S is for Shamelessness (iStockPhoto)

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Trump’s signature behavior has turned every norm upside down!

We’ve known for decades that Trump is shameless, whether it was his predatory practices as a landlord, his lies about raping and groping women, or his fraudulent tax evasions; what’s different now is that he has turned shamelessness into a political superpower.

I have not read a Superman (or other superhero) Comic magazine since I was a preteen, and yet it is hard to avoid the current reality that superheroes and their super powers thrive in our social media-dominated culture, in video games, blockbuster films, and more.

I have never watched an episode of The Apprentice. I know it to have been a stage-managed version of a life lived only to acquire celebrity, wealth, and, subsequently, power. But before twice slouching his way to the White House, Trump’s contribution to TV history would have been a footnote in the dust pile of reality-TV porn. Now the show will be studied in perpetuity for any insight into the most consequential president since Lincoln—and I am not making a favorable comparison.

Perhaps The Apprentice will offer clues to Trump’s bottomless appetite for money, fame, and winning at all costs, but I think there’s more to consider. It proves that even two decades ago (and long before that, through his other business endeavors), Trump was perfecting his signature behavior: shamelessness.

My passing acquaintance with the culture of superheroes allows me to recognize a superpower and to recognize that any superpower can be used for good or for evil; some superpowers, like this one, can only be used for evil.

Hypocrisy has always been a political reality. Every politician has had to succumb to taking a hypocritical position at some point in their careers. This is usually explained away as political expediency, the equivalent of poetic license in the creative process. But excessive hypocrisy has usually been punished at the polls, as has excessive honesty. George H. W. Bush’s one-term presidency exemplifies the former; Jimmy Carter’s one-term presidency exemplifies the latter.

Since Trump burst on the scene, hypocrisy has morphed into shamelessness; it’s the superpower that has skyrocketed him twice to the pinnacle of power. His shamelessness repels criticism, blinds observers to the difference between truth, hypocrisy, and falsehood, and radiates imperviousness, a singular strength created by an impenetrable force field of progressively vicious lies. As I write this, and immediately following the worst air tragedy in the U.S. in over 20 years, the Donald is denigrating FAA employees as DEI hires with “severe intellectual and psychiatric disabilities” before the black boxes or the dead bodies have been recovered.

Shame scholars like Brené Brown believe there is a significant difference between shame and guilt. They believe guilt is adaptive and constructive, whereas shame is destructive, an emotion associated with feelings of unworthiness, in particular, unworthy of love or connection.

The Christian take on shame, most forgivingly practiced in the evangelical community, is that it is a destructive emotion and that one should not wallow in it. If one commits a sin, one should acknowledge their guilt, and through confession, or some other recommitment to their faith, be absolved of that guilt enough to move forward with their lives and their proselytizing.

A forgiving relationship between guilt and shame might be useful in the realm of wellness, religion, and self-help, but it is not a useful distinction in the realm of morality, legality, politics, or public discourse.

Public shamelessness, the ability to maintain a dishonest demeanor in the face of moral, ethical, and scientific truth seems to be captivating to people in our social media-dominated world. Shamelessness, as embodied by Trump, replaces ethics, morals, the Ten Commandments, and scientifically observable facts. It seems the ability to lie, or to absorb a lie, despite obvious truths to the contrary, is more seductive to people than love or science, because it allows some people to embrace whatever they need and to comfort themselves at any given moment. The emperor may have no clothes, but he can wrap himself in the super cape that gives him the superpower his minions are equally hungry for.

Shamelessness, as epitomized by The Donald, has turned the world of politics inside out. It has taken the art of rational questioning out of the realm of possibility. That is why no other politician (Democrat or Republican) could compete with the Donald on a stage or in a debate. That is why no news organization could fact check, criticize, or effectively present him as an uninformed, immature narcissist who is intellectually and morally unqualified to lead a country, because without shame, there is no framework to judge what is real or true. If you question his decisions, pronouncements, or actions, you will be threatened by lawsuits (as I write this, multiple media companies have negotiated, or will negotiate, settlements over Trump lawsuits largely motivated by his perception of unfavorable coverage) or violence at the hands of his shameless followers, elated by their newfound power and protection.

And with his superpower he has upended our entire legal system. He has broken the guardrails that separate legal behavior from criminal activities, that separate professional ethics from performative antics (think of the difference between Merrick Garland and Matt Gaetz or Donna Shalala and RFK Jr.), that blur our moral understanding of right from wrong, and that forgive retrospectively and preemptively the Biblical sin of lying. Trump is enabling shameless behavior to thrive, indeed, to dominate our political landscape.

The combinations of pardons and commutations of the January 6 criminals will reverberate for decades to come. The lawlessness of their behavior in general, their vandalism of the seat of our government (my government, not to put too personal a point on it), and the violent criminality that some acted out on the police was visible to us in real time and is captured in unedited videos for all time. Yet all this is unacknowledged by his followers because Trump has demagnetized their moral compasses. In his world, might is right. And without guardrails against the abuse of power, might turns out to be right enough.

As a person raised without religious prejudice, but as a person of good will, I believe that shame is the emotion we should feel to a sufficient degree to keep us from committing a sin a second time. It helps redirect our moral compass northward.

In December, conservative New York Times’ columnist Brett Stephens wrote, “Who and what is Trump? He’s a man and the symbol of a movement. The man is crass but charismatic, ignorant but intuitive, dishonest but authentic. The movement is patriotic – and angry.”

That charisma comes from shamelessness, the new superpower in public discourse; that anger leads to retribution. Again, as I write this, he is purging the Justice Department and the FBI of qualified personnel deemed insufficiently loyal to his immorality.

His Second Coming is complete, thanks to his superpower.

Footnote: I’m borrowing from William Butler Yeats’ 1919 poem, The Second Coming, which uses an apocalyptic tone to reflect on the chaos and collapse of traditional structures, post World War I.

     

Sam with Debbie and their six grandchildren

[Update from Sam] It has been three weeks, and on the subject of politics and world affairs, I have not read an article or looked at the news since the election. I have not listened to a podcast. I have not read a Substack expert. I have assiduously avoided all references to the president-elect and his transition.

Of course, I am aware of some occurrences, as it is impossible to get to the word games in the NYT without seeing some headlines. It is hard not to see some banner crawl in a train station or airport. But I have taken this time to wrestle with my thoughts, nay, with my emotions, following the failure of the Democrats to deal with a country that has always needed to be governed from the center. I have done as little as possible to engage with post-election narratives (although I have sent money to Ukraine and to the ACLU), hoping that somehow, if I waited long enough, some inspiring understanding would spontaneously come to me. No such luck.

I am embarrassed to say that my response to the election was, and to a significant degree remains, visceral and emotional.

I take this election very personally, because it is a repudiation of the values that I have tried (with imperfect results) to live my life by, both personally and professionally. Those values are honesty, decency, compassion, science, and education; obviously, this shows that I have read political lawn signs. But these were my values long before they became a bumper sticker or sign.

As a citizen, I also value trust, order, the rule of law, fairness, equality, tolerance, and professional reliability.

I also deeply value education and efforts to gain wisdom by applying education to life experience.

I grew up revering patriotism, service to country (my father, uncles, and grandfathers served with honor and distinction), selflessness, and a desire to help those less fortunate.

None of the values that I have enumerated are values that our current president-elect shares.

I know where intolerance and inequality lead. I am old enough to have worked in a massive hospital built to twice the necessary size to accommodate the South’s Jim Crow ‘separate but equal’ laws. I remember news reports of Texas schoolteachers and their students applauding the assassination of JFK.

With that in mind, what will be the long-term consequences of the lack of consequences for political violence when January 6 patriots are pardoned?

I have followed the career of Donald Trump (and other shysters) for as long as I can remember. Long before his storied descent down the golden escalator, I have taken note of his business failures with all the pleasure schadenfreude can offer. I have followed his scandals with relish; I have appreciated the fines he has paid for his racist and fraudulent business practices; and when I have dragged myself to the hospital in the middle of the night to deal with someone’s medical emergency, feeling sorry for myself and wishing that I could be compensated much more for my efforts than some insurance company was willing to pay, I consoled myself by thinking, at least I am not cheating the system like a guy like Donald Trump.

In elections past, I  have voted for both Republican and Democratic candidates, usually holding my nose over particular policies and basing my vote on the candidate who best mirrors some combination of my values and ideas.

I am comfortable discussing policy issues. Should the government be smaller? Probably. Should the government be more efficient? Yes, but what do we sacrifice? Should we have blanket tariffs? I don’t think so, but I am willing to listen to reason. Should we have more border security? Yes. Should there be more education about the benefits to the economy of immigrants, documented and undocumented? Yes. Does deregulation really increase efficiency sufficiently to justify the loss of safety that routinely ensues? No, but deregulation that retains adequate safety measures is an admirable goal. Should American medicine be shaken up? Yes, largely because privatized insurance is a moral failure and delivery of health care to low-income groups is inadequate.

But do we turn these discussions over to a man who has studiously avoided responsibility for anything and everything for his entire life?  Why did a near majority of the country give such awesome power to a man who values only those things that promote his self-promotion? How can we return to a country governed by reason and not created by a right-wing propaganda machine? A country that values the heroes of my youth.

