Suddenly, They’re All Gone

Suddenly They're All Gone

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Suddenly, They’re All Gone

By Carol Mithers

Caring for the old is just like parenting an infant, only on really bad acid. It’s all there: the head-spinning exhaustion, the fractured brain, the demands and smells. Only this time with the knowledge that it won’t get better.

That was my life for five years. First came my mother-in-law, then my father-in-law, then my childless aunt, then my mother — all needing different kinds of help as they weakened and started going downhill, all the care overlapping, and almost all of the work to be done despite distance.

You’re so good, friends would murmur, but I wasn’t — there were plenty of days I muttered, “Can’t do this anymore,” and nights when I threw back too many drinks, feeling how badly I needed for it to be over.

Now, though, it is done for real, everyone is dead, and the surprise is that instead of being relieved, I feel worse.

More than a year after the last funeral, I still have all the numbers on speed dial: my in-laws’ neighbors in Texas and my aunt’s in upstate New York; the security guard at my mother’s gated San Diego community; doctors, hospitals and emergency rooms in three states; two home health agencies; the 24-hour hospice nurse. I still sleep with the phone on and stashed on my night table, where I can grab it fast. It’s over, but I can’t let go. No, it’s worse than that: I don’t want to.

Maybe there is nothing new to say about the nightmare of shepherding the old through the time that is the prelude to death but not active dying. I knew it would be bad, but you don’t really understand until you’re there, any more than the childless can grasp why a new mother goes three months without shaving her legs.

“Drowning” was the word that came to my mind as the endless crises unspooled. My terminal mother-in-law, abandoning the 50-year pretense that she could stand her husband to demand: “Put him in a nursing home! Get him out of here!” My father-in-law, newly widowed and alone in an early Alzheimer’s haze, barricading himself in the house against caregivers. My aunt, her lungs destroyed by a three-pack-a-day cigarette habit and reeling from one hospitalization after another, begging me to send morphine so she could end it all.

Alerts peppered every hour. Do something! Your father-in-law’s behind the wheel again. Your aunt’s in the hospital with pneumonia; she’s recovering; no, she’s failing, come quickly; no, she’s been yanked back from death into a life of oxygen concentrators and cognitive crash; find a nursing home — wait, are you in New York? Because your mother’s in the hospital in San Diego and it could be serious, can you get on a plane?

Frantic was my new normal and normal the new never, because when someone is old, especially if dementia is involved, nothing is routine. Even the answer to a straightforward question, like “What day is it?,” vanishes on the wind; every patched-together arrangement works only until it doesn’t.

“Drowning” — also buried, shredded, torn apart. Helping my daughter prep for the SAT, cooking family dinners and maintaining a professional life, while also paying three sets of bills, running three houses in three cities, either planning a trip to see how things were going or recovering from that trip, and never living in just one place.

I started keeping my cellphone on my desk, then leaving it on all night, and finally didn’t even risk putting it down because the one time I did, to watch my child in a high school soccer game, there were five frantic caregiver messages by halftime: Where are you, what should I do, she can’t breathe!

And yet: Parenting on bad acid is still parenting. I wasn’t one of those women who went all dewy-eyed the second she gave birth. “I don’t feel anything,” I remember thinking in dull panic as I looked at my squash-faced, just-born daughter. “How can I love her? She’s a stranger.” Within two weeks, though, I was transformed, flattened by a passion I had never even dreamed existed, and it was the grunt work of motherhood that did it to me, the holding, touching, watching, feeding, smelling — the getting to know the specifics of this little creature in a way that went down to my bones.

I had always imagined that you put up with the job of caring for a baby because you loved her, but for me it was the unfathomable, slightly terrifying intimacy of caregiving that brought the love.

And with my old people, it was the same. The fried-brain resentment that gets you drinking at night fades when you are with someone in the living room or kitchen. Just as it is with a baby, your job is tending, and the comfort you bring is simple and physical. You sit for hours, the heat always cranked up high, doling out pills and pouring water, changing the nitro patch, combing hair. You fix lunch, rub in skin cream.

You come to know the precise texture of thin, dry skin, the kind of touch that pleases, the small things that bring a smile. My father-in-law had to have vanilla ice cream every day, but only Blue Bell brand and in a waffle cone. Even with her thinking garbled, my aunt needed the New York Times crossword puzzle and endless games of gin rummy. My techno-challenged mother wanted written computer instructions to consult the next time the infernal machine swallowed her text.

