HW # 22 - Illness & Dying Book Part 1

Mountains Beyond Mountains by Tracy Kidder
Published by Random House, 2003

In the first third of Mountains Beyond Mountains, the two sections that stay in my mind are first the time when Tracy Kidder asks Paul Farmer what he gets out of sacrificing so much of his life for a job with so many hardships and second when they both witness the mango truck overturned and the dead “mango lady” lying on a bed of fallen mangos next to it. In the first passage Farmer talks about feeling “ambivalent” about “selling my services in a world where some can’t buy them.” For desperately poor people who are sick and dying he thinks he should feel ambivalent about making his living out of their dying. In fact we know that he thinks all doctors should feel this way and everyone who isn’t upset about the unfair distribution of money for medicine in this world. We know this because he uses his special word, “comma” after these opinions, which Tracy Kidder
says comes before the unsaid word, “asshole,” meaning what all of us are who are comfortable with the world as it is and its great injustice. In the passage about the tipped over mango truck, Farmer is silent for a long time after seeing the dead body of the “mango lady.” We know from the opinions he’s expressed earlier that his is thinking about all that is wrong with the world that would have made that “accident” happen including the terrible dirt roads that are just tracks with huge bumps, the wreck of a truck that is completely unsafe to drive, the deforestation that makes the heat burn much more, and the fact that the poor woman had to go so far to sell her mangos to help her hungry family. There are many more reasons why the poor “mango lady” died than just having been hit by a turned over truck, and they should not have been allowed to happen. After reading these sections in just the first third of the book, I think the loud message is that we all have responsibility for the poorest people of the world and that not thinking about the fact that most are sick and dying or what we can do about it is not acceptable.

Quotes

Page 25
A sixteen-year-old boy too weak to walk, who weighs only sixty pounds. Farmer diagnoses an ulcer. “His body’s gotten used to starvation. We’re gonna buff him up.” Farmer hefts a can of the dietary supplement Ensure. “This is good stuff. WE’ll give him three cans a day. So we’ll give him a couple hundred dollars of Ensure, and I’ll take great pleasure in violating the principle of cost-efficacy.”

Farmer shows here that he will do whatever he can to save this boy. If that means giving him enough Ensure to get his weight back up, he will do it no matter whether someone far away in the international health community thinks that spending that much to save one person is cost-effective. If you can save a life, do it. What would be the point in half-saving people, meaning not giving the amount they need to survive just to save money.

Page 31
Then he (Farmer) walks back up the hill, to the TB hospital…Most of the patients have gathered in one room and are sitting on the beds watching a soccer game on a wavy, snowy TV screen. “Look at you bourgeois people watching TV!” Farmer says.
The patients laugh. One of the young men looks up at him. “No, Dokte Paul, not bourgeois. If we were bourgeois, we would have an antenna.”

.This is a great paragraph because it shows how close Farmer is to his TB patients that he can joke around with them and they with him.. It also shows how much understanding Hatians have of their place in the economic hierarchy.

Page 32
In a bed by the door of the hospital lies a moaning thirteen-year-old girl, just arrived y donkey ambulance… “I’m very good at spinal taps”…The veins stand out on Farmer’s thin neck as he eases the needle in. Wild cries erupt from the child: “Li fe-m mal, mwen grangou!’ Farmer looks up, and for a moment he’s narrating Haiti again. “She’s crying, “It hurts, I’m hungry.” Can you believe it? Only in Haiti would a child cry out that she’s hungry during a spinal tap.”

Farmer shows his incredible sympathy for the girl and also the fact that he can still be surprised by the pain of hunger being so extreme that it can even overpower the pain of a
spinal tap. He is also probably making it clear to Tracy Kidder who is there to write about him about the crime of hunger in the sense that it should not be allowed for anyone to be that hungry.

