Separation

How do I begin to write? How do I, a mid-thirties white male physician who is happily married to the love of my life, begin to write about a 20-year-old Native American woman, incarcerated as a bystander to a violent crime, who gave birth 40 hours ago and must now give up her baby?

The first thing to say is how very little I know about this woman.

I don’t know the story of her family, other than that there is a history of substance abuse. I don’t know the details of her own birth, whether there was alcohol involved in her mother’s pregnancy, if she was born early, if she was breastfed. I don’t know if she was wanted or loved or ignored or abused or some of all of these things.

Our electronic medical record could be called comically inadequate, except in this case the inadequacies are anything but amusing. Her chart lacks a Y/N checkmark beside “Less than 8th grade education”, and the checks for “Alcohol” (N), “Drugs” (Y) and “Tobacco” (N) are the opposite of what she has told me—she admits to alcohol and tobacco around the time of and possibly after getting pregnant, but denies drug use. There are negative checks next to “Abusive relationship” and “Cats” (cat feces being a risk for a parasite called Toxoplasmosis, although in developed countries a more common source of this infection is from consumption of undercooked or cured meat or meat products).

There are affirmative checks next to “No family support,” “Poor living environment,” and “Significant social problems.”

What I can speak to is what woman has been through. When I assumed her care late in the second half of her pregnancy, she had just had preterm contractions and been told that she was a bad mother to the fetus for not taking a medicine that was making her sick and for which there is no evidence of improved outcomes. For every clinic visit, she would be escorted into the exam room shackled at the ankles and wrists. Not one but two generously-proportioned guards would stand outside while we talked. For her delivery, she was allowed to have no family or other support present.

To their credit, all of the wardens and nursing staff always treated her kindly and courteously.

At our first visit this young woman was very guarded. As the number of visits increased both in number and frequency—she had several more scares for early labor—she seemed to open up little by little. Occasionally she even smiled. Whether she grew to look forward to our prenatal visits, I’ll never know.

Because of horror stories she’d heard about epidurals, she wanted to “go naturally” when it came time, without medicine in her spinal fluid to numb her pain. LL and I had just watched The Business of Being Born and I supported her decision; at the same time I did my best to dispel the myths regarding epidurals.

2 days after she’d made it to term, having had several previous visits to the hospital for which she was “ruled out” for labor, her bag of water broke and her cervix began the often-tortuous dilation to 10 centimeters. She stuck with her decision to not have an epidural. Throughout the labor she remained quiet, stoic, and polite. Every time I came in to talk with her she asked appropriate questions. Mostly she would be looking down with her face a blank slate, but on rare occasions she would let a smile escape, and even more rarely let her pain show. As I would be walking out of the room, she would invariably look up and quietly say, “Thank you for everything.”

17 hours, several bags of Pitocin, 5 doses of GBS-prophylaxis antibiotics, a last-minute epidural, internal monitoring, and 20 minutes of pushing later, she delivered a 5 pound 7 ounce beautiful crying baby girl.

For the next precious 40 hours she got to hold her baby. The baby was more consistent with being 2 weeks early than being term, and had difficulty latching onto her breast to feed. But it did not become febrile, lose more than the accepted 10% of its weight, or become jaundiced. Somehow through all that this woman had endured her baby was healthy. And in her eyes, for this baby, was something I had not seen. It was love. It was pure and simple love.

I again find it difficult to write. For me it was hard but easy this morning, when she had to go back to jail and her baby had to go to a grandmother somewhere to be taken care of: I am there, I cry with her, I leave. I carry on with my life. I cannot know, cannot imagine, what this woman went through. Is going through. Right now everything is up in the air. If all goes well for her in court, she and her baby could be re-united as early as the end of next week. If not it could be months, or years.

Ojala that it goes well. Ojala that it goes well.

God's country

It is Wednesday morning. This is my day off from work.

