Guilherme Coelho
São Paulo, Brazil

Josefa Maria do Carmo—Dona Zefa to everyone—was the kind of woman you knew before you met her. The whole favela spoke of her like a patron saint: with respect, affection, and a reasonable fear of not wanting to disappoint her.

Seventy-two years old, the widow of Seu Agenor, she was mother and grandmother to people scattered across the hillside. On her veranda in Mangueira Alley, Dona Zefa occupied a role that in other times would have belonged to a healer. She sat daily in the same white plastic chair, leaning against the wall where the morning sun hit and afternoon shade fell, and received visitors. She did not charge a fee, judge, or gossip. She listened with the grave attention only someone who has lived a long life can muster, then spoke little—always little—but in the right places.

My own wife had gone to her twice. Both times, she came back lighter. Not cured—Dona Zefa did not cure anything, she said so herself—but lighter, as if someone had helped carry a burden.

I greeted her whenever I passed through the alley. Good morning, Dona Zefa. Good afternoon. She would respond with a nod, sometimes a small smile, and those brown eyes—yellowing slightly with early cataracts—would rest on me for a second before returning to gaze on the horizon of rooftops and water tanks.

But Dona Zefa was not well, had not been for months. At first, nobody noticed—she had always been quiet, so becoming quieter did not raise alarms. But then came the forgetting. Small things first: a neighbor’s name she had known for forty years, where she put her sewing scissors. Then, larger things: she burned the beans twice in one week, forgot her eldest granddaughter’s birthday, and asked three times in a row if her husband had eaten lunch.

Her husband had died in 2000.

The family took her to doctors. A neurologist ordered a CT scan, which was normal. He said it was age, and prescribed donepezil for dementia. It didn’t help. Another doctor said depression and prescribed fluoxetine. That didn’t help either. Finally Shirlene, one of our community health workers, brought the case to Dr. Helena—our family physician, a woman who believed that houses spoke louder than lab results.

“I want to see her,” Dr. Helena said. “Tomorrow, first thing.”

Dr. Helena arrived early, left late, and did something I had never seen: she walked with us, engaging deeply with the environment and patients, reminding us of the value of attentive, holistic care.

She wrote everything down. Not just the patient’s name, complaint, and medications—she noted the color of the living room walls, the smell from the kitchen, whether there was water damage on the ceiling, and whether the yard plants were alive or dead.

One day, I lost patience and asked, “Doctor, why do you need to know if Dona Carmen’s rosebush has fungus?”

She looked at me as if I had asked why the sky is blue.

“Because a rosebush with fungus means an abandoned yard. An abandoned yard means Dona Carmen isn’t going outside. Dona Carmen not going outside could be due to knee pain, fear of falling, sadness—could be many things. The rosebush tells me what Dona Carmen doesn’t.”

The body speaks, she told me once, but the house shouts. Listening to these stories deepens our understanding and empathy for our patients.

Dona Zefa’s small room, with its faded quilt and view of the neighbor’s rooftop, reflected her limited environment, reminding us that living conditions are integral to understanding health status.

She wasn’t the Dona Zefa I knew.

The woman in the bed seemed to have shrunk. Her face was swollen strangely—not from overeating, but as if retaining water in the wrong places. Her skin had a yellowish pallor and was dry, with fine cracks at the corners of her mouth. Her hair, which had always been pulled back in a bun, lay loose on the pillow—thin, brittle. But what struck me most were her eyes. When she turned to look at us, her brown eyes were there—the same as always—but what was behind them had changed as if someone had switched off a light.

Dr. Helena examined her slowly, explaining each step. But her eyes were elsewhere—on things no one else saw.

I watched her look at the skin on Dona Zefa’s arms and frown. She pressed the shin and observed how long the fingerprint took to disappear and examined her tongue—thick and pale, as if too large for the mouth. I watched her ask Dona Zefa to say her full name and pay attention not to the name, but to the voice—hoarse, dragging, as if coming from a well.

Blood pressure: ninety over sixty. Heart rate: fifty-two. Numbers I knew, after fourteen years as a health worker, were too low.

“Dona Zefa,” the doctor asked, “have you been feeling cold?”

