February 26, 2024

Millions of people turned 75 in September 1938, as I did yesterday. That month British Prime Minister Neville Chamberlain created his sad legacy when, after three meetings with Hitler, he announced that he and the Fuhrer, in Munich, Germany, had achieved “peace in our time.” The two leaders, one naive, the other ruthless, agreed along with France and fascist Italy that Nazi Germany should annex a huge chunk of Czechoslovakia.

Germany had already seized Austria. As initial negotiations on Czechoslovakia went nowhere, Hitler threatened to invade the country. The British government began to prepare for war. On September 29 the Czech government bowed to the political pressure. The next day at 1:30 AM the Munich Agreement was reached.

Czechoslovakia ceded its Sudentenland region to Germany. Later that day Chamberlain asked Hitler to sign a statement that the PM said was “symbolic of the desire of our two countries never to go to war with one another again.” Hitler signed.

On returning to Britain that same day Chamberlain made his tragic “peace in our time” speech. He was welcomed by the Brits as a hero who had kept the country out of war. A few months later, in March 1939, Hitler broke his promise to respect Czechoslovakia’s sovereignty and German troops occupied the rest of the country. In August Germany and the USSR signed a non-aggression pact. On September 1 Germany and the Soviets invaded Poland, starting World War II.

Through the decades the names “Chamberlain” and “Munich” have become synonymous with the shameful term, “appeasement.” 

Today, on the first day of my 76th year, the Republican-controlled House of Representatives is in recess, ignoring a bill passed by the Senate by a 70-29 vote to provide $60 billion in military aid to Ukraine, 90 percent of which would be spent in the U.S.

Saturday, the 24th, was the second anniversary of the Russia’s invasion of Ukraine that, if successful, will position Russian forces on the borders of four of America’s NATO allies. Russia continues to rain missiles on Ukraine’s cities, slaughtering innocents. The Republicans refuse to support funding for Ukraine because they say they’re focused on “border security.”

The poverty-stricken migrants crossing the southern border aren’t launching missiles and rockets at U.S. cities.

Turning 75 means I’m older than most people I know. Those of us in our eighth decade don’t know everything, but we remember lots of things. Folks who grew up in the second half of the twentieth century witnessed a vast scope of human tragedy unfold: in Vietnam, Cambodia, Central America, the Middle East, Central Africa. Then Iran. Then the Middle East again. Then Iraq. Then Afghanistan.

Some of these crises burned out, some have reignited. But the baseline threat to American security for 46 years was confrontation with the Soviet Union. Two months after I was born, in April 1949, the Western powers established NATO as the bulwark of defense against the Soviet-led Warsaw Pact in Central Europe. The USSR imploded in 1991. Thirty-one countries now are NATO members. They face the Russian Federation led by the dictator who launched the Ukraine war, with all its atrocity and brutality.

John Bolton, Trump’s third National Security Adviser, reports in his powerful memoir, “The Room Where It Happened,” that Trump as president viewed NATO as a transactional arrangement based on members’ financial contribution, set at 2 percent of GNP. Because some members didn’t reach that benchmark, he threatened again and again to withdraw the U.S. from NATO. That began at the NATO 2017 Brussels summit, five years before the Alliance stepped up to buttress Ukraine’s defense.

Trump is back with the same threats, applause lines for Republicans (and others) who ignore or belittle America’s historic leadership of the Western alliance. They see easy votes among Americans angry at non-White poor people on our southern doorstep. They’re listening, not to the Ukrainian troops as they run out of bullets, but to the Trump cadre who don’t care about America’s traditional role in defending Western security.

In mid-month the Ukrainian military leadership conceded that Ukraine’s troops had withdrawn from the eastern front town of Avdiivka because of lack of ammunition. The Carnegie Endowment and Ukrainian sources in the field estimate that Russian artillery is firing at five times the rate as the Ukrainians.

Unverified Ukraine military sources said that from October 10, 2023 to February 17, 2024, Russia lost more than 47,000 men, 364 tanks, and about 750 armored fighting vehicles in the assault on Avdiivka. But the Russians keep coming.

America in the 1930s was scarred by tragedy. The country and the world lived through the Great Depression, which destroyed millions of jobs. U.S. unemployment exceeded 25 percent in 1933. Nazi and Communist sympathizers infected the country, including the federal government. But Americans lost interest in the world. Nazi Germany and fascist Italy seemed very far away. Japan may as well have been on another planet, although the Roosevelt administration knew better.

