HALF THE SKY

Little Cate had her first birthday last Wednesday. It is hard to believe how quickly time has passed since her birth on that glorious Fall day last October. She is one of the most spirited people whom I have ever met, and she seems to be someone who feels as though we are incapable of comprehending what all is going through her head. Her teacher at daycare said that Cate thinks she is 2 years old and that she might just be 2 years old, intellectually. I have a sense that she is going to (already is) be one precocious kid. While "glass ceilings" surely do still exist in this country in 2009, I believe that Cate, herself, and the loftiness of her dreams and ambitions will be the main determinants of her success. Unfortunately, in most of the rest of the world, women and young girls face much more dire obstacles.

No one has written more extensively and persuasively on this topic than Nicholas Kristof of the New York Times. His columns that appear twice per week in the Times serve as a bully pulpit for the world's forgotten and oppressed. He and his wife, Sheryl WuDunn, with whom he shared a Pulitzer prize for their reporting from China during the Tienanmen Square crisis in the early 1990s, have a new book out called, "Half the Sky," which is a discussion about how oppression of women worldwide (and especially in the underdeveloped and developing world) is the challenge of our time. The title is taken from Chinese proverb that says, "Women hold up half the sky," which stresses women's importance to us all. Improving the lot of women in the 3rd and 4th worlds is not just a moral issue, in Kristof's mind, it is also an economic and national security imperative. I have only read the first few chapters, but I can say already that if you only read one book this year, read "Half the Sky."

Last night, I had the good fortune to hear Mr. Kristof, who is a native of Oregon, speak and discuss his views on the world and on the plight of women worldwide. His stories from his encounters with the world's oppressed will break your heart, but in every account, there is some measure of triumph and some kernel of hope. He also rouses his readers' consciences to think beyond our own comfortable existences and to contribute to improving our world one person at a time (you, too, can get involved by going here). At the end of his talk, he took questions from the audience. Some 10 people asked questions, some of which were self-serving (my non-profit www.fillintheblank.com....) while others were polemical ("Don't you, as a man, feel hypocritical writing a book about oppressed women?"). I, too, felt the need to express myself, so I arose from my seat on the 4th row and strode to one of the two microphone stands and took my place in line behind an elderly woman. When it was my turn, the moderator announced that mine would be the last question of the night. Of note, the moderator had clearly stated at the beginning of the Q and A that "the best questions are... actual questions." I spoke into the microphone that I had both a comment and a question (probably a few snickers were heard). It went something like this:

"First, I want to thank you for coming to Portland. Your writing and your work disprove the adage that one person cannot make a difference and that one person cannot change the world. (Applause...) You are in a town where 90% of the populace voted for Barack Obama, and I am not sure if this is an issue of news coverage, but why has this President not been more out front on the issue of global oppression of women? We give billions of dollars annually in economic and military aid to many of the chief offenders. We can send 40,000 more American men and women to fight in a war, or we can build 40,000 schools to truly try to make our world a better and safer place (Raucous applause). What are your thoughts?"

Mr. Kristof thanked me for my question and said it was a good one on which to end. He replied, that he thought that there had been bright spots in the first 10 months of the Obama Administration and that this Administration's good works had not been sufficiently covered in the press, but he did go on to say that we must hold the feet of our leaders (and particularly those whom we admire and worked so hard to elect) to the fire. He said we should demand as much of them and expect as much of them as we did of former President George W. Bush. He said that the US has the power to lead on this issue, but it will only happen if we force our elected officials to lead in this crusade to improve the lot of women worldwide.

After the talk, I went up to him and shook Mr. Kristof's hand. I told him that I was an oncologist and that, in many respects, my work also allowed me to experience both tragedy and triumph every week and that I understood the joy that he derived from his work which took him into some of the darkest places, figuratively and literally, on this earth. The hopefulness that underlies his work (and mine and the attitude I want both my children Cate and Nicholas to espouse) was best captured in an anecdote he shared during his talk about the story of a young man who was walking on a beach scattered with starfish. The young man proceeded to throw some of the beached starfish back into the sea. An older gentleman, who was also standing on the beach, said to the young man, "There are thousands of starfish. Throwing a few back cannot possibly make a difference." The little boy, as he threw another starfish back into the sea, said, "Tell that to this starfish..."

