A Flicker of Hope

It’s interesting what catches our attention when we surf the apps on our smartphones nowadays. Some of the more provocative articles have dubious sources, of course, but with a little digging the original study can often be found and the claims checked. The problem, however, is that even these results need to be reproducible in case either the methodology or the results were unreliable –and also the conclusions drawn from them. That’s why it’s often unwise to believe everything you see reported –or, on the other side, to report everything you want to believe… Fear and Hope are wonderful incentives, and so the issues in the study need to be thoroughly researched and vetted for bias and innuendo and references to the original study need to be included.

Perhaps because I am now retired, any article about time-related changes catches my eye more easily. So I find myself particularly interested in studies that suggest progress is being made -not with respect to age itself, but more the evolving process of aging: the gerund. It was with considerable interest that I read the BBC news on the use of flashing light therapy for Alzheimer’s http://www.bbc.com/news/health-38220670

I also attempted to read the original paper from MIT (entitled Gamma frequency entrainment attenuates amyloid load and modifies microglia) published in the December 2016  issue, of the journal Nature should you wish to struggle though it, but I have to confess that for me, even the title was difficult…

At any rate, the article suggested that flashing light in the eyes of mice that were genetically engineered to have Alzheimer’s-type damage in their brain, ‘encouraged protective cells to gobble up the harmful proteins that accumulate in the brain in this type of dementia. The perfect rate of flashes was 40 per second – a barely perceptible flicker, four times as fast as a disco strobe.’ And ‘Build-up of beta amyloid protein is one of the earliest changes seen in the brain in Alzheimer’s disease. It clumps together to form sticky plaques and is thought to cause nerve cell death and memory loss.’ Research has focused on ways to prevent this plaque formation using drugs, but with limited success so far. If a non-invasive method like a flickering light can activate the immune system to do it by itself, so much the better. ‘The researchers say the light works by recruiting the help of resident immune cells called microglia. Microglia are scavengers. They eat and clear harmful or threatening pathogens -in this instance, beta amyloid. It is hoped that clearing beta amyloid and stopping more plaques from forming could halt Alzheimer’s and its symptoms.’ Fine with me.

I did, however, initially wonder about how bothersome the flickering would be –news reports on television usually caution their audience whenever even flash photography is found in the report, presumably because of the risk of triggering epileptic seizures. But, as the article discussed: ‘For the patient, it should be entirely painless and non-invasive “We can use a very low intensity, very ambient soft light. You can hardly see the flicker itself. The set-up is not offensive at all,” they said, stressing it should be safe and would not trigger epilepsy in people who were susceptible.’ Better and better! It’s just preliminary stuff, of course, but at least it opens up new pathways and ideas for further research.

As if even reading about the concept was in itself therapeutic, the article immediately triggered what, at first blush, would seem to be a non-sequitur memory of a patient I saw many years ago. The issue as I recall was not so much about mental aberration -although the patient herself was apparently suffering from paranoid schizophrenia- but more about her speculation on the possible effects of flickering light on mental function.

I was, I think, in my first year of residency training in the gynaecology program and was doing a rotation in one of the older teaching hospitals in the city. In those days, things were very busy on the wards and so our tasks were apportioned according to our seniority, the senior residents doing the lion’s share of new consultations, while we juniors were given those jobs that, while important, required less experience -pap smears, usually.

My senior’s name was Sara, I remember, and she decided I should be the one to go to the psychiatric ward to do a pap smear on one of their more ‘unusual patients’ as she said to tease me.

“What do you mean ‘unusual’?” I asked. Sara didn’t like to go onto that ward, for some reason, so she usually made some excuse.

She stared at me for a moment before answering, I remember. “Oh, you know, she has paranoid delusions and hallucinates, or something…” But it was clear that Sara really had no idea why our department had been asked to do the pap, nor had she any intention of doing it herself.

I was beginning to suspect this was merely another sluff. Sara fancied herself a consultant now and able to delegate things she didn’t want to do. “But if she’s paranoid and hallucinates, wouldn’t it be better if the doctor doing the pap smear was female?”

Her expression turned angry at that point, and I recall her almost attacking me with her eyes. “Oh for god’s sake, there’ll be a nurse there with you the whole time… Or maybe they said two…” she added, uncertainty softening her glare, but not her resolve to send me to that ward.

I showed up at the psychiatric area and was allowed in only after identifying myself via the phone just outside the door. Then I was led to the brightly lit nursing station, and a rather large matronly nurse handed me the chart of the woman needing the pap.

“She hasn’t had a pap smear in years,” the nurse said in a soft voice, so it couldn’t be heard in the corridor outside of the station. “And her voices told her she has cervix cancer…”

“Her voices?” I should have been more professional, but I was already feeling a bit apprehensive about being inside a locked ward. “I mean, shouldn’t we wait until she’s feeling a bit better before we…”

“We can’t seem to find any good medication for her yet,” the nurse interrupted. “The doctor thought that we could at least calm her by checking her cervix.”

