Saturday, September 20, 2014

We Were Here: Remembering the North American AIDS Epidemic

 
The title of We Were Here, the 2011 documentary about the AIDS epidemic in San Francisco tells you why it was made: a nearly cataclysmic event that changed the social and cultural landscape is about to tip into the mists of barely remembered history (at least as an event that made itself felt in North America); but a cohort of men and women were there in the eye of this vortex of sickness and death, and are here to remind you. A little like “Shoah,“ the Holocaust history by Claude Lanzmann, We Were Here takes an epic historical event and recreates it from the bits and pieces of it that were experienced by individual men and women. With the exception of Shoah, it is the best piece of oral history rendered on the screen that I know of.    

A lot, let’s face it, has happened since 1981 when the epidemic first surfaced, and some people may be inclined to think of the crisis—as many did at the time—as something that affected a small, isolated cohort of the population. In this they would be missing, and misreading, quite a lot. The most acute phase of the AIDS crisis in North America (it is still very acute in the Third World) was a hinge event, with a distinct “before” and “after.” We Were Here tells a story that straddles both sides of the hinge.

It is told through the stories of five San Franciscans, four gay men and a female nurse who worked the AIDS ward in San Francisco General Hospital. They are all now in their fifties and beyond, and carry with them the weathered wisdom of survivors. And they are all distinct personalities; together they round out a portrait of a community. They are Paul Boneberg, a political activist; Daniel Goldstein, a highly accomplished artist; Ed Wolfe, a shy and awkward volunteer at the Shanti Project, which linked the sick and dying with healthcare services, their families (where it was possible) and with home and community-based services; Guy Clark, a flower salesman who for 28 years commandeered a post at a corner in the Mission District; and Eilleen Glutzer, a bedside nurse.

Each in their own way is perfect—perfectly themselves, and telling their own story their own way, a story without which the rest would not be whole. Paul arrived in San Francisco in the mid-70s, bearded and lanky-haired (“We were just crazy dreamers,” he says over a photo of himself meditating bare-footed on the beach), but later is seen in suit and tie, clean cut (in the wide-lapelled, big-haired way of the period) being interviewed on television and demanding action from the federal government. Daniel came to the City to be an artist and because, he says, “I always wanted to meet a cute, blonde surfer.” Gregarious, big-hearted and social, he is the only one of the four men who was infected; he has seen a lot of death. “None of my friends are around from the beginning,” he said. In the earliest days, before scientists or doctors even knew what they were fighting, he participated in an experimental trial of a drug (Surinam) whose side effects were so vicious it killed a number of subjects before the trial was halted; Daniel dropped out early enough to be spared. Eilleen has a clinical view of the illness (“One of the infectious disease guys said, `why don’t you put on gloves Eilleen, we don’t know what this is,’” she recalls being told when the tide of illness was just beginning to swell) but she is loveable and warm and human (“I love bedside nursing.”) And she displays a genuine fellow-feeling for her dying patients with whom she used to go clubbing and dancing. “I think a lot of us came to San Francisco because we didn’t quite fit where we were,” she said. Guy has a street-level view of the illness from the days before and the days after. Of those days before, he recalls, “If you had a bus ticket it had better be saying San Francisco, because that was the place to be.” Ed is a most inspired inclusion; shy and awkward—and yet oddly self-possessed in his awkwardness—he didn’t fit into the high-speed, fast-lane lifestyle of the period. “I was terrible at anonymous sex,” he says, rolling his eyes.

We Were Here brings the period alive, and vividly renders the social context in which thousands of young gay men descended on the Castro, as they did in gay ghettos in New York and Chicago and Los Angeles, in the 1970s, seeking “liberation” in the only way it was understood at the time—in a vigorous pursuit of sex, presumed to be without consequence. The abandon with which young men felt free to indulge this pursuit can scarcely be imagined today; in flight from homes and communities that did not sanction anything like “normal” courtship, romance, and commitment between men, what was to be expected of them when they arrived, together by the thousands, in cities of relative tolerance and told to finally be who they were? “ “You get a whole lot of young men in their twenties and early thirties together and tell them to have as much sex as they can,” Paul says. “How much sex are they are going to have?.....A lot of sex.”

