fifteen

WITNESSES

It always surprises me what people will reveal to a physician. Every day, I introduce myself to strangers, and they answer my personal questions, even the most probing. I ask where they live and with whom, whom they love, with whom they lie down, how they make and spend money, and what they hope for in the future. When physicians ask the right questions, people answer.

Jonah answered our questions, but only after being attended to through the logic of care. Not that Jonah spoke. Jonah answered our questions, but I never heard him say a word.

I met Jonah during my residency. He was eleven years old. When I met him, he had already been refraining from speech for three months, and he would remain silent for three more. While Jonah was silent, I spoke to anyone who would speak to me, and I gathered every record I could find of when Jonah had spoken to physicians.

When we unfolded Jonah’s medical records on a table in the nurse’s lounge, each text was fragmented, beginning mid-thought and ending without resolution, with more aporias and erasures than a postmodern novel. The authors of these texts—ever changing, for the same physician rarely saw Jonah twice—always deferred diagnosis until after a new test or study was procured from another physician. No physician saw a result from all these efforts; diagnosis was the ever distant horizon.

Looking at the gathered charts, we reconstructed a history. Jonah was conceived in poverty, the last child of a family fissured by illness and substance abuse. When not drunk, his father, Matta, was encouraging. When not depressed, his mother, Deb, was caring. Deb had many reasons for her frequent dysphoria. She supported herself through public assistance and sex work. She did not know the fathers of several of her children. Some of her children lived with her, some with her parents, and some were in foster care.

After birth, Jonah was hospitalized in a neonatal intensive care unit with pulmonary edema. He went “home” two weeks later. Sometimes he lived with his mother and sometimes with her parents. We sketched out his family tree—it was twisted in on itself because two of Jonah’s half-siblings had a child together—and included the known diagnoses of each family member. The number of diagnoses increased as we worked down the generations, and the diseases listed read like the table of contents of a health inequality textbook; they included bipolar disorder, diabetes, fibromyalgia, hepatitis C, major depressive disorder, pancreatitis, and schizophrenia.1 By the time the family tree reached Jonah’s generation, the names of adolescents were often wreathed by five or more chronic illnesses.

Except for Jonah’s name. He had remained healthy enough to avoid physicians. He enjoyed reading and was a good student, earning As and Bs. He kept his grades up even when, at the age of seven, he entered foster care after his maternal grandfather, Floyd, was convicted of sexual assault on a woman. In foster care, Jonah received counseling but no psychotropic medications or diagnoses, a surprising circumstance because foster children are often overmedicated and overdiagnosed with psychiatric illnesses.² Two years later, Matta sobered up, won custody of Jonah, and took him out of foster care. They shared a modest house, but it was their own.

When Floyd was released from prison a year later, he moved in across the street and helped out. Over the next year, Jonah began seeking the help available to him. He entered the sick role. Around his tenth birthday, he began showing up at the Emergency Department near his home. He came in with vague complaints. A subjective fever. Occasional diarrhea. Back pain. Choking episodes. Throat pain. He told one physician, “I strain my brain to think.” An MRI was ordered. A bone scan. Both examinations were “unremarkable,” which is the euphemism we physicians use when we suspect something is broken but cannot quite see where. Jonah was sent home with a large bill for services rendered, but without a diagnosis.

Over the following summer, Jonah gradually stopped walking. First he borrowed a cane from his grandfather Floyd. Then two canes. Then a wheelchair. His parents were concerned enough to return to the Emergency Department, despite the cost. After one visit, for wheezing and painful swallowing, Jonah was hospitalized overnight and received a fistful of medications—albuterol, dexamethasone, diphenhydramine, and epinephrine—that only marginally improved the wheezing. The physicians sent him home the next day with a provisional diagnosis of “spasmodic croup vs. somatization vs. malingering”; no diagnosis at all.

At home again, Jonah stopped attending school. Someone filed a report on the family with Social Services, alleging assaults by the adults on the children and by the older children on the younger children. Twice, the Department of Social Services checked in on Jonah’s family. Twice, the caseworkers could not substantiate the reports, so Jonah stayed at home. His silence began soon after these visits.

His parents took him to a local pediatrician, who ordered procedures to look at his throat, a direct laryngoscopy and rigid bronchos-copy; these examinations were equally “unremarkable.”

