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…

 

Advertisements

The Problem of Freedom

The rough, shadowed texture of a log fallen across a meandering stream, the scattered sparkles of the water as it murmurs briefly to a rock it passes, the deep, barely moving green of the leafy tunnel that shrouds the gently dancing blue beneath -these are what I know of freedom: permission to imagine, permission to believe… Nothing else –nothing, at least, that matters more… As Voltaire said, Man is free at the moment he wishes to be…

I’m not sure what I’m supposed to envisage when the topic arises as it does sometimes in the office. I’m not sure what I’m supposed to say, or how I’m expected to react. Freedom is a charged word. A troubled word. It so often refers to an imaginary, or a that-which-is-not. It is contextually defined, and so often spiritually embossed. Like Goodness, or Happiness, it is something to which we are expected to aspire, and because we can never assure ourselves that we possess it, the search, like that for the end of the rainbow, is never done.

It is also a partitioned concept, like being freed from a cage that is locked in a closet that is locked in a room that is locked in a house… To escape from one thing is always to be imprisoned in another –the escape from the innermost Russian doll only to be trapped within the next in line. Freedom, I had always thought, is simply where and when you are; it is a frame of mind, not a frame of circumstance. But I’m not so certain anymore…

This problem of freedom surfaced one day in the office, although I didn’t recognize it at first. The more curious of my obstetrical patients often wax philosophical at unexpected moments. I didn’t think Thira was one of those, I have to admit, but pregnancy –especially the first- has a way of changing a person. Opening them up like the petals of a flower in the morning sunshine. And Thira was a flower. A thin, short woman, she was a Greek with smiling eyes, and spoke with an accent that enchanted me each time we met. I think I sometimes asked her questions just to hear her talk.

But occasionally, she felt it was her turn to ask, and one day, midway through her third trimester, when talk of contractions and labour occupied most of our time together, she suddenly turned serious and her iconic smile disappeared for a worried moment. “Doctor,” she said after I had listened to the baby’s heart beat, “What does the baby’s movement mean?”

I was busy entering in my measurements and the heart rate in the chart, so I didn’t even look up. “What do you mean, Thira?”

“Well, she used to be so predictable. She’d kick after I ate dinner and then start rolling around about ten o’clock when I was in bed. Like she sort of knew what I was doing and was signalling me to say hello. Showing off…”

I looked up for a moment from the chart and smiled. “But you said, ‘used to’…”

The worried look resurfaced. “Well, last night she didn’t stop. She just kept rolling and kicking all night. At first I thought maybe it was the way I was lying in bed, but she kept it up no matter what I did. The kicking even got worse when I got up.” She took a deep breath and looked at the floor. “Okay if I ask you a silly question?” I nodded reassuringly. “Well… I keep thinking she feels trapped in there. I mean, it’s a pretty small space and she’s growing… Wouldn’t it be like being trapped in a small elevator when the electricity and the lights go off?”

I’d never actually considered whether a fetus would –or could- feel imprisoned before. My first thought was to wonder whether the baby, rather than feeling trapped, was actually feeling stressed for some reason –an accident with its umbilical cord, for example, or maybe a change in the placental circulation. I molded my facial expression into neutral so as not to alarm her. “Well, I would think that the uterine cavity space and the darkness is all she’s ever known, Thira. She must be used to it by now, don’t you think?”

She shrugged and painted an anxious smile on her lips. “I suppose… But what if she’s panicking because she’s just discovered she’s trapped? That after all this time, she realizes she’s not actually free?”

I said that before we assumed something like that, it would probably make sense to be sure the baby wasn’t telling us it was in trouble. I reassured her as best I could and sent her right over to the hospital for a non-stress test (NST) to assess the baby’s heart rate in response to its environment; its own movements for example would be the equivalent of someone doing exercise and should raise the heart rate briefly. If there was no change in the rate, or worse, a fall in the rate, it would be unusual and unexpected at the very least. It might signify fetal distress.

The NST was fortunately completely reassuring, as was a bedside ultrasound we did to visualize the umbilical cord and the amount of fluid around the baby. Thira still seemed concerned, though. “I still think she was telling me something, doctor.”

I sat down on the bed beside her. “Well, we can’t find anything wrong, so what do you think she is trying to tell you, Thira? What does she want?”

A weary smile appeared from nowhere. “Freedom, doctor. She wants her freedom.”

