Chapter 1 The One Strike Law
p. 6 ~ Referring to a doctor who worked in correctional medicine at the Tombs, a prison in Manhattan “...[Dr. Heyman] knew that the game of life could change quickly for anyone and the only difference between the rich and his patients was that the rich had options.”
Chapter 2 Tanisha
p. 30 ~ “Tanisha’s mother had been a victim herself of a mother who had been a gang member, drug user, and petty dealer who didn’t actively abuse her children so much as neglect them. Feral was the term ACS used in a report that had been shared with Tanisha by a social worker when she was a young teenager. Tanisha had no idea what feral was. She had thought it was an animal, a pet tiger.”
p. 33 ~ “Tanisha showed no emotion when I shook her hand and asked if she minded if I sat in with Francesca [on call child psychiatrist]. She nodded ok, looking me directly in the eyes. It made me feel vulnerable. This sixteen-year-old, five-foot-one Dominican Haitian teenager with a thick Bellevue chart from multiple hospitalizations, evaluations, emergency room visits, and psychological testing was rapidly sizing up the two adults in the room who would be evaluating her and making some determinations about her future. I switched roles with Tanisha and felt the weight of her “chart” on all of us … “
p. 34 ~ “ ‘Why did you run away from the foster home in Bushwick?’
‘I did not run away. I left of my own free will at a time of my choosing. I never ran.’
‘Sorry, I didn’t mean run away in that way. Why did you leave?’
…..
Carefully calibrated, Tanisha responded, ‘ACS has sent me to so many s***holes, with so many a**holes that want to f*** with me or f*** me. Just who should you be interviewing?’ ”
p. 40 ~ “I watched her through the glass. [Emily] was so young. As she sat drawing with Tanisha and the younger child, I found it hard to believe that she’d be medicated for most of her life. In fact, watching them, I was struck by how very difficult it is to grow up in our environment. Both of these young women thought actively about dying, about taking their lives. Money did not cushion all the blows.”
p. 42 ~ [Tyrone] was on the waiting list for the state hospital. There had been too many failures sending him home and to alternative “residential” homes in the archipelago of child and adolescent facilities. What was his future? His life trajectory? Next stop adult psychiatric unit, or Rikers Island, or a mix of both? You don’t need to be a soothsayer to see into the future.
p. 48 ~ Emily and Tani were from opposite poles of the universe. A product of abandonment at birth, Tani had ricocheted like a pinball around a system desperately trying to find a safe haven. In her sixteen years, she’d had a couple of loving experiences between forced death marches in enemy territory. Emily was picked up by a car service and driven to her private school, then sat down to dinner overlooking a backyard with a Bach clavichord playing in the background. And yet barely out of first grade she was melting down and unable to regulate her emotions.
Chapter 4 Beso de Angel
p. 89 ~ “Neither of them or their families had any financial resources. It was day-to-day, every day. Everyone worked at whatever job was available to pay the bills that kept coming in for rent, for food, schools, cell phones, electricity. Chicken or pork was a once-a-week treat. … The tiny bit left over went for an emergency fund for health care. Inflation in Mexico was very simple. You had to run faster every three months to stay in the same place as the peso bought less and the government removed its subsidies for corn, gas, and petroleum. It was a kind of slow torture. A quarter of a turn of the screw and then another.”
p. 104-5 ~ [Due to the cartel and drug problems in Mexico] “ “I am more worried about unemployment and the young people, though. What will they do to support themselves? How will they live? I couldn’t even support Octavio, my own son in my own business. … The corruption is everywhere in government and could spread to the men who cannot support their families, who cannot afford a house or an apartment, a girlfriend. If you cannot afford to get married to have a family, you are creating a different kind of desperation.’ “
p. 105-6 ~ “ ‘I hate the narcos, but I can see where things are going. Where the pressure is. Without jobs or a future, what are you going to do? Just how do you survive? Maybe if I was a young guy like my son I would go to the States and take the risk. It is kind of like a prison staying here if you are a man like Octavio. So what is the difference, really? I see my grandchildren and don’t see what they will do, where they will live. Who will they marry and how will they bring up children? We can barely bring them up. … The U.S. news reviles us, makes fun of us, makes us into thieves and criminals. Who are the criminals exactly? If Mexico is a criminal state or at risk of becoming one, why sell us advanced military assault weapons at border depots? Why launder the narco money in the biggest U.S. banks? Why purchase billions of dollars’ worth of drugs?’ “
p. 107 ~ [in regard to the grandchildren mentioned above] “Both children had obvious severe developmental delays in language and skills from benign neglect. They were never abused; they had food and decent clothes, and a loving household. The energy required to read to them, talk with them, and participate in meaningful activities for their age did not exist. The time, effort and money required if they were to socialize with their peers, or take part in activities that might engage them both mentally and physically, were unavailable.”
p. 108 ~ “[Octavio] had survived the human traffickers, the desert, terrible loneliness, and extreme working conditions to send a few dollars home to his family. His hope was to someday have his own concrete-bunker-like home with a couple of rooms on the empty lot next to his parents’ house. A rogue cell had not obeyed molecular signals to stop unbridled DNA replication.”
p. 109 ~ “In a world that is increasingly stressful and less predictable, more economically challenging and politically less governable, medicine is still about looking after the individual who seeks care.
