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Cycling in a Dish

Where do they get this stuff? Menses in a dish –or, to be more academically abstruse, ‘A microfluidic culture model of the human reproductive tract and 28-day menstrual cycle’?

It has a pedantic ring to it, even though it doesn’t exactly roll off the tongue, but I have to ask a simple, quasi-lay interrogative: why? Critical Thinking 101 –at least as they used to teach it- would demand to know why it is important that we make this model. If the answer is vague, or even unnecessarily complicated,  then one begins to suspect academic foppery.

The model is unique –I’ll give them that –let me refer to a succinct description of the model from a BBC News article: http://www.bbc.com/news/health-39421396 ‘The 3D model is made up of a series of cubes that each represent the different parts of the female reproductive system.

‘Each cube contains collections of living cells from the respective bits of this system – fallopian tubes, uterus, cervix and vagina (all human cells), and the ovaries (taken from mice).

‘The cubes are connected together with small tubes, which allow special fluid to flow through the entire system, much like blood.

‘This also means the “mini organs” can communicate with each other using hormones, mimicking what happens in a woman’s body during a “typical” 28-day human menstrual cycle.

‘Tests suggested that the tissues in the system responded to the cyclical ebb and flow of hormones, in a similar way to those of the female body.’

At first, I have to admit, I was skeptical of the need for the model –and yes, I was inclined to see it as foppery. But when I actually read the paper (http://www.nature.com/articles/ncomms14584) I was impressed. Why not just obtain the same cells from, say, hysterectomy specimens, grow them, and subject them to whatever hormones or chemicals you pick to study? It quickly became evident that there are two types of scientists: clinical, and laboratory –as a practicing doctor, I’m afraid I fall squarely into the clinical end, and never the twain shall meet… The reason became all too clear as I continued to read.

First of all, as they explain in the introduction, ‘Preclinical studies often begin with individual cells, separated from cellular and physical contacts that are important for biological function. These dispersed cells must be propagated through weekly reduction divisions and maintained on flat plastic; however, these cells are missing the cell physicochemical microenvironment, three-dimensional (3D) tissue-specific architecture, and blood flow perfusion found in natural tissues.’ In other words, they take a long time to grow and aren’t subject to the same environment they would have in the body (i.e. in vivo).

Secondly, what is used to perfuse them may not have the same effect as the blood circulation they would receive in vivo: ‘typical media composition is based on basal nutrients, bovine serum and a few specialized factors that are placed in a static setting with random mixing. As a consequence, cell–cell and tissue-level cytokine and endocrine signals are not integrated into signalling pathways.’

So not only can delicate organs be assessed as if they were still in the body (like the rhythmic beating of the hair cells that line the Fallopian tubes –cilia), but the effects of different pharmaceuticals could be safely tested in the model before expensive clinical trials were undertaken. ‘Despite large investments in research funding, only ∼8% of drugs for which Investigational New Drug applications have been filed will be approved by the FDA.’

I have to say that I am intrigued, and not a little embarrassed that I was put off by the title of the article. Perhaps to expiate that guilt a little, I mentioned it to Ted, a –I hesitate to say ‘older’- colleague of mine that I met for lunch the other day.

We are both retired now so, apart from our similar past histories, talk heads more towards hobbies and bowels, than to scientific literature. I’m not even sure how it came up, except that his niece was trying –unsuccessfully, it seems- to conceive and his sister had phoned him for advice. She had mentioned several chemicals she’d discovered in an online search –both as potential therapies, as well as putative endocrine disruptors. She wanted to know what Ted thought.

“So what do you think?” he asked me as he carefully cut his hamburger in quarters so he could manage the entry problems. “You retired a couple of years after me…” he added, as if that meant that I was a couple of years smarter than him –or at least a bit more up to date.

“Ted, you know as well as I do that it’s dangerous to speculate on the effects of chemicals on human pregnancies. There are too many variables, too many potential effects that may not show up till birth, or even later…”

He nodded. “I remember DES for threatened first term miscarriages and the later damage to reproductive anatomy -not to mention the clear-cell cancers of the vagina that didn’t show up till years later…”

“Or thalidomide for morning sickness in pregnancies…” I added solemnly.

He nodded thoughtfully and after carefully picking out shreds of lettuce that were hiding under the bun, attempted to cram a freshly-cut piece of the hamburger into his waiting mouth, but it leaked somewhere south of his lips. “They can’t even design a portable hamburger,” he said, unsure whether to laugh or blush. He wiped his face, picked up the meat, and then searched for more hidden pieces of lettuce and placed them on his plate.

When he noticed me watching his lettuce hunt, he shrugged. “I’ve always hated lettuce,” he explained. “So does my niece for that matter. Probably hereditary,” he mumbled and then licked his fingers, contritely. “I mean, look,” he said with a crooked smile on his face, “I solved this problem using in vitro techniques.” And he held up his now-clean fingers and licked his lips in embarrassed satisfaction. “There’s gotta be a way to test these drugs without endangering a pregnancy. Mice and rats are not humans and you can’t safely extrapolate the results to us.”

“Amen,” I said, shaking my head sadly. We’d had similar discussions over the years, so I suspect he was merely venting his frustrations again.

We sat in silence for a moment while he tried to improve his in vitro technique, as he insisted on calling it.