Page 36
Just recently, a TB patient from a village called Morne Michel hadn’t shown up for his monthly doctor’s appointment. So – this was one of the rules – someone had to go and find him. The annals of international health contain many stories of adequately financed projects that failed because “non-compliant” patients didn’t take all their medicines. Farmer said, “The only noncompliant people are physicians. If the patient doesn’t get better, it’s your own fault. Fix it.”

Farmer shows how he understands the reasons behind the reasons. When poor Haitians don’t take all their medicine, it is the fault of non-compliant physicans who aren’t taking the responsibility they have to heal their patients. Farmer knows that there can be many reasons why desperately poor and starving people might not be taking all their medicine.
He conducted a test and found that when patients were given a little cash for food, transportation and child care they did get and take their medicine.

Page 42

“And if it takes five-hour treks or giving patients milk or nail clippers or raisins, radios, watches, then do it. We can spend sixty-eight thousand dollars per TB patient in New York City, but if you start giving watches or radios to patients her, suddenly the international health community jumps on you for creating nonsustainable projects. If a patient says, I really need a Bible or nail clippers, well, for God;s sake!”

Farmer shows what a maverick he is. He is not going to stick to economic rules made by people in the international health community thousands of miles away that come down hard on small items needed by impoverished TB patients in Haiti when thousands of dollars can be spent on TB patients in wealthy areas.


After reading these sections in just the first third of the book, I think the loud message is that we all have responsibility for the poorest people of the world and that not thinking about the fact that most are sick and dying and what we can do about it is not acceptable.
Reading this book is what made my brother decide to major in public health at Tufts University. It inspired him to apply for a fellowship to work for a summer with the street children of Nairobi. I remember his saying that the poorest children receive a tiny amount of milk in a paper bag that has not been refrigerated in the morning and can’t get any more that day. They all look ill and hunt for food on the garbage heaps. I have seen how Paul Farmer could inspire someone (my brother)to take action to prevent the dying of the world’s poorest people, and maybe this book will influence what I decide to do in college too.

HW # 21 - Comments

BEN

I liked your first connection about visiting your good friend's mother with ALS in the hospital and how you would chat about the Patriots (cannot believe you're a Patriot fan) in order to keep the conversation upbeat. I know that ALS is a terrible disease and it would be interesting to hear how seeing someone with it firsthand affected you. I myself have never been with anyone with a serious disease. I think that having that experience must be powerful and important in the way that it makes death and dying more real, making us aware, as Beth said, of our own mortality. I also liked the connection you made to Beth's taking care of her husband with only the help of her son when you told us that your aunt took care of your sick grandmother all by herself. I think it must be true that many more women take care of sick and dying relatives than men do. It's obviously much nicer for a sick person not to have to be in the hospital but it must have been a huge burden in this case for your aunt.


Natalie

I was really impressed with the connection you made from your own experience with your dad to Beth's treatment of all those who were helping her husband in the hospital. Without judging your father (we all have our impatient moments), the fact that you felt so badly for the waitress and could imagine I think that if he had suddenly started choking she might not have performed the Heimlich Maneuver with much gusto. Hospital workers are paid to help patients but they are obviously going to perform their jobs with more good will when they are treated with respect, and even more than respect with friendship. Your mother's story about the poor man who died alone was really interesting because of your point that maybe it is easier to die if you don't have anyone to live for. It's true that a dying person would naturally feel terrible about leaving people who are dependent on them. On the other hand I think for many people death is scary because whether you have people or not to share your life death is still scary because it is unknown. Obviously you’re an excellent writer and this is an excellent blog post. I would like to emphasize the magnitude of your last line “When does death stop being the enemy…and become the natural idea.” Death has been my greatest enemy for as long as I can remember, and I think it will take an awful lot for me to picture it as “the most natural idea,” but I hope I can. In fact, ideally I hope I can think of it as a great adventure when my time comes (but I wouldn’t put any money on it.)

HW # 21 - Expert # 1

- Beth treated everyone who worked at the hospital with an equal amount of respect no matter the task s/he performed in treating her husband.

