My childhood piano teacher, Marcy Meyer, died tonight. She was at home, her loving husband having gone for a drive, her son, my life-long friend, Jason, at her side. In her honor, I've lit a candle in my kitchen and am listening to the final two movements of Mahler's 2nd Symphony, the "Resurrection."

It's hard to find a simple way to describe the intricate ways Marcy and the entire Meyer family have always been part of my existence. She taught me piano, Arlen taught me to see and create art in every act of life, Jason taught me to laugh and get along with the guys, Kaarina taught me to be fun and feminine and strong and graceful. We families went to plays, recitals, musicals, operas together for as long as I can remember. Jason and I played duets, trios, quartets, and eventually in symphony together, he on cello, I on the violin. We'd go up to the balcony at church to rehearse with Marcy for some music in the Sunday service and Jason, always looking to push the envelope, would fire up the organ and blast out some Van Halen as Marcy slowly made her way up the steps. She didn't need to say much in order for us to come back to our good behavior, but I remember her mostly uttering the culprit's name with a tone of resigned disappointment as she approached, as in, "......Jaaaasooon....."

Once while I was in fourth grade we were having refreshments around her dining room table at an after-school mini piano recital. Jason told a story that I found incredibly funny and unfortunately the punchline hit right as I'd taken a big gulp of Marcy's famous post-recital punch (which will forever be known as "Marcy's Punch". No recital was a real recital without this punch, which Marcy would have to create while the last piece was being played. I remember the anticipation of the imminent refreshments when I would see Marcy quietly, purposefully rise from her place to attend to the punch.) The carbonated fruity-sherbet liquid sprayed from both oral and nasal orifices and all over the table and other guests, eliciting an even greater reaction from my fellow music students. Marcy, however, waited several beats and then simply said, flatly, ".....Oh, Suzy...." and then quietly moved from the dining room to the kitchen for cleaning supplies.

Another favorite Marcy story comes from Kaarina, this one involving the death of a farm animal on a drive to Lincoln. Just outside what we Seward County-ites refer to as the "Garland Curves," there was a farm on the North side of Highway 34 that had what seemed like hundreds of wandering chickens, often in the ditch and near the shoulder of the road way. Marcy and Kaarina drove this route countless times to get Kaarina to her dance lessons in Lincoln, and on one such fated journey, Kaarina herd a loud thump and realized they'd run over one of these innocent birds. She waited for confirmation from Marcy, who sometime in the next 1/2 mile or so uttered the famous, under-toned comment, "Oh.......I hit a chicken."

Marcy had a head of thick, beautiful, black hair, and the most quiet, hazel eyes that gazed at you quite directly anytime you interacted with her. She used to play my piano assignments for me at the end of each piano lesson, and I remember looking up at her in the warm light of the den, watching her long, tan fingers, well-manicured nails, the shadow her hair made in the light, the delicate way she initiated her music-making. I remember how excited she got about good music, about being able to assign me things like a Chopin Nocturne, or some difficult Mozart piano variations.

I remember the beautiful jewelry she wore, how well-dressed and classic she always looked, and that Mr. Meyer bought her a new vase every year, either for her birthday or their anniversary.

Marcy was also the first grown-up I knew who fully admitted to liking to sleep, and was unashamed of the fact that she, unlike most in Seward County, did not get up in time to milk the proverbial cows. This marked what I perceived as a strong sense of self and individuality, and I continue to be grateful as I grow into adult life for such role models throughout my childhood; people who were unafraid to be just who they were.

I don't know what it will be like to live in a world without Marcy, or without hearing my parents talking about spending time with Arlen and Marcy. She and they have been a constant for as long as I can remember, even through acknowledged periods of hardship in our individual and family lives. Since her diagnosis, and especially in these last months, I've watched the loyal and tender manner that Arlen, Jason, Kaarina, and their circle of friends have gone about expressing their love and commitment to Marcy's life. Every day in my work in the ICU, I watch as family members and friends and the medical establishment run from the pending death of their fellow human beings. But not with Marcy. Everyone showed up and stood by her and took turns guiding her and being guided by her down this most challenging, heart-wrenching, reality-ridden path.

