Being Mortal: Medicine and What Matters in the End, by Atul Gawande

9780805095159_p0_v5_s118x184

When my father was taken ill that last time, he did everything he could to keep from going to the hospital. He tried to hide what was happening, even though as a doctor he knew exactly what it was and what it meant. When discovered, he argued with my mother, trying to keep her from calling for an ambulance, and he fought the EMTs when they arrived. He yelled as he was being carried into the ER of the hospital where he had been chief of staff that he wanted to be left alone to die.

He knew what was going to happen. He was kept alive for three agonising months, undergoing one treatment program after another over his continued protests. His advance medical directive was no protection as his doctors persuaded my mother to override it.

So I thought I knew what I would encounter in this book by Gawande, a surgeon at Brigham and Women’s Hospital. I knew that a huge percentage of medical costs come in the last few months of a person’s life, the problem being that we aren’t always sure that it actually is the end and not just another stage where recovery may be possible. I had also seen a friend’s family want to deny her treatment because they were concerned about the cost of assisted living and later a nursing home.

And, indeed, Gawande speaks directly to the issues around my father’s last illness.

. . . in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can’t, someone who understands that the damage is greatest if all you do is battle to the bitter end.

The book is a surprise, though. Gawande examines these issues through stories of his patients and his own family, encouraging us to look at that phase of life that we mostly try to pretend will never happen, that inevitable decline into death. Most interesting to me, he takes us through the history of solutions for how to make the end of life meaningful, comfortable and affordable, from the first retirement communities to exciting new ideas.

New to me was the story of Keren Brown Wilson, one of the originators of the idea of assisted living.

Wilson believed she could create a place where people like Lou Sanders could live with freedom and autonomy no matter how physically limited they became.

The key word in her mind was home. Home is the one place where your own priorities hold sway. At home, you decide how you spend your time, how you share your space, and how you manage your possessions. Away from home, you don’t. This loss of freedom was what people like Lou Sanders and Wilson’s mother, Jessie, dreaded.

Some later adopters of her concepts have not stayed true to her vision, instead returning to the idea that safety is the only thing that matters. Gawande astutely points out that it is usually the children of the elderly making decisions about care, and they are more concerned with the safety of their loved ones than with their possibly risky independence.

I was overjoyed to learn about Bill Thomas’s work as medical director at a nursing home in upstate New York. Throwing out the safe option of keeping the elderly drugged and confined to wheelchairs, he filled their room with parakeets and plants. He added a day care center, so the residents could interact with children, to their mutual benefit. To the surprise of everyone but Thomas, these changes brought immediate improvements in patient outcomes.

The stories of patients and providers, along with Gawande’s stories of his own family’s confrontations with these issues makes this an enormously readable book. The stories bring the science to life.

All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties.

I would have liked to see Gawande address the issues related to the people working in these institutions. Yes, the structure of the institution and the principles behind that structure are the first step, but you must have people on the ground to carry them through on a day-to-day basis. As our population ages, care homes of every type will have an even harder time than they do now finding and adequately paying workers. We need to be thinking of how to expand our workforce of compassionate and well-educated people willing to take on an often unpleasant job.

Still, I am thrilled with this book. I hope it opens a much-needed conversation. My father would have loved this book and talked about it with everyone he met.

Heart Mountain, by Gretel Ehrlich

9780140109061_p0_v1_s118x184

February 19 is the anniversary of the day FDR signed Executive Order 9066 which took over 11,000 Japanese immigrants and Japanese-Americans from their homes and businesses and sent them to concentration camps for the duration of WWII. One of those was the Heart Mountain Relocation Camp in Wyoming. Ehrlich’s novel is based on these true events. She imagines—based on her research—what life must have been like for those in the camp and those in the surrounding communities.

McKay is a young man whose ranch borders the camp. A serious injury from a “horse accident” prevented him from following his two older brothers into the military. Like Testament of Youth, this is a story of those who didn’t go to war. McKay is left to run the ranch with only the help of an older alcoholic cowboy named Pinkey and the long-time family cook, Bobby Korematsu. On the day his brothers leave, McKay sets up a cot on a screened porch and proceeds to sleep there through the blistering summers and harsh Wyoming winters.

Ehrlich brings her personal knowledge of ranching near Heart Mountain to make it all come alive, not just the way the grass looks in August or the river in flood, but the details of cow camps and moving the cattle when it snows, even the way the men and women talk to each other, a careful reticence masking deep emotion.

McKay rode out through the west pasture, roping, doctoring, and ear-tagging calves. He and his brothers had always loved these early spring days “when a man could get a rope down and let his horse run awhile.” When he finished, he rode to the river. Overhead the clouds looked more like waves, the kind of waves that come toward shore but never break, whose cresting swells suddenly flatten and return to deeper water. He thought he had reached the bottom of his loneliness, but now another depth revealed itself—one that he could not push beyond and as he approached the river, orange and scarlet clouds traveled over him without breaking.

I’m grateful to my friend Laura for recommending Ehrlich’s work.

