By KARL OVE KNAUSGAARD
Photographs by PAOLO PELLEGRINDEC. 30, 2015
Gjinovefa Merxira after her operation. Paolo Pellegrin/Magnum, for The New York Times
I arrived in Tirana, Albania, on a Sunday evening in late August, on a flight from Istanbul. The sun had set while the plane was midflight, and as we landed in the dark, images of fading light still filled my mind. The man next to me, a young, red-haired American wearing a straw hat, asked me if I knew how to get into town from the airport. I shook my head, put the book I had been reading into my backpack, got up, lifted my suitcase out of the overhead compartment and stood waiting in the aisle for the door up ahead to open.
That book was the reason I had come. It was called “Do No Harm,” and it was written by the British neurosurgeon Henry Marsh. His job is to slice into the brain, the most complex structure we know of in the universe, where everything that makes us human is contained, and the contrast between the extremely sophisticated and the extremely primitive — all of that work with knives, drills and saws — fascinated me deeply. I had sent Marsh an email, asking if I might meet him in London to watch him operate. He wrote a cordial reply saying that he seldom worked there now, but he was sure something could be arranged. In passing, he mentioned that he would be operating in Albania in August and in Nepal in September, and I asked hesitantly whether I could join him in Albania.
Warning: Images in this article may be disturbing to some viewers.
Now I was here.
Tense and troubled, I stepped out of the door of the airplane, having no idea what lay ahead. I knew as little about Albania as I did about brain surgery. The air was warm and stagnant, the darkness dense. A bus was waiting with its engine running. Most of the passengers were silent, and the few who chatted with one another spoke a language I didn’t know. It struck me that 25 years ago, when this was among the last remaining Communist states in Europe, I would not have been allowed to enter; then, the country was closed to the outside world, almost like North Korea today. Now the immigration officer barely glanced at my passport before stamping it. She dully handed it back to me, and I entered Albania.
In the arrivals hall, a young man dressed in a bright white shirt came over.
“Welcome to Albania, Mr. Knausgaard. My name is Geldon Fejzo. Mr. Marsh and Professor Petrela are waiting for you at the hotel. The car is right outside.”
The car was a black Mercedes, with leather seats and air conditioning. It turned out that Fejzo had just completed his medical training as a neurosurgeon. He was 31 and had studied in Florence. He had also worked as an intern for a few months at a London hospital with Mr. Marsh, as he called him, in the manner long preferred by British surgeons.
“What is he like?” I asked.
“He’s a fantastic person,” Fejzo said.
Marsh was in Tirana to demonstrate a surgical procedure he helped pioneer, called awake craniotomy, that had never been performed in Albania. The procedure is used to remove a kind of brain tumor that looks just like the brain itself. Such tumors are most common in young people, and there is no cure for them. Without surgery, 50 percent of patients die within five years; 80 percent within 10 years. An operation prolongs their lives by 10 to 20 years, sometimes more. In order for the surgeon to be able to distinguish between tumor and healthy brain tissue, the patient is kept awake throughout the operation, and during the procedure the brain is stimulated with an electric probe, so that the surgeon can see if and how the patient reacts. The team in Albania had been preparing for six months and had selected two cases that were particularly well suited to demonstrating the method.
I leaned back in my seat and looked out into the darkness, which extended all around, as if we were deep in the countryside, and then increasingly it was broken up by lights from houses, shops, intersections. As always when I was in a car driving toward a large town, I thought of a poem by the Swedish poet Tomas Transtromer; it had become almost compulsive. “The funerals keep coming/more and more of them/like the traffic signs/as we approach a city,” he wrote toward the end of his life. And then I thought of something Marsh put in his book, a quote from the French physician René Leriche that begins: “Every surgeon carries within himself a small cemetery.”
We stopped at a red light. A large square spread out before us.
“That’s the national museum,” Fejzo said, pointing at an imposing building on the left. “The Chinese built it during the Communist era. And there, on the other side, is the opera. The Soviets built that.”
I bent my head toward the window and stared up at a giant mosaic of people in heroic poses. A shiver ran down my spine. If there is one thing I have a weakness for, it is the Communist Era, especially the secretive culture behind the Iron Curtain, with its working-class heroism, its celebration of industry, its massive architecture, its Tarkovsky films, its cosmonauts and its supernatural ice-hockey teams. I don’t know why it appeals to me, because in actual fact I oppose everything it represents: the veneration of the collective, the industrialization of everyday life, the monumental aesthetics. I believe in blundering man and in the provisional moment. But something about the aura of the Soviet Age attracts me, sometimes with an almost savage force.
The car swung to the side and stopped next to the hotel. A group of people were seated around a table outside, and they stood up as we walked over. I recognized Henry Marsh from photos and from a documentary about him.
“Ah, the famous writer has arrived!” he said.
He was shorter than I expected, with a body I at once thought of as tough and resilient; his movements had a touch of old age about them, while his eyes, the upper part of which were hooded by his lids, looked simultaneously energetic and mournful.
Dr. Henry Marsh after performing surgery in Tirana. Paolo Pellegrin/Magnum, for The New York Times
His handshake was firm, and I glanced surreptitiously at his hands, which were sturdy, with broad fingers, like the hands of a craftsman.
Fejzo introduced me to the others. Paolo Pellegrin, the photographer who would be recording the procedure, a tall man with curly hair and glasses who appeared to be in his late 40s; his strikingly handsome young assistant, Alessio Cupelli, who had covered his long dark hair with a head scarf; and Mentor Petrela, who ran the department of neurosurgery at the hospital in Tirana. He was in his mid-60s, elegantly dressed, smiling, his eyes full of warmth.
“We have booked a table at a restaurant nearby,” he said. “Do you want to join us?”
At the restaurant, we gathered outside on a narrow terrace just as a call to prayer was sounding. Fejzo conferred with the waiter, and while Marsh and Pellegrin took up their previous conversation, I listened to the strange voice of the muezzin rising and falling out in the dark. I didn’t understand the words, but the sound of them filled the air with mournfulness and humility. Man is small, life is large, is what I heard in the ring of that voice.
Pellegrin removed his glasses and rubbed his eye, and after he replaced the glasses, he looked at me.
“We’re talking about an eye ailment that I have,” he said. “My vision is gradually getting worse and worse.”
“He wonders whether that is what is driving him on,” Marsh said. “Knowing that his time as a photographer is limited.”
“You’re a war photographer, aren’t you?” I said.
“That too, yes,” Pellegrin said.