“The return to Mexico for a dying young man and his young wife was our opportunity to take the caring as far as we could. How people die and how we participate in their deaths is as much about us as about them. Our own humanity is at stake. In a society that is increasingly mesmerized by efficiency, measurement by numbers and a bottom-line mentality that extols profit and wealth over any human value, the risk is now clear to everyone I work with. When health care is now measured by a ‘medical loss ratio,’ and the percentage of spending on health care is considered a ‘loss,’ then we really are lost.”
Chapter 5 The Qualification
p. 123 ~ “A few hours later, the tox screen came back positive for alcohol, benzos, OxyContin, marijuana--and PCP. This was the sort of OD we normally see rolling in from the ghetto or with pimply teenagers from New Jersey suburbs in their parents’ black Benz SUV. Not from a guy who owned a floor in the Dakota.” [expensive apartments in NY]
Chapter 6 A Heart for Rabinal
p. 141 ~ “Her sister had been a highly trained nurse in a Guatemala City hospital and was hardwired for trauma and decision making on the fly. Like many immigrants who were lawyers, doctors, PhDs, and accountants, but here drove taxi cabs or worked in homes and back offices.”
p. 145 ~ “Clara talked openly and clearly. She had a story to tell and an audience who was not going to judge her.”
p. 152 ~ “ ‘It is not possible under any circumstances, Doctor.’ She was emphatic and clear. I heard No way. ‘There is no one who can care for the children. My parents are old and need help. My own kids are struggling and barely keep their heads above water. But even more important, I will not send them to Guatemala. There is simply no future for them there except more of what we went through. They are much better off here as orphans of the state.’ “
p. 155 ~ “ ‘I understand, Doctor. My heart is failing and there is not much time left. How much do you think?’ Time is all relative. Prediction of death in medicine is notoriously difficult. One the other hand, it would be a copout not to answer her question. She had to make arrangements. And she wanted to live. Despite the difficulties in her life, the few pleasures it had offered her, she had been happy listening to stories in the middle of the night at the laundry, seeing her sister, watching her son and daughter grow up. She was thankful for the kindnesses of people who were taking care of her.”
p. 157 ~ “I was physically in the room but mentally in another zone as Renee ran her meeting. I drifted back to my first conversation with Lenny. I was pissed off and tried not to show it. Why shouldn’t she get a heart? The undocumented could donate organs. And did at appallingly regular intervals as young, undocumented workers accepted high-risk jobs. But they couldn't receive organs, even when donors (like siblings) were ready to donate and physicians were willing to operate for free.”
p. 158 ~ “The heart for Soraya came shortly after she was accepted into a transplant program in NYC. The evaluation team at the transplant at the transplant program adopted her immediately. They fell for her graciousness, her smile, her ‘gracias a Dios.’ They fell for her life from Salama to Tapachula, the coyote transfer to a gang of human traffickers. The night laundry work and the catch in her breath several years ago. I think they fell for the fact that in her entire life she’d had only a few weeks, maybe a few months, of happiness. Sometimes one person stood for all of the others who didn’t make it.”
p. 159 ~ “We had moved heaven and earth to get her a heart so she could have some years that were joyful and lived without fear and the threat of death, rape, or harm to her children. … She would never have thought she would have any time of enjoyment in her life. She never entertained a fantasy of happiness, satisfaction, or relationships; she never thought that anything was owed her.”
Chapter 7 Four Generations
p. 168 ~ “ ‘A lot of people would choose to do nothing. It is an okay decision. Sometimes doing nothing is the harder decision to make.’ “
p. 169 ~ “ ‘But you have to operate on him, it is his only chance. He will die otherwise.’ The internists were adamant. The surgeon responded just as adamantly: ‘We operated on him for a valve infection and heart abscess and put in a brand-new plastic valve eight months ago. He chose to inject himself again and reinfect his valve. Not me, I didn’t choose to reinfect him. He will die from this surgery. That is a near certainty. I don’t want to be his undertaker. I am just a surgeon.’ “
p. 174 ~ “Were the members of this multigenerational family victims of their own irresponsible behavior, an inability to make the ‘right’ health decisions for themselves and their kids? No one forced them into White Castle or Wendy’s. No one else loaded up baskets with high-fat salty snacks in the neighborhood bodegas or carts in C Town supermarkets.
