Sunday, June 5, 2016

Please Don’t Take the Z-Pak!

We have been having a terrible spring this year in St. Louis as far as pollen and mold go. Perhaps it’s been the mild temperatures since late February combined with more rain than usual. At any rate, I know that I have been blowing my nose and have had red, itchy eyes a lot more this year than I have had in many previous years. In addition, my pediatric colleagues and I have certainly been seeing a lot more of these sorts of symptoms in the kids in our practice. It’s been tough for kids and parents – as well as for the many friends who ask me what they should do about it.

What I say is that, with the stuff that’s floating around in the air right now, most people are going to have some nasal stuffiness and irritation, even if they don’t have an official diagnosis of allergic rhinitis, a.k.a., nasal allergies. Look at your car windshield, I’ll say, what did it look like this morning? Green stuff, they’ll say, I had to use the windshield washer and wipers before could I drive anywhere. Right, I’ll say, and you’re breathing that stuff into your nose too. This is where I should see a light bulb go on, and then I can say, so what we need to do is clean that stuff out of your nose. The reason you’re stuffy, the reason you’re sneezing, is that this is what our body does to get rid of the bad stuff we breathe in.  The mucus in your nose is there to capture all this possibly bad stuff – dust, mold, pollen, bacteria, viruses, fungus – that floats around in the air we breathe before it goes any further and gets down into the lungs. (Fun Fact #1: The average adult produces about a quart of mucus every 24 hours in your nose, throat, and lungs. Fortunately, it’s not produced all at one time. We create it slowly, and it acts like flypaper to capture this bad stuff, then transport it to our throat where we unconsciously swallow it and send it all hurtling down to your stomach – more on that later – where the mucus gets digested and recycled. Enjoy your lunch!) The more bad stuff you breathe in, the more mucus your body produces to get rid of it. You can help to get rid of it by getting some salt water, i.e., saline, nasal spray and spritzing that up each nostril and then blowing your nose. That cleans your nose out the same way your wipers clean your windshield. And since it’s not a medicine, it doesn’t have medication side effects so you can use saline spray every couple of hours if you need it. This may even help red, itchy eyes a bit since tears are always being produced in the upper eyelids by the lacrimal glands (from the Latin “lacrima,” a tear) and then are swept across the eyes by the eyelids to wash away the stuff that lands on your eyes from the air. In that way the tears and eyelids are also very much like that windshield washer/wiper analogy. This then drains into the lacrimal duct, a tiny tube which goes from the inner corner of each eye (the opening of which is often seen as a little dimple in the pink stuff at that corner of the eye) and runs down into the nose. (This is why you often have to blow your nose whenever you watch a movie based on a Nicholas Sparks book. Those tears have to go somewhere!) This all then drains down your throat into your stomach where any infectious stuff is supposed to get destroyed by the acid in the stomach. (Fun Fact #2: Yes, that’s why we have stomach acid. The stomach, as the first stopping point for foreign matter that enters the body, is essentially an acid bath that sterilizes whatever enters there, and this helps to keep us from getting bad infections. So stomach acid is not just there to annoy you when you’re doing your taxes.) If you clean out the lower end of the lacrimal ducts with saline spray in the nose, your eyes might drain better and get that irritating stuff out of there. (You can also massage the bridge of your nose below the eyes to compress the ducts, pushing the mucus down and clearing them out a bit.)

Then there are the sinuses. Why do we even have sinuses? One recent paper in “The Journal of Laryngology & Otology” [2009 Jan;123(1):4-8] concluded, “The paranasal sinuses may act simply to improve nasal function; certainly, it has been demonstrated that they may act as an adjunct in the production of nitric oxide and in aiding the immune defences of the nasal cavity. However, there is a distinction between utility and evolutionary origin. It may still be that the sinuses arose as an aid to facial growth and architecture, or persist as residual remnants of an evolutionary structure with an as yet unknown purpose, and in doing so have found an additional role as an adjunct to the nasal cavity.” In other words, no one really knows. As a singer, I know that they certainly do have a role in vocal production, and when I’m stuffy, it makes a difference in how I sound – and how much I feel it’s fair to charge an audience! The thing is, they’re there, a group of four paired air-filled rigid, pouch-like spaces that surround the nasal cavity. Each of them has essentially one way out, a small opening, called an ostium. If you have a lot of mucus building up in a sinus and it clogs up an ostium, it can cause pain and tenderness. And if bacteria are clogged up in there, it may cause a problem.

So now let’s talk about bacteria for a minute. Bacteria get a bad rap. We have been programmed to think of them as being irredeemably awful, like the slimy, snarling, evil principle target in a POV shooter game. In reality, though, probably less than one percent of bacterial species cause human disease. And because of how our immune system works, even a lot of those potentially pathologic bacteria exist on or in our body with no problem because we keep them under control. A lot of that control has to do with fluid flow. For example, most of the time, people don’t “catch” bacterial pneumonia. What happens is that something else, perhaps an irritative problem like we’ve been discussing or asthma or a viral illness, has increased the production of mucus in the lungs significantly, and you can’t clear out the mucus. Bacteria like pneumococcus, which can cause disease but often are just part of our body mass of bacteria (Fun Fact #3: the average adult’s body mass includes anywhere from 1 to 3 percent microorganisms, e.g., in a 200-pound adult, that’s 2 to 6 pounds of bacteria. Yeah, I know…), are usually already in our lungs, and as they reproduce, are routinely disposed of by the mucus transporting them up to the throat and then down to get fried in our stomach. But when air passages get blocked, they have nowhere to go, they multiply, creating a critical mass of bad stuff, and you get sick.

