One-Hoss Shay

Have you heard of the wonderful one-horse shay,
That was built in such a logical way
It ran a hundred years to a day,
And then, of a sudden, it--ah but stay,
I'll tell you what happened without delay,
Oliver Wendell Holmes "The Deacon's Masterpiece or the 'Wonderful One-Hoss Shay'"

For more that sixty years, my body worked pretty well without much intervention by medical science. No broken bones, not much in the way of infections, not too much routine maintenance. I got fat in my forties, but other than slowing me down a bit, it didn't change my general perception that I was a healthy guy. I ate what I wanted, did what I wanted, and generally felt fine.

Last fall that sense came to a sudden end. Within the course of a few weeks, I was labeled a borderline diabetic and diagnosed with urothelial cancer of my kidney. I had my kidney removed and learned to control my blood sugar by changing my diet. I lost a few pounds. I felt pretty normal, but my sense of immunity was gone.

Now, the cancer has come back in my bladder and I have lost all confidence in my body. It's like Oliver Wendall Holmes's "Wonderful One-Hoss Shay," the buggy that was built to last 100 years, each part equally strong. It ran perfectly for a century and then, on the anniversary of its construction, collapsed into a pile of rubble, as every part failed at once. It seems like a perfect metaphor for my situation, but when I've alluded to it, nobody gets it--apparently Holmes isn't much read any more.

So, follow the link and read the poem. It's funny. And it helps me think about my mortality.

What do you think the parson found,
When he got up and stared around?
The poor old chaise in a heap or mound,
As if it had been to the mill and ground!
You see, of course, if you're not a dunce,
How it went to pieces all at once,
All at once, and nothing first,
Just as bubbles do when they burst.

End of the wonderful one-hoss shay.
Logic is logic. That's all I say.

A slight change in direction

It's been almost a year since my last post on this blog and I am sure that no one is still checking to see if anything new has been posted. So, I've decided to revive it for a new and different purpose. Maybe someone will find it and read it, but mostly I'm just writing for myself. If you do happen to come across it feel free to comment.

Last September (2010), I was diagnosed with a urothelial tumor in my left kidney. I had my kidney removed and hoped that the surgery would cure the problem. Within a few weeks I was up and about--about 30 pounds lighter and with a big scar on my belly--but otherwise no worse for wear. However, recently I discovered that the cancer has now manifested itself as multiple tumors in my bladder. Obviously, this new development ups the ante considerably.

Next week I'm off for a consult at the GenitoUrinary department at M.D. Anderson Cancer Center in Houston, the same hospital where my late wife, Helen, was treated for breast cancer for almost seven years, a place that, I fervently hoped, I would never see the inside of again. Having confronted death by cancer in people I loved on several occasions, I have developed some pretty definite notions as to how one ought to deal with the challenge of this life-threatening disease. We'll see if I'm up to it now that it's my turn.

My plan is to post ongoing reports on my journey through life as a cancer patient--a journey I've observed from close quarters but never before from the inside. I hope this will be helpful for me, and, if anyone ever reads this, for my readers.

False Positives

Last month, the Preventive Services Task Force of the United States Department of Health and Human Services issued a report recommending a significant reduction in mammographic screening for breast cancer. This recommendation was received with what can only be described as hysteria. While some of the protest was a cynical ploy by those who oppose Obama's proposed health insurance reform and some of it (very little) was a serious disagreement over the Task Force's calculation of the net benefits of mass breast cancer screenings, most criticism of the report centered on the idea that it is immoral not to screen millions of healthy women if, by not screening, there is one life lost that could have been saved. "So what," these critics argued, "if the chances of saving a life of a woman between ages 40 and 50 by screening is 1 in 1900, we should do everything we can to save that life." The problem with this sort of thinking is that it completely ignores or minimizes the costs of routine mammography for the 1899 women who undergo the test but whose lives are not saved by it.

In most of those cases, the x-ray shows no sign of cancer. These women are reassured, but they do pay a price in radiation, money, inconvenience, and discomfort. They receive no tangible benefit from the test; indeed, the radiation exposure slightly increases their chances of developing breast cancer in the future. Most women who are now being screened probably think that the psychological comfort of a "negative" mammogram is worth these risks, but this "benefit" is purchased at a cost, much of it paid by other women.