I am quite comfortable stating that The Donald will prove to be the most consequential president of my lifetime, and I don’t mean that in a good way. In fact, I mean that in a very bad way. As a non-historian, indeed, with all the historical acumen that a retired gastroenterologist can offer, I think he might be the most consequential president since FDR. And I am distressed that I won’t live long enough to see the longterm effects of what his recklessness will cause, although some in my position are likely to say that they are glad not to live long enough to see the short-term effects that his genius for chaos will bring.

Obviously, I have a lot of work to do to soothe myself. I must get past this sense of personal repudiation. Time and distance have helped, but three weeks is not enough. I have comforted myself with friends. I hope to rebuild my damaged soul by focusing on local philanthropy. I need time to put this election into a historical perspective that makes sense to me and allows me to value myself again, recognizing that I will not be here to see its shock waves turn to ripples. I long for a world where sowing chaos, bullying behavior, speaking word salad, and behaving shamelessly are not rewarded.

I close with the memory of my father’s favorite quote from one of his favorite historical figures, Lord Melbourne (William Lamb, 2^nd Viscount Melbourne):

“Neither man nor woman can be worth anything until they have discovered that they are fools. This is the first step to becoming either estimable or agreeable; and until it be taken, there is no hope. The sooner the discovery is made the better, for there is more time and power for taking advantage of it. Sometimes the great truth is found out too late to apply to it any effectual remedy. Sometimes it is never found at all; and these form the inveterate causes of folly, self-conceit, and impertinence.”

Recognizing that I am a fool to have written this and to take the election so personally, I do not look forward to living in the shadow of the epitome of “folly, self-conceit, and impertinence.”

     

But there’s good news (at least I hope you’ll think it’s good news): I’m still writing**, over on Substack, where I publish the best-selling newsletter, [B]OLD AGE, about what it’s REALLY like to get old, from the blessings to the bullshit. I invite you to follow me to [B]OLD AGE and to subscribe!

At almost 73, I offer an insider’s perspective, or maybe I should call it beginner’s mind, because I’m frankly surprised to find myself in the land of the old. You’ve heard about the typical blessings: increased wisdom and perspective, gratitude for big and little things, more rest and ease (if you’re lucky enough to retire). And the bullshit (meaning the bad stuff): ageist stereotypes (especially for women), health issues, losing loved ones, grief.

Enter: [B]old Age

This is the quandary of [b]old age that I write about; it’s a both/and of learning to savor what’s still ahead, while also accepting, sometimes with regret, what’s behind me.

As a subscriber to [B]OLD AGE, you get:

1. Personal essays examining what it’s really like to grow [b]older. (Paid subscribers can read my most revealing essays.)
2. Q&A’s with [B]old Women about their lives and their writing. I love doing these and they are very popular with readers. (Q&As are open to all, until they are archived).
3. My answers to Ask Debbie questions such as, How will I cope if my husband dies? (For paid subscribers.)

Paywalling, or reserving some of my work for paid subscribers, is the best way for me to keep more private my essays that touch upon sensitive topics.

Learn more here. Subscribe (free or paid) here.

**Sam has surprised us with a new post.

     

In the Swiss Alps in June ’23 with Ruthie

{Update from Debbie} It’s been busy here the past few months. You heard from Sam about our trip to San Miguel de Allende in February. In March we took all our children and grandchildren to Puerta Vallarta to celebrate our 50th anniversary. In June we took our 11-year-old granddaughter Ruthie on a one-week hiking and biking trip to the Swiss Alps.

Get all the details in the wrap-up of Season 5 of my [B]OLDER podcast.

It’s been relentlessly foggy on the Maine coast. I’m pretty sure it’s our version of the extreme heat elsewhere!

     

Enjoying San Miguel’s warm weather, evening light, and rooftop restaurants in February 2023

{Update from Sam} For years Debbie has been badgering me about looking into a place in a warmer climate where we might spend some of our dotage. This is a reasonable response to, and outgrowth of, spending the first five winters in Maine following our gap year.

As the winters grew longer, the ice slicker, the snow shovel heavier, the back weaker, the knees wobblier, and the bones colder, the siren song of temperate climes called loudly to Debbie. And I admit that sometimes I found myself humming that same tune.

But I did not want to think of myself as a snowbird. I did not want to think of myself as travelling just to follow the sun or to flee from the periodic snow storm.

Palm Beach, Sedona, Palm Springs? Been there and could not get excited. Key West? Crazy enough to be very likable, but it is a small place and my sister got there first.

Before and during Covid, we have spent some time in Baja. It was nice enough. Pleasantly exotic. Plenty dusty. But awfully far for a regular commute.

Southern France? Certainly, my first choice, but again, a bit too far afield.

Condé Nast Recommends San Miguel de Allende

Rooftop view of the Parroquia, the iconic cathedral in SMA’s main square

So why not try San Miguel de Allende, about which one reads so much? Of course, it is not much different a commute than Baja, but it is well known as an affordable refuge for American retirees and my sister-in-law returned with glowing reports of an excellent experience having spent three months there during COVID. Besides, it has been judged the “best small city in the world” three years running by Condé Nast.

With that in mind and thinking that booking several weeks in such a town would either win me over or break Debbie of her obsession, we signed up with AirBnB for most of February 2023.

The first feeling that overwhelms me on arriving in a Central American or South American country is how little English is spoken, compared to Europe, and how completely adrift I feel even where a romance language is in use. I might as well be in Greece or Burma. Yes, I can puzzle my way through most signage and with a clownish use of hand gestures and a few words of Survival Spanish I can stumble through most transactions. But the regularity of misunderstanding someone based on a “false friend” mistranslation is constantly anxiety provoking.

Our rooftop terrace at sunset

I know this doesn’t reflect well on me, and I understand that when living in a continent and a half united by a single common language there is little pressure on the average worker to learn an additional one, but wouldn’t it be a good career move for people in the hospitality industry to speak English – the fallback language for so much of the rest of the world?

Are Your Ankles Strong Enough for SMA?

The second thing that struck me – like the hot kiss on the end of a wet fist – when arriving in the center of town is that the best possible career move in SMA is to practice orthopedic surgery (alternatively personal injury law – although I suspect the city is indemnified against the same). It is as if the city planners set out to create a pedestrian environment intended to cause as many broken bones as possible.

Quick photo as the local bus barrels down: note the sidewalk and the projecting lintel at head height

There is not a flat walking surface, a standard tread or rise to any step, a right angle on any curb, a true horizontal plane anywhere in the city center.  The sidewalks are too narrow to navigate in pairs. They are cracked by ‘frost heaves’ without the benefit of freezing weather. They are interrupted by stone stairs up into shop doors or down into house stoops. The streets are cobble stone. Curb cuts are engineered to slant unexpectedly and there is no attempt to blend them in with the line of the sidewalk or the line of the street.

Of course, navigating these infinite surface irregularities requires constant concentration with eyes cast down and forward, but this pose guarantees hitting one’s head on the window lintels that protrude out and over the sidewalk at the height of the average gringo’s temple or cutting one’s forehead on the awnings of the ubiquitous food trucks. In sum, the overall effect is to make the Ninja Warrior obstacle course look like child’s play.

76 Light Switches: Why AirBnB Makes You Pay For Utilities

My first impression of arriving at our AirBnB on the exquisitely picturesque Callejon Blanco (side street) was that security would be an issue. We were handed two sets of keys, each set included seven keys, for six lock worthy doors and a safe.

Afternoon light on Blanco, our little side street.

After passing through the two entrance doors (the first was a steel gate and the second a three-inch-thick mesquite door with steel reinforcement), we entered a beautiful entrance passageway that took us sixty feet off the street into what must have formerly been the courtyard, or backyard, of other homes where our rental was built as an afterthought. We stepped down into a small courtyard with two garden level bedrooms and then up to a living room, dining room, kitchen space.

One flight above that was a sunroom and sun deck with dining space and hot tub. A perfect venue for watching the sunsets for which SMA is well known. There were two and one-half bathrooms, four fountains, two light shafts, two oculi, and a dumbwaiter. Architecturally, it was a wonder with welcoming pastel pink walls, fourteen altars, a similar number of representations of Christ on a cross, dozens of unadorned crosses, and innumerable rosaries.

As two agnostics whose forebears were fallen respectively from Judaism and various forms of low-voltage Christianity, Debbie and I felt completely out of our depth. It was like living in a cathedral except we had better lighting. Indeed, there were 76 electrical switches in this living space designed for four. Mood lighting to fit every mood except the frustration of finding that flipping one switch on the garden level seemed to turn on something on the rooftop and vice versa.

The Pleasures of Daily Shopping

Working in the open air public library (very popular with the ex-pats)

Finding the larder bare (except for the requisite welcoming pitcher of Margaritas and associated plate of guacamole and chips), we plunged out to the local bodegas along Calle Insurgentes. At first a challenge, shopping for staples and sundries became my go-to happy place. The clerks and shopkeepers were unfailingly patient and polite despite the fact that their small shops with narrow aisles were crowded with elderly North Americans trying to decipher the contents of any given package of food or fluid while puzzling over where and when to submit produce to be weighed and bagged. There was none of the sighing or sucking of air that might greet a similar situation in a Parisian market. Ever.

Mercado de Artesanías

Every door along the local, commercial streets – as distinguished from the high-end tourist shops and restaurants – opened into a small (frequently tiny) shop that sold meat or produce, bread, trinkets, clothes, cell phone accoutrements, hats, metal works, hair cutting or rotisserie chickens. Every one hundred yards there was a doctor’s consultation next door to an associated pharmacy and the cycle of storefronts would repeat itself.

