With mirth and laughter, let old wrinkles come

“Bear with my weakness. My old brain is troubled. Be not disturbed with my infirmity”, says Prospero in Shakespeare’s Tempest. But at what age does one become old? And if we could answer that without resort to comparisons would it be a useful thing? Or does it, in fact, require perspective to sort it out? The famous passage in the King James version of the letter Paul wrote to the biblical Corinthians declares, ‘When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.’ Really? I’ve always thought of the journey through the years as more the chiaroscuro in a painting. I can still see shades of childhood, despite my age, in the bright colours of a laugh, or the shadows of a memory. Indeed, I’ve come to see my life as a pentimento -nothing wasted, nothing forgotten, merely painted over as best I could.

I am drawn, therefore, to others who recognize their own plasticity and smile when the veneer of time is chipped. The patterns underneath persist -or would, if encouraged with a little wipe. It has become fashionable to talk of today’s ‘seventy’ being our parents’ ‘fifty’, although, again, a comparative rather than an established fact. A trope, rather than a datum. But, there are hints that this is changing, as an article in the BBC reports: http://www.bbc.com/news/health-43308729

‘Doing lots of exercise in older age can prevent the immune system from declining and protect people against infections, scientists say. They followed 125 long-distance cyclists, some now in their 80s, and found they had the immune systems of 20-year-olds.’ As a long-time runner, and avid cyclist, I am happy to hear this kind of thing.

‘Prof Janet Lord, director of the Institute of Inflammation and Ageing, at the University of Birmingham, and co-author of the research, said: “The immune system declines by about 2-3% a year from our 20s, which is why older people are more susceptible to infections, conditions like rheumatoid arthritis and, potentially, cancer. Because the cyclists have the immune system of a 20-year-old rather than a 70- or 80-year-old, it means they have added protection against all these issues.”

‘The researchers looked at markers in the blood for T-cells, which help the immune system respond to new infections. […] They found that the endurance cyclists were producing the same level of T-cells as adults in their 20s, whereas a group of inactive older adults were producing very few. […] A separate paper in Aging Cell found that the cyclists did not lose muscle mass or strength, and did not see an increase in body fat – which are usually associated with ageing. “You don’t need to be a competitive athlete to reap the benefits – or be an endurance cyclist – anything which gets you moving and a little bit out of puff will help.”‘

A few months ago I was driving back from a day of cycling along some forest trails in the mountains, and feeling rather smug that I had managed to avoid the rain now pounding down on the car. I was still on a narrow, pot-holed asphalt road winding through the trees, and even though my bike was securely fastened to the rack on the trunk, I had to drive slowly. Visibility was limited because of the meandering road in the rain, and more than once I confused a tree, waving its limbs in the wind, for someone standing along the side of the asphalt wanting a lift.

And then I saw him -or rather it: a figure walking slowly along the side of the road with its head down. It didn’t acknowledge my approach, and I couldn’t really tell if we were heading in the same direction. The figure was sodden in the driving rain and walked with a pronounced limp. Wearing a rather thin jacket and a toque, it slogged doggedly on as if it didn’t mind the weather.

I don’t usually offer rides to hitchhikers, and especially not here in the wilderness, but sometimes conscience beats down harder than rain. I slowed, and rolled down my window enough to shout at the bedraggled figure. On first glance he appeared to be a thin man, but as I stared inquisitively I could see long grey hair streaming across the face, almost covering a pair of bright, but suspicious eyes inspecting me.

“Do you want a ride?” I yelled, trying to be heard above the din of rain pounding on the metal of my car.

The eyes, alternated between wariness, and disinterest as they inspected first me and then the car. And finally, when I could see them resting on the bike on the trunk, they suddenly softened. “Yes… Thank you,” said a very female voice.

We were both silent for a while as we wound along the endless sinuous road, each of us waiting for the other to speak. Finally, my curiosity won out. “So, why were you walking along a lonely forest road, so far from town?” I asked. She was probably in her nineties and certainly not dressed for the weather.