The story also follows Kai Nakamura, a young graduate student from San Francisco who is swept up and deposited at the camp along with his parents, from whom he’d been estranged. The dislocation only tightens his parents’ grip on the old-fashioned ideas they brought with them from Japan, making Kai seek out others. In the camp he meets Mariko, a beautiful and outspoken artist newly returned from Paris, and her grandfather, Mr. Abe, a Noh mask carver who tries to teach Kai some of his zen habits.

The two groups are brought together when Bobby goes to the camp looking for relatives and later when McKay accidentally shoots Mr. Abe. It is this uneasy meeting ground, the space between the camp’s prisoners and the surrounding community that the novel explores, mostly by following McKay and Kai, but also through other inhabitants of both sides of the fence. While there is some intolerance, the characters we follow are thinking more deeply about what it means to be human and about what connects and separates us.

They stood in the V where two creeks met. A kingfisher, perched on a branch, dove into the water and came out again, as if untouched, unscathed. She looked at McKay. In his eyes, slabs of gray were cut into the blue. It’s the kind of imperfection Japanese love, a sign of beauty, she thought, smiling, and grabbed him around the waist.

“Your bones are so light. I always forget that,” he said, touching her wrist. “Like a bird’s.”

They heard flapping and laughed. Upstream and around a bend, a blue heron lifted into sight and flew behind a screen of willows.

Ehrlich uses every small moment, every brief image, every cloud and bird, to deepen her story and bring us more thoroughly into the hearts and minds of these brave, flawed people, thrown together by history and a disgraceful action by a government newly at war. FDR was persuaded by the mob’s fearful cries, but Ehrlich shows us, one person at a time, what happens when we see each other as individuals.

Have you read any other books about the relocation of Japanese immigrants and Japanese-Americans to camps during WWII?

Stirring the Mud: On Swamps, Bogs, and Human Imagination, by Barbara Hurd

9780820331522_p0_v1_s118x184

I loved this book so much that the person from whom I borrowed it actually gave it to me (thanks, Anne!). Reading it, I was reminded of Annie Dillard’s Pilgrim at Tinker Creek, a book about encountering the natural world and the human condition, a book that stunned me. So much so, now that I think of it, that the person from whom I borrowed it gave it to me (thanks, Jill!).

Stirring the Mud is a slight book, only nine essays, but I’ve been reading and rereading it for weeks, pondering the images and leaps of thought.

To love a swamp . . . is to love what is muted and marginal, what exists in the shadows, what shoulders its way out of mud and scurries along the damp edges of what is most commonly praised.

My love for the natural world tends to lean toward trees and streams, long walks on ocean beaches, and the rosemary and warm tomatoes in my garden. I’ve had an inchoate fear of swamps since childhood, when one third of our property by the Chesapeake Bay was a swamp. Or at least, that’s what my mother called it, warning us to stay out of it because it was full of snakes.

What unnerves me now about swamps and bogs, having stumbled into more than a few, is the uncertainty, the way what seems solid suddenly gives way under you. Hurd persuades me to treasure this experience. She reminds me that this feeling is both the fear and the joy of creativity: each time I start to write, I plunge into uncertainty.

Reading these essays, I came to love standing with Hurd as she lets her shoes sink into the mud, water seeping in to wet her socks, thinking about what grows there, what is lost there, what is preserved there. She examines the liminality of these places, how mysteriously hidden their edges are.

When by some act of grace, the lines we think are there dissolve, something else appears, something timeless and rich, an intermediate zone, languid and latent, the lushness of something about to be and in no particular hurry to make it happen.

I appreciate the information she includes to provide context, telling us for example that Finzel Swamp is a palustrine wetland and explaining what that means. Most of all, I love her close observation of the swamps she visits and the way she includes us in the experience.

One time, not far from the alders at Finzel, I found a small congregation of Indian pipes sprouting out of the leaf mold. Two inches high, these albino plants resemble a sculpture of dripped wax turned upside down in the dirt. The color of breast milk, bluish, almost translucent, they are saprophytic plants, meaning they need decay in order to live. I don’t know what it is about such ghostly whiteness that suggests silence, as if color were also sound and the absence of one means the absence of the other. Lovers of the damp, they don’t look like pipes to me but like nuns, their heads bowed, lips open, mouthing a constant and silent syllable.

Look at the lovely consistency of imagery in that description: congregation, dripping wax, ghosts and nuns. Even their name suggests the pipes of the organ with their open mouths, singing. And other images set against them, muddling them: breast milk, decay, absence.

I know I will keep coming back to this book. For the last few years I’ve been pondering margins and thresholds, but Hurd’s essays have caused a fundamental shift in my thoughts. I realised I’d been thinking of margins and thresholds as horizontal, stepping through a door for instance. Hurd makes me consider the vertical, what is below me, invisible if my eyes are trained on what may be in front of me. Similarly, based on reading poet David Hinton’s work, I’ve been letting go of the idea of time as linear and instead thinking of it as a constantly changing present, a present that I am sinking into ever more deeply.

What do you associate with swamps or bogs?

