** Roadside bombs have caused hundreds of dire brain injuries to soldiers in Iraq. One of them is Shurvon Phillip, and a team of specialists has worked avidely trying to find . . . **
THE SERGEANT LOST WITHIN By Daniel Bergner
New York Times Magazine
May 25, 2008
[PHOTO CAPTION: Shurvon Phillips, right, who has been unable to speak and can barely move since he was injured in Iraq, with his mother, Gail Ulerie; his nephew, Malik; and his niece, Kyla.]
[PHOTO CAPTION: Keeping Hope Alive Shurvon’s mother has been his greatest advocate and believer.]
“You want to wear this or this for therapy tomorrow?” Sgt. Shurvon Phillip’s mother asked, holding two shirts in front of him. On one wall of his bedroom hung a poster of a marine staring fiercely, assault rifle in hand and black paint beneath his narrow eyes. Shurvon’s eyes, meanwhile, are wide and soft brown. He sat upright, supported by the tilt of a hospital bed. He cannot speak and can barely emit sound or move any part of his body, and sometimes it’s as if the striking size of his eyes is a desperate attempt to let others understand who he is, to let them see inside his mind, because his brain can carry out so little in the way of communication.
He gazed at the two shirts and, with excruciating effort and several seconds’ delay, managed to jab his gnarled right hand a few inches toward his choice, a black pullover with writing on the front. White letters declared the man, and a white arrow pointed upward to his head; red letters proclaimed the legend, and a red arrow pointed downward to his groin.
Gail Ulerie, Shurvon’s mother, had already received his O.K. -- a painstaking raising of his eyebrows -- on a pair of jeans. Mostly, Shurvon can answer only yes-or-no questions. The slightly lifted brows, a gesture that stretches his eyes yet wider, signify yes. A slow lowering of his lids indicates no. Now, with tomorrow’s clothes decided, Gail, a Trinidadian-American, reclined Shurvon’s bed for the night. He wore a hospital gown and tube socks pulled up tightly on the twigs of his caramel-colored shins. The socks were immaculately white, as if Gail believed that if everything were properly and precisely attended to, right down to the cotton that sheathed his toes, her son’s brain could recover.
In Iraq’s Anbar Province, in May 2005, Shurvon, who joined the Marine reserves seven years earlier at 17, partly as a way to pay his community-college tuition, was riding back to his base after a patrol when an anti-tank mine exploded under his Humvee. The Humvee’s other soldiers were tossed in different directions and dealt an assortment of injuries: concussions, broken bones, herniated discs. Along with a broken jaw and a broken leg, Shurvon suffered one of the war’s signature wounds on the American side: though no shrapnel entered his head, the blast rattled his brain profoundly.
Far more effectively than in previous American wars, helmets and body armor are protecting the skulls and saving the lives of U.S. troops in Iraq and Afghanistan. But according to the Defense and Veterans Brain Injury Center, a joint Defense Department and V.A. organization, about 900 soldiers have come home with serious traumatic brain injury, or T.B.I., which essentially means dire harm to their brains; it can be caused by explosions that deliver blunt injury to the helmeted skull or that send waves of compressed air to slam and snap the head ruinously even at a distance of hundreds of yards from the blast. (The 900 also include injuries caused by shrapnel or bullets that have managed to penetrate.) Some of these veterans have been left -- for protracted periods and often permanently -- unable to think or remember or plan clearly enough to cope with everyday life on their own; others, like Shurvon, have been left incapable of doing much at all for themselves. (A recent Rand Corporation report estimates that, additionally, 300,000 soldiers have suffered milder T.B.I., frequently including brief loss of consciousness, disorientation or cognitive lapses.)
In the explosion’s aftermath, Shurvon was airlifted to the American military’s hospital in Landstuhl, Germany, and then to the National Naval Medical Center in Bethesda, Md., where Gail saw him for the first time since he was sent to war a few months before. By that point a portion of the left side of his skull had been cut away to relieve the pressure of the casing of bone against his swelling brain. “His head,” she told me, “looked like a ball with the air half out of it.” She was confronted, too, with a CT scan taken by the hospital. “I didn’t do much biology, but I’m thinking, That’s not a brain I’m looking at,” she said, describing her reaction. “Everyone has a right hemisphere and a left hemisphere, but this didn’t look like that. Do you remember Play-Doh? When children play with Play-Doh” -- she slammed her palms together to demonstrate -- “it’s just a gray blob. That was Shurvon’s brain.”