I consider these last months and days a testimony to the essence of the life Marcy shared with all of us while she was here. She endeavored. She pressed on. She took her time. She told her story, often without saying too much, sometimes by saying a lot. But, like with any member of the Meyer family, the elements of creativity and art pervaded it all. There was an arching story, a set of diverse characters, a graceful, human dance. And, finally, a quiet ending.

I'll close with the final text from the last movement of the Mahler Symphony, both German and English text included (since Mr. Meyer taught me to love German):

Mit Flügeln, die ich mir errungen, With wings which I have won for myself

In heißem Liebesstreben, In love's fierce striving,

Werd'ich entschweben, I shall soar upwards

Zum Licht, zu dem kein Aug'gedrungen! To the Light which no eye has penetrated!

Mit Flügeln, die ich mir errungen Its wing that I won is expanded,

Werde ich entschweben. And I fly up.

Sterben werd'ich, um zu leben! Die shall I in order to live.

Aufersteh'n, ja aufersteh'n Rise again, yes, rise again,

wirst du, mein Herz, in einem Nu! Will you, my heart, in an instant!

Was du geschlagen That for which you suffered,

zu Gott wird es dich tragen! To God will it lead you!

Trivandrum Part I

I spent my final four days in India visiting Dr. Raj Gopal and the Trivandrum Institute for Palliative Sciences, (TIPS), which he founded and currently runs in the capitol city of Trivandrum, Kerala. The Institute provides both outpatient and inpatient palliative services, as well as home-visits throughout all of Trivandrum and into several of the rural districts surrounding the city.

My first morning there I arrived to attend the weekly team meeting of the TIPS medical and administrative staff, and experienced a wonderful, warm welcome from each person I met within the group. Soon Dr. Gopal was sending me with one of their mobile medical teams, including a physician named Dr. Sunil, two nursing assistants, a volunteer, and a driver.

We went to a nursing home/hospice/shelter run by Catholic nuns. Though the home itself houses some fifty patients, eight of them were currently TIPS patients, the entire group managed in-house by a very capable caregiver named Sister Elizabeth. I was taken immediately by the Sister’s unfazed manner, especially when I learned of her vast responsibilities and little help (two nursing assistants).

There was a small, elderly, mentally ill woman who, though not a TIPS patient, colored our time with her frequent appearances during patient visits, often with the potential for violence, at one point with a large bamboo stick in hand ready to beat one of Sister Elizabeth's nursing assistants. I noted quickly how all the staff embraced her with humor and understanding, quietly listening to her or, if need be, gently grabbing hold of her swinging arms and subduing her as they lead her out of the room.

I also observed Dr. Sunil's manner with the patients; the time he took respectfully listening to and examining them; the quiet, mindful tone he used as we walked from room to room, explaining to me each patient’s medical history and current plight. The entire TIPS team carried themselves in this quiet, engaged, respectful manner.

The first patient we saw had breast cancer with bone metastases and some psychiatric history. Dr. Sunil turned to me during a pause in her examination and said, "She's now over three years living inside these four walls, and we know that takes a significant psychological toll on her and are working to manage and recognize that in her care and treatment."

She was old and, in a certain light, haggard in her appearance – tousled hair, groggy, swollen eyes, confused. We’d awakened her by our arrival, and it took a marked period of minutes for her to begin to get her bearings, all of us standing close by and smiling, listening. But in between brief moments she would relax into the most beautiful smile. Inside those moments, an utter radiance beamed from this old, lonely, slightly deranged woman with cancer. We said our good-byes and left her there, sitting alone in her beige-colored room, the walls with scattered finger prints, cobwebs, unnamed stains, and toward the floor, the occasional reddish, dried-up spit-pile betraying her hidden betel chewing habit.

Next we saw a laryngeal cancer patient whose tracheotomy was stainless steel and wide open to air. I was jarred at the initial site of it, the patient putting his finger over the open hole occasionally to attempt to phonate as he communicated with us. He told us his pain was under control, he was sleeping well, having regular bowel movements, and seemed positive in regard to his current status and day-to-day comfort level.

