SQUASHED

(Published in the East Bay Psychiatric Association Newsletter, January 2008)


I read an article in the New York Times recently that parents are encouraging their youngsters to take up the game of squash. Kids as young as 8 years old are enrolling in squash classes. The reason for this is that elite eastern colleges have squash teams, and according to one parent who was interviewed for the article, “it could give my son a leg up on his Harvard application some day.” There are now so many kids playing squash for this reason, yet so few students needed to fill a squash team, that such an effort is doomed from the start, not to mention the misguided nature of the effort.

I’ll tell you that when I read articles like this, I get the feeling that we psychiatrists will never run out of work. When parents are programming their children as tightly as this article suggests, there will be no shortage of neurotic, anxious, and insecure adults in the future to fill our schedules.

It is a failure of awareness of normal childhood development for parents to direct their children to have a primary focus on building a resume rather than enjoying their childhoods. It’s a good way to have a child lose out on much of the spontaneous friendships, fun, and laughter that characterize youthfulness. I am concerned when I learn of parents scheduling their young children for every kind of lesson and activity, leaving no time for “free play”. Optimal childhoods allow time for youngsters to explore the world they live in, become curious about life, and feel carefree.

When you understand that children on average laugh over 300 times a day, while adults laugh fewer than 10 times a day, you have to ask yourself what the rush is to get children out of childhood and acting more like adults. This parenting approach of excessive scheduling of children to be involved in structured activities is called “green housing”--a way to ripen and prematurely age something artificially. Have you ever compared the taste of a tomato ripened in a green house to one ripened naturally on the vine?

Another common childrearing style today is called “helicopter parenting” because these parents hover over their children excessively. These folks do not allow their children to play outdoors unsupervised, do not ever leave their children with baby sitters, do everything for their children (often including their homework), and think of their children in such idealized ways that they cannot accept imperfection in them. If that’s not a breeding ground for neurosis, I don’t know what is.

So much of life is serendipitous and not really under our control. When parents exert such “over control” of their children, either by “green housing” them or by being “helicopter parents”, they interfere with the normal development of a youngster. The only reason to play the game of squash is because a person finds it enjoyable to play. As a resume builder, it’s a loser. And can you imagine the child dragged off to “squash class” at age 8 because the parents have Harvard in mind for that child’s future? All I can imagine coming from such an effort is not the cost of a Harvard education but the cost of the likely future psychotherapy sessions.

WALKING
(Published in the December 2007 edition of The East Bay Psychiatric Newsletter)

Recently I learned of a study comparing the average walking speed of people from different countries. The people with the fastest pace are in Japan. The U.S. is in the top five, which also includes other industrialized nations. At the bottom of the list—the slowest pace—are people from Malawi.

Now that I am semi-retired and have more leisure time, I have decided to do more errands by foot rather than by car. I have always done a lot of hiking and walking recreationally, but this is something different. When I need a haircut or have to go the post office, I go out my front door and hit the pavement. There are many destinations within a mile and a half of my home, and I truly enjoy walking the three-mile roundtrip. Because of this behavioral change, there is quite a difference in how I feel, and I’ve noticed that my pace is probably getting closer to the folks in Malawi than to those in Japan.

Walking provides an opportunity to see things that I would not observe if traveling by car. It is interesting to see the variety of plant life along the path, and how houses have such interesting designs. There are scores of things I see now that before were just a blur as I hurried in my auto to get to the next place. It’s also far more civil when one walks. We fellow walkers generally greet each pleasantly, as opposed to the tension and disregard that typifies interactions between fellow drivers competing for position. Sometimes even a conversation develops with others, or if you see someone you know, there’s an opportunity to get reacquainted. I expect all this has reduced my blood pressure, pulse rate, and irritability quotient, as it feels to me like the rat race is occurring on some track that I am not on.

On the negative side, there’s the smell of gas fumes and the sight of litter that one would not be aware of if not walking. But the worst observation is how hurried and harried people seem to be while driving. No one appears to have enough time to get where they are going as they speed along, using up fossil fuel, not getting any exercise, and feeling tense on the roadway. Believe me, I know from where I speak, as that was surely a picture of me for a very long time, and occasionally still is.

I suppose in an ideal world we would all live about a 10-minute walk to our jobs and we would have enough discretionary time to feel unhurried. It’s difficult in a metropolitan area to slow down our pace, observe the world that surrounds us, and interact pleasantly with others. There are times that nothing but our automobiles will do, but there are times when we probably do not need a car, yet are just in the bad habit of using one.

Similar to starting a diet, developing new, healthier habits can take time. But depending on your living situation, walking more to do errands may be a habit worth considering. It might even make your life more interesting and pleasant, and perhaps lengthen it as well because of the cardiovascular health benefits. Just think, if the worldwide supply of oil continues to be less available and more expensive, you could be well ahead of your friends and neighbors if you get started right now on this new 21st century essential behavior called walking.

COMMERCIALISM RUN AMOK

(Published in the East Bay Psychiatric Association Newsletter, October 2007


Excessive advertising has always been a pet peeve of mine. It is difficult to watch a ballgame on TV these days without being inundated with ads for cars and trucks, and more recently even for medications for erectile dysfunction. You’d think people watching these games had nothing else to purchase but another gas guzzling vehicle, or for that matter, care to have it suggested to them that they might need an erection-enhancing medication.

Our economy depends on people purchasing things, and commercials are the engines that propel those purchases. There comes a time, however, when people have to realize that things are either “bought” or they are “sold.” You “buy” something when you have a need or desire to make a particular purchase, and go out make that purchase. You are “sold” something, when no such need or desire exists within you until enough glossy ads, store models, or media commercials seduce you into thinking that purchasing that product is in your interest. One’s long term financial stability may actually be based on how well one is able to make this distinction.

It is one thing when cars and trucks, fancy clothing, or high-tech gadgets are pushed on us by commercials. But it is quite another when prescription pharmaceutical agents become the daily grist of advertisers. This morning my computer’s home page had an ad for a “Seven day free trial of Ambien-CR.” In just one click you can be connected to a “health care provider” who will send you this free sample, become registered to get a free monthly newsletter on sleep problems, and get to be part of a group of people who will be nurtured along and encouraged to take this medication. Imagine that. You go onto your computer for some routine e-mail, and you get a message to take a sleeping pill free for seven nights—perhaps just long enough to get you accustomed to it so that you become a long-term customer.

This direct-to-consumer advertising for prescription pharmaceutical agents is a good example of commercialism run amok. We physicians must speak up about this intrusive and inappropriate behavior on the part of drug manufacturers. If you think Madison Avenue should determine diagnoses and enlist physicians to get people started on controlled substances, then perhaps you are in the wrong field. We physicians have a fiduciary responsibility to tell our patients what is in their interest—not in the interest of some corporate entity. If one wants to be a salesperson, fine, but that should not be confused with the art and science of practicing medicine.

Don’t get me wrong. I use the fancy pens drug companies give me, find it handy to put the free boxes of tissues out in my office which contain the drug company’s logo, and enjoy the free dinners that these companies sometimes provide. But after seeing that ad on my computer this morning for a free sample of Ambien-CR, I have made a vow to stop enabling these companies’ improper behavior. I will no longer accept or use any of these free offers and will tell the drug reps that visit my office just how I feel about this behavior of advertising directly to the consumer. I hope you will consider doing the same. After all, if someone needs Ambien-CR because they have a serious problem with insomnia, the treating physician is the proper one to make that judgment, not someone in a pharmaceutical company’s sales or marketing department, or worse yet, an anonymous physician employed by that company to write a prescription for such a product.

