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Standing on Jell-O


Books about death and dying were once rare, but today they are ten a penny. Few are any good. Then along comes one that's outstanding, because it makes one think, is courageous, and is well-written.

Barbara Ehrenreich is 76. She is an American, but despite our loathing of more or less everything American, we won’t hold that against her. She has a PhD in cellular immunology – an expert on macrophages, to be more specific. The author of around 20 books of social and cultural analysis, she has now published her latest: Natural Causes: An epidemic of wellness, the certainty of dying, and killing ourselves to live longer. Like the rest of her books this one is lucid and written in a razor-sharp style. It may be her most important book, because she focuses her objective and dispassionate analysis on the biggest topic of all: our death, and how we deal with it. She reminds us that despite all our efforts to stave off the final moment, eventually it comes: “everything devolves into a stinking pool or, what may sound even worse, a morsel in a rat’s digestive system.”

“everything devolves into a stinking pool or, what may sound even worse, a morsel in a rat’s digestive system”

But before she reaches that point we learn something of how Ehrenreich deals with the most obvious sign that her own mortality cannot be far off. At 76 she says she has more or less given up on the techno-invasion of her body by medical ‘experts’. This may well be because of where she lives: America, the land of endless inventiveness coupled with infinite consideration of how best to separate your money from you. The “great promise of modern scientific medicine” is that you don’t have to “get sick and die (at least not for a while), because problems can be detected ‘early’ when they are readily treatable.” Her friends – educated and middle-class – are all doing whatever they can to fend off death: yoga, food fads, purges, diets, exercise regimes; but she is different. She says: “I had a different reaction to aging: I gradually came to realise that I was old enough to die, by which I am not suggesting that each of us bears an expiration date.”

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This courageous realisation – that mortality is around the corner – doesn’t mean that Ehrenreich has given up, just that she has “decided that I was also old enough not to incur any more suffering, annoyance, or boredom in the pursuit of a longer life…As for medical care: I will seek help for an urgent problem, but I am no longer interested in looking for problems that remain undetectable to me. Ideally, the determination of when one is old enough to die should be a personal decision, based on a judgment of the likely benefits, if any, of medical care and – just as important at a certain age – how we choose to spend the time that remains to us.”

“A cynic might conclude that preventive medicine exists to transform people into raw material for a profit-hungry medical-industrial complex.”

Ehrenreich lacerates the US medical profession for its invasive and usually pointless drive to invade the body, seeking out ever-increasing numbers of ‘threats’. A few years ago her “primary care physician” told her she needed a bone density scan. She asked him, if her bones were found to be thinning due to age, what could be done? There’s now a drug for that, he said. She had the test, which diagnosed osteopenia, thinning of the bones, “a condition that might have been alarming if I hadn’t found out that it is shared by nearly all women over the age of thirty-five. Osteopenia is, in other words, not a disease but a normal feature of aging. A little further research…revealed that routine bone scanning had been heavily promoted and even subsidized by the drug’s manufacturer. A cynic might conclude that preventive medicine exists to transform people into raw material for a profit-hungry medical-industrial complex.”

Ehrenreich has form when it comes to cynicism, or, as I prefer to see it, clarity of thinking. One of her previous books, Nickel and Dimed: On Not Getting By in America, is a riveting account of three months she spent on trying to survive on minimum wages as a waitress, hotel maid, cleaner, nursing-home assistant, and serf at Walmart. She’s co-chair of the Democratic Socialists of America, a tiny organisation that regularly makes no inroads into mainstream American politics and is all the more important for representing decency in public life in the heart of the US.

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It would be a mistake however to regard Natural Causes as her swansong, but even it it proves to be that she has done all those who read it a great service. Her experiences of the US medical trade – it’s not really a profession – are fascinatingly depressing. The dentist who tried to sell her “a terrifying skull-shaped mask that would supposedly prevent sleep apnea [of which she had no symptoms – he told her she might not be aware of it but it could kill her] and definitely extinguish any last possibility of sexual activity”; the pressure from the trade to get a colonoscopy, even though she had no symptoms of bowel cancer; the list goes on.

Her experiences of the US medical trade – it’s not really a profession – are fascinatingly depressing

The profit motive underlies all this testing, screening, examining: “How is a doctor – or hospital or drug company – to make money from essentially healthy patients? By subjecting them to tests and examinations that, in sufficient quantity, are bound to detect something wrong or at least worthy of follow-up.” Of several unnecessary medical operations widely performed she identifies thyroid cancer surgery: “An estimated 70 to 80 percent of thyroid cancer surgeries performed on US, French, and Italian women in the first decade of the twenty-first century are now judged to have been unnecessary.” There’s a price (not just money) to be paid for all this needless medical invasiveness: thyroid surgery patients, for example, are left with a lifelong dependency on thyroid hormones “and since these are not always effective, the patient may be left chronically ‘depressed and sluggish’.”

She lays waste to the absurd rituals of modern medicine – why do doctors wear white coats? no obvious reason – and illuminatingly compares them with, for example, tribal rituals conducted in Zambia. She devastates what she calls the “veneer of science” and illustrates this by a particular bugbear of mine, the absurdity of testing for prostate cancer, which “consists of a blood test for prostate-specific antigen (PSA) plus a digital rectal exam. As with mammography, statistical studies have found no overall decrease in mortality that can be attributed to the PSA screening that has been in place since the late 1980s. Here too, the price can be high for overdiagnosis and treatment: radiation and hormonal therapies that can lead to incontinence, impotence, and cardiovascular disease.”

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She wryly points out that “many of the people who got caught up in the health ‘craze’ of the late twentieth century – people who exercised, watched what they ate, abstained from smoking and heavy drinking – have nevertheless died.” Jim Fixx, who wrote the best seller The Complete Book of Running and who believed he could “outwit the cardiac problems that had carried his father off to an early death by running at least ten miles a day and restricting himself to a diet consisting mostly of pasta, salads, and fruit” was found dead at a roadside in Vermont (where else do the hipsters go?) in 1984 aged 52. She recalls the famously creative food faddist and general nut job Steve Jobs, a vegan evangelist who died aged 56 from pancreatic cancer. Jobs once started lecturing Mitch Kapor, founder of Lotus, for plastering his lunchtime bread with butter, taking him to task about cholesterol. Said Kapor: “I’ll make you a deal. You stay away from commenting on my dietary habits, and I will stay away from the subject of your personality.” Kapor is still happily alive at 67, and no doubt still smearing butter on his bread.

“I’ll make you a deal. You stay away from commenting on my dietary habits, and I will stay away from the subject of your personality.”

This is a wonderful book, full of good common-sense rationality, in a world that increasingly seems to have taken leave of its senses. Just because Ehrenreich is a sensible sceptic it doesn’t mean she is uninterested in taking care of herself; she goes to the gym, does yoga, eats and drinks what she likes because life “is too short to forgo these pleasures, and would be far too long without them”. She reminds us that it’s not dying per se that scares most people when they have reached her age, but suffering as you go; yet suffering can be minimised to the point of elimination these days, thanks to hospices, painkillers, psychedelics. Physical pain can be minimised – enjoy life to the full and don’t let the doctor in where you don’t need to.

In the end, and there will always be an end, “death is not a terrifying leap into the abyss, but more like an embrace of ongoing life”. She quotes a poem Brecht wrote on his deathbed: “He was dying, but that was all right. The blackbirds would keep on singing.” Death is inevitable and because of that is all right; just live your life as you want to and don’t succumb to the illusory temptation that you can fend it off. Great book.