Before his injury, Shurvon was, as his younger sister, Candace, recalled, “a big kid” who liked to come home from his job at Wal-Mart, stocking shelves and counting cash, and curl up with his older sister’s son to watch Spider-Man cartoons. Short and slender, he squirmed through every tunnel his nephew slithered into at Chuck E. Cheese. But he was “the brains of the family,” Candace said, and Gail added that, besides being something of a ladies’ man, he had a 3.4 G.P.A. at college and was on his way to an associate’s degree in computer science when he was called up.
Her round face framed by overlapping brown, cream, and white headbands, Gail remembered the military doctors at the National Naval Medical Center stopping by her son’s bed in the weeks after his injury and commanding: “‘Sergeant Phillip! Sergeant Phillip! Give me a thumbs up!’” His hands remained still. “When I called his name,” she said, “sometimes he fluttered his eyelids a little bit.” And his eyes seemed to focus on her, at moments. Those were about the only signs of awareness. And even those may have been her imagination. Col. William O’Brien, then the director of the Severely Injured Marines and Sailors program in the Department of the Navy, visited Shurvon in the hospital during that time. “She was a true believer,” he said of Shurvon’s mother. O’Brien saw no purposeful fluttering of eyelids, no responsiveness whatsoever. He saw a man with a misshapen head, his mouth open, staring vacantly into space. But as Gail recounted to me, she would plead with her son, in a voice infinitely closer and quieter than those of the staff, “Shurvon, give me a thumbs up, please give me a thumbs up.” One day she saw the tiniest shift of his right thumb.
There have been, since then, three years of tiny shifts, tiny increments of progress, tiny indications that Shurvon’s brain could somehow -- to some unknown degree -- heal. “They say your brain cells cannot regrow,” Gail said to me in February after putting her 27-year-old son to bed. “But God has been smiling on him.”
Gail credited, in addition to God, Dr. Felise Zollman, a neurologist who runs the brain-injury unit at the Rehabilitation Institute of Chicago, or R.I.C., a pristine private hospital where Shurvon was treated between August and December of last year. Zollman’s patients tend to be survivors of car accidents, falls, assaults. But starting in early 2007, with a soldier whose brain was ravaged by a roadside bomb in Iraq and whose family learned that R.I.C. was rated the top rehabilitative hospital in the country by U.S. News & World Report, 15 soldiers wounded in Iraq or Afghanistan have made their way -- often with the relentless advocacy of their families helping to pry payment from the military for private treatment -- to Zollman’s ward. Shurvon, more than two years after the explosion of his Humvee, became one of them, through the persistence not only of his mother but also of Cmdr. William Bailey, a Navy reservist lawyer in Shurvon’s home city, Cleveland, who took up his cause. The military paid $310,000 for Shurvon’s months at R.I.C.
Some of Shurvon’s infinitesimal advances were made at the military’s own facilities -- the naval hospital in Bethesda, a Veterans’ Administration polytrauma center in Minneapolis that specializes in T.B.I., the V.A. hospital in Cleveland -- where he was treated before his stay at R.I.C., but Gail said that Zollman and her staff had transformed his life, had fostered miracles, a process Zollman described, less metaphysically, as aiding the adaptive capacities of the brain. Gail was right: the prevailing scientific understanding is that, for the most part, the adult brain cannot grow new cells, new neurons -- though there is evidence that the implantation of stem cells into the brain may someday alter this basic neurological truth. But the brain can adjust, rerouting or reinvigorating its wiring. And in what Zollman called “a perverse positive consequence of the war,” attention recently focused on brain-injured troops will likely quicken future discoveries about the brain’s adaptive potential, about ways to prod that potential and about why even a case like Shurvon’s isn’t quite what Colonel O’Brien once thought it was: hopeless.
“The day I met him,” Zollman told me, remembering Shurvon’s arrival at R.I.C., “I realized he was so in there.” With sharp features accentuating brown eyes that appear almost as large as his, she said she felt a connection -- “he was really present” -- with something behind his still and silent carapace. She asked him about the tattoo on his left forearm, a panther with the words “Trini Boy” near its paws. Fondly she recalled his voiceless reply: the intense brightening of his eyes and the slight, scarcely perceptible shifting of his lips, an attempt to smile with a mouth distorted by the way the blast broke his jaw and, too, by the way it wrecked his brain, causing a muscle spasticity that pulls his lower jaw behind his upper, so that he sometimes seems to have no chin at all. He couldn’t relate whatever story or explanation was behind the tattoo, but it seemed clear that there was one and that it amused him. He has humor, she remembered thinking. He has abstraction. His mind, behind the frozen exterior, was alive.
