Preparing for death

by Brian on March 29, 2020

in Cancer,Health,In the News,Science

OK, that headline is a bit of a red herring. I’m not dying now nor am I planning to any time soon. But ever since I was diagnosed with an incurable, albeit mostly treatable cancer, one that compromises my immune system and puts me in the most at risk category during the current coronavirus pandemic, I’ve been thinking about death a lot. 

Preparing for coronavirus in Jerusalem

When the time comes, I want to be prepared – mentally at least (there may not be a whole lot I can do about it physically).

That turns out to be a challenge. Research last year from Bar-Ilan University in Israel claims that our brains may be hard-wired from childhood to shield us from thinking about our own deaths. 

Call it the “mortality paradox” – we all know we’re going to die someday, but our brains are not able to fully grasp the concept of no longer being alive.

“We cannot rationally deny that we will die,” the study’s leader, Yair Dor-Ziderman, says. So instead, “we think of it more as something that happens to other people. When the brain gets information that links the self to death, something tells us it’s not reliable, so we shouldn’t believe it.”

The Bar-Ilan researchers developed a test where they monitored participants’ brain activity while showing them photographs of themselves as well as pictures of strangers. They did this several times in succession. Half the photos were accompanied by words relating to death. The other half had no such connotation. 

The participants were then shown an entirely new face, which the brain would normally react to with a signal of “surprise,” since the image clashed with what the brain “predicted” from the previous sequence.

However, when death-related words appeared alongside the participants’ own faces, their prediction systems essentially shut down, registering no surprise when the “new” face appeared. 

This dulling of the brain’s predictive function, the researchers posit, demonstrates the mind’s inability to process the idea of our own deaths.

Such an incapacity to imagine a world in which we no longer exist, despite knowing that our deaths are inevitable, has led human beings to develop a number of imaginative narratives where death is not what it seems. 

In his 2012 book Immortality: The Quest to Live Forever and How it Drives Civilization, philosopher Stephen Cave describes four main coping strategies we mortals – the “aspiring undying” – have cooked up to deal with the mortality paradox.

The first path Cave calls simply “staying alive.”

“Almost all cultures contain legends of sages, golden-age heroes or remote peasants who discovered the secret to defeating aging and death,” Cave writes. 

Since no one has ever found this long sought-after magical “elixir of life,” a second strategy has evolved. 

The “resurrection narrative” is the belief that “although we must physically die, nonetheless we can physically rise again with the bodies we knew in life.” In addition to the clear Biblical allusions, we see this reflected in the modern-day concept of cryonics, in which people pay to be frozen upon their death in the hope of one day being “repaired.” 

A third path, Cave writes, is “surviving as some kind of spiritual entity or soul,” where we give up “on this earthly frame and believe in a future consisting of some more spiritual stuff.” This is where the concept of an afterlife, a heaven or olam haba (”next world” in Hebrew) finds its most evocative expression.

The fourth and final path is “legacy,” where we achieve life after death through our creative works or the influence we have on the world even after we’re gone. 

“The Greeks believed that culture had a permanence and solidity that biology lacked,” Cave writes. “Eternal life therefore belonged to the hero who could stake a place for himself in the cultural realm.” 

From the view of science, our genes, as continued through our children, are both a legacy and a kind of immortality, since DNA represents “a traceable line to the very beginnings of life and, if we are lucky, [one that] will also continue into the distant future,” Cave says.

Cave’s four paths are intellectually engaging, to be sure, but they haven’t really helped me all that much in getting comfortable around my future non-existence.

That’s because my biggest fear about death may be a much more familiar one: Fear of Missing Out. FOMO “is very often at the heart of people’s fear of being dead,” says Dr. BJ Miller, a palliative care physician at the University of California, San Francisco Cancer Center and the co-author of the book A Beginner’s Guide to the End.

When it comes to death, FOMO is about “all the things you’re not going to get to see,” Miller said on an episode of the NPR program Fresh Air, and “the idea that the world’s going to continue on without you.”