“Do you see any similarities with what you do?” I said, turning to Marsh. “Brain surgery is about life and death, too, isn’t it?”
“No, no, not at all,” he said. “As a neuro-surgeon, you’re not risking anything personally. I’m a coward. I’m full of anxiety, you know.”
The waiters, all of them young men with close-cropped hair, came gliding up with the hors d’oeuvres, and soon the plain white table, until then colored only by the pale green olive oil in transparent bottles, was filled with dark red tomatoes, green lettuce, blue-black octopus sliced to expose dazzling white flesh, pink shrimp, reddish brown slabs of ham, slices of beige bread with dark, almost black crust.
It was Marsh who kept the conversation going during the dinner. He explained the awake craniotomy procedure, saying that for a neurosurgeon, it is a constant temptation to try to remove the entire tumor, but if you go too far, if you remove too much, the consequences can be severe. It may lead to full or partial paralysis of one side of the body or other functional impairments or personality changes. When the patient is awake, this allows the surgeon first of all to determine where the dividing line lies, and second, to observe the consequences of the procedure directly and immediately, and stop before any serious damage is done.
Marsh was articulate, well informed and entertaining. He spoke just as easily about political conditions in Zimbabwe or the books of the German writer W. G. Sebald, which he loved, as he did about the various parts of the brain. At the same time, I had the feeling that something else was going on within him that had little to do with the conversation at hand. When someone said something, he might say, “Exactly,” and elaborate on the theme, but he might also become very quiet, as if he had fallen out of the world, into himself. And that’s where he doesn’t want to be, it occurred to me, as we sat around the table talking, under the strong light of the ceiling lamps, the sparkle of the glasses on the table and the gleam of the white tablecloth intensified by the dense, impenetrable darkness beyond the green bushes that grew on the terrace wall.
Before he decided to become a surgeon, Marsh studied philosophy, politics and economics at Oxford University, where he took an interest in the Soviet Union. After the Cold War ended, he began working pro bono at a neurosurgical ward in Kiev, where conditions were primitive and appalling. The 2007 documentary about his work there, called “The English Surgeon,” showed some unbelievably brutal operations; in one, they used a Bosch drill, the kind you would buy in a hardware store, to open the skull; in another they used a wire saw, which sent dust flying and blood spattering. He sent the surgeons medical equipment; once he drove there in his own car, loaded with instruments. Seven years ago, he operated on the future British ambassador to Albania and made friends with her, and she introduced him to Petrela.
“We became friends instantly,” Petrela said as Marsh told the story. “Instantly! Henry Marsh is an honest doctor. His book is all about honesty. The truth. It is so important, the truth.”
“Was it because of your son that you specialized in neurosurgery?” I asked, as I leaned back to make room for the waiter, who was laying lettuce on my plate with a pair of tongs.
Marsh’s eyes narrowed, and the corners of his mouth pulled back in a grimace, while he spread his hands as if to say that he had been asked this question many times and that it might perhaps seem that way, but it probably was not the case.
“You can never know, can you,” he said. “Maybe it played a part. But not consciously in that case. Either way, there is no doubt that it made me a better doctor.”
His son was only a few months old when he underwent surgery to remove a brain tumor, while Marsh was still a medical intern. In his book, he describes the wild despair and the total helplessness he felt waiting to hear the results, before it became clear that the operation was successful.
“What I do keeps the wolf from the door,” Marsh said. “Maybe that’s why I have been doing it all these years. It has been a way to keep the wolf from the door.”
When the alarm on my cellphone woke me the next morning, I had a faint memory of having panicked during the night, that I had gotten up abruptly from the bed, unable to remember where the children were. Where are the children, where are the children, I had thought, looking for them in the bathroom, out on the balcony, down on the floor by the bed. But no children. Where were the children? I finally realized that I had been walking in my sleep, but I still couldn’t understand where I was or where the children were. Had I lost them? Then I remembered everything, and it was as if I had suddenly become one with myself and with the room I was in. Everything made sense and, relieved, I had lain down to sleep again.
I showered quickly, dressed and went to the reception area, where Marsh, Pellegrin, Cupelli and Fejzo were already gathered and two cars were waiting to take us to the hospital. We seemed to be driving through a different city. What in the evening had seemed dark and mysterious was now flooded in sunlight, completely stripped of its mystery. We followed a river, framed in concrete, upward, past row after row of brick houses, many of them run-down, full of small, makeshift cafes and simple shops. The mountains beyond the city, which I noticed only now, rearing up steeply, faintly blurred by the haze, but still a clear green against the cloudless blue sky, seemed to frame the town and to provide its distinct character. They stood there as motionless witnesses to the human struggle against entropy, just as they had when this land belonged to the Roman Empire in the fourth century and to the Ottoman Empire in the 17th.
The cars slowed down, and we parked in front of the hospital, a plain, functionalist concrete building, the sharp angles and hard planes of which contrasted with the people outside, sitting or standing in the sunlight with their soft bodies, wearing floral-print dresses or shirts and suit trousers, not unlike the way my grandparents dressed, I thought, in the 1950s and ’60s.
Inside at the neurosurgical ward, Petrela stood waiting for us, immaculately dressed and smiling broadly.
“Welcome, my friends,” he said. “You can leave your things in my office, if you like. And then I can show you the operating theaters.”
We were fitted with surgical gowns, caps and face masks and taken to the second floor, through a small labyrinth of corridors and into the operating theater.
To my horror, an operation was in progress.
The silence was total. The single focus of attention was a head clamped in a vise in the middle of the room. The upper part of the skull had been removed, and the exposed edge covered in layer after layer of gauze, completely saturated with blood, forming a funnel down into the interior of the cranium. The brain was gently pulsating within. It resembled a small animal in a grotto. Or the meat of an open mussel. Two doctors were bending over the head, each of them moving long, narrow instruments back and forth inside the opening. One nurse was assisting them, another was standing a few yards away, watching. A whispery slurping sound issued from one of the instruments, like the sound produced by the tool a dentist uses to suck away saliva from a patient’s mouth. Next to us was a monitor showing an enlarged image of the brain. In the middle, a pit had been scooped out. In the center of the pit was a white substance, shaped like a cube. The white cube, which appeared to be made of firmer stuff, was rubbery and looked like octopus flesh. I realized that it must be the tumor.
One doctor looked up from a microscope that was suspended over the brain and turned to me. Only his eyes were visible above the mask. They were narrow and foxlike.