“But, I thought, that does not explain the epidemic nature of this disease. What about the trillion-dollar industry that overproduces food in gargantuan quantities and fights for every square inch of the attention of every consumer around the world? It targets young consumers using social media experts who test colors and songs and pay off sports figures and media stars to hawk their wares. There’s no gun to anyone’s head, but there is a brain trust of uber-advertisers, marketers, psychologists, sociologists, anthropologists, food scientists, and brain researchers unlocking the secrets to taste and pleasure. They study brain-based neurohormonal control and the environment to create vast demands for their products. What’s the difference between this kind of addiction and the cultivated addictions to nicotine, cocaine, crystal meth, or heroin, for that matter? This is real translational research from the National Institutes of Health bench laboratories to the corporate marketing strategies to your neighborhood food store.”
p. 178 ~ “How could I, or any doctor, treat a medical disease that was essentially a public health catastrophe? … How do we put a stop to the obesity epidemic that is killing patients globally in massive numbers? Just talk to your neighborhood pediatrician. My peds colleagues were becoming internists as obesity and its medical ‘side effects’ became ubiquitous. Obesity and its Siamese twin Type 2 diabetes were obvious correlates of calorie-dense foods, from Agent Orange-colored chips to the vast dead sea of colas. ‘Pouring rights’ put sodas within the reach of every school kid and hospital patient, all in exchange for the pathetic amount of bribe money that went to school districts and municipal budgets starved for tax dollars. These predatory practices of focused advertising consciously, purposefully, put populations at risk.”
p. 179 ~ “This experience in my office was repeated in millions of office visits by millions of patients with similar efficacy. The zero-effect dilemma. The magnitude of the obesity epidemic and the failure of medical weight reduction interventions has outsourced the ‘problem’ of dieting and weight management to the innumerable diet ‘authorities.’ It has spawned a multibillion-dollar industry that has ballooning as fast as the obesity epidemic itself. With depressing and predictable regularity, studies have replicated the irrefutable facts. Dieting has a very limited effect on weight loss that is at best moderate and transient. The traumas and stresses of everyday modern life can be assuaged by instantaneous food gratification. For anyone experiencing a bad day at the office, domestic tension, parenting challenges, and financial downturns, food is one of the sure ways we can get some relief no matter how transient. Then we push Repeat a few hours later.”
p. 187 ~ “We did the best we could with each patient in our hands. And yet I wondered what we could do to prevent our patients from getting these preventable diseases. We always said our job was not to solve world hunger, just take care of the patient in front of us. Where exactly did our responsibility start and where did it end?”
Chapter 8 The Singularity
p. 197 ~ “The line between health and illness is a thin line, very thin You never know which side of the line you will be one and when or who will be there to look after you.”
p. 221 ~ “Despite existing as long as humanity, mental illness has not escaped strong public and private censure, stigma, and shame. Psychiatry as a profession was and is seen as something less than a hard science built on biopsies, CAT scans, and blood tests. Its bible of diagnostic categories, the DSM (not going on its fifth iteration in committee), is a phenomenology of signs and symptoms bundled into disease states. It is used by insurance companies for billing purposes and as a justification for disability claims, insanity defenses, access to Social Security, longer time for SAT exams, early retirement, and World Trade Center compensation. If you don’t fit in a category, then you don’t exist as an entity. Thus the ‘fight’ to be legitimized as an illness continues in the back rooms of lobbying groups and in the psychiatrists’ committees themselves: Legitimization follows funding, and powerful players in the field control funding. It is a work in progress very much embedded in politics and payment systems.”
Chapter 10 Index of Suspicion
p. 272 ~ “Undocumented immigrants are summarily convicted of a misdemeanor and deported or spend a few months in detention. The next offense is a felony with up to twenty years in prison. As the US is facing a prison crisis domestically while state budgets reel from the loss of tax receipts from an enduring recession and it can no longer afford to keep 2.5 million under lock and key, a parallel private detention system is growing in hundreds of sites in rural America, competing for jobs and political favors, off the radar screen for most of Americans. Tough justice for complex socio economic problems that are not amenable to tough-justise solutions. Just as the War on Drugs has not solved the ‘drug problem’ and has ignited a reign of violence in our neighbors to the south. Here I was talking to one of the warriors.”
p. 273 ~ “A nurse’s aide, Sharma, came into the room. … [of the patient above] Sharma had been in exile for many years in a Nepalese transit camp for displaced Tibetans. The 1959 Chinese invasion of her Himalayan country left her an orphan. ...