Greta –I still remember her name- was already in the examination room, sitting in her gown on a little table that had a set of rickety old metal stirrups at one end. They’d apparently had to borrow everything from another ward for the job. As soon as I entered with the nurse, Greta examined me from top to bottom with suspicious eyes.

“You’re a man,” she said before we were even introduced.

The nurse, whose name I forget, walked over to Greta and held her hand. “You remember we talked about this, Greta,” she said in the same soft voice she’d used before. “And you said it was okay…”

Greta nodded, smiled and lay back to put her feet in the stirrups. “They said I should show you my cervix,” she said, the italics staring at me between her knees. “Not the one with cancer, though…  I’m supposed to keep that one hidden.”

“Her voices,” the nurse quickly whispered in my ear as I sat on a little stool they’d also borrowed for the occasion along with a light on a long, flexible metal pole. It looked as old as the stirrups.

I got the speculum and the pap smear paraphernalia ready as the nurse readied the light. The bulb kept flickering, though. I fiddled with the bulb to see if it was loose, but it seemed tight enough. And it was obviously plugged into the wall. On, off, on, off… the light was beginning to annoy me. I snapped the switch a few times, but still, it insisted on flickering. On, off, on, off…

“I’ve got a flashlight,” the nurse said, but when she turned it on, it was so weak, I knew I wouldn’t be able to see cervix high up in the vagina with it.

“Well, maybe I can do the pap smear with the flickering light,” I said and shrugged.

Suddenly Greta raised her head and stared at me again. “Sometimes the prongs don’t make good contact in the wall. Everything’s so old in this place,” she added, shaking her head. “Take the plug out and squeeze the prongs.”

By this time I had the speculum in my hand, so I nodded to the nurse to try Greta’s suggestion. Sure enough, squeezing the prongs stopped the flickering.

Greta was still staring at me through her legs. “I may be crazy, doctor, but I’m not stupid…”

I put the speculum down on the medical tray I had on my lap. I sensed Greta wanted to explain something. “It’s a signal, you know.” I didn’t think I should reply. “The light’s always trying to tell you something –sometimes it’s angry, but more often it’s just trying to help…” Her feet still in the stirrups, she raised herself onto one elbow and continued. “It gets right into the brain to help, you know. It doesn’t stay there long enough, though, and that’s why it has to keep going in and out, in and out… And each time it tries, it flickers…” Then she stopped talking for a moment and stared at the nurse with an amazed expression on her face. “That’s what the doctors should be trying –not all those horrible pills…”

Maybe that incident stands out because it was the first pap smear I’d ever done. I don’t remember the result in Greta’s case –I was near the end of my rotation in that hospital- but I do remember Sara asking me what I’d done with that patient.

“Why?” I asked, afraid Greta had accused me of doing something improper.

“The ward told me that your patient seemed much calmer after you left and she apparently kept telling everybody you’d come up with a new treatment, or something…” And then I remember Sara smiling condescendingly at me, as if to say that junior residents could never do anything of the sort.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Happily Ever After?

I suppose we all revisit our childhoods from time to time –those memories have a special hold on us. But they are stories thick with varnish, and when analyzed too closely, soon fall apart in our hands like dreams. And yet, handled gently, stories are what we are –they are our names- and that we awaken the same person from day to day is like reading further in the book.

Maybe that’s why fairy tales can have such a fascination for children –escaping into an imaginative narrative that is as magical and surprising as their own. A time to believe we can become the story –maybe even are the story. For most of us, it was an enchanting time of fairies, and wishes coming true; of escape from tragedy, or finding a special person in the deep, dark forest; of finding happiness in the midst of sorrow.

Well, at least that’s what I thought was happening as I snuggled in the arms of my parents when one of them read to me before I went to sleep each night. But we only know what we are told, I suppose; we only understand the world that is laid out for us. I certainly never suspected an agenda; I never thought to ask if what I heard was only a manifestation of the time of writing. And I certainly neither questioned my mother’s world-view, nor my father’s integrity –I assumed I was being told the truth about the once-upon-a-time days.

And yet, viewing them through a modern lens, I suppose their faults were obvious. Not my parents’ –they, too, were products of their own times. No, I mean the stories that I found so innocent and sweet, had rougher underbellies than I had reason to suspect. In fairness, I think we acclimatize to the things to which we are habitually exposed. Who can smell the garlic on their own breath? And so, the undergarment of sexism in many fairy tales came as a revelation to me. https://www.bustle.com/articles/149098-5-fairy-tale-tropes-that-perpetuate-sexism

And I have to say that on first glance, I suspected this was yet another example of historical revisionism –the reinterpretation of the umwelt of another time through the sensitivities and biases of our own. There is some of that, to be sure –we do not easily appreciate the perils and depravities that were rampant in medieval Europe- but even so, we can no longer blindly accredit tales of infanticide or child abuse, nor turn a blind eye to attitudes like misogyny or tropes like the evil inherent in non-conformity that may have been prevalent and believed in that time. And, indeed, it often seems to be women that are treated unfairly in these tales, when appraised by modern eyes.

