America's Hidden Racial Divide: A Mysterious Gap in Psychosis Rates

Black Americans experience schizophrenia and related disorders at twice the rate of white Americans. It’s a disparity that has parallels in other cultures.

The New York Times Magazine
By Daniel Bergner
Published Dec. 3, 2024 Updated Dec. 4, 2024

Earl Miller’s favorite book is “The Old Man and the Sea.” Growing up, whenever he moved, he made sure to pack a copy of Hemingway’s novella in one of his two black plastic trash bags. One bag held the books he had stolen along the way; the other, his few clothes. His homes, from the time he was 12, were psychiatric wards, residential programs and the foster homes of white parents who quickly decided they couldn’t handle a heavyset, badly troubled Black kid.

“I’ve always been really attracted to the idea that even in the ultimately unsuccessful effort, in the futility, there is beauty,” Miller said about the story of the luckless fisherman. For three months, when Miller was 22, he lived under the wooden bench where we now sat, facing a small lake in a park in Springfield, Mass., his hometown. “In the struggle itself,” he went on about the book, “there’s this poignant almost-conversation between the fish who’s fighting for his life and the old man who is fighting for his livelihood. I also just like the way Hemingway describes things, the way he labors over a point, the way the sun glistens off the fish even while everything is being dashed.”

We weren’t supposed to be talking about Hemingway. But Miller, who is 38, is reflective, and with a family of ducks at our feet and a breeze bending the shore reeds, we had detoured. Our main topic was race and psychosis.

As a growing body of research reveals, Black people in the United States suffer the hallucinations and delusions of psychosis — the voices that seem to emanate from outside a person’s head, the visions, the paranoias, the breaks with common reality — at a rate roughly twice that of white people. In Europe, racial disparities regarding psychosis are yet wider. Even after researchers control for socioeconomic factors and address issues of diagnosis, the alarming racial gaps remain.

Studies suggesting a link between minority or outsider status and psychosis run back about a century. A 1932 study looked at hospital admissions for psychosis in Minnesota. It found that Norwegian immigrants were admitted at twice the rate of native Minnesotans or Norwegians in their home country. By the 1970s, researchers were turning specifically to racial divides in psychiatric disorders, and by the 2000s, the relationship between race and psychosis (which appears to outstrip any correlation between race and more common conditions like depression) was becoming well studied in both the United States and Europe. Yet despite the mounting data, in the United States, until recently, the issue was relegated to the edges of mainstream psychiatry — or perhaps beyond the edges.

“A voice in the wilderness,” Roberto Lewis-Fernández, a professor of clinical psychiatry at Columbia University, says, describing the feeling that work on the issue was long marginalized. He and Deidre Anglin, a leading U.S. researcher into the relationship between psychosis and race, both point to the keen cultural focus on pervasive racism after George Floyd’s murder as one reason for what Anglin calls an “exponential increase in attention” to the striking racial patterns in psychosis.

Though psychiatric disorders have mostly eluded precise scientific explanations, proving too complex for brain imaging and other technology to illuminate, it’s clear that some combination of genetic and circumstantial factors contributes to psychosis. The genetic creates a predisposition. But predisposition is not disease; it is susceptibility, a shifting of the odds that is, researchers assume, equally distributed across races. Triggers are needed to profoundly alter the mind. Current explanations for the racial gaps in psychosis tend to zero in on the catalysts of discrimination, denigration and the insidious sense of helplessness — or “social defeat,” as psychiatry terms it — that racism can impose. The data is strongly suggestive, if short of proving causation. Intuitively, the link is hard to ignore.Experiences of racism seem to stir and amplify the deafening voices of self-condemnation and fears of terrible danger that can be part of the alternate realities of psychosis.

For Miller, the damning, lacerating voice started when he was around 13, on his first psych ward, where he wound up after physical abuse by his mother, a failed placement with a foster family and a spiral into suicidal thinking. On the ward, he remembers, his anger led to being locked into an isolation room and bound in restraints. He was given Thorazine, an antipsychotic that can also act as a drubbing sedative. In his childhood eyes, and in his adult analysis, his race was a big reason for such treatment. “They couldn’t see me as a kid,” he said. “I saw white kids throw furniture at the staff, do all these things that were always de-escalated, because the staff knew they would have to call the parents who would say how are you doing this to my child, whereas it seemed like me and every other Black and brown kid in that space was a foster kid, and there was no one to hold them accountable.”