But FOMO around death can be turned on itself, Miller continues. It points us “very squarely towards all the things we love and care about. And then that becomes a nice compass for our way forward – how we’re going to live until we die.” The things we’re afraid we’re going to miss out on are exactly where “we should uptick in terms of our attention now.”

That won’t necessarily help us break past the mortality paradox. And it’s little hard to do all the things you love when you’re in an extended COVID-19 lockdown. But it’s a clever reframing that provides some small comfort when facing the ineffable. 

I first began my preparations for death at The Jerusalem Post.

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As COVID-19, the disease caused by the new SARS-CoV-2 coronavirus, transitions into a global pandemic, numerous countries have enacted varying degrees of travel bans and quarantines.

Israel has taken some of the earliest, most severe steps in the world, banning travelers from affected regions, canceling public events and conferences, placing tens of thousands of potentially infectious travelers in 14-day home quarantines, and recommending that Israelis not fly abroad for the time being, prompting pictures shared to social media of an eerily empty Ben-Gurion Airport.

Many Israelis are up in arms over the disruption to their lives the new regulations are causing. 

They have some reason to be skeptical.

Travel bans simply don’t work for these kinds of respiratory viruses “because they move too quickly,” says Jennifer Nuzzo, an epidemiologist at the Johns Hopkins Center for Health Security. “I think this virus will turn up everywhere because that’s how respiratory viruses tend to spread.”

Harvard epidemiology professor Marc Lipsitch predicts that within the coming year, some 40 to 70 percent of people around the world will be infected with COVID-19, although he emphasized in an article in The Atlantic that most will have mild disease or be asymptomatic. By this time next year, he quipped, “cold and flu season” could become “cold, flu and COVID-19 season.” 

A 2014 British meta-analysis on the effect of travel restrictions on influenza outbreaks concluded that bans slowed disease spread by no more than 3%. But that may be enough to stop a country-wide outbreak that overwhelms the medical system. If we can push the full contagion off until after the “regular” winter flu season – to “flatten the curve” – the thinking goes, it may be more manageable.

I’d like to suggest another reason why Israel has been so extreme in its approach: a long-standing fear of the other.

The new coronavirus is highly triggering to the Jewish people’s collective memory – it reminds us of all those in our past who have tried to wipe us out (even if this time it’s not a nation doing the killing). The holiday of Purim only reinforces that message.

Now that we have our own state, we Israelis are hyper aware of anyone – or anything – coming to harm us; our commitment to “never again” means that Jewish survival has become one of our ultimate imperatives.

While that may provide some explanation for what’s happening in the country, there is still something unsettling about Israel shutting itself off from the world and turning into a ghetto of its own making.

I know we’re talking about a health ghetto whose borders are intended to save lives. But there have been less savory examples of “others” that recent Israeli governments have tried to keep out: refugees from Africa, immigrants with Jewish backgrounds deemed “questionable” by the rabbinate, leftists whose political activism is seen as threatening. 

This is clearly not an approach that I support. So, should it also impact my views on COVID-19 prompted bans and quarantines?

I’ve found myself ping-ponging over the last few weeks – at times defiant (“bans are stupid”), other times appreciative (as someone who is immunocompromised from cancer treatment, I’m in the group that’s most vulnerable to coronavirus complications). 

There’s a lesson from Israel’s recent past that may help guide us through this confusing period. Let’s treat COVID-19 as we do terror attacks.

How do Israelis respond to bus bombings and stabbings and rockets? By continuing to live our lives. 

Sure, during the Second Intifada, we took precautions. We made sure to frequent cafes with armed guards and kept the keys to our bomb shelters handy. Tourists were wary, but many still came. 

Terrorism didn’t break us. Nor should the new coronavirus. 

Terror attacks – like viruses – can arise at any point. Missiles from Gaza, Lebanon and Syria are always poised to be launched, but that hasn’t stopped us from going about our daily activities, just like we don’t think twice about driving our cars on Israel’s dangerous roads. It’s how we compartmentalize risk in the Middle East.

That doesn’t mean we should ignore the Ministry of Health’s advisories. If I were to come in contact with someone who had the virus, I would of course accede to the Ministry’s regulations.