For more than a year before his arrival at R.I.C., Shurvon was treated by the V.A. hospital in Cleveland, sometimes as an inpatient, when infections and a crisis with his feeding tube imperiled his very survival. And Zollman is careful not to critique the work of the Cleveland staff. But she suggests, as many doctors and advocates for wounded soldiers have argued, that the military medical system just wasn’t prepared for the prevalence of brain injuries among its troops in Iraq and Afghanistan and that T.B.I. units like hers have gained a complex understanding of the brain’s capacity for healing through long concentration on civilian injuries. Traci Piero, a nurse practitioner at the Cleveland hospital and the coordinator of Shurvon’s care there, both before and after his time at R.I.C., told me that in the spring of last year, the Cleveland staff considered reducing Shurvon’s physical therapy to a maintenance level. This would have meant abandoning the attempt to help him toward some degree of autonomous movement and focusing simply on preventing bedsores and keeping the muscles in his inert limbs from tightening more than they already had. It was a consideration born of futility. Piero and Dr. Clay Kelly, the hospital’s chief of physical medicine and rehabilitation, explained that Shurvon had hardly progressed from when he first arrived at the Cleveland facility after five months at the V.A.’s Minneapolis polytrauma center; he remained in a nearly vegetative state and was seen as having, in the words of an evaluating neurologist at the Cleveland hospital, “little hope for improvement.”
But by a system of nostril-flaring mastered with his speech therapist at the Cleveland facility, Piero recounted, Shurvon became able, last spring, to respond reliably to yes-or-no questions; Piero said that this breakthrough dissuaded the team from diminishing his physical work. Commander Bailey, Shurvon’s advocate, told things differently. The decision against cutting back Shurvon’s physical therapy was made, he said, in response to desperate pleading from Gail and some urgent lobbying of Bailey’s own.
When Shurvon came under Zollman’s care, he was taking a narcotic painkiller, Fentanyl, prescribed for him by the Minneapolis center and by the Cleveland team. Fentanyl suppresses the function of the brain, Zollman said, and may stunt recovery in T.B.I. patients. Kelly, the Cleveland chief of rehabilitation, who is closely involved with Shurvon’s treatment now but didn’t work with him before his months at R.I.C., referred to case notes and told me that Shurvon’s grimacing (or what grimacing his frozen features allowed) had indicated pain and that the narcotic had been necessary to address it. He compared caring for someone as noncommunicative as Shurvon to a veterinarian’s guesswork. But Zollman managed to communicate with Shurvon well enough to determine that he could do without the Fentanyl and weaned him from it. She weaned him, as well, from the Valium he’d been given, partly for anxiety, by the teams in Minneapolis and Cleveland -- Valium, too, dulls the workings of the brain. She prescribed a drug to enhance alertness and cognition. And she started to direct a program of therapy that, she hoped, would give him some fraction of a full life.
In both hemispheres of Shurvon’s brain, the frontal lobes, which are involved in motor control, facial movement, language, judgment, and the restraint of impulse, problem-solving, and planning, were, Zollman said, “extensively atrophied.” Harm to this region is typical in the nonpenetrating brain injuries so commonly inflicted by explosives in Iraq and Afghanistan. The inside of the bone plate that guards part of this region is full of ridges. Rattled against the rough surface, the frontal lobes are left bruised and hemorrhaging.
Zollman characterized a blast’s initial jarring of the brain as a kind of earthquake, which is followed by a storm that is just as devastating. Neurons communicate with one another through a series of electrical and chemical reactions that define the brain’s pathways. The mechanical energy of the earthquake in Shurvon’s frontal lobes had almost surely, Zollman explained, upset the electrical balance of his neurons, causing a deluge of neurotransmitters, chemicals like glutamate and dopamine, in toxic excess. “It’s like a conquering army has passed through,” she said of the aftermath, “and left a wasteland of swelling and bursting cells and burnt out pathways.”
