The Coffee Cantata

"You should shave your head, Martin, and stay. They wouldn't come for you here."

"Not sure I'd be very good at all this," Martin said, "being an atheist and all."

"Oh?" she said. "What do you think comes next? After all this is over?"

"I think I'll just close me eyes and be done with it."

"Yes. You are ready. You should stay."

He laughed, then he saw the look in her eye and took a deep breath, reached into his pant's pocket. He fished around for a moment, then pulled out a couple of keys.

"Ben? This first key is to the Porter. The second is to a safety deposit box. I'll give you the particulars in a bit. There's an aeronautical chart under my seat that will get you into India. Tell the authorities you found this aircraft and are repatriating it. Officially, it still belongs to those Air America chaps of yours, so you haven't stolen anything."

"Martin? You sure you want to do this?"

"Yes. With any luck at all, those girls are in California already. I told them to leave, and who knows, maybe they got out. Maybe you tell the authorities in India I was killed in Burma, or that I had contacts in the military?"

"That would do it."

"At any rate, I doubt they'd try to enter Bhutan, even if they knew I was here."

"What about Bao?"

"Tell them we all got out in Burma, that you came back and borrowed the Porter after I was killed."

Bao came in when prayers were over, and they filled him in on the morning's decisions. The colonel nodded his head, then turned to Martin. "I will walk with the lieutenant to the aircraft," he said, then he left, apparently very angry.

"Now what's that all about?" Martin said, and Mai Ling smiled, then turned away.

"I'm going to get my things," Ben said, looking from Martin to Mai Ling and back again. He stood, went to the woman and hugged her. "Thank you," he whispered, "for everything."

She kissed him on the cheek. "You will not forget us, will you?"

"Never."

"Go now, before I shave your head and make you stay."

He kissed her and walked quickly from the room, and Martin followed a moment later, but not before he looked at Mai Ling and grinned.

+++++

The three of them walked up to the Porter and stopped, looked at one another, then Martin took the key and opened the door. "Here are the charts you'll need. There's some cash in this envelope, a few Sterling and some Swiss francs. You'll have just enough fuel to carry on to Bagdogra airfield," he said, pointing it out on the chart. "And here are the ADFs and VORs you'll need."

"Alright."

"Now, about the second key. USB, main office, Zurich. You can only access it on 7 July. 7-7, got it?"

"Okay."

"And Ben? Don't lose the fucking key."

He grinned. "I'll try."

Martin handed him another scrap of paper. "Here's what you'll need to sign in for the box."

"Okay, but Martin, what the hell's in this thing?"

"An envelope, old boy. You want to leave the bank immediately, by the way, and get to London as soon as you can. Follow the instructions inside the envelope to the letter, as lives may depend on it."

"Alright," Asher said, noting the serious expression he saw in the old Englishman's eyes.

"Well, this is it, Ben. I'm so glad you dropped by..."

They laughed, then hugged -- the old man slapping Asher's back.

"Colonel? Shall we go?" Martin said.

"I must have a word with the lieutenant, please," the colonel said, and Asher could see the emotion brimming in his eyes as he walked up. "Lieutenant," Bao said, addressing him as a superior officer, and Asher snapped to.

"Yes, sir."

"I came to you with nothing but evil in my heart. I came to kill you. Now I understand you. Now I see you as my friend. As my good friend. And as a friend I ask you a favor."

"Yes, Colonel?"

"Mai Ling will have my son," he said. "In seven years, I want you to return, to come -- here. Right here. I want you to take my son to America. Fly by the monastery, rock your wings, and I will bring him."

"Alright, Colonel. Seven years from today. I'll be here."

They looked one another in the eye for a long time, then Bao turned and walked away; Martin let slip the wing tie-downs then helped Ben with his walk-around. They shook hands and he climbed in the Porter and started the engine; he watched the gauges for a moment, then lined up on the clearing and took off. He circled the riverbed once, flew over the trail and rocked his wings, and he saw Bao standing on large rock, saluting, as he passed.

+++++

She felt better now, with the wind in her hair and the sun higher in the sky, but she felt unsure of herself, of her footing in this strange new landscape. She watched him handle the car, listened to him talk about his daughter, about his other son in Boston. About Madeleine and her lingering HIV, and the promiscuity that had been her downfall. Their downfall.