IMMIGRANT WORKERS

(Published in the East Bay Psychiatric Association Newsletter, August 2007)

Looking at my checkbook recently, I noticed that the last three checks I had written were to people named Javier, Geronimo, and Lupe. They are, respectively, a gardener, a house painter, and a domestic. They all speak some English, certainly better than I speak Spanish, and they all are dependable, honest, hardworking, and nice people. I have relied on them to do tasks for me that I no longer am able to do, or no longer want to do.

A lot of the current fuss about immigration escapes me, as I’m not sure where I would find the kind of help that these folks have provided for me of late if they were not living here. Some days when I drive off to work, the block I live on is half lined with cars and trucks of Latino workers who are mowing lawns, installing roofs, laying cement, or providing a myriad of other services for people who have the good fortune to be able to afford to hire help. I have never once heard a complaint or learned of any difficulty that anyone in my neighborhood has experienced from an immigrant worker.

Some Latino workers charge very little for their services. There are probably many reasons for this, but one is that they are more motivated simply to have work than they are to get rich. Making a marginal living is better than making no living at all. But if I sense that someone is vastly undercharging me for his or her services, I make sure to provide additional funds for those services when they are completed satisfactorily.

I don’t ask these workers if they have a “green card” or what their immigration status is, or how they came to be here. But if they are working on my property, I do ask them if they need to use the bathroom, or if they need something to eat or something to drink. I don’t ask if they have health insurance or what kind of a place they live in when they are home, but I do try to make small talk as much as I can, sometimes using my newly acquired basic Spanish: “De donde eres? En qual ciudad vivia?” “Le gustaria algun comer o beber?” My struggle with Spanish brings a smile to their faces, at which point they become the teacher and I the student, and the playing field is somewhat evened. Then we have a chance to experience a more co-equal relationship, and friendliness comes more easily.

If I lived in a country with little economic opportunity, and I needed a way to support my family, I would find some way, any way, to do just that. If I needed to escape my country and find a place somewhere else where I could make money and send some of it home, I would do it. All of us have raw survival skills—we just don’t have a desperate need to use them given our circumstances.

I have had the good fortune to be born in a land of opportunity, but this is only so because my great-grandparents left their countries of origin where they were persecuted, oppressed, and had no opportunity. Taking care of the stranger in one’s midst, which is how I see my role in interacting with immigrant workers, is exactly what I would hope for if I were that stranger, as my ancestors in fact had been.

There are many ways to behave in a community. One is to feel entitled. Another is to feel grateful. I don’t know what it is like to be uneducated, impoverished, and highly dependent on the good auspices of others. But I do know how I should behave if I interact with someone with such a background. Being considerate, thoughtful, and helpful to people is, after all, simply a matter of being a decent human being—nothing more and nothing less.

SIBLINGS AT THE MOMENT OF TRUTH

(To be published in the East Bay Psychiatric Association Newsletter, August 2007)

One of the least well-studied subjects in human psychology is the relationship between siblings. There are plenty of twin studies related to genetic factors of inherited illnesses, but ordinary sibling relationships take up very little space in the catalog of human inquiry. Sibling relationships are the longest ones that occur during one’s lifetime—longer than for spouses, parent and child, or for friends. We psychiatrists tend to minimize the importance of sibling relationships--I know that when I take a psychiatric history, I make relatively short shrift of this subject including the order of birth of my patients in their family, even though I recognize these issues as crucial aspects of anyone’s development.

One critical time in the history of sibling relations is when the last parent dies. It is at this juncture that I have witnessed major problems in a number of my patients’ relationships with their siblings. In fact, I have seen several patients through the years who sought my psychiatric assistance solely because of problems they encountered with their siblings during the time their parents’ estate was being settled. The problems encountered are often very ugly, with siblings battling each other for advantages in inheritance matters. Often the problems can be traced to parents not making the hard decisions before they die as to whom will receive what. Leaving too many decisions to the surviving children to sort out can lead to trouble more often than not.

Most parents have the fantasy that all of their children are level headed, fair-minded, and free of excessively competitive impulses. The parents want to believe that their children will matter-of-factly execute their will and never encounter a bit of conflict. But attorneys who specialize in estate matters will tell you that siblings only agree about 30% of the time on how to execute a will equitably. The larger the inheritance and the more illiquid the assets, the more opportunity there is for trouble to arise. The Clark brothers, heirs to the Singer Sewing Machine fortune, are but one example of siblings who never spoke to each other again after their wealthy parents’ estate was divided because of the resentment they experienced due to their perceived inequities in the division of the assets they inherited.

Siblings in this modern age of mobility often spend their adult lives in communities far apart, may have spouses with very different needs and personalities, and may often have very different financial circumstances. Mix these factors with some unresolved sibling rivalry, and you have the ingredients for a toxic brew. It is unrealistic to expect that several siblings with differing life-styles and ethical standards will agree on all significant matters. Parents may leave their children better off financially after they die, but worse off in more important matters if they do not address these matters preemptively. Some siblings, of course, have never been close or care much for each other, and in those cases, regardless of advanced planning, things may fall apart after the last parent dies.

Proper legal advice is essential in estate related matters, but sometimes attorneys are not so astute about psychological issues. Whether your patient is an aging parent or an adult child with aging parents, common-sense advice would be to encourage an open family discussion of estate matters, assuming they are deemed appropriate issues in the context of your patient’s therapy. It may prove helpful to have the family decide together which child should be trusted to be the sole executor, as having multiple siblings appointed as co-executors often leads to unnecessary complexities. Parents may also be wise to decide on the disposition of most of their assets during their lifetime, so as to minimize the possibility of excessive avarice, competition, and jealously arising in the surviving children. Failure on the part of your patients to address such estate matters within the family when it is still possible to do so may cause you to witness some of the more difficult and unpleasant family dynamics that one can encounter.

A BEAUTIFUL MIND

(Published in the East Bay Psychiatric Association Newsletter, January 2002)


Hollywood had not been too kind to the mentally ill or to psychiatrists in the past. Portrayals of emotionally disturbed individuals has often been stereotypical and demeaning, and psychiatrists have often been portrayed as eccentric, emotionally detached, or sadistic. All this has changed with the recent movie, "A Beautiful Mind" , where paranoid schizophrenia is presented in a most dramatic and sympathetic fashion.

This is not a movie that psychiatrists should try to see. This is a movie that psychiatrists must see! As more and more people see this film, more and more are asking me, “Is this what schizophrenia is really like?” This provides an opportunity to discuss the nature of severe mental illness. More importantly, the population at large should come to be far more empathic with the plight of the mentally ill. This movie could do more to advance the cause of psychiatric treatment than any educational program the American Psychiatric Association could dream up to create support for our work.

The movie has certain flaws. It is about a real individual, John Nash, who is still living today, who was such a brilliant mathematician as a graduate student that he eventually won the Nobel Prize for his work. But subsequent to his graduate school years, he became schizophrenic. The movie leaves out certain less than pleasant details of Nash's life to create a more sympathetic character. And there is a note of unreality in the depiction of a remission of the illness that might give families false hope for an ill loved one. The implicit message is that sufficient community support, an enormously loving relationship, and proper medication can cure the illness.

Nonetheless, the overall dramatic impact of the film is enormous. It was so great on me that I left the theater shaken. It took me a long time to feel composed enough to express my thoughts, as the reality of the portrayal overwhelmed me as it reminded me of all those broken minds in patients of mine through the years that I have toiled to mend.