Nora Webster, by Colm Tóibín

9781439170939_p0_v3_s118x184

Newly widowed Nora doesn’t want to answer her door. In the Irish town of Wexford in the middle of the 20th century, it is customary for people to stop by the home of someone in mourning in the evening. Without phones there’s no way to call first to see if they are welcome, so they just come and knock on the door.

Despite her yearning to be alone, Nora always opens the door. To a neighbor who commiserates with her, she says, “‘They mean well. People mean well.’”

Bound by convention, missing her husband’s steady presence, Nora must begin making her own choices. As the sole support for her four children, she is first confronted with financial decisions. Later she has to contend with emotional issues as her two young sons come to terms with their own grief. Their two older sisters are away at school.

Nora is a fascinating character. She does not seem to be close to anyone, now that Maurice is gone. Though she says at one point that she never loved her mother, she’d expected at some point they would find a place to meet. However, it hadn’t happened before her mother has passed away. Nora is not interested in being with her two sisters and aunt, though she and they make the customary visits.

She is not even close to her children, thinking at one point “that she had never before put a single thought into whether they were happy or not, or tried to guess what they were thinking.”

She seems to hold herself at the same distance. Practical, focused on the everyday things that must be done, she barely touches the fringes of introspection. The reader, too, is held at a slight distance from her. Tóibín uses a close third person point of view, telling the story through Nora’s eyes, but her lack of self-analysis leaves us as much in the dark as she is. We hear her think one thing and then see her do the opposite, and have to assume that she is giving in to convention again or to what another person wants her to do.

When we discussed this novel in my book club, one person pointed out that much of the drama in this quiet book came from the space between Nora’s thoughts and her actions. Whether you call it drama or conflict or tension, I think that this analysis is accurate.

I called it a quiet book, though things large and small happen, and there are plenty of emotional upheavals. Another book club member praised the way political events of the time were woven into the story, giving it additional depth and universality.

In the end, though, what we all liked about this book was the close look at an ordinary life, one of the reasons we like Anne Tyler’s novels as well. A master storyteller like Tóibín can make us care about a single, ordinary individual. He can find the value in that life and as a result help us understand more about ourselves and our own lives.

In the first chapter, a neighbor Mrs. Lacey mentions her daughter. Ellis Lacey is the young woman whose story is told in Tóibín’s best-seller Brooklyn, recently made into a film. What did you think of that story? How do you think it compares with this one?

Reading the Forested Landscape: A Natural History of New England, by Tom Wessels

51kuaxPyi9L._AA160_

Tom Wessels’ book helps me understand what I’m looking at when I examine the woods that come almost up to my porch. Although I live in the mid-Atlantic, we share the same type of forest as southern New England, one of seven types in the U.S. Ours is called the Central Forest. There are differences, but the trees I see from my porch are those I saw in Massachusetts: oak, maple, white pine, honey locust, maple, ash. We also have sweet gum and black walnut, which are not found up north, or at least not yet.

This is not a tree identification book, however. It’s more like a magic decoder ring. It gives the information you need to look at a patch of woods and make a pretty good guess at what it looked like 100 years ago and what has occurred to disturb it in the meantime.

Wessels sets up each chapter as a mystery, starting with an etching of a forest by Brian D. Cohen and then pulls out the clues that tell us what has happened there. Was it once a pasture or farm that was left to reforest itself? Has it been logged, and if so, how many times? Has there been a hurricane or a forest fire? Have they been affected by blight? What do the trees tell us about the soil and topography?

At the end of most chapters, he takes a look back at the historical context of the disturbance. For example, in precolonial New England, Native Americans used fire as a forest management tool. They burned the litter on the ground and low-growing vegetation to control insects and make it easier to move silently. “These precolonial, fire-managed woodlands looked dramatically different from New England’s present forests. They were parklike, with massive hardwoods creating a canopy over forest floors carpeted with grasses and berry bushes.”

However, the diseases brought by settlers decimated the Native American population, whose knowledge was then lost. “Within fifty years of the landing at Plymouth Rock, the Native American, fire-managed ecosystems of southern New England became a memory,” replaced by the dense, almost impenetrable forest that I see from my porch.

There are also fascinating nuggets buried in this irresistibly engaging book. For example, in the last major gypsy moth outbreak in central New England in the summer of 1981, scientists found that “the oak trees not yet attacked by the gypsy moth larvae changed their leaf chemistry, apparently in anticipation of the approaching insects.” The trees were communicating with each other using an airborne chemical message (jasmonic acid).

This discovery reminds me of another book I’ve heard of but not yet read: The Hidden Life of Trees: What They Feel, How They Communicate — Discoveries From a Secret World, by Peter Wohlleben. A German forest ranger, Wohlleben explains that trees are social beings, working together in networks and sharing resources. I’m looking forward to reading this book.

Now when I stand on the porch, I can read the history of the trees in front of me. More than that, I’m aware that what I see are not the separate individual trees I’ve always thought them, but rather a community. These trees are talking to each other in ways that I cannot decipher.

What book has changed your view of the natural world?