The danger is that by ignoring the hidden message, we risk normalizing it. Condoning it by not pointing out that we no longer sanction that kind of behaviour.

Of course, it can also go too far -come too close to serving an agenda that seems more retributive and spiteful than merely corrective. Some of the fairy-tales –Cinderella, or even Sleeping Beauty (despite the apparently more malevolent early versions)- have a sweetness and charm that, at least when examined only superficially -as might be the case by a child- spin a message of hope and rescue for even the poorest among us.

But that said, I have to confess that I never really thought about the main character -in most of the ones I remember, at any rate- being almost always a girl. Think of Goldilocks, Little Red Riding Hood, Rapunzel… Even Gretel in the Hansel and Gretel story. And the frequent portrayal of old and eccentric women as witches, or at least as malicious step-mothers. I suppose that Jack in the Beanstalk was a refreshing exception, but nevertheless, point taken.

Perhaps it’s my age, or a comment on my epoch, but have to say that I didn’t realize the extent to which these stories were recognized as violating the currently prevalent societal ethos.

A few years ago I remember seeing Ada, a young twenty-something woman for antenatal care. It was her first pregnancy and she was bursting with dreams and bubbling with questions about problems she hoped to avoid in the pregnancy. But one of the things that made her stand out in my memory was her hair. She had incredibly long shiny black hair that hung down to her waist when she didn’t try to confine it in a messy bun on top of her head. She was extremely proud of it, and told me she rarely had to work at keeping the sheen that was so striking to everybody in the waiting room. She was used to stares, she would tell me with a big smile on her face.

And yet, as the pregnancy progressed, she found that not only was the length starting to annoy her, but she was also beginning to find clumps of it on her brush each morning. I tried to reassure her that, although not the rule by any means, it is not uncommon to lose some hair in the course of a normal pregnancy. This usually corrects itself three or four months after delivery.

“So I’m not gonna go bald, then?” she said with a twinkle in her eye. I shook my head and smiled. “My husband says it’s probably because the long hair weighs so much it’s pulling on the roots and weakening them or something.” Her expression suddenly changed and instead of twinkling, I found her eyes wandering over my face like robins listening for a worm. “He even jokes about me being a black-haired Rapunzel…” A look of concern appeared, and her eyes immediately flew home. “He says maybe I should cut it shorter while I still have some left. ‘Remember the witch’ he says.

“We had a big fight about how unfair that was…” She glanced at me for my reaction, and seeing the puzzled expression I was unable to hide, she shrugged. “The story hides behind the idea that long hair not only allowed her captor, but also her rescuer to reach her in the tower.” Suddenly her look was a glare. “In medieval times, men were the oppressors –they had the towers- so why make some old woman the villain?”

I wanted to say it was just a story, but she beat me to it. “Ted says it’s just a story –a way to allow a prince to rescue her…” Ada turned her eyes into predators and suddenly unleashed them on my face. “I told him it seemed a bit contrived to me. An example of assumed male privilege, and Woman’s desire to be rescued. Of course he was a prince, and of course that’s what she needed…”

I suppose my face said I still didn’t follow her logic, because she immediately softened her expression and touched my arm. “I majored in medieval European literature in university –Ted was messing with the wrong woman…”

She smiled and sighed at her reaction to her husband. “Poor guy. I really gave it to him,” she confessed with a chuckle. Then she twinkled her eyes again. “So, doctor, was Ted right? Should I cut my hair shorter?”

I shrugged to indicate that I wasn’t at all sure. “Are you certain Ted wouldn’t miss it?”

She sighed. “That’s the problem with princes, isn’t it?”

 

 

 

 

 

For my Pains, a World of Sighs

What does pain look like? An intriguing question to be sure, but one I hadn’t even thought to ask until recently. Pain is one of those things that, like St. Augustine’s quandary over Time, presents a similar difficulty in defining. The International Association for the Study of Pain made a stab at it: ‘Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,’ but somehow, it seems to lack the immediacy of its subject matter –it stands, like an observer, outside the issue. Poets have done a better job, I think. Emily Dickinson, for example: After great pain, a formal feeling comes. The Nerves sit ceremonious, like tombs’; or Kahlil Gibran: ‘pain is the bitter potion by which the physician within you heals your sick self’; or even Oscar Wilde: ‘Pain, unlike Pleasure, wears no mask.

But I was reminded of another of Wilde’s observations -‘We who live in prison, and in whose lives there is no event but sorrow, have to measure time by throbs of pain, and the record of bitter moments.’- when I read a CBC article from November, 2016 entitled ‘Indigenous children, stoic about their pain, are drawn out with art’ http://www.cbc.ca/news/health/aboriginal-youth-art-pain-hurt-healing-1.3852646

‘”Aboriginal children feel and experience pain just like anyone else. It’s just that they express their pain very differently,” said John Sylliboy, community research co-ordinator with the Aboriginal Children’s Hurt and Healing Initiative.

‘”They don’t necessarily verbalize their pain, or they don’t express it outwardly through crying or through pain grimaces,” he told CBC News.’