Depicting COVID-19 as a viral terrorist confounds the narrative of fearing the other. It allows us to think logically – from experience – not out of hysteria.

Indeed, much of the strategy to contain COVID-19 seems driven by panic. It’s like when two airplanes crash in quick succession. 

“Flying suddenly feels scarier – even if your conscious mind knows that those crashes are a statistical aberration with little bearing on the safety of your next flight,” writes Max Fisher in The New York Times. With the new coronavirus, we’re focused on the fatalities, not on the 98% of people who are recovering or who had mild cases. 

That’s why, when a friend’s mother died recently, we went to the shiva. A few days later, we attended a house concert (with just 30 people) of a lovely new indie folk band (shout out to Saltwater). At the same time, we’ve adopted a form of greeting that I promoted in this column already two years ago when I started chemotherapy: elbow bumps instead of handshakes. Now it’s public policy. 

I’m not trying to be fatalistic. Obviously, if the situation deteriorates, I’ll not stand on chutzpah or ceremony. (I wouldn’t go to that shiva or house concert now.)

Still, I hope that a smart balance can demonstrate that “fear of the other” is not the inevitable epigenetic legacy of the Jewish people’s millennia-long shared trauma and that there are better ways to formulate a response to these challenging times.

This column was submitted for publication a week before it appeared in the Friday Jerusalem Post. So much has changed in the ensuing days, including my then skeptical attitude towards bans and quarantines. But the main points – the influence of Jewish “fear of the other” and treating coronavirus like a terror attack – still remain worth considering.

Image from the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH)

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“Patience is a virtue”

by Brian on February 29, 2020

in Cancer,Health,Mindfulness

“If your fever spikes to 100.4° Fahrenheit (38° Celsius), you need to get to the ER right away.”

That was the mantra from my doctor that has haunted me since I began treatment for follicular lymphoma two years ago. So, when my temperature rose to 100.3° during my recent bout with pneumonia, I rapidly descended into a full-on panic.

I popped the thermometer in and out of my mouth every 10 minutes. I took a hot shower; my temperature went up. I downed a couple of Acamol (Israeli-branded paracetamol); it went down a notch. 

Throughout it all, my wife, Jody, was by my side, but she didn’t know any better than me whether we should stay at home or head to Hadassah. Ever since my immune system got pummeled by chemotherapy, we were in uncharted territory.

Eventually, my temperature dropped into the 99°s and I felt safe enough going to bed. In the morning, my fever was down further and stayed that way as the antibiotics finally kicked in.

On a purely physical level, I felt like I’d dodged a bullet. My cerebral response was more extreme, like an anxious clown being shot from a cannon under the big top of my brain. 

Now that it was over, I couldn’t help but wonder: Was it all necessary? Could there be another way to approach such uncertainty the next time it arises?

Sometimes, it’s the most overused expressions that turn out to be the best way to internalize a new behavior. “Patience is a virtue” is one of those.

Patience is something I have traditionally had little of. I want things to be solved fast. A fix for that computer glitch now. A solution for my cataract complications immediately. 

But here’s the thing about patience: unless it’s an emergency – like a heart attack or a rapidly growing tumor where you can’t afford to take risks – usually if you give something a little space, there’s a good chance it will go away without further intervention. 

Three years ago, when I first started getting the terrible stomach pains that ultimately led to my cancer diagnosis (but that turned out not to be connected to it), I had zero patience. On one particularly bad night, I begged Jody to take me to the emergency room. 

The doctors hooked me to an IV and the pain abated. But there was nothing wrong that the doctors could see. So, was it the drugs … or just the benefit of time?

A few months later, when the same pain arose again, I chose a different path. I was in agony for hours. But I didn’t go to the hospital and the distress eventually passed. 

The first time the expression “patience is a virtue” appeared in English was in a poem called Piers Plowman written by William Langland around the year 1360, although Its origins date back even further – to Cato the Elder who included it his popular Latin textbook of wisdom. 

As with most things we know are good for us, getting there is easier said than done. How does an impatient person cultivate more space – especially when panic can handily overwhelm any attempt at maintaining mindfulness?