More than anything else, when you’re with the old, you listen. My Greatest Generation/Army veteran father-in-law, whose interest in the world essentially ended in the late 1950s, talked in endless circles about his small-town childhood and the World War II campaigns of Italy and North Africa. My aunt, obese and isolated for years in a small upstate town, had spent her 30s and 40s single, teaching history in New York City public schools for nine months a year, then buying elegant clothes and setting out for Europe and Africa.

The giraffes came down to the water hole every night, right in front of where I stayed…. One night, in Turkey, in a cafe next to the sea, we danced in the moonlight….

When the present is unbearable and there is no future, the past comes rushing back: family history, secrets and buried memories rising out of the ether. My relentlessly forward-thinking mother never dwelled on sorrow or regret, but she told me one night as we sat among the empty cups and crumbs at the dinner table: My Aunt Belle committed suicide by jumping in front of a subway train.

I was home alone when someone called. I had to tell my father that his sister was dead. I’d never seen him cry before.

I could see it all: my father-in-law’s bungalow in Kaufman, Tex., whose open front door proved irresistible to a contrary billy goat one day in the 1920s. The 10-cents-an-hour wage my aunt earned tending a booth on the Coney Island boardwalk during the Depression — I was saving to buy myself a new pair of shoes, but my mother took the money and I still can’t forgive her for it. My mother’s quiet, wild joy during her first winter in Ithaca, N.Y., when a Cornell scholarship let her escape the dirt and smudge of Queens to a snowfall that stayed white.

All the years I was young, the center of life’s drama, I barely saw these people. Now they were simultaneously disappearing and becoming unbearably real to me, heartbreakingly diminished and yet still powerful, deeply rooted trees that against all reason would not let go.

There was my 98-pound mother, befriending the immigrant podiatrist who tried to relieve her painful, bunion-crippled feet; limping to her desk and squinting her one good eye at that maddening computer, so she could finish an article for her community newspaper. There was my wheezing, demented aunt, frowning at the sign “Don’t Toutch” that her caregiver had placed above a complicated new hallway thermostat, and pushing her walker to it so she could correct the spelling.

Their singularity dazzled me. Their selves, revealed in all their layered complexity, could never be replaced. I came to know them — and I fell in love.

When you care for the old, life can go on unchanged for years. Then suddenly, without much warning, everything shifts. Six months after her cancer diagnosis, my mother-in-law died; 18 months later, my father-in-law fell, had a small stroke, fell again and lasted only two months in the Alzheimer’s unit of a nursing home.

Two years after she survived near-death by respiratory failure, my aunt’s breathing got so bad she couldn’t even make it to the bathroom; she wanted only to sleep, to talk to her long-dead sister, who she insisted she heard on the stairs. You’d better come quick. Minutes after my plane landed at Kennedy Airport I got the call saying she was gone.

Not long after my mother, radiant in a sun-colored jacket and pearls, celebrated her 90th birthday with a huge party, she said her stomach hurt. A week later, I was in a hospital room sobbing against her cold, still shoulder.

I have my life back now, but that fact is less simple than it was before. When I look at the mementos I’ve inherited, the crumbling photo albums, cookbooks that smell of cigarette smoke, ’50s furniture and cut glass, I also see where they used to sit, in other places and rooms. I miss the quiet afternoons, the houses that eventually came to feel like home, in cities I’ll never again have reason to visit. I miss it all. I miss them.

Sometimes, when I’m out, I catch a glimpse of a short, gray-haired man in a baseball cap or a skinny old woman in a tailored bright jacket and my heart stops. I see my old people everywhere, which only reminds me that I’ll never see them again.

When you have a baby, it’s as if your whole self shifts, reshaping itself around a presence that later you can’t even remember living without. You reach down and take a small hand, and joined, you hurtle toward the future. Death just offers stasis, absence, dissolving shadows.

None of that was a surprise, but it’s still a shock. While you’re caring for the old, you can’t believe what you’re called on to do and where you find yourself, can’t believe that your time with them will ever end. Then one day, it just does.

The Veterinarian Brings His Healing Presence to Pets of the Unhoused

 

 

The man standing outside the tent on Skid Row in downtown Los Angeles clearly doesn’t live in the neighborhood. Tall and fit, he’s dressed in jeans and a doctor’s blue scrub shirt and carries a medical bag. The tent, one of many rough structures on the stained sidewalk, sits amid heaped wooden pallets, old furniture and trash. But the man’s eyes are fixed on the dog lounging nearby.

