August 18, 2009

DATELINE: Tierra Tranquila, a house on a mountain above the Pacific in Costa Rica

LAST NIGHT we sat out under the equatorial stars and listened to the sounds of howler monkeys, birds, and cicadas. At 2,000 feet, there are no mosquitoes. This morning at dawn we watched three toucans zoom in and slash at their breakfast – a bunch of bananas we cut down from our trees and hung beside the patio. Among the plantains, mangoes, papayas, avocados, and limes, birds abound: hummingbirds hovering under the leaves of the purple banana flowers, flocks of parrots, a pair of blue-crested mot mots with tails twice as long as their bodies, soaring hawks, and portending vultures. Each morning you can spot a new, rolled-up banana leaf and watch it on and off all day until it unfurls fully, a lime-green flag of fecundity. On the dirt road, our neighbor goes by with his oxen dragging the trunk of a pechote tree – a wood that, like the native teak, resists termites. It is valuable, and protected. Only fallen trunks can be gathered and sold.

The community of 20 farm families live along the road up the mountain. There is an elementary school, a social center, and a women’s cooperative micro-loan bank, which in 11 years has never had a default. The nearest village is down a dirt road with 13 hairpin turns, and has two paved streets. Costa Rica is a designated world “Green Zone’’ – getting top scores for environmental policy – and our province is a world “Blue Zone,’’ for the longevity of its inhabitants.

The summer of 2004 my wife and I were asked to lead a cultural dialogue here between American and Costa Rican (“Tico’’) teenagers, in which our daughter participated. Our trepidation about what might happen in an America ruled by a second Cheney/Bush, coupled with our sense of sanctuary in Costa Rica, led us to buy the house. We have returned to the dialogue/camp each summer.

On a trip with the campers to a local waterfall, one of the counselors fell on the rocks and gashed his head. In the village was a modern, fully-equipped clinic: doctor, nurse, and pharmacist. The young woman doctor saw the patient right away, did a thorough exam, and sutured him up. By the time she was done, the pharmacist had brought in the antibiotics and pain medication. Our cost: zero. She told us that every village of any size has a clinic staffed by a doctor – all of it free.

How do they do it?

The answer came from a question the Ticos asked the Americans in dialogue: “What does it feel like to live in a country that’s always at war?’’

For my whole lifetime, America has been fighting an endless progression of foreign wars – and, truth is, it feels insane. America’s effort in World War II fattened into a military-industrial economy that has devoured our national purpose, which now includes lies and torture. Our healthcare, a for-profit “industry,’’ leaves 50 million uninsured, a national disaster. Here, every Tico has free healthcare. Hospitals are good – some Americans come to San Jose for the joint repairs they cannot afford at home.

How is this possible in a small country without valuable resources such as oil, gas, or metals? Simple: In 1948, the government outlawed an army. It cannot go to war. It spends zero on its Department of Defense – there is none. Rather, there is a single department for both Environment and Energy – all the energy (except gasoline) is renewable, from water and wind to geothermal and solar. The country is not a utopia – the Tico teens admired the Americans’ sense of freedom and individual possibilities, material wealth, and world leadership – but it is an enticement.

If you don’t waste money on an empire, you might just have money for a true democracy. This country that cannot go to war, that has a president who won the Nobel Peace Prize, generates a certain peace among its citizens. They know that if they get sick, they get care; if they want an education, they get one; if they want work, they can have it (not just bananas or coffee, but Intel chips); and whether or not they want natural beauty and the blessings of animals, plants, friends and family, and long life, they have them.

Throughout the country there is a common greeting: When we meet on the mountain and ask, “Como esta?’’ – “How are you?’’ – they answer, “Pura vida’’ – “Pure life,’’ or “Life is good.’’