The woman from whom I bought rotisserie chickens sold a whole chicken with salad and tacos for 130 pesos. The size of her roaster limited her to 12 chickens per day. 1560 pesos translates to $86 US. For her sake, I hope her overhead was very low.

I never paid more than 50 pesos for some combination of broccoli, grapefruit, and limes that were the staples of my home cooked meals (dinner, breakfast, and cocktail hour respectively). And I know they were organic because I saw the broccoli being trimmed on the floor.

Finally, I cannot remember the exact price of eggs, but it wasn’t much. News about inflation for eggs has not reached SMA.

OAPs, Locals, Well-To-Do Mexicans Abound

We made a friend: Bonnie Lee Black, an American ex-pat who has retired to SMA

Clearly, one can get by on comparatively low wages in SMA, but the appeal to old age pensioners from North America has to be more than cheap produce. I suspect it is some combination of low rent and minimal heating and cooling costs that makes SMA attractive to those on a fixed income. The average daily temperature in February ranges from a low of 45 Fahrenheit to a high of 75 F. In July the numbers are 57 F to 78 F. Elimination of one’s heating oil bills and lowering one’s electrical bills looks good on a fixed budget.

Unfortunately, we did not enjoy such manageable temperature swings. The first week we were there we endured lows of 28 degrees in the morning. Central heating is unknown in SMA and the natural gas fireplaces didn’t really cut it comfort-wise, especially when admonished by the house manager to use them sparingly as they tend to “use up all the oxygen” and there were no carbon monoxide detectors. We spent most mornings in the limited winter clothes we had with us for travel.

Two special friends from Stonington, ME came to visit

Evidence that SMA has served as a haven for old age pensioners is everywhere. One cannot swing a cat on a local commercial street without hitting several northerners who look like escapees from American nursing homes, replete with compression stockings, orthopedic shoes, walking sticks, and knee braces.

But not everyone to be seen is aging in place. The streets catering to tourists are thick with well-dressed locals, Mexicans from the big cities, well- to-do Guatemalans, prosperous Yankees, and youthful backpackers. The shops are packed with high end linens, scarfs, household goods, jewels, ceramics, and home furnishings. Although not a shopper by nature, and inclined to try to dampen Debbie’s ardor in this regard, when two of our friends from Stonington arrived, I was able to enjoy their pleasure as they went from store to store picking up ideas and objects.

SMA Comes Out At 4PM

But the real persona of San Miguel does not reveal itself until about 4 PM when the atmosphere begins to change. The bustle of locals slows down, bars and restaurants reopen their doors, the mariachi bands start assembling in the central plaza, and people watching becomes the preferred activity. Well dressed locals, aspiring models with their fashionistas, and families of all backgrounds pose in the Parroquia, trying to catch the light off the church towers in the background. And these are not typical gothic towers. These start with a gothic premise but multiply in number to appear as pink candles on a pink cake.

Afternoon mariachi serenade in front of the Parroquia

The atmosphere between 4 and 7 PM in SMA is extraordinary. The temperature is sublime, the air is dry and, unless you are standing downwind of a city bus, relatively pollution free. Sunsets themselves do not compare with parts of the world with moisture or particulate matter in circulation. But the several hours before sunset have a special quality that does not seem to vary from day to day. It is a quality that says, ‘slow down’ and get ready for your first margarita while you make your way to your sunset viewing spot of choice. A charming bridge on Quebrada spans Canal Street and serves as a free, open to the public, viewing site for those who are not ready for a bar stool or who want a margarita-free atmosphere.

Sampling pulque and tequila at La Mezcaleria, one of our favorite restaurants

Margaritas are not the only way to consume tequila. As a spirit, tequila can stand on its own. One new pleasure this trip was the discovery of pulque, a low in alcohol, fermented beverage that also comes from the agave plant. Pulque has the taste and texture of coconut milk that has had the coconut flavor removed. That might not sound like much of a recommendation, but it pairs brilliantly, yet softly, with tequila or mezcal.

Sticking with the theme of responsible alcohol consumption, SMA does not have a craft brew pub within walking distance of the town center. This is definitely a strike against it as a habitable city. Or it might be a business opportunity for someone looking for a second career.

Spanish With Alma

One of the most pleasant discoveries was Spanish with Alma, a small language school on Canal Street. Originally, we planned on taking Spanish lessons with one of the bigger schools as a way of making the acquaintance of other transients.  But we found the classes at the more established institution to be full and the scheduling of private classes to be too complicated.

Debbie with Diana, at left, our wonderful teacher at “Spanish With Alma” (name of the language school)

Spanish with Alma paired us with a charming young woman, Diana, who had a good grasp of how to teach “Survival Spanish,” an excellent sense of humor, and the mien of a kindergarten teacher – which was useful given our constant bickering. I learned only one word, ‘disculpe,’ which means ‘excuse me’ or ‘forgive me,’ but that is very useful, of course. It works well to get someone’s attention while typing a real question into Google Translate or to apologize to a local when taking up space on the sidewalk during the morning rush.

One question I came away with that Diana could not answer is why the verb form for the formal you (“vous” in French) is the same as for they (“ils” ou “elles” in French) This is quite different from French and English (if I’m getting this right).

Almost fitting into the local scene

Do other romance languages do this? If younger (and I don’t mean this as an “ageist” generality – Debbie is always on my case about ageism) I would embrace any language that simplifies verb conjugations, but I simply have too much French invested in the language center of my shrinking cortex to start over. Besides, the Spanish verb ‘to be’ is so complicated that it erases any benefits from the simplification of regular verb conjugations.

Another question I have is this, does Mexico export all its garlic? Except for shrimp dishes served at Mediterranean themed high-end restaurants, I could find no suitable amounts of garlic in any restaurant meal. What gives? Apparently the first Asians forgot to bring it with them across the Bering Straits/Land Bridge 15-30,000 years ago, so I can forgive the Mayans and the Aztecs for not having it, but how about the post-colonial centuries when Europeans were plundering Mexico? Wouldn’t the incorporation of garlic into the cuisine have improved the quality of life for everyone? Just a bit? Just wondering.

We celebrated our 50th anniversary in SMA

I don’t see myself going back to SMA soon. I definitely don’t consider it my winter haven. But I would recommend it anyone as a pleasant foray into the interior of Mexico and I predict that Debbie is not done with it, with me or without me. I am going elsewhere in search of truffles and garlic.

More about San Miguel de Allende

– A recent [B]OLDER podcast episode with Bonnie Lee Black on the topic of retiring to affordable and beautiful SMA: Bonnie Lee Black on the Pros (& Very Few Cons) of Retiring to San Miguel de Allende.

– Bonnie interviewed Debbie for her WOW (wise older women) blog: Debbie Weil on Purpose.

– “Watch Your Step” with more details about SMA’s uneven sidewalks.

– Bonnie gave Sam’s book, AT PEACE, a very favorable review alongside Atul Gawande’s BEING MORTAL.

     

One of the medical take-home lessons that a long-term physician absorbs regarding disease and death is that, like the fundamental principle of entropy, on average, the most likely thing is going to happen. People are going to age, weaken, and die. The older one is, the faster the decline from weakness to death.

This is a concept that most patients don’t grasp. Most patients think that they are going to beat the odds. Most powerful, accomplished, educated patients think that they will be the exception. Unfortunately for them, exceptions are few and far between.

The Legacy of RBG

One of my granddaughters, Ruth Alice, is a great fan of the former Justice Ruth Bader Ginsburg. It is not just a shared first name. It is a common embrace of life and purpose. My granddaughter wears RBG tee shirts. She dresses up as RBG for Halloween, and RBG is her favorite topic for essays and oral presentations at school. Of course, my granddaughter views the legal icon and her legacy as a pioneer of human rights in the U.S. legal system, particularly as viewed through the lens of women’s rights. And for this inspiration to my grandchild, I thank the Justice.

But I see the legacy of RBG to be that of Amy Coney Barrett and the decades of votes that Justice Barrett will make dismantling progressive human rights accomplishments. This legacy is the result of Justice Ginsburg’s hubris.

She died at age 87 and was 82 in 2014 when Obama’s White House tried to suggest that she step down. To be fair, she almost certainly assumed that Hillary Clinton would beat Trump. But politics, unlike disease, does not follow the laws of physics and disease. She never made the critical calculation that if Trump won, she would almost certainly not survive his term or terms.

It appears she believed, at age 82, that she could beat not only colon cancer but also pancreatic cancer. That was magical thinking. It was a form of chutzpa (although I know that sounds harsh).

Did she also believe at age 82 that her mental capacity was such that she, and only she, could continue to contribute to the work of the Supreme Court, and that no younger, more energetic legal scholar was qualified to replace her? Apparently, because we have no satisfying explanations for her resistance to requests to step down.

Were her doctors unwilling to share with her the seriousness of her disease and its prognosis? Or did she not listen if they did. Did they not explain to her that her frailty, something we could all see from afar, was an additional risk factor for disease and disability? Yes, in her public outings her mentation was remarkably nimble for an octogenarian, but that is a much lower bar than what we expect of an accomplished quinquagenarian.

In my practice I had many accomplished patients that I followed for thirty years. I cannot think of one that was as mentally nimble when I retired as when I first met them.