The isolationists had no problem with Hitler, Mussolini, Tojo. They found easier targets in Jews, Catholics, immigrants.

House Speaker Michael Johnson, on Trump’s orders, pounds his fist for border security. The Republican conference has fallen in line. Some of us have seen it before. “Appeasement” became an uncomfortable word when Chamberlain’s agreement revealed its tragedy eleven months later. The Chamberlain legacy, the stench of Munich, is still potent. It is in the air again.

For my birthday, family and friends gathered to launch me into a misty future, touching and sustaining me for the ride. Let’s hope and pray for a birthday wish: courage, forbearance, faith, for ourselves, and for those suffer, as history repeats itself.

February 19, 2024

The highway north out of Greer, South Carolina, S.C. 290, enters rural country on the way to Spartanburg. After a couple of miles it passes the massive Upstate Inland Port, a truck and rail depot where trailers are unloaded from trucks and loaded onto trains, and vice versa. From the highway the view is the silhouettes of hundreds of stacked trailers being hoisted by giant cranes to and from trains and trucks.

The road otherwise is a straight and level stretch of asphalt traveled mainly by the few folks who live in Duncan, a small place beyond scrub woods and small truck gardens, or Lyman, farther north, and other small towns that mix old farmhouses on big lots with treeless new subdivisions. So Greer is a fringe place: the last outer northeastern suburb of Greenville, which is the lively center of what’s called Upstate.

In our three years here we had never come out this way, but now we drove 15 miles up 290 through Duncan. For a stretch the two-lane highway was empty of traffic. Eventually we passed a few vacant industrial buildings, a barbecue place, a large church, and James F. Byrnes High School. These signs of civilization quickly fell away, the road took us back through more scrub, offset by the occasional ramshackle homestead bordered by wire fencing. We exhaled and turned back.

Greer has a business district, a museum, a couple of streets of small shops and upscale restaurants. We stopped at the Stomping Grounds for a sandwich and coffee. It’s furnished with small tables against a couple of sofas and preserves the well-worn brick walls of the neighboring buildings. A large wall sign, “C.O.F.F.E.E., Christ Offers Forgiveness For Everyone Everywhere” reminded me we’re in the revivalist Southland.

The coffee was tangy and hot. I took a long sip. Was I forgiven? I couldn’t tell.

The place was nearly empty, a couple of guys sat nearby looking at a laptop, four older folks sat near the door nursing drinks and lunch. It was Hemingway’s clean well-lighted place. We sat and reviewed our lists of things to do, the medical appointments, the home maintenance chores, while time marches relentlessly before our eyes.

Up the street, a couple ate lunch at a sidewalk table in front of a clothing store, the “Trades Café.” We walked in, the place was not one but four tidy antique dress shops melded to a tiny restaurant, where folks sat dining alongside the racks.

We smiled at the oddness of it, lunch in a dress shop. Beyond the three or four blocks of downtown the place has some energy to it, a well-groomed park, a kids’ playground, ballfields, a modern city hall, a new block-like Hampton Inn that clashes bizarrely with the style of the old brick and frame houses nearby.

A mile or so from the town center acres of red Carolina clay are being bulldozed to make room for new homes, condos, and an apartment complex.

The city limits extend miles north, encompassing a couple of manmade lakes and up I-85 towards Charlotte. To the southeast Greer runs to Greenville’s intense commercial/retail strip where the big-box stores, fast-food outlets, and auto dealerships are massed astride the I-385 spur, which runs into the city or southeast towards Columbia.

It’s called the “city” of Greer, population 35,000 or so at the last census, so very different from the “city” of Cowan, Tenn., population once over 2,000, now down to 1,500, where Sandy grew up. Greer is in some ways more like the “village” of Ridgewood, N.J., 20 miles west of New York City, home to 25,000, where I lived as a kid. In both places the central business district is more or less intact, with the shops, restaurants, and coffee bars in a neat symmetrical grid.

Ridgewood’s downtown is far larger, oriented to its well-off profile. When I joined the Marines and moved away decades ago, the place exploded with affluence as Wall Street types bought homes and over the years demolished hundreds and rebuilt them twice the size. The old Ridgewood Lawns neighborhood now has a weird, klutzy look to it, with many if not most once-humble Cape Cod foundations supporting three grafted-on colonial levels, like plastic surgery gone wrong.