You don’t need to be a plumber to know that clogged pipes are a bad thing. And our bodies are made up of all kinds of systems of pipes and fluids: the circulatory system carrying blood; the digestive tract carrying food and eventually stool; the pancreatic ducts carrying digestive juices; the biliary tract carrying bile; the urinary tract carrying urine; the respiratory tract carrying air. Even our central nervous system has fluid that is produced in the center of the brain and then travels down, bathing and cushioning our spinal cord, getting reabsorbed in the lower back. If fluid stops anywhere, it’s a problem, and stuff that our body doesn’t like starts to grow. Think about a mountain stream: Water splashing over rocks so crystal clear that you can see at the bottom of the creek bed. If that stream drains into a stagnant pool, we now find still, murky, greenish water that you can smell before you see it. Stuff grows there. This is what happens in your body when fluids don’t flow.

So back to our sinuses: Yes, this can happen. Stuff can build up in our sinuses and lead to infection. However, as with that stagnant pool, sometimes clearing out that blockage may be all you need to do to flush out the bad stuff and clear or prevent an infection. When it comes to sinuses, that may simply mean using the saline spray, drinking more water to make your mucus thinner, spending time in a humidified environment, and staying away from irritants. (And since I haven’t said this yet, I’ll say it now. If you smoke, quit. If you’re around smokers, insist they smoke outside. The particulate load in smoke is huge and can easily overwhelm the ability of your respiratory membranes to 1] produce enough mucus to capture it all, and 2] clear away the mucus once it’s loaded with all that crap. And if you think vaping is any better, you’re wrong. There’s more and more evidence to show that it causes just as many problems as plain old, bad old cigarettes. Just walk away.)

So if your sinuses can get blocked up and you can get a bacterial infection there, why am I starting this whole thing with, Please don’t take the Z-Pak? Well, because that might be the worst thing you can do.

Remember Fun Fact #3? That 1-3% of your body is bacteria? Well, they’re not just there for the hell of it. They’re there because over time your body and its various systems, including your immune system, have figured out which bacteria you can live with and which might even be helpful. For example, the normal bacteria on our skin and in our mouth, what we call our bacterial flora (Fun Fact #4: I live on Flora Place! Not because of all this, but it’s a nice coincidence), help to prevent us from getting yeast infections in those places. We commonly see yeast infections in newborn babies because they come into the world essentially bacteria-free from being in the womb with mom’s membranes intact. It takes a while for babies to build up that bacterial flora and sometimes a type of yeast called candida gets there first causing a cheesy white irritation in the mouth called thrush and/or a reddish candidal diaper rash. Why those two areas? Well, candida likes to live on parts of the body that are warm and moist and dark and relatively sheltered from the air, and the inside of a baby’s mouth and the inside of a baby’s diaper both fit those criteria. After babies establish their normal flora, candidal infections become much less common. In fact the most common cause of a recurrence of thrush or candida diaper rash is, you guessed it, antibiotics.

Now don’t get me wrong: If I have a really good suspicion from a child’s history and physical exam and maybe blood or urine or skin or throat tests that detect the presence of bacteria that this child actually has a bacterial infection, antibiotics can be lifesaving and should be used.

But when it comes to sinusitis, that is, a sinus infection, here are some of the things a doctor really needs to find to consider the possibility that this might have a bacterial component that needs treating:
·      Facial pain or pressure
·      Nasal stuffiness
·      Nasal discharge
·      Loss of smell
·      Cough or congestion
·      Fever
·      Bad breath
·      Fatigue
·      Dental pain
And all this needs to have been going on for at least 10-14 days. Even then, you and your doctor may decide that it’s best to try things that will help drain your sinuses, like draining that stagnant pool, before going to an antibiotic. Things we talked about above like increasing your water intake, saline spray, a humidified environment, eliminating irritants, and perhaps medications to thin out the mucus, decrease the amount of mucus, or reduce inflammation.

Whatever else, your doctor should see you and examine you before prescribing anything. Treatment should be individualized based on what’s going on with you. Even then, if your doc prescribes a medication, please ask what good it’s going to do and what problems it might cause. I assure you your doctor will look at you differently if you ask these questions. We doctors are used to people telling us that unless they get a prescription, usually an antibiotic, they feel like we’re not talking care of them. Since we have only so much time and we are often given the very clear message that only a prescription is going to satisfy you, a lot of docs see this as a Kobayashi Maru* scenario, give up, and write a script for something, often a Z-Pak, just to get on with the day.

In 1977, my sophomore year medical school pharmacology professor at Creighton University said something in a lecture that has stuck with me ever since. “For every good effect a drug has, it will have at least ten bad side effects. You better be damn sure that that one good effect is going to be good enough to outweigh those ten bad side effects.”