I drive in to work and work until noon. When I leave I am headed for a funeral, but instead turn my car around on Highway 97 and take a left up Cameron Lake Road. As I climb the hill the snow deepens and the sagebrush is joined by the occasional ponderosa pine. The small fragments of light offered by mid-December are gathered up carefully by the new snow and amplified, reflected, a thousand million tiny suns making the short day bright. At the top of the hill I pull over and climb out to take in the view.

The air is colder here and I haven't brought my hat or jacket; I can only stand outside for a few moments before returning to the valley, to the funeral, to people and community and the warmth offered by the shared experience of living and dying. But for this instant I am alone with the indifferent and utterly beautiful landscape.

Directly below me a small lake is identifiable as a flat expanse of uninterrupted snow, which in this rocky terrain can only be explained by water. Below that a bluff blocks my view of the Okanogan River, and in the places where I can see further, the river itself is mostly hidden by trees. Wherever there are trees there are houses, at least in the valley floor, and from here the towns of Okanogan and Omak appear to be only slightly dense accumulations of the the farm buildings that dot the river's path to the north and south. But for the most part what I am looking at is wide-open space. It is rugged country writ large, basalt cliffs rising to timbered slopes and painfully white peaks, and all human endeavors look small and transient by comparison.

I think of the writer Ed Abbey, describing the desert southwest he so loved, God's country, Abbey's country. The same wide-open beauty.

In a few minutes I will drive down and cross the river and go into a church. I will hear about how wonderful God is to have given us this time here on earth, and I will find it hard to argue. The pastor will tell me that we are here to glorify God and be thankful, and who am I to argue? I will hear this message, spoken perhaps in different words than I would use, but expressing the same idea. We are here to love one another. We are here to be a part of this beautiful world, and if given the opportunity, to leave it a better place than when we entered it.

In a few minutes I will hear all of this, and be grateful for the human companionship, the hugs, the offers of pie and coffee, the warmth. In a few minutes.

Right now I am happy to just be here on the ridgeline with my thoughts.

Snow is a force that gives us meaning

As a kid growing up in eastern Oregon I loved snow. No matter how much it snowed, it was never enough for all the skiing, sledding, snowforts, snowball fignts and snowjumping (jumping off of the roof into a big snowpile) which could be dreampt up by my siblings and I. In fifth grade the snow reached over my head, the closest it ever came to my imagined quota. Now, 25 years later, I again find myself in snow country. And once again I want more.

This morning it snowed a couple inches while I stayed inside and fiddled with the new projector that LL and I have decided to treat ourselves to. Now that that is done--as with all projects remotely electronic and/or mechanical, it always take way longer than expected--I am temporarily at a loss for what to do. Not that I don't have any number of things I could/should be doing. But none are as fun as...

Of course! Snow. Outside I go, shovel in hand, to tackle the driveway.

As I push snow my mind relaxes. The task is simple and at hand. The reward is tangible, measurable, satisfying. Even as I clear a path, I wish for more: as long as it snows, I will have something which must be done, just as after finishing the driveway, I have to take LL's rig in for studded tires.

I wonder--not yet having read Chris Hedges's War is a Force...--if our urges toward violence might not be taken out more benignly on snow. We (and by we I mean of course I) have within us (me) the occasional urge, borne of the daily stresses accumulated by living an imperfect life, to destroy something. Snow is beautifully unique in its range of accommodation. Like water it can be hit and pushed without harm to do-er or do-ee, but in a way that water can't it can also be used for creation. In skiing and sledding, the desire for speed, even reckless speed, can be satisfied with yet a soft landing for crashes. In moving snow, there is unfettered access to the physical labor that is so often lacking in our lives. Maybe we all could use a little more snow.

Maybe, too, part of my love affair stems from the sense of something fragile and vanishing. We are in a La Niña year so it's supposed to be colder and wetter. But the numbers implied by global warming do not bode well for snow in the years to come. Snow, at ever-higher latitudes and elevations, may be an endangered species.