"A Beautiful Mind" is a beautiful movie, with stellar acting on the part of Russell Crowe who plays John Nash, and Jennifer Connelly who plays his wife, and whose talent appears equal to her substantial beauty. The movie is based on the book by the same name written by Sylvia Nasar, and while I have not read the book, others who have, rate the book as superior to the movie, which is indeed a great compliment.

ONLY IN AMERICA

(Published in the East Bay Psychiatric Association Newsletter, April 2002)

This past weekend, my wife and I, along with three other couples, went out to dinner. This was not your ordinary evening out, as you will see. We four couples were joined by our adult sons, now about age 28. Our boys have remained close since childhood, despite having scattered far and wide during their college and graduate school experiences.

For many years, we four families would see each other at our children’s events like soccer games, scout troop meetings, and other school activities. We adults were never really close friends, just very good acquaintances, and we had never before gone out to dinner together as a group.

The idea for this dinner, sadly, was borne out of a tragic situation. Two months earlier, our sons’ other closest friend--my own son’s best friend since fourth grade--committed suicide. The loss was sudden and catastrophic--and nearly unbearable for our boys. As parents, we were also devastated.

What seemed to arise out of our mutual shock and grief, was a greater appreciation for our ongoing relationship with each other, and we felt a need to form closer ties. We wanted to strengthen our previously casual relationship, and somehow consolidate our closeness with each other and with our sons in the face of this tragedy. There were hugs and kisses all around that night in the restaurant--and enough warmth to keep you cozy all next winter. We four families, who previously had been living out our joys as parents together, now had to confront our sorrow together, too.

The diversity of the families who found themselves sharing this moment in their lives was also unusual: one family is Muslim originally from Pakistan, one Armenian Christian, one Catholic, and one Jewish. And we spent the evening sitting around a table in a CHINESE restaurant.

That such a meaningful experience could be shared by such a diverse group of individuals is a strong affirmation of our American democracy and our way of life. In this difficult time in world history, it is good to keep such stories in mind, because only in America is an event like this likely to have occurred.

WHEN LESS IS MORE

(Published in the East Bay Psychiatric Association Newsletter, January 2000)

We psychiatrists like to use words. We believe that by using language we can explain, clarify, and help resolve emotional problems. Without the use of language, we are helpless. Would you consider me crazy if I told you that absolute silence can also be highly therapeutic?

I saw a documentary movie recently about the use of the Buddhist meditation technique "vipassana." Inmates in prisons in India can elect to participate in a 10 day meditation treatment program which requires absolute silence. After these 10 days, we were shown prisoners who had been transformed from violent, aggressive inmates, to calm, controlled individuals; their behavior and motivation had altered drastically.

The dynamics of what happened to these inmates is complex, as in India one may have to wait for years in prison just to get a trial. Thus, there is a lot of motivation to look inward and use this open-ended amount of time to gain control over one’s frustration and rage. Regardless, what was once a hell-hole of a prison filled with violence and chaos, has been turned into one of relative calm and serenity.

I have two acquaintances who periodically go to “silent retreats.” They spend a number of days in complete silence, and leave the retreat feeling emotionally cleansed and renewed. And it is well known that monks throughout the ages have taken vows of silence to enhance their own state of piety.

There are many studies that show that people do better health-wise when they have outlets to verbally express their feelings to others. Paradoxically, the opposite may also be true--that periods of absolute silence may also be emotionally beneficial. It is thought provoking to realize that saying nothing has more therapeutic impact on some individuals than vast amounts of verbal expression has on others.

WORK

(Published in the East Bay Psychiatric Association Newsletter, September 2006)


I recently heard about a study that found that people who take vacations function better in the work place. The study’s findings revealed what most of us probably already know. But unfortunately, the work force in our country is actually becoming more and more “work addicted,” either out of fear of losing one’s job because one might be seen as a slacker, or because social and economic pressures increasingly communicate to people that their worth as a person is measured in the dollars they earn--and staying on the job longer means more dollars. On average, Europeans get three times more vacation time than Americans. During the 1990’s, The Netherlands, Sweden, and Denmark matched our productivity rate without our over-zealous work ethic. The explanation may well be that working extra hours does not make you more productive, because after a certain point, you are exhausted and burnt out.

How did we get to this place in our society where people have come to believe that they should not take time away from work? Where did our society lose its sense that a balanced life requires intellectual, cultural, spiritual, and recreational activities in addition to one’s job? Is our country’s raison d’etre simply a matter of getting more economic productivity out of its citizenry, rather than also promoting individual well-being and social progress?

Today, parents of newborns compete to gain enrollment in more and more competitive pre-schools for their little scholars-to-be. First graders get homework. Taking the SAT’s in high school is a nightmare for the competitive college-bound senior. And many high school students and their parents believe that not getting into a prestigious college dooms their chances for a successful life. Getting ahead means just that, and if you are not always working, perhaps you will not get ahead. In other words, children don’t get to have a childhood, and adolescents don’t get to have an adolescence. Everyone gets to be a “work addicted” adult right from the start.

I see adults in my practice who are the result of these overly driven and competitive childhoods. They are anxious, fearful, and lacking in the capacity to experience their lives as joyful. They may have panic attacks, high blood pressure, high blood sugars, as well as dysfunctional relationships with their spouse and children. In fact, they unknowingly have become unhappy as a result of following this prescribed course toward happiness, which apparently now includes the belief that taking a vacation might interfere with success.

The ability to step back from our work--whether it is by traveling to some distant shore, or simply by going to the shore--provides us a chance to relax and reflect on the meaning of our existence and to find new meaning in our lives. We become re-awakened by vacations and ready to return to a job with a new sense of vitality. Vacations allow quality time for a family or for an individual. It exposes us to places and activities that we cannot access in our ordinary work world.

Driving to and from work or the grocery store in vehicles with names like Yukon, Serengeti, Outback, or Tahoe, is not anything like being in those actual places. But if a person does take a vacation, he might actually come to understand first hand what all the fuss is about in places with those names, and he might even like his job more, knowing that it’s not an activity that will consume every one of the 52 weeks of a year.

Suicide of a Patient--The Psychiatrist and Grief

(Published in the Northern California Psychiatric Society Newsletter, December 1998)


This week was a difficult one for me. My normal schedule was interrupted by attendance at the memorial service for a patient of mine who leapt from the Golden Gate Bridge the day I returned from a week-long vacation.

I don't remember being so saddened by the loss of a patient. Throughout the course of most of her treatment, she remained suicidal, despite extensive medication, ECT trials, and intensive psychotherapy. But I had come to believe that the power of our close therapeutic relationship would overcome her pain. When I was told of her death, I was not wholly surprised, and actually felt some relief for her. But when I went to her memorial service, I could hardly believe she was gone, and I felt an enormous sense of loss. My disbelief was so great that I had numerous fantasies of her showing up at my office during the following days because she had not really killed herself.

What surprised me most, was how attached I apparently was to my patient, despite the presumed mastery of "detached concern" I thought was so much part of my professional makeup. After the cermony, the patient's sister and I, not ever having met, mutually embraced, instinctively knowing each other's need for comfort. The sister, who looked and sounded so much like my patient, held on to me, and I to her, and for a moment I thought I was embracing my patient, now in death, the way I knew I never could in life. It was a profoundly emotional moment, a "cleansing" moment, and one which I will not soon forget.

