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God’s Node

 

Rare diseases arrive with a distinctive sting of unfairness, as though a higher power were putting extra effort into being creative, to send an unambiguous sign. There is hardly anything known about cancer that arises in the thymus, a tiny organ in the center of our chests. Most of what I know about it, I learned from Dr. David Elkowitz, a specialist in the diagnosis of cancer who taught our medical school about it, before he was diagnosed with it himself.

 

The headaches came first. Then came the nagging discomfort in his jaw, then the aches all over his body. When the weather turned cold, he began to notice that his fingers would change colors. Over just a few minutes, they would fade from pink to white, and then, just as suddenly, from white to an eerie blue. His hands made it look as though he were beginning to disappear. When he told his wife and children about it, they made him promise to agree to an endoscopy and colonoscopy, two common cancer screening tests for men in their fifties. To his relief, both of the tests were negative. But the symptoms persisted. Eventually, he obtained an x-ray of his chest, then stepped into the radiologist’s back office to look at the image himself. When the picture appeared on the radiologist’s screen, David spotted it from across the room and said, “Please tell me that’s not mine.” Hours later, a more detailed three-dimensional scan revealed a tentacled mass, larger than a fist, strangling the organs in his chest.

 

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Like me, David grew up with one Jewish and one Christian parent. (His birth parents were both Jewish, but when David was twelve, his mother left the family without a word. He never heard from her again, and his father re-married outside his faith.) As a result, menorahs stood on his windowsill while Christmas trees adorned his living room. To him, they registered only as winter lights. In early childhood, faith seemed less like a revelation than as a choice between different clubs. It seemed possible not to join any club at all.

 

Without a mother and without self-discipline, he had the foresight in his early teenage years to realize that he might benefit from a military school where life would be more regimented. At Norwich University, the oldest private military academy in the country, he cultivated an interest in science that later steered him toward medical school. The academy also styled him into a NASCAR fan with a love of whiskey, chewing tobacco, and a high-and-tight fade that he would wear for the rest of his life. Of that time, he remembers that only an hour or two before the most important exam of his life, he received a phone call in which he learned that his sister had suddenly died. He finished his exam, then returned home, where religion was no consolation. In his view, the clergy who offered condolences seemed more interested in cultivating a new donor than in doling out spiritual succor.

 

When I finally met David, he was an associate dean and a favorite professor of mine and many of my classmates. He was in his fifties, a father of five, and as lean as a marathon runner. From time to time, I used to visit him in his spartan office. He still wore his Norwich University class ring and did ninety push-ups a day. He had a wry sense of humor, like the gym teacher you wish you had who also happened to be an expert on cancer in every part of the body. As part of his classes, he used to dim the lights of our lecture hall as if it were a planetarium. The close-up images of human cells looked more like the Milky Way than skin or gut. Naturally, beneath this spectacle was the knowledge that at some point every cell on those slides had been excised from human flesh, sliced like deli meat, affixed to glass plates the size of cocktail crackers, and peppered with color.

 

With the diagnosis of his first cancer, David began to picture himself on one of those slides, an object of study, an estranged bit of flesh. “I freaked out a little bit,” he said.

 

The thymus (not to be confused with the thyroid) is an unsung organ draped just behind the sternum. Like David, it is an educator. In fetuses and newborns, when it is big enough to see on x-rays, the thymus presents facets of the body’s native proteins to newly fledged immune cells in order to train them not to attack the “self.” Cells that flunk this test are removed from the body in a process that is most active around birth. Starting off small, the thymus grows until it peaks in size at puberty. When its role as a teacher is done, it retires, dwindling in adulthood to a tiny fraction of its size.

 

Because the organ is dormant in adulthood, cancers of the thymus are rare, but when they occur, they are life-threatening. Technically, thymic tumors can be classified as benign or malignant, but “benign” is a relative term - when it comes to masses in the chest, even lumps that refrain from invading other tissues can grow large enough to compress the airway, squeeze off blood flow, or choke the esophagus. Given the scale of David’s mass – nearly half a foot long – he needed an operation to debride it, which meant that, at the very least, a surgeon would have to crack open his breastbone and place a scalpel near the balloons of his lungs.

