Lament for the Injured, Pt. 2

Riyas Komu, from exhibit "Safe to Fight" (Azad Art Gallery, Tehran, 2010)

Fear of ACL injury has replaced fear of intimacy as my number one issue. Plenty of people come back from an ACL tear and still play in leagues and pick-up games. But plenty also leave the sport forever.

If I turn a cold eye on my fear, I see that I am less afraid of never playing soccer than I am of the rehabilitation that it would take to go from a torn ACL to playing again. It isn't the tear that scares me, but being off my feet, not being able to run - sinking into depression and giving up. Not having the emotional strength and discipline to take on something like that.

I called my HMO the morning after my injury and pushed to see someone that day - I was clear: "I am afraid I tore my ACL." I was determined confront my fear - or rather, I should say, my knee insisted.

I said the magic word to describe my pain ("acute") and soon gained entry to orthopedics (I had asked for Sports Medicine, but was re-routed). I am not a difficult patient, but I have something to say about what's going on with my body. Unfortunately, this doesn't always make one's journey as a patient smoother.

A detour through past medical trauma

In 1984, I was hospitalized for eight days. A couple days before I found myself in an ambulance, I had gone to the student health clinic at Rutgers College because I was afraid I had a kidney infection.

A good friend of mine became deathly ill from this when we were first-year students. I knew the symptoms, and mine were identical to hers.

An affable young male doctor saw me. He didn't seem to take my concerns seriously. I had constant, deep pain in my lower back - off to one side exactly where the kidney is located. I had a low-grade fever, symptoms of a UTI, I was starting to feel like I had a flu or something. I could feel that this back pain wasn't muscular - it was deep, and constant.

He asked if I lifted heavy things - maybe I sprained my back. I worked in a kitchen and lifted heavy things all the time - but didn't recall hurting myself. "And how would that explain the fever, anyway?" I asked.

He told me to take extra-strength Tylenol. I said I wanted to be sure I didn't have a kidney infection. Would he please run a test? Could I please pee in a cup so we could just be sure - I was really concerned because kidney infections are really serious, and if you get to the point were you need to be hospitalized, the recovery is slow. As a working student, I couldn't afford to be out of commission for a month. I peed in a cup and went home. I took the Tylenol and felt better, but the symptoms kept returning as the pills wore off.

The next day I called the clinic to ask about the test results - they said: "The test came back negative." I bought nice food for myself because I hadn't eaten a decent meal in days. I took more Tylenol - I ate cheese and crackers, some fruit, and went to bed.

That night I was violently ill. There was a reason I had no appetite: my body couldn't handle food. I soaked the sheets with sweat. My fever kept climbing, dipping, and climbing again. By the morning I couldn't keep down water. It was the last week of the semester, and I couldn't imagine not going to my feminist political theory seminar. Being young and delirious, I went to class.

I sat on the floor in the hallway with the other students and waited for the professor. My classmates (an intense collection of college activists) insisted I go directly to the nearest university health clinic (attached to the women's college, different from the one I used). I must have been a sight - gray and sweaty. Having trouble staying vertical, and having little will of my own by this point, I went. It was about three blocks away, and I remember walking there being really hard.

I more or less collapsed when I walked in the door. My fever was 104. I remember telling the staff taht I'd been to the other clinic about fearing I had a kidney infection, and that this clinic said I was fine. The doctor on duty at the women's college clinic was soon yelling into the telephone, swearing. She shouted "You did what?!" and said "What fucking assholes," or something like that when she hung up. She then ranted to her colleagues.

I later learned that the doctor I'd seen (a resident) had decided that I w as trying to manipulate him into giving me a pregnancy test, on the assumption that I was too ashamed to ask for one. So, when I called about my test results, I had gotten the result of a pregnancy test I had not asked for.  This is bad enough. But when I went to that first clinic, I had told the resident who treated me that I had my period.

The picture I should have presented to that doctor was that of an articulate young woman, who was quite frank about what was going on with her body, and who was worried that she had a kidney infection. The doctor, I guess, saw me as a dumb slut trying to manipulate him. I don't think that's too harsh a way of reading his actions.

As I was being rushed off to the hospital in an ambulance, as the school worked on locating my family, I was far too sick to care.