“Do you want to have a look?” he asked.
The doctor stepped aside, and I bent down over the microscope.
A landscape opened up before me. I felt as if I were standing on the top of a mountain, gazing out over a plain, covered by long, meandering rivers. On the horizon, more mountains rose up, between them there were valleys and one of the valleys was covered by an enormous white glacier. Everything gleamed and glittered. It was as if I had been transported to another world, another part of the universe. One river was purple, the others were dark red, and the landscape they coursed through was full of strange, unfamiliar colors. But it was the glacier that held my gaze the longest. It lay like a plateau above the valley, sharply white, like mountain snow on a sunny day. Suddenly a wave of red rose up and washed across the white surface. I had never seen anything quite as beautiful, and when I straightened up and moved aside to make room for the doctor, for a moment my eyes were glazed with tears.
In the courtyard outside, the air was filled with voices, the roar of engines, the shrill rasping of cicadas. The people there, sitting or standing, some chatting busily, others silent and withdrawn, were the patients’ relatives, who spent their days out here to be close to their loved ones, Fejzo had told me.
I lifted my gaze and stared up toward the top floor of the hospital wing. It was hard to imagine that the silent, faintly humming room, with its islands of high-tech equipment, was just a few yards away from the chaos out here. Still harder was grasping that within that room, there was an opening into yet another room, the human brain.
Did I really look straight into it?
I felt a sudden, sharp pang of guilt. That brain was part of a human being, with a personality entirely its own. But I had peered into it and thought of it as a place.
I went back inside and found Petrela and Marsh sitting in the outer office, drinking coffee and chatting.
“Are you ready to meet the first patient?” Marsh asked.
Marsh always spoke with the patient before and after the operation; he repeated several times that this could be the hardest part of his job. He had to tell the truth, yet at the same time he must not deprive the patient of hope.
“You can meet him in my office,” Petrela said.
I followed Marsh into the next room, where we sat down around Petrela’s desk. Soon there was a knock on the door. The patient, a short, stocky man with a strong, youthful face, and Florian Dashi, the neurologist who would talk to him during the operation, walked in together. The patient smiled, and his movements seemed confident, but in his eyes, there was a hint of concern, maybe even fear.
His name was Ilmi Hasanaj. He was 33 and worked as a bricklayer in Tirana. He lived on the outskirts of town and was married but had no children. He had been working at a building site, he said, on the roof, and in the middle of the day he had gone to fetch something in a storeroom when his left arm and hand began to tremble uncontrollably. His mouth and his left eye moved uncontrollably, too. He managed to sit down on a chair. Some colleagues, recognizing that something was seriously wrong, took him to the hospital.
“What did you think was happening?” I asked.
“I thought maybe I was just tired and stressed out,” he said. “I had been working a lot lately.”
There was a pause.
“Are you afraid of the operation?” I asked.
He nodded even before Dashi could interpret the question.
Marsh leaned forward.
“I have done over 400 of these operations,” he said. “My experience with English patients is that it’s usually very easy for them. And I suspect that the Albanians are much tougher than the English. I believe that the Albanians will do very well.”
Hasanaj laughed when this was interpreted.
“It’s not painful,” Marsh said. “The reason for doing the operation like this is to make it safer. First we will touch your brain with a little electric instrument that I brought from London, and when we touch the movement area, we’ll make you move. And that way we’ll know where the movement area is. And the second part is, as we remove the tumor, we’ll be continuously asking you to move your foot, to move your knee, to move your hip, to move your fingers, to see if you can still move them. And if, when we are removing the tumor, you start to feel a little weak, then we’ll know that it’s time to stop. It is quite possible that after the operation there will be some weakness on your left side, but you almost certainly will get better. The risk of leaving you permanently paralyzed is not zero, but it is very small, less than 1 percent. I hope we can remove all of the tumor, but we might not, and you will need brain scans in the years to come. If there is no weakness after the operation, I hope you will be back to bricklaying in five or six weeks.”
Ilmi Hasanaj awaits surgery to remove a brain tumor. Paolo Pellegrin/Magnum, for The New York Times
The next time I saw Hasanaj, later that afternoon, he was under general anesthesia and lying beneath a sheet in the operating room, with only his skull visible, clamped in a metal vise. His head was partly shaved in preparation for the initial opening of the skull. The actual removal of the tumor would take place tomorrow. Marsh more often performed both steps in a single day, but in this case, largely because it was a new procedure for this hospital, the operation would take place over two consecutive days. Petrela and his assistant surgeon, Artur Xhumari, the man with the foxlike eyes, bent over the patient. Petrela waved a small mapping device around the head as he looked up at a monitor. The images on the screen, which showed the brain, changed as he moved the device, like the ultrasound images I had seen of my children when they were in my wife’s belly.
Petrela and Xhumari conferred in low voices, and I guessed they were deciding where to open the skull. Then Xhumari placed the scalpel two inches above the ear and pushed it hard, down through the skin. Blood oozed up through the cut and ran down along the side of the head. Xhumari drew the scalpel in a semicircle across the crown. Petrela used a suction device to suck up the blood that was seeping out. Then, with a flat instrument that he inserted into the incision, Xhumari folded back the skin, along with the flesh beneath it and the sinews that fastened it to the skull. Inch by inch, the scalp loosened from the bone of the skull. He partly cut, partly pushed and scraped it loose from the underside, while simultaneously pulling it backward from above, as if he were peeling an unripe fruit, the skin of which still clung to the flesh. When he had finished, he folded the scalp over to the side and quickly covered it with gauze pads, which immediately turned red with blood.
The skull, now laid bare, was yellow-white, with thin stripes of blood trickling in all directions. Xhumari brought out a shiny metal instrument, shaped like a baton or a large soldering iron, with a bit at the end. He placed the bit against the crown and started to drill. A hard, buzzing sound rose faintly through the operating room. A small pile of finely ground bone formed around the bit as blood flowed down over the hard skull. When the drill had gone through the bone, Xhumari pulled it out; the result looked like the hole for a screw in a piece of plastic furniture. Xhumari made two more holes just like it. Then he took up another instrument, also made of shiny metal, and inserted the tip into the first hole. I realized that this was the saw. It, too, buzzed hard and intensely, and seemed to get louder as the work got heavier. Xhumari dragged it slowly along toward the second hole, while Petrela sucked away the blood and the bone dust. A narrow crack grew slowly behind it, as when you cut a hole in the ice with a saw. When the saw had come full circle and reached the first hole from the opposite side, Petrela lifted the top of the skull like a lid and held it up into the air in front of me.