The Compression of Morbidity

A diagram showing the compression of morbidity on page 31 in my book, AT PEACE. Courtesy of the New England Journal of Medicine.

There is a concept in gerontology called the compression of morbidity. This is the idea that as we age in the current era of modern medicine, when leading longer and healthier lives than those of the Victorian era, for example, the time between the onset of illness and the occurrence of death is foreshortened.

There is some truth to this because with the advent of modern medicine, in particular antibiotics, vaccines, and surgical advances, we are living more healthy lives during our middle years. In that sense seventy is the new fifty.

You’ve heard this from me before: seventy is the new fifty but 86 is the new 85

But the concept is also misleading, because, since 1960, our general good health (“health span”) has grown faster than our actual lives and life expectancy. In the sense of general good health, seventy is the new fifty. But in the sense of longer life expectancy, 86 is the new 85.

Illustration of why 86 is the new 85 on page 32 of AT PEACE. Sketch by my daughter, Eliza Myers MD.

Contrary to what is bandied about, we as a population are not really living longer so much as being generally healthier until illness strikes. Among responsible gerontologists, as compared with wide eyed optimists, there is the understanding that even under optimal social circumstances there is a limit to average human life expectancy, and under optimal circumstances that physiologic limit is centered – again, I emphasize, on average – around the age of 86. Some of us will beat the average, but many of us won’t, and if we elect a president at age 82, we are toying with that natural limit. We are approaching the limit of a physical fact and the edge of a political precipice.

Period Life Table from Social Security Actuaries

According to the government’s own actuarial tables, if an 82-year-old man is elected to the office of the presidency, there is a 29 percent chance he will not fulfill his term because of death. I do not know how to calculate the chance of a disqualifying disability during that same time frame, but I would guess that it is a similar figure. To be conservative, let’s cut that in half and say a disqualifying disability would affect 15 percent of people over that four-year period.

That means a roughly 45 percent chance that Biden could not finish his term if re-elected in 2024. And that is not to mention the inevitable mental decline that occurs between the ages of 82 and 86. Maybe he takes Prevagen (whose active ingredient is found in jellyfish), and who is not impressed by the mental gymnastics of the paid performers in those Prevagen commercials? Not me.

By contrast, if a 58-year-old female were to take office in 2024, one Kamala Harris for example, that person would have a 97 percent chance of surviving their first term and, similarly, a much lower chance of a disabling illness.

What Can We See When We Observe Our Current President?

Joe Biden has run for the presidency on many occasions. I met him at a soiree at my in-laws’ home during his bid in 1988 (or 1992). A much younger man, he gave a smooth stump speech (no need to attribute verbal tics to overcoming childhood stammering) and answered questions with facility. He projected knowledge and experience. In fact, he never stopped talking.

Now I see a man with a hair transplant, a Botoxed forehead, a facelift, evidence of Parkinsonian changes, a shortened stride length, diminished vigor that he tries to hide by hurrying to each and every podium, and strangled speech. I am sorry to sound petty, but it is worth calling out these attempts to project youth where it is not.  It is also worth noting these cosmetic changes because they indicate his awareness that age is working against him and his attempts to hide it.

I do not see any major decline in Biden’s mental competence, and I know that he is surrounded by a vast team of advisors and assistants so that his decisions are not made in a vacuum. So, I do not worry about that now. Those of us who lived through the Reagan years know that mild dementia need not stand in the way of a successful presidency.

But Parkinsonian changes do forecast an increased risk of dementia, an increased risk of trauma from falls, and an increased risk of aspiration pneumonia, at the very least. We don’t know what other illnesses lie beneath the surface.

I don’t know much about politics

I don’t know much about politics, but I did practice medicine for more than thirty years with a gerontologist’s eye toward the human condition.

I have also experienced enough political upheaval (the war in Vietnam, Kennedy’s assassination, MLK’s assassination, Watergate, Reagan’s attempted assassination, Clinton’s impeachment, the attempted dismantling of democracy by Trump and his Republican associates) to think that that putting forward a candidate who barely has an even chance to finish a four-year term is not a recipe for success in the election or stability in office.

Joe Biden can project empathy and democratic values with the best of us, but he can no longer project personal power and mental flexibility. As he physically declines over the next few years, that problem will worsen.

Presidential Fever

Joe Biden has been a good public servant, overall. He has served the country for over 50 years, although, like all successful politicians, he has been handsomely rewarded for that “service” in terms of power, prestige, perks, and profit. I do not begrudge him that, but like most successful politicians (and most Supreme Court Justices) he seems disinclined to give it up. I do worry about that.

With his political and emotional stability, Vice-President Biden was the right person to stand up to Donald Trump. But at age 82, with visible evidence of a neuro-degenerative disorder, he is not the right candidate to stand up to any Republican opponent, even Trump at age 78 (minimum chance of death greater than 22 percent between 2024 and 2028 – more the pity, though I try not to wish harm on anyone.)

It has been said that the only cure for Presidential Fever is embalming fluid, but let’s not nominate someone where that treatment is so likely to be infused.

Perhaps the legacy of RBG will be that Biden sees the light and steps aside. I hope so.

AT PEACE: Choosing a Good Death After a Long Life by Samuel Harrington, MD (Grand Central Publishing, 2018)

     

I am embarrassed to say that it was the most exciting week of my life since turning sixteen and losing my virginity – an experience that did not last a week, I can assure you of that!

I doubt that I will embark on a moose hunting trip again for a couple of reasons. The chance of winning another moose lottery permit before physical infirmity takes hold of me is nil.

Besides, I wouldn’t want to “hunt” without the best possible companion, in this case, my best friend from childhood.  Finally, although all hunting trips have their special rewards, moose hunting, as you will glean from my subsequent descriptions, is constantly engaging. I recommend it to anyone without a moral opposition to hunting and with an interest in seeing the world through a new lens.

Trigger Alert

Pictures and descriptions await you. If you don’t want to read about hunting, stop here.

And let me address any sensitivity about hunting at the outset. If you don’t want to read about hunting, please stop here. This is not a forum to discuss the morality of responsible hunting as exercised by me, my friends, and responsible guides. No one who has leather products, eats meat, or uses cosmetics with ingredients sourced from animals has any foundation for criticizing others for their choice of harvesting sustenance. If you don’t source any form of sustenance from animals, I applaud you for that lifestyle choice.

On another note, anyone who is unwilling to explore the world of outdoor sporting life is contributing to the widening gap in our society defined broadly by conservatives (who make up most of the outdoor sports aficionados) and liberals (who don’t); or by the well-to-do who can afford to buy meat versus the rural poor who cannot.  Finally, everyone must keep in mind that responsible and regulated hunting allows the state to study animal populations for better wildlife management control. *

Now, a second aside. Although some descriptions of the conditions of our hunting camp might be off-putting, that might be because I am not well versed in camping techniques, and it is hard to maintain hospital standards of personal hygiene when dealing with twenty disparate individuals living outdoors without electricity or running water. I want to emphasize that our guides were consummate professionals, devoted to their craft and dedicated to responsibly harvesting animals. I would recommend them, without equivocation, to anyone interested in a successful hunt.

But, back to the excitement.

Stumbling into the world of sport hunting

I am not a hunter or outdoorsman by nature. I enjoy my creature comforts. As a physician, I can get up in the middle of the night and go to work, but I prefer to sleep long and sleep well. I get no thrill from the anticipation of killing an animal. I do not look forward to challenging myself physically. I exercise only to slow the decline of aging. When it comes to embracing progress, I am generally lazy. I avoid change. I rail against technology. I work modestly to maintain the status quo of my life and I only tolerate change that I cannot avoid. I do not want to be bullied into the future.

These descriptors do not apply to my friend of 57 years and my boarding school and college roommate. David is a ball of energy with a restless mind. He likes to push the envelope of gentlemanly pursuits like organic gardening, gourmet cooking, sport fishing, hunting, land conservation, wood working, boat building, boating, golf, tennis, and community service. He embraces new technologies at every opportunity to enhance these endeavors. Give me a compass, a map, and leather hunting boots. David prefers a satellite phone with GPS coordinates, topographic imagery, and technical gear.

Ten years ago, when I moved to Maine, I looked forward to seeing him more frequently. I did not foresee the slippery slope he would set me on when he admonished, “Sammy, you have to take the Maine gun safety course. We need to do some deer hunting.”

The hunting course was a ten-week lecture series, every Monday evening, in the auditorium of the Maine Maritime Academy in Castine. It ended with a practical demonstration of safe gun handling, a written exam, and an oral exam focused on the safety equipment required by responsible outdoorsmen and women.

 The course was a pleasant undertaking during the first autumn of my newly-retired-physician status. Surrounded by gung-ho students, it was an enjoyable diversion for the lengthening evenings. I appreciated the lessons on ethics and fair hunt practices by senior Maine Guides. I enjoyed the quiet of the hour-long commute from Stonington. But, as a non-gun owner, I saw little practical use for my new knowledge.

David handled that by increasing his arsenal with the purchase of a Thompson Center rifle with interchangeable barrels for small and medium size game and a 7mm Remington Magnum for my use with our moose hunting partnership in mind.

PETA as our sponsor?

