Fara's pain complaints migrate from visit to visit. She reports fatigue, difficulty sleeping, an upset stomach, and intermittent heartburn. Initially, I pursue the full workup: radiographs of painful joints, blood work. My differential is short but reasonable: osteoarthritis, rheumatoid arthritis, GERD. I delve into a few zebras endemic to eastern Africa—schistosomiasis and other intestinal parasites. I check blood levels of vitamin D, thyroid hormones, iron.
Based on laboratory results and images alone, nothing is wrong with Fara. A year goes by. We chase the pain the way one might chase a butterfly through a field—a bit wildly but with a clear intention of catching it. I help her fill out an employment application and am even a reference for her. But the main jobs for a 67-year-old woman with limited English, all-over body pain, and little education are cleaning floors or houses, and Fara can do neither. The daughter picks up a fourth job.
During that same year I meet other women from eastern parts of Africa, many with all-over body pain. I befriend community members and am told I am likable, “because you believe in our pain.” I begin to learn about family members left behind and of the civil war that is a daily occurrence for many of the refugees I treat. I confront the genital mutilation still done to young women every day in parts of the world I have only dreamed of visiting. I experience both the fear and the absolute love and joy of a culture much different from mine. I learn that, for many, the turmoil of their loved ones back home keeps them paralyzed with worry. I also learn that the Muslim culture does not allow for discussion of the negative aspects of life when so much of life is good.
I wish for conversations without the need for interpreters. I long for an opportunity to get to know my patients at their core, their true thoughts and experiences. I long for connection. I long to try out words like depression and stress and anxiety to explain symptoms, but these are all Western words. I eventually find that the phrase thinking too much is one I can use without stigma in talking to all of my patients. Fara agrees that she does indeed think too much, but I still never know what of.
The last time I see Fara for her all-over body pain, I decide to ask questions about happiness and sadness. Discussing emotions is still taboo, but she has children who are still in Africa; I know she worries about them. Her eyes go soft. She listens to her daughter—our interpreter—but watches me, her humped back and stooped shoulders slowly opening like a book of hymns. I start a PHQ-9 depression screen and make it to question 2—the one about hopelessness—when I suddenly stand up and raise both of my hands to the ceiling. I watch myself offer up an image of a woman running to the street and yelling. “Do you ever just want to yell!?” I exclaim, loudly and with conviction, surprising all three of us.
“Yes!” she erupts, the only English word she knows.