“You know, Ted,” I said after it looked as if his practice runs at the lettuce were failing, “I did read about an in vitro way being developed for safely testing things in women. It was in the journal Nature and entitled something like ‘Microfluidic culture model of the human reproductive tract’. I’m not sure they could adapt it to pregnancies, but maybe it might be helpful in seeing what effects drugs or other chemicals could have on reproductive cells in the events leading up to a pregnancy…” I tried to remember more. “And it seems to me they were even able to replicate a 28 day menstrual cycle…”

His eyebrows shot up, and then one stayed elevated, as if scotch-taped to his forehead. “Micro fluidic what…? My god, is your retirement that bad?”

I think I blushed –he made it sound as if I’d been caught downloading porn. “Uhmm, it’s called ‘body on a chip’, or something –or at least this part is…”

He suddenly turned his attention to the chips still languishing on his plate and smiled. “Thanks for the excuse,” he said. Obviously his wife or maybe Chrissie, his sister, had warned him not to order them, let alone eat them.

“Yeah, I gather that the idea, eventually, is to be able to take cells from somebody who needs a particular treatment and test those cells in the model with various chemicals to see what happens.” It seemed quite exciting to me.

“Mmmh,’ he said, polishing off the last of his fries, while the puzzled lettuceal remnants stared at him from the plate. “I don’t think I can tell Chrissie about it, though.”

I looked up from my napkin and cocked my head. “Why not, Ted? Wouldn’t she find it interesting?”

He rested his head on his hands and peered at me as if he were looking over a pair of bifocals like a professor with a sleepy student. “She’d be on Craigslist trying to buy one as soon as she got off the phone… In fact she’d probably try for a matching set –a male one as well as a female one,” he added when I stared at him.

I must have still looked puzzled, because he smiled and picked up a piece of lettuce. “Chrissie’s a dietician and she thinks her daughter has a terrible diet… and she certainly remembers mine,” he explained, shaking his head. “She’d be trying to feed this to the model to prove her point.” He sighed. “I’d never hear the end of it…”

I suddenly realized I’d not thought about it that deeply. He’s right, maybe the ‘body on a chip’ thing needs a bit more work before they advertise it on Facebook…

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The Stealing Steps of Age

Elderspeak. We’ve all heard it: baby-talk for seniors, an almost unconscious reaction to those we deem cognitively impaired, or hopelessly out of date. It’s a kind of pretend-communication with those who seem unreceptive, or beyond the pale of verbal comprehension.

Although the term is aptly descriptive and eerily evocative of rows of beds with wrinkled heads whose staring eyes peek out from where their bodies are tucked, I have to admit I had not heard the word before seeing an article in the CBC News. It described a study published in The Gerontologist about the way a group of nuns cared for their elderly colleagues from their convent: http://www.cbc.ca/news/health/nuns-elderly-1.4039508

‘The sisters caring for cognitively impaired elderly nuns in a Midwestern convent spoke to their care recipients in a way that sounded strikingly different to linguistic anthropologist Anna Corwin. The nuns rarely used “elderspeak” — a loud, slow, simple, patronizing and common form of baby talk for seniors. Instead, Corwin reports, they told jokes, stories and blessed the sick nuns, all the while speaking to them like they were completely capable, even though their ability to communicate was significantly diminished.’

‘The nuns in the infirmary suffered from dementia, Alzheimer’s disease, aphasia, stroke and neurological deterioration, and all had limited or impaired communication abilities. Sometimes the caregiver nuns held the sick nuns’ hands, and sometimes they massaged their legs, Corwin said.’

It all sounds so… sensible. So empathetic. And yet, so often we are frustrated by our apparent inability to effectively communicate that elderspeak becomes a sort of default –almost as if those to whom we are speaking are not really listening, or, depending on their condition, are minimally aware of our presence. And this can be especially prevalent among overworked care providers in geriatric wards.

‘Kristine Williams, a professor at the University of Kansas School of Nursing in Kansas City, trains nursing home providers to use less elderspeak. Her studies found that communication training can reduce the number of diminutives, terms of endearments and collective pronouns senior caregivers use.’ But training to do what?

The nuns offer an interesting option. ‘The caregiver nuns had long-established deep relationships with their elder charges, Williams noted. “They are in almost a family-like relationship, as opposed to someone who’s a nursing assistant in a home,” she said.’ And what they offered, was not condescension or inadvertent humiliation. Not patronage or mere toleration. ‘”They see these older adults, even when they’re lying in bed moaning and can’t move, as not being reduced by these chronic conditions but still as whole individuals.”’

The study was an interesting one, and yet its findings should not surprise us. ‘Beauty doth varnish age, as if newborn, and gives the crutch the cradle’s infancy’ as Shakespeare said. In other words, finding beauty in old age can transform it and make it bearable –in this case both for the aged as well as the caregiver.

Now that I think about it, I suspect I learned that years ago when I was a beginning medical student and visiting my aunt Shirley who was hospitalized after a stroke. She was stored –that’s the only word to describe it- in an older part of an already-old hospital on a ward –a large room, really- lined on both walls with beds like a dormitory. And for the most part, as I described above, all one could see looking down the rows were heads peeking out from neatly tucked bedsheets, white hair splayed across the pillows or stuck to the scalp with sweat. Some had eyes that moved, but mostly it was a room of mouths –none speaking, all busy with just the chore of breathing.

Shirley was one of the exceptions, propped as she was by a series of pillows and a cloth bib whose tethers kept her from tipping over the bed railings and onto the floor. Her voice was slurred and indistinct, so I had trouble hearing what she had to say, but I could tell she was getting better because she was complaining about the woman in the bed next to hers.