(The bathhouses, treated censoriously by Randy Shilts in The Band Played On, are given a slightly softer touch here. They were not always, or only, venues for lonely, soul-less, anonymous sexual encounters, but a kind of community gathering joint. “A big group of us, all my friends, would go together,” Daniel recalls. “We called it `going to church.’….It was fun.” In time, though, the baths were closed when evidence became irrefutable that they were vectors of deadly infection. The “controversy” that surrounded the closure—some argued along what might be considered standard conservative lines that it amounted to a state intrusion into private lives; others claimed it was a threat to gay identity, perilously founded on sexual freedom—is viewed in the documentary in the context of really more ominous efforts, such as an initiative that received serious consideration to quarantine the infected.)

It was in the summer of 1981 that the Centers for Disease Control published, in its jauntily titled “Morbidity and Mortality Weekly Report,” an article describing cases of a rare lung infection, Pneumocystis carinii pneumonia, in five young, previously healthy, gay men in Los Angeles. All the men had other unusual infections as well, indicating that their immune systems were not working; two were already dead by the time the report was published. In short order, reports came in of similar cases from around the country; some of these reports included cases of a rare cancer, Kaposi’s sarcoma, believed to be primarily a disease of aging Jewish men, now
appearing among young gay men.
In the movie, Ed describes a vivid and haunting moment from that summer, stopping at a shop window on Castro Street to peruse a handmade flyer showing photos of the infection sores that covered a man’s throat and tongue. “Watch out guys, there’s something out there,” he recalls the flyer stating. His recollection is heard over a black-and-white photo of young men clustered around the flyer; it’s clear (and Shilts’ history is especially good on this point) that there had already been a mounting apprehension in the community, well before there was anything approaching a public recognition of a health hazard. (As it happens, I was travelling through San Francisco in August the year before—I was 20—taking a bus excursion across the country and staying at youth hostels along my way. At the hostel in Fort Mason on the wharf I somewhat vaguely remember asking at the desk where the Castro neighborhood was and being warned about going there; something was going around. I knew nothing about it at all; but I was in any case far too conflicted and remember strolling past Castro Street curiously, as if I was looking up the street out of the corner of my eye; it was a lazy mid-morning, mid-week, in summer—nothing to see. What, I wonder, did I expect?)

In time, pictures of San Francisco’s dead gay men would fill page after page after page of a special issue of the Bay Area Reporter. Ed Wolfe describes his first encounters with the afflicted, working with the Shanti Project. His job was to make friends, connect them to services in the community they needed, connect them to family when it was possible (“I’d rather have a dead son than a gay one,” one father told him of his vanquished child.)   

It was a kind of leveling for him, an opening for a sweet and human soul to connect to the community around him. In a statement somehow emblematic of what may have been happening between gay men throughout the city, and in stricken neighborhoods in other cities, he said, “Suddenly, my whole way of being with gay men changed.” The Shanti Project was one of the most successful of a number of efforts to deal with the widening plague. The AIDS ward in San Francisco General would be a model—the “San Francisco model,” in fact—of wrapping around the patient not just medical care but a variety of home and community-based services. Those in the know about trends in medicine and health care may know that a current buzz-phrase is “integrated care” or “collaborative care,” or alternately “the patient-centered medical home”—in any case, an endeavor to provide coordinated primary and specialty care (including mental health care). Promoted in various ways by the Affordable Care Act and seized upon by private sector insurance companies as more cost-efficient than the traditional system of ad hoc care—a doctor here for this ailment, a doctor there for that one—it seems to have passed the tipping point of a mere fad and promises something really transformative. What may not be so well known is that the specialists in AIDS care were doing collaborative, patient-centered care 30 years before anyone gave it a name.