“Hi, how are you?” he says when the tent flap opens. “I’m a veterinarian, Dr. Kwane Stewart, and I offer free pet care to people experiencing homelessness.” He gestures at the dog. “Can I examine your pet?” 

First comes confused silence—you’re who?—then suspicion: Is this animal control, here to take my dog? Finally, a slow nod. Stewart, who calls himself the Street Vet, kneels, pulls out his stethoscope and goes to work.

These Skid Row streets hold the nation’s largest concentration of homeless people who are not staying in a shelter, and at first glance it’s an unrelieved landscape of despair: mental illness, poverty, addiction. But love exists, too, including the love of pets. Across the nation, 10 to 25 percent of the people who are homeless keep pets, and there’s no reason to think the number is lower in sunny Los Angeles. Cats sit on sleeping bags, pit bulls, scruffy terriers and mutts trot alongside filled shopping carts, and chihuahuas ride in bicycle baskets and the laps of people who themselves are in wheelchairs. Various local groups and volunteers help the owners of these animals care for them, with weekly and monthly clinics, mobile spay and neuter vans, handouts of flea meds and food. 

Stewart, 50, has usually worked solo, walking the streets and looking for animals and people in need. “Maybe it’s because when I began this work, it wasn’t uncommon to find a pet that had never received care,” he says. “Everyone I met looked at me as if I’d just dropped out of the sky.”

Stewart grew up with dogs, loved them and science, and by the time he was 10 knew he would become a veterinarian. It was an unusual ambition for a Black track star in Albuquerque. Once, a coach asked about his future plans and laughed with disbelief when Kwane told him. “I’ve never met a Black vet,” the coach said. Stewart goes on, “At the time I didn’t think much about it. But here’s the thing: He was Black himself.” Decades later the number of African American veterinarians is still so small the Bureau of Labor Statistics has reported that it might as well be zero. 

Stewart graduated from the University of New Mexico, got his DVM degree from Colorado State University College of Veterinary Medicine and Biomedical Sciences, and headed to San Diego. He spent a decade there treating a suburban clientele with “bottomless bank accounts.” Then, in 2008, he relocated to Modesto, in California’s Central Valley, for a job as the veterinarian for Stanislaus County. And everything changed. 

The Great Recession flattened Modesto, a city of around 200,000, with plummeting home prices and 17 percent unemployment. And when humans go broke, animals often pay the price. Pet surrenders surged until the area’s aging shelter, built for 200 animals, held twice as many, and its euthanasia rate became one of the nation’s highest.

“I was destroying 30 to 50 animals every morning,” Stewart says softly. “Healthy dogs and cats. It was killing my soul. I felt like God was keeping score and I was losing. I didn’t go to school all those years to destroy animals. I wanted to help and save them.”

At first that meant he helped a homeless man he encountered almost daily by treating the man’s dog, which suffered from a bad flea bite allergy. Then he held a free clinic at a local soup kitchen. And then, on his own time, he began to walk around Modesto and some Bay Area sites looking for pets to help. He moved to Los Angeles to serve as chief veterinary officer for the American Humane Association, which makes sure animals are treated well on film sets, and his ramblings shifted to San Diego and Los Angeles. He wore scrubs to identify himself, carried a bag filled with meds, vaccines and syringes, nail trimmers, and he did what he could, free of charge. 

He was stunned by what he found. Like many people, he questioned why homeless people had animals to begin with—if humans couldn’t take care of themselves, how could they be responsible for pets? And yet they were. In fact, numerous academic studies over the years have revealed the vital role pets play in the lives of unhoused men and women—providing structure, purpose, meaning and love. “Researchers have consistently found very high levels of attachments to pets among the homeless,” Leslie Irvine, a sociologist, writes in her 2012 book about the phenomenon, My Dog Always Eats First.

Stewart agrees. “Pets were a lifeline to the people I met,” he says. “Most of them were great pet owners. They did remarkably well with the resources they had, and made sacrifices for them well beyond what you or I would. The bond between them was on a completely different level. They needed each other.”

 

For five years, his efforts were a kind of secret hobby that he says even his family—he has three children—didn’t know about. Then, in 2017, he and his brother, Ian, produced “The Street Vet” as a reality TV series­—it has aired on broadcast TV in Scandinavia and Eastern Europe and in the States on a Utah cable channel­—and Stewart acknowledges he’s now a “media personality.” These days he’s founding a new veterinary practice in San Diego and writing a book about his experiences on the street.