‘These children are socialized to be stoic about their pain, to hold in their pain.’- Margot Latimer, Centre for Pediatric Pain Research, IWK Health Centre in Halifax. ‘”We noticed we weren’t seeing any First Nations youth referred to our pain clinic at the IWK hospital and wondered why that was so.”‘ It didn’t make sense, she thought — especially since research shows that chronic illness in First Nations communities is almost three times higher than in the general population. Aboriginal children are especially vulnerable, says Latimer, with higher rates of dental pain, ear infections, and juvenile rheumatoid arthritis.’

I found it very moving, and yet disturbing, that ‘[…] cultural traditions, and lingering effects from the residential school system, are some of the reasons Indigenous kids pull on their suit of armour against pain and hurt.’ But they’re children, and perhaps not yet completely shackled to all the subtleties of culture. ‘A group of Indigenous children and teenagers from four First Nations communities in the Maritimes were asked to paint their pain, to express their hurt through art. Researchers were hoping to tease out emotions from a population more inclined to show resilience to pain.’ But soon after, the children began to depict not just physical pain, but emotional pain as well. As Sylliboy points out, ‘”These kids told us about loneliness, sadness, darkness, bullying, hopelessness. It’s not the typical anxiety [or] depression. It is more complex than that.” “To these clinicians who are just asking about physical pain and not looking at emotional pain as well, it is important, because Aboriginal kids are showing us that there is no difference between emotional and physical pain”, said Sylliboy. “It’s just pain.”‘

And I learned another thing about pain –or maybe about children – ‘It’s all about creating a safe space for the children when they come to the hospital, says Latimer.  She says it’s about learning a bit about them and gaining their trust. “When they come to the health centre, or a physician or a nurse practitioner, they want to tell their story, but we do not train health professionals to assess pain that way.”’

It reminded me of a patient I first met in the Emergency Department at the hospital when I was the gynaecologist on call one night. Edie, an aboriginal woman arrived with heavy bleeding –she was  apparently in the throes of miscarrying an early pregnancy- and had brought her eight year old son to the hospital because she had no one to take care of him at home. The bleeding settled shortly after her arrival and an ultrasound in the department revealed that there was no further tissue left in the uterus, so fortunately we didn’t have to take her to the operating room. But the process of diagnosis and decision was not instantaneous. Although the little boy, Timmy, was clearly frightened, his face stayed neutral. And yet it seemed as if he was peeking through hole in a fence, and I could see his eyes carefully following my every move. One of the nurses volunteered to sit with him in the waiting room while I examined his mother, but I was the last one he stared at before leaving; I was the thing he didn’t understand.

I decided to let Edie rest on the stretcher for a while before discharge, and I thought I’d reassure Timmy before I left. He was sitting on the too-big chair as quietly and unmoving as an adult and when I approached, he stared at me like a deer hiding in a forest.

“Your mom’s going to be okay, Timmy,” I said with a big smile.

But he still seemed just as frightened, and stayed silent for a moment. “There was blood on her pants,” he mumbled, perhaps making sure I’d noticed. He allowed his eyes to venture out further into the open and he examined me again. “And she was hurting…”

What do you tell a little boy about his mother’s suffering? I knelt down on one knee in front of him so our eyes were on the same level and put a hand on his knee. I couldn’t  think of anything else to do. “She’s not hurting now, Timmy,” I said and smiled again.

He looked at my hand and then he finally smiled. “Can she go home now?” When I nodded, he reached out and carefully touched one of my fingers, and then when I didn’t pull away, he patted my hand.

I never saw little Timmy again, but a few weeks later, Edie came to my office for a follow-up visit and to thank me for seeing her in the hospital in the middle of the night. “Timmy was really impressed,” she said and smiled. She ruffled through her purse and brought out a rumpled piece of paper she’d nonetheless folded carefully. “He drew this for you, doctor,” she said proudly, and handed it to me.

When I opened it up, it was a drawing of a hand in red crayon.

“He said it was to thank you…” She seemed embarrassed, and hesitated before continuing. “I asked him why he drew it in red…” she said.

She still seemed embarrassed, so I stayed silent until she felt ready to continue.

Edie studied me for a moment with her big brown eyes, still uncertain. Then her face relaxed and a big smile appeared. “He said maybe you were one of us, now…”

I could have cried.

Baa Baa Black Sheep…

Okay, I’ll admit I’m intrigued by investigations that attempt to prove things the rest of us simply take for granted. Things that seem so obvious, that I wonder why they ever extracted them from the background for analysis. When you live in a forest, why would you single out a tree?

Do babies do better when they are loved? I can’t even imagine the need to ask that question, but I suppose we only see the world through the filter of the prevailing ethos of our society. It was not so very long ago, for example, that the psychologist Harry Harlow devised an experiment that, although cruel to contemporary eyes, was an honest attempt to explore what it is that infants need. He separated infant monkeys from their mothers and placed them in isolation in little cages. He then gave them a choice between a metal dummy holding a bottle of milk, or a soft, fuzzy cloth dummy without milk. And, no surprise, the babies chose the soft cloth dummy so they could cling to it. A mother is more than a source of food –much more.