We Were Here recreates an era some of us can remember well. For those too young to remember, this documentary may be a revelation: how far and fast things have changed in the space of a few generations, and how much the openness and opportunities enjoyed by young gay men and women is owed to the travails of an earlier generation. That may sound invidious to some, but it seems to me that whether we like it or not, this is the way
 history works—events and circumstances are born of the circumstances and events that preceded them; the “marriage equality” movement may not have achieved the successes it has, were it not for the changes the AIDS epidemic wrought, especially in the way gay men thought of themselves. The five story-tellers of We Were Here have moved on, found new partners or are otherwise living their lives in middle-age. One wonders, knowing what they endured, whether aging and all the drama the rest of us bring to merely growing old, can even touch them now. “I can begin to envision a future again,” says Daniel, whose art work can be seen in public spaces in major cities around the country. “My spirituality,” says Guy, the flower salesman, when asked what the epidemic gave to him. “It helped me find my spirit.” When the tidal wave of dying finally, in the early and mid-nineties, began to subside with the advent of the antiretroviral “cocktail” drugs, he recounts seeing again on the street one of the many—worse for wear, but now revived—who had previously been in a wheelchair, up and walking around. “He wasn’t quite what he used to be,” Guys says. And he adds, providing a kind of coda to the entire story, “But that’s okay, I’m not what I used to be either.”

Thursday, July 17, 2014

Recalling Chestnut Lodge: Seeking the Human Behind the Disease

Chestnut Lodge as it looked in its heyday. The main building burned to the ground on June 7, 2007.

Photo courtesy of Peerless Rockville.
 
By Mark Moran
(Reprinted from Psychiatric News)
 