“There’s nothing there,” she kept saying, her eyes pointed at the head beside her that was staring, unblinking, at the ceiling. “They’ve put me in an empty room, dear, and I don’t like it.”

My aunt had always been gregarious, some might even say nosy, so to be confined to a room where she couldn’t extract vital gossip and life histories, was a type of exile for her. A punishment.

“You seem to have improved each time I come here,” I said, trying to cheer her up. For my part, the ward depressed me. “They’re obviously treating you well,” I added, quickly running out of small talk.

Part of her mouth smiled, but most of her face seemed still asleep. Not at all happy.

“Your aunt is improving, sir,” a soft voice said from behind me.

I turned and saw a short, smiling, grey-haired nurse dressed in white trousers and a white shirt buttoned up to his neck. His eyes were twinkling, and he was gazing at my aunt as if he, too, was proud of what she’d accomplished. There weren’t very many male nurses then, so I was surprised. “I expect they’ll be transferring you to another ward, soon, Shirl,” he added locking her eyes in his and ignoring me for a moment. “So quit complaining, eh?” He chuckled when he saw her smile broaden and the rest of her face follow suit. He reached out and squeezed her toe through the sheet and wandered off to check on the next bed. Shirley giggled, obviously pleased.

I could hear the nurse talking to that unresponsive woman in the next bed, although he spoke quietly. First, he tilted his head to stare at the ceiling above her bed. Then, he smiled. “You know, Liz, I figure you must have much better eyes than me…” He liberated a skeletal arm whose flesh hung from it like curtains on a window and held it tenderly. “…Because no matter how often I look, I still can’t see whatever it is that you find so interesting up there.” He gently squeezed her hand. “We’re gonna have to discuss this over a beer someday, eh?”

Her face didn’t change, but her breathing seemed a little less laboured. A little slower. More even. “Anyway, is there anything you need me to help you with today?” he said as he ever so gently massaged her arm then flexed and relaxed her fingers. When he’d finished with that arm, he tucked it under the sheets again and repeated the exercise on the other. “I’m going to come back and move you into a different position in a few minutes, Liz, so don’t get too comfortable like that, eh?” He loosened the sheets around her and raised the railings around the bed again that guarded her from falling. “And I’m going to make sure that physiotherapist you like comes with me to massage your legs.” He winked at her flirtatiously and gave her leg a squeeze through the sheet.

“He might as well be talking to the pillow,” Shirley whispered, as he busied himself with the railing. “All she does is stare at the ceiling. She doesn’t seem to notice when I talk to her…”

“So wait for me, Liz. I don’t want to have to go looking all over the ward for you again,” he said, laughing, and wandered off to yet another bed.

“I do like Bill,” Shirley said when he was out of earshot. “He treats us all like family –like we matter.” She was silent for a moment and then, just when I was about to leave, she managed to snag me with her good hand. “But I don’t know how he stays so cheerful here. I think half of the patients don’t even know he’s talking to them.” And her eyes wandered over to the woman in the next bed again. “It must be terribly discouraging for him, don’t you think?”

I glanced at the woman, and for a moment, I thought I saw her eyes flicker as if they were searching for something. Someone. And then, a tear? But maybe it was just a trick of the light, because, as her face relaxed a tiny bit, they closed and she began to snore. Not loudly, not as if she couldn’t breathe –but quietly, comfortably, and slipped from the waking dream, into yet another more peaceful one further inside.

 

 

 

 

 

 

 

by

When the wheel has come full circle…

What’s it like to live on the other side? As far as I can tell, I’m neither trans nor bi; I do not have any genderqueer feelings or aspirations, and for as many years as I’ve been in this body, I’ve been happy with my gender assignation. I’m merely curious about things I have not experienced –about things that I am not, I suppose. Is a rose by another name really the same -really a rose as we have come to experience it? Or would it be more appropriate to phrase it as the converse: does calling something else a rose, make it a rose? Even if it feels it is? It begs the question ‘what is a rose’, doesn’t it? And is the answer –even culturally contextualized- relative, temporal, or in fact, meaningless? Perhaps for someone invested in linguistic definitional stability, the idea of reassigning nouns is more confusing than helpful –notwithstanding the in-your-face examples of homophones and homographs… But I think it is worth exploring.

Jiddu Krishnamurti, the Indian philosopher, argued that naming the Divine -and therefore essentially defining­ it- confined what that concept meant, limited it. I can see parallels with gender appreciation and denotation. But this is certainly problematic for many of my generation who seem to be invested in the immutability of anatomically assigned gender –or perhaps merely question the wisdom of reallocating something that already is, to something it does not appear to be…

Confusing? An interregnum usually is. When those things to which we have become accustomed are swept aside –or, more disturbingly, simply ignored as if their validity had always been in question- there is often a feeling that some moral law has been violated. An ethical boundary crossed. No matter that the boundaries were themselves arbitrary, templates from a different paradigm, to borrow from Kuhn –a different time. It’s not so much that they were wrong, as that they saw the world from a different perspective –much like we might view the customs of another country as being quaint, if not inimical. But, hopefully, when analyzed carefully, there are usually negotiable commonalities. Values which transcend differences, attitudes which, on reflection, are not that hard to accept. Not that different from those we had come to trust.

So, in time, the misgivings fade, and it becomes not only uncomfortable to deviate from the new norm, but to wonder how we had ever thought otherwise –the subtle memory readjustment that neuroscientists tell us occur with time and circumstance.