An article in the BBC news last year caught my eye. It posited ‘[…]that babies need to feel safe, secure and loved for brain connections to be properly formed to enable them to learn effectively.’ http://www.bbc.com/news/science-environment-38002105

This was suggested by a study from Cambridge University in England that utilized brain scans. The researchers scanned the brains of babies and their mothers while the two were interacting in learning activities. ‘The early indications are that when the brain waves of mothers and babies are out of sync, the babies learn less well. But when the two sets of brainwaves are in tune they seem to learn more effectively. Dr Victoria Leong, who is leading the research, has discovered that babies learn well when their mums speak to them in a soothing sing-song voice which she calls “motherese”. Dr Leong’s research shows that nursery rhymes are a particularly good way for the mums in her study to get in sync with their babies.’

Fascinating, but taking it even further, ‘[…] babies respond better when there is prolonged eye contact. Mums who sang nursery rhymes looking directly at their babies held their attention significantly better than those who gazed away, even occasionally.’

I recognize how important it might seem to subject the intuitively obvious to some form of scientific scrutiny –just in case, as it were- and I am all for it. Who would dare question what is plain to see and even easier to hear every day in my waiting room? Certainly not me. But sometimes I am, well, surprised at the venue.

I first met Janice in the delivery suite late one night when I was the obstetrician on call. The midwife was concerned about the progress of labour and had asked me to consult on her client. After examining Janice, I had reassured them both and counselled patience and then, with smiles all around, had left to attend to other matters. The midwife later informed me that she delivered a healthy baby boy only a few minutes after I’d left, and so I assumed I’d probably never see Janice again.

So I was surprised when, a month or so later, Janice showed up in my waiting room. At first I didn’t recognize her, but she was singing to her baby and the voice sounded familiar. It’s funny how some things seem inextricably linked to people –a mannerism for one, or a facial expression for another… For Janice, it was undoubtedly her voice. As a small, even petite, woman, I suppose my expectation would be for her sound to match –thin, soft, fragile, perhaps- but like the Pacific wren, the volume far exceeded the source. As did the duration and enthusiasm with which she serenaded her infant. In fact I stood, in thrall, just behind the front desk, not wanting to interrupt her song by inviting her into my office.

Eventually, and not without some concern about interfering with the obvious bonding process, but seeing the baby snuggled contentedly in her arms with his eyes closed, I decided to intervene.

“Janice,” I said, walking over to where she was sitting, and the baby seemed to stir.

She knifed me with her eyes, and a finger flew to her lips to caution me to be silent. She wound down the nursery rhyme slowly and deliberately, all the while gazing intently at her sleeping baby. She seemed to be assessing his breathing pattern and only when she had decided that it accorded with her expectations did she rise and follow me into my office down the hall. I could tell by her subsequent shrug that she hadn’t meant to be rude, or to keep me waiting, but was merely trying to stay in sync with her sleeping infant. That, of course, was fine with me –it’s hard to talk with a patient when her baby is crying.

She settled in a chair by my desk almost by brail; she was so intent on her baby, her eyes never left his face. “I’ve just fed him,” she explained with a smile that only caressed the infant, so I’m not sure whether I was supposed to share. “I think he’ll sleep now,” she added with another misdirected smile.

I decided to respond with a smile of my own, this one directed at Janice, however –a sort of ‘teach by example’, I suppose.

But before it even reached her, the baby opened his eyes and stared quietly at his mother, contentment written across his face like a tattoo. It immediately galvanized her into action, however, and she began to sing another nursery rhyme and rock him in her arms. He obviously enjoyed it and stared lovingly into her eyes as if there were no other reality. No other world. He seemed to be spellbound by the endlessly repeated ‘Baa baa black sheep’ song although after a few minutes, I have to say I became more interested in the rhythmic, hypnotic nodding of her head and felt myself occasionally fighting to focus my eyes.

I began to wonder what the end point of her singing would be. The baby seemed content, he wasn’t crying, or squirming and yet on and on she sang. I tried a few times, unsuccessfully, to ask her why she had come to visit me in the office; the midwife usually follows her clients post-partum unless there is a problem. But each time I spoke, the baby would open his eyes, and Janice would risk a quick glare at me and resume rocking him with yet another song.

Finally, she stood up and looked at me with an embarrassed smile. “I’m sorry, doctor,” she said, heading for the door. “I just can’t seem to settle him today… I’ll have to make another appointment,” she added before launching into ‘Three Blind Mice.’

As she disappeared down the hall, and the song faded into the distance, I realized I never did discover why she’d been sent to see me. But I felt grateful for that final smile, however. Sometimes it’s the little things that matter…

 

Grapple them unto thy soul with hoops of steel.