Marlene, the daughter, answered: “Doctor, she stays wrapped in that quilt all day. It’s late winter—August in Brazil—but not that cold. Yet she says she’s freezing.”

“And her bowels?”

“That’s an old problem. She’s always been constipated. But it’s gotten much worse.”

Dr. Helena nodded. On the nightstand, beside a glass of water and a black rosary, sat three medicine bottles. She picked up the third one, which I didn’t recognize.

“What’s this for?”

“Vitamins. Another doctor prescribed them because she was weak.”

Dr. Helena read the label and put it back. Said nothing. But I saw the furrow between her eyebrows deepen.

On the way out, she stopped at the doorway.

“Marlene, before the forgetting started, did your mother have any health problems? Anything different?”

“No, doctor. She was always strong.”

“And her thyroid? Has anyone ever checked her thyroid?”

“Thyroid?” Marlene frowned. “I don’t know what that is.”

“It’s a gland here.” She touched her own throat. “Controls many things in the body. Metabolism, energy, temperature.”

“No, nobody’s ever looked at that. Why?”

“I don’t know yet. I’m going to order some tests. Meanwhile, I want you to stop giving her the donepezil and fluoxetine.”

“Stop? But the neurologist prescribed them—”

“Those medications are for other diseases. If your mother doesn’t have those diseases, they won’t help. They might even make things worse.”

The results came back in a week. What mattered was one number.

TSH: 89.4.

Dr. Helena explained: “TSH is a hormone the brain produces to tell the thyroid to work. When the thyroid functions well, TSH stays low—the brain doesn’t need to shout. When the thyroid stops working, the brain shouts louder and louder, trying to wake it up. Normal is up to 4. Dona Zefa is at 89.”

“That’s very high?”

“It’s as if her brain has been screaming for months, and the thyroid can’t hear. Without a functioning thyroid, the whole body slows down. The heart beats more slowly. The intestines stop. Metabolism freezes. And the brain—” She paused. “The brain becomes slow. Confused. Forgetful. It looks like dementia. Looks like depression. Looks like many things. But it isn’t. It’s a problem with the thyroid.”

That afternoon, she explained everything to Marlene. Showed her the test, the number, and what it meant.

“So my mother isn’t senile?” Marlene’s voice broke.

“No. Your mother has a disease affecting her thyroid. It probably started long ago, worsened gradually, and nobody noticed because the symptoms looked like other things. But it’s treatable. One pill a day. In a few weeks, she’ll start to improve.”

Marlene began to cry—not from sadness, but relief.

Dr. Helena took a medication box from her bag. Levothyroxine, 50 micrograms. She explained how to take it: fast, every day at the same time, without coffee or calcium.

The improvement came slowly, in pieces. First, Dona Zefa stopped feeling so cold. Then her bowels started working. Then her voice cleared, losing that deep, muffled hoarseness. Then her eyes.

At eight weeks, she was sitting in the white plastic chair on her veranda. When I passed, she looked at me and waved.

“Good morning, Seu Tião.”

It was the first time she’d called me by name.

In three months, she was sewing again. People returned to climb Mangueira Alley, to sit in the other plastic chair, to speak softly as if in church.

Many years later, when Dona Zefa died of old age at eighty-six, sleeping in the same bed where Seu Agenor had slept, Marlene found me at the wake.

“My mother had eight more years because of that medication. Eight good years with her mind intact, watching grandchildren grow, sewing dresses, listening to people. You can’t put a price on that.”

I wanted to say it wasn’t me, it was Dr. Helena, I just walked up the hill with her. But Marlene continued:

“You know what my mother said once? She said that the doctor had a gift. That she looked at people and saw what was hidden inside them, like a seer. But it wasn’t spirits—it was study, paying attention, caring.”

I stayed a while longer looking at the old mango tree that gave the alley its name. I thought of Dona Zefa in her plastic chair, her brown eyes almost amber in the afternoon sun. I thought of Dr. Helena noting things in her black notebook, paying attention to fungus-covered rosebushes and hoarse voices and numbers nobody else looked at.

The body speaks, she had told me, but the house shouts.

Now I understand.