I have re-learned many lessons from this tragedy: the limits of my powers as a physician, the extent of some of my patients' dependency on me, and not the least, the magnitude of my own attachment to some of the people who make their weekly trip to my office. I hope that the peace that so eluded this person in life is with her now, as no amount of my understanding or attention to her psychiatric condition was sufficient to bring her that relief in life.

THE FUTURE
(Published in the East Bay Psychiatric Association Newsletter, January 2005)

One thing is certain: no one can predict the future! While this sounds obvious, people behave as if they can foretell what lies ahead. In reality, the world moves forward in accidental, serendipitous, and random ways. If one looks at the contents of “time-capsules” that people left behind with instructions to be opened 100 years in the future, what one finds are predictions that are wildly off base. And many major scientific breakthroughs often occur serendipitously during a search for unrelated scientific truths.

Fifty years ago no one had any notion of the home computer, a technological advancement which influences things we do almost every minute of every day. One small aspect of the computer revolution is how the lives of seniors have been enhanced. The elderly, who often live alone and have limited ability to move around, have enormously enriched lives now because of their in-home access to e-mail and the Internet. Do you think that Dell or Apple had any inkling years ago that the market for personal computers would be so huge for the senior population?

Back in the 1800’s, before recording devices existed, if people went to a concert, they would hear a performance of a piece of music that they would likely never hear again, regardless of how much they enjoyed listening to that piece of music. This week my son bought an I-Pod, which has the capability of holding 5000 songs of his choosing in its memory. In a little mechanism smaller than his wallet where he can listen to music over and over again wherever and whenever he chooses. Find me an article from a couple of decades ago that foretold of such an innovation.

We are even less capable of controlling our future than we are of predicting it. Did you really control how you met the person who is your life partner? Did you really have control over the specific job offer that has led to so much of what you do everyday? Of course the most accidental and unpredictable of all things is whether or not you were even born in the first place. Think about all the couplings of people that had to occur in your ancestors exactly at the right moment, leading up to the existence of your parents, and then the precise egg and sperm that had to unite to form you. Talk about overcoming extreme odds.

Perhaps life is best lived without excessive regard to trying to control what is going to happen in the future. In other words, try to live in the present. Some future planning obviously makes sense, but what you are going to be doing five years from now, let alone what happens to you tomorrow, may be a lot less predictable and a lot less in your control than you think.

"Brokeback Mountain" and The Art of the Screenplay

(Published in the East Bay Psychiatric Association Newsletter, January 2006)


It is not often when a book and a movie are equally masterful. But within the recent Academy Award nominated best film category is "Brokeback Mountain", adapted from the short story by the same name in Annie Proulx’ book of short stories of the American West entitled "Close Range". The movie and the book are both exceptional artistic achievements, neither to be missed.

According to Ms. Proulx, when asked to discuss “that gay cowboy movie”, she said, “Excuse me, but the story is about two inarticulate Wyoming ranch hands who experience something they don’t understand and can’t put words to.” So much for the romantic fantasy of the hard drinking, gun toting frontier cowboys as heroes who won the West—this story completely explodes that mythology.

The story/movie deals with homosexuality in the pre-AIDS and pre “out of the closet” era of 1963, but it is not so much about sexuality as it is a love story between two people who are lonely and isolated. The full-length movie is amazingly true to the relatively brief, 35 page long short story, as it is virtually identical in dialogue and content. It is a creative tour de force for the screenwriter to be able to flesh in the details of the characters in the movie so well, based on such a brief tale. Yet this is also to the credit of the story’s author, who has been able to create such full and colorful characters in such a brief story.

As much as I liked the movie "Brokeback Mountain", I enjoyed reading that story and the others in "Close Range" even more. The loneliness and emotional impoverishment of Ms. Proux’ characters are so penetrating that one feels transported into the lives of these people in the rural ranch-land of Wyoming.

As a psychiatrist, it was notable to me that this story so effectively conveyed the difficulty that emotionally deprived people have in “making love” as opposed to “having sex”—or in some of the stories “taking sex.” This seems to be an underlying dynamic in the lives of many of the Proulx' characters, as it is in some of my patients as well.

Whether you see the movie, read the story, or do both, I think you will agree, "Brokeback Mountain" represents a breakthrough in cinema and story telling. And it is the screenwriter who can take credit for transforming one media form into the other so masterfully.

“ALL THE SAME”

(Publshed in the East Bay Psychiatric Association Newsletter, August, 2006)

I recently left my one-half day a week part time job at the Contra Costa County Forensic Mental Health Clinic. My responsibilities there for 14 ½ years had been primarily to provide medication management for some 40 conditionally released offenders who were undergoing mandated treatment in the community after a period of years stabilizing in a state mental hospital. Typically, these patients had committed major felonies while psychotic, had been found “not guilty of reason of insanity”, and were diverted from the prison system to the state mental health system. Their crimes were the worst kind, such as homicide (including infanticide), unprovoked assaults, and arson.

I enjoyed this part time work as a contrast to my own private practice. These two patient populations were about as different as night and day. The forensic patients typically came from minority groups in the inner city, had disadvantaged or abusive backgrounds, and often had psychoses complicated by substance abuse. These were the “throwaways” of the population—the people no one wanted. In contrast, my private patients were drawn mostly from the white, suburban, professional class—the people of privilege.

What surprised me was the impact that my leaving this job had on some of the patients. I had not realized that my relatively brief visit with them monthly for prescriptions and support had had such an impact on many of them. Some simply said polite goodbyes at their last appointment. But others amazingly spoke eloquently about how they felt at a little retirement party. And one of the female patients, with whom I felt very little connection, said something very poignant. She suffered from a major psychosis as well as a personality disorder. At her last visit, she brought me a small bouquet of flowers, an appropriate retirement card, and said, “Dr. Winig, you’re a good doctor. You treat us all the same,” and she started to cry.

I realized then, without having fully appreciated it before, that I was taking care of certain people for whom being taken care of was a very foreign experience. Perhaps no one else in their lives cared very much about them, or certainly never treated them as if they were “the same.” It was natural for me to do this. I was just being their doctor. But for some of these patients, the nature of the human relationship that they had with me may have been qualitatively different from anything else they had ever known.

It is important to keep in mind the powerful impact we may have on our patients. Even brief contacts may bring an individual hope and the sense that they are worth something, in the face of a lifetime of experiences that may have communicated something quite different. Sometimes, what seems so simple may actually be quite profound.

THE PRICE OF SELF-DECEPTION

(Published as a review of Arthur Miller's play "The Price" in the East Bay Psychiatric Association Newsletter, October, 2005)


I recently saw Arthur Miller’s play "The Price" at the Aurora Theatre in Berkeley. This is another one of Miller’s incisive and insightful dramas, like his Death of a Salesman, that cuts to the quick regarding the failure of families to face their own reality. This play was written in 1968 as a metaphor for our own government’s lack of honesty in facing up to its failed policy in Vietnam. As Miller himself said then, “50,000 Americans and millions of Vietnamese paid with their lives to support a myth and bellicose denial.”

The struggle for many families to deal honestly with their lives probably lies in their attempt to maintain a fragile balance between practicing a certain amount of self-deception versus risking the total breakdown of the family unit. Many families have an “elephant” that sits at the dinner table every night that is never mentioned, so that the family can survive, albeit dysfunctionally.