Jonah was sent home again. So that someone could be with him at night, Jonah began to share a bed with Floyd. In Jonah’s family, this was part of the sick role. Whenever Jonah had been sick as a small child, he had slept in Floyd’s bed. Floyd began offering Jonah liquid nutritional supplements, which he had brought home from one of his own hospitalizations. Despite their sweet flavor and gentle texture, Jonah declined the Ensures. He ate and drank less each day.

Four weeks later, Jonah’s parents carried him again to the Emergency Department. The emergency physician rehydrated him with intravenous fluids and diagnosed Jonah with failure to thrive, hysterical stridor, and perioral abrasions. The physician suspected a psychiatric problem, so he referred Jonah to a community mental health center.

Jonah and Matta went once to the community mental health center. They left with a prescription for fluoxetine, a drug to increase his available serotonin, but they never filled it and never returned.

A week later, Jonah was hospitalized for pain with swallowing so severe he was refusing all food. Once admitted, the medical staff reported that he only sipped juice and ate ice chips. Consulting psychiatrists prescribed mirtazapine to increase his appetite and improve his mood, but Jonah refused the medication. Pediatricians observed that he spit up half of every meal and diagnosed him with anorexia nervosa, a diagnosis that described Jonah’s behavior without explaining it.

Physicians ordered more tests. A pharyngeal function study. An otolaryngologist consult. The physicians were still looking for a broken part while Jonah was silently fading away. The physicians threaded a nasogastric tube into Jonah’s stomach, taped it in place, and began feeding Jonah pureed meals.

Finally, a new pediatrician joined the team, and she looked again at Jonah. She tested a sample of Jonah’s urine and found chlamydia. She treated Jonah with antibiotics for chlamydia and, since they often travel together, a presumed gonorrhea infection. She asked Jonah if she could swab his urethra to see exactly which bacteria were present, but Jonah refused. With the pediatrician’s encouragement, though, he opened his silent mouth long enough for her to swab his pharynx. The sample grew gonorrhea. The inquisitive pediatrician recalled that Jonah had been sharing a bed with his grandfather and asked to speak alone with Jonah’s grandmother, who admitted that Floyd had a history of sexually transmitted infections.

The pediatrician called the police. A few days later, she transferred Jonah to our psychiatric hospital. When he was wheeled in, he was eleven years old, weighed sixty-six pounds, and did not eat, talk, or walk independently.

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When we talk about reforming medicine by restructuring it around the needs of customers, I think of patients like Jonah.

On one hand, his experience points to many of the failures of our systems. He was seen by multiple physicians, who did not consult with one another, were trained to examine only specific parts of his body, ordered numerous expensive tests and procedures, recorded their findings in incomprehensible medical records, and never integrated the results into a comprehensive account of Jonah’s condition. These physicians engaged in unceasing activity, most of it unnecessary and uneconomical, while Floyd continued to molest Jonah. The physicians maintained the clinical volumes and operating margins that keep our hospitals and clinics afloat but missed many opportunities to halt Jonah’s decline into silent dependency.

On the other hand, I doubt that the most recent prescriptions for healthcare reform would have helped Jonah either. In these accounts, Jonah would be understood as a customer for whom healthcare providers should deliver the best outcomes. They would optimize the benefits physicians and other healthcare practitioners provided him with. In practice, that means following standardized clinical guidelines, comparable to the computerized instructions displayed at the line chefs’ stations at the Cheesecake Factory, which rarely account for situations like Jonah’s, and measuring outcomes by performance on quality measures that assess compliance to those guidelines rather than true outcomes of a patient’s well-being. In a psychiatric hospital, the “quality” of Jonah’s hospitalization would be measured by seven items, such as whether a complete list of his medications and his treatment plan were transmitted to an outpatient practitioner at discharge. These seven items are necessary but insufficient measures of whether or not we have provided the “quality” care that patients like Jonah need.3 A psychiatric hospital could achieve perfect quality scores for Jonah’s care even if it discharged him home to Floyd, because one can often meet the quality metrics without addressing the real problem.

Even if we could develop the right evidence-based guidelines and patient-centered outcome measures to enable physicians to practice medicine with impeccable customer service, another obstacle would remain: too few practitioners are willing to care for the poor, even though a sadly extensive body of literature shows that race and poverty are powerful predictors of illness.⁴ Illness increases as inequality increases to the extent that, if you tell an epidemiologist your zip code, he or she can estimate how long you are likely to live.