Perhaps the first step is to understand that sheer will is not enough. “You want to train, not try, for patience,” Dr. Sarah Schnitker, an associate professor at Baylor University who researches patience, told The New York Times. “It’s important to do it habitually.” 

One way is to practice patience during less intense situations, where the stakes are not as high. For example, if your impatience is triggered by standing in line at the grocery store, see if you can interrupt the stress cycle. Designate a specific game on your phone or a particular podcast that you call up in those circumstances. 

“If you do it on a daily basis,” Schnitker says, patience “can grow and develop just like a muscle.” 

Cognitive reappraisal can also be helpful. 

“Feeling impatient is not just an automatic emotional response,” writes Kira Newman for the University of California Berkeley’s Greater Good Science Center website. “It involves conscious thoughts and beliefs, too.”

Schnitker gives an example of how to cognitively reframe an experience. If you’re struggling to be patient with your child, ask yourself about the “big picture: Why is being a parent an important role to you? What does that mean in your life?” Similarly, if you’re aggravated by a co-worker, think about the times you’ve been the one who has frustrated others. 

My son, Amir, suggested a different approach. 

“You’re already too much in your head. You need a more spiritual practice,” he said. 

Spiritual doesn’t only signify religious observance. Yoga, meditation or even exercise can also work. 

What about a “spiritual partner?” I proposed; a like-minded coach, someone with whom you’re on the same page, who can hold you accountable to practicing patience. 

Someone like Jody.

After the fever incident, Jody and I made a deal. 

“When you see me start to panic, I want you to tell me to take 20 or to take 60 minutes and we’ll revisit then,” I submitted solemnly. “I’ll go and do something – I’m not sure what. Maybe I’ll write, maybe I’ll watch TV or walk the dog. The point is, through this agreement, I’m giving you permission to say that to me and I’m promising I’ll do my best to listen and follow through.”

Will it work? I guess we’ll have to practice patience and wait to find out.

I first practiced patience at The Jerusalem Post.

Picture from Sam Holt (Wikimedia Commons).

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“I need a break,” I said to my doctor after finally recovering from the flu and pneumonia that had made my life miserable for 6 weeks straight.

“I agree,” my doctor responded. “I’m writing you a prescription. For a vacation. Doctor’s orders.”

My face brightened – now this was a medication I could get behind.

“Any idea where you want to go?” my doctor asked. 

I had in fact been making plans, even while sick, and had put together an exotic itinerary.

“Vietnam,” I replied. Along with Cambodia and Laos, Vietnam had long been at the top of my personal travel bucket list. Plus, our youngest son had just been there as part of his post-army trek last year.

Halong Bay, Vietnam

“Oh,” my doctor said quietly, and her face dropped.

I had expected this reaction: cancer patients with compromised immune systems, especially those getting just over pneumonia, probably shouldn’t travel to countries not so rigorous about high standards of hygiene.

This conversation took place a week before the Wuhan, China-based coronavirus now known as COVID-19 began dominating headlines. And then our travel plans necessarily changed. 

One after another, airlines began canceling routes to and from mainland China. Countries sealed borders. Face masks sold out.

Vietnam declared a public health emergency and banned flights from its northern neighbor – including from Hong Kong, which was how we were planning to fly to Hanoi. (Hong Kong flights have since been reinstated, but by the time this is published, that could be reversed again.)

This is not the first time that we’ve had to change plans due to a virus in Asia. In 2002, my wife, Jody, and I were planning a vacation to China just as the SARS epidemic hit. When El Al suspended its flights to Beijing, we opted for India instead. 

With Southeast Asia out – for now at least – Jody and I began reviewing the rest of our travel bucket list. When the time is right again, where else could we go – preferably far from the epicenter of this current outbreak?

Bucket lists are more than a pleasant distraction: they have real psychological value. Fulfilling a bucket list “is an attempt to make life memorable and is consistent with [Israeli Nobel Prize Winner] Daniel Kahneman’s peak-end theory,” which holds that what people retain most from events and experiences are their peaks, writes Prof. Christopher Peterson in Psychology Today. “Bucket lists, if accomplished, set memories in place that structure life as remembered.” 

