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Andy Nichols--physician, political leader, friend of rural health and the uninsured, expert on the health care issues of the U.S.-Mexican border, and man of faith--died suddenly of an undiagnosed heart condition in April, at his desk, at work. He was a doctor, a professor of medicine, a liberal voice in a conservative state, and a state senator. His last words, I am told, were, "Let me make just one more phone call." He was undoubtedly trying to convince a senatorial colleague to support a bill that would increase access to care for some group that had been dealt out of the prosperity that had lifted so many boats.
Andy Nichols was 64; he didn't even live to qualify for Medicare. But he had been a righteous advocate for those hospitals and clinics and community health centers and nursing homes that serve rural Americans, and he had been a ferocious proponent of increasing access to care for the poor of Arizona. Not once, but twice, he and those with whom he worked got referenda onto the state ballot that would force the governor and the legislature to spend any tobacco settlement money on expanding Medicaid eligibility and protecting at least some of the uninsured poor.
He faced powerful and talented opposition, who wanted the money to be spent in other ways. But he believed, and he won. In honor of this liberal Democrat, the basically conservative Arizona legislature passed a bill ensuring that tobacco settlement money would be spent in keeping with the expressed will of the people of Arizona.
Hundreds of people attended his two memorial services, in Phoenix and in Tucson. The American Public Health Association gave him a posthumous award for service to the people of the United States. The Arizona Star newspaper published an editorial cartoon in which Andy was at the gates of heaven, and God was saying to him, "Andy...Andy Nichols...It says here in our records that you did 'missionary work' on behalf of children, the sick, and the poor. Goodness! Tell me...in what part of the Third World did you do this work?" St. Peter says, "State of Arizona." Andy Nichols, a man of deep religious faith, would have loved it.
Philip Justin Smith died in September. He was an editor, an executive, a consultant, a photographer, and an environmentalist. He was the first and only editor of Health Management Quarterly, then published by the Baxter Foundation, which was one of the few "egghead" journals--and in many ways the best one--geared toward health executives during the go-go days of the 1980s and early 1990s. The top minds in health care wrote for him, because he was honest, and knowledgeable, and above all ethical.
After HMQ ceased publication, Phil went on to do high-level corporate public relations work and, at the end of his too-short life, to indulge in his true passion, photography. He was good; he was really good. His cards and posters, made from shots of his favorite haunts in Wisconsin, were treasured by his friends and purchased by admirers. Even in this most personal of work, he had a cause: the preservation of prairie and wild lands in his dear Midwest. He believed in right living by human beings, and part of that belief was a conviction that we are responsible for taking care of the land.
The most intensely private of men, Phil chose that his valiant fight against a dread disease be known only to those closest to him. And so it was with shock and sorrow that many of us learned of his death without ever having known that he was ill. Suddenly, one of the true voices of impartial intellectual honesty in our lives was gone.
And so many people died on September 11th. Bill's beloved wife, Ginger. Mandy's husband's colleagues. John's two old friends--incredibly, one in the World Trade Center and the other on the plane that killed him. And so many more--among them EMTs, paramedics, firefighters, Port Authority employees, and police officers.
And after them the postal workers, possibly the most maligned of public employees, including Thomas Morris, Jr., who worked at the contaminated New Jersey facility and who suspected that he had been exposed to anthrax but could not get anyone to listen until it was too late. He died of anthrax in October, as did Kathy Nguyen, a Vietnamese refugee who worked in a stock room at the Manhattan Eye, Ear, and Throat Hospital; as of this writing, we do not even know how she contracted it.
I had been packed, dressed, and ready to get on a plane that morning; the grounding of all civilian aircraft by the Federal Aviation Agency was announced as I was walking out the door--shaking--for the airport. I did not want to get on a plane; indeed, I could not think of anything I wanted to do less, up to and including undergoing a root canal with no anesthesia. But I was feeling uppity, and it was the only thing I could do to protest what had happened that morning. Still, I was glad that I did not have to make the gesture.
Instead, I sat there and watched the tube, with my friends and neighbors. I watched the towers come down, the flames at the Pentagon, the debris field in Pennsylvania. I watched the angry New York City ironworkers, tools in hand, marching toward the wrecks of the buildings that, as one of them pointed out, they had helped create, determined to be of whatever help they could be among the architectural corpses of their efforts. They, and the rest of us, were running on adrenaline.
I sat, and I watched. I watched Howard Lutnick, the chairman and CEO of bond trading firm Cantor Fitzgerald, weeping on television about how the 700 dead employees of the firm had been like family, and that he was going to treat their survivors like family. I learned afterward that for weeks, the firm did absolutely nothing to take care of them. I watched as the Red Cross tore itself to pieces over whether money donated in good faith to help those who were so grievously wounded by the day's events should be the only beneficiaries of the hundreds of millions of dollars that flowed into the organization's coffers.
I watched the reports of the "rescuer" who stole a fireman's coat so that he could pillage the stores at Ground Zero while pretending to dig for those who might still be alive. And I read the stories of the investment firm executives who, under the cover of the disaster, apparently made off with millions of their clients' dollars.
And like everyone else, I watched and worried about anthrax, about where it had come from, and whether we could have responded to the threat better--and by "we" I mean everyone from the federal government to the health care system to the news media. At the very least, it seems to me that we might have been slightly more egalitarian in our public health response than to provide antibiotics on demand to VIPs while ignoring dying postal workers' pleas for information about what was making them sick.
