Fairness Which Strikes the Eye

Sometimes it seems we cannot help ourselves –the pull of the tide is just too strong to resist. And sometimes an argument, when considered too quickly, too uncritically, captures us with its ostensibly intuitive wisdom. We have no need to question it. No need to probe the basis of its logic.

The rhetoricians of old were well versed in this form of argument –the art of persuasion and how to best achieve it. Aristotle, for example, suggested three essential features of a convincing argument: ethos –the credibility of the contention; pathos –understanding the needs and emotions of the audience; and logos –the patterns of reasoning and the words chosen. His wisdom, although modified and woven into the contemporary tapestry, has not been lost in modern times.

What could provoke a greater sense of outrage in a population than the 1% contention? That is to say, in at least one of the iterations fostered by the Occupy Movement, that in the United States, 1% of the population controls 40% of the wealth. And to many, that unequal distribution of wealth, is symptomatic of what is wrong with Capitalism. It certainly resonates with those of us in the 99% who hear it. It begs for remonstrance; it demands rectification.

And yet there are usually many sides to a story –or at least this one, at any rate. There are times  when we need to move back a step or two in order to appreciate the different perspectives. Even so, I have to admit that an article in the BBC Future series came as an intriguing surprise: http://www.bbc.com/future/story/20170706-theres-a-problem-with-the-way-we-define-inequality It allowed me to entertain an alternative that I had not even considered.

As they tease at the beginning, ‘Some researchers argue that income disparity itself may not be the main problem. The issue, they say, is not the existence of a gap between rich and poor, but the existence of unfairness. Some people are treated preferentially and others unjustly – and acknowledging that both poverty and unfairness are related may be the challenge that matters more […] While many people may already view inequality as unfairness, making the distinction much clearer is important.’

They go on to say that ‘In a paper published in April in the journal Nature Human Behaviour called ‘Why people prefer unequal societies’, a team of researchers from Yale University argue that humans – even as young children and babies – actually prefer living in a world in which inequality exists. […] Because if people find themselves in a situation where everyone is equal, studies suggest that many become angry or bitter if people who work hard aren’t rewarded, or if slackers are over-rewarded.

‘“We argue that the public perception of wealth inequality itself being aversive to most people is incorrect, and that instead, what people are truly concerned about is unfairness,” says Christina Starmans, a psychology post-doc at Yale who worked on the paper.

“In the present-day US, and much of the world, these two issues are confounded, because there is so much inequality that the assumption is that it must be unfair. But this has led to an incorrect focus on wealth inequality itself as the problem that needs addressing, rather than the more central issue of fairness.” And as Mark Sheskin, one of the co-authors remarks, ‘“People typically prefer fair inequality to unfair equality”’.

In a way, a lot of the argument hinges on definitions. There are, after all, several ways to look at inequality: equality of opportunity, equality of distribution of benefits, and of course, equality of outcome. Must all of them be addressed, or is there a priority? Is the existence of a super-rich 1% the problem, or would it be more helpful ‘ to concentrate more on helping those less fortunate, who via a lack of fairness, are unable to improve their situation’?

‘Harry G Frankfurt is a professor emeritus of philosophy at Princeton University. In his book On Inequality, he argues that the moral obligation should be on eliminating poverty, not achieving equality, and striving to make sure everyone has the means to lead a good life.’ Poverty, in other words, is the problem; it is unfair…

I suppose, when considered practically, it would be unrealistic and unduly Utopian, to think that we could ever dispense with at least some degree of income disparity. People ‘don’t typically work, create or strive without the motivation to do so’. It seems to me that the unfairness does not lie in the money fairly accumulated for work done, so much as in the fact that ‘not everyone is afforded the same opportunities to succeed, even if they put in that hard work.’

But, on the other hand, it’s not all simply a matter of the equality of opportunity, nor even of equality, per se. Fairness is something different. The issue of fairness is in a different Magisterium altogether. I’m Canadian, and I believe that no one should have to live in poverty. Not everyone has the skills, or indeed, the capacity to hold a job, even if an opportunity presents itself. Some are disadvantaged by appearance, or gender; some are discriminated against by virtue of their origins, or life-style; some, even, have succumbed to past failures and have given up trying… It is unfair to give up on them –any of them- simply because of the lotteries of birth or circumstance.

Fairness, it seems to me, is universally available and accessible health care. It is a living wage that allows even the poorest to feed their family. It is safe and obtainable shelter. It is the respect afforded even to those we do not understand. It is toleration of difference, even when the rest of us may not understand, or agree with it.

It seems to me that inequality, by itself, is not what drives revolutions. Inequality is not what causes societies to weaken and their moral fabric to unweave. Inequality is just the chipped and discoloured veneer most easily visible on the surface. What festers directly underneath, sometimes only detectable when the surface weakens or is pulled asunder, is inequity. Injustice. Unfairness… Poverty, unlike wealth, offers little protection. And that is the iniquitous thing.