Her eyes made the trip to my head at last, but danced about trying to find a place to settle. Finally, they chose my cheeks. “I try to go for long walks each day…” she said slowly, obviously trying to decide how much to tell me. She was, after all, a vulnerable elderly woman, in a car with a stranger.

I smiled. “I was out for a rather long ride today myself,” I said, trying to open up the conversation further.

She smiled in return and stared out of the window at the rain for a while. “My husband and I used to ride our bikes every day -even in the snow…”

She trailed her sentence off again, like she didn’t know how much she should reveal to me. “And now you walk?”

She nodded and I could see her sigh with the memory. “My husband had an… accident,” she said, looking out the window again.

“I’m sorry.” It was the right thing to respond, I suppose, but it sounded so anemic, so empty, in the full fury of a May storm.

She looked down at her lap, her face contorted for a second before she wiped her cheek with a damp sleeve.

I glanced at her out of the corner of my eye as I drove slowly and carefully along the bumpy road through the increasing fury of the wind-driven rain.

“We didn’t mind the rain,” she began again. “It was a challenge to see how far we could get before one of us noticed the other was tired. Neither of us would ever admit we were, of course.” She sighed again, this time deeper -as if it was a relief valve for things that were building up inside her. “But we always looked out for each other.”

I was concentrating on the road in the worsening conditions, but I could tell she was watching me carefully.

“We were always like that,” she continued, as if she had to let me know. “We’d ride until we were exhausted.” I could feel her eyes poking at my cheeks like little birds. “In our younger days, we’d take a tent and strap some supplies on the bikes and just take off. It didn’t matter where… Just to be together on a new adventure, not knowing where we’d end up…” She sighed again -this time loudly. Then she was quiet, as we both listened to the rain on the windshield and the wipers pretending to help.

“I really miss him,” she said suddenly, her voice barely audible as the car visibly shivered in a gust of wind. “It will be a month tomorrow since he died…”

I risked a glance at her. Sorrow was written like a paragraph across her face, but her eyes were resting on me in a coda of gratitude, and I think I blushed.

She took a slow deep breath and exhaled it softly. “I wasn’t going to turn around, you know,” she said, suddenly. “I was just going to keep going…” A gentle smile slowly formed on her lips and she closed her eyes and sat back on the seat, relaxed and relieved that she’d been able to talk about him. “Then I saw your bike…” she sighed again. “He had one just like it.”

And then uncertain quite what to do, she reached out and touched my arm. “I know he was telling me to turn around…”

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Screening in the Digital Age

I never thought it would happen to me, but all the same: ‘I grow old … I grow old … I shall wear the bottoms of my trousers rolled’. Or at least some days in the office feel like that. Perhaps it’s the clientel who’ve worn the years with me –people whose children I delivered who are now patients of mine, with their babies, in turn, waiting for liberation: Samsara… the eternal round of birth and death.

Or maybe its just the mood that Ellen drags along with her on her annual visits. Lennie, as she insists on being called, seems to straddle that razor edge between then and now. Like someone dressed in layers to cope with changing climate, she seems to wear Time like a jacket that she can don or shed as the mood strikes. And just when I think she has lost all contact with the here and now -that dementia has finally arrived- like a bodhisattva she doffs her jacket and enters my world again. Or is that giving both of us too much credit? We are each of an age when the past is retrospectively falsifiable to endorse the visions we have created for ourselves –our personal myths. The trick, of course, is finding a buyer. I think this is why Lennie insists on returning to me year after year for a pap smear despite my insistence that in her case, with her pristine and otherwise untouched cervix, the interval is too short. And in my region, if the pap smears have always been normal, we stop doing them at 69, so I don’t know what she’s going to do next year…

“Can’t you make and exception in my case, doctor?” she said, anticipating my usual advisory monologue. Then she moved her chair so close to the desk it hit the edge, rattling the little wooden statue I’d hidden behind a plant for some reason. She always did that. And she was always dressed the same: a black, knee-length skirt with a white frilly blouse that hugged her neck like a noose. Her hair was short and died dark brown. She managed to wear it like a bathing cap that was so impeccably arranged, it could have been painted in place. She was tall and slender –too slender perhaps, but the hair style suited her.