What is a friend? I think I could parallel St. Augustine’s answer about Time: ‘What then is time? If no one asks me, I know what it is. If I wish to explain it to him who asks, I do not know.’ Friendship is such a universal concept, such an acknowledged need, I’m not sure why it is difficult to define. Perhaps it is so much a part of our Umwelt that the only aspect of it that becomes consciously discernible is its absence. It is our air…

But of late, it seems to me that its meaning has been further eroded, further diluted, by its use in social media. It is now a verb as well as a noun –all well and good if we are willing to enrol people as friends much as we might solicit them to join a political party, or consider anybody that smiles at us as worthy of the designation.

Obviously, friendship is a spectrum and simply because we use the same word to designate the entire range does not reveal much about the meaning or the importance of its constituents to us. In a sense, if used generically and without a more descriptive adjective, the word is an empty shell –‘Full of sound and fury, signifying nothing’ as Macbeth said of Life. And that life is actually not so full of friends -‘Which the poor heart would fain deny and dare not.’ to quote Macbeth out of context once again. We do not have as many friends as we think –nor is it even possible to sustain the emotional effort necessary to acquire and succour more than five, or so, close friends. http://nyti.ms/2baJQPL

So, I suspect we should be careful how we use the term and in what context –for what purpose. The number of ‘friends’ we think we have are akin to the denominator of a fraction. It’s the numerator –the number of close friends- that determine the size. The value… I would have thought this was so obvious as to be almost trite. Uninteresting. But maybe the idea that a friend is someone requiring at the very least, an ongoing personal, non-virtual, interaction is a generational thing. Am I just having a semantic argument with myself; am I merely a Cassandra unable to understand that it is only my opinion that is being contested, and that its tenets have already been superseded? Food for thought…

And yet, there are consequences. Sometimes it is best to check in the rear-view mirror from time to time.

*

I’ve always liked Jennifer. She is a twenty-something year old woman I have known for several years now. I first met her because of a minor abnormality of her pap smear, and have seen her every year or so since then. I think she sits in the same place in the waiting room each time, too; I always associate her with the seat in the corner by the window –the one partially hidden by the Areca palm. She’s a small person, and her never-varying outfit of jeans and sweatshirt seem to blend beautifully with the green of the plant. Even her dark, shoulder-length hair sometimes resembles the type of shadow I imagine the plant would cast if it could… I don’t know why I think that; maybe because they’re both quiet. Both still. Both background.

The other day when I saw her in her usual spot, she was typing away furiously on her cell phone. She looked on edge, and the troubled expression did not disappear even when she saw me smile and walk across the carpet to greet her.

There’s often an easy-to-spot anxiety in some patients –the kind I usually can’t hide when the dentist ushers me into his chair- but I knew Jennifer, and the referral note just said she was back for a repeat pap smear.

“You look worried today, Jennifer,” I said when we were both seated in my office. “Are you concerned about the pap smear?”

She’d put the phone in her pocket and was staring absently at a terra cotta woman sitting on an oak stand with her begging bowl. I’d had it there for years, so Jennifer had certainly seen it before. She shook her head, but left her eyes gently stroking its contours. “She always makes me relax… I’m glad she’s still here.” I could see her trying to disguise a sigh. “It’s nice that some things stay the same…” She was quiet for a moment as she thought about it. “…Stay the way they’re supposed to be,” she added to herself as she moved her eyes slowly over to my desk like sleeping birds and left them lying there. They didn’t see me, I don’t think.

I waited for her to continue, but she merely repositioned her attention onto her lap. “What do you mean?” I asked, when it became clear that she needed to talk about it.

Up flew the eyes to the box of tissues on the desk and she grabbed a handful to wipe away some tears. “It’s nothing about my pap smears,” she said in a hoarse voice. “I don’t need to take up your time…”

“The pap smear talk can wait for a bit, Jennifer. Tell me what’s upsetting you.” I smiled reassuringly, but her eyes never reached my face.

She took a deep and stertorous breath and then decided to send them on a reconnaissance flight in my direction. “Oh, it’s just my ‘friends’,” she said, making sure I understood that there were quote marks around the word. “I invited all 147 of them to like a business website that I’m starting…”

I have to admit that I was a bit confused. “Like? As in Facebook ‘like’ you mean?” I had no idea what message that sent. A friend had once asked me to ‘like’ her barbershop on Facebook and I had duly complied –it seemed simple enough… and if it made her feel good, what the heck, eh?

She nodded, although I could tell by her face that perhaps I shouldn’t have needed to clarify such an obvious point.

“And…?”

She took a deep breath and shrugged. “And, well I guess I don’t really have 147 friends.”

I didn’t ask her how she knew -I figured that was probably obvious, too. But I must have looked surprised, because she giggled at the notion. “I mean I didn’t really think they’d all like the page, but…”

I had to chuckle –I couldn’t help myself. “I don’t even know that many people, Jennifer. I mean not counting patients…” I quickly corrected, as her face interrogated me in disbelief.

“How many friends do you have on Facebook, doctor?”

I shrugged. “I don’t know… I mean, counting my kids and a few close friends… twenty, maybe…?”