The problem with “I called my doc, and he called me in a Z-Pak” – a phrase I overhear with some regularity at the gym, the supermarket, rehearsals, restaurants – is that the bad effects of antibiotics are serious, and we know they are getting worse.

First, for the individual, antibiotics not only kill off the bacteria you want to kill off but bacteria all over your body. This not only can lead to yeast infections in, say, the mouth and the groin, but to changes in your bacterial flora that took your body’s immune system years to create. Some of the new bacteria that come in to take the place of your established bacterial flora may not be as friendly to your body’s ecosystem, much as rabbits were devastating to the flora and fauna of Australia in the 19th Century.

More importantly for all of us, bacteria, like all living things, evolve. And they evolve astoundingly fast because they reproduce rapidly. Depending on the species of bacteria, under ideal conditions bacteria can replicate as often as every 20 minutes. Think of that: a new generation every 20 minutes. If we think of humans as having a generational timespan of 20 years, this means that a species of bacteria can evolve as much in one year as human beings have over the past half million years – essentially our entire existence as a species. This is why we have been reading more and more stories about antibiotic resistant bacterial “superbugs” and why some scientists are warning that we may be heading for a “post-antibiotic era” when we will no longer have effective anti-bacterial coverage for what were once easily-treatable infections.

So here’s the point of this whole thing:
  •         Do things to take care of your body’s plumbing. Drink water, don’t smoke, use a saline nasal spray if you’ve got some pollen-y crap up your nose.
  •          If you get sick, talk to your doctor.
  •      If at all possible, see your doctor.
  •      For your own sake, please do not demand a specific treatment from your doctor. Start a conversation with your doc about what might be going on with you and the best way is to deal with it.
  •      If your doctor recommends a prescription, ask questions about what that medicine is supposed to accomplish and what downside you might expect.

*For those of you who are not Trekkers, the Kobayashi Maru scenario is a no-win test for Starfleet trainees in which the cadet receives a distress signal stating that the civilian freighter Kobayashi Maru has struck a gravitic mine. There is no way to save both the freighter and the cadet’s ship. The only person who beat the test was a cadet named James T. Kirk who surreptitiously reprogrammed the simulator so that it was possible to rescue the freighter. Despite not following the rules, Kirk was awarded a commendation for “original thinking.”

As patients and as doctors we have created our own Kobayashi Maru no-win health care scenario where patients feel they have to make demands and doctors feel they have no choice but to meet them, even when these actions are not in anyone’s best interest. Be original, reprogram your encounter with your doctor, win at the Kobiashi Maru, and don’t accept the Z-Pak, or any treatment, without a complete explanation of what it should do for – and might do to – you.

Friday, August 7, 2015

Our Long Climb to the Mountaintop: One Year after the Killing of Michael Brown

I took a walk today. This weekend I’m in Colorado, near Avon, at a continuing medical education conference, and after today’s sessions were over, I walked up the mountain a ways and then back. About 5 miles altogether. Beautiful day. Clean, cool, thin air. Spectacular views.
I saw thousands of aspens, two ski lifts, and of course, lots of gorgeous houses up that mountain, set back from the road, but designed, I’m sure, to afford dazzling views to their owners. To be clear, I’m not a hiker. This walk was on a paved two-lane road, and I regularly encountered cars and a few trucks driving up and down the road. I’d nod and wave, and the occupants of the vehicles, when I could see them, would smile and wave in turn. In all, a peaceful, contemplative way to spend an afternoon.
Of the many things I mused upon, the first anniversary this weekend of the death of Michael Brown was chief among them. A year ago he had his fateful encounter with Darren Wilson, and the world changed forever. Except of course, when it didn’t. Since then, we have seen the deaths of Eric Garner, Walter Scott, Samuel DeBose, Sandra Bland, and all too many more African-Americans at the hands of police or while in police custody. 
About ten years ago, I was part of a weeklong workshop called Dismantling Racism in Education put on by the National Conference on Community and Justice of Greater St. Louis. The fifty participants were assigned to one of four cohorts: African-American men, African-American women, white woman, white men. We met in various permutations of our groups during the course of the week, and I will never forget what an African-American man, a high school assistant principal whom I had gotten to know quite well during the week, said in one of the men-only groupings: “I wake up every morning, and for a few moments as I’m becoming conscious, I feel good. Then it hits me. Something bad is going to happen to me during this day because I'm black. It might be a clerk at a mall looking nervous when I walk by, a woman on the street clutching her purse a little closer, a cop car slowing down to get a good look at me when I’m riding my bike. But I’ve got to get ready for it because it always, always happens.”
Today I didn’t think twice about putting on a pair of shorts and a t-shirt and a ball cap and sneakers and leaving the hotel and climbing the hill lined with multi-million dollar homes with earbuds in my ears. I didn’t have to. I can walk anywhere I want. I can smile and wave, and people will smile and wave back. Because I’m white. And I have privilege. And the fact that my high school assistant principal colleague, someone who is as at least as powerful and smart and kind and good as myself, would have to think twice about doing the same thing… Well, that is wrong. That is unjust. That is immoral.
I cannot NOT be white. This is who I am. This is how I was born. And because of this accident of ancestry, I am given privilege, access, freedom that people of color do not have. And if you are white, you have it too. And let’s be clear: Privilege is nothing to feel guilty about. It simply – is. It becomes a problem when we – and by “we” I mean my white cohorts – act like this privilege does not exist. Denial is toxic. And it keeps people of color oppressed and gets them killed.
My first ten years in the St. Louis area, I practiced pediatrics in East St. Louis, a predominantly African-American community. I moved there because my mentor, Father Joseph Brown, an African-American Jesuit priest originally from East St. Louis, encouraged me to act on my deep sense of mission and vocation. Over time, though, I began to wonder whether my telling my young African-American patients that I thought they were wonderful kids, that I looked forward to seeing them again, and that I knew that they could do anything they wanted, really made a difference. I mean, here I was, an upper middle class white pediatrician. Even though I firmly believed every good thing I said to that these kids, what kind of credibility did I have? One day I talked to Joseph about this. “Oh, Kenneth,” he said, shaking his head. “Everywhere they turn, they hear they are worthless. You have no idea how important it is that these children hear from someone who looks like you that they are precious and valued.” 
If you are white like me, you don’t need to feel guilty because you’re a member of the club. But we must – MUST – realize that until everyone, including Michael Brown if he were alive today, belongs in that club, that the default greeting for everyone should be a welcoming nod and a smile, that we all should be able to climb to the mountaintop without a second thought, our work for justice will never be done…