For some reason, I’m reminded of Shakespeare’s King Lear: Through tattered clothes great vices do appear; Robes and furred gowns hide all. Plate sin with gold and the strong lance of justice hurtless breaks. Arm it in rags, a pigmy’s straw does pierce it.

Prove me wrong…


Sweet Flowers are Slow



It never ceases to amaze me what unfettered minds can discover. Sometimes I wonder how they do it. How they set out 180 degrees from the target and still end up hitting it. Of course, the world is full of answers scattered like flowers in a field, in plain sight for anybody who has learned to see them. It’s not the answers that are hidden, just the appropriate questions. But maybe that’s the point –questions are often like detours pointing away from where you think you want to go, and yet arrive you do, having learned unexpected things along the way –Frost’s Road not Taken.

Socrates, although he initially disavowed the Delphic Oracle’s apocryphal pronouncement that he was the wisest man in Athens, knew that Truth, like Wisdom, was slippery. He realized he didn’t possess all the truth and so he asked many questions, whereas others -those who never thought to investigate- were complacent about their knowledge, unpuzzled by what they experienced, content with their grasp, however tenuous.

Maybe that’s just the way we’ve been taught to interrogate reality, though: if A equals C, and B also equals C, then we need look no further –A, B and C are equivalent, or at least interchangeable and otherwise individually uninteresting. Perhaps it takes a Socrates to ask why that is –or at least why we are satisfied with our assessment.

An article in the BBC News about an unusual approach to decreasing the spread of malaria brought this to mind: http://www.bbc.com/news/health-40495958  While researchers are trying desperately to engineer a vaccine, there have been many interesting attempts to ameliorate the prevalence of the disease. Some are relatively high tech –like genetically altering mosquitoes to produce genes to prevent the development of the malarial parasite within themselves and therefore stop its transmission to people when they bite; some are more humble methods, more attainable in the short term -such as pyrethroid-treated mosquito netting around beds. I suppose the boundaries between discovery and invention are fluid, but even so, either of them can lead to uncharted territories. New possibilities.

Still, until we do have an effective and safe vaccine, we need to use as many other methods to decrease the ravages of the female Anopheles mosquito as possible –however indirectly they may achieve this. Sometimes you just have to try stuff. Sometimes, you have to think inside the garden.

‘Gardening could be a powerful weapon against malaria, culling mosquito populations by cutting off their food supply, say researchers.’ The idea is to starve the mosquitoes before they get a chance to pass on the malarial parasite. A pilot project in Mali, West Africa, found that ‘Removing flowers from a common shrub appeared to kill off lots of the older, adult, female, biting insects that transmit malaria. Without enough nectar the “granny” mosquitoes starve, experts believe.

‘These Anopheles mosquitoes carry the malaria parasite in their salivary glands and pass it on to people when they bite and draw blood. The infected person can then infect other younger, biting, female mosquitoes – which are looking for a rich blood meal as they become fertile and make eggs – because their blood now contains the parasite. It takes about 10 days for a newly infected young female mosquito to become contagious to humans. By the time she can transmit malaria, she’s pretty old. Although she will feed on blood, she also relies on flower nectar for energy to stay alive.’

So, ‘Experts in Mali, along with researchers from the Hebrew University of Hadassah Medical School, Israel, and the University of Miami in the US, set up a horticultural experiment to see if removing the flowers from this plant might help kill off local mosquitoes. […]Villages where they removed the flowers saw mosquito numbers collected in the traps fall – the total number of mosquitoes across these villages decreased by nearly 60% after removal of the flowers.’

Admittedly, as the researchers concede, although it was an appropriate technique in a place like Mali, ‘it might not work so well in lush tropical regions where nectar-rich plants are in abundance.’

I suppose one of the reasons why this approach intrigued me so much, was that it seemed like a rather simple –albeit laborious- technique for mosquito control. Much like removing standing water that has collected in puddles or old tires where the mosquitoes can lay their eggs, it could be a community-led project that requires no additional external resources. But even more than that, as Professor Jo Lines, from the London School of Hygiene and Tropical Medicine, has observed, ‘”It appears to show that by changing the landscape, not using insecticides or drugs, we can make a difference.”’

What a thought –changing, not destroying something to achieve an aim. Being clever and asking the right questions about what was already in front of the eyes of anyone inquisitive enough to actually notice. Curious enough to ask ‘what if…?’

So, back to Socrates who, in the end, conceded that perhaps the Delphic Oracle had been right all along about him being the wisest man in Athens. He was still searching for knowledge, still questioning the completeness of what others had already decided was necessary for them to understand. He was still unprepared to pretend that he knew something he didn’t. To the end, he refused to accept that there weren’t always more questions to ask.

After all, it’s not what you look at that matters, it’s what you see; it’s not what you hear, so much as what you understand… The rest, as Hamlet said, is silence.

