My Sister's Keeper

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I am taking a shower when Kate jimmies the lock and comes into the bathroom. "I want to talk to you," she says.

I poke my head out from the side of the plastic curtain. "When I'm finished," I say, trying to buy time for the conversation I don't really want to have.

"No, now." She sits down on the lid of the toilet and sighs. "Anna . . . what you're doing--"

"It's already done," I say.

"You can undo it, you know, if you want."

I am grateful for all the steam between us, because I couldn't bear the thought of her being able to see my face right now. "I know," I whisper.

For a long time, Kate is silent. Her mind is running in circles, like a gerbil on a wheel, the same way mine is. Chase every rung of possibility, and you still get absolutely nowhere.

After a while, I peek my head out again. Kate wipes her eyes and looks up at me. "You do realize," she says, "that you're the only friend I've got?"

"That's not true," I immediately reply, but we both know I'm lying. Kate has spent too much time out of organized school to find a group she fits into. Most of the friends she has made during her long stretch of remission have disappeared--a mutual thing. It turned out to be too hard for an average kid to know how to act around someone on the verge of dying; and it was equally as difficult for Kate to get honestly excited about things like homecoming and SATs, when there was no guarantee she'd be around to experience them. She's got a few acquaintances, sure, but mostly when they come over they look like they're serving out a sentence, and sit on the edge of Kate's bed counting down the minutes until they can leave and thank God this didn't happen to them.

A real friend isn't capable of feeling sorry for you.

"I'm not your friend," I say, yanking the curtain back into place. "I'm your sister." And doing a damn lousy job at that, I think. I push my face into the shower spray, so that she cannot tell I'm crying, too.

Suddenly, the curtain whips aside, leaving me totally bare. "That's what I wanted to talk about," Kate says. "If you don't want to be my sister anymore, that's one thing. But I don't think I could stand to lose you as a friend."

She pulls the curtain back into place, and the steam rises around me. A moment later I hear the door open and close, and the knife-slice of cold air that comes on its heels.

I can't stand the thought of losing her, either.

*

That night, once Kate falls asleep, I crawl out of my bed and stand beside hers. When I hold my palm up under her nose to see if she's breathing, a mouthful of air presses against my hand. I could push down, now, over that nose and mouth, hold her when she fights. How would that really be any different than what I am already doing?

The sound of footsteps in the hallway has me diving underneath the cave of my covers. I turn onto my side, away from the door, just in case my eyelids are still flickering by the time my parents enter the room. "I can't believe this," my mother whispers. "I just can't believe she's done this."

My father is so quiet that I wonder if maybe I have been mistaken, if maybe he isn't here at all.

"This is Jesse, all over again," my mother adds. "She's doing it for the attention." I can feel her looking down at me, like I'm some kind of creature she's never seen before. "Maybe we need to take her somewhere, alone. Go to a movie, or shopping, so she doesn't feel left out. Make her see that she doesn't have to do something crazy to get us to notice her. What do you think?"

My father takes his time answering. "Well," he says quietly, "maybe this isn't crazy."

You know how silence can push in at your eardrums in the dark, make you deaf? That's what happens, so that I almost miss my mother's answer. "For God's sake, Brian . . . whose side are you on?"

And my father: "Who said there were sides?"

But even I could answer that for him. There are always sides. There is always a winner, and a loser. For every person who gets, there's someone who must give.

A few seconds later, the door closes, and the hall light that has been dancing on the ceiling disappears. Blinking, I roll onto my back--and find my mother still standing beside my bed. "I thought you were gone," I whisper.

She sits down on the foot of my bed and I inch away. But she puts her hand on my calf before I move too far. "What else do you think, Anna?"

My stomach squeezes tight. "I think . . . I think you must hate me."

Even in the dark, I can see the shine of her eyes. "Oh, Anna," my mother sighs, "how can you not know how much I love you?"

She holds out her arms and I crawl into them, as if I'm small again and I fit there. I press my face hard into her shoulder. What I want, more than anything, is to turn back time a little. To become the kid I used to be, who believed whatever my mother said was one hundred percent true and right without looking hard enough to see the hairline cracks.