Many years ago when I first opened my specialist practice in gynaecology, attitudes were different from today. I was asked to consult on conditions that would now be referred to sub-specialists –doctors who have gained added expertise in specific fields. But in those distant times, we were left to deal with things we had never seen in our training as best we could.

It’s when I first met Jo. There were few computers then; my day sheet was typed and the name seemed to have been left purposely vague. But Jo sat straight and proud in the chair, anything but vague -beautiful, in fact. Dressed in a full-length light blue dress, and large, dangling earrings, I wondered how she avoided getting the slowly swaying waves of her long black hair entangled. I could see her bright brown eyes following a little diapered baby crawling erratically across the rug, both of them smiling at each other, both of them obviously delighting in the moment, however fleeting. Another newly pregnant mother, I thought, although in those days, my day sheet was just a list of names and times of appointment –no other details.

Her eyes lit up when she saw me coming across the floor to greet her, and a warm smile surfaced on her face as if it had been carefully wrapped and stored for just this occasion. For me.

I led her into my office down the hall and showed her a seat across from my desk. I have to admit I was smiling broadly by that stage as well –her face was contagious. “So what can I do for you today, Jo?” I started. I hadn’t yet learned the value of the small-talk that often helps to dispel the initial anxiety before having to confront the reason for the visit.

For a brief moment, her smile disappeared, and her eyes examined the window beside her. “I guess my doctor’s note didn’t arrive…” She summoned her eyes and promptly dropped them in her lap. The smile tried to reassume it’s command of her lips, but I could see it was having some difficulty. “It’s a bit complicated,” she said, shooing her eyes from her lap.

I smiled, picked up a pen from the desk and opened her chart to show that I didn’t mind. That I would judge just how complicated it was. It was then that I saw the note from her GP.

But before I could read it, I could feel her gaze leaning heavily on me so I looked up. I remember her expression was almost pleading with me to listen –not write.  Begging me to understand. I put the pen down and leaned forward in my seat.

“I…” she hesitated, clearly wondering how to begin. Wondering if the explanation she had memorized would suffice. “…I’m not what I seem, doctor,” she said, her voice trembling slightly.

I said nothing; I sensed it was a time for silence, even though I had not yet learned its value.

“I don’t think I’ve ever been what I seemed… But I’m 23 now, and I realize that I can’t live like this.”

I watched her face slowly dissolve into tears, so I reached for the tissues I kept on the desk, and handed her one.

She accepted it with a wrinkled smile she found somewhere and wiped her cheeks. “Sorry,” she said, the smile disappearing again despite her efforts to pin it to her lips. “It’s just that my GP didn’t know what to do with me. He said he didn’t know anybody who could help –apparently there’s nobody here in Vancouver…” She took a deep stertorous breath and grabbed another tissue from my desk. “Anyway he said you might know more about it.” Her eyes suddenly perched on my cheeks and stared at me. Through me, as if my eyes were only guardians of the doors into my head. “I’m a man, doctor…”

She –he– waited to see how I would react. She –I couldn’t help but regard Jo as a ‘she’- had obviously had uncomfortable reactions to the revelation in the past. And I couldn’t disguise my expression, I’m afraid –this was not a time of social media or tolerance of any egregious flaunting of norms. Homosexuality was beginning to evince some token acceptance in many circles, perhaps, but transsexuality was still felt to be beyond the pale. Cross-dressing was a deviance that needed to be closeted away.

Jo shrugged and sank further into her seat, as if my reaction had somehow punctured her only hope. “You know, I’m only Jo, doctor. I’m really no different from the person you met in the waiting room… I want to be that woman you greeted so innocently.” Her eyes sought mine again, like supplicants before a judge.

But in that moment, I could not judge. She was the Jo I had first met moments before –the delightful woman in the waiting room engaging with the trusting toddler. “I know,” I said with a reassuring smile, my heart taking over my words. “Let me see what I can do to help.”

And with that simple acknowledgement, Jo straightened in her chair again, her eyes alive as she adjusted an errant strand of hair that had wandered onto her now hopeful face.

Sometimes, there are surprises in all of us just waiting to be discovered.

by

Zealandia?

Sometimes things are not as they seem and we see, as the biblical Paul wrote, ‘through a glass darkly’. Sometimes there is more than meets the eye; it is what makes the world so interesting. Maybe it’s why we wrap gifts –or give them, for that matter. They are such stuff as dreams are made on…

I have always loved New Zealand; to me, it is a gift, and so is what I’ve recently learned about its origins. To think that Aotearoa –the land of the long white cloud- is more than the ribbon I can see today, more than the Maori seafarers could see even a thousand years ago when they first arrived, is astonishing, and not a little intriguing. An article in the Guardian (https://www.theguardian.com/world/2017/feb/17/zealandia-pieces-finally-falling-together-for-long-overlooked-continent?CMP=Share_iOSApp_Other) reports on a paper published in GSA Today -the journal of the Geological Society of America: ‘Zealandia covers nearly 5m square km, of which 94% is under water, and encompasses not only New Zealand but also New Caledonia, Norfolk Island, the Lord Howe Island group and Elizabeth and Middleton reefs. The area, about the same size as the Indian subcontinent, is believed to have broken away from Gondwana – the immense landmass that once encompassed Australia – and sank between 60m and 85m years ago.’