The Tales We Write in Water

We are all stories, aren’t we? Largely untold, and seldom transcribed, we travel through our lives like cups filled to overflowing, spilling drops like patterns on a dirty tablecloth. It’s often not so much a reticence that keeps our information bottled up, as opportunity to share it. It’s why, I suppose, there is such a need for counsellors. Therapists. Ears, not just to hear what we feel is important to us, but to listen. Someone to understand our need for time on the pedestal…

Diaries do that as well, albeit with little feedback unless they are publicized. No feedback in fact if they are left unattended and unnoticed in a drawer somewhere for fear of discovery -disclosure of inner secrets too personal to admit, embarrassing moments too painful to discuss, dreams we fear are out of reach. And yet the very act of writing them down may not be wasted: http://www.bbc.com/future/story/20170601-can-writing-about-pain-make-you-heal-faster

Okay, I don’t really buy the premise of the article suggesting there may be something immunologically regenerating about writing, that healing occurs faster, or that there may be beneficial effects on health in general –and yet I readily admit that, as a sometime writer myself, it intrigues me. I’ve always thought about it in terms of catharsis, but now I’m not so sure. In 1986, a psychology professor named James Pennebaker asked his students to ‘spend 15 minutes writing about the biggest trauma of their lives or, if they hadn’t experienced a trauma, their most difficult time’. Six months later, he discovered that this seemed to have had an effect on their general health as measured by fewer visits by them to the health center. A bit tenuous, it seems to me, but it was his subsequent analysis that interested me more.

‘What does the act of committing words to paper do? Initially it was assumed this simply happened through catharsis, that people felt better because they’d let out their pent-up feelings. But then Pennebaker began looking in detail at the language people used in their writing. He found that the types of words people used changed over the course of the four sessions.’ The students ‘[…] began by using the word “I” a lot, but in later sessions moved on to saying “he” or “she” more often, suggesting they were looking at the event from other perspectives. They also used words like “because”, implying they were making sense of the events and putting them into a narrative.’

The perspective change that evolved in their writing is fascinating. As I write this, I’m reminded of a fragment of a poem by Robert Burns (To a Louse, On Seeing One on a Lady’s Bonnet at Church): ‘O wad some Power the giftie gie us to see oursels as ithers see us!’… But, come to think of it, isn’t this very non sequitur an example of how the act of putting down words unlocks unexpected doors? Could writing be the Power to which Burns was referring…?

Well, perhaps that’s a bit of a stretch, I’ll admit, and yet…

I had travelled into town to buy a piece of technological kit at a store in a huge mall in the center of the city, when I suddenly felt overwhelmed by the noise, the movement, and even the smell of the thronging crowd flowing over and around me like a debris-strewn river. I wanted to sit down somewhere, but it was lunch time and all the benches were full, so I headed outside to a little dog park I’d noticed on the way in. Even there the pews were occupied, although admittedly, not by dogs, but people eating fast food out of wax-paper wrappers. I felt a bit nauseated and I didn’t think I could handle sitting beside one of them, so I chose a seat beside a young woman who had eschewed her stomach for a little notepad on which she was furiously scribbling. A thin woman, with short blond hair and a blue business dress, I thought at first she was just catching up on office work; the fact that there was neither a laptop nor a phone in evidence, seemed only passing strange. Her face, young and unblemished, was somewhere else – certainly not here, despite the soft breeze that rustled the leaves, and the sound of birds flitting from branch to branch above our heads. But she looked happy. Content. Absorbed…

It was pleasant sitting outside, and the trees that ringed the tiny urban meadow seemed to keep the more annoying attacks of traffic noise at bay. After a while I became aware of something I hadn’t heard since I was at school, I think: the sound of pencil hurriedly scraping across paper. There was something atavistically soothing about it –something that brought back childhood memories: the sound of walking on fallen autumn leaves maybe, or the soft hiss of bacon that my mother was frying in the kitchen… Sounds totally unlike what I was hearing, to be sure, and yet compelling. Comforting.

In my reverie, I’m afraid I began to stare at her –or rather, at the notebook on her lap. Eyes, when left unleashed do things that are hard to explain. Hard to justify. And because of my unsolicited proximity to her on the otherwise crowded bench, she noticed. At first it was a scowl that tried to shoo my eyes, if not my very presence away, but then, seeing my embarrassed smile at being caught in flagrante delicto as it were, she smiled.

“Just writing down some thoughts,” she said glancing at her watch and then carefully closing up the notebook as if it were a bible.

In some way exculpated by her words, my face relaxed.

“Sometimes I just have to write them down before my office thoughts take over,” she added, shrugging contentedly as she stood to leave. “Helps me cope somehow…”

I saw her walk away along the wide gravel path, stopping from time to time to stare up into the trees, oblivious, it seemed, to the city that roared around her. And as I watched, I have to admit, so was I.