 

He took time off for his surgery during my second year of medical school, and when he returned to teaching duties months later, it was immediately clear that his surgery had nicked the nerves that controlled his vocal cords. He sounded raspy, and he could no longer project his voice to the back of a lecture hall. The effort of speaking through paralyzed vocal cords left him short of breath, and he had prematurely aged. Chemotherapy had dusted off his hair, and he had lost ten pounds. But he deemed these setbacks a decent price for beating a cancer with a 75% fatality rate. By the end of the year, he began talking about his illness as if it was over, as though he was cured.

 

Within the year, though, he began feeling pain on the right side of his chest that shot through to his shoulder blade. Advanced images subsequently revealed a 95% obstruction in the largest artery to his heart. Incidentally, the pictures also spotted a new lesion on his liver, suggesting that his original cancer had not only never been cured, but worse, had metastasized. To hunt down signs of more distant spread, further testing was performed, and in the search, his doctors stumbled upon a completely unrelated, second cancer in a place where, two years earlier, testing had been clean. In addition to metastatic thymic cancer, he now also had colon cancer.

 

At what point do you begin to wonder whether your bad luck is a form of punishment? In Illness as Metaphor, Susan Sontag noted that leprosy, tuberculosis, cancer, and HIV/AIDS have all been ascribed to divine judgment. “With the advent of Christianity,” she wrote, “the idea of disease as punishment yielded the idea that a disease could be a particularly appropriate and just punishment.” In its various guises, disease has historically been attributed to ancestral sins, moral transgression, weak will, lack of resilience, unregulated emotions, and a failure to cope with stress. This kind of thinking resurfaced with COVID-19 and again with monkeypox, another highly stigmatized virus. (In times of limited resources, some have even suggested that withholding treatment should also be part of the punishment.)

 

In one of the earliest versions of the myth of Prometheus, disease is invented by the gods as a penalty for deception and disobedience. When Prometheus tricks Zeus into agreeing to accept the worst remains of an animal sacrifice from his human worshippers, Zeus withholds fire from mankind, depriving us of the ability to cook. Reversing the decree, Prometheus steals fire and bestows it to humans anyway, but when Zeus learns of the insubordination, he devises a trick of his own. He creates the beautiful maiden Pandora, whose box, once opened, unleashes every form of misery and woe, disease included. The book of Genesis offers parallels to the Prometheus myth. When humans eat a forbidden fruit, God installs a flaming sword at the gate of Eden, keeping immortality out of reach. The agonizing labor of childbirth is a special additional punishment, just for Eve.

 

 

Christianity had re-entered David’s life in middle age. Stumbling upon broadcasts from the pastor Joel Osteen, he had found them helpful in difficult times. Over the years, he had started listening to them in earnest until, eventually, he had come to think of himself as Christian. Now, as he learned the devastating news of his heart, liver, and colon over the span of only five days, he developed insomnia, which sleeping pills, prescribed by a psychiatrist, did nothing to ameliorate. As David came to understand it, his problem was essentially religious: he could not shake the sense that there was a God, and that he was somehow failing Him by fearing death. At his wife’s insistence, he agreed to speak with a hospital chaplain, a rabbi who was himself fighting cancer. “He told me that tension is how we grow. Tension is what shaped me into a doctor. Working constructively through tension is what makes relationships grow. And tension is one of God’s ways of bringing us closer to Him. It hit me like a ton of bricks,” David told me later.