It didn’t help that “the people making the decisions” — about treatment plans, privileges, discharge dates — “were all white.” Or that “the kids who were there for a long time all looked like me.” A hallucinatory voice screamed at him that staff were poisoning his water, his food. “You’re going to die. Look what you did. Nobody wants you. Get out! Get out! Get out!”

Miller’s impoverished, chaotic family was also an essential spark. He learned, on the ward on his 13th birthday, in a phone call with his grandmother, that his mother had moved across the country to Las Vegas. There would be no more visits with her. She once tried to strangle him with a phone cord, he said, but that didn’t mean he wanted her to disappear.

Feelings of foreboding and overwhelming futility tracked him through his teens and into his 20s. During the frigid months when he slept under the bench at 22, the police stopped him a few times coming out of a bodega where he bought loose cigarettes. They pressed him to a wall, cuffed his wrists, insisted he was buying drugs and emptied his pockets and garbage bags onto the pavement. A voice lurking beside him warned of impending death. He tried not to respond to it, knowing that any strange outburst might well spur the police to load him into their squad car and leave him locked in another psych ward. He bit down hard on the inside of his mouth, drawing blood and adding to a network of wounds in the soft flesh.

Miller now works for a nonprofit, the Wildflower Alliance, helping people in the Springfield area who are homeless, mired in addiction or wrestling with psychiatric conditions. He tries to connect them with services or just tries to connect, human to human. But neither steady employment nor the passing years have stilled the voice he hears.

As we sat on the bench by the lake, he told me about a recent incident: For his job, he was driving a man to pick up his prescribed methadone when a state trooper’s car began tailing him. There was an eight-year period when Miller didn’t drive at all, for fear of being pulled over for some slight infraction he wasn’t aware of. He has never been arrested, but he was terrified of any interaction with the police. “I look like someone they should hurt,” he told me, though he was no longer the unshaven, unkempt, unhoused person he had been, just a stocky, round-faced Black man wearing little frameless glasses.

His fears were compounded, that May afternoon, because of the man in his passenger seat: Hispanic, homeless, with his lower leg, exposed in shorts, blackening with necrosis from injections of street drugs. The situation stoked his voice into a frenzy. “We have to get out of this thing!” it demanded. “Hit the gas! He can’t follow you into Connecticut.”

Miller heeded the trooper’s loudspeaker command to pull off the highway. The trooper leaned down to the passenger side window. Miller’s hallucinatory voice was yelling, “He’s going to pull you out of the car. You’re going to get shot.” Miller clamped his teeth on the inside of his mouth, hoping the pain would keep him from losing all bearings and talking back to the voice. The trooper wrote no ticket, Miller recalled, but warned him about driving too close to the lane divider. Miller felt a familiar shame; he believed that people he knew were driving past and judging him, as a Black man, guilty of unspecified crimes.

For a bit, when he was back on the road, the trooper’s car trailed him. Finally, after dropping the man at the hospital that dispensed the methadone, Miller sat in the parking lot. “You’re a pussy,” the voice shouted into his ear. “If you had any heart, you’d have said something to him. You’re an Uncle Tom.”

Deidre Anglin, who has spearheaded much of the past decade’s research on racial disparities and psychosis, is Jamaican American, the daughter of first-generation immigrants. Her maternal grandmother got herself from Kingston to Brooklyn, worked as a nanny, saved and sent for her family. Anglin’s parents, who eventually settled in a Long Island suburb, had one career in mind for her. “I’m part of the immigrant story,” she says. “My parents were sure I was going to be a physician.” But as an undergraduate at Cornell University, Anglin started “thinking hard about how underaddressed mental health is in the Black community, even though it’s so obvious that if anyone is going to experience mental-health challenges, it’s folks who experience oppression. I shifted gears. Quickly.”

She set out to become a therapist. Then, during her doctoral program, while she trained on a psychiatric ward, she got to know a patient who was brought in by the police. For months, treatment by the psychiatric team failed to lift his psychosis. “This young Black man was getting sicker and sicker under our watch,” she recalls. In the end, a change in diagnosis and a change in medication helped, but what stuck with Anglin was that “there is a strong tendency for psychiatry to be less nuanced in how it applies its skill to Black patients, to spend less time figuring out what is going on for people like this young man. We foreclose on people we’re not as connected to. We foreclose more than on someone who could be our brother. We foreclose on someone who causes fear, and let’s be honest, that’s often young Black men.”