And she felt like a foreigner, like a stranger in a strange land, like the ground kept shifting under her feet, trying to slide out from under her. Then she thought of Portman, and his first lecture -- before she lurched back to the present.

They turned of the coast highway onto old Highway 33 and climbed into the oak crusted hills that looked over the Pacific, and he set his course to the hospital where his daughter lay waiting. She listened to him talk about Lacy's disease warily now, like she really couldn't believe something so vile and pernicious could still exist in the 21^st century, but the more she listened the more she believed. And the more she believed the more afraid she became.

"I had no idea," she said at one point. "I thought anti-psychotics had all but wiped it out?"

"It's an insidious disease, Lindsey. Medication can help alleviate symptoms, some symptoms, anyway, while others percolate just under the surface, just out of view. The underlying mechanism, the inability to the brain to correctly encode and retrieve memory, makes it feel as though what's experienced is real. In other words, what the patient experiences does not feel unreal, it's not a hallucination to them. When Lacy's being attacked by knife-wielding demons, it's real to her. When she tries to recall something from childhood, say a memory of Christmas, the memory may come back in the form of an attack. Think of the brain as a computer, if you can. Memory's are stored in something like a hard drive, but instead of binary coding the brain uses chemical coding. In a schizophrenics mind, the ability to address memory, and to retrieve it intact, is corrupted. It's confounding, too, because some regions may be intact, may offer some semblance of order, then some other mechanism distorts the ability to recall. No one can tell with much certainty why this happens, let alone how, but when you look at Lacy she appears normal. She speaks normally. You just can't let your senses be your guide here, because you and I want to see normal. We want to see progress. We want to see hope."

"Are you're saying there isn't any?"

"With the current state of the art? Doubtful. And again, it's the nature of the beast. There isn't just one 'kind' of schizophrenia, Lindsey. There are a whole bunch of them, yet they're not all separate and distinct diseases. There're crossovers and permutations, too, a little bit of this one and little bit of that one over there. One med may work well for this combination and be completely ineffective for one that looks the same, but maybe that's because there's just one subtle little difference between the two. And guess what? It's hit or miss, trial and error."

"But the news coverage..."

"The meds are only effective at quieting the noise, Lindsey. They turn off the hallucinations, for a while, anyway, but the side effects are not inconsequential. Sleeping twenty hours a day isn't uncommon, and uncontrolled weight gain the norm. Then all the other components of weight gain join the parade. Hypertension, diabetes -- then liver toxicity creeps in as the meds take their toll. Lacy weighed 115 when we brought her here. She weighs 250 now, she's on insulin and beta-blockers, and she's not even twenty."

She saw him wipe away a tear and she put her hand atop his arm.

"Well, here we are," he said as he turned off the highway.

"It looks like a country club, Doug. Look at that view..."

"It was. Went out of business in the crash, a group of docs in LA bought it and rebuilt the main building. A lot of the land was sold off to developers, and that allowed them to add buildings, increase space. There's a year long waiting list to get in now."

"But if there's no cure?"

"The goals are simple where Lacy is concerned. Get her stable enough to move into assisted living, maybe with a roommate."

"Not home?"

"Doubtful. I can't see moving her back into an environment that may have been the primary cause of all this? And when I'm not around? In the office all day?"

"I see. Any other options you can think of?"

"Well, we'll meet with her docs first, then if she's up to it we'll go see her. Then you tell me what you think."

They walked inside, to the reception desk, and then were escorted to a conference room, and after a few minutes wait a lab-coated physician and two nurses came in and sat. Lindsey looked at the physician, a psychiatrist, she assumed, and thought he looked troubled; the nurses looked harried -- worn out and at their wit's end.

The physician looked up from his chart and at Lindsey: "This is your visitor?" he asked.

Doug spoke first: "Yes, Doctor Tremble, this is Lindsey Hollister, a friend..."

"The writer? You wrote A Pound of Flesh?"

"Yes, I did?"

"Are you here in a professional capacity? "The pound of flesh which I demand of him is deerely bought, 'tis mine, and I will haue it." Does that about sum things up? Are you here for your pound of flesh?

She thought the question paranoid, and almost wanted to laugh. "Well, no actually, Doug is a friend, and I want to know what he's facing."