As a resident at Chestnut Lodge in Rockville, Md., “David” was not unlike many with schizophrenia at the famed institution—his illness was chronic and longstanding, he had been treated unsuccessfully with the few medications then available for psychosis, and the Lodge was not the first institution he had been to.
   For Thomas McGlashan, M.D., the young psychiatrist assigned to him, David was a vexation and, in time, an illuminating case study. Trained at Massachusetts Mental Health Center, McGlashan was drawn to the Lodge for its emphasis on intensive psychoanalytic treatment of psychosis. “I was told `if you really want to do this kind of work with psychosis, the Lodge was the place to be,’ ” McGlashan recalled.
     So he analyzed unconscious motives and transferences and attempted to engage David in a therapeutic dialogue about his past and its relationship to his present difficulties; silence or evasion in therapy was interpreted as resistance.
   But David’s inability to engage was stubborn and began to seem less like a psychological symptom than a reflection of a neurological deficit. And his delusions were painful—for patient and therapist alike. “His voices were clearly torturing him,” McGlashan said. “After a while I started him on neuroleptics. That really made a difference—he still hallucinated, and the hallucinations were dysphoric, but they weren’t terrifying.”
   The Lodge was psychoanalytically oriented but open to experimentation, and McGlashan began to change his tactics. He let David enjoy the silence between them during therapy and instead concentrated on building the rudiments of an interpersonal relationship of the kind the patient had never had. They took walks together around the grounds of the hospital; later David earned privileges to leave for brief shopping trips in town on which McGlashan would accompany him.
   “Just being able to be with someone—a real person, not an inquiring therapist—was in itself a therapeutic goal,” McGlashan recalled. “I became essentially a companion.”
    It was a case example of how the approach to psychosis at the Lodge would change in coming years. In 1986, McGlashan hired Robert Heinssen, Ph.D., a cognitive-behavioral psychologist, as a research coordinator, and in time Heinssen would help organize an institution-wide treatment strategy for schizophrenia that combined antipsychotic medications with cognitive interventions, social skills training, psychiatric rehabilitation, and supported employment in the community.
   Today, McGlashan and Heinssen remember their experience at Chestnut Lodge as formative, laying the groundwork for an approach to schizophrenia emphasizing psychosocial and rehabilitative services to target what came to be understood as “negative symptoms”—avolition, poor cognitive function, lack of affect, and anhedonia—combined with the use of neuroleptic medication to treat positive symptoms of delusions, hallucinations, and disorganized thinking.
   Most important, the legacy of intensive, one-on-one work with patients at the Lodge would underscore the developmental nature of schizophrenia. And the rich case histories of patients who passed through the institution—nearly always revealing signs of trouble that might have been apparent very early in patients’ lives, well before the onset of acute psychosis—would inform a new movement focused on early identification and intervention in the “prodromal,” or preclinical, stage of the disorder.
    Today, both men are leaders and champions of that movement, which started in Australia and has grown to include research projects in Europe and North America that promise to dramatically alter the trajectory of schizophrenia.
   In an interview with Psychiatric News, Heinssen noted that it was another Chestnut Lodge luminary—Harry Stack Sullivan, M.D.—who very early on presaged this direction in a prescient comment in 1927. “The psychiatrist deals with too many end states and deals professionally with too few of the prepsychotic [states]…,” Sullivan wrote in The Onset of Psychosis. “With this in mind it would seem we should lay great stress on the prompt investigation of failing adjustment, rather than, as is so often the case, wait and see what happens…. I feel certain that many incipient cases might be arrested before the efficient contact with reality is completely suspended, and a long stay in institutions made necessary.”
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Anchor for JumpAnchor for JumpPhoto: picture of house.
The cottage where Frieda Fromm-Reichmann, M.D., lived still stands on the grounds of what used to be Chestnut Lodge.
Photo courtesy of Peerless Rockville
When McGlashan arrived at the Lodge in 1975, its renown had been established in part because of the work of Frieda Fromm-Reichman, M.D., a contemporary of Sigmund Freud and one of the émigré analysts who fled Europe during World War II; Fromm-Reichman was the real-life counterpart to the fictional “Dr. Fried” in I Never Promised You a Rose Garden, the best-selling autobiography by a former patient at the Lodge.
   At the time, the Lodge was a 70- to 80-bed hospital with seven inpatient units and a day hospital. McGlashan recalled that patients were routinely treated without medication (few drugs were available then for psychosis). “It was rationalized that most of the patients had been overmedicated,” he said. “Drugs were viewed as the enemy because they dulled the mind and inhibited feelings that were necessary to access in therapy.”