In a significant number of cases, the mammogram shows a suspicious breast lesion which is biopsied and diagnosed as benign. These are the classic "false positives." These women typically receive more radiation in the form of additional imaging and suffer additional expense and pain. Most importantly, however, they understandably suffer a good deal of anxiety during the time between the "positive" mammogram and the post-biopsy "all clear" signal. Mammography advocates typically dismiss this psychological cost as trivial, but they can't have it both ways. If the emotional reassurance provided by a true negative mammogram is a good reason to do them, then the psychic pain caused by a false positive is a reason not to do them.

The group of women most hurt by being screened are those in whom the mammogram leads to the discovery of a slow-growing cancer, one which, if undiscovered, would never have cause illness or which, at least, would not have metastasized before it reached a size at which it would have been discovered without x-rays. Some of these women will be treated unnecessarily, typically undergoing surgery, chemotherapy, and/or radiation. All of these treatments are dangerous and unpleasant. In addition, these patients are deprived by the screening test of the blissful ignorance which allows them to live their lives innocent of the existence of mutated cells within them.

The same considerations apply to those women in whom mammography finds aggressive, incurable tumors. They will die with or without mammography, but without it they will have more time in which to live normal lives,free of the knowledge they they have a life-threatening disease.

While it is impossible to tell in advance which woman is in which of these groups, it is possible for scientists to make informed judgments about the relative sizes of these groups and to consider these facts in making a cost-benefit analysis of the benefit of screening mammography for different groups. That is apparently what the Task Force tried to do. Others can contest their measurements of costs versus benefits in good faith, but many of those denouncing their recommendations do so without acknowledging that there are, in fact, serious costs to mass screening of healthy people.

November 22

The anniversary of the murder of Jack Kennedy usually sets me thinking about that long-ago day. But this year I was yanked back to it in particularly brutal fashion. Yesterday, I had a meeting at a law office in the 3300 block of Elm Street in Dallas, in the now hip, formerly industrial neighborhood of Deep Ellum. At the end of the meeting, two of the participants, both baby boomers, walked me to my car. "What's the best way," I asked, "to get onto Interstate 35?"

"Oh," one of them replied, "just follow Elm Street all the way through downtown, like you were in the Kennedy motorcade."

November 22, 1963, was a bright, beautiful fall day in suburban Philadelphia, where I was an eighth-grader. Shortly after we began our Latin class, the principal came on the PA system to announce that our president hat been shot in Texas--a few minutes later he came on to say that President Kennedy was dead. The teacher tried to continue with the lesson, but without much luck. I sat in my seat sobbing. The following Wednesday my family stood in a long line at Arlington National Cemetery, waiting for hours for the privilege of filing past his fresh grave.

I loved John Kennedy in a way that I have never loved any public figure since. He was for me, and millions of my generation, much more that a politician. He was young and beautiful and full of possibility. He was the promise of what we could grow up to be in a post-war America that was the greatest country that had ever been. The announcement over the junior high school public address system yanked the veil of innocence from my eyes; it never returned. For me, part of the attraction of the Obama campaign was the suggestion, the hint, that, if we could manage to elect this man, perhaps we could return to the world as it was on November 21, 1963, before we saw what was behind the facade.

Iowa

A couple of years ago, I read Gilead, a novel by Marilynne Robinson. I knew nothing of her work at the time--my recollection is that I selected the book at random from the "new arrivals" shelf at my local library. I loved it so much so that I emailed passionate recommendations to my family and friends, not something that I am in the practice of doing. This was strange because the book is explicitly a Christian one--the novel is in the form of a long letter written by a dying Congregationalist minister in the small town of Gilead, Iowa. Since I am not a Christian, I was hard put to explain my attraction to the book. In the end I put it down to my interpretation of the book as being largely about the history of white northerners' attitudes toward race--that and the fact that, as an alumnus of a congregationalist-founded college and Presbyterian Sunday School, I am familiar with and interested in the culture and theology of American Calvinism . My admiration for the book was widely shared; it won the Pulitzer Prize and our President-to-be listed it as as one his favorite books.

I've just finished reading Robinson's new novel, Home. It is also set in Gilead. And it has strong theological themes. And I love it, despite the fact that the racial/political/historical threads are much less prominent than in the earlier book.