There is another equally extensive body of literature showing that physicians and hospitals often preselect the patients who will have the best outcomes and the best reimbursements. High-skill physicians frequently seek low-risk patients to maximize their scores on quality report cards.5 Basil built his hospital where the indigent ill lived; today’s clinics and hospitals are clustered where the wealthy live. We physicians often serve the wealthy instead of the poor.

The great critic of this trend is the physician Paul Farmer, who excoriates contemporary medicine for its unjust distribution of medical services. Farmer argues that the problem is not that we do not know how to deliver the advances of contemporary medicine but that we choose the wrong people to whom we deliver the advances. It is not simply that we do not bring the meal to the table on time and at the right price; many people are never invited to the table at all. Farmer observes that by any measure the poor suffer a disproportionate share of the burdens of illness, and he insists that they ought therefore to receive a disproportionate share of the benefits of medicine. Medicine could be renewed, Farmer wrote in Pathologies of Power: Health, Human Rights, and the New War on the Poor, if physicians and other practitioners engaged in “pragmatic solidarity . . . delivered with dignity to the destitute sick” instead of customer service.⁶

For Farmer, a medical practice seeking “pragmatic solidarity” would consist of observing, judging, and acting. By observing, Farmer meant identifying the social and economic conditions that limit the agency of the poor and imperil their health. By judging, Farmer meant identifying the structures that inflict suffering upon the poor. Finally, by acting, Farmer meant the obligation of medicine to redress the suffering of the poor. Farmer wants justice rather than charity for the indigent ill.⁷

In contrast, noted Farmer, conventional medicine usually consists of preventing, treating, and curing. Farmer admired these activities but lamented that they were unable to identify and act against the underlying economic and political causes of suffering. So he disparaged medicine as consumerist while envisioning its renewal, writing, “In a world riven by inequity, medicine could be viewed as a social justice work. In fact, doctors are far more fortunate than most modern professionals: we still have a sliver of hope for meaningful, dignified service to the oppressed. Few other disciplines can make this claim with any honesty.”8

And few other physicians are capable of making this claim with more rhetorical currency than Paul Farmer, because few physicians have so fully realized their commitments. When Farmer wrote that “pragmatic solidarity” demands making the best contemporary medicine available to the destitute ill before making these resources available to the privileged ill, he was describing his own work. With colleagues, Farmer founded Partners in Health, a nongovernmental organization that extends the advances of contemporary medicine to the poor in countries as diverse as Haiti, Malawi, Peru, and Russia. Where other agencies have declared that it is impractical to deliver the best care in such impoverished locales, Partners in Health has repeatedly proven them wrong by pioneering methods that bring excellent care to the poor.

They do so not by imposing a model developed by corporate headquarters that is exported to the local franchises of biomedicine but by building partnerships with local organizations. They resemble CrossFit more than the Cheesecake Factory. The name of Partners in Health is literal—Farmer and his colleagues believe we must be “partners” with local communities and with the poor. The organization’s mission is, simply, “to provide a preferential option for the poor in health care.”⁹

Farmer developed the idea of being a partner to the poor, and of seeking a preferential option for the poor, from his encounters with the Peruvian priest Gustavo Gutiérrez. Gutiérrez is a Dominican, like those with whom I volunteered in Chicago, and a pioneering liberation theologian. Developed in Latin American communities in the 1950s and 1960s, liberation theology asserts that God is especially engaged with the poor, and church and social structures must thus be reoriented to serve the poor first. Farmer was introduced to liberation theology as an undergraduate while volunteering with a nun serving migrant farm workers. As he has said since, Farmer was drawn to liberation theology because it “does not call for equally good treatment of the poor; it demands preferential treatment for the poor.” The experience led him to Haiti. He was overwhelmed by the poverty and suffering he witnessed there, but he found that liberation theology helped him “make sense of the poverty I saw around me.”10 When he subsequently attended medical school, Farmer spent most of his academic year in Haiti, living with and working alongside the indigent, helping build a clinic, and delivering medical care, then flying back to take examinations.

In Haiti, living in solidarity with the poor meant that Farmer needed to resume his practice of the Catholic faith in which he had been raised. He was not a visitor, but a partner. He found that his Catholic neighbors in Haiti were seeking justice and mercy, while many of his secular colleagues in medicine and anthropology were seeking prestige and power. Living alongside the indigent ill in Haiti as a partner, Farmer felt God’s presence.

