The Post-Birthday World

by Lionel Shriver

  “But it’s that you can’t, isn’t it? Why didn’t you tell me?” All this time it was what Ramsey hadn’t been complaining about that should have concerned her.

  “Figured it might get better, like. And I were scared.”

  “Denial’s not just a river in Egypt?” The hackneyed wisecrack wasn’t funny; already, jokes came hard. Even Ramsey’s It’s my prostrate—he was not that illiterate; he knew the difference—had fallen flat.

  “It seems so unfair,” she said. “Why couldn’t it be a little patch of something suspicious on your shoulder blade? It’s as if someone up there is gunning for us. Hitting literally below the belt.”

  “Can’t say I ever been persuaded that you always kill the thing you love, but sure as fuck somebody’s going to.”

  “But it’s not definite. You need more tests.”

  “Yeah,” he said hopelessly. “But when that Paki stuck his finger up my bum, his face went queer. Geezer didn’t look happy.”

  “You shouldn’t call him a Paki, I guess,” she said dully. It wasn’t attractive, but the large numbers of Third World doctors that now stocked the NHS drew universal mistrust, on the arguably unfounded presumption that they weren’t well trained. “When do the lab results come in?”

  “Dunno.”

  “Meantime, how are we going to do anything? I can’t imagine making dinner, and not only tonight, but ever. Eventually we’ll starve. And forget drawing dopey little pictures. How do people manage in such circumstances? How is it that you don’t trip over hundreds of people on any given day who’ve simply flopped down on the sidewalk? There’s your prostrate cancer.” Suddenly a door had opened onto the anguish that had surrounded every side of this charmed house for years, and she realized that until now her life had been exceptionally pleasant. It would have been nice to notice.

  IRINA RECOVERED HER CULINARY powers—in fact, she was so anxious to do for Ramsey that he objected she was going to make him fat—and otherwise occupied much of the next several days reading medical pages on the Internet. The upside of this research was that it gave her something to do, the downside that it made her sick.

  The assertion on each of these Web sites that virtually every man will come down with some form of prostate cancer sooner or later was reassuring, though just because the malady was common shouldn’t make it ipso facto any more palatable. Every therapy described, and they were legion, posted encouraging success rates, but also a list of possible side effects. Though these varied in specifics and severity, a pattern began to emerge: pelvic pain, mild urinary urgency, scrotal swelling, impotence. Infection around incision, postoperative bleeding, incontinence, impotence. Blood in urine, burning sensation in lower scrotum, difficulty in urination, impotence. Diarrhea, rectal irritation, nausea, impotence.

  It would not do to feel sorry for herself, though she hoped it was not reprehensible that she might feel sorry for Ramsey and Irina the couple. In the days she was agonizing over whether to part with Lawrence, she’d thought a lot about sex, about whether it was important. In choosing Ramsey, she had clearly concluded that sex was very important. Now it was time to revisit the question, and for the sake of her husband, herself, and their future happiness try to conclude instead that they could live without it.

  Well, of course they could live without it. Despite the great cultural to-do over the matter, it didn’t take very long, did it; it didn’t occupy much of the day. Its gratification was fleeting. It was merely an exercise in putting one thing inside of another, and a woman could experience the same sensation, more or less, by other means. As for emotional deprivation, maybe she’d have been more anguished if something along the lines of Alex Higgins’s throat cancer prevented them from kissing. She could still fall into his mouth like sky-diving in the dark; they could still interlock into an inscrutable coffee-table puzzle in the morning. They could still dine together (if no longer in a restaurant…), and hold hands on the way to the cinema. Ramsey was no less handsome, and she would still melt unexpectedly when glancing across the rim of her coffee cup. Why, veritably all of life’s smorgasbord was still spread before them, and to fix-ate on the removal of one tasty dish from the table seemed churlish in the extreme.