SOMEONE TO WATCH OVER ME

So, whenever I leave the house without Nicholas, during his waking hours, he insists that he follow me outside (weather be damned, darkness be damned) in order to watch me leave. Mind you, he does not want to do this from the front door or even the front porch. He likes to stand on our sidewalk to watch me run off or drive off. At times, it is a little painful to get him dressed or help him use the bathroom prior to having him come out and watch me depart, especially when I am (invariably) running late.

Once we get outside, he always runs up to me, prior to my leaving, to ask, "Which way are you going to go, daddy?" I am struck by how sweet this is and how one day he will grow tired of this ritual and will eventually find his old man uncool. However, these moments (and when I write this blog) remind me how lucky I am to be his dad and to be his friend. That, I will always cherish.

THE AUDACITY OF HOPE

Today, I met with the wife of one of my late patients who died this summer after a very long battle with prostate cancer. The appointment was arranged by our social worker, who thought that bringing Mrs. __ back to meet with her husband's providers would be therapeutic for her. Mr. __ had been diagnosed with metastatic prostate cancer over 10 years ago and had responded very well to initial treatment until I met him a little over 2 years ago. Mind you, the average life expectancy for patients with cancers like his is about 3.5 years. During the course of his various treatments under my care, his wife always accompanied him to his appointments, and she kept him honest by not allowing him to downplay side effects and symptoms. I could tell that they had a very loving marriage by the fact that they seemed to "bicker" in a very endearing way during their visits.

For much of the visit today, we just sat back and listened to her recount the tale of Mr. __'s final days. She spoke freely and without prompting about the symptoms he experienced and about how he did not seem to be in pain at the end. She was tearful through much of the visit and became quite upset near the end of her account when she described how Mr. __ had stated that he had wanted to die at home but that he had become very short of breath before his passing, which prompted her to call 911. The paramedics arrived, and he was taken to the hospital, where he eventually passed away within several hours. She had been married to him for 40 years, had given him 3 children, had been with him for every step of his journey with cancer, had given him his medicines, advocated for him with his doctors, and served as his primary caregiver when he went on hospice, but she said she felt as though she had violated his dying wish to pass away at home and hence had let him down. She thanked us and said she felt blessed to have us care for Mr. __ and her, but I could sense that she felt as though he had died in vain.

I wanted Mrs. __ to know that her husband's life and his death had great meaning to all of us in the room. When I see patients like him, invariably they have read the statistics and know how grim their prognosis may be. They are looking for hope- not false hope, but the possibility that their cancer may not take them too soon, that they might make it to their 12 year-old son's high school graduation or their 21 year-old daughter's eventual wedding...someday. I always bring up the outliers, like Mr. __, with these patients, and I know it provides them some relief. Although he never knew it, Mr. __'s course has brought solace and hope to innumerable patients whom I have encountered since meeting him. I shared this with Mrs. __ today because I thought she needed to know what her husband's resolve, strength, and his story meant to me and to countless other patients today. I thought she deserved to know that today.

Afterwards, we hugged and held each other tight, with no attempt to fight back the tears, and no other words were necessary.

AND SHE'S OFF

Little Cate started walking recently, and there is no stopping her now. Here is one example of her new-found ambulatory skills.

THE TRUE FACE OF HEALTH CARE REFORM- UPDATE

I was informed by our Social Worker that Mr. W. qualified for a subsidy by my hospital, and he was eligible to receive his anti-cancer treatment one day later. Safety nets such as this help seal some of the many cracks in our health care system, but they are band aids and do not apply to the 40 million Americans who lack health insurance of any kind.

You can share your own health care (horror) stories at the Obama administration's health reform site.

THE TRUE FACE OF HEALTH CARE REFORM

I was confronted by the tear-strewn face of a patient's wife today. I had spent 30 minutes explaining to the patient, Mr. W., and his wife that he needed to start shots to lower levels of testosterone, which acts like fuel for prostate cancer cells, because his cancer had recurred and was growing rapidly. That discussion and an in-depth overview of the many side effects of this form of medical castration drew no tears. It was only after the couple who has Medicare, without an insurance supplement, were informed by the clinic that their 15% share of the cost of these $4000 shots, given every 3 months, was $600 that a handkerchief was necessary. They were not able to afford this shot as they are on food stamps currently and have exhausted their savings. They left without receiving this non-curative, but life-extending and symptom-reducing anti-cancer treatment today.

The 'birthers,' 'tax patriots,' and Republican Congress talk about health care reform as an affront to humanity, as a form of socialism, and as the end of civilization as we know it. They see Obama as the enemy... as the Joker... as a shadow of themselves. They do not get it or are blinded by their own racism or desire to see the President and the Democrats fail.