"Ah, well then. And here I had hopes of becoming the evil villain in a taunting exposé vis-à-vis the ills of modern psychiatry?"

"Are you an evil villain?" she asked -- and the man snorted.

"Yes, of course. Just ask any one of my patients."

"I see your point."

"Good," Tremble said, chewing on a ball point pen. "Now, Doctor Peterson, a lot to report this week, I'm afraid. She's refusing food and water again, which is causing all kinds of problems with her sugars. We started an IV to hydrate her and she ripped the line out last night, so she's in hard restraints this morning. Another 24 hours and we'll need to insert a gastric tube again. Miss Hollister, for your benefit..."

"To feed her," Lindsey said, cutting him off. "Yes, I'm familiar with the concept."

"Are you? Well, good. As we discussed last time this occurred, we've started Haloperidol IM, so we're anticipating major GI issues if we restart her on a feeding tube..."

"Excuse me," Lindsey said, and Tremble put down his pen, looked exasperated, "but you're saying Lacy is tied down, refusing to eat or drink, that you're giving her medications that will cause GI issues if you start to force feed her? Is that about it?"

"Yes, Miss Hollister, that's about 'it'," he said, hanging quotation marks in the air with his fingers.

"Okay," Doug said, "why do I get the impression you're holding something back this morning." Then he looked at the two nurses. "What's going on? Talk to me."

The nurses looked at Tremble, then at Peterson, then one of them spoke: "Doctor Peterson, Lacy exists in two states of mind now. She's either asleep, a very restless sleep, or she's awake and fully engaged in her hallucination. She writhes in agony, screams out as her demons assault her, cutting her with knives. She screams when they throw her into fires. She screams when the demons bring innocent babies before her and cut them up, throw them into the fires. I think the point I'm trying to make is this..."

"And let me say I disagree with this assessment, but they are a part of her treatment team so have a right to speak."

The nurse looked intimidated, but continued. "The point, Doctor Peterson, is simply this. She's suffering, and treatment doesn't appear to be working. After five years, she's symptomatically worse. She is clinically depressed on top of everything else, has given up hope of getting better, and her nurses are of the opinion we should DC life sustaining measures..."

"DC means discontinue?" Lindsey interjected.

"Yes, sorry."

Doug looked down, nodded his head. "I was afraid of this," he whispered.

Lindsey looked at Tremble again. "Doctor? What do you think of this position?"

"I'm against it. I simply can't give up."

"Why? I mean, an oncologist fights a cancer until there's no longer any benefit to further treatment? Are you saying you think there's a chance for improvement?"

"There's always a chance, Miss Hollister."

"Well then, let me rephrase. Is their a reasonable likelihood, with current medical knowledge and with the tools you have on hand now, today, of your altering the trajectory of this illness?"

"No, not really."

"So," she sighed, "what possible motive could you have for continuing treatment, other than, say, a financial motive?"

"Now look here, I resent the implications of that statement..."

"As do I," Lindsey said, "but nothing else comes to mind. What you've described to me this morning is a portrait of unmitigated suffering, suffering without chance of remission. Could I ask you one more question, doctor, before you stab me with that pen?"

Tremble looked at the mauled pen, then put it down. "Yes, of course."

"What would you advocate if Lacy was your best friend in all the world? Or your daughter?"

He sighed, looked down at his hands. "I don't know. I might try a Hail Mary Pass, but at this point, I just don't know."

Doug looked up. "Such as?"

"ECT," Tremble said.

"Jesus," he sighed. "I didn't think..."

Tremble sighed. "Like I said, Doug, this would be a Hail Mary play."

"Doctor," Lindsey said, "I'm not blind. I can see that you care, that you're frustrated and feel the same hopelessness your nurses feel, but when is enough enough?"

"When I've tried everything, I'll let you know."

"Logistics?" Doug said.

"Only place worth trying is Spokane, Sacred Heart."

"Air ambulance?"

Tremble nodded. "Probably around a hundred grand. Insurance won't cover."

"How about ECT? Is that covered?"

"No."

"Any guesses?"

"Two to three hundred thousand?"

"Any idea of a success rate?" Lindsey asked, incredulous now.

"No, but not very good."

"So," she said, "3-4 hundred thousand for an unproven treatment with little chance of success? On top of five years and how much money?"

"Close to a million," Doug said, "out of pocket. So far."