Of course, even with satellite-derived bathymetric data, it’s hard to appreciate. And the skeptics, largely silent in their apathy, still sit in the shadows wondering what difference knowing  this  makes. After all, it’s almost all underwater, some of it way underwater –one edge of it ‘can be placed where the oceanic abyssal plains meet the base of the continental slope, at water depths between 2500 and 4000 m below sea level.’ http://www.geosociety.org/gsatoday/archive/27/3/article/GSATG321A.1.htm Would we be any the worse, the unimpressed might argue, if this remained undetected? Would the ignorance handicap us in some way? Any way…?

In the conclusion to the paper, the authors assert that: ‘As well as being the seventh largest geological continent Zealandia is the youngest, thinnest, and most submerged. The scientific value of classifying Zealandia as a continent is much more than just an extra name on a list. That a continent can be so submerged yet unfragmented makes it a useful and thought-provoking geodynamic end member in exploring the cohesion and breakup of continental crust.’ But it seems to me that questioning the value of this discovery misses the point entirely. Misses, perhaps, the point of gifts and the wrapping in which they are concealed.

Although I am now retired, I am reminded of something that happened late in my career as a gynaecologist and which continues to intrigue me. It makes me wonder just how many other assumptions limit our vision…

Sometimes in medicine, we feel the need to step back from the fray, to attempt an objectivity denied to those whom we treat. It allows us, we explain, to adopt another, more reasoned perspective -one which is unadulterated by their pain and emotion. ‘A thought which, quarter’d, hath but one part wisdom’ as Hamlet said.

And yet, looking out from the forest of my age, I realize that sometimes people don’t want to be treated as patients, but as people. Fellow travelers. What they want is a knowledgeable friend, not a textbook to which they can turn. One has to learn to gauge the needs…

Jean was not a new patient, but her visits were erratic and unpredictable. Sometimes it was for a pap smear, but more frequently it was for what she would only characterize as an ‘infection’ –“The usual one,” she would inevitably add with an embarrassed laugh. But neither I, nor any of the other doctors she had seen were ever able to find the infection, so it had become a sort of standing challenge as to who would find it first.

Jean was a very fit woman then in her early fifties, who taught both English and drama at a nearby high school. Meticulous about her appearance, I would see her in the waiting room sitting bolt upright, shoulders back, head perched on her shoulders like it was suspended on fine wires to keep it from despoiling the immaculately dressed body below. Her hair was brown and short with each strand assigned an immoveable location lest it be chastened with the brush she kept on her lap in a little purse.

That day, however, I noticed she had added another weapon to the arsenal on her lap –a little pump action plastic bottle, the content of which she would surreptitiously spray on her hands from time to time, followed by a vigorous rubbing as if she had just applied some soothing lotion.

She smiled when she saw me and extended a just-sprayed hand in greeting. “I think I’ve solved my problem, doctor,” she said as soon as we were settled in my office. “I just wanted you to check and see if there was any difference –you know, down…” She blushed before she could finish her sentence. She immediately produced the little bottle and sprayed her hands again. “No infection,” she added, regaining her composure after the little entr’acte.

“And the little bottle?” I had to ask.

“Sanitizer,” she answered proudly. “It’s antibacterial,” she added, and dived into the purse to read the label to me. “It contains triclosan… For some reason it’s really  hard to get nowadays.” Her face suggested that puzzled her. “I mean it kills bacteria doesn’t it? And they’re the troublemakers…”

I suppressed a sigh and sat back in my chair. “It also encourages bacterial resistance, Jean. And it doesn’t seem to be any more effective at cleaning than good old soap and water.”

She blinked, but whether in surprise, or disbelief I couldn’t tell. “But…” She gathered her thoughts before continuing. “We pick up bacteria from our environment and dirty hands are how we transmit a lot of diseases. We have to keep them clean… Bacteria” –she said it as if the word itself were dirty- “Bacteria are everywhere.” She pointed to an alcohol-based hand sanitizer I kept on my desk. “And I see you don’t take any chances either. ”She relaxed in her chair as if she’d proved her point.

I allowed myself the sigh I had avoided earlier. “An interesting dichotomy, isn’t it?” She raised an eyebrow. “That we live in a world jam-packed with so many bacteria that they are virtually ubiquitous…” I continued, “…and yet so few cause us trouble.”

“But…” She leaned forward on her seat.

“But we seem to want to malign them all; we act as if they were all our enemies. And yet, our own microbiome –the bacteria living in our intestines- are absolutely essential for our health in ways we are just discovering. And apparently the number of bacteria normally living in and on a healthy human body outnumber our own cells by ten to one.” I stopped and smiled at her incredulous expression. “We –our cells- are only the tip of the iceberg.”

I suppose I thought I’d just be reminding her of something she already knew, but her eyes were saucers. “Zealandia,” she said after a moment’s reflection.

“Pardon me?” I’d never heard the word, and wondered whether she was referring to the title of some obscure novel she was teaching at school.

“Zealandia,” she repeated as if she were surprised I didn’t recognize the term. “You know, doctor, the continental landmass of which New Zealand is a part? It’s 95% underwater so you can’t see it and therefore don’t appreciate it’s importance. We usually only judge what we can see, don’t we…?” she added with a wink and a big winning smile.

We all have our blind spots.

by

Weight and See

 

Obesity and dietary issues have been seen as major contributors to diabetes and cardiovascular health for some time now. No longer regarded as outward manifestations of status or wealth in most societies, they are now often subjects of disparagement, and those carrying extra weight frequently stigmatized and derided. As if the very fact of being overweight was an act of moral depravity, or at the very least, a manifestation of weakness. Self-neglect.