  Be that as it may … if fucking didn’t take very long, something about the diversion benefited the rest of the day. While she was resourceful enough to counterfeit the sensation, she didn’t want it by other means. Indeed, when Ramsey moved to pleasure her these nights, she gently dissuaded his hand, for the prospect of getting off while her husband stayed put was no more appealing than the idea of going on a romantic island holiday all by herself and sending postcards. Since his checkup, even kissing had subtly transformed. Oh, any number of times of an afternoon she was accustomed to reaching for his lips and going no farther. Yet now kissing was a reminder of constraint—not of what they might do, but of what they could not. Even in private, Irina installed a moratorium. Cat’s-away shenanigans in her studio while Ramsey made runs to Safeway suddenly seemed like cheating, like sneaking bars of chocolate when your spouse was on a diet. If Ramsey was doing without, Irina would do without. In all, it was a small sacrifice—wasn’t it? It should have been. It really should have been. Alas, the fact that it should have been didn’t mean it was.

  Yet while any wife would naturally ponder the matter, the intensity with which she brooded over the prospect of everlasting celibacy was suspect. Perhaps she seized on her husband’s incapacity in bed to distract her from what could prove another pending impotence, of a more ultimate sort.

  “OF COURSE, IT’S NATURAL for your imagination to run away with you,” said Irina as they walked to the clinic to which Ramsey had at last been summoned. “But most of what I’ve read on these Web pages has been comforting. Even if you have it, so long as it’s at a reasonably early stage, the chances of a complete recovery are high. They’ve come a long way with this stuff, and there’s a huge range of different treatments. Granted, they all come with a little—discomfort—but most of that is temporary.”

  “Most of that,” said Ramsey, who’d not come near the computer. “What bit ain’t temporary?”

  The, ah, pattern that Irina had detected in sets of side effects she had kept to herself. “There’s really no point in talking about this until we’re sure that anything is wrong.”

  “But you was just talking about it.”

  “I’m nervous. Motor-mouthing. It’s not helpful, I’m sorry.”

  Cherry blossoms in bloom, Victoria Park was viciously beautiful. Clasped in her own, Ramsey’s hand, usually so dry from cue chalk, was sweating. “Irina,” he said softly, “they’re pretty much gonna cut my dick off. Ain’t that right?”

  “Shh.”

  As they sat again in the waiting room, Irina was mystified why she had ever been anxious about anything else. She marveled how she could ever have worried whether Ramsey would win a mere snooker match, or have lost ten minutes’ sleep over a cheap bauble like the Lewis Carroll. It was inconceivable that she had repeatedly dithered over an editor’s reaction to a few inconsequent drawings, and the fact that she had devoted an iota of concern to whether a stain came out in the wash seemed beyond preposterous, indeed profane. But then, maybe none of that had ever qualified as anxiety. Maybe in the end choosing the wrong color blue for a backdrop, losing checks in the post, and dropping an irreplaceable button from your favorite shirt down a storm drain were all just forms of entertainment.

  Once they seated themselves before the Asian’s desk—who wasn’t Pakistani after all, but Indian—Irina didn’t like it that Dr. Saleh spent a long moment looking down at Ramsey’s file before raising his head. She didn’t like it one bit.

  “Mr. Acton,” the small brown man began. “I am referring you to an oncologist at Guy’s and St. Thomas’s.”

  “Excuse me,” said Irina, flushed with fury. “Is that your idea of how to tell my husband that he has cancer? That he’s being ‘referred to an oncologist’?”

  “It is one way,” Dr
. Saleh said warily.

  “Ramsey is a snooker player. I doubt he even knows that word!”

  “Mrs. Acton,” he said quietly. “I am not the enemy.”

  “I’m sorry,” she said. But she wanted to stay angry. As soon as she let go of the rage she started to cry.

  Remaining stoical, Ramsey stroked her hair. Bankruptcy may have inspired him to childishness, but the likelihood of major illness had had the opposite effect. Since his checkup, he had been somber, serious, and adult. “But you can tell us something,” he said; summat, even his pronunciation made her ache. “You ain’t going to shift us to some other bloke and keep shtum.”