I was struck by Thira’s use of the word ‘freedom’ all the time. She didn’t appear at all surprised that there didn’t seem to be any problem we could find with the baby: no umbilical cord around its neck, no decreased amniotic fluid around it, no worrisome changes in the NST. And when I once again reassured her about the findings, she responded with another shrug.

“How can any of your tests measure the need for freedom, doctor? I’m sure most prisoners have normal heart rates, normal responses to exercise…” She stopped talking and looked in my eyes for a moment. “It’s only when you look in their eyes you can tell something is missing. Freedom can’t be tested, I don’t think…”

I had to process that for a moment. “But…  But you’re only 34…” I had to look at the chart I was holding. “34 weeks and 4 days pregnant. Your due date isn’t until 40 weeks… Surely your baby is far too young to appreciate such an abstract thing as Freedom.” I was proud of that response; I thought I had her.

Her face wrinkled in curiosity at my explanation. “I can calm my baby down by talking to her. She seems to respond if there’s music in the room… That’s pretty abstract, don’t you think?”

I blinked. I couldn’t think of another response. But I wondered if this was really cause and effect, or maternal attribution.

“When do babies start to think anyway?” she asked and scrutinized my face. Then she paused for a moment. “Only as soon as they’re born –freed?” she continued after she could see I wasn’t able to answer. “And what about the increasing number of studies showing the abstract conceptual abilities of even young babies?” I must have had a blank look. “Have you read that book: The Philosophical Baby, by Alison Gopnik…?” I hadn’t, actually. “There are others, too,” she said, reading my expression.

“But…” I shook my head slowly in -what? Desperation? Frustration? Or maybe in fascination at something about which only a mother could be convinced.

“If babies only a few months old can demonstrate a sense of injustice or fairness in the studies researchers do with them; if they can be seen reacting to things that seem to them to be unusual or unacceptable, then why would it be so hard to believe they could also have a simple concept of Freedom?”

I have to admit that I didn’t have an answer for Thira, although she certainly opened up a few questions that still trouble me -a Pandora’s box. Is the desire for Freedom innate –like curiosity, the desire to learn, or the impetus to find and create Beauty? Is it so abstract that it doesn’t even exist outside the mind as I said at the start? And is it so integral to our existence, that we need to manufacture it when we don’t think it’s there? There is a problem with Freedom I think: knowing what it is… and where. But maybe Robert Frost got it right: ‘You have freedom when you’re easy in your harness.’  Maybe it’s as simple as that.

The Mistaken Identity

Communication is a fascinating thing. It enables descriptions of the world in different sounds, different gestures, different expressions. A shrug of indifference in one culture is a greeting in another. A nod can convey a myriad of intentions -context is everything. Only the smile seems a common currency. As a gynaecologist, I am ruled by boundaries, beyond which I dare not venture without, at the very least, the permission of a smile.  It is a sign hung upon the face that needs no words -the Rosetta Stone that unlocks the mysteries of culture and walks the unfamiliar language like a bridge.

My office is a tiny United Nations, with a rainbow range of clothes on display, and skins to match. The waiting room is impossible to ignore, but equally difficult to understand. Words are encrypted by language, and intent masked by the panoply of expressions encoded in millennia of habitual use. It is a place of pleasant noise. Expectant. Pregnant, if I may say, with expectations both imminent and anticipated. Now is just a passing fancy; it is the future they await: a baby, a diagnosis, or just the reassurance that they are in not imminent need of help. It is a place of smiles, both nervous and shy -signals that they understand their different reasons for sitting side by side.

But it is sometimes a more confusing world once they have entered my consulting room. Words matter there. Meanings are crucial, explanations need context, symptoms require a modicum of description. Except for the more flagrant and visible aberrations of bodily integrity, diagnoses require detail. Language. And patients who are adept at simple conversations in English often struggle with words they would not encounter in the home. What is hidden from sight, is usually hidden from discussion: there is seldom a need to talk about an ovary nor, for that matter, a vagina -even in their own language. It is more often passed over with a blush, or an anxious smile.

I tell the referring doctors to ask their patients to bring a translator with them if they think it may be a problem, but too often it is a family member with similar language skills who accompanies them -a daughter who is too embarrassed to say the words, or a husband in front of whom she is ashamed to admit the problem. Everyone smiles, but often with incomprehension or discomfort.  I love the challenge.

Sometimes the challenge is of a different sort, however; sometimes it is me who is embarrassed.