Our deer hunting started modestly enough. For the first three years, hunting through the woods in parts of Maine and New Hampshire, we did not see a deer. We finally settled on hunting on David’s large property, effectively his back yard, in exurban Maine. We knew he had plenty of deer on his property, although we almost always saw them before or after “shooting time” – a time that is specific to the minute for a given day, in a given location,  when there is enough light to responsibly sight in an animal. It proves to be, roughly, 6:30 AM to 4:15 PM in November.

PETA would have been happy to be our sponsor. For the first five years of hunting companionship, we did not fire a shot except to sight in our rifles. We simply complained about the other person making too much noise, or engaging in too much wiggling, to attract an animal while sitting in a blind, or snapping too many twigs while walking through the woods.

With time, and without my help, David learned more about the movement of turkeys and deer around his property. With the help of friends and neighbors, he was able to site his hunting blinds in the most advantageous spots. Now he was taking game quite regularly and, ultimately, I joined in. My biannual trips to join him for Spring Turkey or Fall Turkey season were great. My annual trip to join him for deer season in November was always exciting. In year six of my journey as a hunter, I shot my first turkey. In year eight, my first and only deer.

I have written, before, about how hunting places one at the heart of nature and its beauty. Nature is more acutely appreciated by those who are actively and purposefully analyzing its changing face, whether they are foraging for animals, vegetation, or photographs. I will add that David’s encouragement opened new doors in bonding and friendship. Quiet hours in a hunting blind will bore some but are savored by others. Teamwork is involved in maintaining hunting sites and settling into tree blinds.

The Maine Moose Lottery

I will not bore you with details about the Maine moose lottery. It is a big money maker for the Maine government and the odds are slim that any single person will win in any given year (2,000 to 4,000 permits for 70,000 applicants). People go for decades without winning. Suffice it to say that I never thought that I would win. And then I did. David (listed as my sub-permittee) was ecstatic!

We basked in our glory for several weeks. Residents of Maine wait for the lottery results and peruse them like a racing form or gossip column.  Acquaintances in town came up to me and congratulated me on my status as a permitee, uniformly with envy. But David and I postponed making plans.

We did not fully understand that there are two kinds of moose hunters. There are those who know exactly how they plan to get a nine-hundred-pound animal out of the north woods (think a mile or two off the nearest dirt road and sixty miles from cell service) and those who want to think about it. Those who know what they are doing have a pick-up truck equipped with winches, hundreds of yards of rope, block and tackle equipment, a flatbed trailer, a friend with experience as a butcher, and a refrigerator truck at hand. Those who don’t should hire a guide.

While David and I struggled with the logistics of the do-it-yourself approach (what could go wrong with two seventy-year-old men and 900 pounds of flesh miles from civilization?), we lost precious time hiring a guide. Within days, all the good guides were booked, and we spent several weeks trying to get on a waitlist for one.

Ultimately a slot opened up with a reputable group and we were on our way.

Although most guides work with lodge owners and offer cabins or buildings, our guiding company had a “camp.” This camp, a small clearing, was licensed from a private logging company, that owned more than 3.5 million acres of land overlapping the wildlife management district where my permit applied. The camp was advertised to consist of six walled tents for twelve “sports” (aka hunters), a cooking tent, a shower tent, and a loo.

Moose permits apply for one of three discrete weeks in the Fall from shooting time on Monday morning to the end of shooting on the next Saturday night. There is no hunting on Sunday in Maine. Permittees are expected to arrive on Sunday afternoon or evening. To ease our way into the wilderness, David and I drove to Presque Isle, ME on Saturday to spend one last  night in civilization at the state’s northern-most Hampton Inn before driving 90 miles west (including 60 miles on dirt roads) into the woods.

On Sunday morning in Presque Isle, we woke to a light snow and significantly colder weather than predicted. Anxiety mounted as I reviewed the layers of clothing that I had packed. One of the unfortunate hallmarks of life in rural Maine, but a Godsend on this morning, is that you can count on finding a Walmart open at 8 AM on any given Sunday. In this case it was just a short walk across a wide street from our Hampton Inn. We found the hunting aisles crowded with other anxious permit-holders looking for extra thermal layers before heading into the wild. I found an amazing camo belt which I continue to wear as a trophy of surviving my first Walmart adventure.

Compared to the small size of most New England states, northern Maine is its own beautiful country. It is on approximately the same latitude as Quebec City. The eastern half of the northern expanse is devoted to potato farming. The western half is devoted to logging. Although, from a distance, the logging forests look untouched, they are crisscrossed with dirt roads. Some of the roads are almost two lanes wide and have names. Most of them are one lane and in progressive stages of being overgrown with grasses and alders. There are also vast “cuts” – areas that have been denuded of pines that are lying fallow pending the planting of new firs or spruce.

Looking across this vast landscape from any elevated vantage point is inspiring, especially while fall color still holds sway. Driving into this landscape for the first time is exhilarating in a “Heart of Darkness” sort of way.

Turning a city slicker into an outdoorsman

Our campsite

We arrived at our campsite in the midafternoon, one mile off a main road and two hundred yards down a rutted path with branches scraping both sides of the truck. We were the third pair of twelve “sports” to arrive that day. We were introduced to our guide, a 23-year-old electrician from Rhode Island, and subsequently to our tent, its woodstove, the woodpile, the loo, the guides’ tents, and the cook tent. The guides’ tents were at some distance from the hunters, presumably so that they could discuss plans without our input.

Soon we were introduced to the cook, a thirty-something, licensed clinical social worker who told us she found camping (in her case, getting up at 3:30 AM to prepare breakfast sandwiches and coffee for 18 other souls – twelve hunters and six guides – and getting to bed after some clean up, sometime south of 9 PM) to be therapeutic. With ice chest refrigeration, no running water, a grill, and a griddle, her repertoire was understandably limited. Much of it was meat. Much of that proved to be grouse breast* or moose heart,* a delicacy that I struggled to appreciate. Moose heart has the eye appeal of escargot and the texture and taste of boiled hockey puck.

The week before ours, the tent was occupied by bird hunters and their dogs. We swept aside their dirt and dog hairs. There was no place to unpack. We stowed our belongings under our cots. We reorganized our daypacks and fortified our sleeping bags with frost and snow in the forecast. We stoked our fire. We took a walk in the fading light and assembled for supper at 6 PM.

At supper we exchanged names with the other hunters. Two of the pairs were married couples. We discussed the organization of the camp. We learned the two inflexible rules of camp culture that could get one ejected from the group: first, no loaded weapons in camp and second, no mention of politics.  We choked down the evening equivalent of a breakfast sandwich and, watching our breath congeal, we went to bed under a full moon.

Our tent

Six tents cheek by jowl with each other added an unexpected auditory component to the evening’s overall sensory experience. There was surround-a-sound snoring. There were rhythmic sleeping bag adjustments. Wood stove doors creaked and clanged as wood was added throughout the night. We heard every tent zipper rise and fall as our companions stepped out to void and then returned to their groaning cots.

The next morning, after fitfully sleeping with the wild temperature extremes that an unregulatable wood stove guarantees, we rose at 4 AM for breakfast and a 5 AM drive to a site, about an hour away, where our guide’s drone had spotted a large bull the day before. We parked at the end of a rutted and overgrown track and, at 6:30, when there was enough daylight to both take a responsible shot and to satisfy the “shooting time” regulations, we hiked through glades of alder into a small clearing.

On the opposite side, amid some thick undergrowth, a medium-sized bull reared his head, waved his paddles (antlers), and analyzed our silhouettes. Our guide put his hand on my arm saying it was too early in the week to settle for such a small trophy and, with a sigh of relief because I could not see the animal’s heart/lung target area through the brush, we let this one slip away. The animal was left to wonder if we were a female moose worth pursuing or another bull encroaching on his territory.

We spent the rest of the morning hiking several miles through the dense woods, over deadfall, through streams, under leaners, between dense alders, around ponds, and through creeks hoping to engage another moose in conversation and thanking the Lord at every turn that we had not slipped and broken an ankle on a moist rock or tree trunk, or lost an eye to a spring-loaded branch. We returned to camp at midday for a sandwich and a rest.

Moose hunting 101

For the uninitiated, moose, like deer, rest most of the day and graze most of the night. The best chance to catch them up and about is early in the morning or late in the afternoon. Without snow or mud to help track them to their wallows, there is little point punishing oneself in the woods at midday. Unlike deer, moose have very bad eyesight. They have exceptional hearing and smell, however. Whereas deer run from noise, during the rut the male moose respond to the noise of branches breaking and leaves rustling by approaching the noise in pursuit of a cow in heat or to defend its territory from a trespassing bull.

This is where moose calling comes into play. Using the scapula bone of  a moose or a dairy cow, a good guide simulates the noise of a moose walking (sometimes crashing) through the woods. They also simulate a bull call that translates loosely as, “Come challenge me,” and a plaintive cow call which has a “come hither” quality.

A tired bull will not respond to an aggressive bull call. A spent bull might not respond to a cow call. Every bull will avoid a human scent, a human voice, or a mechanical noise like a car door slamming.

That afternoon we returned to the woods for more hiking. At sunset we drove back to camp for dinner, a beer, some stories, and an early bedtime. The older pair of brothers from New York had “tagged out” (gotten their moose) that afternoon and we watched as they stripped their animal’s skull and antlers of flesh, preparing their trophy for a “European” mount – familiar to us as the typical naked skull and longhorns of a steer seen over the gate to a Texas ranch.