Ever since, Farmer has described liberation theology as the leavening of his medical practice and anthropological research. Liberation theology taught Farmer that to be better, to improve, required attacking poverty and inequity, the fetid conditions in which illness thrives. You must listen to the poor, not preach to them about salvation or health. You must not only treat poor patients, you must also accompany them in their struggle. He told a graduating class at Harvard’s Kennedy School of Government, “To accompany someone is to go somewhere with him or her, to break bread together, to be present on a journey with a beginning and an end. . . . Accompaniment is about sticking with a task until it’s deemed completed—not by the accompagnateur, but by the person being accompanied.” (Accompagnateur is the name given by Partners in Health for community health workers who accompany their ill neighbors as they seek and receive medical care.) When you understand yourself as a partner to the poor, Farmer told the graduates, your life’s work is “to accompany the destitute sick on a journey away from premature suffering and death.”11

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To accompany the destitute sick is a mighty task that most of us, even on our best days, have trouble accomplishing. I was fortunate to see it at work in Jonah’s case.

When we read Jonah’s gathered medical records, it was clear that while most of his physicians had worked in the usual register—prevention, treatment, cure—they were silent about his suffering. Searching for a broken part, a bone or an organ, they said little about the culture of poverty and abuse in which he lived, the domestic version of the systemic injustice that Farmer so potently associated with illness. Prevention, treatment, and cure had not worked, so we resolved to try Farmer’s prescription and observe, judge, and act on Jonah’s behalf.

When the silent Jonah was wheeled into our psychiatric facility, he had already been diagnosed with a psychiatric disorder, anorexia nervosa, but we always reconsider the initial psychiatric diagnosis. Although he had surely altered his eating habits and subsequently lost a significant amount of weight, his weight loss was precipitous rather than insidious, and he was preoccupied with throat pain rather than body image. Jonah’s behavior had begun not because he disliked his body, but because his grandfather had invaded it. When a person who suffers trauma develops a mental illness, it is most commonly depression or posttraumatic stress disorder. Although Jonah’s affect was often constricted and he exhibited ambivalence toward his own well-being, he exhibited depressive symptoms only on a situational basis. And though he occasionally had difficulty initiating sleep, he shook his head when we asked if he was having the intrusive thoughts and nightmares characteristic of posttraumatic stress disorder.

Jonah had not suffered the classic version of trauma, a discrete moment in which his life was imperiled by a violent attack or an abrupt explosion during which he believed he would die. He had suffered what some psychiatrists call complex trauma. For children, complex trauma is the experience of multiple traumatic events in interpersonal relationships throughout their developmental history.12 Jonah’s caregivers repeatedly exposed him to a variety of traumas, including hunger, shifting parental figures, poverty, physical abuse, and sexual abuse.

A child who suffers complex trauma can develop dysfunction in every aspect of his life, and while we considered other possibilities, we ultimately saw Jonah’s symptoms as a kind of somatization, the bodily experience of an emotional state.¹³ We all somaticize at one time or another, experiencing a discouraging remark as a headache, a difficult conversation as a stomachache, or a disappointing reversal as a backache. Since Jonah’s somatization was profound enough to threaten his life, we diagnosed him with a conversion disorder, an alteration of his motor function that was incompatible with a recognized medical or neurological disorder. If he could resolve his emotional state, his legs could walk, his stomach could digest food, and his vocal cords could produce speech. But since he could not do so, he converted the unresolvable into a series of physical deficits. The term “conversion” entered the language of physicians through Freud’s classic studies of hysteria, but it is the elegant formulation of the British psychiatrist Henry Maudsley—“The sorrow which has no vent in tears may make other organs weep”—that expresses why someone like Jonah somaticizes.¹⁴

In psychoanalytic theory, somatization is accounted as an immature defense mechanism, and children often somaticize. So pediatricians and parents are accustomed to asking about physical complaints as a way to assess the emotional state of a child.

Confusion often arises, though, because many episodes of somatization follow a physical problem; the well-intentioned care they received when ill encourages children to somaticize. For Jonah, the concerned attention of medical practitioners and his parents encouraged somatization all the way to dependency. As he declined into somatization, Jonah acquired medical supplies. After he stopped walking, he rode in a wheelchair. After he stopped eating, pediatricians snaked a nasogastric tube into his stomach. But as he stopped speaking, he needed something that could not be found in a hospital supply closet. He needed someone to speak on his behalf.