There were just two of them in the waiting room -sisters, likely, and not too far apart in age. As I walked into the room to greet them, they were huddled together whispering loudly about something and didn’t notice me until I was standing right beside them.

“Wei?” I said in a rather tentative voice, reading the name off the referral letter that was written on a piece of paper, but not certain I had pronounced it  correctly.

I was immediately greeted by a smile -two smiles- and they both stood up. Neither made eye contact, but they followed me down the corridor to my office -normally a good sign. I felt confident that one of them was Wei.

“Wei, you sit in this chair by the desk,” I said, addressing the space between them, and hoping for clarification in the assigned seat. But instead, they seemed confused and I could almost feel the mental flipping of coins as to who sat where. I addressed the Wei seat first. “Wei?” I said, to cement the relationship.

They both smiled -nervously, I thought. The Wei seat answered for them both. “Wai,” she said -by way of correction I assumed. Even though I’d taken conversational Cantonese many years before, I never mastered even the rudiments of the many variations of pronunciation, let alone meanings of words that seemed otherwise identical. But I was happy at the confirmation of identity and smiled my acknowledgement.

“So why are you here today, Wai?” I said, careful of my pronunciation. And careful to differentiate her from her sister. Apart from the name, the referral letter was illegible.

They exchanged glances, apparently trying to decide who should answer. Obviously one of them was better at English, and they wanted to make sure I understood. It was Wai in the assigned patient chair who answered. She seemed pleased that she was able to speak, but she, too, seemed to need to clarify the situation before proceeding any further. “She my sister,” she said pointing at the other chair.

I smiled and nodded at the information. “How do you do?” I said to each of them. Clearly there was a series of preliminary introductions and small talk that were deemed necessary. Polite. I decided not to rush things, but after conferring briefly with her sister, she got right to the point.

“Me?” she said, pointing to herself. I nodded in assent. She smiled broadly and looked at her sister. Proudly, I thought. I could see her struggling to find the correct words. “Baby,” she said, and her smile almost split her face in two. “First baby!”

I could tell this was going to be a difficult. Her sister stayed quiet, merely nodding whenever Wai said anything. “Do you speak English?” I said, politely turning to the sister. Hope springs eternal. But she shook her head smiled. “Only little,” she added after a moment and an inquisitive glance at Wai.

It was Wai’s turn. “I the good English,” she said confidently and not without an ill-disguised condescending glance at her sister.

I wasn’t really sure how to proceed. Taking an adequate history was impossible -even finding out if there were problems with the pregnancy so far seemed remote. But Wai appeared so enthusiastic and happy, I thought I’d try for a few basics. “So, when is the baby due?” I immediately regretted the word ‘due’ because her face fell. I decided to try a more basic form: “When baby come?” I felt embarrassed to say it like that -it too, seemed condescending- but Wai understood and smiled again.

“Seven,” she said, holding up seven fingers.

Encouraged, I considered pressing on with more detail. I thought I’d try for the date of her last period -that would  help me plan what to do next in terms of ultrasounds, blood tests, and so forth. “When did your last period start?” I said as slowly as I could without sounding silly. But I quickly realized I’d framed it poorly. “When last bleeding?” I tried, blushing at the clumsy attempt.

Again the smile. “June one,” she said, this time holding up one finger confidently.

Great, I was getting somewhere at last.  But when I then tried to ask her if she’d had an ultrasound yet, it became immediately apparent that I had reached the bottom of the well. I shrugged and put on my best smile. “I’m going to need more information…” I sighed to show I knew how difficult it must be for her. “You’re going to need to bring an interpreter next time, Wai…” She looked disappointed, so I think she understood. She turned unexpectedly to her sister and quickly said something to her that sounded like she was confused. They both looked at me for a moment, and then huddled together in quiet conversation, occasionally risking a puzzled stare and then submerged themselves in words again.

“So, you not talk to Wei?” she said, pronouncing the name as I had in the waiting room and pointing to her sister.

“Are you not Wai?” I said, confused at the pronunciations, then glancing at my watch.

She nodded vigorously and smiled. “I Wai; my sister Wei,” she said, touching her sister gently on the arm. Then they both began to laugh. “You make mistake..?” said Wai -I think it was Wai; I was becoming quite confused. But I have to admit I blushed all the same.

I managed to chuckle along with them; they seemed quite amused by the whole encounter.

“Not problem,” said Wai, glancing at her watch. “We come back.”

And so began another day at the regional section of my own United Nations Gynaecology division… Do you see why I love what I do?