"You can't think," said a physician at St. Vincent's Hospital, the downtown New York City institution that received the most victims, dead and alive. "If you think, you fall apart." That is the burden, and the protection, of the emergency health care professional.
But most of us did think. We thought about it a lot. There are not too many of us who can waltz through life like water spiders, skipping along the surface of things and not delving into the meaning of any of them.
And, surrounded by loss and larceny, many of us fell apart, or at the very least, became dispirited. Bob (these are not their real names) was insomniac for weeks; Travis was depressed and ceased to believe that his work was useful to anyone; Ahmed, dealing with having witnessed the horror in New York up close and personal and then facing severe discrimination because of his Middle Eastern looks and heritage, struggled to understand; others told me that what they do or what they think no longer has meaning for them. Exhausted by pain, fear, and stress, we threw up our hands and said, "The bad guys are winning. What does it matter anymore?"
I was not immune to this. I like to think of myself as a strong piece of work, but this undid me. I forgot to return crucial phone messages. I kept leaving the computer on all night. I got sleepy at 7 p.m. and woke up in the middle of the night. I blew deadlines. I had bad dreams about airplanes. I still have bad dreams about airplanes. This has been aided no end by a commercial airline security system that resembles nothing so much as a piece of Swiss cheese, through which an undocumented foreign alien resident of Chicago, claiming that he had no job and no permanent address, slipped through, not once, but twice, with seven knives, a stun gun, and a can of pepper spray. He got within 10 feet of boarding a plane.
And I wasn't near the scene of any of the calamities. I did not lose anyone I loved. I was not in danger, except, perhaps, on the planes I have flown since. Others were hurt much more grievously than I was. But given what most people went through, even vicariously, I would be suspicious of anyone who is not at least a little stressed out, depressed, frightened, out of sorts, or dysfunctional to one degree or another.
In F. Scott Fitzgerald's novel Tender Is the Night, the protagonist, a psychiatrist named Dick Diver, walks across a World War I battlefield and says to a friend, "All my beautiful, lovely, safe world blew itself up here with a great gust of high explosive love." Many Americans are feeling the same about what happened to us, except that we would substitute the word hate for the word love.
And in the aftermath, any federal concern for the uninsured poor seems to have evaporated in favor of a wave of corporate welfare, and most other health care issues have disappeared just as suddenly. And this shell-shocked nation and its health care sector seem unable to come up with much of a response.
But Andy Nichols didn't spend his entire adult life serving those who are unprotected and have no voice, those who live in underserved rural areas and that third society called the border, so that we could shrug and say that these problems don't matter because we are bummed out, because something dreadful has happened, and he is dead, anyway, so his lifetime of devotion and belief didn't matter.
And Philip Justin Smith didn't devote his time to the pursuit of beauty and reasonable thought in health care so that we could say such things have no meaning because we are hurting, and he is dead, anyway, and what do philosophy and thinking and careful examination of issues have to do with health care in the first place?
And all those public servants in New York City and Arlington, Virginia, who put their lives on the line and lost them, did not put themselves in harm's way so that we who are still alive can assume the fetal position and enjoy an existential crisis. Years ago, a Chicago firefighter who was making a joke at the time said, "It does take a certain type of personality to run into a building that everyone else is running away from." It took the right stuff, and they had it.
And the passengers and crew of United flight 93, who thwarted whatever attack had been planned at the cost of their lives, did not do so in order to enable the rest of us to cower in fear or worry about our stock options or decide, 1960s-style, to "drop out."
They all believed in what they were doing. And they would tell us, if they could, that they died for a reason, for a belief, for a commitment, and that the rest of us had damned well better live for a reason, for a belief, and for a commitment. Otherwise their sublime sacrifice loses its meaning, as do the lives of we who remain.
By this I do not intend, in any way, to say that we should just put it all behind us, or pretend it didn't happen, or that what has taken place wasn't that big a deal. "I was inconvenienced," said a friend of mine who was stranded for days on the East Coast. "But they're dead." Yet, we are told, get on with your life; have a nice day. Having lost altogether too many people whom I loved, I can say honestly that possibly the worst part is when people ask, "Are you okay?" Yeah, I'm great. My husband was just murdered by a religious fanatic whose beliefs pervert everything his faith holds sacred. I have two little kids, the Red Cross says I have to fill out 52 forms to get food money, and I have a hole in my heart the size of the Grand Canyon. But don't worry about me; I'm just fine.
We are not fine. We are most definitely not fine. But for the sake of all who died and all who suffer for that loss, we must pick up the pieces of the world that we envisioned and of the society that was, despite the brutal and thuggish behavior of individuals, fanatical organizations, and nations, and do what we are supposed to do: heal ourselves. Heal others. Take the rush of community spirit and fellowship that poured out of the ruins of those buildings and those lives and hold onto it. Try to learn from what happened, and remember the old lesson: that when people are in trouble, they turn, without hesitation and with complete trust, to the healers. We must be there for them.
We must pick up the shattered pieces of our lives and our world and put them back together, tenderly, gently, but also with determination and strength, and create something beautiful with them, something that reflects not only our pain and our fear, but also our courage and our triumph.
We must go on, with hope and with belief, despite our losses--not because it's the macho thing to do, not because if we suppress our feelings we don't have to deal with them, not because we don't want to face all the implications of death and disaster, not because it's easier to refuse to admit that we are wounded. We must go on, and go on with will and with pride, because we owe it to those who died; we owe it to those who loved them; we owe it to ourselves; and we owe it to the future.
This article first appeared in the January/February 2002 issue of Health Forum Journal
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