Learning to Live and Let Live

photo by Nate Gibson

Along with millions of Americans these past seven days, I’ve tried to comprehend the tragic shootings in Tucson last Saturday, reaching deep within myself to find compassion for a young man who has forever changed the world for himself and so many others through his actions.   For those of us who assess, diagnose and treat college students struggling with mental illness while trying to succeed in their academic pursuits, the events leading up to his impulsive killings were chilling indeed.  As a college health physician, I and my colleagues all have known progressively destabilizing students like Jared, have tried valiantly to keep them in school while coordinating complex therapy and medical treatment and we all have, at times, failed to turn things around.

As I have tried to remind myself over two decades of this work, the primary mission of an institution of higher learning is not to be a residential psychiatric treatment center, but this level of care often is expected by students and their families, and this week, this opinion was echoed by a chorus of media pundits, bloggers and commenters.  They say: how could the college have forced this student out of school when he was clearly so ill?  Didn’t the college understand that removing him from school would make things worse and remove him from daily monitoring of his behavior?  Wasn’t there a way to compel him to get psychiatric assessment and treatment?  From being on the mental health treatment side of those questions,  there are times when the student simply can’t remain in the classroom, yet won’t cooperate with seeing a psychiatrist, and is not impaired enough for the state to go through commitment proceedings.  They are truly lost–no longer appropriate for school, angry about being suspended, but within their civil rights to remain unevaluated and untreated.

Most students I have seen with disruptive or impairing mental illness symptoms agree to take a medical withdrawal to invest full time in their recovery for a few months or a year, or occasionally they choose entirely on their own to drop out, never to return.  Very few are so gravely disabled they are committed to mental hospitals or end up in jail because of extreme behaviors that harm others.  Tragically, some commit suicide, most without ever seeking help.  Rarely, they become too disruptive or dangerous to self or others so they have to be suspended from school until they can demonstrate stability and fitness to return.  One in a million will kill others.   Those of us who see mentally ill students every day understand all too well what is at stake.  I have had numerous students and families tell me that the routine of school is the only thing that will keep things from destabilizing more.  It is the only place mental health treatment is easily available and affordable.  It will surely cause increased stress for the student to leave the academic pressure cooker, getting behind in their course sequence, delaying graduation and a career,  even if that student is not attending class, not completing assignments, not making progress, possibly exhibiting disruptive or threatening behavior.   Too often, there is simply no stable home for the student to return to for treatment and recovery.   Much of our time is assisting students in making that transition to care outside of the campus environment as there may not be family members who can help.

Young adult students are living with more academic and social stress than they’ve ever known before at a vulnerable time in their development:  their support system is changing with families broken and fragmented, their identities are still forming, their values and moral underpinnings are continually being challenged, and their brains are still developing.   Add to that mix the ubiquitous and noxious presence of alcohol and recreational drugs that exacerbate or even trigger mental illness, and it is not surprising that some college students find they cannot cope with life.  The epidemic of depression, suicidal ideation and behavior among college students is a crushing reality.  I have had to personally go to apartments where I suspect a “no show for an appointment” student is holed up, not reaching out for help, planning to commit suicide, and talked them into agreeing to a psychiatric inpatient hospitalization to keep them safe.

Despite deep budget cuts, many institutions of higher learning are still doing everything possible to address exploding student mental health needs, and must handle crises twenty four hours a day.  Psychiatric prescribing is standard student health care on many campuses for increasingly complex students as there is rarely affordable access to mental health care off campus in a timely fashion.   Some students arrive at the University on five or six psychiatric medications considered crucial to their stability–some families make the decision about which college to attend based on the quality of the mental health care available on campus.  It takes seasoned expertise to help a student manage that kind of pharmacopeia and still stay awake in class, sleep soundly at night, and maintain balance in their social life.  We are doing our best to help keep these students in school, even when their behavior seems odd, or their thinking is tangential, or they struggle to keep both feet in every day reality.

College is a time for learning–that is something we can all agree on.  It is also our responsibility to keep the academic environment safe, free from threats, while supporting students with mental illness who need help to learn to live and let live.   When that support is not sufficient, when a student is unable to “learn” effectively due to the degree and severity of their illness, or their symptoms are compromising the learning of other students,  they must take a break to work full time on learning how to manage their illness.   I have seen many return after that break and be successful in completing their degree.  Even better than the diploma earned is the knowledge they have overcome the challenges of mental illness to make it happen.