- Beth also made the effort to get to know the people who were caring for her husband, asking about their own lives and families in order to build stronger relationships.

- Beth questioned everytihg the doctors had to say about her husband's terrible illness.

- Beth displayed her husband's artwork and pictures of him and the family in an attempt to make people aware of the individual man that he was -- an artist.

- Beth rejected the option of having hospice care for her husband and chose to look after him herself with the help of her younger son Evan.

- Because she knew what a close relationship her older son had with his dad, Beth shielded him from her husband's deterioration in the last two weeks of his life.

- Beth said that there was "an indescribable stillness" at the moment of her husband's death. It was almost as if time stood still.

- Beth did not cry right away and mentioned that she had the realization that we would all die.



I can relate Beth's experience of time standing still when situations of monumental importance occur. When my soccer team went to France to play in the Nation's Cup, we played against the Ukraine in our second game of the tournament. In front of 30,000people I nutmegged one player en route to delivering a through-ball to my forward, who scored easily. Immediately after seeing the ball hit the back of the net, I did a front flip, and time seemed to be suspended while I was in the air. I remember wondering when I was going to come down. I believe that the silence Beth experienced was a way of acknowledging and honoring the moment of her husband's death that would have been quite different if she had been hysterical or crying profusely.



I can certainly relate to Beth's experience in getting to know all the people who were caring for her husband so that she could be confident that he would be treated well. On a much less of an important scale, when my mom and I shop at Dean & Deluca, which is near her office, we have made it a point to build great relationships with the people who work there, always asking about their lives and keeping them up to date with the most interesting stories we have to offer. As a result,we receive numerous amounts of free food. Others stores that I have built similar relationships with include Jamba Juice, City Bakery, and the Adidas store near the Broadway/Lafayette subway. This is not to say that I think it is a good thing to form good relationships with people only to get something from them. Having good realtionships with the people around you is good in and of itself. Good relationships create harmony in the world, and I am certain that for Beth the atmosphere of harmony that she created with the people at the hospital made life more pleasant for everyone and took away some of the stress of a very stressful time.

Further Thoughts

When she first began her talk I wondered whether she had any feelings of regret about speaking to our class about such a painful experience. I was thinking that in her place I wouldn't have wanted to be so open about such a personal time with a room full of strangers. By the end of her talk though, I think I had some insight into why she wanted to share what had happened with us. None of us want to think about death, so most of the time when it comes, we aren't prepared for it. She was actually giving us some preparation in a positive way by making death real for us and telling us how she was able to make this time as bearable as possible for her husband, her family, and herself. I could picture all the photos and his artwork in her husband's room. Not only did they show the person that her husband was and make the room warm and homey, but they also must have been good conversation openers for anyone coming in the room.



I was also interested in the hallucinations that her husband had and her thought that he might have been trying to fight off death. My grandmother's sister died having her first child. She seemed to be unconscious and then suddenly sat up, threw her arms out, and said, "How beautiful! This is gong to be such an exciting adventure." I like the idea of people having some kind of awareness of their own death and being brave enough to fight it or brave enough to want to accept it and go to it like some new part of the world not yet visited.

HW # 19 - Family Perspectives on Illness & Dying

In our family there has definitely been more dying on my father’s side than on my mother’s side. My father’s mother often leaves a message on our phone saying that someone has died and to call her. I hear my father saying, “Who is it this time, Fatty?” (He calls her Fatty although she has not been fat for twenty years, according to Fatty.) After she responds, I hear my father say “Fatty, I have no idea who that is and have no intention of going to their funeral.” Then he finds out that it was second cousin LeMelle’s adopted daughter who was the actual daughter of distant cousin LeRoy, who had to give her up because he couldn’t handle drugs. My father thinks that everyone should be cremated and that the funeral business is a racket.