Last September he started a nonprofit, Project StreetVet, raising money on GoFundMe to cover the cost of treating pet medical problems beyond the scope of a sidewalk exam. He has occasionally volunteered with larger organizations assisting people who are homeless. Though he says “there are probably more efficient ways I could spend my time,” he likes doing it his way. 

“The wound is healing well,” he reassures a man named Ben, whose pet rat had been attacked by a cat. (“I’ve seen birds and snakes, but this was my first rat.”)

“The puppies look great,” he tells Julian, a tattooed man who has lived on the same stretch of pavement for two years and whose dog recently gave birth. (He also vaccinates the pups.) 

Stewart marvels at the generosity of a young man named Reggie, who lives in a school bus and uses his own cash to make lemonade that he gives away to his neighbors. Stewart vaccinates the man’s dog, Daisy. “You’re doing a good job,” Stewart says.

“Oh, this is such a blessing,” the young man replies. 

Most Americans Have Pets. Almost One Third Can’t Afford Their Vet Care

Since mid-2020, more than a thousand low-income families have brought their sick and suffering pets to the nonprofit Pet Support Space, housed in a tiny Los Angeles storefront. One 14-year-old dog had a tumor that a veterinarian had quoted $5,000 to remove. A four-year-old pit bull had been vomiting for days, a cat’s painful bladder stones required surgery, a pug limped from the foxtail embedded in its paw. Skin and ear infections abounded. Neither the animals’ problems nor their owners’ inability to afford help for them was a surprise.

recent nationwide study found almost 28 percent of households with pets experienced barriers to veterinary care, with finances being the most common reason. In low-income households, the researchers found, financial and housing insecurity can increase the risks that animals will not receive the care they need. Sociologist Arnold Arluke, author of Underdogs: Pets, People and Poverty estimates that 66 percent of pets in poverty have never seen a vet at all.

The “why” behind those numbers is complex. Of course, money is the primary problem. Veterinary care is expensive. A majority of practitioners work in for-profit clinics, consolidation in the industry has increased emphasis on profit margins, and vet prices have risen faster than the overall rate of inflation. That has checkups starting at $50, dental cleaning going for $70-$400, and blood work and x-rays at $80-$250. If a dog breaks a leg or eats a sock, surgery costs begin at four figures.

High prices aren’t necessarily about greed. Michael Blackwell, a former Deputy Director of the Center for Veterinary Medicine at the FDA, is the chair of the Access to Veterinary Care Coalition (AVCC) that was formed in 2016 to study this very problem. Veterinary training, he said, teaches vets to practice a “gold standard” of care, which means running every possible diagnostic test and pursuing every treatment option, even when a client’s budget is limited. (Many pet owners don’t know they can decline a recommended procedure, such as blood work, and even fewer are willing to decline care for fear of looking heartless.)

Some private vets offer struggling clients discounts, added Jeremy Prupas, DVM, Chief Veterinarian for the City of Los Angeles, but they themselves carry an average of $150,000 in student loan debt, so they simply “can’t carry the immense existing need on their own.” Telling clients you can’t help them because they have no money is one of the leading causes of burnout in the veterinary profession, according to Prupas. Pet insurance might help defray costs but requires monthly premiums and comes with such a complicated array of deductibles, co-pays, caps, and exclusions that one how-to guide recommends hiring an attorney to review the policy. Credit cards designed for medical care financing, if one can qualify, can carry punishing interest rates as high as 26.99 percent.

Equally critical is a long-term failure on the part of the animal welfare movement to consider, much less prioritize, the needs of low-income pet owners. Since the 1990s, the rescue/humane world has poured vast amounts of funding and energy into cutting shelter euthanasia through adoption, but far less into helping those without money take care of the pets they have. “If you can’t afford an animal,” the thinking went, “then you shouldn’t have one.”

“Until recently, we focused on shelter-centric challenges,” acknowledged Amanda Arrington, senior director of the Humane Society of the United States’s Pets for Life Program, which assists low-income pet owners. “There was a lot of judgment and making determinations on who was or wasn’t deserving of support and resources that was influenced by what I think a lot of society is influenced by, which is classism and racism. We conflated a lack of financial means and access with how much someone loves their pet or desires to care for it.”

In fact, owners can be punished because they can’t afford veterinary care — “most humane neglect cases stem from an inability to get care for a pet,” said Prupas. In Michigan, for example, failing to provide an animal with adequate care, including medical attention, is a misdemeanor that can carry 93 days in jail and/or a fine of up to $1,000. With a second violation, it becomes a felony.