“You’re 69 now Lennie and your pap smears have always been normal. You won’t need them after this.”

A coy look that I’d never seen her use before, gradually crept onto her face. “You told me the reason you stop doing paps at my age is because most of us don’t get exposed to new sexual partners and the sex virus…”

“HPV you mean?” I thought I’d add that for clarity.

She brushed off my attempt at information with a dramatic flick of her wrist. “Whatever.” She stared at me sternly in silence for a moment to heighten the suspense. Then her face relaxed and the wrinkles reappeared around a broad smile. “My girlfriend, Shirley, has been helping me to learn the computer,” she said proudly. “She’s showed me how to enroll in a dating site… And she lent me her tablet… It was a gift from her daughter, but she can’t figure it out. Touching the screen makes her nervous, for some reason.” She studied my expression for a moment, then apparently satisfied that she hadn’t shocked me with her technological savvy, continued sotto voce. “Problem is, I can’t figure out what to do some of the time either.” She shook her head slowly. “Kinda gets away on me sometimes. And then when I touch the screen to try to enlarge one of the…”-she searched her memory banks for the word- “…one of the apps to see what it says, the stupid thing thinks I’ve chosen it and I get rerouted onto something I don’t want.” She shrugged, as if to admit that it’s an adventure that all techies have to endure. “Ever happen to you?” she asked -to be polite, I suppose.

I sat back in my chair, remembering my visit that morning to the cash machine. They’d installed a newer, faster model over the weekend. But, whereas on the old one –the one I was used to- you actually had to touch the screen to make a selection, the new one seemed to sense my finger when it was a few millimeters away while I was on my way to another choice. It took me a few seconds and several more attempts to figure out what I was doing wrong. I suddenly felt old.

And what was I doing discussing dating sites in the consulting room anyway? I was running an office, not a coffee shop. But she was looking at me as a child might for validation that it wasn’t just her that was struggling with technology. So I nodded.

There was a recent article I’d noticed on the IPhone BBC app I routinely read at breakfast that had addressed that very same issue: ‘The response time for icons on an Apple screen is 0.7 seconds, but the over-65s have a response time of about one second’ Or perhaps more worrisome –I’m a surgeon after all: ‘And tests suggest that if an older person has a slight tremor, it can be registered on a device as a swipe rather than a touch.’ http://www.bbc.co.uk/news/technology-32511489  Wow! Was age so apparently disabling that they realized they’d have design stuff differently for us? New apps? New screens? New innovations to deal with tremors? Were we being offered technological walkers? Worse, was Lennie trying to include me in that group?

“So,” I began, trying to change the subject -trying, in fact, to change the mood in the room, “how did we get on to this subject anyway?”

“My dating site,” she said, but seemed a bit uncertain herself. I sighed a little too obviously I’m afraid, and she noticed it. Her eyes narrowed for a second. “But I don’t trust it, you know.” She chuckled softly and looked at me. “Shirley tried it, too, she said. The guy was in a nursing home and didn’t tell her –it wasn’t in his profile… But she had trouble with the apps as well; she probably hit the wrong one.” She blinked -a cautionary flicker of her eyelids. “Scary, eh? I mean it’s not worth it to go through that just to get another pap smear.”

She stared at the wall behind me for a second. “Maybe next year I could see you for my osteoporosis…”

What’s in a Word?

Alexithymia. Ever heard of it? Me neither. It sounds like one of those words you’d get in a national spelling bee when they’re trying to off you. Fortunately it has a rather pedestrian etymology: ‘a’ meaning ‘without’; ‘lexis’ –speech, or words; and ‘thymos’ – soul, or emotions. In other words: no words for feelings. Hmm… Who would have thought it was a condition? Mind you, since there’s one called anhedonia, the gloves are off.

