She was the first Navajo woman ever to become a surgeon, but Lori Arviso Alvord never forgot the traditional hogans of her people on the reservation. After finishing her training at Stanford Medical School in 1985, the young doctor returned to care for the Navajo in Gallup, N.M. In a new book, The Scalpel and the Silver Bear, Alvord (with journalist Elizabeth Cohen Van Pelt) recounts her struggle to blend modern medicine and traditional healing.
The little Navajo girl with a neat French braid and new high-top sneakers lay on her side on the examining table, her face glazed with pain. Her mother sat beside her. At the foot of the hospital bed stood her grandmother in full traditional dress -- a bright cotton print skirt and a red velvet blouse with silver buttons, numerous squash blossom and beaded necklaces, and heavy silver-and-turquoise bracelets.
The little girl was desperately in need of medical help, and the older generation was deeply afraid to agree to it. Three generations of Navajo women were before me. Yet all the decision-making power clearly belonged to the grandmother.
The girl's name was Melanie Begay, and while her grandmother and mother watched anxiously, I pressed my hands against her warm skin. I felt the tenderness in her belly. She winced, even when I brushed gently against her. Her stomach felt tense, like an inflated balloon. When I pressed down again, she began to cry. Tears pushed out of the corners of her eyes, making coffee-colored stripes as they rolled down the sides of her dusty face.
Based on the result of the brief exam, as well as her high white-cell count and other preliminary evidence, I made an immediate decision: Melanie should go right to the operating room for an appendectomy. I did not know if her appendix was perforated, but it seemed very clearly to be infected. It could rupture at any moment.
Unfortunately, Melanie's grandmother, Bernice Begay, had overheard the Navajo nurses discussing Melanie's case before I arrived. The bilagáana doctors were not going to cut open her granddaughter, she'd said loudly to a Navajo hospital aide. Did we know for sure what was wrong? There had to be something else we could do.
Deep inside, I understood Bernice's fears. They came from the history of our people and our relationship to Anglo society. Bernice appeared to be in her 70s, so I knew she'd had firsthand experience of Navajo land taken away, of children forcibly sent to white boarding schools, as had happened to my grandmother. At those schools, their language and culture had been replaced by biligáana beliefs.
I was in a dilemma. One side of me said, Roll her into the O.R. now! But the Navajo part of me could see the inappropriateness of interfering. Navajo eyes warned: the beauty of the body would be disturbed. A surgical knife would defile an intact, miniature universe, with rules and systems that evolved naturally over millennia. I could see the sacredness of that body, how all its many parts are one harmonious system.
My medical training told me that the 8-year-old girl could die if we did not remove her appendix right away. But her grandmother's fears and objections were just as real and true. The two worlds were colliding.
After much thought, I told Bernice that the decision was hers to make. It was something I had begun to tell patients more and more, a show of respect that I believed would be empowering: that they alone, not the doctors or anyone else, control the fate of their bodies. Melanie's grandmother looked as though she weren't sure she could trust me. She seemed to be weighing whether I had another agenda.
In fact, some of the hospital social workers were seeking a court order so that surgery could be performed on the girl in opposition to her family's desires. I did not want to bring in biligáana authority -- although the court order might save the girl's life, it could also be a cultural disaster, and it would make a liar and an enemy of me. To wrench Melanie from her family could be extremely traumatic for her. That, in my view, would increase the odds of complications during her surgery.
The family's relatives had been called in from around the reservation, and while we waited for Bernice's decision, they began to arrive. On a bank of chairs outside the room, a pile of well-worn jackets and wraps, cowboy hats and bags mounted. Chunks of snow and mud from boots melted into a brown soup around the door. Inside the room, the soft murmuring and clicking music of Navajo was accompanied by the sound of shuffling feet. For a while, I stood helplessly waiting in the hall, wondering exactly what was being said.
I imagined Bernice telling the others that they must not allow us to do the surgery on Melanie. She might be saying that surgery is a biligáana practice, but they are Navajos. She could raise the issue of the risk of surgery, which we had had to inform her about. Perhaps she was saying that they should take Melanie home and call the medicine men back. She might believe that the piece of Melanie that we extracted would fall into the wrong hands and someone would bewitch her. She might be saying that even the tiniest piece -- a sliver of flesh or a hair -- would do.
At nightfall Melanie's father, Victor Begay, arrived. He stood outside the room, and from time to time other family members came out to speak with him. Because Melanie's grandmother, Victor's mother-in-law, was in the room, he was not allowed to enter. Among Navajos, mother-in-law avoidance is a strict cultural rule. He would not discuss even the crisis concerning his daughter with her.
A sense of fear had begun to emanate from the assembled family and from the members who emerged to speak with Victor. They had a look of growing intensity in their eyes.
I was not on call and was about to drive home. But I told the nursing staff to beep me if the Begay family came to a decision. If they consented to it, I would drive back and do the surgery. Just as I was heading off the floor, Victor indicated with a gesture of his head that he wished to speak with me. I went and stood beside him. I was on Navajo time now. Many minutes could pass before the time was right for us to speak of personal things.
For a moment we were both silent, in a manner that indicates respect among Navajo people. We were careful not to look directly at each other. I broke the silence by greeting him.
"How is she doing, doctor?" he responded, his eyes focused on the ground.
"Melanie is getting sicker," I said. "Her heart rate is up, and so is her fever. She needs to have this operation before it's too late." I decided to push a little harder. "This is your decision -- but if you decide against the surgery and Melanie doesn't make it, you may find your own decision very hard to live with."
My words hung between us in the air like a dark bird. If he listened to me, he would be going against the ancient Navajo ways whereby the women make decisions like these. He would be going against the will of his mother-in-law. For a very brief moment, I let my eyes cross his face. His eyes, the color of dark stones, looked away.
A little while later, I was checking in one more time before heading out when my beeper went off.
Please tell me that she didn't rupture, I thought, and then allowed the worst-case scenario to flip through my mind. Please tell me she isn't coding. "Dr. Alvord, please call extension four-five-nine, four-five-nine," demanded the device at my hip.
I picked up the nearest phone and held my breath while it rang.
"Dr. Alvord?" asked the pediatrics nurse.
"Yes?"
"The consent form has been signed."
Relief swept over me. I didn't know how the decision had been made or who had made it. I was just glad it had been made: we would operate on Melanie Begay, remove her infected appendix and save her life.
Lori Arviso Alvord, MD '85, lives in New Hampshire with her husband, Jon, and her two children, Kodiak and Kaitlyn. Elizabeth Cohen van Pelt is a staff writer for the New York Post. Passage excerpted from the book The Scalpel and the Silver Bear copyright 1999 and reprinted by arrangement with Bantam Books, an imprint of Bantam Dell Publishing Group, a division of Random House Inc.