Her ambitions turned toward research, focusing on the racially divergent rates of psychotic experiences and diagnoses. Anglin, who is 48 and a professor of clinical psychology at the City University of New York, has published a flurry of papers with titles like “Racial Discrimination Is Associated With Distressing Subthreshold Positive Psychotic Symptoms Among U.S. Urban Ethnic Minority Young Adults.” Her work belongs to an expanding set of studies on the vast racial differences in rates. Some research has looked solely at people diagnosed with schizophrenia, the most severe of the psychotic illnesses, while other studies include a spectrum of psychosis-related disorders, and still others encompass a continuum of psychotic symptoms that may foreshadow full-blown illness but that, for some, may never reach a threshold for clinical diagnosis. Despite the variations in method, the results are consistently noteworthy.

In the United States, Black-white ratios are at least 1.9 to one; some studies show that disparities for nonwhite Hispanics are narrower but still notable. In Europe overall, Black-white differentials hover in the vicinity of four to one. In England, the gap for Black Caribbean and Black African immigrants runs between four to one and more than six to one. In the Netherlands, for Moroccan, Surinamese and Antillean immigrants, the ratio is around three to one.

Among the immigrant groups, one plausible factor is the dislocation and stress that can come with the immigrant journey itself. But while such trauma may seem an obvious trigger, given that many immigrants arrive in their new nations after dangerous journeys and unable to speak the language that surrounds them, researchers have found repeatedly that second-generation immigrants to the United States and Europe develop psychosis at rates at least as high as their parents. Something is happening in the new country.

For a long while — more persistently in the United States than Europe — misdiagnosis was the dominant explanation for the psychosis disparity between Black people and white people. This line of thought concentrates on schizophrenia, the psychotic disorder with the most vivid connotations of eruptive violence. Boiled down, the theory is that because of racial bias, a practitioner confronted with two similarly hallucinating, delusional and struggling patients, one white and one Black, is much more likely to be deeply frightened or disturbed by the Black patient and to categorize him as schizophrenic. In this way, the thinking goes, the rates of diagnosis become skewed.

Jonathan Metzl, a psychiatrist and professor of sociology and psychiatry at Vanderbilt University, explored and extended this idea in his 2009 book, “The Protest Psychosis: How Schizophrenia Became a Black Disease.” He argues that in the 1960s and ’70s, the clinical application of the schizophrenia diagnosis — and even aspects of the official diagnostic criteria — changed in response to white fears about the civil rights and Black Power movements. Mining records from a Detroit-area psychiatric institution, Metzl traces a transformation: from schizophrenia’s being seen as a largely female — and unthreatening — disease to its becoming a disorder of aggression and a means, whether or not consciously intended, to lock up Black men.

The misdiagnosis theory is compelling, and some studies have continued to support it. But Anglin and other researchers have removed the issue of practitioner judgment by looking at self-reported hallucinations and delusions that haven’t yet led to diagnosis. Racially divergent rates remain glaring.

A pair of Anglin’s studies focuses on reasons for the difference in rates. In this research, involving a total of over 9,000 subjects, self-reported experiences of racial discrimination correlated tightly with self-reported psychotic symptoms. The number of symptoms rose, in close alignment, with the frequency of the discrimination, suggesting causation. It was possible, of course, to take this data and argue that psychosis, which is frequently infused with paranoia, leads to a heightened sense of being subjected to discrimination, rather than discrimination being a trigger for psychosis. Anglin explained that she tries to mitigate this problem by examining the link between discrimination and psychotic symptoms that are distinct from paranoia; she has found that those other symptoms are also in close alignment.

The emphasis on divergent rates as a real phenomenon — and not just a product of misdiagnosis — pushes against a core tenet of contemporary American psychiatry. Since around 1980, mainstream psychiatry in the United States has asserted what’s known as the biomedical model, an approach that tries to understand and treat the brain much like any other organ. The model views psychiatric conditions in predominantly physiological and often genetic terms. This is the case, above all, with psychotic disorders, probably because their symptoms can appear so alien, so much a manifestation of faulty neurological wiring. Under the sway of the biomedical model, American psychiatry’s prevailing assumption has long been that because psychosis is primarily genetic, the prevalence of the disorder should be fairly equal across populations and shouldn’t be overly affected by societal forces.