     But out of the experience of treating David and other patients, a pattern emerged, and McGlashan began to believe that the silences, inability to engage, and apparent lack of motivation were somehow intrinsic to the illness—rather than manifestations of “resistance” to therapy. In the 1980s he launched a long-term follow-up study of patients at the Lodge and in 1986 published a landmark paper that came to a dispiriting conclusion—roughly two-thirds of the schizophrenia patients were functioning marginally or worse at follow-up.
   Heinssen arrived at the Lodge that same year as a research coordinator; trained in cognitive-behavioral therapy, he was “an odd duck” among psychoanalysts at the Lodge, where there was little else in the way of structured therapy. Called to participate in a case conference for a patient whose family was extremely dissatisfied with the progress of treatment, he recalled that an outside consultant had recommended a more structured treatment plan built around social learning theory and a rehabilitative approach that would require the active involvement of nurses and staff as “change agents.”
    Heinssen liked the idea and suggested that a sub-unit of the hospital be dedicated as a behavioral treatment program for schizophrenia, using the consultant’s recommendations, and in 1988 the Lodge initiated a pilot program. The success of the program led the medical director—Dexter Bullard, M.D., whose family had owned the hospital since the turn of the century—to make the behavioral unit permanent, and in 1990 Heinssen was appointed director of behavioral treatment.
   The principles used in the inpatient unit were later adopted as a guiding philosophy for the institution’s approach to treating schizophrenia, and—partly owing to McGlashan’s follow-up findings—Heinssen contributed to the transformation of Chestnut Lodge in its last years of existence from a long-term residential facility devoted to psychoanalysis, to one offering a continuum of services including cognitive therapy, rehabilitation and social-skills training, partial hospitalization, and supported housing and employment in the community.
    At the same time, the seeds of a new movement aimed at early intervention and prevention of acute psychosis began to take root in Australia with the work of Patrick McGorry, M.D., who advocated staged treatment of at-risk individuals in the preclinical phase of the illness.
    It caught the attention of McGlashan who had come to the same conviction, an insight made possible by the psychoanalytic method and the highly individualized treatment approach at the Lodge. “For all of the patients who were admitted to the Lodge, there was this fantastically rich developmental data set that raised the question, `When did the disorder start?’ These records went way back [in each patient’s history] and were very detailed,” McGlashan said. “You could tell that in almost every case something started going wrong three or four years or more before the first psychotic break.”
   And when McGlashan left the Lodge in 1990 he resolved that the “prodrome”—the distinctive and lengthy risk period prior to acute psychosis—would become the focus of his work.
   Heinssen, too, shared this conviction and the imperative to begin looking “upstream” earlier in the developmental narrative of schizophrenia was brought home in a poignant dialogue with the mother of a patient who had been treated at the Lodge. Invited by a local chapter of the National Alliance for the Mentally Ill to speak about the innovations he had helped bring about at the Lodge, Heinssen recalled the conversation. “This woman’s son had `graduated’ from the behavioral program, he had started community college, he had a part-time job and was living in an apartment in the community,” Heinssen told Psychiatric News. “I’m thinking to myself, `this is a great outcome.’ But when his mother continued to speak to me, she burst out crying. She told me, `I know I should be grateful, but I can’t help thinking about what might have been.’ ”
Today, Heinssen is the National Institute of Mental Health’s science officer for the North American Prodrome Longitudinal Study, a nine-site consortium of clinical research programs dedicated to the early detection and prevention of psychotic disorders and other forms of serious mental illness. McGlashan has been a leading investigator in the ongoing Early Treatment and Intervention in Psychosis (TIPS) study in Scandinavia, and developed the Scale of Prodromal Symptoms, which is used to assess at-risk individuals for inclusion in early-intervention programs.
   The Bullard family sold the Chestnut Lodge property in the 1990s, and the hospital closed in 2001. The property changed hands several times before a developer purchased it with the intention of converting the property into condominiums; but on the morning of June 7, 2007, the main building burned to the ground under mysterious circumstances.
    Its ruins—the old cottage where Fromm-Reichman lived still stands—persist as a monument to an extraordinary and heroic effort to understand the individual behind the psychotic disorder, an individual with a history and a human story that might have taken a different turn.
“There were some phenomenal teachers and therapists there,” Heinssen said. “To the uninitiated, people with psychosis can appear alien, and it is no surprise that they get pushed away. There is something extraordinarily unsettling about interacting with someone who experiences a different reality. But at the Lodge there were many heroic doctors and nurses who sought to find the human being behind the disease. They taught me to look beyond psychotic symptoms and to connect with the real person who has a soul and value and worth.”