She thought about that for a few seconds. “I don’t know how I got so many.” She glanced at the statue again. “Sort of like collecting tee shirts, I guess. They look so nice in the store, but I hardly ever wear them.”

A thought suddenly occurred to me. “Do you know how many ‘liked’ your… uhmm, page?” I tried to sound knowledgeable about the words, but to tell the truth, I was on slippery ground and I think it showed.

She caught her eyes, before they completed a roll and managed to salvage a serviceable smile out of what I’m sure was headed for a smirk. Then her eyes twinkled without her planning on it, and she giggled with delight at my expression. “Only seven, so far…”

It was my turn to nod, and I sat back in my chair as I did so. “Well maybe you come out the winner, then…”

She tilted her head, as cute as a button, and I could see the adult stirring behind the mirror of her eyes.

“Now you know what ‘friend’ really means…” I said, smiling.

Her eyes hovered around my face for a moment before they returned to their owner, and I think she blushed.

The Doors of Persuasion

The Doors of Perception, by Aldous Huxley -I loved that book; I read it when I was a teenager and was intrigued by the idea that there could be doors to abstractions as well as to rooms -doors to other areas, other places. Invisible portals that existed alongside more tangible things, and yet magical, somehow -like the door to Communication.

Communication is such an obvious and basic requirement to enable us to function that it is often invisible until pointed out. Almost everything we do is a form of communication; writing, creating, building -perhaps even imagining- are all done for someone else to notice –despite our ego-dominant protestations to the contrary. We, none of us, live in a vacuum –nor would we be able to, even if we mistakenly thought we might like to try it for a while.

No, the need to communicate is a given; we are social creatures. And there are many reasons for it: to reach out and feel the presence of another is a major one -to share the solitude we all inhabit and reassure ourselves that we are not alone.

And yet the other main purpose of communication –the imparting of information- can be more difficult. Is more difficult. We are all unique, and we guard the differences behind a variety of walls: culture, education, gender… There are so many ways. So many reasons. So many locks on so many doors. The art of communication has always involved the art of persuasion; to open a door, you must first want to open it -and trust that what is on the other side is neither harmful, nor antithetical to what you have become accustomed to, or are able to accept. Willing to accept.

In medicine, to open doors, we have often relied on the magic of arcane knowledge. But although communication through authority can force, it cannot persuade. Cannot convince people that what we advise is necessarily in their best interest, especially if the advice flies in the face of what they have always believed, what those around them have always lived, or what their culture or milieu has always prohibited. There is always other advice, other authorities they can consult that harmonize more readily with what they have been taught, so why should Western Medicine, as we have come to classify ourselves, be specially privileged?

I’m not convinced that in all cases, and in all circumstances it should be. There is usually not one answer that suffices, not just one approach to a problem. But if someone has come to a doctor for advice, or more unfortunately, has been swept into his purview through circumstances not of her choosing, it would be helpful to approach the issue with all the respect it demands. The trust one engenders as the doctor is assigned; it has not yet been earned on that first encounter. Authority of the sort we as doctors possess breaks down rapidly when it attempts to enforce an opinion. Contradicts a belief.

If I, for example, say that something is my belief, I may be closing a door unless the person to whom it is addressed already shares that opinion. Especially if uttered in a fashion or in a circumstance that negates the other person’s opinion -makes them lose face, or does not allow for a compromise that permits their own beliefs, and makes allowances for their own cultural practices. I am not talking life-and-death situations where emergency surgery is required to remove a ruptured appendix, say, or an antibiotic is needed to rescue the body from an overwhelming sepsis… More the situation where there may well be other options –some, perhaps not as appropriate or effective, but where the choice could still be construed as a matter of opinion –mine.

Each of us is the agent of our own lives and we should be free to decide for ourselves what path to walk. Some choices may be unwise and later we may wish we had chosen something else, but wherever possible, the choice should not be forced upon us. And indeed, one of the major premises of medical ethics forbids just that: the principle of autonomy –we should be free to choose whatever option we wish, even if the doctors disagree.

So, if we feel persuaded about the validity of our own beliefs, our own view of the world, it behooves us to unlock the doors of persuasion, not coercion. We are not always right –and that is surely not the point- but we have the best interests of our patients at heart and believe we can help. We do that by earning their trust, their respect, and their confidence. The object, after all, is not to prove that they are wrong and we are correct, but rather to help them to see that, in the face of the legion choices they could make, the one we suggest is most likely to produce the results we both desire.

I sometimes find that is the hardest part. It is difficult for me to listen sensitively to a monologue on ‘cleansing’, say, when I do not accept the thesis that disease is caused by toxins in the gut that need to be removed. It smacks too much of bloodletting, or leeches, of purgatives and enemas, of spells cast on the unwary… Attestations that the poor heart would fain deny, yet dare not. Even placebos help for a while, after all -it is the kingdom of Hope.