“This isn’t the thinking everywhere in the world,” Roberto Lewis-Fernández said when we spoke about American psychiatry’s concentration on what he called “the figure and not the ground — not the context in which the figure sits.” Lewis-Fernández has led marginally successful efforts to widen the lens of the Diagnostic and Statistical Manual of Mental Disorders, the diagnostic bible of U.S. psychiatry, to complicate the biomedical model. “British thinking has been focused for much longer on contextual factors. One reason why the U.S. is more focused on the organism is our incredible focus on individualism. We tend to not want to agree that there is a collective world that impacts some more than others and creates pathology in certain groups.”

“I want to say the genetic part isn’t real,” Miller told me, as we talked about causes. “But it’s so clear that predisposition moved down my mom’s side and my dad’s side. I want to say it doesn’t exist, but it’s there.”

His mother, who is white, was diagnosed years ago, he said, with a personality disorder, and his father, who is Black, is a hard-core alcoholic. A cousin on his father’s side has been diagnosed with schizophrenia. Miller’s sister died of a fentanyl overdose in 2018. Miller’s 14-year-old son was asked to leave his school not long ago and spent time on a hospital psychiatric ward at his own request, because of suicidal thoughts. He was then placed in a residential psychiatric program.

Miller visited him on the ward one day when the boy had spent time in restraints. Miller found him sedated, “unable to pick up his head in bed.” Ten years ago, Miller took himself off his antipsychotics and other psychiatric medications, because of their side effects and their failure to silence his voice. While antipsychotics reduce symptoms for perhaps half of patients to varying degrees, they can also cause debilitating torpor, substantial weight gain, diabetes, a deadening of emotion, spasms, tics.

Miller’s son is now home with his mother (the parents separated when the boy was 2), going to a local school and passionate about visual art — but for Miller, his son’s replication of his own past is haunting. He said he wasn’t sure of the boy’s diagnosis. He added: “I don’t know how to ask him if he hears voices. I don’t know if he’d feel safe enough to say.” Miller knows all too well the terror, shame and sense of isolation that come with psychotic symptoms.

In having his son, Miller told me, he rescued himself. “So much of my life getting better was about him, getting outside myself. The reason I didn’t kill myself back then was about him. But I don’t know if my son would say life is worth it, given what he’s going through now. If you asked me at his age, I would have told you no.”

He returned to the conundrum of nature and nurture: “Anyway, I wonder how much of what looks like genetic predisposition is really generations of trauma.” The cumulative impact of racism throughout his family’s and community’s history, the palpable impact in his own life and a propensity toward the delusional seemed to feed endlessly on one another, building toward the barely manageable.

This destructive symbiosis was a common dynamic among the range of Black psychosis sufferers I talked with. Keris Myrick, a vice president at Inseparable, a mental-health policy organization, has endured what she terms “persecutory” hallucinations for four decades, since her late teens, around the time she was asked to take a leave from Wellesley College because of psychological instability. Her hallucinations have spanned from voices telling her that the Cheerios boxes on a grocery store shelf were filled with poison to ongoing visions of “ginormous bugs with hairy arms around me, trying to get on me.” About what lay behind such breaks, she asked: “Could the racial be a factor? It would have to be there among the causes, because racism eats away at the ego, and when the ego starts to deteriorate, mental health takes a nosedive.”

She worried that people might “dismiss my words because I’ve been given a diagnosis of schizophrenia.” She spoke in steady tones: “We weren’t supposed to be here to begin with. We’re still unwanted.” She traced her consciousness of being unwelcome back to her parents’ insisting that she sit at the front of her childhood classrooms and that she do “200 percent more” than her classmates, because “the teacher will expect you not to want to learn.” Maybe, she offered, “we need a diagnosis that just says ‘struggling with racism,’ because it is emotionally at the core of who we are, and it is devastating to the internal part of the person. If anyone has had to struggle with the impostor syndrome,” she explained, “this is that times a million.”

Richard Williams, a Ph.D. candidate in special education curriculum and instruction at the University at Buffalo, told me about living in a white neighborhood where people rarely walk anywhere. He doesn’t own a car and feels that he is being surveilled and in danger when he walks home from grocery shopping. His voices — “rapid-firing, frenetic, aggressive, scared,” he said — warn him: “Look over there. Did you look behind you? Don’t look crazy though.” Twice-monthly injections of a long-acting antipsychotic help only so much. Sometimes his fear is amorphous; sometimes it’s focused on the police officers who gather at a coffee shop along his route. “There’s the worry that if I start looking abnormal, I’m going to end up shot, because I don’t understand what the cop is saying and I’m raising my voice, because I’m scared, and they’re seeing that as aggression.”