Because we believed that Jonah’s sorrow was related to his trauma, we began our care of Jonah by judging who could (and who could not) see him. Floyd was free on bond, but we forbade contact. We met with each member of his family to determine who would be willing to accompany Jonah as he pursued health and justice.

Matta proved to be Jonah’s best partner, but he needed assistance of his own. He had been absent during Jonah’s early childhood, and even though he had lived with Jonah for the previous two years, Matta admitted that he was often distant. The psychologist taught him to relate to Jonah. The social worker found him a place to stay near the hospital, and Matta began visiting daily to speak with Jonah and the team. Even though he was still not speaking, Jonah brightened in Matta’s presence. The hospital became the place where Jonah and his father became reacquainted.

As their relationship grew stronger, our treatment team met daily to discuss Jonah and make certain we provided consistent treatment. The team included the full complement of professionals available in a contemporary academic medical center—attorneys, nurses, nutritionists, occupational therapists, pediatricians, physical therapists, psychiatrists, psychologists, speech therapists, and teachers. Jonah initially responded to this treatment team with oppositional behavior and refused our interventions. He disliked the physicians, like me, who encouraged him to eat, speak, and walk. He disliked the nurses who enforced the unit’s rules and measured the vital signs that signaled his physical well-being. He disliked the social workers who encouraged him to consider another foster care placement.

But he loved a psychology student who read to him. She would visit the unit in the charged quiet that followed the physicians’ rounds. While the nurses and physicians were occupied with updating the electronic medical record, the student would visit Jonah in his room, pull a chair up to his hospital bed and read Harry Potter books out loud. Page after page, chapter after chapter, she read to Jonah about an orphaned child raised by a neglectful relatives who learned, on his eleventh birthday, that he was actually a wizard. Jonah’s grandfather had forbidden Harry Potter books as devilish, but Jonah thawed in the warm concern of the story and the constant company of the psychology student.

Toward the end of the first month of his hospitalization, he began to accumulate advances, though they came fitfully. Following each advance, there would be a regression. The staff would reassure him, and within a few days he would progress again. He progressed from a wheelchair to a walker to a cane to holding hands with staff to walking on his own. He ate his first solid meal in five months from the hands of an occupational therapist, and two weeks later he was alternating nasogastric feeds with a regular pediatric diet; when he spontaneously vomited his nasogastric tube during an occupational therapy session, the tube was never replaced.

Meanwhile, Jonah received therapy from a trauma nurse. She would visit him independent of the team. She spent two weeks simply building a therapeutic alliance. Then she worked to help him relate his emotions to his physical experiences. When he made somatic complaints by grabbing at his stomach or pointing at his throat, she used fantasy action figures and metaphors like “growing pains” to discuss his emotional state. She instituted a token economy that allowed Jonah to begin controlling his immediate environment. He started writing to her with pencil and paper, asking about his safety.

I witnessed much of this, but I never heard Jonah speak because I rotated off the service before he started talking. Friends of mine who heard him told me that his speech returned two and a half months into the hospitalization. He started with cries, inarticulate grunts, and monosyllabic responses. His written questions to the staff became pointed, asking where he would be sent once he started speaking. Jonah met with the attorney who was prosecuting his grandfather. Jonah met with the social worker, who promised discharge to a therapeutic foster home. Jonah met with the trauma nurse, who agreed to provide intensive outpatient psychiatric follow-up at the foster home and, eventually, Matta’s home. Jonah met with Matta, who promised daily visits, his own sobriety, and Jonah’s safety.

Now Jonah spoke freely. He asked for books, pizza, and time off the unit with Matta.

Jonah spoke only after his team left behind prevention, treatment, and cure in favor of witnessing his suffering and committing to protect him from further suffering. After he was assured of justice, Jonah said his good-byes out loud and walked off the unit on his own.

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In medicine, we are often intimate witnesses to profound suffering. We see every day how poverty, neglect, and abuse distort the bodies and minds of the people we meet as patients. We see how the poor receive profoundly different care from the rich, how they age early and die young.

We grow accustomed to such sights.

On psych units, insurers and regulators advise discharge from the hospital when patients are “stable,” a euphemism meaning that a patient can survive outside the hospital. I often discharge patients to situations where bare survival is all I can offer and any hopes for an end to suffering can only be called modest. I rarely accompany people to justice and mercy.