Cowan, two states due west of Greer, is pastureland, one main street, two traffic signals, a post office, a gas station, a fast-Mexican food outlet, a couple of secondhand shops. The railroad museum is the anchor. Cowan, just west and north of the Cumberland Plateau, once prospered as a rail stop but slid into depression when the shoe factory and cement plant closed.  The once-cozy Cowan Café turned into the Mexican place. Young folks moved away. Sandy’s parents stayed until her dad lost his job, then left for Nashville.

The common thread linking Greer and Ridgewood is nearness to a larger city; Greer without Greenville and Ridgewood without New York both might look like Cowan. When we want to go “downtown” we don’t go to Greer.

For a short, hectic year, 1986, we lived in Red Bank, N.J., roughly 50 miles south of New York. It seemed right at the time, a clone of Ridgewood, but work drove us to Virginia in ‘87. The Lake Ridge section of Woodbridge, Va., is a series of now-pricey subdivisions linked to strip malls. The main artery is a six-lane thoroughfare nearly always gridlocked with commuters to D.C. and the federal contractor ghettoes of northern Virginia. We left without a backward glance.     

Our last visits to Ridgewood (two years ago) and Cowan (one year) tugged the chains of memory, of the quiet childhood hometown in the years before the chic boutiques, and the roughhewn Middle Tennessee community that calls itself a city. Special, lifelong-lasting things happened for us in those vastly different places.

The past lingers forever, but Ridgewood ravaged itself by tearing down the venerable old firehouse and putting up a multi-level parking garage.  Happy places I recall—faintly—the little bookstore, Trilby’s, and the stationary store, Drapkins, disappeared decades ago. The church elementary school closed a lifetime ago. Cowan some years back lost its only supermarket, a modestly classy bed-and-breakfast, an Italian restaurant, and a bagel shop. People who want those things don’t go there anymore.

Now we have Greer with the Stomping Grounds and its revivalist wall décor, and the Trades Café for lunch and browsing used-clothing racks, if we ever want to. There’s a Great Bay Oyster House, four hours from the coast, a Brass Beard Barber Shop, a Cartwright Food Hall, a Namaste Fitness Studio on Jason Street. Then the Stomping Grounds. Coffee, for sure. Forgiveness, who knows? Memories, probably not.

February 12, 2024

The woman on the other end of the line spoke slowly, loudly, deliberately, spelling out the website “newprograminformation.com”:  “EN … EE … DUBILYEW …” and so on, pausing for breath between each letter. I did not ask her if she thought I was a doddering old coot, because she obviously did. After all, I am a senior. Of course she was trying to be helpful. I thanked her for it. 

About fifteen years ago I stepped onto a Washington, D.C., Metro train heading home from work. It was rush hour, I saw no open seats and grasped a handrail. As the train moved forward a young woman rose and offered me her seat. I was a little embarrassed and declined. I was wearing what I thought was a sharp-looking business suit and carried a briefcase. She must have seen the gray wisps above my ears. You know what she thought.

It’s been years since I last rode the D.C. Metro. But the same thing happened again a couple of times on our trip to London last fall, as we rode the Underground. I gladly accepted the offers. I thought, well, the English are so polite. Or I am old. Or both.

It’s fun being a senior, up to a point. You get discounts, usually a couple of bucks, on movies, hotels, train tickets. Some restaurants have a “seniors” menu. Younger people sometimes hold the door. Seniors who do special things, like finishing marathons, caring for stray animals, or working at homeless shelters may be interviewed on the evening news. The questions usually are simple-minded and patronizing, the reporter looking for “yeses” or noes,” while wearing an impatient smile.

The U.S. is facing a presidential campaign of two old men, Biden 81, Trump, 77. Both have subjected the country to mental flubs typical of people their ages. Nikki Haley proposes a mental competency test for 75-year-old candidates. Many Americans agree.

In 1998 then-NBC anchor Tom Brokaw wrote a book entitled “The Greatest Generation,” a closeup of the lives of 46 people—men and women, famous and non-famous, servicemen and civilians, who served the country during World War II. The “greatest generation” became a catchphrase for all those who lived through the Depression, then stepped forward.