Stephen Bergman is a guest columnist. Under the pen name Samuel Shlem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

Read Bergman’s speech as prepared for delivery

Listen to Bergman’s speech:

John was the second writer I ever met. It was 1979, my first novel had come out, he was 46, I 34. We met at a party of PEN New England at the house of the writers Robie Macauley and Pam Painter. My first impression was clouded by nervous awe, but luckily it was summer and our conversation turned to golf, John’s passion, and my sport at our shared alma mater, Harvard. A week later I was out on a forlorn public golf course packed with carts-full of beer-swilling guys in T-shirts whose swings were converted from hockey. There had been a mistake and we were a five-some. A six-some, actually. Another young writer in the group, supposedly happily married, had brought along his petite blond girlfriend and spent a lot of time in the woods with her while we played on. Reappearing, flustered, they would walk along with her arm around his waist, her hand tucked neatly into the hip pocket of his jeans—a true Updikean touch.

You can tell everything about a person by the way they play a sport. Last night I calculated that in thirty years John and I spent at least 5000 hours playing golf. We had a regular foursome, and often played with his son David, now also a dear friend. But often it was just John and I, walking along together, bags on our shoulders, talking. In golf John was meticulous—our scorekeeper, cherishing those little yellow golf pencils; frugal, picking up pencils and tees all during the round; steady as a fair Christian but for an uncontrolled deviance into the raw sensuality of woods and briars and swamps and lakes and sand traps; reliable to a fault on the greens; capable of astonishing flights of golf poetry and sudden crashes into golf trash—and really funny. Once when he and I were teamed up against the other two and I complained of a bad back, on the 2nd tee he said, “Steve, I want you to know that if it’s a choice between helping the team and hurting your back, I want you to hurt your back.” Always on the 4th hole he and I would talk about his medical questions, and always walking up the long par five 8th fairway we had our “literature and career” chat, what we were reading and writing, the folly of both popular and literary taste, what the gossip was. Often he would repeat something I said, and I knew I would soon see it in a book. He had an astonishing eye, and in golf gathered details—one fall day he walked off the course to make sure he knew the name of the last tree to turn color—I believe ash, or hickory. Harry’s condo in Florida in RABBIT AT REST was, in fact, my parents, whom John stayed with to make sure he got it right.

Janet and I had a house in Gloucester, twenty minutes from him and Martha, and we became another foursome—seeing each other often for dinner, celebrating each birthday together, and Christmas at their home with their mixed families. Soon there started arriving book after book, and private editions as birthday presents, as well as cartoons and drawings—such as a set of four golf balls, on each a cartoon of the face of a member of our foursome. One night Janet, a psychologist, insisted that John and I take the Meyers Briggs Personality Inventory, and then announced the results. I came out as a writer; he came out as an office worker or clerk. So much for psych testing. Every book he sent had an inscription, often blaming me: “For Steve, who ruined this novel by a) suggesting it, b) inquiring after it constantly and making me talk its lovely essence away.” For a New Yorker review of The Bible: “For Steve, without whom this piece would have been composed with much less distraction”—but to each of these he added, “with affection and esteem.” John was the most loyal friend I ever had: he would always show up at events for my books or plays, he would listen attentively to my publishing woes, and if I was going through a rough time and we hadn’t talked on the phone for a while, he would always call—imagine, a man who always calls! When my publisher asked him if he’d write the introduction to a 25TH anniversary edition of my novel THE HOUSE OF GOD, to my surprise he said yes, and included it in one of his anthologies. Though never directly, in postcards and letters and half-joking inscriptions, he pointed out my strengths and weaknesses as a writer, always in an encouraging way.

I never saw him yawn, and he rarely lost his temper: mostly on the golf course, once at dinner at home when he was so angry that he pointedly let his napkin drop a full five inches from his hand to the table. He was the most generous of critics; only in the last few years did I ever hear him voice irritation at a writer—one in particular, who shall remain nameless. He talked freely with me about the craft. I learned an enormous amount from him.

We had a secret joke: in THE WITCHES OF EASTWICK, he wrote “The new young editor of the Word, Toby Bergman, slipped on a frozen stick outside the barber shop and broke his leg.” In my next novel, THE SPIRIT OF THE PLACE, I wrote, “The new young editor of the Crier, Toby Updike, slipped on a frozen stick…” etc. And when last year I received his last novel, THE WIDOWS OF EASTWICK, sure enough there “Toby Bergman” was again. In my new novel there is a final, leg-rebroken, “Toby Updike.”