 

Given a framework that imbued his disease with meaning, David soon joined Osteen’s church. (On its website, the Lakewood Church outlines the belief that God is “actively involved in humanity,” and a video of Osteen features him on stage proclaiming that “the God who causes the Earth to rotate has ordered your steps.”) Eventually, he began to think of Osteen as part of his cancer treatment team, as important to him as the hospital chaplain, his surgeons, his oncologists, and his family. Photos of the two men together now hang on a wall in David’s office, including one in which Osteen is dedicating David’s son. Osteen has a clenched fist and a flexed arm, as though he is pulling God down out of heaven for the occasion.

 

A former skeptic, David now began to see signs. Once, during his commute to a radiology center, he asked God for an indication that He was still mindful of him. “And please don’t be subtle,” he prayed. A moment later, his radio cut out for twenty seconds before tuning back in, something that had never happened before in the half-dozen times he had driven along that road. He felt overwhelmed by the presence of God beside him. Later, on a sweltering walk during a ninety-five-degree day, in another moment of doubt, a breeze unexpectedly blew over him, so unseasonably cold that it gave him chills. When he returned home, he discarded all the amber bottles of anxiolytics his psychiatrist had prescribed. There were other signs, in other forms, times when the rabbi, a physician, or his son uttered words that were so reassuring and uncharacteristic of them that it seemed as if God was speaking directly through them.   

 

Could Christianity offer alternatives to Sontag’s claim that it intensified the moral dimensions of disease? In Marilynne Robinson’s 2004 novel, Gilead, Reverend John Ames recounts an episode that in our post-COVID world seems uncannily prescient. “People don’t talk much now about the Spanish influenza,” Ames writes, “but it was a terrible thing, and it struck just at the time of the Great War. It killed the soldiers by the thousands, healthy men in the prime of life.” Members of his congregation had asked him how, if God is good, such deaths could occur. “I would comfort them,” Ames continues, “by saying we would never know what their young men had been spared. Most of them took me to mean they were spared the trenches and the mustard gas, but what I really meant was that they were spared the act of killing.” Ames’s God of 1918 is an Old Testament deity, a god that dispenses plagues. But his faith allows for a version of reality in which curses can be blessings in disguise.

 

David doesn’t believe that God gave him his cancers, but he believes God let them happen. Though his idea of God does not involve divine tinkering with DNA on a molecular level, David believes that God set the rules in motion, along with their consequences, which sometimes include suffering. This reasoning puts David in the difficult position of believing that God allowed his specific cancers without exactly intending them, a subtle argument if God is also omnipotent. It also begs the question: if the mystery of God’s intentions allow for this variety of interpretations of human events, including those in which good can arise out of illness, what exactly are the faithful worshipping? And then there is the larger question: if faith is so helpful when coping with disaster, is there any benefit in doubting another person’s belief?

 

In Pragmatism, William James argued that when a belief is impossible to prove and there is no benefit to convincing someone otherwise, any idea that makes someone happy might as well be considered true. The philosopher Bertrand Russell disagreed. To Russell, James’s logic of allowing church members to believe anything they like so long as it pleases them would in effect replace rigorous faith with a mere shadow of it. James “wants people to be happy,” Russell quipped, but the religious man believes in God “as he believes in the existence of Roosevelt or Churchill or Hitler; God, for him, is an actual Being, not merely a human idea which has good effects.” Believers believe in God for better or worse. They feel what David felt while driving in his truck – what Augustine called “the sweetness” and Aquinas called “the prophetic light” – even when it is not to their advantage.

 