In which case, maybe snow could become the icon that finally galvanizes the floundering (or dead, as per the title of Hedges's latest, Death of the Liberal Class) progressive movement into action.

Ok, so that's a stretch. But such recent events as the failure to pass I-1098, which the 98$ of people who DON'T make more than $200k/yr would have benefited from, against a backdrop of huge cuts to essential services in healthcare and education, have me grasping at straws. At fragile and ephemeral things. At snow.

I'll write again when it's over my head. Until then let it snow!

Pumpkin soup

1 large pumpkin
A few ripe tomatoes
Hot peppers--3 or more, depending on BTU level
1 freshly picked coconut, or, if you don't live where coconuts are freshly picked, 1 package of processed coconut product
3-7 cloves of garlic
fresh ginger root, grated
2-4 orange and/or red bell peppers, depending on size
some ground nuts (e.g., hazelnuts, cashews, almonds--probably 1 cup)
1 beer of your choosing. Moose Drool is nice. If the beer is too tasty, more of it will end up in your belly than in the soup...
salt and pepper to taste
cilantro to garnish

What would you do, if you knew you could not fail?

Facing the end of another week in which the in-box is not empty I think of this quote. I don't know the author. The words are printed on a wooden placard in LL's parents' house in PT.

It is Friday morning and I am making some pumpkin soup before heading in to work. In point of fact it will be a turban squash soup. And also, I will be finishing it when I get home after work. This will probably be the time at which I'll take the baked squash and blend it with the roasted red peppers and roasted tomatoes, and throw them into the pot where the garlic, ginger and hot peppers will be sauteing. Also I still have to buy the hot peppers. I'm hoping for habañeros.

Also, in looking for an enye (ñ) to copy and paste, I learned that habanero is actually spelled just like that, and that ñ is incorrect--and on the screen just below that, I learned that "octopi is ignorant in three languages simultaneously", as it is derived from Greek instead of Latin and thus would be octopodes (while in modern English octopuses is considered "correct"). Thanks Wikipedia!

But I digress. What would I do if I knew I could not fail?

Hopefully, I would still be doing exactly what I am doing now, which is to say, I'm about to turn off the oven and go into the hospital where one of my patients was just admitted and then go to clinic and finish some charts and make some phone calls and look up some information on how better to treat chronic pain and how better to diagnose chronic suffering and how better to encourage a healthy diet and regular exercise and nurturing relationships, which are the things that keep all of us out of the hospital, and all the while I hope to be learning, learning, learning, which of necessity requires some letting go of previously learned information and letting go of some long-held habits and prejudices and beliefs, not all once of course because that would be too easy, but perhaps bit by bit.

And maybe if I can keep working at this I can not fail. Maybe if I can slowly change, bit by bit, my self-expectations, I will not let myself down. Perhaps if I keep reaching out to others, asking for help where appropriate, which is really almost always, we will succeed.

Perhaps the question should be re-framed, to What would we do, knowing that we can not fail?

We have to go for it. As Andrea Gibson says, we have to create. Whether a jack-o-lantern or pumpkin soup, a patient care plan or meaningful relationships, this is what we are here for.

And then of course I look back at what I've written and realize it's too pithy. Too canned, too hokey, too much of this, not enough of that. I have failed. I think that now that my blog frequency has dropped off to near-zero, I am trying to squeeze too much metaphor into too little space, and the result is--well, to forge on anyway, it's a soup.

And at the same time, why not go for it? Most of us, as LL likes to say, are going to die. Most of us will start out looking like the pumpkin at the top, and slowly wither to become the pumpkin below. Why not make a soup of it? Why not do it anyway?

Perhaps the question is, If we know we are might fail anyway, what will we strive for?

The answer, I hope, is Yes.

Processing speed

It has been 4 months since my last post. When last I wrote, spring was in the air, blah blah blah ("they" say 3-element lists have a nice ring to them), and I was sitting at LL's computer in our little duplex in Seattle. Now it is October in Omak. It is cold outside. Blah blah blah.