Anyone who has had a recent medical bill or a serious medical illness, whether or not they have insurance, clearly understands and can explain the fierce urgency of now when it comes to health care reform. The aforementioned opponents of reform need look no further than Mr. W and his wife's tear-strewn face (and their own faces in the mirror) to see the true embodiment of those whom our medical system and society fails everyday.

A HAPPY MARRIAGE

Last night I finished reading the new novel by Rafael Yglesias entitled "A Happy Marriage." It is easily the best book of 2009 and perhaps the best book I have read in the the past decade. You may have heard about this novel on NPR, which details a couple's relationship over thirty years. The main character Enrique Sabas, like the author, published a novel as a teenager and is a screenwriter, and the novel details the lives of Enrique and his would-be wife Margaret Cohen, who eventually comes to struggle with cancer. Of note, Mr. Yglesias was married to the artist Margaret Joskow for thirty years, and she passed away of bladder cancer in 2004. It is hard not to speculate that the events which unfold in this book are largely autobiographical, but Scribner and Mr. Yglesias clearly offer this book as a work of fiction. Only Mr. Yglesias knows for certain what details from the book actually occurred and which are fictional, but the reader is allowed a sneak peek into Enrique's and Margaret's life.

The book shifts alternately between the past and present in the lives of this couple. In doing so, the author takes the reader on a roller coaster ride of a marriage. Through much of the novel we are left to wonder whether this truly was a happy marriage, and the question of what it means to love someone remains unanswered to the protagonist and the reader until the very end. The protagonist, Enrique, is what gives this book its life and its verity, and I cannot recall another literary figure with whom I have felt a greater kinship. This book, more than any I have ever read, made me think about my own upbringing, my own choices, my own shortcomings, and my own marriage and family. I also thought a lot along the way about the difference between pleasure and love.

Pleasure is a state of gratification due to another person- being with someone who always has the witty quip, the seemingly flawless body, the ostensible disinterest in anything outside of you. This is something that is commonly experienced early on in relationships- think the third date after the incompatibles have already been weeded out in favor of the possible soul mate and the nerves have been calmed since the first date (see "A Happy Marriage"). This state, like that engendered by a good drug, is utterly euphoric but also unsustainable. As one spends more time with an individual (dating, marriage), the whole of a person is exposed day in and day out. One might call this revelation a person's true self, but that would seem to suggest that early interaction between two people is mere play-acting. I think this is an oversimplification. People are complex. They want to be accepted before they allow themselves to reveal the parts (which are no more "real" than those initially divulged but) which are less likable.

Love, on the other hand, is a state of affection for another person in many cases despite that person and their needs or shortcomings. Anyone can find the character in the romantic comedy (think Zooey Deschanel in "(500) Days of Summer" or Julie Delpy in "Before Sunrise") winning, but in our day-to-day relationships which are often suffused with disagreements, differences of opinion, diapers, and an utter dearth of emolument, it is easy to feel unfulfilled. Show me someone with a long view of relationships who can still appreciate and enjoy the person with whom they share that quotidian, seemingly banal existence, and I will show you love.

I suppose what drew me in to Enrique Sabas and Margaret Cohen was the fact that Mr. Yglesias wrote a book about what he knew best- love, life, loss, and longing (but not necessarily in that order). In this blog, I have attempted to write similarly, perhaps with some success, because to write about that which one does not know or does not feel rings hollow and offers no comfort to the soul (one's own or one's audience's). In that sense, there is no more profound book than "A Happy Marriage," which revealed to this reader how lucky he is/how flawed he is and exactly what the definition of a happy marriage is.

In a book review, i.e. plot synopsis, from the New York Times, the critic Dinitia Smith stated that in this book, "he (Yglesias) has found the novel of his life." Her words refer less to Mr. Yglesias' "autobiography" than to his achievement. I leave you with a passage from "A Happy Marriage," which I found to be particularly poignant. I hope to not lose sight of these words and this book in my own daily life with my wife, my children, my family, my friends, and my patients, but Mr Yglesias has done his part to make forgetting these truths quite difficult.

"In that pre-dawn twilight, returning from his father's death to the life of his wife and children, he had a dim consciousness, saw a faint outline of the rampless bridge between birth and death, and death and birth, that people traverse all their lives convinced they are on a highway to somewhere new."