Wednesday, July 8, 2015

Marriage, Matrimony, and The Baltimore Catechism

I was an altar boy growing up in Hicksville, Long Island, NY. I went to St. Ignatius Catholic School and went to Mass at St. Ignatius Roman Catholic Church. Starting in the fifth grade, becoming an altar boy and serving at Mass on Sundays and weekdays, serving at funerals when I was needed, serving at weddings on Saturdays; all of this is what started me on my life of service. And as an altar boy and a student at St. Ignatius, I learned everything there was to know about being Catholic. I studied my Baltimore Catechism, and I realized how lucky I was to be raised in the One True Church, the one that would allow me to most expeditious, most sincere, most sure route to Eternal Salvation.

There was one problem: I would worry about my father. He was a Protestant, a Lutheran to be precise, and as such a heretic. The Catechism was quite blunt about the fate of heretics.

Q. 509. Are all bound to belong to the Church?
A. All are bound to belong to the Church, and he who knows the Church to be the true Church and remains out of it cannot be saved.

The fact that he was even my father, that he had married my mother was a source of some confusion and anxiety for me. After all, there it was right in my Catechism:

Q. 1036. Does the Church forbid the marriage of Catholics with persons who have a different religion or no religion at all?
A. The Church does forbid the marriage of Catholics with persons who have a different religion or no religion at all.

Nevertheless, my parents did get married, and by a priest. Their wedding picture was displayed on the shelf by the front stairs in our house. But though they are both smiling, it does not look like a wedding picture. My mom is not wearing a white dress and veil but rather a blue suit and hat. It seems that a non-Catholic who agrees not to interfere with the exercise of religion of their Catholic spouse and agrees to raise their children as Catholic can marry, but with a catch:

Q. 1041. How does the Church show its displeasure at mixed marriages?
A. The Church shows its displeasure at mixed marriages by the coldness with which it sanctions them, prohibiting all religious ceremony at them by forbidding the priest to use any sacred vestments, holy water or blessing of the ring at such marriages; by prohibiting them also from taking place in the Church or even in the sacristy.

As such, my parents were married with little ceremony in the rectory, the priests' residence, at St. Luke’s Catholic Church in Carnegie, PA. They were not allowed to have the ceremony in the church itself or even to enter it. So my parents’ humbling marriage was legal, in the Catholic sense, if just barely. But then I thought, what about my uncles and aunts in my dad’s family? None of them were Catholic. They had all gotten married, but not in a “real” church? And what about their kids, my cousins? Were all of them going to go to hell?

These vexing thoughts and memories have come flooding back the past few weeks as I’ve watched the considerable backlash against the Supreme Court decision on marriage equality. County clerks have agonized over being unable to uphold their religious convictions if they are forced to give marriage licenses to same sex couples. Priests, ministers, rabbis have been gnashing their teeth over the threat to religious freedom.

The thing is, they are all full of crap. And they know it.

As I got older and had long conversation with other people raised in other religious traditions – my Protestant cousins among them – I realized that the Catholic Church was not the only religion telling their people that everyone else is a heretic who’s going to go to hell. The best example I’ve ever heard of this comes from an exchange in the movie, “The Positively True Adventures of the Alleged Texas Cheerleader-Murdering Mom” (1993). Wanda Holloway, the Mom of the title, played brilliantly by Holly Hunter, is having a conversation with her daughter, Shanna (Frankie Ingrassia), about salvation:

  • Shanna: Momma, isn’t it true that only a certain amount of people are allowed in heaven, and we’re saved, right?
  • Wanda: Uh huh. That’s ‘cause we’re Missionary Baptists as opposed to the other kind of Baptists who if they make a mistake, they have to start all over again. But Missionary Baptists – once saved, always saved. Your grandma and grandpa were real smart. They chose a sect that has guarantees.