But it is not enough to merely try to keep an open mind -as the King says in Hamlet: My words fly up, my thoughts remain below: Words without thoughts never to heaven go. The object, where ever possible, is to stop for a moment to listen -no matter what is said. There is often fear in the other voice. And it’s a dare of sorts that the patient issues: ‘Prove me wrong; convince me if you can -I need something- but first, listen, then explain your point of view. Let me believe I have been heard…’

I want to believe that hope springs eternal in both our breasts.

 

Trust in the Tameness of a Wolf?

Okay, enough is enough! All these years I have been an advocate of cultural relativism. Ethical parity when societal mores and folkways are accounted for. I still am a staunch defender of freedom of belief and societally derived variations from what might be seen as a Western norm, but there are times when I must step back and shake my head. Some things beggar all tenets of humane behaviour. Beggar belief, for that matter… Beggar all conceptions of canon, doctrine, creed… They are ethically and philosophical bereft!

The example -the proximate cause of  this jeremiad- is one that was reported in a BBC News article entitled The WhatsApp Suicide: http://www.bbc.com/news/magazine-37735370 ‘A 40-year-old woman from northern India killed herself in January after a video of her being raped was circulated on WhatsApp.’ And, as if this madness itself weren’t sufficient to turn the country inside out, the article goes on to say ‘At village level, many are more bothered about women using mobile phones at all than they are about men using them to intimidate rape victims or to share videos of sexual assaults. A number of local councils in Uttar Pradesh, concerned with what they see as technology’s corrupting effect on traditional moral values, have prohibited girls from owning mobile phones.’ This follows from what seems to exist in some villages -at least in the region of northern India: ‘[…]in the patriarchal and honour-bound culture of the village, she could be blamed for “inviting” the sexual advances of a man – even if those advances were unwelcome, intimidating, or violent.’

It’s a two-edged sword, really, isn’t it? The women are able to use the phone and its network both for business and, presumably, to call for help, but the same phone can be used to shame and intimidate her. Blackmail her.

‘In August 2016, the Times of India found that hundreds – perhaps thousands – of video clips of sexual assault were being sold in shops across Uttar Pradesh every day. One shopkeeper in Agra told the newspaper, “Porn is passé. These real life crimes are the rage.” Another, according to the same report, was overheard telling customers that they might even know the girl in the “latest, hottest” video.’

But lest we delude ourselves into thinking that India is somehow unique in this regard, consider the case of a young woman in Egypt named Ghadeer: http://www.bbc.com/news/magazine-37735368 She shared the enthusiasm of youth throughout the world –they are, after all, young and although as privy to the social constraints as their elders, not necessarily as wedded to them. She was 18 and videoed herself dancing –fully clothed, mind you, but too clearly enjoying the freedom. It ended up being shared on YouTube by a former boyfriend in an attempt to shame her in ‘a society in which women were required to cover their bodies and behave with modesty.’ But, unlike many, Ghadeer decided to fight back.

‘[…] in the years since she had sent the video, Ghadeer had also taken part in the Egyptian revolution, taken off her hijab, and started to speak out about the rights of women. Outraged that a man had attempted to publicly shame her, she took legal action. Although she succeeded in having him convicted for defamation, the video remained on YouTube – and Ghadeer found herself attacked on social media by men who sought to discredit her by posting links to it. In 2014, sick of the abuse and tired of worrying about who might see the film, Ghadeer made a brave decision: she posted the video on her own Facebook page. In an accompanying comment, she argued that it was time to stop using women’s bodies to shame and silence them. Watch the video, she said. I’m a good dancer. I have no reason to feel ashamed.’

But as the article goes on to note, ‘Most cases of this form of abuse go unreported because the same forces that make women vulnerable also ensure they remain silent.’ Just being photographed in defiance of the prevailing dress code –a hijab, for example- could be used by the unscrupulous for blackmail or intimidation.

Or another example –one of too many, unfortunately: ‘the 16-year-old victim of a gang rape in Morocco, set herself on fire in July this year, after her rapists threatened to share images of the attack online. The eight accused were trying to intimidate the girl’s family into dropping the charges against them but instead drove her to suicide, as she suffered third-degree burns and died in hospital.’

Enough examples! That anyone would disparage the ebullience of youth is in itself despicable, but to turn that same scorn on the most vulnerable of that demographic –the culturally disadvantaged status of females in many countries- smacks of almost terminal insecurity on the part of the (largely male) perpetrators. It’s still unclear to me what it is that renders them so fearful. Surely our very identity as males derives from our difference from –not inferiority to- females.  Much as ‘up’ is only so, in relation to ‘down’, there is an ‘inside’ only if an ‘outside’ exists. These are not value-laden; not better or worse –they merely mark a difference. We are mutually needful of the contrast.

And yet, the two have come to be pitted in an almost eternal battle within both myth and reality alike -the Givers of Life against the beneficiaries… As if Oedipus had turned on his mother or sided with the Sphinx rather than killing his father -all equally pointless. Meaningless.

In a way, I’m reminded of the Fool in Shakespeare’s King Lear: ‘He’s mad that trusts in the tameness of a wolf…’ –or the excuses so readily proffered by those who, in any sane world, should have none.

A question might well be asked about the state of our domestication.