The next day we resumed our cat-and-moose hiking and calling in the morning and the afternoon. Although we made voice contact with an animal every day, we did not see another bull until Friday evening. But the pace of camp life, the excitement of connecting with an animal, the stories of the pairs of hunters who tagged out on Tuesday and Thursday, and the changing weather, kept us fully engaged. This is not to mention the restless anticipation – and I don’t mean this in a good way – of the next meal of coagulated griddle fare* or of the related concern that one’s bowels might permanently lock up or, alternatively, explode.

A gastroenterologist explores the world of north woods sanitation

Of course, no narration of mine, as a gastroenterologist with a comfortable familiarity about intestinal activity and yet a respect for hygiene, would be complete without a discussion of bodily functions, so let me describe the public health and sanitation measures practiced in the north woods. There were virtually none. There was truly a Middle Ages quality to camp life with dogs circulating around the central wood pile which anchored our tent quadrangle and defecating on our stoops, moose skulls in various stages of preparation at the door to the successful hunters’ tents, the New Yorkers butchering their animal on the tailgate of their pickup, and the “wash station” (a large container of cold spring water and a soap dispenser) inches from the trash station and the sandwich preparation station.

The privy was a boxlike, plywood throne in an old hunting blind. Suspended below the opening of the “one-holer” was a contractor’s trash bag – the thickest plastic bag one can obtain for a 55-gallon drum and a bag that is destined to survive millennia. The “flush” consisted of a trowel full of lye. The “sink” was a combination of baby wipes and hand sanitizer.

Exactly what the plan was to dispense of this contractor’s bag at the end of our stay captivated my thoughts.  How would they maintain its integrity until that plan could be exercised?  But how best otherwise to deal with three weeks of accumulated fecal matter and lye from the innards of 20 people is a conundrum. My own attitude is that with three and a half million acres of wilderness to deal with the waste of a few humans for a few weeks a year, a “carry in/carry out” approach is unnecessarily impractical. Besides, a contractor’s plastic trash bag that will never disintegrate but might fill with fermented gas and explode is not the definition of “leave no trace.”

The cooking tent

Indeed, the combination of a fiber free diet and a revolting latrine played enough tricks on the autonomic nervous system of the most avid camper to disrupt one’s daily regularity. It put me in mind of Cromwell’s admonitions to his soldiers to, “Work hard, trust in God, and keep your bowels open!”  Locked bowels can be more debilitating for a soldier than diarrhea – true too for a novice hunter.

To our guides’ credit, Tuesday and Thursday were shower day. Pulling this off was no mean feat. Large containers of water were filled from a nearby spring and brought back to camp in a pickup truck. A hose was fed from these containers through a pump that was energized by a generator, via a propane camp water heater, and into the shower tent. All of this was held together by duct tape and illuminated by a head lamp.

The women were offered a bit more time and a bit more privacy, but because the water could not be turned off between bathers – for fear of disrupting one of the tenuous components of this Rube Goldberg apparatus or running out of water – each of the men had to stand in line in the mud and cold, draped in their towels, awaiting their allotted few minutes in the shower, and then we had to sprint many yards to our tents to dry off. It was an invigorating experience.

So, enough with the digressions, back to the actual matter at hand, hunting.

Moose hunting as narrative

One of the sports was Joan, a 50ish year-old woman with a corporate job, an engaging personality, and a phlegmatic but hilariously on-point boyfriend. She always wore a string of pearls. On Wednesday, she engaged in, and subsequently described the quintessential moose hunt. It went like this.

Their guide heard a moose respond to the guide’s thrashing of brush, simulating a bull moving through the forest. When they ascertained the direction from which their prey was approaching, they moved further down wind and started calling. First a bull call, then a cow call. After nearly twenty minutes, the bull appeared about thirty yards away and thrashed the alders with his paddles, trying to make an intimidating sound and trying to decipher if he was facing a bull he had to fight or a cow he had to seduce. At that point, he moved into a broadside position and Joan felled him with a single shot.

From a hunting perspective, our activities and the weather on Tuesday and Wednesday and Thursday were like Monday. The weather changed on Thursday evening with the development of wind and rain. The latter made for a swamp in the cooking tent and the former meant there was no point in hiking through the woods. Swirling winds meant that the moose could smell us and hunker down or evade us before we could engage them. So, we spent Friday in the truck looking for moose across large open spaces. The shrubs and early growth in the cuts along the road serving as delicious moose buffets. It was a long day driving from area to another.

Early in the afternoon, we saw two cows cross the road ahead of us. We waited for a bull who might be following them. Nothing. We circled back and waited again. Nothing.

As the light faded and feeling as if our chances for a trophy were dwindling rapidly to the last day, Saturday, our guide turned the truck toward camp. Still an hour away, riding shotgun, I saw a cow at about one hundred and fifty yards, up a slope, on the driver’s side of the road. David saw a small bull appear behind her exiting from a copse of alders. The guide stopped the truck. “Get out, get loaded, don’t shoot the cow,” he hissed.

David and I got out and walked quietly to the driver’s side. The cow moved a step or two ahead. With the scope I could see the bull’s small rack. “The cow is in the lead,” confirmed the guide with his binoculars. “Take him,” he directed with respect to the bull. I dropped him with the first shot. David and I scrambled one hundred yards up the hill and each put a bullet into the chest.

Our chests were pounding with excitement and exertion. The light was fading. The temperature was falling. We felt exhilarated! The work was about to begin.

With a satellite GPS phone our guide texted our location to camp and within an hour a combination of nine guides and our companion hunters arrived at our location and made their way uphill with backpack frames, meat bags, knives, and a chain saw.

There are two ways to get a moose out of the woods. One way is to gut it (field dress it) and haul it out with ropes and pulleys in one piece. Another is to quarter it (cut it into manageable pieces) and carry it out piecemeal. Because we were within two hundred yards of the road, either option was available to us, but our team’s modus operandi was to quarter the animals and that is what they did here.

I stood aside as the more experienced hunters skinned, quartered, and bagged the meat. I reviewed and relived the details of the hunt with our be-pearled campmate. One guide chain-sawed a path through the deadfall so that we could carry our loads, now attached to frame packs, downhill more safely. When we got back to camp the guides iced the meat down. We ate, drank, and repaired to our cots. It would be another 4 am alarm so that we could drive back to Ashland to register the moose and keep an 8 am rendezvous with the butcher who would refrigerate the meat and prepare it for pickup later that week outside of Portland.

After returning to camp, we spent the rest of the day in and out of the truck. David hunted grouse, but my blood lust was sated, and I was happy to simply wind down.

Sunday, two old, old friends drove back home. A long, quiet drive through a large, beautiful state.

A different world with a lot to offer

Putting myself in this totally new world of hunting and camping was a personal challenge. For this, I thank my friend, David. The fact we survived without injury offered enough excitement to have justified the experience and the expense. But after the emotional and physical investment of six days in the woods, getting a moose was truly a highlight reel moment.

The sports with whom we shared the week were from various backgrounds. Two were blue collar workers in their early twenties. Half-brothers, they loved hunting and had no other family responsibilities. Two others were also brothers, retired, small business owners from New York. Four were corporate types who enjoyed the big game hunting mystique. Two of them were also friends from high school. The final pair was a physician’s assistant who enjoyed bird hunting with his wife and their dogs.

Our guides were a mixture of construction managers, blue collar workers, and firemen/EMTs whose vocation supplied the steady income but whose passion was clearly to be out in the woods, hunting and fishing. Their professionalism came through in many ways. They worked late into the nights to pack and protect the meat and trophies. They worked together to help each team with its animal. They spent their off hours scouring the roads and flying drones to spot potential game animals.

Although I do not foresee any more big-game hunting trips in my future, I am thankful that I won this lottery. Who knew what it truly entailed? Who knew that I could do it? I wear my camo belt with pride. I feel like Teddy Roosevelt.

Afterword

*Maine moose are suffering from a serious tick infestation caused by winter ticks, also known as moose ticks. These parasites are enjoying a population explosion as the result of a warming climate. They hunt in packs and can infest a moose with up to 50,000 to 90,000 ticks. Two manifestations of the disease process influence the moose population and have resulted in the deaths of 90 percent of calves born in certain areas. Calves suffer from infestations before their coats are mature. When calves scrape their hides against trees to rub off the ticks, they denude their own skin. These bare patches of skin do not regrow, and the affected calves freeze to death during the winter. Other moose, suffering from massive infestations, become weak from anemia, making them susceptible to predation, infertility, and illness. Curiously, no ticks were obvious on our bull. In recent years, Maine officials have been issuing many more permits in Wildlife Management Zone 4, the zone with the largest moose population, to study how decreasing the density of the animals might decrease tick transmission.

*To be fair, the food could have been perfectly edible and, I am advised, under the circumstances comparatively good. However, it was the custom for the group to wait until all the pairs of hunters reported back to camp before starting the evening meal. We had one pair of sports who insisted on driving nearly two hours away to further isolate themselves and by the time they returned, two hours after sunset, much of the dinner was predictably cold.

Recipes:

Grouse breast appetizer: slice the grouse breast into bite size pieces; dip in milk and roll in a bag of crushed Cheetos; sauté on the grill; salt and pepper to taste.