My mother holds me tighter. "We'll talk to the judge and explain it. We can fix this," she says. "We can fix everything." And because those words are really all I've ever wanted to hear, I nod.





SARA




1990

THERE IS AN UNEXPECTED COMFORT to being at the oncology wing of the hospital, a sense that I am a member of the club. From the kindhearted parking attendant who asks us if it's our first time, to the legions of children with pink emesis basins tucked beneath their arms like teddy bears--these people have all been here before us, and there's safety in numbers.

We take the elevator to the third floor, to the office of Dr. Harrison Chance. His name alone has put me off. Why not Dr. Victor? "He's late," I say to Brian, as I check my watch for the twentieth time. A spider plant languishes, brown, on a windowsill. I hope he is better with people.

To amuse Kate, who is starting to lose it, I inflate a rubber glove and knot it into a coxcomb balloon. On the glove dispenser near the sink is a prominent sign, warning parents not to do this very thing. We bat it back and forth, playing volleyball, until Dr. Chance himself comes in without a single apology for his delay.

"Mr. and Mrs. Fitzgerald." He is tall and rail-thin, with snapping blue eyes magnified by thick glasses, and a tightly set mouth. He catches Kate's makeshift balloon in one hand and frowns at it. "Well, I can see there's already a problem."

Brian and I exchange a glance. Is this coldhearted man the one who will lead us through this war, our general, our white knight? Before we can even backpedal with explanations, Dr. Chance takes a Sharpie marker and draws a face on the latex, complete with a set of wire-rimmed glasses to match his own. "There," he says, and with a smile that changes him, he hands it back to Kate.

*

I only see my sister Suzanne once or twice a year. She lives less than an hour and several thousand philosophical convictions away.

As far as I can tell, Suzanne gets paid a lot of money to boss people around. Which means, theoretically, that she did her career training with me. Our father died while mowing the lawn on his forty-ninth birthday; our mother never quite sewed herself together in the aftermath. Suzanne, ten years my senior, took up the slack. She made sure I did my homework and filled out law school applications and dreamed big. She was smart and beautiful and always knew what to say at any given moment. She could take any catastrophe and find the logical antidote to cure it, which is what made her such a success at her job. She was just as comfortable in a boardroom as she was jogging along the Charles. She made it all look easy. Who wouldn't want a role model like that?

My first strike was marrying a guy without a college degree. My second and third were getting pregnant. I suppose that when I didn't go on to become the next Gloria Allred, she was justified in counting me a failure. And I suppose that until now, I was justified in thinking that I wasn't one.

Don't get me wrong, she loves her niece and nephew. She sends them carvings from Africa, shells from Bali, chocolates from Switzerland. Jesse wants a glass office like hers when he grows up. "We can't all be Aunt Zanne," I tell him, when what I mean is that I can't be her.

I don't remember which of us stopped returning phone calls first, but it was easier that way. There's nothing worse than silence, strung like heavy beads on too delicate a conversation. So it takes me a full week before I pick up the phone. I dial direct. "Suzanne Crofton's line," a man says.

"Yes." I hesitate. "Is she available?"

"She's in a meeting."

"Please . . ." I take a deep breath. "Please tell her it's her sister calling."

A moment later that smooth, cool voice falls into my ear. "Sara. It's been a while."

She is the person I ran to when I got my period; the one who helped me knit back together my first broken heart; the hand I would reach for in the middle of the night when I could no longer remember which side our father parted his hair on, or what it sounded like when our mother laughed. No matter what she is now, before all that, she was my built-in best friend. "Zanne?" I say. "How are you?"