And when it comes to marriage, well, let’s go back to the Catechism:

Q. 1011. Can a Christian man and woman be united in lawful marriage in any other way than by the Sacrament of Matrimony?
A. A Christian man and woman cannot be united in lawful marriage in any other way than by the Sacrament of Matrimony, because Christ raised marriage to the dignity of a sacrament.

So, there you have it: the Catholic version. And though I’m not a theologian, I daresay that pretty much every religion – every Western religion, anyway – has some version of it. What it comes down to, for those with deeply-held religious convictions is this: UNLESS YOU ARE MARRIED IN AND BY A CHURCH – AND A SPECIFIC CHURCH, AT THAT – YOU ARE NOT MARRIED… PERIOD!

So to you Catholics out there, those who share my faith tradition and are agonizing over gay and lesbian people marrying their same sex partner, you’ve got a lot more to agonize about. Everyone you know who was NOT married in the Catholic Church is NOT MARRIED! Look at Q. 1011 above. It does not matter if they are one man and one woman. They have not accepted the authority of Holy Mother Church. As such, they cannot receive the Sacraments. Matrimony is a Sacrament. They are not married, just as much as same sex couples are not married.

I suspect that the same is true for many of you out there who are Christian and not Catholic, because as Wanda Holloway tells us above, unless you choose a “sect that has guarantees,” you lose.

Which, of course, brings us to the county clerks who feel that issuing a marriage license to a same sex couple violates their deeply-held religious beliefs. My question is: What are you even doing issuing civil marriage licenses? Because unless every single one of them is going to go to YOUR CHURCH, and they intend to receive the blessings of sacramental matrimony in YOUR FAITH TRADITION, you are sinning every time you hand out one of those pieces of paper. Have you issued marriage licenses to Jews? They’ve rejected Christ! Atheists? On the road to hell! The wrong kind of Baptist? Heretics!

While the point of religion is usually stated as the effort to bring us closer to God and to each other, the part that’s often conveniently ignored outside the walls of individual churches is that they all feel – again the Western ones – that they have it right and everyone else has it wrong. The logical end of this is that a Catholic employer could say that they will only grant spousal benefits to Catholics married in the Catholic Church, and county clerks would only issue civil marriage licenses to members of their own congregations with the pledge that the fianc├ęs will get themselves to that one true church for the marriage to be “real,” and anyone else who wants a license will have to wait till someone from their religion is on duty.

So are these people hypocrites? Are they consciously and willfully deciding only to judge same sex couples when the tenets of their own faith should cause them to judge those who do not share their faith just as harshly? Are they anti-gay bigots?

Well, I’m sure they would all answer No to all those questions. And to call up my own faith tradition, it is not my place to judge them either.

Q. 288. Why is it wrong to judge others guilty of sin?
A. It is wrong to judge others guilty of sin because we cannot know for certain that their sinful act was committed with sufficient reflection and full consent of the will.

So this is my invitation to those in churches and in county offices who are acting so offended by marriage between people of the same gender: You folks know very well that what happens in a government office is not a religious ceremony. It never was, and it never will be. For you to object to gay men and lesbians getting married at City Hall is like a clerk at Macy’s objecting to someone buying white pants after Labor Day. It may violate every law of fashion, but your job is to sell people what your business has to offer. So if you work in a government office, and you cannot treat every citizen of that jurisdiction equally under the law, you do not belong in that job.

And if you are a Catholic clergyman railing about this being a violation of religious liberty, well, Baltimore Catechism or no Baltimore Catechism, dude, you’ve either got a screw loose or you are lying through your teeth. Because you know better. You know that same sex marriage will have absolutely no effect on your ability to lead your flock or practice your faith. You also know that if some same sex couple decide to sue you to force you to marry them, they would be laughed out of court. And frankly, I would be on your side with that one. I believe in separation of Church and State as much as, if not more, than you, and it would be an outrageous violation of the First Amendment for a court to force you to marry a gay couple, or a Presbyterian couple or a divorced Catholic couple. And you know that. So cut out the “violating religious liberty" crap. It’s disingenuous and dishonest, and you know better.

Nearly fifty years ago when I was an altar boy, I liked serving weddings best. People were nervous but happy, and I was part of the Sacrament of Matrimony. As the years went on, though, and I began to realize that I was what I would later call “gay,” it slowly dawned on me that when it came to weddings, I would always be a spectator and not a participant. In the past few years as I began to realize that participation might actually be a possibility, I still knew that it would be highly unlikely that that participation would be in a Catholic church. And that’s okay. The Church did set me on a lifelong road of service for which I am very grateful every single day. I continue on that road thanks to Saint Louis University and Cardinal Glennon Children’s Hospital, two Catholic institutions that welcome me fully. And if I do get married, even if it’s not in a Roman Catholic church, I do feel that the spirit will be with me in that moment, whenever, wherever that might be. In Matthew 22:36, Jesus is asked, “Master, which is the greatest commandment in the law?” He replies:

  • “Thou shalt love the Lord thy God with thy whole heart, and with thy whole soul, and with thy whole mind. This is the greatest and the first commandment. And the second is like to this: Thou shalt love thy neighbor as thyself. On these two commandments dependeth the whole law and the prophets.”