“Every brain surgeon, at some point in his career, drops this on the floor,” he said, laughing. He handed the bloody lid to the nurse, who placed it on a dish and covered it with a green plastic sheet.
Under the opened skull lay a wet, blood-tinted membrane.
“That’s the dura mater,” Petrela said. “The outermost of the meninges.”
Xhumari cut into it with scissors, creating a flap. Its underside was white and resembled a piece of soaked cloth. He gently pulled the flap back, exposing the brain. It pulsated slowly and looked bluish in the sharp light of the lamps.
“Now we sew it up again,” Petrela said. “And we’re all set for the operation tomorrow.”
The whole process was reversed. They sewed the meninges back down, and the nurse handed Xhumari the lid of the skull. When he pressed it into place, blood oozed up, as if he had put the lid on a cup that was overflowing with thick cranberry juice. They fastened the lid with metal clips, then stitched the scalp back together.
Not once had it crossed my mind that it was Hasanaj they were slicing into.
Ilmi Hasanaj before leaving the operating room. Paolo Pellegrin/Magnum, for The New York Times
Petrela invited us all to dinner at his apartment that evening. His family owned a building in the center of town, just above the central mosque. His predecessors had been politicians and businessmen; his great—grandfather was prefect of Tirana when the city capitulated to the forces of the Austro-Hungarian Empire during World War I. His grandfather traded in olive oil and was wealthy; it was he who had built the building, in 1924. When the Communists came to power after the war, the family lost the house; it was confiscated, as all bourgeois homes were. His father, who was a professor, had to teach at a primary school in a village in the mountains far outside Tirana, Petrela told me in the twilight on the terrace that ran around the top of the apartment. His voice was full of sorrow when he spoke about his father.
“He told me we had to put on a mask before going out,” Petrela said. He pretended to put a mask on his face with his hands and made a zippering motion across his mouth. “And then we took it off again when we closed the door behind us back home. I have a mask hanging on the wall in the hallway to remind myself.”
He laughed. It struck me that Petrela was still, first and foremost, a son, for that was the nature of his charm — boyish, joyful, vulnerable somehow. But at the same time I sensed that there was a great deal here that I didn’t understand. I had noticed that his word was law to the other hospital employees, and for the neurosurgical ward at the hospital in Tirana, which otherwise was poor and lacked resources, to be able to perform at such a high level, which Marsh called “state of the art,” surely something more than kindliness was needed.
Standing there in the darkness, beneath the stars, while the sounds of the city below us came rising up through the air, Petrela then told me a story about his former boss: that he used to remove certain types of brain tumors with his index finger. No instruments, nothing, he just poked his finger down into the brain and — plop! — out came the tumor.
Petrela gave a demonstration. He held his long index finger up in the air, bent it like a hook and pretended to jerk something out while he laughed.
As he did it, I knew I would remember the gesture for the rest of my life.
Dinner was served in a dining room, two floors below, that was furnished as it must have been in the 1920s. The ceiling and the floor were both made of dark wood, and the walls were covered with paintings; a long, antique pistol lay atop a rustic chest, and hanging in one corner was a white dress like the one, Petrela said, that his grandmother wore to her wedding. It was a deeply romantic room.
Not until we were seated around the table, which was covered with a white tablecloth, stiff and formal, but also beautiful, set with porcelain and crystal, did I think about what I had seen only a few hours earlier, the drill that penetrated Hasanaj’s skull millimeter by millimeter, the lid that Petrela had then removed. Hasanaj must be awake now, I thought. He was lying awake in his hospital bed, with strange pains in his head and the thought that tomorrow he would remain awake while two doctors — the ones who were sitting here now, eating and drinking and talking and laughing — cut into his brain.
Marsh once again dominated the conversation, in his typical English way, full of wit and charm. My impression, after having spent a day and a night in his company, was that he was a manual person. He bicycled everywhere, he did all kinds of woodwork, and he kept bees at his garden in London. He told us that he recently bought a lock keeper’s cottage by the river in Oxford. The previous owner had died wretchedly, amid old junk, garbage and loneliness, and Marsh said he was going to renovate the place himself. It seemed that his way of living was to keep moving, filling his days with things to do, as during dinner he filled it with things to say.
There was something reassuring about being in his company, because he took charge of the conversation in such an entertaining way, but at the same time there was a touch of insecurity there, for within the broad range of topics that he mastered, there appeared from time to time traces of self-assertion, well camouflaged, but not so well that I didn’t notice that it was important to him to get across that his wife was beautiful and smart, that his book had been very well received, that David Cameron, for instance, had read it and apparently been moved to tears. When we talked about cars, the story he chose to tell was about his old Saab, which he intended to drive until the day he died, and that he had once driven it when he was going to meet the queen, and how beat up and shabby it looked next to other vehicles. It was the kind of thing I might say and later feel ashamed about for months. It was a big problem I had, the urge to put myself in a flattering light by mentioning favorable events as if in passing, so that the others would understand that I wasn’t just a boring and silent Norwegian. It was almost compulsive.
Could Marsh, this brilliant neurosurgeon, be troubled by a constant need to call attention to himself? Weren’t his extraordinary qualities, so obvious to everyone around him, fixed securely in his own image of himself?
I thought of what he said the night before, about keeping the wolf from the door. I had thought he meant something big. But perhaps, to the contrary, it was something very small?
I looked at him, there at the end of the table, seated at the place of honor, his strong fingers distractedly holding the stem of his wineglass as he talked, the round spectacles in his round, lined face, the lively eyes, which, as soon as he stopped talking, turned mournful.
The next morning, which was as warm and radiant as the day before, Marsh was reclining on a black sofa in the lounge next to the operating room, dressed in his blue surgical gown, the face mask dangling beneath his chin. He smiled briefly as I entered.
“Are you nervous before operations like this?” I asked.
“Always. But today’s operation is relatively simple. The main thing is knowing when to stop.”
I entered the operating room. Hasanaj had already been wheeled in. He was lying in the same position as the day before, partly upright, with one arm on an armrest and his head clamped in a vise. This time, however, he was awake. His eyes stared straight ahead. A doctor was swabbing his head with a brown substance. When he was done, he pushed a syringe into Hasanaj’s scalp, pricking him all along the stitches from the day before. It had to hurt, but Hasanaj didn’t make a sound; he lay there motionless. A green drape was stretched all the way up to his eyes, so that his face was covered under a kind of tent, while his skull remained bare. Dashi sat down on a chair next to him. Marsh entered the room and began studying a monitor on which the last brain scan was displayed.