Sometimes this fragile balance breaks down in unanticipated ways. Recently I saw the mother of a 21 year-old son who had bipolar illness and alcoholism. For years the family had not been strong enough to confront this child’s chaotic, dysfunctional behavior, which escalated at times to physical assaults and death threats on the part of the son within the home. The family remained largely codependent, choosing to avoid confronting the son and practicing self-deception, until one day they finally called the police. The son was then in turn jailed and hospitalized, but tragically took his own life while in confinement—not exactly the kind of resolution the family had wished to accomplish.

Miller’s "The Price" is an attempt to show “that through the mists of denial, the bow of the ancient ship of reality could emerge.” His metaphorical use of family self-deception to reveal the nation’s problem confronting the Vietnam War in 1968 holds true today as well. We as a nation are now facing a similar dilemma as our administration explains its rationale for the war in Iraq in varying ways depending on how events unfold. Most recently we were told that the reason to “stay the course” is not to dishonor those brave soldiers who have already died in the conflict, as if simply sacrificing more troops will do more good. (We were also told that in the Vietnam War era when only 100 soldiers had perished). A more honest approach, a la Arthur Miller, would be to come clean as to why we are in Iraq in the first place—why we are building the biggest American Embassy building that exists anywhere in the world, and why we are establishing Air Force bases around that country. But to do that would risk the already eroding public support for the war, and throw the “family’ into chaos. Better to practice deception, it seems our administration has concluded. But this also robs the nation of a chance to change course correctively.

People (and nations) will pay “the price” in the present for dysfunctional decisions they have made in the past, and then take no corrective action in the present. As an individual, for instance, one may be overly attached to a parent, or manipulated by that parent, to make a choice of a career or spouse that is not really one’s own. The price paid can be a lifetime of unhappiness if self-deception is practiced. Similarly, Miller tells us, we pay a price as a nation when we make choices and then do not deal with the reality of the consequences.

Whether one is running a government, a company, or just helping a family or individual to cope, denial and self-deception can get you only so far. At some point you will pay “the price.”

THE NONEXISTENCE OF RACE

(Published in the East Bay Psychiatric Association Newsletter, September 2000)

When I was a little boy, before the age of 4, I lived in a town in upstate New York. In my neighborhood, there lived a family with two girls close to me in age, the Chu sisters. I would play at their house and they at mine. When we moved away, the Chu family gave my brother and me a copy of Grimm’s Fairy Tales as a present, inscribed with best wishes from them. I did not know that they were Chinese, as I had no concept of race.

A few years later, my parents were told by our extended family who still lived there, that the Chu’s were forced to move--that some of the neighbors had maliciously banded together and pressured them to leave: “No Chinese Allowed!” As a youngster, I did not understand then what had happened, as I still had no real concept of race.

When I was growing up as a schoolboy, race began to be presented simplistically. One was either of the Black, White, or Yellow race, and everyone could see that such differences existed. Then as Native Americans were considered, a Red race was discussed. As time went on, I began to ask questions about people who were not Black, White, Yellow or Red. Few answers were forthcoming, so I turned to the encyclopedia. There the concept of race was enlarged to 9 groups, including such exotic peoples as Micronesians, Melanesians, and Australoids. I felt satisfied, based on encyclopedic information, that I now was beginning to really understand the concept of race. However, later, while in college, I read an article that expanded racial groupings to 21, and now I was beginning to get confused and to question how scientists were coming up with these groupings.

Now that the human genome project is marching forward, some remarkable information is being uncovered. The geneticists at Celera Genomics Corporation, which were the first to unravel the human genome sequence, have drawn some dramatic conclusions. The different physical characteristics that make up different “races” appear to be only “skin deep.” One-hundredth of one percent of our genetic material accounts for these physical differences, such as skin color, lip contour, hair texture, etc. The other 99.99% of our DNA is the same from one ethnic group to another. Genetic endowment of such complex characteristics as intelligence requires at least 1000’s of genes, and cannot be distinguished by looking at the DNA of one ethnic group or another.

In a recent article in the New York Times, the “Out of Africa” theory is outlined. According to this theory, modern Homo Sapiens originated between 200,000 and 100,000 years ago, at which point, a small number of them, perhaps 10,000 or so, began to migrate into the Middle East, Europe, Asia, and across the Bering land mass into the Americas. Since that time, a mere 7000 generations have passed. Because of such a limited founding population and such a short time since dispersal, humans are strikingly homogeneous, differing from one another only once in a thousand subunits of the genome.

Because Homo sapiens have only been around for these 7000 generations, only different ethnicities, with differing physical traits, have become distinguishable. Ethnicity is a broad concept that encompasses both genetics and culture, whereas race only takes genetics into consideration, and therein lies the crucial difference. We seem to be a single human race, as biologically we have the same complex set of human genetic characteristics, as do all our fellow men.

Those obvious physical ethnic differences that do exist are adaptations to the environment, stemming from specific mutations that gave that group living in a certain region an advantage (like pale skinned people in Northern Europe being more able to produce Vitamin D from pale sunlight). Formulating the concept of a single human race, which comes in a variety of “flavors,” should alter our current categorization of each other which falsely places us into several different racial groups.

Learning about race while growing up in American society has misled most of us into believing that somehow we are biologically different from people of other races. What may be true, is that we are significantly different culturally, and that may be the source of distrust or prejudice. Race is very politicized in this country, unlike elsewhere. Here, it may be good to be of a different race, as you represent diversity. (College admissions committees are intensely interested in racial diversity of their student bodies). Or it may be bad to be of a different race, as is the case when people band together to keep away people who are unlike themselves. (Realtors often work hard to keep neighborhoods racially distinct, believing that this keeps property values higher). Whatever the case, race in America is rarely viewed from a neutral perspective.

The elimination of biology from the formulation of race as a result of the human genome project may be a quantum leap forward toward helping us all coexist more compatibly. Unfortunately for the Chinese family in that neighborhood of my early youth, this data comes somewhat late, as it does for all other individuals who have suffered the indignities of racial prejudice. However, just as placing a man on the moon led to a variety of scientific discoveries unrelated to space travel, the human genome project may lead to certain sociological advances unanticipated by this biological research.

G.I.'s Battered by the Trauma of Iraq

( Published as a letter to the Editor in the New York Times, December 17, 2004)

To the Editor:

Re ''A Deluge of Troubled Soldiers Is in the Offing, Experts Predict'' (front page, Dec. 16):

As President Bush cavalierly hands out Medals of Freedom to three people who were central figures in the war in Iraq, it might behoove him to observe what his policies have wrought: tens of thousands of soldiers with psychiatric problems who, you report, ''are going to need help for the next 35 years.''

The president is trying to write the history of the Iraq war as a success despite its uncertain outcome.

Expert predictions of the emotional devastation befalling another generation of young Americans sent to war is one of many reasons Mr. Bush sounds more like a salesman than a statesman.

The psychiatric impact of this war on our troops was as predictable as night following day by those of us who work in the field.

Hugh R. Winig, M.D.

(The writer is a psychiatrist.)

Dangerous Precedent—The Unabomber Case

(Published as a letter to the editor, New York Times, December 5, 1997)

To the Editor:

Re “Brotherly Intervention” (Op-Ed, Nov. 29): We can all be indebted to David Kaczynski for helping the authorities apprehend his brother Theodore Kaczynski, the suspect in the Unabomber case. But there will be little assistance from family members again in such cases if we put their kin to death: this would create too great a moral dilemma for even the most law-abiding among us.

For prosecutors in the Kaczynski case to close their eyes to this human conflict is to create a dangerous precedent. No one else will ever be harmed by Theodore Kaczynski if he is imprisoned for the rest of his life, but someone likely will be if he is executed for his crimes. Here is yet another example of how the death penalty creates problems instead of solving them.