Among the well-known figures Brokaw covered were George H.W. Bush, Robert Dole, George Schultz, Mark Hatfield, and Daniel Inouye. Bush and Dole, following their heroic wartime service, had distinguished political careers. George Schultz is one of only two men to serve in four Cabinet posts. Hatfield served in the Navy at Iwo Jima and Okinawa, then as Oregon’s governor, and 30 years in the Senate. Inouye was wounded five times in Italy, lost his right arm, and won the Medal of Honor. Later he represented Hawaii for 49 years in the Senate.

These five and most of the greatest generation have passed into history. Many younger people know nothing about them. Time is speeding by in a kind of blur. About a year ago I met a couple of young folks who never heard of the Cold War. The term “Vietnam” doesn’t register either.

The oldsters of today are those who followed the greatest generation, including me. We had the Cold War, Vietnam, the Sixties. We had Kennedy, Goldwater, Nixon. We now are the ones who have simple words spelled out for us by others decades younger.

We are forgetting where we left our keys, and sometimes forget where we live. Senior moments, they’re called. As everyone knows, seniors slow down. Not everyone knows the costs, emotional and financial, to those close to them. Whimsical absent-mindedness we observe in elders may translate into something darker: six million Americans suffer from Alzheimer’s, the most common form of dementia.

The numbers are ominous. The Centers for Disease Control reports that for 2015-2017, Selective Cognitive Decline (SCD), an early symptom of dementia, ranged from 6 percent of South Dakota’s over-45 population to 16.2 percent in Arkansas. Percentages of adults over 45 with SCD who live alone go from 37.6 percent (Oregon) to 52.9 percent (Wisconsin).

Dementia, a disease of aging, is projected to affect some 152 million people worldwide by 2050. We know some victims: Ronald Reagan, Margaret Thatcher, Rita Hayworth. Charlton Heston. Glenn Campbell. Tony Bennett. Sean Connery.

Sources available suggest, ironically, that longer lives due to healthier lifestyles and better healthcare add to the dementia numbers. Exhaustive research back to the work of Alois Alzheimer from 1906 through 1911 and up through today have achieved breakthroughs in identifying dementia’s likely cause: buildup of mysterious proteins in the brain that tangle and clump to destroy the brain’s exquisite pathways.

In January 2023 the Food and Drug Administration approved a new drug, leqembi (lecanemab) for treatment of Alzheimer’s. A second drug, donanemab, is awaiting approval. The drugs showed modest effectiveness in extensive clinical trials. They may slow decline for months, perhaps for years for some. The disease remains incurable.  

Natalie de Souza, in a New York Review of Books review of How Not to Study a Disease: The Story of Alzheimer’s, by Karl Herrup, writes that “there is still an element of guesswork in designing Alzheimer’s drugs. … More optimistically, it is possible to reduce the risk of dementia without complete understanding of the biology of the disease.

“Several facets of general health—high blood pressure, smoking, obesity, lack of physical exercise, diabetes, loss of hearing, excessive alcohol consumption, depression, low educational level, low social contact, air pollution, and traumatic brain injury—have been observed to be risk factors for developing dementia.”

The young lady spelling out “newprograminformation” for me may well have assumed I was a statistic, one of those six million Americans. In her job manning the phones at a drug company, she probably has lots of experience with them. Some of them may react to her with anger or impatience, two-sure fire symptoms of that dark place. She did her best.

By the grace of God, some of the eighties- and nineties-plus crowd still drive, play golf, drink wine, run races. They’ve left behind childhood friends now lost to dementia, the insidious tangling within their brains. We see the victims wherever we find ourselves, teaching lessons about our lives and theirs, delicately fragile, but precious.

February 5, 2024

Every so often the answer is just a loud “No!” The specialty pharmacy email was short: “Your insurance has denied the authorization on your medication and cannot be filled at this time. We have notified your physician, please contact your physician to review options.”

The drug is erdafitinib, trade name Balversa.

The nurse at the Cancer Institution said the financial office was going over the authorization request to ensure it was submitted properly. So the financial people have it under control. Don’t they?

The insurance company also sent an email. “Your prior authorization request has been denied. Visit your ‘Secured Authorizations’ to review details.” The details are, contact your prescriber to discuss alternative treatment options. If you think the insurance company is wrong you can appeal.