Snow Light

Snowy woods on our farm

Roused by faint glow
between closed slats
of window blinds
at midnight

Bedroom suffused
in ethereal light
from a moonless sky~
a million stars fall silent

Snow light covers all,
settling gently while it
tucks the downy corners
of snowflake comforter

as heaven
plumps the pillows,
cushions the landscape,
illuminates the heart.

A Farm in Snow

This poem by one of my favorite poets, Jane Kenyon, echoes the history of our farm in winter:

This Morning by Jane Kenyon

The barn bears the weight
of the first heavy snow
without complaint.

White breath of cows
rises in the tie-up, a man
wearing a frayed winter jacket
reaches for his milking stool
in the dark.

The cows have gone into the ground,
and the man,
his wife beside him now.

A nuthatch drops
to the ground, feeding
on sunflower seed and bits of bread
I scattered on the snow.

The cats doze near the stove.
They lift their heads
as the plow goes down the road,
making the house
tremble as it passes.

Snow and Ice Sublime

From Annie Dillard’s Pilgrim at Tinker Creek, one of my favorite books of all time–I suspect she wrote this on a winter evening that felt much like this one:

“In a dry wind like this, snow and ice can pass directly into the air as a gas without having first melted to water.  This process is called sublimation; tonight the snow in the yard and the ice in the creek sublime.  A breeze buffets my palm held a foot from the wall.  A wind like this does my breathing for me: it engenders something quick and kicking in my lungs.  Pliny believed the mares of the Portuguese used to raise their tails to the wind, ‘and turn them full against it, and so conceive that genital air instead of natural seed; in such sort, as they become great withal, and quicken in their time, and bring forth foals as swift as the wind…’.

A single cell quivers at a windy embrace; it swells and splits, it bubbles into a raspberry; a dark clot starts to throb.  Soon something perfect is born. Something wholly new rides the wind, something fleet and fleeting I’m likely to miss.”

Forgetting About the Killers

It’s only been a little over fifty years since vaccinations became routine for the childhood killers like polio, measles, mumps and whooping cough.  People my age and older had no choice but to suffer through childhood infectious diseases given how effectively and quickly they spread through a community.   Most of us survived, subsequently blessed with life long natural immunity.  Some did not survive.  And I think we’ve forgotten that.

As a physician, I help enforce vaccination requirements for a state university.  A day doesn’t go by without my having a discussion with a prospective student (or more likely the student’s parent) about the necessity for our requirement for proof of  mumps, measles, rubella vaccination immunity.  I have been labeled a Nazi, a Communist, a pawn of the pharmaceutical industry and many more unprintable names because I happen to believe in the efficacy of modern vaccine to help keep a community free of infectious disease outbreaks that will kill people.

We have forgotten these are honest to goodness killers of healthy human beings.  We forget that unvaccinated children continue to die in developing countries for lack of access to vaccine.   Yet educated and well-meaning American parents make the decision daily to leave their children unvaccinated, believing they are doing the best thing for their children by protecting them from potentially rare and often unproven vaccine side effects.    I’ve had caring loving parents tell me that God will provide the needed immunity if their child gets sick so taking the risk of a vaccine is unnecessary.    Actually they are banking that everyone else will be vaccinated.  The problem is:  guess again.  There are now too many deciding that they are the ones who can remain vaccine-free.   Babies died in California this past year from becoming infected with whooping cough–in the year 2010– when this is a completely preventable illness.

 

I tell these parents  God does provide  immunity–after suffering through a life threatening disease which threatens those who are unfortunately exposed.  He also provides immunity in the form of a vial of vaccine, a needle and syringe.  I don’t think any one of these parents would deny the life saving miracle of injectable insulin for their child diagnosed with diabetes, nor would they fail to strap their child into a car seat.  Vaccines are miracles and instruments of prevention too, but the rub is that we have to give them to healthy youngsters in order to keep them healthy.