The last few years of our friendship, because of various orthopedic surgeries on my part, were not on the golf course. Rather we would meet for lunch at the Harvard Faculty Club. He timed our lunches to his delivery of boxes of his personal papers to Houghton Library. He always seemed shy when he announced himself to the librarian—John was always wonderfully humble. He was modest, but with a rock-solid confidence. Once, after a novel of his had gotten panned, I asked how he handled it. “They’re talking about my novel,” he said, “not about me.”

Last summer we had a belated joint-birthday lunch at Myopia Hunt Club, John’s exclusive old-Yankee golf course at which he never seemed quite comfortable. I noted his old man’s wrinkled and scarred face but then—when I looked into his eyes—(those eyes!)—I recognized the signature boyish joy at being alive and at play for another great day. He and I, two small-town boys sitting there in a grown-up’s exclusive club eating our BLT’s off bone China on a starched white tablecloth. The sun shone hot on the 18thgreen, lighting it up as if it were made of crushed emeralds. Over lunch we laughed, hard, happy to see each other again and delighted with our good fortune in life, talking about everything as best friends do, and then parting, he with his gentle handshake and slight stammer. As I drove off I turned and saw him walking away slightly stooped, snowy hair shining in the sunlight, but with a bounce in his step as he swung his putter along, heading toward the green to practice.

That was the last time I ever saw him.

There was a last postcard, in November. He told me about his diagnosis, and a few other things, and about the care his family was showing him. After that, he drew back, into himself. I knew that the suddenness and aggressiveness of his cancer had been a shock to his self-image, an end that simply does not happen to those who, despite their bodies, feel young, feel in touch with, in his transcendent line in one of his last poems, : “our heaven at the start and not the end of life.” I kept in touch through David, and notes I wrote him.

There are all different kinds of love in the world, and John wrote brilliantly about most of them. He taught me a lot about the love in a friendship, and I find myself thinking about him most days as if he’s still around, and then, realizing he’s not, missing him pretty badly. When you don’t get to say goodbye, there’s a hole in your heart, sometimes for a long time. So I just want to say, “Goodbye, John. I loved you. You will live with me, and all of us here today, for the rest of our lives.”

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A COUPLE sits on a beach on a brilliant July day. They’ve just had a picnic lunch, and are in that hazy sweet space of watching the waves and the gulls, the passing sailboat, or, far out, the tanker. They feel close.

The woman, wanting to feel even more close, asks: “What are you feeling, hon?’’

Startled, the man blinks, glances at her, and not knowing what to say, says nothing.

The woman asks, “Can you tell me?’’

The man, wanting to respond and trying to gather his thoughts and feelings to do so, still comes up blank. A sense of panic blossoms in his gut and rises to his chest, cold and damp as if clenching his heart. Trying to stay calm he says, “I don’t know.’’

“Sure you do. Can you tell me?’’

The cold rises into his brain, all ice. Through gritted teeth he says, “Don’t spoil it!’’

The woman, startled by his tone and the glazed look in his eyes, says, “I’m spoiling it?’’

Things go downhill. They wind up miles apart, staring at nothing.

What is going on? In our work leading gender dialogues between thousands of men and women, boys and girls, Dr. Janet Surrey and I have come to understand this as a “relational impasse’’ – the “dread/yearning impasse.’’ If the woman, yearning to feel closer, approaches, often the man starts to feel “male relational dread,’’ and retreats. In his head is a little voice: “Nothing good can come of my going into this, it’s just a matter of how bad it will be before it’s over. And it will never be over!’’

As one man put it: “I woke up this morning and she turned to me and I was in dreadlock!’’ The paralytic feeling of dread is familiar to many men. It contains a sense of failure, humiliation, shame, and paranoia. It is part of normal male development – and it is hell on relationships. Anything, even the cap let off a tube of toothpaste, can trigger it. Relational dread is a basic human experience, although the male and female versions may take different forms. This is the male version.