Bucket lists can have a downside, as well. Writing in The New Yorker, Rebecca Mead called bucket lists “a commodification of cultural experience, in which every expedition made, and every artwork encountered, is reduced to an item on a checklist to be got through, rather than being worthy of repeated or extended engagement.”

While it’s true that I rarely go back to a place I’ve already visited (just as I hate watching movies twice), curating a travel bucket list can give you something to look forward to, especially when you’re feeling down. It helps prioritize limited vacation time, too. 

Travel bucket lists can become a bit morbid when, like me, you actually have a serious illness and the bucket, while not in any danger of being kicked in the immediate future, feels slightly more real than metaphorical.

Jody and I have traveled a lot, both with and without the kids, since we moved to Israel: the pyramids in Egypt, safari in Tanzania, 11 days on the Annapurna Trail in Nepal. We’ve journeyed up and down Israel, on foot, by bus and in cars, in our 25 years here.

For our 30th wedding anniversary, we planned to hike into Machu Picchu in Peru. But that was the year of my chemo and a 4-day intensive trek on the Inca Trail at high altitude was out. South America remains near the top of our travel bucket list.

Also on our list (in no particular order):

Iceland – volcanos, the Blue Lagoon geothermal spa, caving and waterfalls galore. (If only it wasn’t so cold, but that’s why it’s called Iceland.)

Morocco – a Muslim country with a rich Jewish past that isn’t overly anti-Zionist. 

Alaska – hiking through the 6-million-acre Denali National Park, gazing at glaciers while avoiding any run-ins with grizzlies, would be an outdoorsy dream.

South Africa – a week-long drive along the Garden Route southeast of Cape Town sounds as romantic as the Far East is exotic. 

Japan – I’ve already visited three times (twice for work) but Jody’s never been. Plus, it’s been years since I had authentic okonomiyaki.

Croatia and Slovenia – the former because Game of Thrones; the latter for a less expensive version of the Alps. (Substitute Georgia or Bulgaria for equally exquisite trekking close to Israel.)

Budapest – time it right and Wizz Air can get you from Israel to one of Europe’s most beautiful capitals for under $200 round-trip.

India – we’ve done the Delhi-centric tourist triangle along with a weekend in Mumbai, but the south still beckons. 

Russia – to tour this world power would be fascinating, but are Israelis welcome there anymore? Even without weed in our suitcase?

It’s fun to fantasize, but with the world in the grips of a possible pandemic, the safest thing to do is probably to hunker down at home and watch travel shows on TV. (I’m pretty sure my doctor would agree.)

When the COVID-19 danger eventually passes, though, there’s one more place I’d hate to miss: China. 

So, what’s on your travel bucket list?

I originally put together my travel bucket list for The Jerusalem Post.

Image of Halong Bay from Thomas Hirsch.

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Foiled by the flu

by Brian on February 1, 2020

in Cancer,Health

It was the flu that finally broke me.

The past two years have not been easy, to say the least: chronic stomach pains leading to a diagnosis of cancer, followed by a year and a half of treatments, a relapse, and then the need for cataract surgery, the latter a probable complication of chemo. 

I coped with each as best I could, trying to spin adversity into life lessons. I got sad sometimes, to be sure, but remained stoic for the most part. 

That was until the flu felled me. 

This winter’s strain has been particularly virulent (and that’s not even considering the new coronavirus raging in China). I’ve never gotten the flu shot – not because I’m opposed to vaccines but because my immune system has always been strong. Even last year, when I was in the midst of cancer treatment, I didn’t catch a bug. So, despite our HMO sending out repeated reminders, I dithered. 

Until it was too late.

“Everyone feels like they’re dying when they have the flu,” my son, Amir, reassured me as I was massaging my sinuses in a vain attempt to reduce some of the pressure. 

I nodded weakly. But inside, I was panicking. 

Was this it – the virus that finally sends me to the hospital like so many of my fellow follicular lymphoma voyagers? Maybe my compromised immune system won’t be able to fight this one off on its own. Should I have been wearing a mask when I went out in public? 

The flu was my cherry on top of an already unpalatable series of unfortunate events. The most recent: cataracts gone wrong.