I honestly don't want to be writing right now. Even inside it is cold, blah blah blah (normally I can fill in these blanks--today my own internal processing speed seems to match that of my decrepit computer), and I'm frustrated by spending two hours online with India only to have my internet security unresolved.

But clearly a part of me wants to be writing right now, or I wouldn't be doing it, right? Perhaps I write from the desire to process the flash that was the last 4 months, and in so doing, dampen the speed with which those memories must inevitably fade. Perhaps someone has snuck into the dark spaces, the interatomic recesses, the quark-quark interface, of the cesium NIST-F1 clock in Boulder, Colorado, and monkeyed with its current accuracy of +/- 1 second in 60 million years--perhaps sped it up by a second or two.

Perhaps I am getting old.

But what is age but the accumulation of experiences? In the last 4 months, we:

...moved out of our little duplex and put all of our belongings into a storage facility located somewhere on the Columbia River

...moved into the basement of LL's parents, for the rare times we weren't traveling

...deposited a check on the one place available for rent in Omak, sight mostly unseen

...ran the lower Salmon River from Hammer Creek to Heller Bar for 5 glorious days and 3 glorious nights and 1 Hells Canyon thunderstorm night, including
--an unforgettable trip though the left-hand side of Snowhole Rapids by my brother Hans and my friend Tyler's brother James,
--a gourmet menu of mole enchiladas by my mom, quinoa salad by LL, and home-made cinnamon rolls (overnight sleeping bag rise action) by Tyler and Loren,
--37.5 gallons of water pumped from side streams using our REI filters

...flew into the world'd 3rd-largest city before traveling further to the 400-person village of Cabo Pulmo and snorkeling the only coral reef on the west coast of North America

...flew back into the world'd 3rd-largest city before traveling, in a truck whose engine exploded (required not only a mechanical fix but also a bribe to the local police to look the other way), on to the loud, dirty, blah blah blah city of Cuernavaca for 2 weeks of outstanding language classes and horrendous host family stay (think hot dogs, chicken nuggets and cold showers)

...finally traveled a 3rd time back to Mexico City where we visited the Frida Kahlo Museum (incredible) and managed to not be mugged

...flew back to the US, had a couple days in Seattle, drove out to Omak where our belongings magically materialized, unpacked with the help of LL's parents, drove back to Seattle

...woke up at 4AM to catch a flight to Minnesota, where we rented a car, bought the audio-CD version of "Three Cups of Tea" by Greg Mortensen, and listened to his incredible story as we drove up to the Gunflint Trail near Canada

...joined my dad for the first couple days of a canoe trip, during which we had our food broken into by bearaccoomooses, ran out of cooking fuel, and generally had a great time

...drove down to the Twin Cities to stay with LL's aunt and uncle, who spoiled us silly with food, wine, and entertainment, before going to one of LL's friend's wedding, and then, to celebrate our own 1-year anniversary, stayed at a downtown hotel and saw the musical "Wicked"

...returned to the Emerald City for one last week with LL's parents and a wonderful send-off party before packing up our almost-final belongings and driving out to Omak to start work.

And now here we are. Somehow I feel better, and I haven't even gone into these first 3 weeks of work, which have included our first hospital calls, my first deliveries in this new hospital, a trip with our beautiful little 14-foot sailing boat out to Omak Lake, the discovery of a local Slow Food group and a co-op and new friends.

In fact, as I reflect on this time, process this speed, I realize how incredibly grateful I am to be here, alive, healthy,
able to be doing the work I want to be doing,
sharing this experience with the love of my life,
here, alive, healthy,
here, alive, healthy,
here, alive, healthy, repeat.