Thursday, February 20, 2014

Lucky you, lucky me




Today I came within a razor’s breath of having a collision with another vehicle on the road. I was at a stop sign waiting to turn right. Yes, there was some waiting involved—you know, how  wrong is it that the traffic coming from the right clears only in time for a bunch of cars to show up from the left? And you have to, you know, wait for god’s sake, for both sides to clear. It’s clearly an imposition on the way things should be. It did finally clear on the right and I was certain that just the instant before there had been no traffic from the left, so I began to pull into my turn. But just as I did so a car sped by from that direction—I would say well over the speed limit—one that must have come into range in that fractional instant I had chosen to glance at the smart phone in my lap for that text or email you sent me and which you know you would not want me to delay in seeing. It was a very close call and I think it would have been rather worse for him—the other guy—as he would have hurtled into the collision front-end first, at high speed and very possibly without a seatbelt.

A couple of weeks ago a man whom I never knew, but who was well known in his west side Cleveland neighborhood as the proprietor of one of Cleveland’s happiest casual venues, died young and suddenly, after a tumble down a flight of steps. That’s it—he fell down a flight of steps, a stairwell at the tavern he co-owned, so one that he must have climbed up and down a thousand times. Maybe the steps were wet that night. Maybe he’d had a drink or two. Maybe, for god’s sake, a shoelace was loose.(And actually someone I knew, and who knew the venue, told me those steps were treacherous.) Any way, he fell and must have fallen hard, and fallen in just such a way that his brain needed to darken the lights, permanently.

And last month, very early in the morning, a terrible fire broke out in the house where I lived. It was confined to the unit above me, where my landlady lived, but this was not a small kitchen fire gone a little out of control. The unit upstairs was largely destroyed, and I saw my landlady, whom I know and like as someone fair and friendly, carried out by firemen into the sub-zero night, unconscious and barely breathing. She survived, owing to the firemen and the EMS and the doctors and nurses at the burn unit where she was taken (in fact, she wasn’t burned, but suffered extensive smoke inhalation). But this could not have been confidently predicted when I saw her carried out in the frigid night, as my dog and I, bewildered, loitered amidst the fire trucks and cop cars and cops assembled in the street.

Though I would have to move abruptly, I do not feel in any way “traumatized” by this event, or aggrieved. (I was terrified, yes, at being woken by fire fighters pounding on my doors, storming the building, busting open locks in the house with a thunderous crash; and I was mortified at the sight of my landlady being carried out, something I will not quite forget.). The “event” itself was over rather quickly, owing again to the great skill and courage of the firefighters on the scene. And the truth is that while it was happening I never felt myself to be in personal danger.

However, I know that this could have changed quickly, and might have been—with the altering of a detail or two—a very different story. (It was the couple next door, unable to sleep, who saw the smoke coming from the second story windows and called 911.) And I have carried away from the episode a sense of something profound having passed my way—a sense of how quickly your life can change, of the hairpin turns it can take while you are, literally, asleep. And of the randomness of events. Awareness of randomness, of the absence of order in the universe, of a rational scheme to things, feels like an encompassing theme of middle age—or my middle age, at any rate. Who can fathom the meaning, an “intelligent design” behind a random tumble down a flight of stairs, the near miss at the traffic intersection, a sleepless couple who saved a life (and maybe mine) with a phone call?

In a whimsical, wise and unpretentious book written as a series of alphabetized observations, Laurie Kraus-Rosenthal, in “The Encyclopedia of an Ordinary Life,” remarks on the ordinariness of random deaths.

There are so many ways to die at any given moment. Just look, look at all those ambulances in your rearview mirror. There are crashes and wrecks and collisions galore: cars, planes, Amtraks, ferries. You could have a heart attack; it’s not unlikely. A terminal illness you didn’t even know you had could, minutes from now, live up to its defining adjective. Now turn your attention to all the freak accidents lurking in the wings. A massive store display tips over (happened). A soccer goal post unroots itself and crushes a skull (happened). Shelving holding five thousand pounds of sheet metal or lumber at Home Depot collapses (imagined). A top bunk falls onto the bottom bunk (imagined). A strong wind unhinges scaffolding and blows it directly onto a sports car; inside are—were—two twenty-year-olds out shopping (happened). Aneurisms that burst midsentence, ending the life of an advertising executive, a promising playwright, a children's book author (happened, happened, and happened)…. People are just dying everywhere, all the time, every which way. What can the rest of us do but hold on for dear life.