Fatty used to like to go from Detroit where she lives to South Carolina for the funerals because they were like family reunions. She would tell my dad whether the relative looked good or terrible in the coffin and whether it seemed like the family had spent a lot on the funeral. My grandmother has a sense of humor so if the person looked good she would say something like, “If only Irma had looked like that when she was alive, she would have been strutting her stuff for another 20 years.” And if the person looked bad, she would blame the family for not spending enough on the funeral. Her family had owned a funeral parlor in the town of Whitmire, South Carolina. When she married my grandfather, they moved to Detroit so that he could work for Chrysler, and their first apartment didn’t even have hot water. No wonder she likes funeral parlors. They made it possible for her to grow up with hot water.


Now that Fatty is almost 90 years old she can’t go to South Carolina anymore. My grandfather is afraid of flying, and he had to have a leg amputated so he can’t drivea car. She has decided that she wants to be cremated now but thinks that she might still want to have “a viewing.” My dad thinks the cremation decision is great but told her that the “viewing” part is one of the dumbest ideas she has ever had. “Let people remember you when you were in your prime and not all gray and wrinkly.” She is still deciding.


My grandmother on my mother’s side definitely wants to be cremated. She says that her parents and the generations before them only thought about being buried because that was the only choice. If there were fewer people in the world, burial would still be okay. Now with billions of people there isn’t enough room to bury everybody. Granny thinks that if you live near a crematorium, you should be cremated. If anyone in the family happened to be going to England after she dies, she would not mind having her ashes sprinkled over the cemetery where her family is buried, but she doesn’t want anyone to go to any trouble. I asked her if she would want the ashes buried in one place with one of those stones that give your name and the years you lived. It would be a place where people could go to think about her. She said that memories are where people thinkof dead people, and hopefully they will be good ones.

HW # 18 - Health & Ilness & Feasting

Our Thanksgiving began with shopping at the Union Square Farmer’s Market. My mother asked me to meet her there to assist with the selection and more to the point the transportation of the big bird back to Brooklyn. We interviewed the lady at the organic turkey stand quite extensively. She told us that her turkeys had been fed only “fresh grasses and wholesome grains. Absolutely no GMO corn!” When I told her what I had read in Michael Pollan’s book about so-called free-range chickens having about a single square foot of “range” with nothing growing on it and a tiny door that led to this nowhere land offering no incentive to the bird to make the effort to go out, she replied that her turkeys did not spend time in cages and “were allowed to have not only their dignity but a well-rounded life.” This comment led me to describe the life of our
bird before passing his parts at dinner as being one of resort-style luxury: his own grassy pasture shared only with non-aggressive friends who would get together for picnicking and square dancing, or touch football with the guys. To make a meaningful contrast I described the real-life “chicken factory” soccer field in Queens where my team would sometimes play located next to a filthy barbed-wire coop where we could see the blood spurting from the neck splicing blades. Our actual selection at the Union Square market was a 16 pound bird, which required a big body-centered effort on my behalf to get home.

My musician cousin, aged 30, and his girlfriend came early to help with food preparation. Unfortunately, my dad, who is useless as a cook, could not remember when he put the bird in the oven, which led my cousin to open the oven door every five minutes because, as he said, “there is nothing worse than a dried-out turkey except for landslides and volcanic eruptions in populated areas.” Opening the oven door a thousand times meant that the total cooking time was about ten hours. We ate at 9 pm. Fortunately, my mother had made apple tarts the night before. Otherwise they would have been iced with turkey drippings. There was great physicality in the chopping and slicing of various meats and vegetables and also in the sporadic dancing to different people’s Ipods with music ranging from lil’ Wayne to Billy Joel to Carlos Santana to Earth, Wind, and Fire, to Aretha Franklin to salsa music. My brother’s basketball team had all taken salsa classes after the season to stay in shape so he demonstrated the technique for any interested guests. Since my mother had cut her hand quite badly on a knife my dad had just sharpened for the occasion, all the rest of us did a lot more work that we were not actually all that qualified to do. My brother made a huge mess making sweet and un-sweet plantains based on the fact that at the Mailman School of Public Health at Columbia he works with a lot of Dominicans who share their delicious plantains with him. Unfortunately, he did not have their recipe or bloodline. The sweet ones were definitely superior to the un-sweet ones, but there were leftovers which was not the case with the other edible contributions.