You heard Him, folks: The basis of everything is love. The rest is up to us. Let us always remember that.

Monday, November 24, 2014

Indictments and ‪#‎Ferguson‬

In the many prayers for peace in the St. Louis region that I’ve been seeing, hearing, reading in the days leading up to tonight’s Grand Jury decision ultimately not to indict Ferguson police officer Darren Wilson in the killing of Michael Brown, I hope that we’re all clear about why we should want peace.

We should want peace because this is the only avenue to eventual dialog, understanding, and empathy. We should want peace because we value the lives and safety of our neighbors. We should want peace because too many young African-American men have been hurt or killed, and no one, ever, should be killed on the streets of their neighborhood.

I bring this up because I have, in some posts on social media, detected an undercurrent that is disturbing. It is the entreaty to protestors to “get past it,” “move beyond it,” “let it go.” This plea usually comes from people of privilege, people who look like me, and the unspoken corollary is, “so things can get back to normal,” “so I can get back to my life,” “so I can forget all this ever happened.”

So, to my white cohorts, mostly the bros, let me be clear: WE have got to get over it. This is not going to go away. That’s the problem: It never SHOULD have been “away.” Us white guys have a nation that was just made for us – take a gander at the painting below of the signing of the Declaration of Independence, if you have any doubt – and read the Constitution, the original. No women in there, and slaves were 3/5 of a man. Three-fifths. And they were slaves.

I am lucky enough to have grown up in the 60s when three things were going on:

1) The Civil Rights Movement was in full flower and was on the CBS Evening News every weeknight.
2) The Catholic Church was in the throes of its post-Vatican II reform, calling on Catholics to serve those who needed care.
3) I was realizing I was gay.

For me the timing was perfect, and those three threads wove a tapestry that has shaped me into someone who has a calling, who has found work that helps those in need, and whose other pursuits in advocacy and the arts serve these same ends.

So I am praying for peace tonight, for all the reasons I mentioned above. But I am NOT telling people not to be angry. Because I am mad as hell, not so much at Darren Wilson or at the Grand Jury, but at a city, a nation, a society that creates these roles, these memes, these archetypes that become "Michael Brown" and "Darren Wilson," tropes almost, that will inevitably clash and immolate each other. And it pains me that so many people of privilege have written such hurtful things in spaces like this and just want it to end so they can get back to posting cute cat videos and scrumptious food pics on Facebook and planning their next vacation.

Now don’t get me wrong. I love fun stuff on Facebook. I post it all the time. And I love vacations. But we have created a world – or have been complicit in its continuance – in which vast communities do not have these luxuries because they are trying to keep body and soul and family together. And if I am angry, I am just as angry at myself as I am at any other middle-aged white guy. I was lucky enough to be made aware that, when I look in the eyes of people who seem so unlike me, I will see myself. Yet I know I can do more. We can all do more. Or in our hearts, we all face indictment.

So I pray tonight, not so much for peace as for non-violence, and I pray everyday for the souls of people in every community to be shaken out of our collective Matrix-esque torpor, to reach out, and to love our neighbor.

Thursday, November 20, 2014

#Ferguson and Kids

In the coming days no one knows what exactly is going to happen when the Grand Jury in the Darren Wilson case hands down its recommendation regarding whether he should be indicted for the killing of Mike Brown. I daresay we all hope for peace and justice, and we all hope that everyone will remain safe. 

I have been a pediatrician for just over thirty years now. I moved to Missouri in 1986 and practiced in East St. Louis for ten years. For the past eighteen years I have practiced in St. Louis at SSM Cardinal Glennon Children's Medical Center. I have always worked in what are euphemistically called “underserved communities.” This usually means people who are poor. This usually means people who are black. This usually means people who are both. I have seen parents endure terrible hardships to keep their families together. I have seen grandparents heroically taking on the care of children years after they thought they were done with childrearing. I have been humbled by seeing kids who have done remarkable things under circumstances that, as a kid, would have sunk me. 

Sadly, I have also seen families who have not been able to withstand the pressure of being poor, overworked, and marginalized. I have seen families fall apart. I have seen kids who have developed behavior problems because their brains have to be on high alert because of various ongoing threats in their environments. I have seen parents unable to continue to be parents because of the constant strain of wondering how they can feed their kids and keep a roof over their heads while working two or three minimum wage jobs that do not make ends meet.

I have also read posts on Timelines all over Facebook saying that these people just need to "get a job,” “calm down and go home,” “pull their pants up.” These commentators have all been white. They do not understand, and do not wish to understand, what it is like to live another reality, one where you are always, automatically suspect, one where you will not be shown houses in certain neighborhoods, one where your family had no alternative but to send you to a crappy public school. They know that they are doing better than the African-Americans who live a few miles away, and they actually believe they deserve it. They believe that their relative success is all due simply to their work ethic and their good choices. They do not believe in White Privilege, i.e., that being white in America confers certain advantages over non-white persons, because, when you have it, it is nearly invisible, and if you know you have it, your first reaction is to feel really guilty about it. So they deny it because it’s initially too painful to accept it.