So I am grateful that I saw, with Jonah, what medicine can achieve. I am grateful to all the practitioners, with their various skills, who were witnesses to Jonah for months, long after the reimbursements for his care stopped. These practitioners, mostly women, patiently cared for Jonah, and in doing so they showed what real improvement in healthcare looks like when practitioners heed Farmer’s call to observe, judge, and act on behalf of a patient. Too often, we forget what medicine can do, but as Farmer also observed, our most costly failures are often failures of imagination.

When I feel especially discouraged by medicine, I make a list of what a reimagined medicine would look like, a medicine where physicians and other practitioners could get to know people intimately, bear witness to the social injustices they suffer, and accompany them to health and justice. On a locked psychiatric unit, my list includes the end of coercive treatment, a shared table where staff and patients could eat together, meetings between inpatient and outpatient teams, and ways to reintegrate patients into the lives of families and local communities. When I am fool enough to share my list with a regulator or administrator, he or she will look at me as if I am as daft as the patients. They know that nothing on my list is paid for by insurers or required by regulators, so they think it impossible. But I know that everything on my list is possible.

Quality-improvement advocates like to talk about battleships staffed by young workers with modest experience and skill who achieve reliable outcomes. I prefer to talk about the Mennonite Mental Health Movement, a group of young workers with comparably modest experience and skill, but more expansive imaginations.

The Mennonites are a small Anabaptist community committed to nonresistance, or meeting violence with nonviolence. Mennonites will not serve on a battleship, but they will perform alternate service in wartime.

During World War II, some fifteen hundred Mennonites performed alternative service in state psychiatric hospitals as members of the Civilian Public Service. Instead of serving in combat, they served in hospitals that were, like the Dorothea Dix Hospital at which I trained, sprawling, crowded facilities. During the war, so many on the staff of these facilities were drafted that in some instances a single staff member was left responsible for a thousand patients. The remaining staff, before the advent of effective psychotropic medicines, and without the imagination for pragmatic solidarity, often engaged in frank violence. They patrolled hospital halls with blackjacks, striking down agitated patients or stripping them naked and spraying them with water.

With little training or experience, Mennonite volunteers joined these wards and found ways to care for agitated patients without violence. On these understaffed units, Mennonites pioneered noncoercive techniques for the care of persons with mental illness.

After the war ended, Mennonite veterans were released from the Civilian Public Service, but many of them decided to build an alternative system of mental health facilities across the United States. These eight facilities directly served people with mental illness. Mennonites worked with leading psychiatrists from the National Institutes of Mental Health to provide state-of-the-art care, just as Farmer does through Partners in Health, as well as the caring environment of a Mennonite family. Forming therapeutic relationships was a part of the treatment, so at most of the facilities staff shared a common table with patients. Near at least one of the facilities, local Mennonites opened their homes to families visiting patients. The facilities also educated members of the Mennonite community about what it means to live with a mental illness and served as places for direct encounters between the indigent ill and the wealthy well. Mennonites provided the evidence-based treatments of contemporary medicine, not in pursuit of consistent outcomes but out of a pragmatic solidarity with the ill and a reimagined sense of medicine.

When the Mennonites reimagined mental healthcare through the lenses of discipleship and nonresistance, or when Paul Farmer called for medicine to become pragmatic solidarity, they were following the example of Basil.

Farmer called his peers to leave consumer medicine, where those who can pay the most receive the best care, and practice a liberating hospitality in which the poor will receive the best care and receive it first. The Mennonites called on psychiatric facilities to cease their coercive practices, where agitated and psychotic patients were violently oppressed, to practice a noncoercive care for persons with mental illness. Basil called physicians to abandon their Hellenistic medicine, where care was provided only to relatives and associates who could afford the physician’s fee, and tend to the poor stranger.

All became witnesses who observed, judged, and acted in the face of injustice. They both provided exemplary medical treatment and saw that not every problem a person brings to a physician is best understood as a medical problem. Some problems will not be solved by biomedical solutions. The Mennonites accomplished something—providing inpatient mental health services to persons with mental illness without using coercive measures—that still seems impossible in most psychiatric facilities, even though we now have dozens of effective medications. The Mennonites had none of these medicines when they began their own efforts, but what they had was enough imagination to look beyond evidence-based outcomes. They had alternative, communal practices of reimagined care. They bore witness in an active sense. They told stories to actuate change in the lives of people like Jonah, so that people like Jonah could write their own stories.