*

Thirty-six hours after Kate is officially diagnosed with APL, Brian and I are given an opportunity to ask questions. Kate messes with glitter glue with a child-life specialist while we meet with a team of doctors, nurses, and psychiatrists. The nurses, I have already learned, are the ones who give us the answers we're desperate for. Unlike the doctors, who fidget like they need to be somewhere else, the nurses patiently answer us as if we are the first set of parents to ever have this kind of meeting with them, instead of the thousandth. "The thing about leukemia," one nurse explains, "is that we haven't even inserted a needle for the first treatment when we're already thinking three treatments down the line. This particular illness carries a pretty poor prognosis, so we need to be thinking ahead to what happens next. What makes APL a little trickier is that it's a chemoresistant disease."

"What's that?" Brian asks.

"Normally, with myelogenous leukemias, as long as the organs hold up, you can potentially reinduce the patient into remission every time there's a relapse. You're exhausting their body, but you know it will respond to treatment over and over. However, with APL, once you've offered a given therapy, you usually can't rely upon it again. And to date, there's only so much we can do."

"Are you saying," Brian swallows. "Are you saying she's going to die?"

"I'm saying there are no guarantees."

"So what do you do?"

A different nurse answers. "Kate will start a week of chemotherapy, in the hopes that we can kill off the diseased cells and put her into remission. She'll most likely have nausea and vomiting, which we'll try to keep to a minimum with antiemetics. She'll lose her hair."

At this, a tiny cry escapes from me. This is such a small thing, and yet it's the banner that will let others know what's wrong with Kate. Only six months ago, she had her first haircut; the gold ringlets curled like coins on the floor of the SuperCuts.

"She may develop diarrhea. There's a very good chance that, with her own immune system laid low, she will get an infection that will require hospitalization. Chemo may cause developmental delays, as well. She'll have a course of consolidation chemotherapy about two weeks after that, and then a few courses of maintenance therapy. The exact number will depend on the results we get from periodic bone marrow aspirations."

"Then what?" Brian asks.

"Then we watch her," Dr. Chance replies. "With APL, you'll want to be vigilant for signs of relapse. She'll have to come into the ER if she has any hemorrhaging, fever, cough, or infection. And as far as further treatment, she'll have some options. The idea is to get Kate's body producing healthy bone marrow. In the unlikely event that we achieve molecular remission with chemo, we can retrieve Kate's own cells and reinstill them--an autologous harvest. If she relapses, we may try to transplant someone else's marrow into Kate to produce blood cells. Does Kate have any siblings?"

"A brother," I say. A thought dawns, a horrible one. "Could he have this, too?"

"It's very unlikely. But he may wind up being a match for an allogeneic transplant. If not, we'll put Kate on the national registry for MUD--a matched, unrelated donor. However, getting a transplant from a stranger who's a match is much more dangerous than getting one from a relative--the risk of mortality greatly increases."

The information is endless, a series of darts thrown so fast I cannot feel them sting anymore. We are told: Do not think; just give your child up to us, because otherwise she's going to die. For every answer they give us, we have another question.

Will her hair grow back?

Will she ever go to school?

Can she play with friends?

Did this happen because of where we live?

Did this happen because of who we are?

"What will it be like," I hear myself ask, "if she dies?"

Dr. Chance looks at me. "It depends on what she succumbs to," he explains. "If it's infection, she'll be in respiratory distress and on a ventilator. If it's hemorrhage, she'll bleed out after losing consciousness. If it's organ failure, the characteristics will vary depending on the system in distress. Often there's a combination of all of these."

"Will she know what's happening," I ask, when what I really mean is, How will I survive this?

"Mrs. Fitzgerald," he says, as if he has heard my unspoken question, "of the twenty children here today, ten will be dead in a few years. I don't know which group Kate will be in."

*

To save Kate's life, part of her has to die. That's the purpose of chemotherapy--to wipe out all the leukemic cells. To this end, a central line has been placed beneath Kate's collarbone, a three-pronged port that will be the entry point for multiple medication administrations, IV fluids, and blood draws. I look at the tubes sprouting from her thin chest and think of science fiction movies.

She has already had a baseline EKG, to make sure her heart can withstand chemo. She's had dexamethasone ophthalmic drops, because one of the drugs causes conjunctivitis. She's had blood drawn from her central line, to test for renal and liver function.

