Sneha Mantri // In this post, I want to reframe and expand on the provocations I presented at the CHCI medical humanities conference this year. The bulk of my talk was an analysis of Mohsin Hamid’s 2017 novel Exit West,[1] through the lens of medical education and practice. As a physician and educator, I’m deeply concerned with the ways medical training transforms idealistic young undergraduates into revenue-generating “providers,” and I see the humanities—particularly the ambiguities inherent in fiction—as a form of resistance to checkbox medicine, where both patients and physicians are reduced to ICD-10 diagnostic codes and RVU targets.
But what does all this have to do with a novel about refugees? Exit West tracks the journey of Nadia and Saeed as they flee their unnamed, war-torn homeland, traveling through mystical black doors to the Greek island of Mykonos, a tenement in London, and finally, to the San Francisco Bay. Throughout the novel, Hamid elides the details of the journey in favor of a focus on what happens after the journey, as Nadia and Saeed struggle to connect with others, and with each other, in these new lands. Ultimately, they separate and find new ways of living apart, rather than together.
Certainly, the plot of Exit West offers an intimate portrait of the experience of dislocation and migration, an experience that few medical students and trainees will have faced. For this alone, it’s worth including in a humanities curriculum for professional students. Despite efforts by medical schools to reduce implicit bias in admissions, the proportion of applicants from underrepresented minorities (URMs) who matriculate into a medical school has declined over the last several years. For instance, in the 2015-2016 cycle (the first year of available data), 48% of applicants with self-reported American Indian/Alaska Native heritage matriculated; by 2018-2019, only 36% did [2]. While these data don’t identify the leaks in the pipeline—the numbers of applicants from URM backgrounds remains steady year-to-year—the implication is clear: many medical students come from a place of racial and socioeconomic privilege, and a core feature of medical training is the ethical demand to learn how to care for people wholly unlike oneself. Exit West demands empathy for Nadia and Saeed, presenting them not as passive victims of circumstance—the dominant narrative of refugees in Western media—but as active agents making specific choices in response to both external pressures (e.g. anti-refugee protests forcing them to move yet again) and internal desires (e.g. Nadia’s engagement with their Nigerian neighbors versus Saeed’s increasing interest in his homeland’s food, language and prayer).
But saying that the trauma of forced dislocation is equivalent to the trauma of medical training erases critical differences between the relative privilege of the student/trainee and the marginalization of the refugee. Such erasure is indeed a form of violence, as Roanne Kantor very rightly points out in her post this week. But the complex style of the novel, with the main narrative broken by short, seemingly unrelated interludes, offers another way for medical educators to think about relocation and dislocation.
The interludes come out of nowhere, disrupting the throughline of the Nadia-Saeed plot and jarring the reader out of literary complacency. Stylistically, the interludes draw me back to my first encounters with clinical care and the complex self-interruptions of taking a patient history. Indeed, the medical students I teach struggle mightily with the interludes, which interrupt the refugee/immigrant fable they have come to expect. That lesson in itself—that a story, including the story of an illness, holds more than a succinct clinical vignette on the board examination or a pre-templated note from the electronic medical record—is important for students and trainees to remember.
I want to turn to just one of the interludes here, to show what it might offer to medical education. A little past the midpoint of the book, Hamid describes an elderly man on Prinsengracht in the center of Amsterdam, sitting on a balcony overlooking “a courtyard that was as lush with foliage as a tropical jungle, wet with greenness, in this city of water, and moss grew on the wooden edges of his balcony, and ferns also, and tendrils climbed up its sides” (Hamid 173-174). As the elderly man smokes his cigarette in this garden of Eden, he watches a “steady stream of foreigners” emerging from a shed which evidently serves as another door, and catches the eye of a “wrinkled man with a squint and a cane and a Panama hat;” as the wrinkled man is about to reenter the shed he “turned to the elderly man, who was looking at him with a degree of disdain, and elegantly doffed his hat” (Hamid 174). This unexpected gesture leads to a flourishing of friendship between the elderly man and the wrinkled man: they greet each other initially with the polite formality of raised hats and glasses, but on the third day, they begin to “cobble together a conversation” despite the language barrier, and ultimately the wrinkled man asks the elderly man to come with him, back through the door, to Rio de Janeiro. Their friendship blossoms into love, their kiss accidentally captured in a photograph taken by a Dutch neighbor.
This is the ideal of open borders: migration that brings people together rather than drives them apart. Notably, this is one of the few instances in the novel where the mystical doors function as corridors, allowing freedom of movement, rather than a one-way passage with no chance of return.
For medical education, though, this interlude also offers a specific opportunity for redemption. The elderly Dutch man, before meeting the Brazilian man, is standoffish, smoking silently on his balcony, observing and judging the people around him. He’s the detached physician, clinically sterile despite the dramatically lush world around him. It is only after he begins to interact with his counterpart that both men find what they had been looking for. The friendship and love of the elderly man and the wrinkled man grows out of unexpected gestures—the doffed hat, the raised glass, the well-mannered nod—and out of a willingness not just to observe but to engage with the Other. Understanding how to cross that border, how to become vulnerable with each other, will help physicians care for not only a refugee population, but also all patients coming to us for care.
[1] Hamid, Mohsin. Exit West. New York : Riverhead Books, 2017.
[2] American Association of Medical Colleges. Applicants, First-Time Applicants, Acceptees, and Matriculants to U.S. Medical Schools by Race/Ethnicity, 2015-2016 through 2018-2019. Available online at : https://www.aamc.org/data/facts/applicantmatriculant/