I only learned the full story about what happened from a nurse, just before I graduated, when for some reason I had to go back that clinic. She saw my name and pulled me into an office to give me the full breakdown on what had happened. (Until then, I thought it had been a lab error, or something like that.)

The residency program at Rutgers was overhauled as a direct result of this incident: residents were not allowed to see especially women patients without supervision. If that nurse hadn't told me what happened, I'd never have known why what happened to me happened, or that the university had cared enough to prevent it from happening again.

The whole experience left me with one rule: Never let a resident talk to you without a doctor in the room. Never trust a doctor to really understand what you are saying about your body - they have their own feelings about the body you are in, and you can't control that. You have to help them see where those feelings interfere with their ability to see and hear you, just as they are there to do the same for you.

The only branch of medicine where I've found this to be less true - where careful listening to the patient is pretty much a base-line from which the doctor works, is, as it happens, Sports Medicine.

Sadly, that wasn't where I found myself the morning after I heard that tearing sound from my right knee. I was at Orthopedics. In a room with a resident.

Germany, playing for more than a win

Germany's coach Joachim Loew lights a candle in Enke's memory

On the eve of the World Cup, players reminded the press that this tournament was different.  This year, they were playing in the wake of traumatic loss, and would do their best to honor the memory of Robert Enke, the German National Team goalkeeper who committed suicide in November 2009.  In his story for The Guardian, Dominic Fifield explains:

The recognition that they had been oblivious to a team-mate suffering so deeply struck home with Germany's players, who were told the news of his death by the national coach Joachim Löw and the manager Oliver Bierhoff as they prepared for a friendly against Chile.

"To have not realised ...well that makes you feel helpless," said Ballack, who had known Enke since he was 13. "There was shock, emotion, lots of tears. The service and memorial were good, a chance to say goodbye to him. We have to learn from this. There is the illness, but also the combination with football and being famous."

Ballack continues:

"He was scared to speak about his problem because he was scared to lose his child, or his job. Or to confess to having a weakness to other players. People have weaknesses. We should accept it. This should never be forgotten. It was a hard time, for everyone close to him and for us, as players. He will always have a place in our team. The players, the staff, the management all knew him, and it's still in our minds, and in the fans' minds. The further Germany go in the, the more emotional it will get." (Dominic Fifield, "Germany spurred on by the memory of Robert Enke" in The Guardian, June 11 2009)

His teammates were devastated not only by his death, but by the realization that someone on their team, a friend, had suffered so much and had not been able to share this burden with them. His death put things in perspective.

It is easy to fall back on stereotypes about the German squad - as clinical, for example - but this particular squad defies such templates not only in the dynamism and vision of their game, but in their public embrace of Enke's memory and in their support for other athletes struggling with depression. The squad has promised a portion of any bonus it earns from the World Cup to the Robert Enke Foundation - set up by the German FA to support research and treatment of depression.

That the team has come together like this, in the wake of such a sad loss, around such a taboo subject (especially in the macho and often heartless world of sports cultures), is truly inspiring.

(See November 2009 post: "On the Suicide of Robert Enke")

On the suicide of Robert Enke

Robert Enke worked very hard over his career for his spot on the national team, playing in Portugal, Spain, Turkey and finally in the Bundesliga, for Hannover 96. He won eight caps for Germany, and was in position to be the country's #1 keeper in the upcoming World Cup. Enke committed suicide on Tuesday, November 10th by throwing himself under a train.

Enke's death is a horrific reminder of the seriousness of depression, and the particular difficulty faced by athletes who suffer from it. Used to toughing out setbacks and injuries - taking the field with bone chips floating around your foot, fractures, sprains and worse - athletes struggling from depression may be reluctant to seek help, for all the ways depression doesn't register as "real enough," and for fear of seaming weak or losing their place on the team (see Dave Zirin's 2008 article about this). This was the case, his wife explained today (see Juergen Voges's AP news story): Enke feared that coming out about his depression would mean he would lose "his sport, his life."

Depression goes after the things that matter most to you, everything that brings you joy: it can take the sport that was once a source of pleasure and make it into a site of misery. I read once that depression separates people from who and what they love with "surgical precision." That strikes me as about right.