How does male dread develop? A patient’s story gave me a clue. When he was 6, he had been beaten up at school. He wasn’t hurt physically, but felt terrible. He walked home up the railroad tracks through the woods so no one would see him crying, and couldn’t wait to tell his mother. He went in through the back door into the kitchen, anxious to tell her. She was at the sink. She turned around, saw the tears, and with concern asked, “What’s wrong, dear?’’ Despite wanting to tell her, he said, “Nothing,’’ turned away and walked back out.

What had arisen was not just in him – after all, he walked into the kitchen intending to tell her. But when she moved toward him emotionally – in the interaction between them – he felt exposed, and dread suddenly arose and did its damage. It was a relational impasse.

Although we all – boys and girls – come into the world with a primary desire for connection, there is an early fork in the path. Many boys are pushed by the culture to disconnect from their relationship with mother in order to grow, and become less valued for their relationships and more valued for themselves; while many girls continue to grow in relationships, and are valued as the carriers of connection in the culture.

But scratch our surface and you find that we men desire connection every bit as much as women, and get sick and even do sick things – think of all the destruction wrought by male “loners’’ – if we don’t experience it. Given the chance, we’re just as good at it as women – witness the revolution in fathering in the past few generations, fathers as caregivers. Male relational dread may arise from time to time, but male relational love, living “in the we’’ with a partner or a child or a dog or a student or a shortstop-or-dancer-in-training, is right there in us, waiting to prevail. We men yearn more than anything to live not in the “I’’ or the “you,’’ but in the “we.’’

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

MEDICAL STUDENTS in their course on diagnosis are taught: “When you hear hoof beats outside the window don’t assume it’s a zebra.’’ This means that you should think of common diseases first, not exotic ones.

Decades ago when I was a medical student in Boston at one of man’s greatest hospitals, I was assigned a woman with “difficulty breathing.’’ She was 56 years old, a mother of three whose husband had died two years before. In good health all her life, she worked in a flower shop. She had never before had trouble breathing. Her husband’s death had been a shock, but with the support of friends and family she had gotten through it pretty well. The resident – my boss – came in and took her history, in a rat-a-tat technique of asking a probing question that had to be answered yes or no, and as soon as there was a response, cutting her off and moving on to the next. I knew he was filling in his grid, a decision tree that would provide the diagnosis. No new information came up. A physical exam showed nothing but her panting. Lab work revealed increased eosinophilia, the blood cell that increases when the body is allergic to something. The resident went back and grilled her on allergies. Nothing.

Her workup proceeded in classic academic fashion, with increasingly refined blood tests and X-rays. The latter showed a diffuse pattern of lung irritation, but no lesions or tumors. Experts were called in, and each diagnosed something in their area of expertise, from the psychiatrist diagnosing “melancholia’’ at her husband’s death, to the surgeons wanting to cut. She kept getting worse, the oxygen levels in her blood falling lower and lower, bluing her lips, paling her face. A look of doom seemed to cloud her eyes. The surgeons did a lung biopsy, which showed only that her lung was reacting to some antigen, as the blood test had shown.

She continued to decline. Palliative treatment was begun. The resident and staff doctors seemed reluctant to enter her room. I felt scared for her and sorry, and spent more and more time sitting with her, just talking – a medical student has time for this arcane procedure. One day I asked where she lived. She said that after her husband died she’d taken in boarders to survive. I asked about them. “One of them’s. . . a real trip,’’ she gasped. “A magician.’’ I smiled and asked more about him. Part of his act involved trained pigeons, which he kept in cages in the basement. “The cages are right above my washer drier.’’ My ears perked up. It turned out that whenever she ran the drier, the pigeon droppings were aerosolized and she breathed them in – for the past two years. I rushed to the medical library – in those days we still used books – and found “Pigeon Breeder’s Lung Disease.’’ Treatment: get rid of the pigeons; and a course of steroids. Prognosis: excellent. The magician suffered. She got well.

Looking back now, what did I learn?