When Shurvon arrived at R.I.C. more than two years after these calamities, it was too late, in all likelihood, for Zollman and her staff to help his brain generate new pathways and find new locations to take over the roles of the areas that were ravaged, a potential known as neuroplasticity and an essential part of Zollman’s practice. Once, the dominant neurological notion was that the realms of the brain are fixed in their responsibilities and that if an area is destroyed, no other domain can substitute for it. This has given way, over the past several decades, to the idea that one domain can, to varying degrees, stand in for another. Rudimentary and repetitive exercise -- the moving of an arm or the making of sounds with the help of a physical or speech therapist -- is the primary means for stirring such substitution. Three floors up from Zollman’s ward, R.I.C.’s researchers are hunting for ways to enhance this dogged and sometimes unsuccessful process. In one lab, a scientist experiments with a crude-looking conductive device that zaps the skull and sends precisely aimed magnetic charges coursing through stand-in domains; the hope is that by stimulating the brain while, say, a physical therapist simultaneously forces a patient’s leg to move in a walking stride, a healthy area of the brain will be jolted into assuming responsibility for that motion. But for reasons that remain unclear, like so much that involves the brain’s hundred billion cells and hundred trillion intercellular connections, the best chance to spur neuroplasticity comes within three or four months of the initial damage. With Shurvon, Zollman was instead reduced to “priming the connections” along the pathways that had survived. To evoke this she conjured another metaphor. “Let’s say you’ve got a railroad station in a small town in the Old West. The switchman is dozing. Trains rarely come, and when one finally does he might be sound asleep. Everything gets slowed down. But if his station is busy he’s more primed to do his job.” Keeping the connections active -- and in this way maintaining a ready supply of neurotransmitters to deliver messages -- could make the remaining pathways work more effectively and give Shurvon some measure of movement.
Priming connections, like generating neuroplasticity, can seem less a matter of ingenious science than of basic and relentless physical therapy. To address the paralysis of Shurvon’s arms, Botox was injected into his muscles to loosen them and permit a therapist gently to bend and unbend his elbows, over and over. The idea was that the neural pathways governing the extensor muscles would be invigorated by this motion and that eventually Shurvon would be able to straighten his arms whenever his mind decided to. By the time I met him, a few months after his stay at R.I.C., he could, when his mother asked, give her a hug, raising his stiff arms inch by inch and reaching outward, not enwrapping her but at least touching her rigidly on either side of her thick body.
A campaign of physical therapy was waged, as well, to give him minimal influence over his right hand. “You have to remember,” Zollman said, “that tiny changes can lead to big changes in life.” The gains he achieved with his right hand, along with a bit of mobility attained with his right leg, led her to expect that he would soon be operating a power wheelchair with a specially formulated set of controls. She told me that R.I.C. designed such a chair for him, that he had driven a mock-up version on the 10th-floor ward and that the Cleveland V.A. was currently having the chair made. Kelly, at the Cleveland V.A., told me otherwise. No chair was on order. The Cleveland staff didn’t think Shurvon could turn his head readily enough to see and steer around obstacles; Kelly said he didn’t envision Shurvon driving a wheelchair anytime in the near future. When I told Zollman this, she said that she was stunned, that her team was confident of what Shurvon could handle. And listening to Zollman’s dismay and passion, I thought, not for the first time, that without the kind of investment and ingenuity that a place like R.I.C. can offer, patients like Shurvon might be cut off, forever, from any aspect of independence.
When it came to the most fundamental capability, breathing, for more than two years, before arriving at R.I.C., Shurvon had been sucking air through a surgical hole in his Adam’s apple. Zollman and her team resolved to cap the tracheostomy. Part of the difficulty in doing this was that the wreckage of Shurvon’s brain left him unable to swallow at will; mucus and saliva welled at the back of his throat, clogging his airway. But capping the hole stirred panic. So Zollman prescribed an anti-anxiety drug that wouldn’t hinder the function of Shurvon’s brain, and her staff combined a gradual process of conditioning, beginning with the cap in place for just five minutes at a time, along with an effort to awaken his brain’s authority over the back of his throat. The awakening involved crude methods, like jabbing a chilled dental mirror repeatedly behind the tongue of a helpless, paralyzed man until he gagged, that might have qualified as torture in a different context. But the cap stays in 24 hours a day now, and with the occasional assistance of having fluid suctioned from his throat, Shurvon breathes through his mouth.
Zollman said that she has never wondered what she and her staff might have accomplished for Shurvon had he reached R.I.C. much earlier, during the period of possible neuroplasticity. For one thing, his condition was so dire, his survival so precarious, during the first months after his injury that rigorous efforts at rehabilitation might have been unfeasible. For another, Zollman says she thinks in terms not only of neuroscience but of Eastern religions. She spoke often about “accepting what is.” This view seemed to pose a paradox in a doctor devoted to the most hard-won kinds of amelioration. Yet it seemed, as well, part of what enabled her to engage fully with Shurvon, part of what kept her from being horrified and repelled by the facts of his existence: fully conscious, nearly motionless, and, when he first came to R.I.C., completely mute.