Living the Lie

I’ve been living a lie all these years it would seem. I always thought it was okay to like some things and not others. Some people, and not their friends… All my life I’ve wandered between likes and dislikes like a child in a supermarket, never wedded to a particular product, always willing to abandon a favourite for another on the shelf –catholic in my tastes, philosophical in my choice. Never absolute in my dismissal, ever willing to reconsider, I felt that it was my duty –my privilege- to sample from every counter. How else to explore the Umwelt?

But I have finally been unmasked it seems; no longer can I plead ambivalence. Capriciousness is not an option. My protean worldview is not seen as versatility. Apparently, it doesn’t even qualify as adaptive. Unbeknownst to me, it is a manifestation of implicit bias. It is part of a pandemic. http://www.bbc.com/news/magazine-40124781

It would seem that explicit bias has been falling over the years  –at least until the populist movements have re-emerged Phoenix-like in Europe and the USA- but ‘implicit bias – bias that we harbour unintentionally – is much stickier, much more difficult to eradicate. At least that’s the claim.’ Testing for this has become popular with many firms. ‘Jules Holroyd, an expert in implicit bias at Sheffield University, traces some of the test’s success to its providing an explanation “for why exclusion and discrimination of various forms persist. And that explanation,” she adds, “is really appealing since it doesn’t need to attribute ill-will or animosity to the people who are implicated in such exclusion.”’

I have to say, though, that in my case it is certainly subtle –a shadow that follows silently in my footsteps. And, like my conscience, I suppose, I only really know it’s there if I look. The BBC article describes a test –the Implicit Association Test (IAT)- that purports to unearth it. Exhume it, if you will. It’s one of those psychologically clever tests that almost tachistoscopically presents images and words to discover what it is you actually associate with what… They offer the ability to do the test online, but I wasn’t able to figure out the words and pictures fast enough, so I gave up.

And, thank goodness for my peace of mind, the IAT –ubiquitous as it appears to be- has its problems. Replicability seems key: ‘One reason for this is that your score seems to be sensitive to circumstances in which you take it. It’s possible that your result will depend on whether you take the test before – or after – a hearty lunch.’ But, ‘More fundamentally, there appears to a very tenuous relationship between the IAT and behaviour.’

There are many manifestations of implicit bias, I’m sure. And many ways to detect it as well. The owners of CVs with Caucasian-sounding names seem to get more jobs. So do male versus female names. Or how about cultural stereotypes? ‘The claim that most of us suffer from various forms of implicit bias is all of a piece with the explosion of research into the irrationality of our reasoning, decisions and beliefs. We are not the cogent, systematic and logical creatures we might like to assume.’

Mea Culpa. I don’t normally pick up hitchhikers. I don’t think it’s usually because I don’t trust them –it’s sometimes because I’ve been shopping and the seats are bag-laden, or I don’t see them in time to stop safely. More often, though, it’s because I just don’t feel like it.

I was driving across Canada a few years ago, and one stormy evening on my way to a little prairie town where I hoped to spend the night I saw a bedraggled figure on the side of a lonely stretch of the highway. I couldn’t see very clearly in the driving rain, but it did have its thumb out so I stopped. The road was empty and I hadn’t even seen a car going in either direction for a long time. For that matter I hadn’t seen any buildings or other roads either; I wondered where the poor soul had come from.

The figure, still in rain-drenched shadows, was wearing a dark sodden hoodie and torn jeans when it came up to my window and smiled. I unlocked the door and smiled back as the stranger climbed into the car.

“Gee, thanks mister,” an unmistakably older female voice said from somewhere inside the hood. “Been standing there for almost an hour…” She wiped the moisture off her face with her even wetter sleeve and stared out the front windshield, smiling at nothing in particular. “Couple of cars passed me a while back, but they didn’t even slow down…” she continued in a matter-of-fact voice that seemed to betray no resentment.

“The place I picked you up seems a long way from anywhere,” I said, curious as to why she’d been standing there.

She shrugged. “My man and I live in a cabin further in from the road,” she responded, still staring out of the window. “There’s a little path…” she added, sensing my unfamiliarity with the region. She turned her head and watched me struggling with the road for a moment. “Where you from?”

I glanced at her quickly –it was all the time I could spare- and smiled again. “West coast… Vancouver, I suppose.”

“Suppose?” She seemed amused at the uncertainty I had just exposed.

I shrugged and peered out between the frantic wipers. “We moved a lot when I was younger.”

She stared silently at the rain lashing the windshield for a while and then turned to me again. “I’ve lived here all my life. Many of my people left, but I stayed…” And with that, she resumed her contemplation of the rain.

“Your people…?” I didn’t mean to pry, but I was curious about someone standing on the side of the road at night in the rain, far from anywhere.

“I’m an Indian,” she said with a moist toss of her head to free her hair from the hoodie clinging so damply to her shoulders. “Sorry,” she added when she noticed she’d sprinkled water over the dashboard.

“Don’t be,” I responded with a chuckle and showed her the dust that had already accumulated from my trip.