Patch Adams

Started on June 6, 2010

Until this morning I had shyed away from news of the Gulf Oil Spill. It seemed a tragedy too enormous to comprehend, much less do anything about. And my fears were not unreasonable. If anything, after reading an article my sister-in-law wrote and following that up with some Democracy Now! coverage, it is worse than I imagined—worse, probably, than most of us could imagine, in no small part because we really have no idea how bad it is. Even BP officicials quietly acknowledge that the amount of oil could be 10 times what we think it is. Already it is turning the entire Gulf of Mexico into one giant dead zone. By next summer, the Gulf Stream could carry that up the Atlantic coastline.

In the face of such overwhelming news, it might seem an odd or even inappropriate time to dedicate one of only two posting in two months to Patch Adams.

And yet I think to Patch Adams I owe in some small way the fact that I am writing at all. In the midst of everything happening in the outside world, LL and I have begun to prepare for our move this fall to remote Omak. As part of that preparation I've been sorting through old paperwork with the not-always-successful goal of throwing most of it away. In such manner I came across a paper I'd long given up for gone: my introductory words welcoming Patch to speak at Johns Hopkins.

Below are two excerpts from the beginning and the end of that introduction; the beginning was mostly logistics and a discussion of how it was that I'd met some resistance to bringing Patch to campus. Apparently he'd come a few years earlier and there was a small but vocal minority who didn't want him to return. So Patch called me up and offered to come for free, and the funds that we raised to thank him were matched by a sympathetic undergraduate dean to give to a local women's shelter.
...

When Patch came to speak at Wesleyan in my junior year there, it was as if someone put into words all the things that I already knew were important in life. I've had a similar reaction when reading the work of Daniel Quinn, and one of the things that struck me was that neither Adams nor Quinn encourages anyone to emulate them blindly. They share a strong belief—based on observation of trends in population, the environment, culture, and politics—that the world society we've created is unsustainable. They also feel that change would, rather than the conventional wisdom of "having to give things up," make us immeasurably richer. But we must find this for ourselves. Patch also said, "If you need a friend, write to me, and I will write back." So I wrote, and he not only responded to that first letter, he remembered who I was and always built on our friendship in correspondence over the years to come.

...

In pondering [my own experience], I couldn't honestly fathom [that some people had responded unfavorably to Patch] until I asked myself: what might I myself find dangerous about this doctor, this clown, this person who had written to me as a friend?

I believe Patch Adams is dangerous to those parts of myself that say, "That's just the way it is."

I believe Patch Adams is dangerous to those parts of myself that say, "Just get through today, and tomorrow you can be revolutionary." Those parts that say, "I'm too busy with school and stressed out to have fun, much less help anyone." Those parts that say, "These four years of college and four years of medical school and 3 or 4 or 14 years of residency and 50 years of paying off debts will be really tough, but then, (if I'm still alive) I'll take a break." And you might laugh, but there are times when it feels like this is the mentality I need just to survive medical school!

Patch Adams is dangerous because he's saying, "Make revolutionary work itself the break." I think Patch is dangerous not because hes's crying out against injustice and the direction our planet is taking—there are numerous folks out there telling us how bad things are—but because he's actually trying to make an alternative work, and he's having the time of his life doing it. If Patch Adams were advocating an alternative program, I don't think he would get such a strong reaction. If he were saying, I want you to recycle more of your Coke cans, and take public transit instead of your car, and water your houseplants on Wednesdays, we could write him off. Because all of these things—while they're good programs—aren't really going to transform our society. Patch is dangerous because he has a different vision. Patch is saying that we can make helping our planet and its people the most fun thing ever imaginable. And that we have within ourselves the power to make that change—that I do, and that you do.

Thus I challenge you tonight to ask yourself not just what you can do to help, but how you can do it so that nothing else could be more fun. In conjunction with Physicians for Social Responsibility and several student groups, we will be arranging a follow-up forum of the ideas of Dr. Adams in the context of medicine and social justice, and I invite any of you who are interested to join us. Regardless, I ask you tonight to listen to the words of Patch Adams, and to think about what they mean for you and your community.

