As the year draws to a close, I know of no better way to end it than to reproduce the sentiments of Oliver Sacks in his posthumous volume, Gratitude. It was written toward the end of his life, as he was in considerable pain.

Marks in the Margin was originally conceived in 2008 as a way to post passages from the books I’ve read. As it turned out, I never really did that. Today marks the exception, as I present the passages I copied from Gratitude.

In this instance, it is better to let the author speak, rather than provide a secondary account. It is also a reminder of how much there is to be grateful for.

Mercury is element number 80, and my dream is a reminder that on Tuesday, I will be eighty myself.

Elements and birthdays have been intertwined for me since boyhood, when I learned about atomic numbers. At eleven, I could say “I am sodium” (element 11), and now at seventy-nine, I am gold.

Eighty! I can hardly believe it. I often feel that life is about to begin, only to realize it is almost over.

At nearly eighty, with a scattering of medical and surgical problems, none disabling, I feel glad to be alive—“I’m glad I’m not dead!”

I feel I should be trying to complete my life, whatever “completing a life” means.

Some of my patients in their nineties or hundreds say nunc dimittis--“I have had a full life, and now I am ready to go.”

hope that some of my books may still “speak” to people after my death.

At eighty, the specter of dementia or stroke looms.

Love and work, the two most important things, Freud insisted, in life

“Whatever has a beginning must have an ending.”

One has had a long experience of life, not only one’s own life, but others’ too. One has seen triumphs and tragedies, booms and busts, revolutions and wars, great achievements and deep ambiguities. One has seen grand theories rise, only to be toppled by stubborn facts. One is more conscious of transience and, perhaps, of beauty. At eighty, one can take a long view and have a vivid, lived sense of history not possible at an earlier age.

I do not think of old age as an ever grimmer time that one must somehow endure and make the best of, but as a time of leisure and freedom, freed from the factitious urgencies of earlier days, free to explore whatever

I feel grateful that I have been granted nine years of good health and productivity since the original diagnosis, but now I am face to face with dying.

Over the last few days, I have been able to see my life as from a great altitude, as a sort of landscape, and with a deepening sense of the connection of all its parts.

There is no time for anything inessential.

I rejoice when I meet gifted young people—even the one who biopsied and diagnosed my metastases. I feel the future is in good hands.

I cannot pretend I am without fear. But my predominant feeling is one of gratitude.

the special intercourse of writers and readers.

Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.

I was fascinated by my patients there, cared for them deeply, and felt something of a mission to tell their stories—stories of situations virtually unknown, almost unimaginable, to the general public and, indeed, to many of my colleagues.

Almost unconsciously, I became a storyteller at a time when medical narrative was almost extinct.

It was a lonely but deeply satisfying, almost monkish existence that I was to lead for many years.

The peace of the Sabbath, of a stopped world, a time outside time, was palpable, infused everything, and I found myself drenched with a wistfulness, something akin to nostalgia, wondering what if: What if A and B and C had been different? What sort of person might I have been? What sort of a life might I have lived?

And now, weak, short of breath, my once-firm muscles melted away by cancer, I find my thoughts, increasingly, not on the supernatural or spiritual but on what is meant by living a good and worthwhile life—achieving a sense of peace within oneself. I find my thoughts drifting to the Sabbath, the day of rest, the seventh day of the week, and perhaps the seventh day of one’s life as well, when one can feel that one’s work is done, and one may, in good conscience, rest.


Where I Live

I live in a six story condominium in the shape of a U with approximately ten apartments on each of the three wings. There is a lovely garden on the first level, in the center of the three wings. Each morning I walk the hallway on my floor from one end to the other and, if I am not too tired, at night too.

I never see another person, the hall is as quiet as the middle of the Sahara. The door of each apartment is shut tight, in most cases locked. The inhabitants are as imprisoned as in any San Quentin cell. Were it not for my sociable wife, I’d never know who lives across the hall or down the way either. In the elevator I nod to those I don’t know and try to strike up a conversation with those I do.

Everything that happens happens inside the apartment. That is perfectly fine with me, as I am an introvert, hard of hearing, and try to deal with the pain in my back. So I sit in the chair at my desk and search for something to write about.

The Portland Streetcar stops across the street from the building’s main entrance. That is one of the attractive features of living in the neighborhood known at the Pearl District in NW Portland. The Streetcar runs on a round-trip route to the downtown area, Portland State University and what is known as the South Waterfront District.

In former times, the Pearl District consisted of vast warehouses, some of which were inhabited by local artists and a few stray mice. More recently the buildings have been renovated or torn down to make way for upscale condominiums.