I’m fairly certain that its shadow would never have darkened my office door, had not a patient pulled it deliberately from her purse while reaching for her phone. Pandora comes immediately to mind, but this lady’s name was Alexis – or, rather, Alexisse as she quickly corrected me- with the accent on the last syllable would you believe? She seemed innocent enough sitting in the waiting room, but in retrospect, she was more a pier in the currents of a hectic room than a middle aged lady. The usual waves of noise and confusion seemed to break over and around her with as little effect as a storm on a breakwater. Throughout the maelstrom, she maintained a smile on her face, but she later admitted to me that it was a well-practiced artifice –a mask that she would always carry with her to help her to blend in.

Her clothes certainly helped as well –a grey skirt worn just below the knees, white blouse buttoned tight around her neck, but loose at the wrist, and black shoes with just a hint of a raised heel. Her light brown hair was short and tidy and her nails long and uncoloured. An average height, she would have melted into any crowd without a trace. Indeed, she followed behind me to my office like a shadow.

I’m describing her like this in the full light of retrospect, however. We always tend to remember things in ways that make sense to us I suspect, although at the time, only the word stood out. She presented as a model patient, and was not at all upset that I was running behind time and was almost an hour late before I was able to see her. “These things happen,” she said with the same smile she’d worn through the whirlwind out front. “I carried a book with me, just in case.”

I brought up her file on the computer as she sat contentedly across the desk inspecting the art work on the walls. I’d not seen her before, but the only thing the family doctor had sent me was the result of a pap smear she’d done recently. Alexisse was a new patient for her as well, and apparently had not had a pap done for over ten years. But worse, the smear was read as showing some malignant cells.

“Did you find the pap smear results?” she suddenly asked, the smile still on her face.

I nodded and looked at her for a moment before speaking. She didn’t seem at all upset so I assumed her GP hadn’t discussed the results with her. Of course the diagnosis was unlikely to be firm until a biopsy of her cervix had been done, so perhaps she had decided to wait until I did that before discussing it with Alexisse.

“Dr. Mandel said you’d be able to confirm the diagnosis with a biopsy.”

The smile never left her face but I was drawn instead to her eyes –they were totally neutral. Cool, if anything. “What did Dr. Mandel say about the pap smear?”

Alexisse shrugged. “Well, for a start, she tried to downplay everything. She said that pap smears are only screening tests and so sometimes they are mistaken…” She stopped for a moment and stared at me with an unchanged expression. “But even when somebody goes to great lengths to paint a black paper white, you know it still ends up looking grey.” Her eyes sought mine to see if I understood.

I approached the topic carefully. “So… What do you think she was trying to tell you?”

Another shrug. “That I have cancer of the cervix.” She said it as if I had asked her about her last period.

I was speechless for a moment. There was no sign that she was upset. No tears. No tightening of her facial muscles. Just the smile –the mask. “You don’t seem very upset. Your family doctor must have done a good job of discussing it with you.”

Alexisse shook her head. “She seemed a little confused about what to say. She asked me if I had any questions, and when I didn’t, said she’d send me to see you.” She stared at me for a while and when she saw that I looked puzzled as well, sat back in her chair.

“I have alexithymia,” she said as she reached nonchalantly into her purse to turn off a phone that was ringing. I must have cocked my head, because her expression intensified. “It’s a condition that makes it difficult to feel emotions –even identify them as such. I’ve learned to put a smile on my face along with my makeup in the morning.”

I started to ask if it was a type of autism, but she saw the word forming in my mouth and waved it away. “Only half of us with the condition are autistic, if that’s what you’re going to ask…” She took a deep breath and let it out slowly. “I’m sure it’s a spectrum disorder –worse in some, less in others.” The smile appeared again. “And the next question you’re going to ask is about my name. Isn’t it a little suspicious that my name is almost the same as the condition? I mean I can almost see everybody thinking it. Go online and you’ll see the community calls its members ‘Alexes’. It’s why I’ve started pronouncing my first name differently…” She sighed briefly. “I don’t think the condition is even accepted by mainstream psychiatrists yet. It wasn’t in the DSM IV at any rate… But I have to admit I haven’t looked lately.”