A few months after his second diagnosis of cancer, I visited David in his chemotherapy suite. Two years had passed since he first began having headaches. Inside, I found him tethered to plastic tubing hanging from a bag above him. His treatment regimen was a nearly 100% match for his thymic cancer, meaning that the medicine would almost certainly eradicate it eventually. He motioned to a pouch beneath his sweater that had been collecting stool; for the second cancer, a surgeon had removed a swath of his lower intestines. Seeing that I was about to offer sympathy, he waved it away. He was more interested in teaching me, from a medical standpoint, how lucky he had been. He knew that at that point in my medical education I was just beginning to learn about the indications for various tests and what their results could reveal. He reminded me that the colonoscopy just before his first cancer had been clean, meaning that under ordinary circumstances, no one would have looked at his colon for another ten years. He lined up the rest of his diagnostic sequence like a row of dominoes: if the chemotherapy for his first cancer hadn’t aged his heart, he would never have had the chest pain that sent him to the hospital; and if he hadn’t gone to the hospital, doctors would never have found the spot on his liver; without the spot on his liver, no one would have looked at his colon before the ten year mark. In other words, though the first cancer had almost killed him, it had also saved his life; it had led to the early diagnosis, and early treatment, of a second, much deadlier cancer, one that would have killed him for sure if it hadn’t been found in its early stages. What if his prayers had been answered at any stage, when he wished for the chest pain, or the testing, to stop?

 

His story reminded me of the little boy in the fable who is gifted a horse on his fourteenth birthday. Everyone in the village says, “How wonderful!” But the Zen master says, “We’ll see.” Years later, the boy falls off the horse and breaks his leg. The village says, “How terrible.” Then a war breaks out, and every young man is conscripted to fight, except the little boy, because his leg had been broken. “How wonderful,” the village says.

 

“We tell ourselves stories in order to live,” Joan Didion pronounced, implying that life is intolerably incoherent, plotless, without beginning or end. Implying that we lie to ourselves. “We live entirely…by the imposition of a narrative line upon disparate images, by the ‘ideas’ with which we have learned to freeze the shifting phantasmagoria which is our actual experience.” Like the mastery of fire or the sense of good and evil, our ability to make meaning – really an inclination, almost an addiction – both defines human nature and underwrites much of our suffering. For some, cancer is proof of God’s absence. For others, it only strengthens their faith. Do the stories we choose account for the difference?

 

In his office, I asked David once whether anything might convince him that he was wrong about God, and he paused. “I thought about what would happen if the surgery hadn’t cured me and the chemotherapy hadn’t worked, if I had gone through all of this just to die at fifty years old.” He looked at the floor, then continued. “And then I thought, maybe this whole ordeal will make one of my children want to become a doctor, and she’ll save lives. It’s hard to say. The problem is that we can only see things within our own lifetimes, but God works in generations.”

 

As a literary text, the Bible has an unusual proclivity for generations. The book of Genesis makes only one mention of a man named Mahalaleel. His name is buried in its many genealogies, but he is said to have lived for 895 years, long enough to have stories to tell. We learn none of them. We know only that he begat a man named Jared, another name in a passage most readers skim over. There is no account of their accomplishments other than their roles in the unbroken generational chain between Adam and Noah, who eventually repopulated the world.

 

David can fathom a purpose in his cancers – they brought him closer to his family, to students like me, to himself, and to God. There may be other purposes yet unknown. But he wrestles with the signs. If his story is, as Didion suggests, a fiction, it is hardly a convenient one. In the surgery that excised half of his colon, eighteen lymph nodes were removed. In the pathology lab where he used to work, all eighteen were analyzed to determine whether his cancer had spread. (Once cancer is discovered in a lymph node, there is no way of knowing whether it has also spread farther until, later, a metastasis grows large enough to see.) During David’s procedure, one of those nodes was positive.

 

What kind of message is sent in the form of one positive node, as opposed to no positive nodes, as opposed to eighteen positive nodes? In all, David has sustained two major operations, five rounds of chemotherapy, two months of radiation, three needle biopsies, and now considers himself cured. But verb tense is a challenge. He’ll catch himself saying “I have cancer” and correct himself to “I had cancer.” At other times, he’ll describe “undergoing treatment” and amend it to “underwent.” His lone lymph node strains grammar. “There is work being done in me,” he says, meaning the node, its uncertainty, its demands on his faith. Ever the instructor, he has shared a photo of it with me, magnified twenty times. It has wisps of purple and blue, peppered with color. It looks like a hurricane, a nebula, an ink blot.

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