Hugh R. Winig

WOMEN’S EMPOWERMENT IN THE GLOBAL SOUTH

(Published in the Northern California Psychiatric Society Newsletter, May 2004)


This adventure occurred only one year ago, but it had its roots more than 20 years in the past, as you will see. It was in May of 2003 that my wife, my daughter and I traveled to Peru to visit two remote areas—one in the High Andes and the other in the Amazon Basin. These are not areas that tourists tend to visit. In fact, in the Amazon, we visited two communities never before contacted by a group from North America. We were 7000 miles away from the Bay Area as part of a delegation of 15 people from the American Jewish World Service (AJWS). We were in Peru to observe the work of two non-governmental organizations (NGO’s) as they furthered the cause of empowering women to better control their health and their finances.

In part, this is a family tale, as my daughter works in international public health and was one of the leaders of the trip. The beginnings of this trip really trace back some 20 years, when our children were fairly young (ages 14,12, and 8). My wife and I decided then to begin to invest some of our resources in foreign travel as a family. We recognized that raising children in the Bay Area suburbs was not a sufficiently broad experience. We felt that the kind of family trips we were taking like camping and going to Yosemite should be supplemented with international travel experiences. This venture to Peru was but one of a myriad of international experiences that members of my family have participated in during these following two decades; but this trip, in particular, seems to have been a direct consequence of encouraging such experiences as a family 20 years earlier.

But back to Peru, which is a country located in what is now called “The Global South,” to be politically correct, as opposed to the more outdated terms such as the “developing world” or the “third world.” Peru is a land of beautiful mountains and captivating sites and people, but also a country with grinding poverty that leaves some children with only rags for clothes, no bed to sleep in, and no shoes to wear. Their runny noses just run—there’s nothing like a handkerchief or a tissue in such circumstances. Giving them a single colored pencil doesn’t just make their day, it makes their whole week! How could the local NGO’s help raise the standard of living in these remote areas, and how could AJWS help?

There were several challenges on this trip, not the least of which were medical in nature. I was not the trip doctor, but since I was the only physician in the group, I had prepared myself with knowledge and medicines to help my fellow travelers if they got into trouble with altitude sickness in the High Andes, or other maladies in the searing heat of the remote Amazon Basin. Suffice it to say, the Diamox, dexamethasone, and Cipro that I brought with me were put to good use! Fortunately, despite the severe environments we encountered, no one took seriously ill and had to leave the trip.

In the city of Puno in the Andes, we observed social workers and group therapists from the NGO “Pro Mujer” (“For Women”) provide services that would make any county public health department in this country proud. These workers built women’s self-esteem with workshops expertly conceived and conducted; they provided “micro-credit” to help start or stabilize women’s small businesses to establish greater financial independence; and they provided medical clinics for all health matters, including reproductive health. Pro Mujer also ran a radio station, which transmitted daily educational “soap operas” which cleverly depict characters having family or health problems that were illustratively solved within the context of the radio show.

The women clients of Pro Mujer, hundreds and hundreds strong, were gradually learning to take control of their lives. They could better stand up to the abuse they often encountered at home, and they could begin to use their financial resources from their succeeding businesses to help their children and themselves. They were already politicking for day care centers for their children so that the children would have a safe place to be during the day while the women attended to their shops in the open marketplace on the streets. In short, the women were learning to break the cycle of poverty and dysfunction that had previously characterized their lives. This NGO seemed to be “heaven sent’ for these women, and our delegation knew that they deserved the technical, financial, and volunteer assistance that our organization (AJWS) was prepared to provide.

In the Amazon, we visited with the leaders from the NGO “Minga Peru” (“Collectives for Peru”). We began by staying overnight in the large city of Iquitos, some 400,000 strong and the largest city in the world not accessible by car (one has to travel there by plane or boat). The following day, we went by motorized canoe some 80-100 miles up the Maranon River, a feeder river into the Amazon, which begins in Iquitos. This river area is three times the size of California, but populated by just 900,000 people. There are 492 communities of indigenous peoples living in the river areas, comprising some 40 different ethnic tribes. Most of the people live in very small, impoverished communities, and some speak only their tribal dialect and no Spanish. They provide their own subsistence, their own health care, and travel about the river by canoes. Infant mortality is high as is death during childbirth. Public Health nurses travel 600 miles up river to visit each of these communities by motorized canoe bringing in health supplies and medical knowledge during their occasional month long trips.

Minga Peru provides amazing services to these remote and impoverished people. We observed childbirth classes utilizing the most modern methods of instruction for the community members who provide these services. Engineers are sent into these communities to help them construct fishponds to be able to grow and harvest fish to sell in the markets along the river. Agricultural experts are sent to teach how to plant the land to raise agricultural products. Minga also runs a radio station in Iquitos with educational soap operas broadcast to the river communities by radio tower transmission that plays on the radio station at 5:00 am over load speakers for all to hear as they start their day. (The communities have no electricity or running water or personal radios).

American Jewish World Service supports community based projects of grassroots NGO’s in an attempt to help groups lift themselves out of poverty a step at a time. AJWS is an independent, not-for-profit organization founded in 1985 to help alleviate poverty, hunger and disease among the people of the world regardless of race, religion or nationality. Their projects involve health, education, sustainable agriculture, economic development, emergency relief and reconstruction, women’s empowerment, and the building of civil societies. They are active in over 50 countries with over 100 projects. The premise of the particular project of women’s empowerment, which we observed, is based in part on studies that show that if women are given funds and supportive services, that they tend to utilize these resources for the benefit of the family. When similar resources are given to men, these monies tend not to be spent for the welfare of the family and are often misused.

Traveling, particularly to countries which are not yet industrialized, has a very broadening effect on one’s psyche. One appreciates more the economic advantage and freedom that we take for granted here in the United States. But even more importantly, one develops empathy and understanding for people around the world and not just from a nationalistic perspective. This is the concept that President Kennedy recognized when he conceived of the Peace Corps originally in 1960.

One never knows what experiences have an impact on children growing up. Twenty years ago, I never imagined that taking family trips abroad could eventuate in a trip to remote river communities in the Amazon Basin. This article has not been about child rearing practices; but it is of more than passing interest to me as a psychiatrist to observe retrospectively how what I thought was a simple way to expose my children to more than just the community they lived in, actually helped shape their careers, their personalities, and their political views of the world. Each of them has become someone more than just an American citizen; they are really global citizens and their psychological sense of themselves has stretched them well beyond the typical boundaries of who they are as individuals.

In these troubled times, it is heartening to know that there are still places to go and activities to pursue, that have nothing to do with national defense or fighting wars. There is a world of poverty, hunger, and despair all around the globe, but there is also a world of opportunity to do something about it.


Hugh R. Winig, M.D.

THE DEPROFESSIONALIZATION OF PHYSICIANS

(Published nationally in Psychiatric News, February, 2000)


Back in the last millennium when I was a young doctor, becoming a physician meant that one had a “calling”, something quite different than “going into business.” In those days, being referred to as “doctor” meant you commanded respect and were esteemed. Back then, the purpose of insurers like Blue Cross and Blue Shield were to see that their clients’ claims were paid. And in those days, the purpose of the hospital was to provide care for the ailing patient until s/he was well and could return home healthy.

Times have changed! CEO’s and other “bean counters” and business people of all sorts have hijacked American medicine and run it as if it were a manufacturing plant. Their “calling” is to make a profit, and the purpose of the insurer is to deny claims. The hospital’s goal, once the procedure or treatment is completed, is to get the patient out of there as soon as possible.