That the science of medicine is astonishing and useful, but it can keep us from practicing the human art of listening and responding, face to face, heart to heart, without a decision tree in mind or a computer on our laps so we stare into the screen instead of look into the eyes, all to “save time.’’ That the for-profit insurance industry dictates that we doctors don’t have time to listen to our patients if we want to get paid. That if we rely on technology and tests and neglect “being with’’ the patient, we may well miss the vital human facts that will solve the mystery and bring the cure. And that the patient is never only the patient; the patient is the spouse (alive or dead), the family, the house and who lives in it, the friends, the community, the toxins, the climate, where the water comes from and where the garbage goes. The patient is the world.

And finally that the “hoof beats’’ outside the window can be zebras – or, if you listen carefully, just the light steps of a common bird.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

LIKE THE arcane process of film developing in a darkroom tray, several Laws of the Novelist have appeared, and are offered as a guide to those so inclined.

Law Number One: Don’t Believe Teachers. The son of a dentist, I always wanted to be a writer. At college I worked like hell on the first essay of the freshman writing course, and got it back with one comment, in red letters: “See me.’’ Her feedback: “This is too terrible to mark, it’s below F.’’ Devastated, I tried again, and again, and always: “See me. Still below F.’’ Later that year, I was on the golf team with a blond Adonis named Ray. He said he was getting a straight A. Ray was a great golfer, but could barely talk, much less write. “What, you an A?’’ “Yeah. I’ve been sleeping with her all year.’’

Could this be the meaning of “See me’’?

I didn’t believe her, and kept on.

Law Two: Editors Are Ephemeral and Don’t Edit. The editor of my first novel moved to another publishing house for my second. In the middle of my third, at another publishing house, she was fired, and my new editor, after sending me terrific edits, was fired the next day. The editor on my fourth novel, at still another publishing house, said, “I love this novel. I won’t change a word.’’ But when I got the manuscript back she had marked it up with so much red pencil that each page was pink. We struggled. I took few of her suggestions. In our final conversation she said, “You’ve ruined this book. It will get bad reviews,’’ and then she was fired.

As one editor told me: “We no longer edit, we acquire and market.’’

Law Three: Publishers Don’t Publish. When my first novel was about to come out, I asked my publisher if it would sell. “No, your novel won’t sell.’’ This startled me. “It’s about medicine, and that’s good, and it’s funny and sexy, and that’s good.’’ Why won’t it sell? “Because it’s a good book. Good books don’t sell.’’ Bookstores can return any book for a full refund, a business model that spells doom for publishing. Only about 5 percent of books pay back their advance. Those hardcover remainders piled up in stores mean that the publishers overpaid, overprinted, and undersold.

Law Four: There Is No Humiliation Beneath Which a Writer Cannot Go. My second novel had come out in paperback, and my wife and I were on a hiking trip in New Hampshire. We stopped in a mom-and-pop store for lunch. There, in a spindle bookrack, were two copies of my novel. I immediately suspected my wife had placed them there, to make me feel good. Nope. I took both books off the rack and went up to the little old lady at the counter, and announced, “I wrote this book.’’

“Oh, you wrote that book?’’ she asked.

I averred yes. I asked if she would like me to sign the copies.

“Oh no, our folks would never buy a book that was writ in.’’

Another standard humiliation: At an author-signing in a bookstore, sitting at a desk near the window, facing a wall of Grishams, watching people hurrying past as if you are a child molester. Not fun, especially if your publisher has overlooked advertising the event.

Law Five: There Is Only One Reason To Write. During a post-second-novel depression, I spent six months, more or less, in the bathtub, trying to give up being a writer. Finally I realized that while I disliked publishing, I still loved writing. But if you want to respect what you write (rather than write for cash), you need a day job. Luckily, decades previously I faced a choice: between Vietnam or Harvard Med. I became a psychiatrist because I might learn about character and story, and could leave mornings free to write. Not as good a day job as my first, working the graveyard shift as a toll collector on the Rip Van Winkle Bridge – you can learn pretty much everything from what goes on at night in cars – but still.

Only write if you can’t not.