"Well," Lindsey sighed, "I just found the topic for my next book. This is incredible. Your money or your life."

Tremble looked away.

"I'm curious," she added. "What about the people who can't afford this. I mean, seems to me that's about 99 percent of the people in the country. What do they do?"

Tremble looked at her. "They cut almost all mental health funding for public treatment programs back in the mid 80s. It's been downhill ever since."

"The Reagan cuts, you mean?"

"That's right. They tried to address that with the ACA, but you saw how popular that was, I suppose."

Doug stood. "Could we see Lacy now?"

+++++

Driving down 33 again, the blue Pacific filling the way ahead, Lindsey tried to shake the sight of the girl from her mind's eye. The lifeless eyes, the muted conversation between an infant and a Spanish speaking woman.

"So, you're saying she was holding a conversation -- between a baby girl and a Spanish demon?"

"She fragmented into Multiple Personality Disorder two years ago, and there are several demons involved now. The Spanish demon tends to be a mediator, asks the baby version of Lacy to repent for her sins, then she leads the punishment phase, calls out all the other demons, with the knives."

"That's when the screams started?"

"That's right."

"What did you think about the whole ECT thing?"

"I read the relevant journal articles months ago."

"And?"

"Promising for unipolar depression. A waste of time for psychotic disorders, including schizophrenia."

"So, it's a Hail Mary?"

"No, it's not even that. Tremble knows she's going to fail, to die, and he wants to pass the buck to another institution. If she dies here, or goes to hospice from here, it's a mark on his record, a possible investigation. Patients in mental facilities rarely die, so the state often looks into these types of events."

"But it's not his fault?"

"Doesn't matter. It's a statistic, an unwelcome one at that."

"This is like Kafka. Every one in sight runs from the bureaucrats and their lawyers, and somewhere along the line doing the right thing becomes impossible."

"It's easy to fall into that kind of thinking, but actually a lot of good comes out of our system. It could be better, but the political will just isn't there, let alone the money."

"You know, the amount of money an F-15 uses in fuel, in fuel alone, to fly one bombing mission would pay for her treatment..."

"And that F-15 might fly a mission that keeps a hospital from being bombed, saving hundreds of lives."

"It's complicated, isn't it?"

"If it was easy they'd have fixed it years ago."

"I read a story recently, about a man from Boston who flew to Copenhagen..."

"Yeah, I read that, too. Every month, month after month, Americans get on airplanes and fly to Scandinavia, walk off the airplane and fall down. Free medical care. I get it."

"Don't you think we should feel some sort or remorse for that?"

"Remorse? Maybe, but look at it another way. Politicians take actions all the time that lead to people dying. And what's the definition of murder? To intentionally or knowingly, by act or omission, act in such a manner that causes the death of another. So, are those politicians murderers? Are politicians who cut medical benefits to the needy nothing more than remorseless murderers?"

"Strictly speaking, yes. But it's not so simple," she said.

"No, it isn't. You have to fall back on simple utilitarianism, you have to try to achieve the greatest good for the greatest number, and sometimes that involves making tough choices."

"So, insurance isn't going to get involved in cases like Lacy's..."

"Of course not. Because their doing so doesn't do society any good -- to pump millions into treatments with poor outcomes. That just won't work out in the long run, and everyone knows it. She's gotten the best care money could buy, but it's been my money, not the states, and not some insurance consortium."

"I tend to side with the nurses. It looks like suffering to me. Suffering without end."

"I know. It is."

"What did you tell Tremble?"

"Offer her solid food and water for another day. If she continues to refuse, they'll move her to hospice."

Lindsey looked away. Away from the enormity of the decision, of the personal implications he must have had to deal with over the years. "So, enough is enough? Is that it?"

"I can't afford it any more, Lindsey. I have to take care of Madeleine, of Bud, and somewhere in there, maybe even me, too. I have to make the same calculation everyone else does, the greatest good for the greatest number."

"But if you lived in Denmark, or..."

"But I don't, so let's not turn this into a political wrestling match. I know the pros and cons of both sides, believe it or not."

"It's not a humane system, is it?"

"Like I said, Lindsey, our system produces some miraculous outcomes, but it's not perfect. And it's not, strictly speaking, humane, because it's more often concerned with the economic realities of trying to care for 300 million people, not their pain and suffering..."