When I found out I’d need eye surgery, I was actually looking forward. If it worked properly, I’d be able to see without glasses for the first time in 52 years!

But the process of swapping out the clouded lens in one eye for a clear new artificial one loosened some flecks of collagen that began bobbing across my field of vision in the gel-like fluid of the eye called the vitreous. 

You may have experienced this, too: most people will develop so-called “floaters” as they age, although cataract surgery ups your chances.

Floaters don’t indicate anything is medically wrong, but they can be maddening – like a swarm of flies buzzing in front of you except you can’t swat them away because they’re literally in your eyes

And there’s not much you can do, my ophthalmologist explained, other than wait to see if they “settle” out of sight or if the brain “neuro-adapts” so they don’t bother you so much. 

In the meantime, I could barely work. I said no to meet ups with friends because I was so distracted. About the only time the floaters didn’t bother me was while watching TV when, for some reason, they would move off to the side.

I’ve been watching a lot of TV.

I never felt disabled the entire time I was going through chemo. I had various aches and pains and fatigue, but I was still able to haul myself in front of my computer and write. I never imagined, as a result of cancer, I would become visually impaired. 

Combine that with the fact that, with my cancer no longer in remission, I’ll have no choice but to restart treatments at some point, add in the misery of the flu, and I finally felt defeated by my body.

And for one of the only times in this somber saga, I broke down and sobbed. 

My wife Jody was there to contain me. She stayed silent for a long time, holding my shaking body. 

“What are you scared of?” she asked eventually.

The answer surprised me. 

“I’m scared that I’ll become like my father,” I replied.

My father contracted polio as a teenager. He recovered and was able to walk with barely a limp until he was later beset by “post-polio syndrome.” Eventually, he required a wheelchair to get around. 

My father was no stranger to kvetching, but I never heard him complain about the hand he was dealt regarding the polio. Still, I could imagine the conversations that must have taken place behind closed doors between him and my mother. I surmised how my mother resented having to become his caretaker. I didn’t want that for Jody. 

“You’ve got cancer, floaters and the flu,” Jody comforted me. “You’re far from disabled.”

“But I don’t know what’s coming next,” I bemoaned.

“Then I’ll take care of you,” Jody said. “Will you let me take care of you?”

What could I say? That you didn’t sign up for this, Jody? But she did – it’s one of the vows we took when we got married. (OK, we didn’t actually recite vows at our chuppah, but it was implied.) 

Now Jody was asking – pleading with me – to not go through this alone. 

I nodded reluctantly for the second time that day. 

The flu turned out to be not just the flu but pneumonia. It took another two weeks and antibiotics, but it finally passed, and I never went to the hospital. 

The floaters are still with me, but there’s a laser treatment I’ve been reading about that’s supposed to have good results. As for the cancer treatments – they’re still coming, I just don’t know when.

I reached a low point with the flu. But I also forged a renewed understanding with my wife – and maybe an added appreciation for what my parents silently suffered through.

This may not be what we signed up for – but it’s what we’ve got. The alternative is unquestionably worse.

The flu originally foiled me at The Jerusalem Post.

Coronavirus image from National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH).

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One-eyed bowling

January 19, 2020

I’ve never been a great bowler. Now try doing it with only one eye. Thoughts on growth through loss and overcoming negativity with the rule of four.

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What’s really happening on American college campuses today

January 4, 2020

What’s really happening for pro-Israel students on American college campuses today? I’m not there. So I asked Liel Zahavi-Asa, an Israel advocate.

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Good news, bad news or no news?

December 22, 2019

“Avoidance is a simple way of coping by not having to cope.” The science behind why we avoid bad news and whether that’s a good coping strategy.

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“You’re not sick enough”

December 8, 2019

“You’re not sick enough to write about your health,” my friend said. “No one will take you seriously unless you’re close to death.” Was he right? An article about health and impostor syndrome.

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Did climate change kill the Jacob’s Ladder music festival?

November 23, 2019

If there was one thing you could always count on, it was that the weather at the Sea of Galilee in May, would be rain-free. Not so anymore.

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