“There you have the tumor,” he said to me. “So I think I know what to expect. But you can never be certain until you see it in reality.”
Xhumari began removing the stitches. He folded the scalp back, baring the skull. The wet underside of the scalp was immediately covered with gauze pads, which encircled the head like a red-and-white crater. Xhumari and Petrela carefully unfastened the metal clips and removed the lid. Both of them stood motionless, their heads bent at an angle of nearly 90 degrees, the same as their arms, which they held close to their sides like bird wings; for long stretches their hands were the only parts of their bodies that moved. They didn’t speak, and the hiss of the sucker filled the room.
Marsh paced to and fro. It struck me that he resembled an actor just about to go onstage; he radiated the same restless, concentrated, faintly anxious energy.
He came over to me.
“In England, everyone would be lively and chatting away by now. Distraction is a good painkiller.” He looked at me. “Here the culture is different. It’s more vertical. In London, it’s horizontal. Ah, this churchlike silence!”
He went over to Dashi.
“How’s the patient?”
Dashi leaned forward, almost into the tent. I heard Hasanaj’s voice say something in Albanian. Dashi looked up at Marsh.
“He is well,” he said.
“Good!” Marsh said.
Xhumari lifted off the top of the skull, the underside of which was covered in congealed blood, and handed it to the nurse, who put it in a dish and covered it. Then he removed the stitches in the meninges, and I could look straight into Hasanaj’s brain, at the same time as he lay staring ahead.
The brain was shiny and covered with blood vessels, which lay twisted like little red worms on the otherwise gleaming yellow-gray surface.
Petrela splashed water on it with a syringe.
Xhumari took a few steps back to make room for Marsh, who leaned forward.
“That’s the tumor there, isn’t it? Interesting.”
He glanced up at me.
“Can you see it?”
I shook my head. Everything looked the same to me.
“It’s there, a slightly pinker area.”
He straightened up, and I moved aside, realizing that the operation was about to begin. He was handed an instrument that looked like a long, narrow tuning fork, which was wired to a box on the other side, beneath a monitor, where a nurse stood, ready to follow his instructions.
“This should be the sensory cortex. If I’m wrong, there will be movement.”
He asked the nurse to set the strength at Level 3 and touched the brain with the fork. There was a humming, electric sound. I positioned myself so that I could see Hasanaj.
“Set it to 4.”
The nurse turned the power up. Marsh touched the brain again. Dashi spoke to Hasanaj, who said something.
“Feeling,” Dashi said.
“Sensing here, face here,” Marsh said, as if to himself. “Turn it up to 5.”
Dashi spoke to Hasanaj.
“Left arm, face, tongue,” he said.
Marsh touched the brain again. This time, Hasanaj lifted his arm rapidly into the air, as if it had been pulled by the string of a puppeteer, and it shook for a few seconds, then lay down again.
I couldn’t believe my eyes. It was like a robot had been switched on.
“Left arm, movement,” Dashi said.
Marsh moved the instrument. Hasanaj’s eye blinked a couple of times.
“Left eye, movement,” Dashi said.
“We can bring in the microscope,” Marsh said.
While they wheeled over the microscope, which was fastened by a mobile crane to a large machine, to which a monitor was also connected, I squatted down in front of Hasanaj.
“How does it feel?” I asked.
He smiled faintly and said something in Albanian.
“It’s O.K.,” Dashi said.
“Does it hurt?”
“He says only a little, in his ear.”
All of Marsh’s restless energy vanished the moment he bent over the microscope and started to operate. It was as if he had stepped onto a podium, where other rules applied. He leaned forward and spoke to Hasanaj.
“The tumor is in a good position. In a little while I am going to ask you to move parts of your body, especially your face.”
Dr. Mentor Petrela and Dr. Artur Xhumari close up the head of Ilmi Hasanaj. The author, Karl Ove Knausgaard, stands second from right. Paolo Pellegrin/Magnum, for The New York Times
On a monitor I could see that Marsh was digging a small hole in the tumor, which to me looked identical to the surrounding brain. He held an instrument in his left hand, which he used to make the blood congeal; in his right hand, he held a sputtering suction device, which, with infinite care, he used to pulverize and remove tiny pieces of tissue, shred after shred. They vanished into the tube, along with blood and water; I could see them whirl away down the plastic tube and disappear. Next to him stood Petrela, splashing water over the surface.
With Dashi interpreting, Marsh asked Hasanaj to move his mouth, his eyes.
The hole in the tumor grew slowly.
Marsh brought out the stimulator again. This time it was turned up to 8 before there was a reaction, and Dashi said, “Face.”
Marsh waved me over.
“See this? This little spot here. That’s the center for facial movement. We have to leave that in peace.”
Were all the expressions the human face could make supposed to originate in this little spot? All the joy, all the grief, all the light and all the darkness that filled a face in the course of a life, was it all traceable to this? The quivering lower lip before tears begin to flow, the eyes narrowing in anger, the sudden cracking up into laughter?
Marsh continued working with the two instruments. Using the sucker, he pried and pushed and shoved continuously, while he used the other tool in between, with no trace of hesitation, without stopping and, seemingly, without thinking.
He brought out the electric stimulator again. This time he pushed it toward the bottom of the hole.
“This should be the face again,” he said.
“Nothing,” Dashi said.
Dashi shook his head, and Marsh went on working.
“The tumor is just like the brain here, that’s the problem,” he said. “Do you want to see?”
He stepped back, and I bent over the microscope again. The view this time was quite different. It was as if I were looking into an enormous grotto, at the bottom of which lay a pool filled with red liquid. Sometimes water came splashing in from the right, as if from a huge hose. I had never seen anything like it, for the walls of this grotto were so obviously alive, made of living tissue. Along the edges of the pool, above the red surface, the walls were ragged. Behind the innermost wall, seeming to swell out slightly, like a balloon about to burst, I glimpsed something purple.
In August, the novelist Karl Ove Knausgaard traveled to Albania to observe an awake craniotomy, the surgical procedure by which brain tumors are removed from conscious patients.
December 30, 2015. Photo by Paolo Pellegrin/Magnum, for The New York Times.