 

As a society, or as clinicians, we simply don’t think about immunizations in the same way as we did in the fifties.  When I received my first DPT vaccination at the age of 4 months, my mother wrote in my baby book:

“Up most of the night with fever 104.5 degrees,  considered a good ‘take’ for the vaccine.”  She truly was relieved that it had made me sick,  as it meant that I would be safe if exposed to those killer diseases that were so common in the 1950s.  Now a febrile reaction like that would almost be considered grounds for a law suit.

 

I’m an old enough physician to have seen deaths from these diseases as well as the ravages of post polio paralysis, the sterility from mumps and deafness from congenital rubella.   My father nearly died from the mumps that I brought home from school when I was eight and he was in his early forties.   My sister-in-law almost didn’t pull through when she was an infant and contracted pertussis.  I’ve seen healthy people develop  encephalitis and pneumonia from chicken pox.    I’ve seen a healthy college student die of influenza within a week of getting ill.   There is an epidemic of fear in our society that is unwarranted: as Seth Mnookin, a journalist covering science topics wrote in Newsweek and his upcoming book “The Panic Virus”, “If only there were a shot for irrational fears.”

 

I wish vaccines were perfect but they aren’t.   Nothing is.  I wish medications that are developed for treatment of some of these illnesses were perfect but we can’t depend on a guarantee of cure once sickened.   I wish our immune systems were perfect, but they too fail and people do die.

 

There will always be a new plague–history has demonstrated that over and over with the appearance of  HIV, SARS, Avian flu, or multidrug resistant tuberculosis.   There is plenty to keep our immune systems at the ready because we don’t yet have effective vaccines widely available.

 

There is simply no good reason to invite the old plagues back into our homes, our schools,  our blood streams, and onto our death certificates.   They deserve to be considered the killers of yesteryear now overcome by modern medicine–merely a footnote in the epidemiology history books.

 

Listen to a child with whooping cough on this link:

Portrait of baby

Taking Down Christmas

What went up must come down.  It isn’t just a law of physics.  It is a reality of Christmas.

True,  some houses have multicolored lights strung along their gutters year round, just not illuminated.  And I’ve known some people’s artificial trees to stay up until Valentine’s Day or longer.   But most of us dismantle what we so lovingly strung up, trimmed and decorated only a month or so ago.  It is a sad day taking down Christmas.

As a child I was so reluctant to see the tree come down that I’d cut a sprig of evergreen branch,  complete with tinsel, and would put it in a vase of water in my bedroom in order for a small part of Christmas to linger a little longer.  By April it would be crispy dry and forgotten and my mother would sneak in and toss it out, without my even missing it.

All the anticipation is spent and our energy wanes.  Winter has only begun and now we’re boxing up the twinkling lights and putting away the ribbons and bows.  All the fun stuff is tucked away for another year in the garage and attic.   Maybe we have the timing of this celebration all wrong.  Instead of the Twelve Days of Christmas it should be the Twelve Weeks–the lights should stay up until St. Patrick’s Day at least, just to keep us out of the shadows and doldrums of winter.

Today, as I swept up the last of the grand fir needles that had dropped to the floor, I knew, like the tree that I watered faithfully in the house for two weeks, I too had been drying up and parts of me were being left behind for others to sweep up.    There had been the excitement of family brought together from all ends of the earth,  friends gathering for meals and games,  special church services, but now, some quiet time is sorely needed.   The party simply can’t be sustained.  The lights have to go off, and the eyes have to close.

So we will now walk into a winter replete with the startling splash of orange red that paints the skies in the evenings, the stark and gorgeous snow covered peaks surrounding us during the day,  the grace of bald eagles and trumpeter swans flying overhead,  the heavenly lights that twinkle every night,  the shining globe that circles full above us, and the loving support of the Hand that rocks us to sleep when we need it.

We don’t need full stockings on the hearth, Christmas villages on the side table, or a music-synced blinking star on the top of the tree to know the comfort of His care and the astounding beauty of His creation, available for us without batteries, electrical plug ins, or the need of a ladder.

Instead of us taking down Christmas, Christmas picks us up.

Every day.

Year round.

January 1 sunset from our hill, taken by Nate Gibson
Self portrait by Nate. Sunset by God.