There is, he went on, “a constant awareness that I have Black skin.” And there is the ever-mindful attempt to mitigate this, partly by tending cautiously to his hair. “I have bushy hair naturally. On the one hand, it’s a badge of pride. But on the other, it’s like walking around with a big target.” So he pulls it back tightly into a short ponytail, keeps it flat to his head, which is one aspect of “the performance I play” — a performance that puts its own acute stress on his psyche. “You can’t explain systemic oppression,” he added, “because people” — “white-bodied” people — “don’t get it, and you’re going to sound psychotic.”

For all that’s unique about the Black experience in America, high rates of psychosis among ethnic minorities are also widespread in Europe. “A lot of people have the belief that what doesn’t kill you makes you stronger,” Els van der Ven says. “But being a member of a minority group and being exposed repeatedly to microaggressions or social exclusion or structural racism may sensitize you to have a psychotic response.” Van der Ven is an associate professor of clinical psychology at Vrije University Amsterdam, and this spring I watched, by Zoom, as she and a team of graduate students ran a set of experiments intended to begin exploring elements of this sensitization. The subjects were 16-to-18-year-olds of Moroccan, Middle Eastern, sub-Saharan or white Dutch descent. Importantly, they did not report psychotic diagnoses. Van der Ven wanted to see if there were relevant differences, by race or ethnicity, in the way apparently healthy subjects processed experiences and information — differences that might point to a divergent susceptibility to psychosis.

In one experiment, in the first phase, subjects filled out a questionnaire asking about the frequency and intensity of what Van der Ven termed relatively “light” psychotic experiences, such as the feeling of being followed. In Phase 2, they were put through something called the Cyberball Social Exclusion Paradigm. Essentially, it’s a video game, in which the subject tosses a ball with two virtual players. Then suddenly — and for the remainder of the game — the two players toss only to each other. The subject is cut out and can’t do anything about it. In the final phase, Van der Ven had her subjects fill out the questionnaire again, to measure the impact of the isolating experience.

When Van der Ven first described this experiment to me, I thought: How can a few minutes of game-playing have a significant effect? And anyway, wouldn’t subjects recall their previous answers and tend to repeat them? But Van der Ven explained that comparable before-after experimental designs with Cyberball as the catalyst had been used successfully before, and as I observed the game, I felt its resonance and could imagine the psychological reverberations being much greater if I were already prone to a sense of social alienation or “social defeat.” Van der Ven is testing whether ethnic-minority participants are affected more powerfully — with markedly more hints of psychosis — by being left out during Cyberball.

In another of Van der Ven’s studies, with data collected in Spain, France, Italy and Britain as well as the Netherlands, subjects with newly diagnosed psychosis were shown photographs of faces — all of them white, representing the dominant demographic — and asked to identify whether the facial expressions were fearful, angry, happy or neutral. The preliminary data showed that subjects from Black ethnic groups misidentified the expressions at a higher rate, with, Van der Ven said, a “negativity bias” — that is, they were more liable to perceive fear or anger where it didn’t exist.

Van der Ven collaborates occasionally with Anglin. In “From Womb to Neighborhood: A Racial Analysis of Social Determinants of Psychosis in the United States,” they reviewed a wide body of research. The “womb” of the title refers to studies demonstrating that prenatal maternal problems like infection and inflammation raise the risk of psychotic outcomes for the baby, minimally but meaningfully. These are among the tangle of possible causes for the increased rates of psychosis. Such prenatal problems are more common among Black women and have been consistently tied to perceived discrimination and circumstances of disadvantage.

The paper’s section on neighborhood encompasses an intriguing paradox.

In Black neighborhoods, adversity and stress are elevated, with correlations to psychosis. But Anglin’s research as well as other studies suggest that for people of color, being in a community of “racially and ethnically diverse folks,” as Anglin put it, can also have a protective effect among those diagnosed as at-risk for full-fledged psychotic disorders. Anglin, who grew up in a Jamaican American enclave, has found that those who spent their childhoods in neighborhoods with a high percentage of minorities have better long-term outcomes: a lower likelihood of persistent symptoms and, for those whose trajectory worsens, better odds of eventual remission. Anglin speculates that this is about having more “social support” and enduring less isolation.