The latest tactic in the health care industry is to supplant the physician with all sorts of “physician extenders”, much like “beef extenders”, I guess. The physician’s care is becoming limited to doing the procedure or supervising the treatment. There is no need for the doctor to have a relationship with the patient--the “extender” will do that!

The art of medicine is dead. Even we psychiatrists, specialists in forming therapeutic relationships, talk more these days about neurotransmitters than about the angst of mental illness. Calling a physician’s office is now less of a personal experience than calling an airline to get a plane reservation. At least the person making my reservation talks to me politely and takes time to explain things. My doctor’s answering machine, in contrast, tells me to hang up and call 911 if I am having a life threatening emergency; otherwise I am instructed, after pushing many numbered options, to leave a message which may be responded to within 24 hours.

Physicians have been deprofessionalized. We are now all just “providers” in a massive health care industry which is increasingly impersonal, detached, and profit driven. Forget about even calling yourself a physician--your patients won’t know the difference between you and your “extender” anyway.

Fortunately for me, my career is in its late stages, and I am still able to practice the old fashioned way. I have a small one-man “cottage industry.” I try to provide personal attention for my patients, answer incoming calls when possible, return peoples’ messages promptly, and (of all things) even do my own psychotherapy. But I fear, as do my peers, that there will be no doctors left in the future to take care of us with the personal attention, patience, and understanding that once was common practice.

Don’t get me wrong, I appreciate much of this new high-tech age in which we live. I love the ease with which the internet connects me to information, and I value the convenience of my cellular phone. But I’ll take the physicians of yesteryear any day over today’s “providers.” Those doctors did have a calling and did know how to practice medicine as an art form. They knew how to comfort and how to ease suffering, and they understood the importance of a therapeutic relationship.

The tragedy of American medicine falling from its Golden Age, to what it has now become, is clearly a product of capitalism at its worst. When medicine is governed by health care planners whose only concern is profit, then the number of people who die because of premature discharge from the hospital amounts to a simple calculation of potential malpractice losses versus salaries saved. But if the person who died unnecessarily happens to be your loved one, the result is actually incalculable! Perhaps if every business person or insurer working in the health care industry today was required to work on an oncology unit, a hospice, or a psychiatric facility for a period of time, they would appreciate the nature of medicine rather than seeing it as just a business.

Medicine was never designed to be a business, and it never has been a good business, as measured by business parameters. Yet, one of the greatest accomplishments of twentieth century America, has been the nearly doubling of the human life span. This occurred, not in the context of worrying about every dollar spent, but by persevering in the development of medical science and improving the practice of medicine.

We are no longer struggling with recessionary pressures in our economy as we were 8 years ago, when the dismantling of American medicine began for the sake of controlling inflation. With the explosion of wealth over the past several years, maybe we can get back to quality in medicine, and let physicians run the show again. Business people can return to running businesses, and we’ll all be better off!

Hugh R. Winig, M.D.

SONS OFF TO EUROPE

(Published in the Contra Costa Times on Memorial Day, 1995)


This Spring I will be attending three graduations--my daughter's from graduate school, my older son's from college, and my younger son's from high school. Our family will also be celebrating my wife's 50th birthday--she was born exactly on V-E Day itself! As my children look forward with hope and optimism to their new lives, and in the midst of all of these wonderful family celebrations, my own thoughts turn to remembrances and gratefulness.

Coincidental with this 50th anniversary of V-E Day, both of my sons independently settled on the idea of marking their graduations by backpacking abroad this summer with a few of their best buddies to see the sights of Western Europe. My wife has felt a bit of maternal trepidation about their plans, especially the younger one's, even though he has traveled or lived abroad the past two summers. But, as their father, I can tell you I have a very different take on this bit of freedom my sons are exercising.

This summer is 50 years since the end of World War II! Fifty years since the liberation of Auschwitz and the loss of 6 million Jews! Fifty years since the Russian war dead numbered 20 million! And fifty years since the execution of Mussolini and the death of Hitler! Fifty years later, and my sons are the beneficiaries of all those who fell at Normandy, on Omaha and Utah Beach. My 22 and 18 year-old young men will be off to Europe with backpacks bought at our local mountaineering store, not government-issue duffel bags. They will leave with water bottles for hiking in the serene hills of Italy and France, not with canteens and mess kits issued by the military to help them survive battle-torn Europe. And they will buy eurail passes to crisscross Europe freely, not find themselves herded into cattle cars headed for a certain death in a concentration camp.

How does a father like me thank all those men lying under crosses and stars in Europe's battlefields and war cemeteries? How do I convey to my sons the good fortune they have to live in this generation, not the one that came of age fifty years ago? Who was looking over them and me when our turn came to travel this way?

I'm not a "love it or leave it" patriotic type, but I do like to fly the American flag on the Federal Holidays. I don't like it that school kids today have little sense of why they don't go to school on Memorial Day. There seems to be little appreciation for how the freedoms we take for granted were earned--most young people simply feel entitled to it.

If we can remember what this last fifty years has wrought, then there should be little but gratefulness that would fill our hearts. Had World War II ended differently, one can only try to imagine the nightmare that would have followed. Surely, none of us would have a life as we know it, or even have a life at all! From my perspective, I can honestly say, it's good to have 2 sons off to Europe this summer.

THE NEW SOUTH AFRICA

(Published in the Esst Bay Psychiatric Association Newsletter, April 2007)

This past February, my wife and I spent 10 days touring 3 major cities in South Africa: Johannesburg, Cape Town, and Port Elizabeth. We went on a Study Tour with The American Jewish World Service (AJWS). This charitable organization provides funds as well as volunteer and technical assistance to grassroots organizations in the developing world. It helps support over 300 projects in some 36 countries in Asia, Africa, and South America. We visited about a dozen such non-governmental organizations (NGO’s) in an effort to understand their efforts in combating the HIV/AIDS pandemic now ravaging South Africa. One thousand people a day are dying there from this disease, and twice that many are becoming newly infected daily.

I knew little about South Africa prior to this trip, outside of its history of apartheid. I learned that from 1948 until 1994 blacks not only had no vote, but that they also were deprived of any meaningful education. In 1994 after South Africa became a democracy and freed itself of their racist white government, blacks were left uneducated, unskilled, and living in townships where they had been forcibly moved, in conditions of abject poverty. Shacks housing millions of people with little or no amenities or employment opportunities stood on the outskirts of the cities we visited. These slums were worse than anything I could imagine, although I have since learned that 1 billion people worldwide, or more than 1 in 7, live in such conditions. I was unprepared for what I saw, and my emotions welled up inside me more than once.

Nearly 19% of South Africa’s adult population is now HIV positive. The Mbeki government made things worse for a time as they denied the link between HIV and AIDS and promoted folk remedies and stood in the way of people getting the Anti-Retroviral Drugs (ARV’s) critical to controlling the virus. Conditions in hospitals were unlike anything we westerners are familiar with. In one hospital, I saw hundreds of people filling every nook and cranny waiting to be seen. The AIDS clinic opened at 8 am and closed at 4 pm that day. People started queuing up in the early morning hours in hopes of being seen. The elderly would have someone younger in their family hold a place in line for them until the clinic opened. If you were fortunate, a health worker would examine you and report to the single physician manning the clinic that day so that you could receive medication and/or other treatment. If you were not so lucky, 4 pm would roll around and you would go home to start the same process again the next day.