“Do you hear the sound he’s making?” Gail asked me as we sat in her kitchen, late one evening, with Shurvon put to bed in his room close by. I barely did, but she heard it keenly: a gurgling, strangulated cry, the best his brain could wrest from his throat and mouth. She seemed to love the progress that cry represented; without the capping of his tracheostomy, no sound was possible.
She went in to see what he needed. She wore blue track pants and a blue sweatshirt and three gold hoops in each ear. With the help of a health aide, who is paid for by the V.A. and who comes in every day, Gail is her son’s all-hours caregiver. Before his wounding, she worked as a nurse’s assistant in hospice care and nursing homes.
The only light in Shurvon’s room beamed from the wall-mounted television that played cartoons silently. Under the beam, and at the foot of Shurvon’s bed, Candace’s 3-year-old son, Malik, in a red-and-blue Spider-Man pajama suit, and her 2-year-old daughter, Kyla, her hair in yellow and white beads, slept on the floor on a blanket and couch pillows Gail had spread out for them. This was where they curled up on the nights when Candace, a single mother who lived with Gail and Shurvon, worked as a stocker at Wal-Mart. With their uncle, Malik and Kyla seemed both comfortable and comforted. Malik had earlier scrambled up onto Shurvon’s bed and onto his inert body to show him photographs from the program of a car show. The children can’t pronounce the word “uncle” and instead call him “Ya-Ya.” They slept soundly below him.
And later, when Gail herself was ready to try to close her eyes, she, too, would spend the night, as she always does, in Shurvon’s room, in a lounge chair right beside his bed. Money from the V.A., along with donations raised privately by Commander Bailey and Marine organizations, allowed Shurvon and his family to move to this house in suburban Cleveland from a downtown apartment where the rooms were so tight that Gail could hardly maneuver his wheelchair. Beyond the benefits that helped with the down payment on the house, the V.A.’s disability program pays Shurvon about $86,000 a year. The house has plenty of bedrooms, but three generations spend their nights in the room with the hospital bed, with a suctioning machine and a respirator ready in case they are needed, and with a feeding tube supplying sustenance to the man who was now, with the cry he could manufacture, asking for some unspecified form of attention.
“Are you wet?” Gail asked quietly, leaning over his face in the gray light from the television. He raised his eyebrows a 16th of an inch. She began to unfasten his diaper. During the days, if he’s taken outside the house, he usually wears a catheter that she rolls onto his penis like a condom; in the house he mostly wears diapers. “Oh, that’s why you’re fussing,” she said. “You did more than one.” She turned his body so she could wipe him, then filled a plastic tub with warm water and a bit of gentle soap.
He was silent now, turned onto his back again. In the near-darkness, she dipped a washcloth and squeezed it from above his thighs so that a tiny waterfall dripped down over him. “Don’t worry, big guy,” she said. “Mama’s got you.” She swabbed him with the cloth.
“The first time I gave my son a bath,” Gail told me about life after Shurvon’s injury, as we sat again at the kitchen table, “I cried. It took me a good while to get used to cleaning him up. In the morning if we have to go somewhere, everything that a mom with a baby has to walk with -- wipes and everything in a bag -- I have to walk with.” She talked about the A&D ointment that kept him from getting rashes, and she talked about how she imagined he thought about this aspect of his life. “Nobody wants anybody else to clean them. He wouldn’t look at it like he’s a child again. He’s this grown man, but he just can’t do it.” Then she remembered that before his deployment, when she would get upset about this or that difficulty in her life, he would say: “‘Mom, what are you crying for? If Plan A don’t work, Plan B will work.’”
At last Gail went to her lounge chair to sleep, and the next morning a special van picked up Shurvon and his mother to take them for one of the twice-weekly, three-hour stints of therapy that, since his stay at R.I.C., the V.A. hospital provides him. There a physical therapist guided him into a sitting position on the edge of a low bed and had him sit briefly on his own, another of the things his brain learned to compel his body to do in Chicago. And at the V.A. hospital a speech therapist with straight blond hair requested a “kissy face,” by way of motivating him to struggle to close his lips. She asked next for a wink; he couldn’t do that, but immediately he shut and opened both his eyes together. “In Trinidad,” Gail said, thrilled by his quick responsiveness, “we call that the sweet eye.”