We sat in silence for a few minutes again. “Why did you pick me up?” she suddenly said in a soft voice.

“Mmmh?” I wondered if I’d heard her properly.

“Nobody but my people usually pick me up…” She stared at me for a second or two, her face genuinely puzzled. “Don’t you think you were taking a risk?”

It was my turn to be puzzled. “You mean by picking up a person in a storm?”

She examined my face and frowned. “Nobody likes us around here. Nobody trusts us…” She thought about that for a few seconds. “Did you know what I was before you stopped?”

I have to admit I chuckled at her question. “A bedraggled person hitchhiking by themselves in the dark -far from anywhere? In the pounding rain…? Is there more I should know?”

Her face lightened and in the headlights of a lone car speeding the other way, I thought I could see a sparkle in her eyes as she nodded her head. “Yes,” she said. “I think there is…”

Surprised, I tore my eyes away from the road briefly and glanced at her -glanced at the hand she was moving slowly towards me.

“My name,” she said and giggled like a little girl.



















Eternal Maternal?

Some things are just not said, just not considered. They fall so far outside of our Weltanschauung they are inadmissible. And we take such comfort in their ubiquity that we no longer feel a need to discuss them. They are so self-evidently true, so axiomatic to our understanding of existence that they seem indispensable. Crucial… Even transcending the need for sentience.

Maternal instinct, for example -the irrevocable compulsion of a mother to protect her offspring even at the expense of her own safety. Characterized as selfless and incorruptible, it often escapes the genetic prison of species boundaries. It is one of those rare attributes that has such survival benefits that it blossomed under the rigorous pressures of evolution. It really is, at least in hominid terms, sacrosanct.

Or is it…? Sometimes there is a need for stepping back from the forever-yawning abyss of unquestioning acceptance. After all, what is instinct? Is it just an under-examined behaviour whose pervasiveness has convinced us of its Darwinian utility? Or is it something else –a hope, maybe? A tachistoscopic view of that which we would like to believe has survived the rigours of the collapse of Eden?

A rather obscure article in the Guardian newspaper –one of many, once I discovered it- attempts a more dispassionate analysis of the universality of maternal instinct: https://www.theguardian.com/commentisfree/2017/may/30/detach-myth-motherhood-from-reality-future-generations?CMP=share_btn_link

It’s addressing the expected attitude of the mother to her baby and the seemingly global societal requirement of her self-effacing altruism towards it –and usually the offspring of others, as well. It’s not attempting to comment on whether or not the woman chose to become a mother –or indeed, whether that might play a major role in her subsequent attitude towards the responsibilities involved. It’s more concerned with the fait accompli.

I have discussed the issues and deeply-rooted cultural assumptions around the decision whether or not to become pregnant in the first place in a separate essay in June 2015: To Have, or not to have ( https://musingsonwomenshealth.wordpress.com/2015/06/02/to-have-or-not-to-have/ ).

No, the Guardian article questions not so much the concept of maternal instinct, as its expanse –or perhaps more accurately, its inexhaustibility. Its sempiternity… ‘[…] maternal instinct is not a switch that exists in every woman, ready to be flipped as soon as she smells a baby. Relationships between mothers and their children are frequently far more fraught than the myth leads us to believe. It shocks us that mothers can be selfish. […]There is scientific evidence to suggest that the maternal instinct may even be contingent on a woman’s circumstances.’

In fairness, I suspect that the article may be a sort of authorial apologia: ‘I myself have had to face down questions from family, friends and even strangers who don’t understand my wish to have only one child. The thought of having more children terrifies me, and has nothing to do with the love I feel for my son. […] a similar argument can be made that maternal instinct may sometimes depend on whether a mother has the support she needs. We’re not a species designed to cope alone. Indeed, we’re at our most social when it comes to parenting, often recruiting many people around us to help. It really does take a village to raise a child. Without any help, it can be desperately tough.’

The author feels that the ‘reasons why women feel the way they do about children is under-studied’ and I certain agree. ‘[…]motherhood is not always an against-all-odds epitome of selfless caring. Sometimes it can involve emotional calculation, weighing the needs of both parent and child. We all assume that a mother always wants the best for her child, above her own needs. What we seem to deliberately ignore is that a child’s welfare can also depend heavily on the mother’s own needs being met.’

Near the end of her essay, I think she makes it clear why she felt it necessary to discuss the topic: ‘For the sake of both mothers and children, we need to begin detaching the myth of motherhood from the reality. It’s unfair of any society to expect women to be the best mothers they can be without economic or emotional support, just because they should love their children.’

I would like to think that as an obstetrician I am not a completely disinterested party in all this –although, of biological necessity, I approach the subject as a non-participant. And now, in retirement, perhaps even more so -I watch from the shadows, as it were, but I’m nonetheless attentive to the roiling milieu. It’s hard to ignore.