Correction: In last week’s column, in reference to the Clark Rockefeller trial, I erroneously reversed the words “prosecution’’ and “defense.’’ The prosecution psychiatrist concluded that the accused was not insane; the defense psychiatrist and psychologist concluded that he was insane.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem, he is the author of “The House of God’’ and “The Spirit of the Place.’’

THE RECENT verdict of guilty in the “Clark Rockefeller’’ trial was an affirmation by a jury of his peers that he was not insane at the time of the crime. But the duel of prosecution and defense psychiatrists was at best a farce, at worst a travesty of the profession and the law. As a former psychiatrist I am appalled.

For the prosecution: one psychiatrist, famous from Fox TV and psychiatric thrillers, was paid $10,000 for his expertise as part of an “insanity defense,’’ testimony that was challenged by his offering opinions about Rockefeller on TV in advance of the trial; a prosecution psychologist agreed with his diagnosis, basically of a narcissistic character who was “delusional’’ – that is, insane. For the defense: a psychiatrist who had seen the accused once for 2 1/2 hours and had never before testified in court came up with the diagnosis of narcissism and sociopathy – that is, not insane.

Diagnosis of mental conditions is not the same as that of kidney disease. From the birth of psychiatry, diagnoses have been determined not by hard numbers but by cultural/historical norms. After Freud “discovered’’ During Freud’s time, after he “discovered’’ hysteria to be “a wandering womb,’’ the diagnosis became all the rage, as if suddenly hysteria had become epidemic, wombs wandering all over Europe; in recent decades the diagnosis of attention deficit hyperactivity disorder has boomed. Hysteria is a rare diagnosis now; perhaps ADHD will decline in popularity as well.

These days, psychiatric diagnoses are based on the “Diagnostic and Statistical Manual of Mental Disorders,’’ published by the American Psychiatric Association. This hefty volume is a main money-maker for the association, upward of a million dollars in annual sales. It is written by panels of psychiatrists who are each specialists in their own diagnosis and it is flawed, one example being its listing “homosexuality’’ as a psychiatric disease long after society had not.

It is also tarnished by many of the specialists being paid to be involved in studies of drugs to treat the illnesses they list as their expertise. The temptation for them to find a drug that will treat a diagnosis they can specify and in which they are the expert is significant.

The current conflict-of-interest investigations – including by Congress – into psychiatrists getting paid to do research that might prove the efficacy of the drugs they use to treat their patients are well documented. If a drug company can link a particular drug to a particular diagnosis, bingo – a blockbuster drug can earn over a billion dollars a year. The lucrative link between a diagnosis and a drug to treat it, when diagnosis itself is culture-bound and often subjective, pollutes the impartiality of the “Diagnostic and Statistical Manual,’’ and opens the courtroom door to the psycho-battles that demean and confuse.

If psychiatric diagnoses and treatments have an element of fuzziness, how could doctors paid by one side or the other not come up with a diagnosis wanted by their employer, prosecution or defense? Luckily, juries are savvy and sensible, and seldom buy an insanity defense. Dueling psychiatrists confuse, more than persuade them.

The solution is simple, and clear. First, do away with psychiatrists being paid by either defense or prosecution. Rather, have a paid panel of psychiatrists and psychologists independent of government or law, charged with determining legal insanity; both sides would have to agree to abide by the panels’ conclusion – as in binding arbitration.

Second, instead of either “guilty’’ or “not guilty by reason of insanity,’’ establish a verdict of “guilty and insane.’’ Convicted, the insane guilty would be held in psychiatric prison, eligible for treatment and perhaps available for statistical and clinical studies of the link between insanity and crime. Useful information – like the data suggesting that 80 percent of violent crimes are committed under the influence of alcohol or drugs – could be obtained, and could be useful in early intervention.

The circus atmosphere of shrinks in the courtroom, which devalues the profession and the law, would cease. As for the what’s-in-fashion friability of the “Diagnostic and Statistical Manual’’ and the money-making links of diagnoses to drugs, that’s another, more scary and intractable matter.

Stephen Bergman, MD, is a guest columnist. Under the pen name Samuel Shem he is author of “The House of God’’ and “The Spirit of the Place.’’