But it’s true, and I know how I benefitted from it. I grew up in a safe, white, middle class suburb on Long Island, with excellent schools (our high school had a full time Russian language teacher), lovely parks and beaches, dependable pubic services, where my dad had a good-paying job as an aerospace engineer that he got as a result of a college education on the GI Bill. All that prepared me to go to an excellent college where I got scholarships and to medical school to do the work I am privileged to do today.

I could tick off, one by one, how many of those advantages are withheld from the kids who come to my office, as well as from their parents and families. The strange thing is not that Ferguson is happening; it’s that it’s taken this long to happen.

As I said above, I am a pediatrician. And in that role, I just want to make one plea to anyone who reads this about what may happen in the coming days: I would ask everyone who may be involved in public displays over the next few days to be aware of how this will affect the children in your lives. 

Children are not just small adults. As we learn more about child development, we know this to be true on every level: physical, psychological, cognitive, emotional. What children need – and the younger they are the more they need this – is stability, predictability, and a feeling of safety. As a species, humans are altricial, that is, we are born more immature than just about any other mammalian species our size. That means that babies need nurturing, caring, feeding, swaddling longer than do infants of other species. The payoff, of course, is enormous in terms of intelligence, creativity, and the ability to love. Part of that process, though, requires that children know who will be tucking them in, who will feed them, who will bathe and dress them, when that will all happen, and who will love them. They need this to be the same from day to day, as much as possible. They need all this because they are trying to figure out how the world works. As infants mature from beings who, at about two months, smile at everybody, to babies who, at around six to eight months, begin to know who loves them and to choose them over strangers, to toddlers who will run off and jump and climb and fall at the slightest provocation, children have unique needs are various stages of life. What does not change is that they always need to be supervised, and they always, always need to feel safe.

So to those who will choose to be part of a demonstration, I respectfully hope that you will choose not to bring your children. While I completely understand the desire that your children should be witnesses to history – and I have no doubt that Ferguson will be part of the litany that now includes Selma and Montgomery – young children will not remember this. Their brains are not wired to retain clear memories during the first few years of life. Everyone in St. Louis and around the world knows that the only thing we can predict about the upcoming days is that they will be unpredictable. And that is not an atmosphere that is healthy for kids. If they see their parents yelling, being yelled at, being assaulted, they will experience only fear and threat, and that is never healthy for a child. I know you love your kids, and you are doing this to make a better world for them. Please leave them with a responsible adult. Please make sure you get home to tuck them in. Please tell them the stories of these days when they are old enough to understand the sacrifices you made for them.

And to those in law enforcement, if you encounter demonstrators with kids, please be aware of how your interactions will affect these children. One thing that has amazed me, both before August 9 and since, is that when I ask African-American kids who come to visit me in my office what they want to be when they grow up, a significant plurality of the boys say, “Police.” So many of these kids already see you as people of power. Please do all you can to make sure that your interactions with them and with their parents leave them with a sense of respect for you and what you do, rather than fear.  

I truly believe that both demonstrators and law enforcement want to assure that everyone remains safe in the coming days. I truly believe that both demonstrators and law enforcement are doing what they do to make the world a better place for our children. And I truly hope that everyone will keep their kids at home where they can be safe and be best prepared for this better world to come.

Tuesday, August 26, 2014


Today, July 6, 2014, would have been my father’s 89th birthday. He died in 1997. He had cancer, then chemo, then a heart attack. He was getting out of the tub at my parents’ home when it happened. Aesthete that I am, I imagine the scene as Jacques-Louis David’s “The Death of Marat.” Doctor that I am, I know the scene was much more chaotic, my mom calling 911, the paramedics arriving and hustling him out to the ambulance. Son that I am… Well, there are no words.

I had gone back to Long Island, to the house in Hicksville where I grew up, to visit him and my mom, but mostly him, a few weeks before that. He had actually been doing a little better, and so I wanted to spend some time with him. So we did what he and I always did. We watched TV, we talked briefly about the rest of the family, we went out to the local diner for dinner, we watched TV some more, we hung out, him on his computer, me on mine.

At one point, I did take him out one evening after his AA meeting, just him and me. We sat at a booth in the Mid-Island Diner, and I ordered a piece of pie off the huge, laminated menu. He just had coffee. We talked about life and death, about love and work, as we had never done before and never would again. I told him I loved him, even though for many years that had been hard to do. And he, after 23 years in AA, made his amends to me and asked for my forgiveness, and told me, without hesitation, that he loved me.

It hadn’t always been that way. The only time before that when I really remember telling my father that I loved him was when I was just starting my pediatric residency at Lenox Hill Hospital in New York City. I had decided to leave my car, a ’78 Toyota Corolla, out on Long Island because there was no point in having a car in the city. I had done an internship at a hospital in Mineola, Long Island, and my dad drove into Manhattan with me with some boxes of my stuff in the back seat and in the trunk. After bringing all my belongings up to my third floor walkup on Second Avenue at 80th, I gave him the keys, and he got in the driver’s seat. I got in for a second on the passenger side and said, “Dad…” He looked at me. “I love you.”

He looked startled. “I…” he said, “Well, I love you too, Kenny,” sounding like he knew that this is what he should say at a time like this. We leaned awkwardly over the stickshift and hugged briefly. After a moment, he sat back, nodded, turned the key, and said, “Good luck.”