After him, we saw what I call another "light-filled" patient, another older woman with breast cancer and bone metastases. She was less confused than the previous woman, in the company of her son who visited and stayed often with her, and had the funniest laugh and a candid, forthright demeanor. I found myself wanting to come over to her bed and grab her into a big hug throughout the examination, her laughter and humorous spirit so contagious. She made jokes and then would slap her knee as she laughed at them herself. It was during this visit that the little beloved insane woman came in and started punching one of Sister Elizabeth’s nursing assistants. Quickly detained, the staff smiled as she was taken out of the room, explaining that this particular assistant was new and thus not trusted as yet by her.

Next was and oral/cheek cancer patient, a young man whose entire mouth was covered with a large gauze dressing, but who spoke audibly through it throughout the examination. Upon removal, we saw what I can only describe as a gory wound of an advanced malignancy that had overtaken his entire lower lip and turned it flat and outward, about the size of a bar of soap. According to his chart, it had initially been infected with maggots, which Dr. Sunil explained to me to be a common occurrence in the TIPS patient population. Often patients are kept separate or even in seclusion in their homes before ever being diagnosed, with their cancerous lesions unclean, open to air, infected, and thus prime attractions for flies and their offspring. This current patient expressed to us a desire to go home and continue treatment there. Dr. Sunil later informed me this was not possible, as his family did not want him to return home.

We next met a warm, gentle-spirited 41-year-old woman with advanced pancreatic cancer. Again we had a good-humored visit from the tiny mentally ill woman, but this time on non-violent terms. I don't understand the Malayalam language, but I could see obviously she said things that made all parties laugh, including the pancreatic cancer patient. I remember thinking clearly that her presence and mostly harmless antics were in some way part of the palliative care and experience of these patients - she made them laugh, an obvious and essential part of any quality of life.

Our final patient was a elderly man who was in remission from lung cancer, but who cried throughout the visit and examination. He'd had a trach, was unable to speak, and so would clap his hands feebly together during the brief moments that Dr. Sunil would look away in order to speak with Sister Elizabeth, or write something down, or go to grab his stethoscope. His affect was desperate, inconsolable. Later I learned he also had some underlying psychiatric issues, but there were limited means at the home to support consistent psychiatric care, and thus the TIPS team was attempting to manage this aspect of his treatment as well. He, too, wished to go home, but was part of a family that did not want him to return. He had two roommates of contemporary age. One sat and snoozed throughout the visit, while the other perched on the edge of his bed, listened intently, and occasionally looked to one of us, shrugging his shoulders and shaking his head in what read as resigned solidarity in the face of his roommate's woes. It was difficult to end the examination. Dr. Sunil, and eventually all of us, seemed hesitant to leave the patient, who was clearly not feeling better than when we’d arrived, and, despite our efforts, would continue into the day with his anguish.

Sister Elizabeth then brought us to the medication room where she filled the prescriptions for all the eight TIPS patients from the medicines we had brought along. We were then served fresh pineapple juice and some cookies. The room had a glassless window into the hallway, and as I crumbled through my cookie, I noticed the tiny, sweet insane woman standing by, looking in at me as I ate. Sister Elizabeth saw the exchange, and I smiled to her what I hoped was an expression of appreciation for the little woman, and for her presence here. Sister Elizabeth responded, calmly stating, “She is harmless. She is one of us. She has no where else to go.”

I thanked the Sister for the refreshments and followed the TIPS team out to the van. The visit to Sister Elizabeth’s shelter left me asking one question: "How do we manage the life and suffering of the world's unwanted?"

I was becoming keenly aware that Dr. Gopal had found and developed a myriad of ways of doing just that.

For reasons known and unknown, leaving Juanga breaks my heart. The following photos depict some of the experiences I had on my last two days there, one of which was also my birthday. There are two pictures of a conversation between Bapa and me, which began with him crying as he discussed my final days in India and how hard we both find it to say good-bye. As you can see, the conversation lightened in the end with his good-humored hope to get himself and his cow, Shiva, on the plane with me. The photo was snapped just after he asked me if they both would need a passport?

This last photo is of Pratima, our head nurse and my room mate/neighbor this visit, painting my hand with henna first thing in the morning on my birthday. Besides its simple beauty, the henna serves as a reminder that even when you go away from a place, part of it stays with you. I wish it felt that simple, or that easy to hold on to, as the days continue and I morph back into the fast ways of the West.