Smoking –especially in North America- suffered a similar fall from grace when it became evident that it was a cause of major health problems. But it is much easier to hide a smoking habit than an overweight or frankly obese body. And whereas public measures to stigmatize smoking and outline the health risks may have some effect on smoking behaviours or smoking persistence, they seem to be counterproductive in successfully encouraging exercise for weight loss according to a large study from Britain: http://bmjopen.bmj.com/content/7/3/e014592

This was a long term study starting in 2002 of 5480 participants of both sexes, all at or over 50 years of age, and carried out by Dr. Sarah Jackson from University College London. ‘In summary, these results provide evidence that weight discrimination may be associated with lower participation in regular physical activity and higher rates of sedentary behaviour. Through this mechanism, weight discrimination may be implicated in the perpetuation of weight gain, onset of obesity related comorbidities and even premature mortality.’

The BBC News also reported a perhaps more easily assimilable summary of the study: http://www.bbc.com/news/health-39191100. The point being, evidently, that shaming or drawing attention to the weight a person is carrying is less likely to get them to exercise than a welcoming and supportive attitude. And environment -‘Exercising when you are overweight can be daunting, and the fat-shaming attitudes of others do not help.’

I suppose this study is much like carrying coal to Newcastle, but nonetheless it is important to hold a mirror to societal attitudes and prejudices. It’s often not so much that we mean to denigrate people who hold different values, or who do not seem to espouse the image we find attractive but rather that we hold ourselves apart. Withholding approval can be as devastating as active discrimination and, at least in this case, seldom leads to positive changes.

Unfortunately the problem of excessive weight sometimes slips by in a gynaecology office as well –noticed, but unmentioned- because of fear of upsetting the patient. Occasionally, an opportunity will present itself, however. One has to be alert –and sensitive.

Janina was a new patient to me. I first saw her in the waiting room sitting in the corner seat which was partially obscured by a large, leafy Areca palm. Her head and face were further hidden behind a magazine whose pages never seemed to turn. A large lady by any estimation, she attempted to camouflage it as best she could with an extra-large, loose fitting brightly patterned sweat shirt and bulky jeans. The effect was really quite beautiful –and so was Janina when she finally lowered the magazine. Her large, brown eyes were captive birds that fluttered delicately behind the bars of exquisite eyelashes. Her face was soft and her smile, although timid and infrequently offered, was captivating. She wore her hair long and auburn waves flowed slowly and gently over her shoulders like water on a beach whenever she moved.

She made a show of being nice in the waiting room, but I could tell that she was uncomfortable as she followed behind me to my office. She closed the door quietly behind her but before she sat she moved the chair as far away from the desk as the room allowed.

I smiled at her in an attempt to put her at her ease, but she had already dropped her eyes onto her lap and refused to retrieve them.

“Dr. Blackstock says you are having some problems with your birth control pills,” I said, when it became evident that she was not going to volunteer any information.

She sat perfectly still, her hands clasped motionlessly where her eyes still lay. Finally, she took a long, slow breath, looked at me, then slowly nodded her head. It was a sad movement, and for a moment, I wondered if she was going to break into tears. But she remained silent.

“What kind of problem are you having, Janina?” I asked, after another sepulchral moment.

She sighed again, but her face changed. “Isn’t it obvious, doctor?”

I raised an eyebrow to indicate that it wasn’t.

“Ever since I started on the pill, I’ve continued to gain weight,” she started. “I was never this heavy before…” She paused briefly to let that sink in. “Never…” She let her eyes drift around the room for a moment, finally settling them on a terra cotta statuette of a seated woman with a begging bowl that I’d placed on a little oak stand in the corner. “I don’t want to end up like her,” she said, pointing at the woman. She sent her eyes back to perch briefly on my face. “But even she isn’t as fat as me…”

As the words sank slowly into silence, a tear began to run down her now quivering cheek. I rose from my desk and walked across the room to hand her some tissues. She seemed to appreciate the gesture and her face softened for a moment. In fact, she used the opportunity to examine me as I walked back to my desk.

“You have no idea how people look at a fat person like me…” she finally volunteered and then her eyes focused on a wooden figurine on my desk behind a plant; it was a woman holding a child and peering out as if she were hiding. “I feel like that woman,” she said, nodding at the plant with her eyes.

I must have let a worried expression escape onto my face, because Janina seemed to focus on it. “It’s a different world when you’re fat, doctor. That’s all people see…”

I sighed. I couldn’t help it; she seemed so sad. “I see beauty,” I said –it just escaped from my lips. I hadn’t planned it…

Suddenly she smiled, and her hair danced once again over her shoulders. She straightened herself on the chair, and then with a gentle shrug stood and moved it closer to the desk.

 

 

 

 

by

The Primrose Path

Age is sometimes mysterious, isn’t it? Despite the experience and occasional brush with wisdom I have encountered, I am still a child in many ways. Naïve -not so much about things I have encountered in my drive through life, but more about those on streets I have not visited. Addresses in the shadows.

I suppose there will always be issues that will never spring to mind in our normal passage through the years and yet, in retrospect, one wonders how they were missed. Or why. What, for example, happens to different populations as they age? And who do we get to care for those who have chosen -or been forced- to walk the darker paths, then fallen neglected and forgotten by the wayside, too old to re-offend? Should we care for those who flout our laws and reject the duty to conform? Are we a family, or just a collection of intolerant strangers easily offended and quick to turn away?