When I stepped aside to make room for Marsh again, I struggled to unite the two perspectives; it felt as if I were on two different levels of reality at the same time, as when I walked in my sleep, and dream and reality struggled for ascendancy. I had looked into a room, unlike any other, and when I lifted my gaze, that room was inside Hasanaj’s brain, who lay staring straight ahead under the drape in the larger room, filled with doctors and nurses and machines and equipment, and beyond that room there was an even larger room, warm and dusty and made of asphalt and concrete, beneath a chain of green mountains and a blue sky.
All those rooms were gathered in my own brain, which looked exactly like Hasanaj’s, a wet, gleaming, walnutlike lump, composed of 100 billion brain cells so tiny and so myriad they could only be compared to the stars of a galaxy. And yet what they formed was flesh, and the processes they harbored were simple and primitive, regulated by various chemical substances and powered by electricity. How could it contain these images of the world? How could thoughts arise within this hunk of flesh?
Marsh stopped and brought out the stimulator again and inserted it into the hole.
Dashi said something to Hasanaj, who replied briefly.
“Nothing,” Dashi said.
Marsh stimulated the bottom again.
“Left arm, face.”
“Left arm and face?”
“Then we’ll stop here.”
Marsh took a few steps back, and the microscope was wheeled away. His eyes, the only part of his face I could see, looked happy.
Xhumari and Petrela took over, and Marsh, after telling Hasanaj that the operation had been successful, left the operating room.
I went over to Hasanaj and bent down to him. He looked tired, his eyes were narrow, his face expressionless.
“How do you feel?” I asked.
Hasanaj smiled and raised his thumb.
Dashi laughed. His back was completely wet with sweat.
After the operation, which lasted nearly three hours, we drove to a park just outside the city center, where there was a rustic restaurant built of brown-stained timber, with waiters dressed in traditional costumes, where we had lunch. The temperature was 95 degrees, the cicadas were singing, all the greenery surrounding us was lit up by the golden rays of the blazing sun. Everyone was in a good mood, especially Marsh. There was a new levity about him, and he seemed more open. Not that he seemed closed before, but the shadow that I had sensed in him was gone.
I was happy, too. The sight of the mountains behind the city, so green and haughty, lifted my spirits, and the sight of the brain, its physiological aspect — the ragged edges of skull within which it had pulsated, the streaming red blood — was also pleasant to think about, for the bright colors within connected the landscape of the brain to the grass that grew beneath the veranda we were sitting on and the trees rustling faintly and nearly inaudibly in the breeze, and what that brain contained, all those images and thoughts that could never be separated from their material state, connected it nonetheless to the city beneath us, so full of dreams, longings, hopes and imaginings.
That the same city was also full of illness and want, tragedy and death, was something I didn’t stop to consider, nor the fact that the brains I had seen had been diseased. The operation had been successful, the tension had been released. All I could see was life and the living.
The next morning we went on an excursion to the port of Durres and to Berat, a town in the mountains. Even though we had spent only three days together, it seemed as if we had known each other for years. Marsh explained the architecture of the brain to me, and the way it functioned. He explained how they reached tumors that were lodged deep in the brain, which is, very loosely speaking, crumpled up like a sheet of paper, and therefore full of folds and ravines that you can push aside and move through. There are also so-called silent areas, which could be cut without damaging any of the brain’s functions. He told me about times when things had gone wrong, and the patient had died on the operating table in front of him. “I have killed people,” he said.
He told me about difficult operations that had succeeded and about the euphoria they produced. He said that 50 percent of surgery was visual, what you saw, and 50 percent was tactile, what you could touch. He said that brain surgery was a craft. To become good at it, you had to practice and sometimes make mistakes, in a profession where mistakes were fatal and impermissible. If your child has a brain tumor, you want the best surgeon. But to become the best, which is merely a question of gaining experience, you must first have operated on children without having experience, and what do you tell the parents then? That their child is important to the future of the young and as-yet-untested neurosurgeon?
He talked for a while about the particularities of operating on children. The tissues are soft and beautiful, very different from those of older people. A child is as fresh and clean on the inside as on the outside. But the problem with blood loss is very great; they can lose a life-threatening amount of blood very quickly. And the desperate anxiety of the parents is a heavy burden to carry. But for the children themselves, it’s easy. If they’re not in pain, they’re happy. They don’t have any existential perspective. He talked about his father, who was a law professor at Oxford University, and about his mother, who came to Britain as a refugee from Nazi Germany before the war, and how they both helped form what is now Amnesty International. He talked about his youth, about how shy he was, how he sat at home reading books when everyone else went out, how he never went to nightclubs, never spent time with girls. He told me about a breakdown he had as a young man, when he fell into a deep depression and spent some time in the psychiatric ward of a hospital. He told me he wrote poetry at that time, inspired by Sylvia Plath. He told me that the medical profession he had chosen seemed safe to him, something to buoy him. He told me about his relationship to his siblings and to his own children. “I competed with my children,” he said, grimacing at the recollection. “Can you imagine? I always wanted to show them how clever I was. That’s one of the worst things you can do to children.” He told me how his first marriage ended, and what his present marriage was like.
He was entirely open but not confessional; it was more that all our conversations seemed to lead to more serious matters, almost regardless of where they began, perhaps because the situations that gave rise to them were so concentrated and involved life and death, and because the places where they occurred were closed to us in a way, amid an alien culture, and yet in another sense, so open: Sitting on a terrace on the seventh floor, surrounded by dark blue sea extending in all directions, glittering in the sunlight, a few tiny people wading through the green shallows, maybe 50 yards out, the slightly lighter blue sky arching above us. Standing in an old Orthodox stone church in the mountains, in front of a row of icons on the wall, in radiant colors, gold, red, blue, beneath a dome with three circular holes that the light sifted down through. Sitting in a car whizzing through the darkness of the Albanian countryside after a long day in the sun. Walking through the heart of Tirana one afternoon, in small, narrow streets that lay in deep silence, past dilapidated houses and walls, with improvised electrical wiring, makeshift home extensions and dirty children playing in back alleys, just a few hundred yards from the main boulevards. Several times, when he mentioned something private, I reminded him that I was going to write about him. “You do realize that I might write about what you just told me?” He just smiled and said that was his strategy: The more personal he got, the more likely it was that I would like him and therefore write favorably about him.
The only time I saw Marsh angry was on the morning before the second operation. He had planned on seeing the patient, only to be informed by Petrela that she was already in the operating room and was having her head cut open.
“Damn,” he said loudly, stamping his foot and striking out at the air with his hand.
“You could see her tomorrow morning, before the operation,” Petrela said.