I was sitting in the corner of a coffee shop recently, enjoying the relative solitude, when two women sat down at the table next to mine.

“My daughter keeps foisting the kid on me whenever she wants to go out,” one of the women said to her friend.

Emily, you mean?” the friend said with a slow, disapproving shake of her head. “And Jacob…” It was obvious that she objected to a mother –not to mention a grandmother- talking about her family as if they were nameless burdens. Then her expression softened. “My Louise used to do that, I remember. She’d show up at the door unannounced and put Andrew in my arms…”

The first woman took a sip of her coffee and shrugged. “I suppose they all do it, eh Joyce?”

Joyce smiled at the thought. “I used to enjoy the challenge of working Andrew into my day.”

Joyce was a happy person I thought, as I tried to pretend I was reading my book, unaware of their presence. She was probably in her fifties, dressed casually in a grey sweatshirt and dark green track pants, and looking for all the world as if she was enjoying her life.

The woman beside me, however, was tense. I could hear the frustration in the timbre of her words.

“It’s just not fair, though,” she said to Joyce, her voice almost whining.

Joyce’s eyes twinkled even in the soft light of the corner where we sat. “Mothers have to have a break, Mary…”

“Break?” Mary interrupted angrily, “I never got a break, Joyce! I had to bring up two kids all by myself after Ralph left… By myself!”

I could almost feel the exclamation mark slamming onto the table in front of her.

It clearly upset Joyce, and I could see her taking a deep breath before responding. “Wouldn’t you have loved it if you’d had someone to leave them with every once in a while?” Her eyes were spotlights focussed on Mary’s face.

Mary shrugged again. “But I didn’t, Joyce… That’s the point.”

A tenderness suddenly appeared on Joyce’s face and she extinguished the angry glare as she  recalled her eyes. “But Emily does, Mary… And that’s the point,” she said, almost in a whisper.

I’d finished my coffee by that point, so I thought it might seem rude to continue to sit there and listen. But as I l pushed back the chair to leave, I couldn’t help but notice the smile that had finally surfaced on Mary’s face. And something deep inside me smiled, as well; the course of true love never did run smooth





A Plague on Both Your Houses

The plague –nothing conjures up death quite like that word -after all, the bubonic plague wiped out half of Europe in the 14th century. But there have been others of its ilk –and all probably caused by the Yersinia pestis bacterium. Although the yet-unnamed infectious agent was identified in the 1890ies by the bacteriologist Alexandre Yersin -working at the time in the Pasteur Institute on plague samples from an outbreak in Hong Kong- the name was initially misattributed… Never work for somebody really famous when you discover something important. Personally, I preferred its previous name of Pasteurella pestis because that’s the name I was first taught and I liked the alliteration. But never mind.

The plague has three different presentations, depending upon the organs infected: bubonic plague, from infection of the lymphatic system and localized as buboes (swellings of infected lymph nodes which may become necrotic and turn black in their attempt to defend the body); pneumonic plague –infection of the lungs, presumably from aerosolized droplets from coughing or the like; and the rarest and likely most fatal of the three, septicaemic plague, which is an infection of the blood stream. All are carried by fleas, which are carried by rats, which then carry them to us.

Although we tend to associate the word ‘plague’ with the infamous ‘Black Death’ of European fame -not least because of the shock value of its name, I suspect- there have been several plagues throughout history. The first was originally thought to have been as early as 430 BCE in Athens, but a study published in the journal Cell in 2015 suggests that it began long before that –about 5,353 years before, actually. But perhaps a more assimilable article that outlines the background is found in a BBC news report, also in 2015: http://www.bbc.com/news/health-34603116

‘Samples taken from the teeth of seven bodies contained traces of the bacterial infection in the Bronze Age. They also showed it had, at the time, been unable to cause the bubonic form of plague or spread through fleas – abilities it evolved later.’ You have to love this kind of information, eh?

‘In its early days, it could cause only septicaemic or pneumonic plague – which is nearly always deadly and would have been passed on by coughing. By analysing the bacterium’s genetic code through history, the researchers estimate it took until 1000 BC for plague to evolve into its more familiar form. One mutation – acquiring the ymt gene – allowed the bacterium to survive inside the hostile environment of a flea’s gut. […]Developing a separate gene, called pla, allowed the infection to penetrate different tissues and cause bubonic plague.’

But all things change, don’t they? Things fall apart; the centre cannot hold, in the unforgettable words of Yeats. And yet why would a pathogen evolve to destroy the very hosts on which it depends? Why burn the hotel…?

I suppose an easy explanation might be that of a game in which each side –host/pathogen- continually attempts to outsmart the other. More virulence in the invader leads to more defensive mechanisms in the invaded –things as overt as quarantine or antibiotics, to the more subtle, but hopefully preventative development of immune resources by vaccination or over the longer term, adaptation of endogenous immune defenses: survival of the fittest.