The actual feast was a sit-down dinner of twelve around a table that can seat six in comfort. The candles hid all the spills that came from wild elbows and absolutely no spaces between foods. I remember that it was noisy and laugh-filled and extremely relaxed since there were no grandparents to impress or difficult family members or friends to make us watch our language. My dad actually began the meal with a toast to
everyone for being people he liked looking at.


After dinner many of us watched the Jets beat the Bengals. Despite great feelings of heaviosity from overeating, there was some movement in our chairs due to Brad Smith’s kickoff return for a touchdown. We also played some minipool, which requires quite a lot of maneuvering due to the smallness of the table and the normal sized cues. We then ate the apple tarts and cakes guests had brought having had some necessary timeout from eating. After dessert there was no further possibility of body movement.

HW # 17 - First Thoughts on the Illness & Dying Unit

My grandmother can’t wait to die. She is 90 years old, and she says that every morning when she wakes up, she is so annoyed that her death wish has not been granted. She says she feels extremely angry if she reads in the newspaper about someone young who dies. “That person should have been me,” she thinks. If someone talented dies, she feels particularly frustrated. Michael Jackson’s death upset her because she loved seeing her grandsons dance to “Thriller,” which they did about 10,000 times.

Granny says she has a box of prescription pills that she keeps in case of emergency. The emergency would be the time when her mind goes. The problem is that when that time comes, she will probably be too far gone to remember to take the pills. She is against suicide because “it could get out of hand and become a fad in this crazy culture.” She greatly admires doctors who practice euthanasia though. They are heroes because they help old people who are ready to die no longer be a burden on society by using up oxygen and being a big drain on the health care system.

I asked my grandmother why she isn’t afraid to die. She says that she is hoping that “death will be an awfully great adventure,” which is a line from the book of Peter Pan. She expects to wake up somewhere else that is not heaven or hell but another world. I asked her if this means that she does not believe in heaven or hell. She says that she does not and that the older she gets the more she thinks that religion is something man created to answer questions that can’t be answered and to scare people into behaving better. On the other hand, she still prays out of habit if she is worried, and she believes our spirits go somewhere. She loves the idea of meeting up with spirits of people she liked, but she is terrified of being stuck with spirits of people she did not like even for ashort time.

I told my grandmother that I am afraid of dying. I think it is related to my fear of the dark. I believe that in the dark surprises can happen and they are bound to be bad. I hatethe idea of dying and being in the dark forever. I must believe in a spirit that lives on after the body becomes a lifeless carcass but since I was not really brought up to be religious, my idea of what a spirit does is not clear. I was baptized, but my last memory of church is of finding the giant chocolate Easter egg in a big hunt with a lot of help from my older brother. I saw the new Harry Potter movie and felt terrible when Dobby the elf died. After Dobby’s body went limp in Harry’s arms, Luna, Harry’s friend, closed his eyes. I think it’s terrible that eyes don’t close by themselves at the time of death. If they did, death would be less horrible.

HW # 8 - Growing Our Own Food

I acquired broccoli seeds because I love broccoli, and I read that broccoli sprouts have large amounts of vitamins and minerals and 50 times the amount of a nutrient called sulforaphane, which is the reason broccoli is called a super food. It is also a cancer-fighting nutrient. The seeds sprouted in about a day and a half. They started to sprout so quickly that I didn't have time to build up a lot of anticipation. I came home from soccer practice the night following the day I had planted them and there were already tips of green. There is something tremendously satisfying about seeing the green of new growth and being responsible for it, and it also made me think about whether undernourished people throughout the world could be given tons of seeds for sprouting. Unfortunately, I don't find sprouts particularly delicious, but now that I know how healthy they are, I think it would be woth exploring ways to eat them with other things that cover up the taste and texture.

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