You sometimes see this played out on the evening news, when a crusading reporter tells a story of a cancer patient sliding into the health-care/insurance swamp: an insurance company refusing to cover a prescribed drug. The patient, and sometimes the doctor, dials 800 numbers, talks to computers, sits on hold, argues with clerks and bureaucrats who have no answers.

It’s not that simple. I called insurance. A pleasant young woman answered. She didn’t treat me like a deranged cowboy or cite a barrage of opaque regulations and procedures. She didn’t place me on hold while she searched the company database, or maybe an old steel filing cabinet, for my profile (I could hear papers shuffling, drawers opening and closing). In the end, she did pitch me back to the doctor’s office. They need to provide more information.

The people at the Institution are pros, they work the health insurance system like a symphony virtuoso with a finely tuned violin. For three years all the doc’s orders—tests, scans, procedures—have sailed over the insurance blockade. A letter shows up, usually just before I have the doc’s requested procedure or therapy, but sometimes after, always marked “Approved.”

Then everything changed. The doc looked at my December PET scan and gave up on immunotherapy.

The theory behind immunotherapy is that it gives the patient’s immune system an extra push to kill cancer. It’s an alternative to bombing the bad cells with chemotherapy and radiation, which also destroy healthy cells. For many, chemo causes the worst side effects, the hair loss, nausea, bleeding, skin problems, blurred vision, others. Radiation is no fun, either.

The immunotherapy drug, pembrolizumab, better known as Keytruda and manufactured by the monster drug company Merck, let me off easy. I showed up for treatment, took the infusion, drove home, ate dinner, slept soundly. But the quality of life/drug effectiveness balance was one-sided.  Three CT scans and the PET over the past nine months showed the drug was not working. The problem on my liver and pleura (lining of the lung), identified as a thymic carcinoma, kept growing. So no drug-induced side effects, but no slowing the disease.

We need a win against the cancer, the doc said, meaning changing the tradeoff: progress against the cancer at the cost of likely negative side effects. His solution: erdafitinib.

The quality-of-life standard is simple: being OK, how I felt when I saw the doc. The standard at the Institution is not OK. Cancer patients don’t look well. For many, perhaps most patients, the treatments, chemotherapy, radiation, and immunotherapy have noticeable outward costs: weight loss, halting gait, caps to hide hair loss, wheelchairs and walkers, leaning on others for support.

The doc said, “You’ve done great, you should tolerate any side effects well. We’ll order erdafitinib from a specialty pharmacy. They’ll coordinate with insurance, including doing an appeal, if necessary.” 

The denial email showed up. The scenario of the insurance company as bad guy kicked in. The patient’s first reflex is frustration. But what does he really know? He knows what the doctor tells him. The amateur internet searches are pointless and dangerous.

So why, after a three-year winning streak of approvals, does insurance say “No—denied?” Is it, as the Cancer Institution people guess, a paperwork problem? Or something else? Sure enough, a couple of days later the doc’s office called to say they filed an appeal and “letter of medical necessity” with the insurance.

Three years ago, in January 2021, Foundation One, a Boston-based medical laboratory, analyzed my cancer tissue samples down to the cellular level. The doctor gave me eight pages of the 20-page report, mostly incomprehensible medical hieroglyphics. Buried in the fine print is the sentence: “Clinical data on the efficacy of erdafitinib for the treatment of thymic carcinoma are limited (PubMed May 2020). Erdafitinib has been primarily studied for the treatment of FGFR-altered urothelial [bladder and other urinary tract] carcinomas.”

Context: this was three years ago. Maybe some breakthrough was achieved. Maybe I’m an experiment, a clinical trial of one.

Patients and doctors both know one thing: cancer is a mystery, in its causes, its treatments, its consequences. Cancer is not one disease, or a dozen, it’s thousands of diseases that evolve and mutate constantly, even as those smart physicians and researchers discover new therapies.

We’re engaged in this mystery—to exist, to persevere, to seek joy alongside it. Twelve months of Keytruda didn’t stabilize this cancer. Erdafitinib probably won’t either. The process, really, is Point A to Point B. But then, what’s Point B? We all know. The doctor and the insurance company have a tough call. So does the patient: find the goodness in life, say your prayers, take your medicine, move forward.