Imponderables, to be sure, and yet, like it or not, there are needs that must be met… by someone anyway. I was intrigued by an article in the BBC News about aging prostitutes in Mexico City: http://www.bbc.com/news/magazine-38677679  One of their members opened a retirement facility for them.

I must admit, that the plight of aging sex workers had never really occurred to me. I’m not sure what I thought would happen as they got old, although, as a gynaecologist, I was certainly aware of their life style risks; their need for consultation in the Emergency Department was a regular and frequent occurrence whenever I was on call. For some reason, I’m reminded of that quote of Queen Katharine buried deep in Shakespeare’s Henry VIII: ‘Like the lily, that once was mistress of the field and flourish’d, I’ll hang my head and perish.’ Is that how they end their days…? I hope not.

But a retirement home –how perfect! The social safety net in Mexico is likely not as comprehensive as that in Canada, and yet even here, I’m not aware of any such facility. Indeed, the oldest profession has undergone other, more callous impediments as I noted in a 2014 blog on prostitution laws: https://musingsonwomenshealth.com/2014/06/12/prostitution-laws/  So perhaps it might be asking too much to wonder if such a facility might be in the offing -if not governmentally sponsored, then perhaps privately funded. Or better still, a legal adoption of  something like the New Zealand model might discourage exploitation and even offer salaries and, who knows, pensions…? Comfort for their end of days?

*

I do not ordinarily sit in malls; I do not ordinarily go to malls, for that matter, but sometimes circumstances foster unexpected opportunities. I was tired that day –tired of fighting through Friday crowds in search of things I probably didn’t need, or at least could likely find with a little effort somewhere else. I had just decided to look for a place to rest and collect my thoughts, when I saw a woman check her watch and stand to leave an uncomfortable-looking wooden seat near where the tide of people was sweeping me. I immediately swam over and moored before the woman right behind me could claim it for herself.

The seat was one of four that served as a kind of breakwater for the waves of people flowing down the shop-lined banks in confused eddies. Bolted to the floor, they were arranged in a little circle, presumably to facilitate conversation, but only two of the occupants seemed to know each other. They were deep in conversation so even an exchange of pleasantries seemed inappropriate, but just before I closed my eyes, I managed to catch their attention and smile at them. In the seat beside me was an old man who also smiled, but seemed more preoccupied with his watch than anything else.

The women were quite old and both looked as if they’d seen better days. Although their clothes were clean and obviously worn with an attempt at style, I could see fraying at the hems, and areas where the patterns were disrupted by attempts at repair. Both their faces were wrinkled, as much by life as age, I suspected, and the one directly across from where I sat, seemed hollow around her cheeks and gummed her words through sparsely distributed teeth. Short and gaunt, she sat proud and straight in her chair, however, her long, greying hair swept back in an elegant ponytail that danced each time she talked. She had dressed that day in a green, fading sweater and black jeans that seemed a bit too large, so the cuffs were carefully rolled to matching folds.

The other was a larger woman with short, ash-white hair that she had scrunched under a blue baseball cap that had some sort of a truck logo on its front. She was dressed in a red and white flower print dress which seemed to hang shapelessly below a tattered and faded nylon jacket that had probably once been totally black. At her feet was a big, stained cloth shopping bag that bulged oddly in places with items too irregular to be just clothes.

Friendly strangers, they both smiled back at me before resuming their conversation.

I closed my eyes and tried to relax into the wooden slats, but their words kept floating over to me during lulls in the storm of voices and accidental elbows hurrying past me. I could tell it was an unsafe anchorage at best.

“Haven’t seen you for a while. You still working, Ethel?” It must have been the pony-tailed woman, because her words seemed strangely distorted and her lips smacked together a little as she spoke.

A gaggle of children passed nearby so I missed some of the response. “… men anymore, Rita…”

“Yeah, I guess, eh?” But I didn’t think Rita sounded very sure. “You still on the…” A demonic laugh surfaced in the crowd for a moment then faded along with Rita’s words.

“Yeah,” Ethel replied. “Hard to get off though, eh?”

I opened my eyes to get a little more comfortable on my seat, and saw Rita nodding in agreement. “Hang out in the same place?”

Ethel shrugged as I closed my eyes again. “They know me there,” she answered.

I imagined Rita nodding in agreement. “Mmmh,” I heard.

School must have ended for lunch, because a group of noisy teenagers rambled past, joking and poking each other. “What shelter you going to nowadays?” Ethel’s words caught my attention, even amidst the confusion of teenage jests and I opened my eyes, pretending to adjust my position again.

I could see the indecision on Rita’s face, and her lips moved as she considered her answer. “Used to go to the one on Main…”

“Yeah, me too,” Ethel agreed, glancing at her. “Got assaulted there, though, so I sometimes try the Sally Ann…”

“Mmmh.”

“What about now, Rita?” She adjusted her baseball cap as she spoke. “Where you headed tonight…?” She sounded suspicious. They were clearly not good friends –just acquaintances, perhaps, who’d found themselves in adjoining seats to shelter from the weather for a while.

Rita stared at Ethel for a moment, obviously uncertain how to answer. Then she ordered her eyes to scan the passing crowd. “Found a new place. Some of the girls got together…” But it wasn’t the noise of passing voices that ended her words.

Ethel tried to find out more, but Rita suddenly stood and waved, as if she recognized someone in the crowd, and dived into a particularly noisy wave and disappeared.