The park across the main entrance of the building I live in has a community wading pool that in the summer is filled with toddlers and young children splashing around for hours on end. At the Streetcar stop there is an ice cream parlor known as Cool Moon. It is one of the most popular shops in all of the great state of Oregon. If you don’t mind waiting a few minutes, you can treat yourself to one or more of about 30 different flavors.

I first moved to this neighborhood about 15 years ago. I felt somewhat of an urban pioneer. There were only a couple of apartment houses then. Soon thereafter a building spree began; now there are numerous high rise condominiums for the countless individuals who are moving to Portland. Nearby are a wide variety of boutique shops, galleries and upscale restaurants.

Powell’s Bookstore is a short walk away and in the days when I was more mobile than I am now, I’d go there every day. Some consider Powell’s the best bookstore in this country. It is surely one of the largest. Reading a good book during the long, wet, and cold winters in this town is one of the reasons it’s so popular.

People usually visit Portland during the few months of summer there are here. This is a terrible mistake for everything appears so inviting then. So they sell their homes, pack up their furniture and head this way. Then the rains begin, the cloudy days stay around for weeks on end and it is often cold enough to snow. I wonder if they begin to have second thoughts about their decision and if a sense of buyer’s remorse takes hold of them.

Nevertheless, they remain here, contribute their share to the city’s air pollution, traffic congestion, and rising housing costs. Meanwhile, I yearn for warm climes and sunny days. Unfortunately, my life-long partner cannot imagine living anywhere else, so I am stuck with this city in the far Northwest of this land and her warm countenance.

Happy holidays to all.


Time Out of Mind

On any given night, about 4,000 people sleep on the streets or in shelters in Portland, Oregon, a city with a population of 625,000 people.

In New York, a city of 8.5 million people, more than 56,000 homeless men, women and children sleep in homeless shelters and at least 3,300 more sleep on the streets and subways in the dead of winter. This means that one in every 143 New Yorkers is currently homeless.

The homeless problem confronts every metropolitan area of this country. In most, solutions have been hard to come by. It was against this background that I watched Time Out of Mind, a film in which Richard Gere portrays George Hammond, a homeless man on the streets, alleys, and in condemned buildings and shelters in New York.

Night after night he looks for a place to sleep, something to eat and, yes, drink. Hammond is an alcoholic and mentally-ill. His sentences are mumbled, incomplete, he has a vague look. cloudy eyes and aimless expression. He has been unable to find a job, has no identification and can’t recall his social security number.

As a result, he doesn’t qualify for the financial assistance offered by City’s social services. He is alone, even when listening to a chatty sort-of-friend, and unsuccessfully tries to connect with his adult daughter, now working in a bar. Hammond is simply down and out, drifting from one day to the next.

I watched this film hoping to find a solution to the homeless problem. None are offered, none are even suggested. What I found was a powerful depiction by Gere of what its like to be homeless on the streets in America today.

The state of Utah has developed a promising approach for homeless individuals. The state had almost 2,000 homeless individuals, many with drug or mental health problems. The approach, called Housing First, starts by giving the homeless a home, a genuine private residence rather than a shelter or halfway house.

In the Utah’s initial pilot program, 17 homeless individuals were placed in homes in Salt Lake City. According to James Surowiecki (New Yorker, 9/22/14) after 22 months, not one of them was back on the streets. Surowiecki reports that, “In the years since, the number of Utah’s chronically homeless has fallen by 74 percent.”

Utah’s program is also more cost effective than the traditional approach of first dealing with drug and mental health issues, as well as maintaining shelters. Such programs generally cost about $20,000 a year for each chronically homeless person. In contrast, placing a homeless individual into permanent house costs the state just $8,000.

Let’s assume George Hammond had a little luck and obtained an identification and social security card. Would his life be any different if he first had a home to call his own? Could he even manage its care and maintenance? Even if he lived in Utah, without a job and some kind of treatment program, I don’t imagine his life would be much different.

The approach to the homeless in Utah offers some kind of hope for what has otherwise been viewed an unfixable problem. Homes first, then a job and treatment, rather than the reverse.

You can watch a preview of the film here


The Laws of Medicine

I had never expected medicine to be such a lawless, uncertain world. Dr. Siddhartha Mukherjee

You are ill, you have a pain here, another one there, you make an appointment to see your doctor. You try to describe why you are there, what ails you. You expect the doctor will tell you what the problem is and a treatment.

It is unlikely you will question his diagnosis or treatment. Yet, everything we know about medicine suggest that is precisely what you should do. Medicine like most every science is imperfect, it is based on probabilities, it is an uncertain science. The diagnosis could be wrong, the same holds for treatments.

There are always exceptions to the usual diagnosis of a medical problem. This is the central message of Siddhartha Mukherjee’s The Laws of Medicine: Field Notes from an Uncertain Science.