Anglin burrows into race and psychosis not only through large studies but also through intimate research. In 2021, she worked with a small group of young Black people recently given a diagnosis of first-episode psychosis. She asked them to take photos in their neighborhoods that would show the role racism plays in their mental health. One woman came back with a picture of an official-looking metal sign, attached to a pole directly below a no-parking sign and reading, “Stop Killing Black People.” The intention behind the sign — to raise awareness of violent racism — didn’t seem to reassure the woman.“How often,” she asked in a discussion with the group, “do I need to keep being reminded that my life matters?” In the sign’s four words, she heard an insistent message of her own insignificance.

One day in June, Miller manned a Wildflower Alliance drop-in center, where the sofas were well worn and easy to sink into. As he set things up, he filled a snack bowl with granola bars and chips. One of his regular tasks was to keep people from shooting up in the bathrooms; in the dim lighting, if they had trouble finding their target vein, they wound up bleeding all over the floor.

From 2018 to 2022, Miller was a director of recovery for the Massachusetts Department of Mental Health. His educational credentials amounted to a high school equivalency diploma, but he had already worked with Wildflower, and he probably got the state D.M.H. position, he said, because of a budding effort in the mental health field to hire “peers” — people with firsthand knowledge of the challenges faced by those they’re trying to help. To Miller, his D.M.H. title, director of recovery, sang with both authority and optimism. He was filled with high hopes. But during his orientation, he toured a ward of long-term adult psychiatric patients at a state hospital.

“It was Black men, drugged. Some of them could barely keep their eyes open,” he remembered. “These men were there for years and years, seen as a danger to themselves or others, just wasting away.” It seemed to him that society almost wanted these Black men there, that racism and its trauma created their psychiatric conditions, which guaranteed this form of incarceration. After the tour, he cried in his car. “I was going to be taking a paycheck from people who did this. I had joined a machine.”

Now, with Wildflower again, he tried to help people like a Black homeless gulf-war vet with a history of psychiatric hospitalizations, who sometimes stopped by the drop-in center to play chess with Miller. Recently Miller found the man a subsidized apartment, but persuading him to use it — instead of sleeping in an encampment by a highway overpass — was an ongoing challenge. At the encampment, the man had fed and befriended a bobcat. But then the bobcat approached other residents and was trapped and put down. On top of that, the man was beaten up twice. Still, he was hard to persuade. “The apartment is 180 square feet — it feels like a coffin for him,” Miller said. “He would prefer to live outside. It’s hard being homeless; people can treat you any which way. But the kind of bravado you need to do it isn’t always conducive to getting out of it.”

Though Miller chatted warmly with whoever drifted through the center’s door, he kept to himself after work. “I don’t go out of my apartment much,” he said, “because I know situations arise” — situations like being pulled over by the police, episodes that overwhelmed him with powerlessness and humiliation and that ignited his hallucinatory voice.

“It’s like living at gunpoint,” he said: He always felt on the verge of slipping up and being seized again by the mental-health system. “There’s so much work I do to not look like I’m hearing voices when I am. What does my face look like? Do I look distracted? Can you see it on me? A lot of my energy goes into not looking crazy.” The pressure was constant and excruciating, pressure to conceal and conform, not only to psychiatric norms, by completely hiding his hallucinatory voice, but also to racial norms. For him, the two were tightly intertwined. “You have to learn to assimilate with white culture. Code switching is one of the skills I have. People who look like me are dangerous. People who sound like people from my community are dangerous. You have to control how you communicate. I can do that, but the duality has a cost. It makes me more distant from my community.” The cost of protecting himself in this way was yet more isolation — isolation that inevitably meant more trepidation, more foreboding and more pressure, and that probably added to the severity of his voice.

“I think there’s a likelihood that I’ll kill myself at some point,” he said, “that it’ll all be too much for me. But better that than dying on a psych ward at 60, hoping they’ll take me out for a cigarette.”

In the meantime, he coped, and listening to his despair and determination, I heard something akin to the futility and beauty he admired in “The Old Man and the Sea.” He went on seeking ways to help the man with the necrotic lower leg, who would probably need an amputation, and the bobcat man and other people like them, people on the other side of lines the rest of us never cross.

“It’s like I’m on a tightrope,” he said. “I haven’t fallen yet, but that feels like a miracle.”