  “Your PSA test indicates highly elevated prostatic acid in your blood. Your oncologist will order more tests to establish to what extent—but your urine test did not turn up an alternative explanation for these results. So it is very likely that the malignancy has metastasized…. You are familiar with this word?”

  “You mean it’s probably in the lymph nodes,” Irina intervened heavily. “Or even in the bones. You mean this may be stage three. Or even four. Already.”

  “We must not leap to conclusions without more tests. But this is a possibility, yes.” He remembered to add, “I am very sorry.”

  “What about the biopsy?” asked Irina; taking charge had become a habit. “What’s the Gleason grade?”

  The doctor’s head tilted. “You have been reading about this subject, madam?”

  Irina shrugged. “Internet…” She had no idea if medical folks were exasperated by the overnight online experts barging into their offices, confident that they know more than GPs, or if doctors were grateful not to have to explain everything from scratch.

  In any event, professionals often take refuge in plain fact, and the doctor’s answer was unadorned. “The Gleason grade is five.”

  Irina slumped, gut-punched.

  “What’s that, pet?”

  She kicked herself for not bringing Ramsey up to speed before this appointment. But she hadn’t wanted to frighten him. And she hadn’t wanted any of this to be true. “It means,” she said, trailing a finger along the tender skin at the corner of his eye, “that the cancer is very aggressive.”

  “Well, the scale’s one to ten, innit? Five can’t be that shite.”

  “No, sweetheart,” she said with a broken smile. “The scale is one to five.”

  “So you can see why it is very important that you act on this referral immediately,” said Dr. Saleh.

  “I know that this isn’t your job,” said Irina, who had gone from belligerent to beseeching in the course of five minutes. “But could you give us some idea of the kind of therapy an oncologist is apt to recommend?”

  “Cryotherapy—”

  “We’ve tried that,” she said wryly. “It isn’t working.”

  Blank. Foreigner. Didn’t get it. “Both cryotherapy and brachytherapy are only options if the cancer has not spread much beyond the prostate. If a lymph-node biopsy is positive, a prostatectomy will not be recommended, either.”

  Irina felt a stab of stupid, selfish relief. The chances of permanent impotence following a radical prostatectomy were 80 percent.

  “Hormone therapy, radiation, chemotherapy, perhaps some combination. Your doctor will decide.”

  Someone had to ask this, and she admired him for daring to bring it up. “Meanwhile,” asked Ramsey, “what about shagging?”

  “You will not harm yourself, ” said Dr. Saleh carefully, “if you find that you are able.”

  “I realize it doesn’t matter now,” said Irina. “But is there any reason? Something he did wrong? Ramsey’s a little young, isn’t he? Statistically?” Too late she caught herself; if she was fishing for smoking as a catalyst, the impulse was to blame Ramsey, which was not very nice.

  “Statistics are a general guide only. In medicine, all things happen under the sun. Or in this case,” Saleh said, and made his one attempt at a joke, “perhaps not under the sun. It is not proven for certain, but there does seem to be a link between increased rates of prostate cancer and lack of vitamin D.”

  Forcing a smile, she stroked Ramsey’s cheek, still milky from a life indoors. “Too much snooker, then?”

  “No such thing, pet.” They rose to leave.

  PHILOSOPHICALLY, IRINA BELIEVED IN Britain’s National Health Service. It was a fine idea, that all medical provision be free at point of care, although critics, surprisingly few considering the size of the National Insurance levy on the average paycheck, were quick to point out that the service was anything but free. Yet however sterling in theory, in practice the NHS was chronically underfunded. Its waiting lists for treatment were infamously and sometimes fatally long. Scandalous cases made headlines in which cancer patients had the wrong breast removed, the wrong kidney, the wrong leg. Public hospitals coursed with a “superbug” called MRSA that by 2002 was killing twelve hundred patients a year. A full third of the NHS budget was dedicated to paying off malpractice suits. It may have sounded horrid, but once they dragged from Dr. Saleh’s office Irina no longer cared about sounding horrid, or being horrid: the NHS was fine for other people.