“O.K., that’ll have to do,” Marsh said calmly, but his eyes were still angry. Instead, he and Petrela went to see how Hasanaj was doing. I came along. Petrela pushed the button by the elevator at the end of the corridor and told us that when the king died, or rather, the king’s son, his heir apparent, the body had been brought to this hospital, and when it was taken out again, they had used this elevator. The elevator stopped between two floors, with the dead king inside, and it took them two hours to restart it.
The doors opened, and we got in.
“It’s one thing to get stuck in an elevator with a corpse,” Marsh said. “Quite another when the corpse belongs to the king.”
Hasanaj was alone in a room on the third floor, sitting half upright in bed, supported by pillows, with the entire upper part of his head swathed in bandages. His face lit up when he saw Marsh and Petrela. But there was something faintly grotesque about his smile, because one side of his face was paralyzed, and his mouth seemed to droop a little, so that it was more like a grimace than a smile. Marsh told him that he had a temporary weakness on one side, that this was quite normal, and that it would get better quickly. Hasanaj nodded, he understood, and he made the grimace again, and laughed feebly, with eyes that shone.
I met the second patient the next day. Her name was Gjinovefa Merxira, and she was 21. She grew up in Burrel, a small town of 15,000 in northern Albania, and moved to Tirana to study medicine, she told me, lying in a hospital bed. Her eyes were brown, her face was broad, her features were pure and young. I asked her to tell me about her very first seizure. She said she had her first fit when she was 7. It was wintertime, she was ice-skating with her friends, and she collapsed. She saw her friends as if through a fog. When she got home, she didn’t recognize her mother. She looked straight at her mother, and she didn’t recognize her. Her mother asked, “Why are you staring at me?” and Merxira said she wasn’t staring at her, and then she began to cry. She was 7, and she had a terrible headache, but no one thought that anything was seriously wrong with her.
She had fits like that once or twice a year. One time, when she was watching TV, the letters of the subtitles began to move out of the TV and into the room where she was sitting. Another time she saw a fire in a garden, a big fire, and she was about to cry for help when it vanished. With these fits came headaches, nightmares, occasional numbness. Sometimes every noise sounded like the chiming of bells. Because the fits were always of the same intensity and occurred seldom but regularly, she didn’t think it was anything serious. She didn’t see a doctor until after an incident that happened when she was 17. She was taking a math exam at school and saw flowers instead of numbers. She started to cry. She wanted to do well at her exam, but she couldn’t do the calculations, because all she could see were flowers, in black and white. That’s when she visited the hospital. They examined her, but found nothing, gave her medication for her fits and sent her home.
In November 2014, she was sitting at a cafe in Tirana with some friends and saw things floating above the table. When she got home, she couldn’t see anything on her left side, and her friends, who were very worried for her, took her to the hospital. As for her, she was calm; she knew that it would pass. This time the doctors discovered what was wrong: She had a tumor in the vision center in the brain. A decision was made to operate, but not until August, and the operation would be carried out by Henry Marsh, who now, this morning, finally stopped in front of her bed in the patients’ ward on the third floor of the hospital in Tirana.
Her head was bandaged, after her skull had been opened the previous evening, and she stared at Marsh with young, frightened eyes.
He told her more or less the same thing that he told Hasanaj: that he had carried out this operation more than 400 times; that it was practically harmless; and that she was going to be awake because it was safer, but he was a little more detailed with Merxira than with Hasanaj, presumably because she was studying medicine and therefore more familiar with what was going to happen. Maybe that is also why she seemed more afraid.
A doctor maps a tumor in the brain of Gjinovefa Merxira before her surgery. Paolo Pellegrin/Magnum, for The New York Times
When I saw her again a few hours later, with her head fixed in the clamp in the operating room, the anxiety was still there, in her eyes. She seemed to sense everything that was in the room, as if she had a relation to all of it, whereas with Hasanaj, it seemed that he held back from any encounter, that he just submitted passively to everything and made up his mind to endure it until it was all over. Pellegrin’s shooting of Hasanaj’s operation had been almost unnoticeable, just a part of all the other movements in the room, but now, because of Merxira’s vulnerability, I was increasingly aware of the camera and the flash.
The doctors attached the plastic drapes to a stand, so that her head lay beneath a small tent and the lower part of her skull was covered while the upper part was bare.
“At operations in London, the drapes are transparent,” Marsh said, “so that the surgeon can see the patient all the time.”
When her head had been swabbed and the injections of local anesthetic administered, the assistant surgeon, Arsen Seferi, began to remove the stitches. Merxira lifted her arm to her eyes and let out a low, long moan.
Dashi spoke to her, and she answered, then fell silent again.
Seferi laid the scalpel aside and began to remove the clips that ran around the skull. Soon the lid of the skull was put aside, the meninges were cut open and the brain was exposed. From a distance, the bloodstained gauze that wreathed the skull resembled flowers.
Marsh went over and studied the brain.
“Just as I thought. The surface looks normal. The tumor is underneath.” A nurse handed him a mapping device, which Marsh and the others called a GPS, and he moved it slowly over the brain while he examined the image that appeared on a monitor.
After a while he switched instruments. Now he pressed the electrical stimulator against the surface of the brain. It buzzed briefly. Dashi spoke with Merxira and said something to Marsh. He stimulated the brain again. The same electric buzz sounded. Dashi spoke again, and Marsh began to operate.
“We should feel a rubbery tumor shortly,” he said.
“Aah,” Merxira moaned.
I looked at her. She pressed her arm against her eyes again.
“We were being misled by the GPS,” Marsh said. “Oh. Here it is!”
“If you trust the GPS too much, you could end up in the cemetery,” Petrela said to me in a low voice.
“Here, you can see,” Marsh said, waving me over. “Do you see the difference?”
One area was more yellowish-gray than the other, but the difference was so subtle that I would never have noticed it if Marsh hadn’t pointed it out.
He continued hollowing out the affected area of the brain.
Suddenly there was almost a shout in the room.
“There’s no feeling in the brain,” Marsh said. “But what can hurt are the blood vessels, when they are moved or get bent. That’s what she is feeling. It can be a shocklike pain.”
He looked at Dashi.
“Is the pain bad?”
Dashi said something to Merxira, who answered him in a low voice.
“She can feel it, but it’s O.K.,” Dashi said.
A flash went off. I looked up. Pellegrin was crouching close to the wall, taking photos of the island of equipment, presumably with Merxira’s face visible beneath the green drape.