Home is a presentation of the incidents of Gilead from another vantage point. Jack Boughton, the ne'er-do-well namesake of Gilead's narrator John Ames, has returned to town after a twenty-year absence. His father, a retired Presbyterian minister, welcomes him but cannot resist the impulse to judge him. If this brief summary brings the words "prodigal son" leaping into your consciousness, you are probably part of the audience for this book.

The novel is not particularly strong on plot, but there is a mildly surprising incident at the end. The writing is beautiful in a plain, Midwestern way that is artful without seeming self-consciously artsy. The characters are carefully drawn. The themes of family, alienation, moral responsibility, and mortality are universal, but the setting is distinctly American.

You don't need to have read Gilead to read Home, but you ought to read both because they are such good books. Home was published in the midst of the recent campaign, so I don't imagine that Barack Obama has had a chance to read it yet. I know he's busy these days, but I hope that someone will send him a copy for Christmas.

Fatal Attractions

Advocates of bikes as transportation often make the point (as I have here ) that motorists' anger at reckless bike riders is overblown because such bikers are primarily risks to themselves. Well, its a good theory, and, I think it's true, but I feel compelled to point out that, here in Austin, we've had 2 fatal traffic accidents this month in which one of the those involved was on a bike but the person who was killed was NOT.

On July 6, Jessie McFarlin, who was struck by a bicycle while he was trying to cross the street at night , died after several days in the hospital. The cyclist was not charged, as police said that McFarlin was jay walking. The bike was traveling 25-30 mph. I don't know many of the details, but the accident does point out the particular dangers of biking after dark. Most bicycle lighting is designed primarily to make the bike visible to drivers, not to illuminate the bike's path to its rider. Thus, it's easy to outride your headlight.

The stranger of the 2 accidents occurred on July 20, when Ernest Kirchner was killed when his motorcycle collided with a bicycle. The bicyclist was treated and released. The story is not very clear as to how the accident occurred, but it did note that Kirchner was not wearing a helmet.

So, I guess that the exception proves the rule. Neither of the people killed in these accidents was in a car. Indeed, the two accidents are notable precisely because of their "man bites dog" aspect. But they do serve as reminders that bike riders can hurt others if they are not careful.

Ruffian

I'm not an animal lover, at least not in the sense that the term is used among the American middle class these days. I'm not an animal hater either--I've had pets and I love them, but I don't feel about animals the way many of my fellow citizens seem to these days. I've never paid a thousand-dollar vet bill. I've never stayed awake at night because my brother, the dairy farmer, sends his dry cows and bull calves to the slaughterhouse. Indeed, I've never been a vegetarian, even for a day. As I write this post, I am simmering a stew composed primarily of the cubed leg muscle of an adolescent sheep who met its untimely end just a few miles from where I live.

So I'm not an animal lover. But this morning, when I opened the Sunday paper and saw that Eight Belles, the filly who placed in these year's Kentucky Derby, had broken down at the finish line and been put down right there on the track, I teared up. I cried partly because thoroughbreds are beautiful animals who deserve better than to die for our amusement, but mostly I cried because I remembered the day, more than 30 years ago, when I mourned the death of a thoroughbred filly whom I had never even seen.

In 1975, Ruffian was the outstanding 3-year-old female race horse in the United States. She had won the Triple Crown for fillies and, in the era of second-wave feminism and Bobby Riggs-Billie Jean King tennis matches, it was inevitable that somebody would decide that a buck was to me made by racing her against the year's outstanding colt, Foolish Pleasure, the winner of the Kentucky Derby.

The match race was held at Belmont Park on July 6, 1975. That summer, I was a 25-year-old law student doing a summer internship in Chicago and living near the lake. I remember driving through the green, elm-lined streets of Evanston, listening to the race on the radio. When Ruffian broke her leg a half mile into the race, I broke down bawling. I was crying so hard that I had to pull over to the side of Dempster Avenue, so that I didn't run my car into one of the beautiful old trees that were dying of Dutch Elm disease.

A few weeks later, I left my internship early to drive to California where my father was waiting for my arrival so that he could die. Maybe that's why I cried for Ruffian and maybe that's why I cried this morning for another horse whom I had never met.