The nurse hangs the infusion bags on the IV pole and smoothes Kate's hair. "Will she feel it?" I ask.

"Nope. Hey, Kate, look here." She points to the bag of Daunorubicin, covered with a dark bag to protect it from light. Spotting it are brightly colored stickers she's helped Kate make while we were waiting. I saw one teenager with a Post-it note on his: Jesus saves. Chemo scores.

This is what starts coursing through her veins: the Daunorubicin, 50 mg in 25 ccs of D5W; Cytarabine, 46 mg in a D5W infusion, a continuous twenty-four-hour IV; Allopurinol, 92 mg IV. Or in other words, poison. I imagine a great battle going on inside her. I picture shining armies, casualties that evaporate through her pores.

They tell us Kate will most likely get sick within a few days, but it takes only two hours before she starts throwing up. Brian pushes the call button, and a nurse comes into the room. "We'll get her some Reglan," she says, and she disappears.

When Kate isn't vomiting, she's crying. I sit on the edge of the bed, holding her half on my lap. The nurses do not have time to nurse. Short-staffed, they administer antiemetics in the IV; they stay for a few moments to see how Kate responds--but inevitably they are called elsewhere to another emergency and the rest falls to us. Brian, who has to leave the room if one of our children gets a stomach virus, is a model of efficiency: wiping her forehead, holding her thin shoulders, dabbing tissues around her mouth. "You can get through this," he murmurs to her each time she spits up, but he may only be talking to himself.

And I, too, am surprising myself. With grim resolve I make a ballet out of rinsing the emesis basin and bringing it back. If you focus on sandbagging the beachhead, you can ignore the tsunami that's approaching.

Try it any other way, and you'll go crazy.

*

Brian brings Jesse to the hospital for his blood test: a simple finger stick. He needs to be restrained by Brian and two male residents; he screams down the hospital. I stand back, and cross my arms, and inadvertently think of Kate, who stopped crying over procedures two days ago.

Some doctor will look at this sample of blood, and will be able to analyze six proteins, floating invisibly. If these six proteins are the same as Kate's, then Jesse will be an HLA match--a potential donor for bone marrow for his sister. How bad can the odds be, I think, to match six times over?

As bad as getting leukemia in the first place.

The phlebotomist goes off with her blood sample, and Brian and the doctors release Jesse. He bolts off the table into my arms. "Mommy, they stuck me." He holds up his finger, festooned with a Rugrats Band-Aid. His damp, bright face is hot against my skin.

I hold him close. I say all the right things. But it is so, so hard to make myself feel sorry for him.

*

"Unfortunately," Dr. Chance says, "your son isn't a match."

My eyes focus on the houseplant, which still sits withered and brown on the sill. Someone ought to get rid of that thing. Someone ought to replace it with orchids, with birds-of-paradise, and other unlikely blooms.

"It's possible that an unrelated donor will crop up on the national marrow registry."

Brian leans forward, stiff and tense. "But you said a transplant from an unrelated donor was dangerous."

"Yes, I did," Dr. Chance says. "But sometimes it's all we've got."

I glance up. "What if you can't find a match in the registry?"

"Well." The oncologist rubs his forehead. "Then we try to keep her going until research catches up to her."

He is talking about my little girl as if she were some kind of machine: a car with a faulty carburetor, a plane whose landing gear is stuck. Rather than face this, I turn away just in time to see one of the misbegotten leaves on the plant make its suicide plunge to the carpet. Without an explanation I get to my feet and pick up the planter. I walk out of Dr. Chance's office, past the receptionist and the other shell-shocked parents waiting with their sick children. At the first trash receptacle I find, I dump the plant and all its desiccated soil. I stare at the terra-cotta pot in my hand, and I am just thinking about smashing it down on the tile floor when I hear a voice behind me.

"Sara," Dr. Chance says. "You all right?"

I turn around slowly, tears springing to my eyes. "I'm fine. I'm healthy. I'm going to live a long, long life."

Handing him the planter, I apologize. He nods, and offe