Of Death, Dust, and Fire

This column is ordinarily about some variant on the theme of my profession, Preventive Medicine. The mission of every preventionist is to do all we can to help the healthy stay entirely well; to help those with risk factors control them and avoid disease; to help those with disease avoid progression, disability, and death. There is almost always something left to prevent.

There is, as well, a career-long lesson in humility. For in the end, every time, prevention fails; the ineluctable force of our mortality prevails. We all die.

In a departure, then, from my customary efforts, and in response to a recent provocation, I want to consider that end of the spectrum this time. What happens when we die?

I don’t mean what happens to us, personally. I defer that to your beliefs, and the debates of theologians. I mean what happens down here, in the void of our absence.

The provocation I noted occurred in three parts, one lesser, two greater. The lesser part was courtesy of The Thorn Birds, a ten-hour saga of star-crossed romance my wife periodically decides it is time for us to watch again. So, we did so recently- and suffered through the triumphs and disasters of the Cleary family over several generations. Among the disasters are all too many premature deaths, with a central protagonist, Father Ralph de Bricassart (played by Richard Chamberlain) inevitably presiding.  He declares somberly that we are dust, and unto dust return.

But let us allow at a minimum that there are many grades of dust. There is cosmic dust. There is stardust. And as we are the stuff of stars, perhaps at least that, too, is the nature of the dust we leave behind.

But there is more to stars than dust; there is also fire. And the two greater provocations direct us there.

On the Thursday before Thanksgiving, I received the devastating news that a friend and colleague, Dr. Nancy Cappello, had died. Nancy’s extraordinary story was well told in her obituary in The New York Times. Many years ago, she was diagnosed with an advanced breast cancer missed by mammography due to dense breast tissue. Nancy endured the hardships of treatment, and became a crusader for breast cancer screening tailored to the needs of women with dense breast tissue, some 40% of the population. Only after effecting legislation in 36 states, and raising awareness around the world, did Nancy succumb to the long-delayed complications of her disease and its arduous treatments.

Her cause, though, continues, in the work of the non-profit she founded, Are You Dense? So it is that Nancy is much more fire than dust, having lit up the lives of those privileged to know her, and passed along the torch of a noble cause. It still burns.

I attended Nancy’s funeral on the Monday before Thanksgiving. And though I knew the torch of her cause still burned, I was mostly just lost in the sadness that she was no longer here to carry it.

Then came the second greater part of provocation. Just 24 hours later, the Tuesday morning before Thanksgiving, I had a scheduled call via Skype with a young physician in Iran. This young woman was seeking career advice in the area of Lifestyle Medicine, but for a very specific reason. She had suffered with devastating atopic dermatitis much of her life, severe enough to resemble burns over much of her body. She told me the pain and itching were nearly unbearable over a span of years, and the humiliation of being seen in that condition almost as bad again.

Much like Dr. Cappello, who received but did not benefit from the standard approach to breast cancer screening, Dr. Shokri received but did not benefit from standard treatment. She was barely able to control her condition with copious applications of topical steroids, ultimately becoming dependent on them – and inadvertently learning about topical steroid addiction. As with any addiction, in this condition the effects of the “fix” grow less over time (this is called tolerance), but it is required nonetheless to prevent withdrawal symptoms. Dr. Shokri’s disfiguring condition worsened if she stopped applying the creams, but did not improve when she did.

Ultimately, Dr. Shokri found her way to the power of lifestyle as medicine, and has almost completely healed herself with an optimal diet. She is now committed to a career in this domain, eager to empower others with what she learned through the pain and ardors of her personal plight.

As was Dr. Cappello. 

That Dr. Cappello’s funeral, and Dr. Shokri’s story populated a single, 24-hour span in my life struck me as significant. I had already been reflecting that dust did no justice to the likes of Nancy Cappello. She was all warmth, and light, and those were with us still. But there was that space where she, uniquely, carried the torch- and that space was poignantly empty. 

Here, in this young physician from Iran, was another torch-bearer. Here was another lesson in how to summon and shelter the better angels of our nature. Here was another luminous commitment to turn personal hardship not into misery, but mission. Here was another stepping up, to pay it forward. Accordingly, I felt some measure of solace. 

The best of us are much more flame than dust, torch bearers of eternal fire. Unlike dust, flame is transmissible as warmth against the cold, as light by which to see more clearly.

We all die. But that does not stop the best of us from shining on.