Enke's wife and doctor speak to his struggles at this press conference, available on the Guardian's website. There is no single event one can point to as depression's "cause." News stories point to the death of Enke's very young daughter, Lara, who died at two years old of a congenital heart problem in 2006. He apparently first sought treatment for anxiety and depression during his tenure at Barcelona in 2003. Given his dogged fight to break into the top flight, such counseling would be normal - just not perhaps for an athlete. Enke hovered for years in the #2 spot and worse for Europe's top clubs. If there was ever an effective external trigger for anxiety and depression, it's the precarious position of a keeper on the edge of playing for his country in the World Cup. News reports keep repeating how he seemed closer than he'd ever been to being at the top - as if this makes his depression more mysterious - but of course this would raise your anxiety, not lower it.

We can't say that any one of these things triggered his suicide. You can't "blame" conditions for a person's depression, and you can't blame the person either - they are already certainly in the vicious grip of a self-blame, which is part of the problem. The demon is the black sun of depression itself. Whether you are in its grip, or are close to someone who is, its nature is very hard to grasp - it infects the way you feel and think on the most elemental levels.

At my own worst moments (I struggled with panic disorder in my 20s), it was the non-judgmental, non-pathologizing understanding of a friend who intervened to help me seek treatment by recommending a wonderful therapist. My friend also suffered from panic attacks - it was a huge relief for me to hear someone talk about this very awful feeling from experience, because until that moment I thought I was not only crazy, but that there was nothing that could be done about it. I am not sure where I'd be today if it weren't for that conversation twenty years ago. My problems, however, were very small by comparison - anxiety is not identical to depression, though the two can go hand in hand. I was just twenty, and had almost no responsibilities to anyone but myself. And I've always been surrounded by art/intellectual/creative types - a queer sort of world where, at its best, we embrace each other's 'mental illnesses' with affection and humor.

Enke and his wife adopted a baby girl in the spring, and people seemed to think he was doing well. His wife said, however, he was afraid that public acknowledgment of the severity of depression might lead the state to take custody of their adopted daughter - he was terrified of this possibility. In his suicide note Enke apologized for misleading people around him into thinking he was ok - it was necessary for him to carry out his plan. The days before a suicide can be, in fact, a gruesomely "upbeat" period for the person planning to kill themselves - set on the plan, a person can even feel a sense of happiness, knowing that it will all be over. People around them relax (the easing up of their worry feels like a relief, because for the depressed person the concern expressed by those around them becomes itself a heavy burden, and source of guilt and shame). Sadly, we usually learn this only in the wake of a suicide, as we gather around and find ourselves saying the same thing to each other - "he seemed like he was doing better." It's baffling.

All we can know for certain is that Enke must have been in absolute agony to have ended his life like this.

In looking for stories about athletes who have been open about depression, I came across this July New York Times article about the brilliant basketball player Chamique Holdsclaw. After years of drifting in and out of the game, dogged by a depression which made the game joyless, she is back on the court playing for Atlanta. Stories like hers are important. In a 2007 Sports Illustrated profile, she explains that after the death of her grandmother

it was like I was in a box and had closed myself in. It was the one time I needed help and I wasn't letting anybody in.

I am not sure how people get out of this box without help from those around them. And I am not sure how we can tell when people in our lives are in these dark places - since all too often people in the grip of this sort of depression isolate themselves, so that people around them can't see what's going on. In the world of professional sports, there is already a structure in place to facilitate this boxing-in of oneself - you don't want to be a "problem," your very livelihood is in fact dependent on your ability to project an image of yourself as invulnerable. And the goalkeeper especially is the heart and soul of a team, the person who radiates confidence outwards and whose solidity grounds us. Like baseball's pitcher, this player carries a particular symbolic weight.

A death like Enke's leaves friends, teammates and family with a tremendous sense of failure. Enke's wife comments

We thought we could do everything and we could do it with love but you can't always do it.

My heart goes out to the people in his life - losing a person this way is absolutely devastating, for it seems to signal a profound failure in our ties to each other. A friend committed suicide in 1997, and those of us who were close to him are to this day marked by this sense of loss and failure.

There is no easy answer here, no smart sentence to write about this. I guess I would just say that if there was ever a moment to censor the ungenerous reflexes of sports culture - the macho , win-at-all-cost worldview, the intolerance for the possibility of failure, the disgust sports culture shows for vulnerability - and to cherish instead sport as a site of collective pleasure and interpersonal connection, this is it.