“So…”

She crossed her arms and stared out the window. “I’ve always wondered about why everybody except me seemed to get excited about things. I can’t remember ever being angry, or crying at a movie. People thought I was weird.” She shifted her position on the chair. “Anyway, I looked up the etymology of Alexis –which is how my parents spelled the name- and realized it came from the Greek for ‘without speech’. It didn’t take Dr. Google very long after that to introduce me to alexithymia.

“And no, I haven’t had a formal diagnosis. Dr. Mandel asked me about that.”

I sat back slightly on my chair to get the computer screen out of the way. “Well, frankly I’m more concerned with doing a biopsy as soon as possible than with any personality disorder you might have…” I wanted her to know that the most important thing to think about at that moment was her health. I meant well, but her facial expression changed immediately. She looked almost angry –hurt, at the very least.

“Personality disorder? And that I might have?” Her whole body tensed at the perceived insult. “I think you’re being entirely too insensitive, doctor!” She shook her head slowly. “Just like my family doctor. Now you see why I don’t go to doctors very often.” She started to get up from her seat. “Your secretary can let me know when you’re going to do the biopsy,” she said, still shaking her head in disbelief. “You all seem to ignore who I am for what I have…” She fixed me with a glare that almost pinned me to my seat then left the room with a toss of her head… Anger?

She never showed up for any of the biopsy appointments despite multiple phone calls from both our office and her family doctor’s. I can only hope she sought help from someone who listened to her pleas for understanding. I don’t know whether she actually had alexithymia or some other mental issue such as schizophrenia, but it clearly seemed to interfere with her ability to process information appropriately. I’ve since learned that alexithymia is often associated with other psychiatric disorders, so perhaps she had decided to fixate on a more acceptable but obscure variation. Maybe she’d been wearing another mask -one that even she had not suspected. Or one that she found too difficult to acknowledge…

I also Googled the word and discovered that the BBC had an article on it that was dated a month or so prior to her visit: http://www.bbc.com/future/story/20150818-what-is-it-like-to-have-never-felt-an-emotion I remain open to convincing, but I keep remembering what Iago said in Shakespeare’s Othello: ‘I will wear my heart upon my sleeve for daws to peck at. I am not what I am.

Placentaphilia

Finally! Somebody has had the courage to think the unthinkable and say what most of us have been too shocked to verbalize, too nauseated to contemplate: that eating your baby’s placenta is not a plus. My risen gorge has been vindicated.

An article in the BBC news http://www.bbc.com/news/health-33006384 reports on a review article on placentaphagy (the practice of eating placentas) from Northwestern University http://link.springer.com/article/10.1007/s00737-015-0538-8#page-1 (published in the Archives of Women’s Mental Health) that suggests that there are no proven benefits and no research on the potential risks.

Uhmm… Well, okay, no blinding epiphany there. I mean even if you saute it and hide it under a leaf of lettuce between two slices of toast, you would think it would still lack that magic je ne sais quoi. But, alas, you would be wrong. There has long been a fascination with the placenta and its powers, no doubt rooted in its dual role in both sustenance and connection. It is, after all, neither baby nor mother, and yet an essential workshop serving the two worlds. A mythological creature, its function does not cease with the accident of birth.

Name the culture, and there’s probably a tradition. Some of the aboriginal peoples of the Pacific Northwest of Canada, for example, have the belief that if the placenta is placed in a tree and then carried off by a raven, the child will travel. The New Zealand Maori suggest that the placenta has a link with the earth and should be returned to it when it is no longer needed. There are even those who believe it was alive and functioned as a companion for the baby but then sacrificed itself so the child could be born –I like that one.