Indeed. Is there anything more ordinary than dying, even when it happens in ways we think are startling or extraordinary? Is it possible that the really extraordinary thing is that we survive so many moments, one after the other? And then there is this scarily reproachful poem entitled “New Year’s Eve,” by Carl Dennis:

However busy you are, you should still reserve
One evening a year for thinking about your double,
The man who took the curve on Conway Road
Too fast, given the icy patches that night,
But no faster than you did; the man whose car
When it slid through the shoulder
Happened to strike a girl walking alone
From a neighbor’s party to her parents’ farm,
While your car struck nothing more notable
Than a snowbank.

One evening for recalling how soon you transformed
Your accident into a comic tale
Told first at a body shop, for comparing
That hour of pleasure with his hour of pain
At the house of the stricken parents, and his many
Long afternoons at the Lutheran graveyard.

If nobody blames you for assuming your luck
Has something to do with your character,
Don’t blame him for assuming that his misfortune
Is somehow deserved, that justice would be undone
If his extra grief was balanced later
By a portion of extra joy.

Lucky you, whose personal faith has widened
To include an angel assigned to protect you
From the usual outcome of heedless moments.
But this evening consider the angel he lives with,
The stern enforcer who drives the sinners
Out of the Garden with a flaming sword
And locks the gate.



Lucky you, lucky me. The providence of luck, of the random, as I’ve grown aware of it has upended the shallower faith of my youth in the providence of a God who would favor me always because of my character—did you know that I’m a pretty good guy with pretty good intentions?—the faith that my good character would be a guarantor of success, an assurance that doors would open for me and lights would turn green. Never mind that, in fact, I have had a fairly blessed passage; I’ve seen enough to know it’s been a crap shoot.

A friend and an Episcopalian priest (who also by the way lived through a house fire when he was a teenager) advised me that he had long ago given up trying to “figure out” how God doles out good and bad fortune. Or why, by our lights, he does such a bad job of it. And it occurred to me later: what kind of allegiance—other than a wary, competitive, adversarial one—could such a god of obscure stratagems summon, even once you had “figured out” the strategy?

Maybe randomness itself is a gift. Because really, how much would we want a god who so intruded upon the course of things that our lives were fixed, as if we were playing craps at a table rigged in our favor to win, forever? Although it seems on the surface to be desirable, I wonder if in fact it wouldn’t come to seem oppressive and intolerable—as intolerable, come to think of it, as a life without death, without dying, in which you wake forever to days, one after the other, drained of salience and urgency. I can’t believe any longer in a God who fixes things if we say the right prayers, go to the right building on Sunday (or Saturday or Friday), but I can believe in one who suffers alongside of us in the randomness of his own creation —Emmanuelle, God-With-Us—a god who might thereby summon in return compassion, solidarity, fellow-feeling, the willingness to suffer with others. 

In the immediate aftermath of the fire, for a couple of weeks, I went about with a little buzz on, a heightened vigilance, and a keen desire to be careful—not just of dangerous things, but of people and their feelings. An instinct to be more mindful, more present. Well…..you can see how long it lasted before it gave way, at a busy intersection, to the siren call of that important text you sent me. Still, I would like to think that this instinct will stay with me, will return to me for practice from time to time.

Great poets may have a more lasting, penetrating and ecstatic sense of it, of the abyss above which we dangle by a thread. And the really enlightened—Jesus, the Bodhisattvas—may couple it with an intuition that what we call the abyss is just a velvet crease in the cupped hand of the universe, of Being itself. Being falling into Being.

Something like that. Meanwhile, the rest of us, sculling for clams in the shallow water, can hope to be a little more awake to each other every now and again, and should make do with some practical lessons--keep a working smoke alarm in your home, buy renters insurance, wear seatbelts and drive the speed limit, and put the goddamn phone away in the glove compartment when you’re driving.

Lucky you, lucky me, that we really do (as I think John Updike pointed out) survive every single moment, except for the very last one.