Every time we say good-bye I die a little,
Every time we say good-bye I wonder why a little,
Why the gods above me, who must be in the know,
Think so little of me they allow me to go.
When you're near, there's such an air of spring about it,
I can hear a lark somewhere begin to sing about it,
There's no love song finer, but how strange the change from major to minor...
Every time we say good-bye, every single time we say good-bye.
- Cole Porter

The good-byes have begun, and I’ve found myself cycling all over our area the past two days trying to make sure I’ve visited my friends just one more time before I go. I’ve told myself this year that it won’t be difficult to leave, but then I arrive at people’s homes and the long faces appear, the special pre-departure treatment begins, and the lump in my throat returns.

I’ve never been good at good-byes. Just ask my parents what it was like leaving my cousin’s house every year when I was a child, driving away from the Colorado Rockies with a little girl in tears for no explainable reason except for having had to say good-bye to people she loves.

This morning Bapa came during breakfast and sat across from me with Manu, my constant friend, meal companion, bodyguard, and trusted translator. This photo shows how much they two enjoyed the daily conversation topic: "HOW TO GET SUZANNE MARRIED!", and whether or not I should bring my potential husband here to Juanga for the wedding, or to do it in America first. The favorite issue in this conversation, and the most redundant, is the dowry. Bapa loves talking about this, as he knows he’s guaranteed a belly laugh from my side of the table while he lists all the livestock he plans to give in order to get me a prime life partner. Initially there were simply cows involved, but now we’ve expanded to water buffalo and goats. Watch out, eHarmony.

After breakfast, Mili and her brother came to the hospital to invite me to their house for a special you’re-leaving-in-three-days event. When I arrived, I found their crazy, fun-loving neighbor, Laxmi, and their mother, Kamala, leaning over a hot fire cooking some pakari, (fried snacks similar to onion rings). I was led into the house and seated on the family bed. There Mili’s older sister, Dali, took to painting my toes and the edges of my feet with olata, a dark red liquid, something they do on special holidays and occasions. Soon Laxmi finished cooking and plopped on the bed next to me, grabbing my leg into her lap so one foot could dry while Dali worked on the other. I’d asked Mili’s brother to take some photos and he quickly captured the exact feeling of the moment – Laxmi on the verge of tears, me trying to keep things light (unsuccessfully), Dali diligently working on my feet.

Later my bike ride took me to Kapasi to see my musician friends there while delivering an invitation to my birthday party. I didn’t tell them in advance of the visit, and found Kalia, a remarkable drummer, in the back of his house working on his rice harvest. No visit, however brief, is complete without some sort of food offering, followed by a series of interactions where I try to avoid consuming said food and then absorb the ardent shouting of my hosts as they bark at me to EAT the food and, today, DRINK the giant glass of freshly garnered warm cow milk. Not even the curdly cream thick and inviting at the top, nor the three tiny ants surfing over the milky bubbles, could keep me from accepting this expression of affection and hospitality. Paul Farmer calls these offerings “the 5th food group,” and I’ve been here long enough to know just what I can stomach, literally. Today’s wasn’t so bad, though drinking warm whole milk in 100-degree heat and humidity isn’t what I’d call “refreshing.” The two photos show not only the milk consumption, but also the presence of a 2nd glass behind me (that I miraculously avoided drinking), and most importantly the group of men, Kalia the young one in the middle, who stood in front of me as I drank, shouting “DRINK IT! DRINK IT, SISTER!” over and over again if I dared to take a moment’s rest between gulps.

On the way back toward Juanga, I pedaled over a rocky road that kept me going slow enough to really take in my surroundings, rather than focus on the list of things I hope to accomplish before I leave. Soon the scene in this next photo appeared – three women walking away from me with giant bowls of cow manure hoisted on their heads, and two “sadhus,” the wandering spiritual men of India who rely on the kindness of strangers for their sustenance, walking toward me, their hair matted and dusty, their beards full, their loins girded with orange cloth, (of particular interest is the covering of the first sadhu’s privates). I was lucky to have my camera in hand and snap the photo. As any person would, I’ve grown accustomed to my surroundings here over time. But every once in a while a scene grabs me, reminding me of just how foreign a land this is, and how grateful I am to be experiencing it from this vantage point.