  Thus for the tests that would establish the baseline of Ramsey’s condition, Irina insisted on going private. At least they didn’t have to wait. She shepherded Ramsey to get a second PSA test and prostate biopsy, to cover the possibility that the NHS labs had been playing silly buggers with his samples and those of some unfortunate who was truly sick, and the whole business was another inside-pages mistake. Once an independent lab stubbornly, maliciously produced the same findings, a private oncologist ordered a computer tomography X-ray, a radio nuclide bone scan, a lymph-node biopsy, and an MRI. But by giving in to the American impulse to buy the best, Irina fell under the sway of the deeper motivation that drove many of her countrymen to exhaust their reserves for the same purpose. She did not want to buy the best of tests. She wanted to buy the best results.

  In which case, her money was wasted—and a great deal of money that was. After extinguishing the greater part of her savings, Irina had to concede that they would have to return, tail between legs, to the NHS. Since many National Health doctors augment their incomes with private patients, after a hair-tearing delay the system coincidentally shuttled them back to the very same oncologist whom they’d seen privately, and who was at least—oh, God, something about mortal illness exposed what a terrible person you were, and apparently had been all along—white. “So,” he said wryly on their return, “back with the proles.”

  It was as Dr. Saleh had foretold. This Dr. Dimbleby recommended hormone therapy in combination with radiation, and chemo if and when—it was usually when—hormone therapy grew ineffective. Burdensomely clued up on the side effects of these gruesome treatments, Irina suppressed her dread in Dimbleby’s office by reciting the we’re-really-gonna-fight-this and I-know-you’re-no-quitter resolutions that she must have learned from a host of made-for-TV movies, films that seemed to confuse a life-threatening illness with a come-from-behind election campaign by the Conservative opposition. Yet Ramsey himself asked quietly if maybe one option was not for him to simply go home and let nature take its course, since if the disease didn’t kill him, the cure surely would. He seemed under no illusion that hormone therapy bore the least resemblance to last year’s brave Tory challenge to an entrenched Labour majority. Moreover, he appeared strangely resistant to the notion that, in addition to being poked and prodded and needled, losing his ability to be a real man with his wife, feeling increasingly off form and facing the prospect of feeling far worse in the days to come, he was now expected to marshal his little remaining energy to grandstand on the stump and shout rousing slogans to the faithful as if spearheading a get-out-the-vote drive.

  When Irina expressed frustration that Ramsey wasn’t joining in her refrain of we’re gonna fight this, the oncologist, who had a mischievous side, intervened. “Contrary to common perceptions,” he said, “extensive studies have compared patients who are determined an
d optimistic versus others who, quote, give up. Surprisingly, demeanor makes no statistically significant difference in survival or recovery rates.”

  Thus brandishing a sword at the heavens or tossing it into the Thames was no more than a matter of whim.

  AFTER THE BATTERIES OF tests and his humble resumption of his place at the back of the NHS queue, Ramsey was not scheduled to begin his treatments until nearly his fifty-second birthday. Assured that a few days would not make any difference, Irina appealed privately to Dimbleby to delay the first round of antiandrogen drugs and relentless radiation therapy until after the sixth of July.

  However disreputable their finances, one night back at Omen or another sumptuous spread of homemade sushi would not have broken the bank. But Irina didn’t like to repeat herself.

  That evening, she lit two candles on the big wooden kitchen table, otherwise barren. It stayed light so late in July that she had waited until eleven p.m., at which point in the candles’ golden glow she flourished a great silver tray before Ramsey’s place. On the tray, in the very middle, lay a single bright blue pill.

  Ramsey looked from his minimalist entree, like a serving on The Jet-sons, to his wife. “This what I think it is?”

  “Dimbleby said there’d be no harm done, and it might be worth a try. He also said that after you start these treatments … you’re likely to want to ‘concentrate on getting well.’”

  “Meaning, I’ll feel like a dog’s dinner,” Ramsey translated.

  “Well, you know doctors.”

  “They’re liars.”