Marsh continued sucking out the tumor at the bottom of the hole. Merxira moaned. Being there was almost unbearable.
“You don’t want to damage that,” Marsh said and let me look at a blood vessel in the microscope, blue amid the folds of the brain. “If that is damaged, the blood can’t leave the head, and the brain will fill with blood.”
“How far away is it from the tumor?” I asked.
“Oh, one or two millimeters,” Marsh said.
He went on with the operation, assisted by Petrela, who squirted water on the surface. Dashi spoke with Merxira at regular intervals, asking her to look at a special eye chart and assessing Marsh’s progress based on her responses.
Marsh removed a whole piece of the tumor, which the nurse placed in a dish.
Aside from the even whisper of the sucker, the operating room had become completely silent. Marsh worked concentratedly. Only his hands were moving.
Dashi held the paper in front of Merxira again.
“Slight blurring of vision on the left,” he said.
He lifted his head from the microscope and looked at me. “You stop when you start getting more anxious,” he said. “That’s experience.”
He bent down to Merxira and said that the operation had been successful, that everything had gone the way it was supposed to.
I hadn’t dared to speak to her during the operation. But now I went over. I wanted to ask her how she was doing, but when I saw her lying there, with her hand shielding her eyes, I said instead, in a thick voice, “You were very brave.”
Afterward, when I took off the disposable gown, the face mask and the cap on the ground floor, I felt shaky.
“Oh, man,” Pellegrin said. “It was like her mind occupied the room.”
Later that day, I went to the National Art Gallery and looked at the paintings from the Communist Era. They were hanging in two large galleries, and during the hour I spent in there, I didn’t see a single person. Occasionally I heard some children playing on the lawn outside, their shouts and laughter rose up above the even, distant hum of the city. Many of the paintings showed people at work. In one of them, what appeared to be an enormous radio tower was being hoisted into place in a barren, mountainous landscape bustling with activity, while a woman, clearly an engineer, studied some drawings and a man pointed ahead. A nation was being built; a new world was being created.
In Norway in the 1970s, Albania was considered a pioneering country by the young intellectuals. A sort of utopia, a land of the future, the ideal we should be striving toward. When I mentioned this to Petrela at our first dinner, he laid his head in his hands.
“But that was just a lie,” he said. “It was all a lie. How could they have believed it?”
“I don’t know,” I said then. But when I saw the paintings in the museum, I felt the pull from them.
The painting I looked at the longest portrayed a young, modern family. The father carried a child on his shoulders, the mother had a satchel in her hand, another child was running ahead of them. They were moving through a landscape of mountains and valleys, the grass was green, bordering on pastel, the sky was light, far up above them a helicopter hung suspended. Everyone was smiling, the adults and the children. They were headed for the future, full of joy and hope.
Everything was clear, pure, simple and forceful.
Why couldn’t the world look like that?
What was so wrong with these paintings? What was wrong with the world they portrayed?
When I came out onto the street again, the sun hung low in the sky, and the previously limpid air had dulled a little. It was faintly hazy, the way it gets in the hour before dusk. The cars on the avenue in front of me were waiting for the green light. An old, crooked woman walked between them, supporting herself on a crutch, a cup in her hand. She knocked on the window of one of the cars. Two women were sitting inside, both of them turned their heads and looked the other way, the way people have always averted their eyes from beggars. I walked into a park, toward a large complex of restaurants that lay in front of a shallow but wide pool, blue, with peeling paint. The Chinese had built the complex, Fejzo had said, and it was known locally as “Taiwan.”
I sat down in one of the few empty chairs outside and looked at people, speculating about the relationships they had to one another and to the world.
I had always considered my thoughts as something abstract, but they weren’t; they were as material as the heart beating in my chest. The same was true of the mind, the soul, the personality; all of it was fixed in the cells and originated as a result of the various ways in which these cells reacted with one another. All of our systems, too — communism, capitalism, religion, science — they also originated in electrochemical currents flowing through this three-pound lump of flesh encased in the skull.
All of which was saying nothing. It was like examining a stone in the foundation wall to find the answer to the secret of St. Peter’s Basilica.
That was all just a lie, Petrela had said about Albanian Communism.
But what wasn’t?
I had asked Marsh if he believed in God, in a life beyond death. He just shook his head. “This is it,” he said.
We use systems to keep the wolf from the door, I thought. And systems are nothing but vast complexes of notions and concepts. Everything that helps us lose sight of the petty, pathetic and meaningless parts of our own selves. That is the wolf. The awkward, twisted or stupid part of the soul, the grudges and the envy, the hopelessness and the darkness, the childish joy and the unmanageable desire. The wolf is the part of human nature that the systems have no room for, the aspect of reality that our ideas, the firmament that the brain vaults above our lives, cannot fathom. The wolf is the truth.
So why would Marsh want to keep the wolf from the door? Seen from the outside, it seemed that the role of surgeon had provided him with a larger context in which he could excel and rule over life and death, where there was no place for whatever was small and insecure in him. The role of surgeon gave meaning to his life, lifted the meaning outside of himself, into a system — it kept the wolf from the door. At the same time, that role revealed the meaninglessness of it all. Tumors grew randomly, people died randomly, every day, everywhere. You could choose to keep this from sight behind numbers, behind statistics, behind the plastic drapes that made the patients faceless. His greatness was that he didn’t hide the smallness but instead used his insight into it to fight against everything that concealed it, the institutionalization of hospitals, the dehumanization of patients, all the rituals established by the medical profession to create distance and to turn the body into something abstract, general, a part of a system.
Fejzo had told me a story he heard in London. Marsh had not mentioned it in his book, and as far as Fejzo knew, Marsh had never spoken about it — it was one of his colleagues who had told Fejzo. Marsh had operated on an infant, only a few months old, and the operation went badly; the child died on the operating table. Marsh went in to see the parents in person. He told them that he had made a mistake, and that their child had died. He cried with them. “No doctor does that,” Fejzo had said. “No one.”
It began to get dark around me. A man came pushing a stroller between the tables. A boy was sitting in it; he might have been a year and a half, and when the father sat down at a table, the boy stretched his hands out to him. The father loosened his straps, lifted him out and set him on his lap. He fooled around with him for a while, and the boy laughed.
That, too, was the truth.
Then the father lit a cigarette, took out his cellphone and began texting. The boy protested against the sudden lack of attention, and the father handed him the pack of cigarettes, which he happily began to play with, while the moon slowly rose over the rooftops, bright yellow against the blue-black sky.