Many Patients Don’t Survive End-Stage Poverty

Medical textbooks usually don’t discuss fixing your patient’s housing. They seldom include making sure your patient has enough food and some way to get to a clinic. But textbooks miss    1    my med students don’t: that people die    2    lack of these basics.

People struggle to keep wounds clean. Their medications get stolen. They sicken from poor diet, undervaccination and repeated psychological trauma. Forced to focus on short-term survival and often    3    (lack) cellphones, they miss appointments for everything from Pap smears to chemotherapy. They fall ill in myriad ways — and fall through the cracks in just as many.

Early in his hospitalization, our    4    (retire) patient mentions a daughter,    5       5    he’s been estranged for years. He doesn’t know any contact details, just her name. It’s    6    long shot, but we wonder if she can take him in.

The med student has one mission: find her.

I love reading about medical advances. I’m blown away that with a brain implant, a person who’s paralyzed can move a robotic arm and    7    surgeons recently transplanted a genetically modified pig kidney into a man on dialysis. This is the best of American innovation and cause for celebration. But breakthroughs like these won’t fix the fact that despite spending the    8    (high) percentage of its G.D.P. on health care among O.E.C.D. nations, the United States has a life expectancy years lower than comparable nations—the U.K. and Canada— and a rate of preventable death far higher.

The solution    9    that problem is messy, incremental, protean and inglorious. It requires massive investment in housing, addiction treatment, free and low-barrier health care and social services. It calls for just as much innovation in the social realm as in the biomedical, for acknowledgment that inequities — based on race, class, primary language and other categories — mediate how disease becomes embodied.    10    health care is interpreted in the truest sense of caring for people’s health, it must be a practice that extends well beyond the boundaries of hospitals and clinics.

What Deathbed Visions Teach Us About Living

Chris Kerr was 12 when he first    11    a deathbed vision. His memory of that summer in 1974 is blurred, but not the sense of mystery he felt at the bedside of his dying father. Throughout Kerr’s childhood in Toronto, his father, a surgeon, was too busy to spend much time with his son, except for a(n)    12    fishing trip they took, just the two of them, to the Canadian wilderness. Gaunt and weakened by cancer at 42, his father reached for the buttons on Kerr’s shirt, fiddled with them and said something about getting ready to catch the plane to their cabin in the woods. “I knew    13   , I knew wherever he was, must be a good place because we were going fishing,” Kerr told me.

As he moved to touch his father, Kerr felt a hand on his shoulder. A priest had followed him into the hospital room and was now leading him away, telling him his father was delusional. Kerr’s father died early the next morning. Kerr now calls what he witnessed an end-of-life vision. His father wasn’t delusional, he believes. His mind was taking him to a time and place where he and his son could be together, in the    14    of northern Canada. And the priest, he feels, made a mistake, one that many other caregivers make, of    15    the moment as a break with reality, as something from which the boy required protection.

It would be more than 40 years before Kerr felt compelled to speak about that evening in the hospital room. He had followed his father, and three generations before him, into medicine and was working at Hospice & Palliative Care Buffalo, where he was the chief medical officer and    16    research on end-of-life visions. It wasn’t until he gave a TEDx Talk in 2015 that he shared the story of his father’s death. Pacing the stage in the sport coat he always wears, he told the audience: “My point here is, I didn’t choose this topic of dying. I feel it has chosen or followed me.” He went on: “When I was present at the bedside of the dying, I was    17    by what I had seen and tried so hard to forget from my childhood. I saw dying patients reaching and calling out to mothers, and to fathers, and to children, many of whom hadn’t been seen for many years. But what was    18    was so many of them looked at peace.”

The talk received millions of    19    and thousands of comments, many from nurses grateful that someone in the medical field validated what they have long understood. Others, too, posted personal stories of having witnessed loved ones’ visions in their final days. For them, Kerr’s message was a kind of confirmation of something they instinctively knew — that deathbed visions are real, can provide comfort, even heal past trauma. That they can, in some cases, feel    20   . That our minds are capable of conjuring images that help us, at the end, make sense of our lives.

Why does everyone feel insecure all the time?

For most of my life, it had never occurred to me to fret over the fat in my cheeks. I’d hardly heard the words “buccal fat,” much less thought of it as something that I could or should worry about, until I saw buccal fat described in The Guardian as a “fresh source of    21    to carry into the new year.” Maybe you read the same article — or maybe you discovered that you were supposed to be insecure about something else: the way you part your hair; the fit of your jeans; the    22    of your car; the size of your home or the way it is decorated.

As the British political theorist Mark Neocleous has noted, the modern word “insecurity” entered the English    23    in the 17th century, just as our market-driven society was coming into being. Capitalism    24    on bad feelings. Discontented people buy more stuff — an insight the old American trade magazine “Printers’ Ink”stated bluntly in 1930: “Satisfied customers are not as    25    as discontented ones.” It’s hard to imagine any advertising or marketing department telling us that we’re    26    OK, and that it is the world, not us, that needs changing.    27   , manufactured insecurity encourages us to amass money and objects as surrogates for the kinds of security that cannot actually be    28    — connection, meaning, purpose, contentment, safety, self-esteem, dignity and respect — but which can only truly be found in    29    with others.

Part of the insidious and overwhelming power of insecurity is that, unlike inequality, it is    30   . Sentiments, or how real people actually feel, rarely    31    rationally onto statistics; you do not have to be at rock bottom to feel insecure, because insecurity results as much from expectation as from deprivation. Unlike inequality, which offers a snapshot of the distribution of wealth at a certain moment in time, insecurity    32    the present and future, anticipating what may come next.

The philosopher Jeremy Bentham wrote about the “fear of losing” and how wealth itself becomes a source of worry. Assets must be guarded and grown, after all,    33    fortunes be diminished or lost. “When insecurity reaches a certain point, the fear of losing prevents us from enjoying what we possess already. The care of preserving condemns us to a thousand sad and painful    34   , which yet are always liable to fail of their end,” he wrote in “Theory of Legislation,” published in 1802.

The dysphoria of feeling you don’t have enough, even when you objectively have a lot, is not simply a spontaneous reaction to seeing others with more, a kind of lizard-brained lust, but rather the    35    of living in an insecure and risk-filled world in which there are no upper or lower limits on wealth and poverty.