“She [Sharma] trained as a midwife in the sprawling camp filled with international NGOs and through ‘fate’ was befriended by an evangelical couple visiting from Michigan. They sponsored her application for asylum and helped her settle in a community. The growing Tibetan enclave in Queens--covering more square blocks and surrounded by Indians, Pakistanis, Colombians, Peruvians--became her home. The final maneuvers of perilous journeys to the US through a hundred different back channels, each with a unique story. The trickles of people from distressed areas around the globe were a message in a bottle--wars over land, oil, diamonds, rare minerals, timber, grazing rights, religion, population explosion, water, environmental degradation, drugs, and shattering local economies. And the petty thugs like Beltran [the patient above]. He was not Pablo Escobar negotiating to pay off the sovereign debt of Colombia for immunity. I wondered if Beltran knew anything about her {Sharma] story, and what he would say if he did. A deadly contagious disease [TB] had brought us all together.”
Chapter 11 The Unloved Woman
p. 286 ~ “Alicia became a paragon of alternative treatments and Googled advice: trips to Chinatown for homeopathic cures, acupuncture, qigong to tai chi. These measures were testimony to the persistence of her symptoms and my utter inability to help her. The feeling that the medical ‘arsenal’ might be part of the problem and not part of the solution nagged at me.”
p. 289 ~ “You have to work your way backward. The patient has the symptom, say, chronic back pain. After testing you see there is no physiological there there. Everything is normal, from the point of view of the medical establishment. Some patients are reassured momentarily. The evaluation relieves them. Others bail and seek all the alternative therapies and healers. For others, it’s frustrating because we have not found the underlying problem. The pain remains unexplained. …
“There are many layers, like an archeological dig. On the top layer we have the physical complaint--say, back pain or headaches. The patient goes to the doctor and, hopefully, gets the diagnosis. Many doctors stop there after running some tests or prescribing some medication. Or they kick the ball to another specialist, For the patient, though, this label has real function. ‘I can’t go to work because I have a back spasm. I need to be alone because I have a migraine.’ The label offers legitimization; it carries rights and privileges. Others might even look after them or help them out.
“A deeper evaluation, however, reveals depression and anxiety, the most common expressions of psychic distress. This is an almost universal manifestation of dis-ease--thus the huge market in antidepressants. The fastest growing market.
“But another level down we see the effects of self-medication--alcohol abuse, drugs, and often violence in the home. This is harder to talk about, and to treat. Most doctors don’t go near this.
“The next layer down reveals a lack of love and intimacy. These go hand in hand with a lack of self-esteem, shame, and a deep sense of humiliation. Humiliation is the well that everything comes from. The anger comes from that humiliation and underlies everything else. It’s the propellant.”
Summary
Men externalize anger and turn it outward, as aggression. Homicide is the perfect expression of the humiliated disrespected male. They find it better to kill and be incarcerated than suffer the pain of shame
Women internalize their anger, not allowed to express it, turn it on themselves with depression, cutting, eating disorders, suicide attempts, and trips to the doctor.
p. 294 ~ “ ‘All my other doctors got sick of me. I could tell. They would refer me and refer me trying to get rid of me, making up some kind of excuse or other. It was a game. I would tell them a symptom I made up and the predictable referral would appear. Plus I got side effects all the time from the meds they were handing out like candy. A conjuring trick you doctors do, you know.’ I knew.
“ ‘You have not ordered anything on me in two years. Not one test, nothing. … How come? You don’t play the game, how come?’
“ ‘I don’t think you have anything worrisome. I think you are a pretty healthy woman. I am here to listen and offer something when I think I have something to offer you. I think you have suffered a lot at some point in your life. You are talking to me with your body, and listening is my treatment.’ “
Chapter 12 Collateral Damage
p. 324 ~ “We were at the end of the road now with what we as physicians could do for Abraham Ramirez. How many pints of blood had he received? One hundred? More? When was enough enough? How do you decide? Who decides?”
p. 327 ~ “I walked through the emergency room doors and reflexively tuned out the surroundings, retreating to a parallel zone to eliminate the pain, the engine noise, the insistent whine of an exhaust fan. A helicopter was coming in low for a landing at the waterside mini terminal when I switched mental channels. I hadn’t processed the day and things were hanging loose and unresolved from too many angles. How much more heartache could I absorb and not turn into a robot or a madman?”
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