But for me, the intriguingly unanswered question still remains: why kill your host? Why not coexist as, say, a parasite –or even a commensal- in the gut, or create a chronic condition that might weaken the owners, but not eliminate them? Of course, some pathogens are just evolutionary dead-ends – fireworks that illuminate the sky briefly and then disappear as suddenly as they appeared, or maybe finally settle into a desk-job and plod along just under the radar. But I suppose even germs want some time on the pedestal, though. Nothing ventured, nothing gained… Ecological opportunities beg for exploitation –leave a window unlocked, and something will find it.

Of course there are other ways of making a living: attack and retreat to fight again… While not strictly analogous, I am reminded of the Champawat tiger of Nepal (and later in the Kumaon district of India) in the late 19th century. She used to attack suddenly and then disappear before anybody could do anything about her. True, she was finally shot, but not before she’d managed to kill almost 450 people in different locations and instilled fear of her return for years. Fear is like that –especially fear of what Donald Rumsfeld (a once upon a time U.S. secretary of Defence, remember?) oxymoronically called the ‘known unknowns’.

The plague has managed a similar trick over the centuries, flaring up in one region, only to hide, then reappear in a totally different region later –often much later. ‘The most recent plague epidemics have been reported in India during the first half of the 20th century, and in Vietnam during wartime in the 1960s and 1970s. Plague is now commonly found in sub-Saharan Africa and Madagascar, areas which now account for over 95% of reported cases (Stenseth, 2008)’ [https://www.cdc.gov/plague/history/index.html]

But, even those of us living in North America are not entirely safe -remember that Hong Kong plague that Yersin was studying in the 1890ies? A ship from there arrived in San Francisco in the summer of 1899 with plague found among some stowaways, two of whom escaped and drowned in the Bay. An epidemic of plague hit San Francisco nine months later. Whether it was from them or from rats that swam ashore, is not known, but the disease has been with us ever since.

http://www.livescience.com/51792-plague-united-states.html  ‘Plague cases occur sporadically in the United States — between 1970 and 2012, an average of seven plague cases occurred yearly […] But plague cases don’t show up everywhere. Rather, most occur in rural areas in western states […] the CDC says. One reason why cases of plague are restricted to the West is that the rodent populations there carry the disease […] “Prairie dogs are one of the major rodent species that serves as a reservoir for plague, and they tend to be west of the 100th meridian” in the United States. For this reason, this line of longitude is sometimes referred to as the “plague line”.’

What, will the line stretch out to th’ crack of doom? asks Macbeth. I suspect that he would have found it fascinating that any of us would think we might be immune from history. And yet, despite all its bad press and the terrifying epithet of ‘Black Death’, plague cases in North America are rare. They can occur when people visit rural areas, says, Dr. Adalja, an infectious disease specialist at the University of Pittsburgh’s Center for Health Security, although ‘people are more likely to be infected with tick-borne illnesses such as Lyme disease, than plague.’

Uhmm, I’d be careful with squirrels in California, though…










Seeing is believing, my mother used to say when she saw I hadn’t finished the spinach on my plate despite my protestations to the contrary. But what if the belief were to persist in the absence of visual corroboration? Suppose I simply closed my eyes and pointed at the plate? My mother, no solipsist, would merely laugh and tell me it would still be there if I ever chose to open my eyes again. I could never win at that –her open eyes trumped my temporarily closed ones every time. I tried that ruse so many times, I got so I could actually see the spinach and the plate even with my eyes firmly clamped shut.

Perhaps I was a slow child, but it did make me wonder about what seeing actually meant. Was it something that could continue even when I tried to turn it off? In the bedroom at night when the blinds were drawn and the room was black, I could still navigate fairly well -and if I did bump into something, I could usually sense it just before the collision.

People talked about noticing things out of the corners of their eyes –meaning when they weren’t looking at them, I guess- and when I grew older, I learned about the sensitivities and image resolution of different cells in the retina. The cone cells in the macula –which you use when you are actually looking at something- were good for colour discrimination and fine resolution, whereas the rod cells, peripheral to that, were more sensitive to light, but not at resolution.

That weird sensation of thinking someone is looking at you, I assumed, was something detected in that peripheral part of the retina by the rod cells –noticed, but not readily identified, and maybe, therefore, not consciously processed until you turned to focus your cones cells on it. It made sense, but every so often I am thrilled to find others who continue to be intrigued by the process: http://www.bbc.com/future/story/20170512-what-causes-that-feeling-of-being-watched

I had assumed that it was fairly straightforward –light hits the retinal cells in the eyes, the signal travels to the visual cortex in the brain, and then it makes us conscious of what the signal means. But, of course, it’s not quite as simple as that. ‘Once information leaves our eyes it travels to at least 10 distinct brain areas, each with their own specialised functions. […] The visual cortex supports our conscious vision, processing colour and fine detail to help produce the rich impression of the world we enjoy. But other parts of our brain are also processing different pieces of information, and these can be working away even when we don’t – or can’t – consciously perceive something.’