He writes: “It is easy to make perfect decisions with perfect information. Medicine asks you to make perfect decisions with imperfect information.” Mukherjee invokes three laws to explain why medicine is such an uncertain world.

His first law states that “A strong intuition is much more powerful than a weak test.” Here Mukherjee acknowledges the limitations of medical research. When faced with such uncertainty, hunches can often lead to an effective treatment.

He illustrates this law by describing a patient suffering from fatigue and weight loss. A comprehensive battery of tests turned up nothing. He could do nothing for the patient until he saw him conversing with a former patient who he had treated for the effects of drug use. Soon after, he realized the mystery patient was a heroin user and had contacted Aids.

Mukherjee’s second law states “Normals teach us rules; outliers teach us laws.” We usually don’t pay much attention to the exceptions to a research finding. Yet, as he acknowledges, they are the very individuals who provide an opportunity to refine our understanding of an illness.

Mukherjee illustrates this law by describing the widely held belief at one time that autism was caused by parents who were emotionally cold to their children, the “refrigerator mom” hypothesis. By paying attention to the exceptions to this notion, geneticists began examining the risk of autism between identical twins. They found a striking rate of concordance, suggesting a genetic cause of the illness.

In his third law Mukherjee holds that “For ever medical experiment, there is a perfect human bias.” Every scientific experiment is prone to any number of human biases, but he believes this problem is especially serious in medicine. Medical researchers hope their medicines will work, their treatments will work. This bias enters into the design, conduct, and analysis of the study.

…when you enroll a patient in a study, you inevitably alter the nature of the patient’s psyche and, therefore, alter the study. The device used to measure the subject transforms the nature of the subject.

Mukherjee claims many medical treatmentss thought to be deeply beneficial to patients based on considerable anecdotal evidence and decades of nonrandomized studies were ultimately shown to be harmful when they were investigated with randomized, double blind studies.

Weak tests, outliers and biases, Mukherjee’s three laws of medicine point to limits and constraints on medical knowledge. That is the state of medicine that doctors confront. It is also the problem you will confront when you have need to visit your doctor.

Is he making the correct diagnosis of your illness? Will the drug she prescribes work for you? Is the suggested treatment approach based on carefully control studies?

While medical technologies are increasingly sophisticated, uncertainties remain endemic to medicine. Once you recognize this, it is wise to keep posing questions, inquiring about alternatives, and being confident you’ve been given the right advice.



And then she made her move. It felt like walking a tightrope, feeling the balance, knowing that a slight shift to either side might be fatal.

Marian Sutro returns to the page. The last time we saw her was in Simon Mawer’s The Girl Who Fell From The Sky. This time it is in his Tightrope. A spy story, a thriller for a change. Nothing special. A time out, so to speak.

We begin with Marian’s work for the Britain’s Special Operations Forces in World War II. She is parachuted into France, joins the resistance, her task to make contact with Clement Pelletier, a nuclear physicist and help smuggle him out of the country. She succeeds, but soon thereafter is betrayed, captured by the Nazis, after killing two SS officers.

She is tortured and sent to a German concentration camp—Ravensbruck—assumes the name of recently deceased prisoner, escapes and eventually finds her way back to England.

“You cannot tell anyone what it [Ravensbruck] was like. It wasn’t the stuff of words.”

She returns to the home of her parents where she is overly pampered, fed, treated like a child. All the while, she longs for the excitement of her life as an agent and heroine of the resistance. When her former handler temps her back into the Cold War world of espionage, she accepts at once.

At this point Marian Sutro begins a new life. We are introduced to her brother and his work as a nuclear scientist, and others who believed the West should share their knowledge with the Russians.

Once again she is drawn back in to the world of deception, double-crossing, struggle to protect her gay brother. Along the way there are various affairs, close escapes, and clandestine acts. An all pervading atmosphere of mistrust, uncertainty. And Mawer writes elegant prose, as if he knew exactly what the world of espionage was like.

“It is so very difficult to unpick the spider’s web of intrigue and betrayal, isn’t it? Some threads are irrevocably knotted together, others snap at the merest breath of inquiry.”

What makes Tightrope such a pleasure is the character of Marion Sutro, her response to the morally complex world in which she found herself, damaged in World War II, yet resilient, clever, calm, subject to great physical passions, able to hold her own at the slightest danger.

To live happily, live hidden. She’d heard the proverb years ago during her training but she’d only recently found the source…Florian’s fables…It comes in the Fable of the Cricket who survives intact while the pretty butterfly dies at the hands of children. She was like the cricket—cryptic, camouflaged, concealed. A survivor.”

In the end Marion never knew if what she had done made the slightest difference. I suppose that is the way with the clandestine world, probably the world in general.