“What is the difference between a grouse and a partridge,” I hear you ask? According to a Down east acquaintance of David (insert Down east accent here), “You shoot a grouse on the ground and a partridge in the air.” Translation: practically speaking, grouse are shot for food when you see them and need sustenance; partridge are shot for sport, after being flushed by dogs. Same bird, different approach.

Moose heart: Brine for 24 hours; open the chambers and remove the valves and lining; slice into ¼” slices; season with salt and pepper; Sauté in butter.

P.S. I have recovered from Long Covid

Long Covid lasted about eight weeks for me. I’m pretty much back to normal at this point. Thanks for your comments and support.

     

Sam enjoying Iceland.

{Update from Sam} When I went into the practice of gastroenterology and internal medicine 40 years ago, I was excited about being the new kid on the block. I was well trained in the most up-to-date treatments and endoscopic techniques. I was looking forward to a busy career.

New techniques were on the horizon. I was excited about preventing colon cancer, inserting balloons into the stomach to promote weight loss, altering pressure in the lower esophagus to cure reflux, and more.

The occasional patient with a bleeding ulcer or a common bile duct stone was the reason to go to the office every day but more mundane problems represented the bread and butter of my work. A large subset of patients in any general GI practice has some variation on irritable bowel syndrome (IBS – a non-progressive disorder of abdominal symptoms with varying degrees of cramping aches and pains and waves of diarrhea or constipation) and sorting through their symptoms was an interesting challenge with a pleasant reward if the symptoms could be improved with simple dietary measures and life-style changes.

Gastroenterology and Chronic Somatic Complaints

A less frequent, but all too often, challenge was the patient with IBS that overlapped with another chronic, somatic symptom such as chronic fatigue. These patients represented an emotional drain for me and many other physicians. Intellectually, I knew there was nothing that I could do for them with routine diets, medical treatments, or scopes. Medical school had not prepared me for them; in fact my medical education and training was largely dismissive of somatic pain syndromes.

At the time, the mid-to-late 70s, these patients were thought to have a largely psychiatric disorder tinged with a hint of a malingerer. These were patients with unquantifiable symptoms and undefinable problems, who usually had a history of failed treatments and complications with standard Western medical practices and a broader history of dabbling in alternative medical practices. To top it off, they appeared helpless and depressed. Or am I projecting?

The recognition of fibromyalgia as a diagnostic entity, but without known cause, was published in a major academic journal in 1987. The connection between Epstein-Barr virus and chronic fatigue was defined by the CDC in 1988. The recognition of Lyme Disease as associated with multiple inexplicable manifestations (including chronic fatigue, fibromyalgia and other idiopathic pain syndromes) came in 1991 when the CDC began a national surveillance program.

Heretofore, those associations were being made by a few responsible physicians and a large group of fringe physicians marketing wildly disparate treatment regimens based on pseudoscientific theories and occasional bio-plausibility. Even in retrospect, recognizing that some of these fringe players were on the right track, most were charlatans.

But a young, energetic physician, interested in scoping patients from top to bottom, had no extra time for studying these infectious disease issues, for sifting through the reams of medical records these patients had acquired, or for the compassion and emotional support these so-called malingerers needed.

Seabiscuit Opened My Eyes

(At that point) I began to change my perspective on the mystery of chronic illnesses caused by infectious diseases.

My perspective began to change when I read Seabiscuit: An American Legend by Laura Hillenbrand, published in 1999.  The book is a masterpiece of writing and storytelling but what caught my attention was that Ms. Hillenbrand suffered from chronic fatigue syndrome and lived a stone’s throw from my office. How could someone, effectively a neighbor, suffer from this malingerer’s syndrome and create such a compelling work?

Somehow, without the benefit of meeting her, but knowing that a gifted author was living a life trapped by inexplicable fatigue, her story resonated with me and I began to change my perspective on the mystery of chronic illnesses caused by infectious diseases.

Fast forward to the final years of my practice. I was no saint, but I was much more sympathetic to the mysteries of chronic fatigue and chronic pain syndromes. As one of my mentors, Jim Kane, a Washington DC infectious disease specialist and a middle-of-the-road practitioner when it came to diagnosing and treating chronic Lyme disease, said, “Sam, the practice of medicine is humbling.” I generally found more time for my IBS patients, especially when they overlapped with chronic fatigue symptoms.

Now, nine years into retirement, it appears that I must have developed some empathy too, because two years ago, when COVID 19 first rolled across the country, my greatest fear was the possibility of “long COVID.” It didn’t much weigh on me that I might die from it (although I knew intellectually that was a possibility) and I assumed that I would eventually get it, but my real fear was developing a prolonged case of inexplicable symptoms, which at my semi-advanced age would be life changing, in the sense that any new major problem would define the last chapters of my life.

And then I returned from Iceland.

In Which I Contract Viking COVID

In early July of this summer Debbie and I took two grandchildren, curiously compatible cousins, on a Backroads adventure around the south coast of Iceland. It was challenging in a variety of ways but wonderful until five hours after touching down in Boston on our return when suddenly I noted that I had a sore throat. Remembering that one of our guides had dropped out of the trip after testing positive for COVID, but reassuring myself that I had had no close contact with him, I antigen tested myself and, you guessed it, I was positive.

Hoping to recreate Debbie’s good experience with Paxlovid (she took it starting on Day 1 of testing positive for COVID and tested negative on Day 6 feeling completely well), I started the medication the next day and isolated for five days with mild symptoms of fatiguability, congestion, a scratchy throat and some COVID brain (in my case fogginess and distractibility). I tested negative on day nine and ten and happily reemerged into society.

Then on day 11 some throat symptoms returned and I tested positive again. I remained positive (and isolated) until day 17 when I finally tested negative. Feeling well enough to exercise, I started trying to recapture my former self.

Day 20 started out uneventfully. I felt fine. I went for a morning bike ride, did some work, had a meeting with town elders, went to an early theater performance with friends – despite feeling exhausted – and went to bed after a late dinner.

At 2:00 AM, as is my practice, I took a middle of the night trip to the toilet (if you are 70-year-old man with a prostate, you know the drill) and sometime later I found myself on the floor in front of my bureau. Clearly, I was not thinking clearly, and I crawled into bed where I slept fitfully while asking myself intermittently, “Why does my shoulder hurt?” “Why does my neck hurt?” “Why does my face hurt?” I woke in the morning to find my face covered in bloody abrasions and my neck and shoulder creaking.

Ever the diagnostician, I performed a neurologic self-exam ruling out a brain tumor and discounting a seizure (despite finding a lacerated tongue).

In retrospect, it was clear that I had passed out and had tried to break the bureau with my face before settling onto the floor to recover. Ever the diagnostician, I performed a neurologic self-exam ruling out a brain tumor and discounting a seizure (despite finding a lacerated tongue). I settled on the most likely possibility of having suffered from post-micturition vasovagal syncope (translation = fainting after taking a pee). I suspect that the confusion I suffered was related to a mild concussion.

After crawling around the upstairs to retrieve my blood pressure cuff, I quickly established that my blood pressure collapsed when I stood up, supporting my diagnosis of postural hypotension, aka orthostatic hypotension, which threatened to deprive my brain of oxygen, yet again. So, I hydrated and rested and eventually my BP stabilized.

It was at this point that I woke Debbie, dressed my abrasions, and declined to spend the day in the ER. Debbie is a very good sleeper so she hadn’t heard the middle-of-the-night thump but she gets quite excited about issues related to my health, so I felt it best not to involve her until I had a good working diagnosis.

Later that morning, and on each of the subsequent mornings, I established that when I had a full bladder my blood pressure was abnormally high, and when I emptied my bladder, it fell significantly to a lower-than-normal value. If I combined the physiological event of emptying the bladder, while sitting, with immediately standing up, the blood pressure fell precipitously to dangerously low readings. My diagnosis was now confirmed and refined to include post-COVID dysfunction of the autonomic nervous system.

Prolonging an already prolonged isolation, I was now trapped at home with a scabrous face. In short order, I visited my primary physician, who begrudgingly agreed with my diagnosis but insisted on performing the routine X-rays and cardiac tests to exclude more serious problems.

Fortunately, those tests were negative, and over the last several weeks, the objective blood pressure changes have diminished. At first, the swings from high to low lessened. Ultimately, my BP seemed to normalize. However, the subjective symptoms of distractibility, fogginess, struggling for words, mild dizziness, and balance issues (intermittently, I felt like a sailor during the first days of shore leave) though better, have not disappeared. Unnervingly, one morning, more than six weeks since the initial diagnosis and nearly three weeks after falling out, my blood pressure was objectively orthostatic again. (Orthostatic means your blood pressure changes dramatically when you stand up – not good.)

“It Could Be Worse or You Might Get Better, But You Won’t Get Well”

 Fearing a relapse, anxious about a downhill slide, and concerned that I felt I had aged ten years in less than ten weeks, I ordered New York Times columnist Ross Douthat’s book, The Deep Places: A Memoir of Illness and Discovery, in hopes of gaining insight into coping with chronic illness following Lyme disease.

A searingly honest chronicle of the trials of intractable pain, it proved to be an effective morale booster – in a backwards way.

Chronic Lyme disease has defied the ability of Western medicine to qualify, quantify, or treat its myriad symptoms and iterations. It has driven thousands of sufferers, including Mr. Douthat (and I am saying this very sympathetically) to the insanity of despair and to such desperate measures that, to avoid suicide itself, they adopt unproven (and unprovable) treatments – some of which have potentially life-threatening complications themselves. I learned from his book that I could be so much worse.