So what would happen if your visual cortex were destroyed by a stroke or trauma of some sort? You’d lose your conscious vision –your cortical vision… but ‘cortically blind is only mostly blind – the non-cortical visual areas can still operate. Although you can’t have the subjective impression of seeing anything without a visual cortex, you can respond to things captured by your eyes that are processed by these other brain areas’ –Blindsight, as a researcher name Larry Weiskrantz called it.

The BBC article reported on a study of a man with just such a condition. They were able to do a functional MRI to watch his brain while faces were presented to his ‘blind’ eyes. ‘The scanning results showed that our brains can be sensitive to what our conscious awareness isn’t. An area called the amygdala, thought to be responsible for processing emotions and information about faces, was more active when TD [the patient] was looking at the faces with direct, rather than averted, gaze. When TD was being watched, his amygdala responded, even though he didn’t know it.’

Exciting stuff. ‘[…]research like this shows that certain functions are simpler and maybe more fundamental to survival, and exist separately from our conscious visual awareness. Specifically, this study showed that we can detect that people are looking at us within our field of view – perhaps in the corner of our eye – even if we haven’t consciously noticed. It shows the brain basis for that subtle feeling that tells us we are being watched.’

The article reminded me of something that happened long ago in my gynaecology practice. At the time it seemed a rather trivial incident, but I suppose the fact that I can even remember it suggests that I found it intriguing nevertheless.

Prisha –I think that was her name- was a young woman whose baby I had delivered, a few years before. She returned every two or three years for her pap smear but I remember being surprised to see her again only a few months after her last visit. A tall, beautiful woman with what seemed to me to be an exquisite taste in saris, it was hard not to notice her in the waiting room whenever she visited. Long black hair that never managed to hide the large gold earrings, and the red bindi in the middle of her forehead marked her as an immediate attraction for whatever children happened to be playing on the carpet with their toys.

That day, however, their attention seemed to be focused on an older lady sitting beside her like a queen. Regal in bearing and bolt upright in posture, she was wearing a dark blue sari with gold trim, and as I recall her snow white hair was tucked away under a lighter blue scarf. I suppose what drew my attention to it was that she sat beside her daughter with her eyes closed even when she talked. A tow-headed little boy with large, blue, curious eyes was standing a few feet away staring at her. He would have been too young to have been Prisha’s son, so I assumed he was just fascinated, as I always was with the saris that Prisha wore. But it was more the older lady that had captured his eyes. As soon as I walked across the room to greet them, the little boy ran back to his mother who was sitting beside the window, but he continued to watch from the corner.

I was welcomed by a big smile as I approached Prisha. “I’m so happy to see you again, doctor,” she said, “but this time it’s my mother, Lakshmi, who needs your help.”

Her mother pursed her lips, but didn’t extend her hand to shake mine as I had expected. Her mouth drooped slightly on one side, but a smile broke through nonetheless.

“She is blind,” Prisha explained, “So I have come to help her, if that is alright with you. She only speaks Hindi, though, so I will also need to translate…”

As Prisha took her mother’s arm and helped her down the corridor to my office, I noticed a distinct limp and obvious weakness on one side.

“Mother had a stroke and lost her vision,” Prisha explained, when we were in the office. She’d settled her mother in a chair beside my desk and pulled another beside it for herself. The two talked for a moment while her mother fussed in her seat. “She says she is very nervous about consulting a man, doctor, but I have just reassured her that I trust you.” She smiled at her mother. “She can see nothing at all now, and with the continuing bit of paralysis, I think she feels particularly vulnerable.”

They chatted to each other in Hindi for a moment, when suddenly her mother’s face changed and I could see her tightening her grip on Prisha’s arm.

“Is there something bothering your mother?” I asked, wondering if perhaps she’d changed her mind about being examined by a man.

Prisha immediately smiled, but I could sense her tension. “She says someone is staring at her…”

I blushed and looked down at the surface of my desk. “I’m sorry, I didn’t mean…”

Prisha shook her head. “No, it’s not you, she says.”

“But…” I was confused. “Didn’t you say she couldn’t see anything?”

Prisha smiled, embarrassed. “Nothing at all. The neurologist says she’s completely blind… But she says she can sometimes feel things,” she continued and then shrugged.

Lakshmi seemed to be staring at the office door –if ‘staring’ is the right word, so I glanced over at it. The door wasn’t completely closed, and through what little space remained I could see a pair of large blue curious eyes examining us like a visitor in the zoo. And then, realizing they were noticed, they disappeared, and the pounding of little feet echoed down the corridor.

Lakshmi’s face relaxed and she said something to her daughter.

“It’s okay now, doctor,” she said, looking at her mother with a bemused expression. “She says the eyes are gone…”

There are more things in heaven and earth, Horatio… Blindsight? I don’t know, but whatever it was, I think I was privy to something special that day so long ago.