Ethel sighed and then gathered up her things and melted into a similar eddy going another direction. Despite her weight, she seemed frail and aged. Her movements were no longer fluid, her gait was unbalanced and she hobbled with a decided limp. But as she disappeared, her eyes brushed mine -by mistake, I thought at first, but when I remembered it later, I wondered if it had just been habit. A desperate plea for another friend –however temporary.

 

 

 

 

by

What We Value

I think it’s about time I revisited the concept of ‘disability’, both in its description and in society at large. It seems to me that the word itself is too value-laden to accept at face value. We are all disabled in one way or another and yet we may not see ourselves like that. And why should we? Disability, like beauty, is in the eye of the beholder –or in this case, the beheld. I first wrote about this several years ago: https://musingsonwomenshealth.com/2012/08/31/antenatal-genetic-testing/

The concept is embedded in context, and like two colours mixed together, can result in something totally different. Totally unexpected –even if innocently mixed. I was reminded of this by another  BBC article on Down Syndrome and antenatal screening: http://www.bbc.com/news/magazine-37500189  Once again there was an acknowledgment that ‘”The whole essence of a good screening programme is the counselling you have before you even have the blood test done or the scan done,” says Alan Cameron, foetal medicine consultant at Queen Elizabeth Hospital in Glasgow.’ And, of course, ‘[…] all experts agree that the way a diagnosis of Down’s syndrome is presented can influence whether parents choose to continue with the pregnancy.’ Even unconscious biases affect the way counsellors present the evidence, and none of us is free of these, I fear. We are all tinted by the colours that surround us, after all.

And I suspect there’s no better place to experience colours than riding in a bus.

I happened to be sitting behind two young women, both of whom were carrying their babies in those little vertical hammocks on their chests that tend to wax and wane in popularity. They evidently were strangers, but as newly minted parents, they seemed anxious to brag and peek at each other’s baby.

“She’s gorgeous,” said the one sitting beside the window, glancing at the closed-eyed head breathing quietly in its tight little container on her seat-mate’s chest. I’m not sure how she ascertained the sex so easily, but maybe new mothers are more adept at that than the rest of us.

“Thank you,” said the other, risking a peek at the sleeping baby beside her. “So is yours,” she cooed, cuing a smile and a flutter of her eyes.

“His name is Joshua,” the window lady responded, as if it was essential to establish that from the start. “Names are important,” she added, more seriously. “It means ‘God is generous’, or something…” To be honest, she didn’t sound too certain.

Aisle-woman was silent for a moment. I couldn’t see her face, obviously, and it might have been rude to look, but I thought it seemed an awkward response. “That’s nice,” she said in a carefully neutralized tone, but that kind of thing is hard to determine when you’re sitting behind someone in a noisy bus. “My little sweetie is called Elizabeth…” I could hear the hesitation in her voice. “I don’t actually know what it means,” she admitted.

“It means God is satisfaction, I think,” window-woman said without a pause. “We were going to name him that –if he’d been a girl, I mean.”

“Oh.” Aisle-woman seemed stumped about how to reply, but her neck-language suggested she was none too comfortable with the God references in both names.

They were silent for a few streets, and then, window-woman, unable to contain herself, peeked at the other baby. “They all look so peaceful when they’re asleep, don’t they?”

The woman nodded and felt forced to reciprocate with a fleeting inspection of Joshua as he snored. I assume it was snoring, at any rate, because it was rhythmic and his mother didn’t seem to be doing it. Elizabeth’s mother reached over and loosened Joshua’s hammock with a finger, thinking that might have been the cause. It was an innocent gesture, meant to be helpful –a mother’s instinct in action- but Joshua’s mother immediately grabbed the offending finger.

“He’s okay,” she said, embarrassed at her protective reflex. “Joshua’s just a noisy sleeper, that’s all…”

Elizabeth’s mother stole another glance at Joshua and I could see the edge of her smile, even from behind. “I’m so sorry, I didn’t mean to interfere,” she said, and adjusted Elizabeth’s little hoodie, just in case. “I thought he looked a little puffy… I wondered if maybe it was the hammock.”

Joshua’s mother forced a smile and then turned to look out of the window. “He isn’t puffy; he looks just like yours,” she said in a soft little voice that I found hard to hear.

“I’m sorry,” Elizabeth’s mother said, touching the other’s shoulder gently. “I… I thought I was helping…”

When Joshua’s mother turned her head to respond, I could see a tear rolling down her cheek. She stroked Josh’s little cheek and the snoring stopped for a second or two. “They told us he’d be…different,” she said slowly, “But he’s really a very good baby, you know…” She stroked Joshua again when he seemed to be rousing, and he immediately relaxed and made some sucking sounds with his lips. “I know he meant well, and everything, but the doctor always looked so sad when he saw me during the pregnancy. You know, like he was trying to console me or something…”

I could see a little tear beginning to form in the eyes of Elizabeth’s mom now. “I’m so sorry,” she said as softly as she could over the rattle of the bus. “I didn’t mean…”

But the window-lady had already pulled the cord for the next stop and was starting to rise from her seat. “God really has been generous to us both,” I heard her say as she reached out and gently stroked her neighbor’s baby as she passed. “It’s just that I’m always going to be reminded of that, I guess…”

She hurried through the opened door and I could see her standing out there as the vehicle pulled away, caressing little Joshua but otherwise not moving… As if maybe the answer was another bus…