I was going to close my introduction with a quote oft attributed to Nelson Mandela but actually from Marianne Williamson which talks about how our greatest fear is not being inadequate but rather being powerful beyond measure, because I think this quote applies to Dr. Adams. He is letting his own light shine, and giving all of us permission to do the same. But rather than recite that quote, I think it would be an injustice for me to not share with you what is for me Patch's most important message. Once this spring when Patch left a message for me, I called him back and said, "My room-mate told me there was a message on our answering machine, but I thought it was just my friend!" Patch said, "I want you to erase that word 'just' from your vocabulary. If anything, I'm a 'just.' To have a friend is gold; that is the gold of life!" And so forgive me for taking this opportunity to say,

"Thank you, my friends, for all your incredible work in making tonight possible. I would like you to meet Patch Adams."

Thousand-dollar diarrhea

56 hours ago I awoke with terrible stomach pains and over the remaining hours of the night vomited three times. In-between vomiting I was kept from sleep by cramps which progressed to diarrhea with accompanying exhaustion, and with each passing minute I saw my hopes of going to work fade. When day broke I finally slept. For the next 24 hours I would be intermittently awoken by the dire urge to go to the bathroom, after which I would sip on gatorade before drifting back to an uneasy slumber.

During this time I missed my most productive workday of the week, wherein, because I start at 7:30AM and often work until midnight plus or minus a few hours more for a delivery, I might earn up to $1000.

Which leads me, 56 hours later and with stomach cramps slowly subsiding, to reflect on where I stand in the global scale of wealth.

Let's say that I worked 100 of these 24-hour clinic+call shifts for $100,000 a year. According to Global Rich List, such an income puts me in the top 0.66% of earners worldwide. If I earned a tenth of that—$10,000 a year—I would still be in the top 13%, with 87% of the world's population earning less. Even at $1000 a year—the amount I missed in a day's work because of a GI bug—I would be in the top 44%, meaning that greater than half of the world survives on less, which is less than $3 a day.

One limitation of this website is that it doesn't delineate the breakdown of salaries greater than $200,000. This might not seem to matter, except that in this tiny fraction of people most of the wealth is concentrated, and the further to the right of the wealth-vs.-number-of-people graph one goes, the steeper the curve.

A site which gives a better idea of this graph, which looks like a reverse letter "L", is called just that: The L-Curve. The L-curve site focuses on America alone. Since America has a median income of $40,000, it's like taking the final three person icons on the Global Richlist site (the top 3% of all earners) and expanding them in detail. The results are shocking.

If income is stacks of $100 bills, America's median of $40,000 is a stack 1.6 inches high. For an income of $100,000, the stack is 4 inches high; for $1 million it is 40 inches high. $1M is reached at "one foot from the goal line"; population is plotted along a football field with the median income at the 50-yard line. One has to zoom out to appreciate the full scale. At $1 billion worth of income, the stack is 1km high. Using what it says was an estimate of Bill Gates's greatest increase in net worth in 1 year of $50 billion, the final stack of bills is 50 kilometers high.

I went to Forbes.com to confirm this. While wealth is not equal to income, the spread is the same. As of 2010:

-There are 1,011 billionaires

-The richest 51 billionaires control over $1 trillion dollars

-The world's 3 richest men control assets greater than the combined GDP of the world's 71 poorest countries (using CIA - The World Factbook, 2009)

-If one of these men lost money because of diarrhea in commensurate fashion to my 2-day loss, that bathroom break would cost him...one billion dollars.

Unsettling, to say the least.

So. Clearly we non-billionaires don't at this time have the power that money commands. On the other hand, there are 1000 of them, and more than 6 billion of us. I cannot help but think of the Jimi Hendrix quote, “When the power of love overcomes the love of power, the world will know peace.”

Such are the reflections of an unquiet stomach, which as I write is quieter already.