen to their stories, obtain their trust and acceptance, treat them holistically, create harmony in the operating room—the poignancy of the narrative derives from difficulties she experiences trying to follow her own advice, trying to be a Navajo practitioner in a hospital with the usual malpractice concerns. After completing her residency in surgery and returning home to the Gallup Indian Medical Center, she quickly realizes that she has much to learn about patient care and Navajo culture if she is going to be an effective practitioner. She knows she must unlearn much of what she learned at Stanford. She recognizes that she must help her patients relax and learn to control her own anger. She attends a yeibechi—a fire ceremony held in the dead of winter to restore a sick person's harmony. However, just as she begins to incorporate Navajo concepts into her practice, she is confronted by a situation that makes the Western medical expert re-emerge. The case involves Carolyn Yazzie, a beautiful, full-blooded Navajo who is diagnosed with breast cancer. While Carolyn is college educated and holds a professional job, she blames herself for the cancer and is reluctant to schedule a lumpectomy. Arviso tries to avoid violating traditional Navajo boundaries by not pressuring her into a decision, although she knows she will soon be asking risk management at the medical center to send an official letter recommending surgery so that the hospital is legally protected. And when Carolyn does finally call, Arviso essentially tries to convince her that her family is wrong, that there may very well be no reason or personal fault that can explain her cancer.

While there is clearly no shortage of books critical of contemporary medicine, it appears that many, if not most, are written by investigative reporters and sociologists and are read primarily by academics, not by doctors or other medical professionals. Medical educators who try to introduce resident physicians and medical students to this literature are keenly aware of this fact. However, there is reason to believe that physicians might actually read and appreciate The Scalpel and the Silver Bell. For one thing, it is written by a Navajo woman who is a doctor. This not only adds a certain legitimacy to text but should enable physicians to identify with the narrator. Secondly, as noted above, it is autobiographical, so the messages—critical as well as affirming—issue directly from the life experience of the author and, thus, have more inherent power than even a well-researched exposé. Thirdly, the book contains a positive message; it is really more about what's right with Navajo concepts of healing—or what Navajo belief can add to high-tech medicine—than what's wrong with modern medicine. This makes the criticism, and the need to reform medicine, appear less blunt, less heavy-handed than other texts. Last, but not least, it is a compact and fast-moving narrative that can be read in a few hours.