In South Africa HIV/AIDS is primarily a disease of heterosexuals, transmitted in the black community by the men who do not acknowledge their HIV status, to the women they have sex with, either consensually or forcibly. The ABC’s that are being taught to the populace are “Abstinence, Being Faithful, and Condomizing.” Because of the overwhelming number of AIDS deaths every week, and because funerals are held only on Saturdays and Sundays by custom, weekends are consumed with funerals, and the graveyards are fast filling up.

Because we were traveling with a group that helps support the agencies we were visiting, nearly everywhere we went the workers greeted us with songs in their tribal dialect with beautiful South African rhythms and harmonies. One Sunday we went to services in a Church in the townships and heard perhaps 1000 such voices singing Gospel songs. Even for a non-believer like myself, it’s difficult to imagine that the beauty of these voices was not being heard on high. It was a powerful spiritual experience.

Every time we witnessed situations that seemed overwhelming and made me feel hopeless, we would meet ordinary people doing amazing work to overcome the double scourge of the residues of apartheid and the current blight of AIDS, and I’d feel hopeful again. We met exceptional human beings throughout our trip, but of special note were three people from three different generations: Helen Suzman, age 89, was the leading voice in the Parliament for 35 years speaking out against apartheid; Helen Lieberman, age 63, a social worker in Cape Town, founded her own NGO, Ikama Labantu, and has devoted her entire adult life to providing social services for blacks despite enormous personal danger to herself for doing so; and Jacob Lief, a precocious 29 year old American, has set up his own extensive non-profit social services organization in Port Elizabeth and demonstrates the acumen of a corporate CEO in dealing with his complex organization.

We drove down the only street in the world where two Nobel Peace Laureates reside—Bishop Desmond Tutu and Nelson Mandela. The prestigious international recognition of these two contributors to overcoming apartheid signifies the importance that others have attached to building a new South Africa.

South Africa looks very much like the United States, unlike what I felt when I was in East Africa some 10 years ago where everything there looked different to me—the sky, the landscape, and the cities. But in South Africa, I felt at home. Johannesburg was like New York City, Cape Town felt very much like San Francisco (including having its own wine lands an hour away), and Port Elizabeth was a lot like many moderate sized beach towns along our coasts. The country is a mix of first world western conditions contrasted with, and lying adjacent to, developing world conditions. It’s a country worth visiting for many reasons, not the least of which is that it is on the brink and needs our help. I encourage you to go there and to educate yourself about this vast land on the opposite side of the globe half surrounded by the Atlantic and Indian Oceans. You won’t regret having made the effort. It’s quite a place to behold and a place worth saving.


--Hugh R. Winig, M.D.

TIME MOVES IN ONLY ONE DIRECTION

(Published in the East Bay Psychiatric Association Newletter, May 2007)


When my Dad turned 80 some years ago, a friend of mine gave him a book entitled “Getting Old Is Not For Sissies.” I didn’t fully realize then the implications of the title, as I was still in my late 40’s at the time. Now, as Medicare and Social Security loom around the bend for me, I am beginning to appreciate better the hard work of getting old that lies ahead. The march of time takes its toll on everyone, and everyone needs to train him or herself to be old in order to avoid certain pitfalls. Getting older requires major attention to one’s emotional, attitudinal, and physical wellbeing.

The emotional side of things is probably the subtlest. People have to learn to be comfortable when they no longer have a schedule, when they no longer are earning an income, and when they are spending more time alone. For most people this is a radical change, as one’s earlier adult years were usually spent maximizing income within the context of a job with a schedule and social interactions. Leisure time, although previously yearned for, may now feel unnatural; and time alone, rather than being enjoyable, may be experienced as isolative.

A shift away from one’s earlier sense of purpose begins to occur between ages 50 and 70. It is during this period that one needs to behave more like we did as children--to be able to play, to enjoy whiling away the time, and to pursue activities just for the sheer pleasure of them. One has to strategize about these new realities or one will be bored, no matter how much money and freedom one has carefully planned for. I’ve known retirees who can’t find enough hours in the day to pursue all the interests they have, but I’ve also known those who complain that “retirement is not all that it was cracked up to be,” and they dread the boring days that stretch out before them.

For those living in the transitional stage going from “working hard” to “hardly working,” it is important to take the time to understand your new needs, to assess your physical, emotional, and financial health, and to develop a plan to address your new realities. Retirement can be a time of creativity, newfound freedom and interests, and revitalization, but alternatively it could become a time of stagnation, isolation, and decline. There are academic courses to be taken, arts and crafts to explore or master, cultural interests to pursue more extensively, more time to spend with friends, and time to travel more extensively.

Attitude can be critical. A year ago my wife and I took an adventure trip to Costa Rica and Panama. It was a small boat cruise with elective physical activities every day, including kayaking, snorkeling, hiking—you name it. One of our travel companions on this trip was a 90 year-old man named Sidney who had taken the trip with a much younger female friend (his wife had died many years earlier), knowing he could no longer partake in the challenging physical offerings on the cruise, but wanting to continue to travel nonetheless. Every evening after the rest of us were pleasantly fatigued from our day’s activities, Sidney and I would sit on deck with a cocktail and he would wax eloquent about his past years of growing his own business and about all the other places he had traveled to. He reported that he had turned over the ownership of his company to his son years ago, but still went to his office regularly to keep busy because “my son was kind enough to give me an office to go to.” Sidney’s companionship greatly enhanced my trip, and I know that he had a wonderful time that week as well. But it was Sidney’s attitude of continuing to engage life so fully that impressed me the most.

The other major challenge of old age is attending to one’s physical wellbeing. The major tactic for helping oneself is this area is developing the habit of exercise. If there is one single thing to do for oneself that can enable you to look better, feel better, and live longer, it is to exercise regularly. This doesn’t mean running marathons. It’s a simple matter of a three-mile walk or its equivalent four or more days a week. Forget all those other claims of revitalization that are advertised. Exercise is as close to the fountain of youth as you can get.

Despite maintaining a regular schedule of exercise, the ravages of physical decline with age may become overwhelming nonetheless. There can be losses that can change everything for the worse, and these losses may mount up and become overwhelming. Your own good health is one crucial requirement for happiness, but for those who are in a long-term committed relationship, the life and health of one’s partner is as critically important as one’s own. If you or your partner’s health seriously declines, or your partner dies, retirement becomes a far different experience than you may have anticipated or predicted.

I would recommend a recent article in the New Yorker magazine (April 30 edition) by Atul Gawande, the Harvard surgeon who is also a gifted writer. The article, “The Way We Age Now,” describes the physical aspects of the body’s inevitable deterioration and what can be done to manage these changes. Gawande is particularly concerned about that lack of trained geriatricians who know how to treat the physical and emotional needs of the elderly, as opposed to the average internist who is best at primarily treating disease entities. Geriatric patients are mainly at risk for depression, social isolation, malnutrition, and the danger of falling. Having a personal doctor who looks after you with regard to these risk factors is important if and when you get to be in your 80’s and 90’s.

To the degree that one does have some control in life’s later stages, it would seem best to exercise that control to maximize one’s happiness. Some things are, after all, out of our control, and since time moves in only one direction, the one thing we know for certain is that eventually we will all run out of time itself!


Hugh R. Winig, M.D.

I will be posting my non-fiction essays as well as letters to the editors of major publications on this site. My short stories and fiction are available upon request by e mail at hughwinig@yahoo.com.

Happy reading--Hugh R. Winig, M.D.