“He’s learning how to flirt!” the therapist exclaimed. “You’ve got the kissy face and the wink and,” she added, referring to his arm movements in physical therapy, “the weight room. You’re all set!”
Listening to this, I wondered whether Shurvon, alive to touch and alive in his mind, but imprisoned, was flattered or tormented. He was beaming, eyes glittering. I wondered, too, what he might have said or done had he been capable of speech or any extensive movement. Damage to the frontal lobes -- “the area of the superego,” Zollman said -- can bring extreme disinhibition. Male patients on her ward sometimes proposition and grope their nurses or therapists; sometimes they masturbate in the halls; not long ago a man masturbated in front of his mother. Sometimes women expose their breasts.
The therapist worked with Shurvon to produce an “ah” sound -- he opened his mouth wide and, seconds later, a faint, agonized approximation came out. And she made him practice on his DynaVox, a computer that can speak for him, its screen fixed to his wheelchair or bed. The various icons can generate phrases, like “I am 27,” delivered in a robotic voice that sounds straight out of an old sci-fi movie.
One problem with the device, which Shurvon began trying to use at the V.A. hospital before going to R.I.C., has been how to best click on the icons. At the hospital in Cleveland he tried a nose piece that communicated with the computer whenever he flared a nostril, and at R.I.C. he tried a camera that directed the cursor by tracking his pupils. But the nostril-flaring proved too awkward, and the slight back-tilt of his head, another symptom of his injury, made it difficult to position the camera. As the mobility in Shurvon’s right hand improved, technicians at R.I.C. settled on using a thin cord attached to his right wrist; his tugs can activate an icon. His tugs are deliberate, delayed.
And the icons on his screen are limited. In Chicago, he graduated from an 8- to a 12-choice system; clicking on the “feelings” icon, with its childish renditions of smiley and frowning faces, will lead him to 12 choices including “frustrated” and “mad” and “O.K.” and “proud,” and the computer will then give robotic voice to his selection. The R.I.C. technicians programmed his DynaVox so that Shurvon can tell people that he wants the TV channel changed or so that he can name one of his favorite reggae songs, “Girls,” by Beenie Man, but his system can’t provide much in the way of nuanced personal expression, and he’s a long, long way from being able to navigate programs that would let him construct speech by picking from a wide array of words. For now, except when he’s practicing with his therapist, his DynaVox doesn’t get much use.
In the van, on the ride home, I asked Shurvon if he ever thought about going back to college. He gave the minimal lift of his eyebrows. His mother added that he wants to get a master’s degree.
Later, I talked with his R.I.C. speech therapist, who had tested his cognitive powers. After she’d put him through weeks of drills to improve his battered capacity for concentration, he was able to listen to passages several paragraphs long -- she showed me an example, and it certainly wasn’t simple -- and could readily indicate the correct answers in sets of multiple-choice comprehension questions. (Eye fatigue seemed the only impediment to his reading extended passages on his own.) Hearing this, I thought that there seemed little reason that Shurvon couldn’t someday earn a master’s degree. But at other moments the reasons appeared too immense ever to be overcome; the notion of college, let alone graduate school, seemed merely a soothing fantasy. And sometimes impossible to overcome, too, was the idea that Shurvon’s life might not be worth living; that I, in his place, would rather stop breathing, cease thinking, that I would prefer to die.
Whenever this idea took hold, I recalled a medical ethicist at R.I.C. telling me about studies showing that doctors and nurses tend to rate the quality of life of severely impaired patients to be far lower than the patients do themselves. The ethicist had spoken, then, about the ways that a life acquires meaning. And I thought about Malik scrambling onto Shurvon’s bed to show him pictures, and about Malik and Kyla curled and comforted on the floor below him. I thought, too, about a kind of exercise that Shurvon’s family discovered recently by chance and that Gail described: with Shurvon sitting in a wheelchair in the driveway, his nieces and nephews tossed inflatable beach balls, one pink and another blue, softly toward him, and he tried to move his arms to bat them back. “They were cheering like at a baseball game,” Gail said, remembering the first time the children did this. “‘Yeah! Go on Ya-Ya!’” Beach balls and high voices of excitement floated in the air around him.
--Daniel Bergner is a contributing writer for the magazine. His latest book, *A Map of Desire*, will be published in January.