Technically, at this time, I am somewhere between “post-acute COVID” and “long COVID.” Now, I must start following the advice that I used to give to patients, not that I can remember what that is given my COVID brain. But let me try to reinvent it here.

I will try to cope. I will try to take pleasure in small improvements. I will try to follow a regimen of healthy behaviors designed to distract me while time heals what it can. I will be grateful that it is not worse. And, I will try to take comfort in the words of an old blues song by Henry “Red” Allen that I quoted to occasional patients in similar circumstances, “You might get better, but you’ll never get well.” Meaning you’ll never be young again.

     

December hike on Little Deer Isle, Maine

{Update from Debbie} Sorry about the radio silence from our end. We haven’t forgotten about you!

2021 has been a strange year. Endless in some ways. Timeless in others. Uncertain throughout. Sam and I both turned 70 this year, which seems like a milestone. (We are not renaming the blog.)

I’ve been intrigued by, and a student of, the backward or forward annual review for years, not just during the pandemic.

Doing a year-end review or making a forward-looking list of goals imposes a bit of order, especially in chaotic times.

In the past I chose Three Words to guide the upcoming year. I wrote about that in 2012, in 2013, and in 2014.

My words included Alignment, Quiet, Compassion, Fearless, Imperfection, and Write. You get the idea.

This year I decided I need an approach that is not too taxing and that is creative and fun. I ran across several review/planning methods I hadn’t considered before and I’m going to try them. Maybe they’ll speak to you too.

1. Make a list of 22 things for 2022

Gretchen Rubin’s list of 21 things for 2021

This idea comes from Gretchen Rubin, the well-known author of five New York Times bestsellers, including The Happiness Project. She has a huge following on social media and recently posted her list of “21 things for 2021” (the scribbled list pictured) to her Instagram.

This is no-guilt approach that I find appealing. It’s okay if you don’t complete your list, she tells her followers.

“I got a fair number of things crossed off my list. Now I’m writing my 22 for 2022 list—and deciding what items to carry over from 2021,” she explains. See here.

It’s noteworthy that many of the items on her 2021 list are NOT earth moving: “Watch Mad Men,” “Get chair recovered.”

I’ve started a 22 things list and have jotted a few items down. Some are big goals; some are practices; some are simply To Do’s.

– Find a network to underwrite my podcast so it will generate revenue and also reach a much wider audience.

– Practice the cello for at least five minutes every day (I started lessons a few months ago).

– Take a solo trip to spend time on my own and learn something new.

– Sort through and toss out the stacks of paper in my office.

It helps to think of things you want to do in a number of areas. To borrow from author Chris Guillebeau, who has created an exhaustive process for an annual review, the categories could be: writing, business, finances, travel, wellness, relationships. 

Then I read about another approach to planning for the New Year.

2. Claire Mackinnon’s energy map

Claire Mackinnon, an executive coach in the UK, is a former writing client who is also a friend.

She describes a planning / awareness exercise called an energy map.

In her words: “Create a map which visually represents how you spend your energy. By energy I mean both ‘doing’, time-spent energy, and emotional/thinking energy… “

She continues:

“Write your name in the centre of a piece of paper.

Around it, write down the names of the people in your life, as well as activities you are engaged in…

Draw arrows to each, with the length and thickness of the arrow representing how much energy you expend on the relationship or activity. It might be that something you don’t spend a lot of time doing, but that you find yourself thinking about a lot, warrants a big arrow.

Then, draw an arrow from the person or the activity to your name, representing how much energy you receive from each.

As you ‘size’ the arrows, go with your gut. As an example, on my map, I drew a long, fat arrow to one name, where I seem to spend a lot of energy thinking about a relationship, and the arrow coming back to me was a faint, dotted line…”

Ha! I love the fat vs. faintly dotted arrows… so true.

You can read Claire’s complete energy map instructions here.

3. Choose one word for 2022

I can’t resist this one – it’s doable. Gretchen Rubin has one word at the top of her 2021 list – Open.

My word for 2022 is Together. 

My feelings about those who refuse to get vaccinated are not charitable. I am angry and unforgiving. But I want to keep reminding myself that we’re all in this (continuing) pandemic together. And that’s the only way we’ll get through it.

And there’s also the meaning of collaboration. Only by collaborating with other people can you get big things done. I’m thinking of my podcast but there are many other examples.

What is your ONE WORD for 2022?

I’d love to hear. Please respond and tell us. Include a few items, mundane or significant, on your “22 things” list.

Sam and I wish you all the best in 2022.

P.S. Here’s a recent podcast episode where we talk about turning 70 and what lies ahead: Debbie & Sam on entering the land of the old.

     

Unfortunately, medical science has not determined if the plaques are the cause of AD (in which case aducanumab might work) or the result of AD (in which case, bio-plausibly, aducanumab should not work).

So, what was the most outrageous aspect of this controversial approval process? Was it the fact that the research showed either no benefit or negligible benefit* from the drug; that 40 percent of patients develop brain swelling (and some have serious bleeding), a complication requiring extra monitoring and intervention; that because of this extra monitoring, researchers failed to maintain a double blind randomized control process; that the cost to society will be enormous (easily more than $56 billion per year) that we all will pay for in increased insurance premiums and Medicare costs; that the FDA defied its own panel of outside experts who voted 10-0 to reject it (one expert abstained); or that despite the fact its trivial efficacy was demonstrated only in early AD patients, the FDA approved it for all AD patients?

No, my outrage boiled over when I heard Mary Louise Kelley and Jon Hamilton (otherwise admirable and responsible reporters for NPR) give credibility to the idea that drugs should be approved not because they work but because it is natural to sympathize with patients and their families who are suffering from a disease.

NPR’s Mary Louise Kelley introduced the segment by saying:

“It’s still unclear whether the drug will help preserve a person’s memory and thinking. But as Jon Hamilton reports, it is already providing a benefit that’s harder to measure – hope.”

Is Hope a Medical Treatment?
But what is hope? Hope is not a medical treatment. It is not even reliably the result of a medical treatment. It is not quantifiable. It is an emotion that falls outside of the purview of a regulatory agency. As Samuel Johnson wrote, hope is “a species of happiness and perhaps the chief happiness that the world affords.”

Given that this is the first new AD drug to be introduced in 18 years, it is not surprising that hopes have been raised. But any benefit we are tempted to attribute to hope is complicated and can be misleading. In fact, when we confuse offering hope with a treatment, we raise expectations that lead patients and their families into decisions that lead to more treatments, excessive treatments, and, ultimately, futile treatments. And, as I’ve said before and will continue to say, futile treatments are physically cruel and morally wrong.

Sherwin Nuland, a renowned Yale surgeon and ethicist, when writing about his brother’s failed colon cancer treatments, said that offering hope “is done with the best of intentions, but the hell whose access road is paved with good intentions becomes, too often, the hell of suffering through which a misled person must pass before he succumbs to inevitable death.”

That point applied here means that for every patient who temporarily gains a point or two of improved cognition, there will be a patient who suffers and dies prematurely (in pain and isolation) because of aggressive treatments of brain bleeds caused by aducanumab or some other complication of AD itself while taking this “promising” new drug.

Offering Hope Should Be a Gift, Not a Transaction
Remember, not all treatments work for every patient, even when they are very effective treatments. Not every patient with pneumonia, appendicitis, colon cancer, or the trauma of an automobile accident survives. For these patients, we supply the proven treatment and offer hope as a supplemental gift. We hope that our usually successful treatment works as intended.

But offering “hope” in the form of an ineffective treatment is not a gift. It is a transaction. No one is giving patients aducanumab, someone is selling it to them. And many are profiting by that. Snake oil salesmen “offer hope,” but do we endorse that?

Similarly, playing the lottery allows us to purchase a tiny glimmer of hope at a small price for most people (full disclosure – I have bought the occasional lottery ticket). But for some people, who don’t understand the miniscule odds of winning, the purchase of several tickets represents a financial burden that they cannot afford. The temporary happiness it offers rapidly gives way to the burden and unfortunate consequence of magical thinking. The lottery is, indeed, a tax on the under-educated.

And so is the treatment of dementia patients with aducanumab.

True Hope is the Gift of Science; Transactional Hope is the Grift of a Swindler
We can give love and emotional support. We can give comfort. In doing so we truly are offering hope. We can sympathize with the suffering of patients with AD and their families, just as we sympathize with patients suffering from any illness. But selling aducanumab to a terminally ill patient is not offering hope, it is taking advantage of them. The resultant false hope is a side-effect or complication of that transaction and that false hope feeds medical futility.

So, when we offer love, comfort, and hope in the setting of a treatment that works well (but not universally) we are supporting our patient. Selling an ineffective treatment in the guise of sympathy accompanied by a false promise is charlatanism.

*negligible benefit
“Looking at the two objective measures, in the positive trial, the high dose made a 0.6-point change on the 30-point Mini-Mental State Examination (MMSE). On the 85-point Alzheimer’s Disease Assessment Scale–Cognitive Subscale-13 (ADAS-Cog-13), the high dose made a 1.4-point change. In the negative trial, the analogous results were -0.1 (worsening) for the MMSE and 0.6 for the ADAS-Cog-13.” Harvard Health Blog, November 12, 2020.