The distorted belief that ‘those people’ don’t care about their pets has never been true.

What exists for pet owners in poverty is a patchwork of low-cost care options, ranging from local efforts — such as Emancipet in Texas and the Philadelphia Animal Welfare Society — to well-funded national enterprises such as Pets for Life, which operates in several dozen cities. The great majority, however, offer only basic services like sterilization, vaccination, and flea treatments. “We are not a full-service veterinary clinic and do not treat sick or injured pets,” warns one low-cost option on its website. Another suggests that needy people travel, since “vets in smaller towns may charge lower fees,” or start a GoFundMe. As a result, many types of care are largely unavailable: emergency care (by some estimates one in three pets will have an emergency need each year), management of chronic conditions such as diabetes or kidney disease, medication, dental care (dental disease affects perhaps 80 percent of older dogs), and the mercy of humane euthanasia (which can run $50-$300).

The final piece of the care gap is a practical and cultural disconnect. Because many economically challenged neighborhoods are “vet deserts,” with few if any practitioners, it’s not easy to find care, and reaching it can require wrangling an unhappy animal over distance and/or arranging private transportation. Keeping an appointment at an office with weekday-only business hours or a once a month clinic can mean losing a day’s pay. Paperwork raises the fear of immigration status inquiries. The veterinary profession also remains one of the country’s whitest: Just as people who feel alienated or unwelcome don’t utilize human health care options, pointed out Arluke, they don’t utilize care for their pets.

The result has been suffering: most directly for animals that remain untreated, die from what vets call “economic euthanasia” (putting an animal down because treatment costs too much), or end up in shelters. Fear of a looming vet bill, and the mistaken belief that all shelter animals receive medical care, is a prime cause of owner surrender.

But people pay, too.

Some sick animals can infect their humans. Roundworms, for example, can pass through contact with pet feces and cause lung, heart, and eye problems. Blackwell reports meeting an optometrist who practices in a low-income Florida community who has seen increasing numbers of children with roundworm larvae in their eyes.

The psychic toll is just as real. Families in poverty who love their pets and for whom “they offer an emotional core and possibly one of the only sources of joy” face “mental and emotional” devastation from the unimaginable choice of weighing that love against potential financial ruin, said Blackwell. Professor Katja M. Guenther, author of The Lives and Deaths of Shelter Animals, called the rupture of an animal-human bond “a kind of community violence” in a 2021 webinar.

Change seems increasingly possible. Covid-19 and the country’s recent racial and economic reckoning has prompted humane organizations to examine their assumptions and biases about who has the “right” to a pet’s love, and, said Arrington, there’s increasing recognition that “racial and economic injustice really impacts animal welfare.” Meanwhile, AlignCare, a new program out of Michael Blackwell’s Program for Pet Health Equity, is trying to create a national model of something like Medicaid for domestic animals. Under the program, families already found to be struggling (because they participate in SNAP or a similar program) and who ask for help at a shelter or veterinary clinic will be signed up and paired with a veterinary social worker or support coordinator. They’ll then be directed to a veterinarian who has agreed to offer preventative, dental, and even critical care, for a reduced fee; AlignCare will pay 80 percent of the cost. After three years of pilot programs in 10 disparate communities, it’s taking on its biggest challenge yet, Los Angeles, where one in five people live in poverty.

AlignCare won’t offer “gold standard” care, instead emphasizing preventative, incremental, and cost-saving measures (such as offering telehealth appointments and limiting diagnostics that won’t change treatment options) when possible. But it will expand the human safety net to include the animals most of us now consider part of our families. And while the effort is currently funded by grants from Maddie’s Fund, the Duffield Foundation, and Petsmart Charities, Blackwell’s goal is “community ownership:” The combined involvement of local vets, city animal services departments, social service agencies, rescue and community organizations, pet food and product manufacturers, and affluent pet owner-donors can make the model self-sustaining.

There is no perfect solution for low-income pet owners who need help accessing veterinary care. But growing awareness of the problem is a big step forward. “What we call ‘animal welfare’ is changing,” said Lori Weise, whose nonprofit, Downtown Dog Rescue, runs the Pet Support Space. “The distorted belief that ‘those people’ don’t care about their pets has never been true. People can’t afford care. Sometimes they don’t even know what’s out there; they themselves have never been in a hospital. As more people are brought into the system, we’ll see the first generation to get proper veterinary care.”

 

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