Juanga Nurses

With about a week left in my stay, the following is brief update of some of what I can do/have done here, with the help of a splendid and very accepting nursing staff, as well as some keen advice/observations from a Spanish doctor named Marta Miquel who lived here the past six months and recently.

Photo one: Perhaps the most exciting of developments, I got a shelf to store our urinals and bedpans. Before that point, it was unclear when a patient was discharged whether or not the devices had been cleaned before they went on to be used by the next patient. This shelf cost 100INR ($2.00 or so) and now there's a system in place.

Photo two: Our weekly nurse meeting where we sit together and discus how they want to improve patient care and the systems in place for them to do their job. Some requests are large: finish the work to get the new transformer so no more nights/days/weeks (as we've had the last two) without electricity. Others are small: is it possible to get a chair to go with each patient bed for their family/attendant to sit? It often ends with them quizzing me all about my work in the US, and what an ICU is like.

Photo three: Pratima, our head nurse, on the phone with a doctor at the new and evolving nurse's station. We've created an ER for abdominal pain, fever, and diarrhea patients, and within it created a nurse's station for them to organize their work. Previously all patient medication were kept with the patient. Thanks to a shipment from Spain that included some organizing boxes and the crafting of a new wood cabinet with a lock, the meds will now be kept by the nurses. We also purchased 17 clipboards (we are a 17-bed hospital) and now each patient has it's own clipboard/chart system. The paperwork was always done, but now it's in one place for each patient. Each nurse individually has expressed her gratitude that they now have a home-base from which to start and end their work. Future goals are to establish an actual nurse's room...

Photo four: A pending OR patient having just received her 2nd blood transfusion (almost all the women we operate on have low hemoglobin and need at least one transfusion pre-operatively), on a new patient bed (thanks to the Spanish doctor) with the new patient organization system in place - each bed now has a number that corresponds to the patient, his/her chart, and the place where his/her meds are kept. You can also see some of the HIV/AIDS posters from the Orissa government procured by an American medical student who was here for a month.

Signs of a Festival

It's been a week of festivals here in Orissa, and I admit I still am trying to find out just how all the traditions began. The fundamental answer I receive is "Lord Krishna," or "Radha and Krishna." Wonderful. Similar to asking how the tradition of Christmas began, and hearing the answer "Jesus Christ." Yes, thank you, I've heard of Him, but can you explain to me why groups of six men from the eight surrounding villages are carrying around extremely heavy chariots with flowers, bananas, coconuts, lights, candles, and small clay vessels with clarified butter burning inside? With mini-statues of different Hindu deities inside of the chariots? Whilst risking their lives sliding down river banks and loading all eight chariots, all the men, and the accompanying musicians, into boats and crossing a river (this happening just one night of the festival) and otherwise parading into each of the joining villages every other night? How ever did this begin?

One day during this week of festivities is called Holi, where people spend the morning and early afternoon chasing each other around and spreading bright colored powder all over the place. The people in some of the surrounding villages tend to get pretty crazy (drunk), so we limit our play to the hospital and early on in the day inside the village. No one is immune to the colorful play; not the elderly (as seen in the Bapa photo), not even the livestock (note the cow).

The chariot came to the hospital the other day, some blessings were given, some holy food prepared (rice, bananas, coconuts, yogurt, grapes, cucumber, clarified butter, all mixed together and handed out by the priest), brief music played, and then it stayed parked in front for a good eight hours.

To the north of Juanga there's small temple by a banyan tree that some people had visited and done what looked to be a unique worship ritual, involving laying their staffs (from herding something) next to clay vessels filled with milk and offerings of their labors, then covered in red cloths. When I asked about this particular rite, the answer I got was "This is the water buffalo people."

I continue to be humbled by the constant revelation of systems and organization in this special, foreign place that so often, on first or second glance, seems to me a sea of chaos. If not chaos, then at least a myriad of unrecognizable traditions and ways of going about life.

But then I sit on the floor with Bapa to drink some tea, or help a patient walk from her bed to the bathroom, and I remember that the basic human systems are familiar everywhere, between everyone, whether we herd water buffalo or catalog library books. And God bless the herders and librarians of the world.

New Juanga Video

YouTube wouldn't allow me to post this with the audio tracks I'd chosen to accompany the clips, so I hope you're able to watch it on this site.