“Thanks,” I said, as I stepped out onto the street. “Take care of my car!” He smiled, and I stood there for a while, watching him drive south on Second towards the 59th Street Bridge and home before turning to walk up the two flights to my new home.

That day, though, watching my canary yellow Corolla evaporate into Manhattan traffic, I did wonder about his love for me. His response had been so stiff, so mechanical. Was I pushing too much? Should I ever bring this up again? Did he really love me? And could I really love?

This was a pertinent question for me because that apartment, at 1553 Second Avenue, was more than a place where I would be living while I was a pediatric resident. It would also be where I would be moving in with my lover, Bob. We had been together for over a year, but now, in 1981, I would actually be living with someone I loved for the first time in my life. As I climbed the stairs, I wondered how this was ever going to work. How much like my father would I be? Bob and I had been happy so far, but were there things about me that I might have inherited from my dad that would make living together with an “other half” impossible? My name is, after all, Kenneth Arthur Haller, Junior. My father was the first Ken Haller. I was his namesake, his heir. How much of him was in me?

It would be many years before I would learn and appreciate all the horrific things that my father and his family went through during the Depression, events and situations that would lead anyone to doubt love and make it seem dangerous to express. I would mourn his own lack of a real childhood and recognize the heroism that led him to faithfully go to work every day and provide for a family, even when they sometimes seemed like strangers to him. I would forgive him for being an imperfect human being who nevertheless did find the courage finally to grow and relax into receiving and giving love as a grandfather to an amazing bunch of kids.

And I did learn from and with Bob that I did know how to love, and even though we split up as lovers after four years, we remained best friends from then on.

I finally did feel the need to tell my father about the fact that I was gay when I was thirty. I was living in South Carolina at the time, working in a small town called Loris as a National Health Service Corps pediatrician, and I was visiting the family on Long Island for a few days. My dad and I were in the living room, and he would be taking me to Kennedy Airport for my flight to Myrtle Beach, South Carolina, within the next half hour. (I had found, even at this age, that it was best to drop startling news on my parents just as I was heading out of town.) Dad was sitting upright in his barcalounger, eating a bowl of cereal off a TV tray, watching CNN, and reading Newsday. I was sitting on the couch, and we had been talking off and on about the family and what my siblings and cousins were up to. “Well,” he said, summing up the conversation without looking at me as he toggled between CNN and the newspaper, “I gotta say, I’m really proud of you. You’ve really made something of yourself.”

I needed a moment to take this in. I could not remember ever hearing him say this. It was wonderful, of course, but I was a man with a mission, and he had given me the perfect opening. I took a deep breath and said, “I’m glad you feel that way because I have something to share with you.” He put down the paper and turned to me, looking over his reading glasses, his expression saying, “Go on.”

“When Bob and I were together, we weren’t just friends, we weren’t just roommates. Our relationship was a love relationship, and if I have another one, it will be with a man.”

He continued to look at me silently, not staring, not glaring, just… considering. Finally, he said, “Well, I’m not surprised.”

I nodded. “I didn’t think you would be.”

A pause. Still considering. “And I’m not shocked.”

Again, I nodded. “I didn’t think you would be.”

A longer pause, his eyes narrowing. “So, are you happy?”

I paused. I could not remember him ever asking me this. His asking alone was enough for me to answer quite truthfully, “Yes, I am. I am happy.”

“Good,” he said, nodding and folding his paper. “Are you sure you wouldn't like some breakfast?”

“Uh, what have you got?” I asked. This was not the response I had expected. We went into the kitchen and toasted some Eggo waffles.

And that was it. We never really discussed it again, and on the occasions when I would introduce him and my mom to a man I was seeing, he always welcomed them. One, in fact, an aerospace engineer like my father, came to New York with me, spent hours talking to my father on their first meeting and told me on the train ride back into the city that my dad was the most brilliant guy he had ever met on the topic of computer languages. I did not know that.

After my father died, I went back to Long Island to be with the family. At the wake, I met scores of people that my dad had gotten to know through AA. In the nearly two dozen years he had been in AA, he had been there for countless people in need at meetings and as a sponsor. These are the two things I heard from his AA friends over and over at the funeral home.

- “Your father changed my life. Any time, day or night, he was always there when I needed him.”
- “You’re Kenny, the doctor? Oh, he loved you so much. He was so proud of you.”

To be honest, it was not always easy to hear. When were you there for me? I wondered. You couldn’t tell me this yourself? I accused.

And then I heard his voice, his request for forgiveness of just a few weeks before, his declaration 17 years earlier that I had made something of myself, his tortured “I love you too, Kenny” four years before that. And I realized then that his difficulty saying I love you came, not from a lack of love for me, but from his own doubts, indeed his surprise, that anyone could love him.

And so today, on his birthday, I’m proud to say that, yes, there is so much of him in me, that his growth from fear to love, from desolation to generosity, has shown me how to thrive as a man. Being who we are, my father, Kenneth Arthur Haller, and I went as far as we could during his lifetime, and he challenges me every day to go even further as a man serving others in this world.

I am proud to be Kenneth Arthur Haller, Junior.