My point, I suppose, is that given the magic surrounding the placenta, it should not come as a total surprise that some might feel that the power it wielded might be transferrable if it were consumed. Or, perhaps, that some of its constituents may be beneficial. But I wonder if it’s the same kind of logic that Macbeth’s three witches used. It’s certainly a stretch to suggest that the placenta offers something that isn’t more readily and efficiently available in some other more acceptable format. The fact that it came from within the body and has served as a treatment plant in utero does little to recommend it in my opinion.

But I am more than a little disappointed with my own Medical culture’s lack of imagination. Its lack of narrrative. We are a society of stories –it’s not only how we impart information, its how we value it. Evaluate it. Surely we could have made something up as well… Tradition wrapped in metaphor is far more meaningful than facts trapped in lists. Sometimes facts must wear scratchy and uncomfortable clothes to attract attention. Gather adherents.

Once upon a time when I was young and still wore a stethoscope around my neck, I found myself in the midst of nothing less than an epidemic of placenta-eaters. Wave after wave of them swept into the case room, teeth sharpened, and bread sliced. They couldn’t wait to enter the Kingdom of the Enriched –some even partaking before they left the delivery suite. Usually they were discreet and waited until we had left them alone in the room to bond; sometimes they seemed in a rush.

I’m not certain what started the practice –it was, as I recall, before the days of social media- but start it did. Suddenly, and with an enthusiasm I had never witnessed, it was upon us. But until I saw my first bite, it was a horror that lived in legend alone.

*

The hospital nurse assigned to the couple was an English-trained midwife and she shooed us out of the room as soon as we doctors had congratulated them and put away our instruments. I should have known something was up when I was even led away from the little window in their door.

“They need some privacy, doctor,” the nurse informed me as she grabbed my elbow and steered me away. “This is a really important time for them,” she added, winking at me cheekily and then hobbling into the lounge to get a coffee.

I wandered over to the ward desk and pulled out the chart to enter the usual description of the delivery and write some orders when I discovered I didn’t have a pen. I checked the counter and even riffled through some drawers, but to no avail. It was around two-thirty in the morning, and no one else was around. I decided I must have left mine in the delivery room, so I walked down the corridor to their room and pushed open the door.

Mistake. The father was lying on the narrow bed beside his wife who was holding the swaddled baby on her chest. Three things struck me: the baby was preternaturally quiet; the parents both had silly, embarrassed smiles on their faces; and he looked like he had been practicing with bright red lipstick. He’d even got it on his teeth.

I quickly looked away so I wouldn’t embarrass them in their intimacy. “Sorry to disturb you like this,” I said, a bit uncomfortable that I had maybe caught them in flagrante delicto as it were. “I left my pen in here,” I mumbled and searched around on the floor for it. It was then I noticed the umbilical cord suspended from the edge of a blood-tinged sheet on the bed. I was horrified; I thought perhaps the placenta had somehow gotten mixed up with the blankets after the delivery.

I stood up suddenly beside the bed. “I’m so sorry,” I said, in my most apologetic voice. “Did we forget to clean up your bed after everything?”

He looked up at me sheepishly, still holding a fragment of placenta in one hand. “I’m afraid it was us…” His voiced trailed off as his wife looked at him with hooded eyes. A profound silence blanketed the room suddenly. No one spoke; the baby snortled; and I could hear all four of us breathing. Labouriously. Expectantly.

The husband broke the tryst. “Not what I expected, actually,” he mumbled cryptically. I could see his wife giving him a poke under the covers. “Wouldn’t recommend it to anybody, that’s for sure…” She sighed loudly and glared at him over their still sleeping baby.

I thought it was unusual for the baby to be so quiet –they usually cry a fair amount after delivery to fully open their lungs and adapt to life outside the womb. I reached over and vigorously rubbed its back through the blankets he’d been swaddled in –at that time the parents weren’t taught the importance of skin-to-skin contact for mom and baby like they are nowadays, so it would have been difficult to spot breathing problems in the infant through all of the layers.

The baby made a weak attempt to cry while mother sat up immediately and demanded to know why I had attacked her baby. She pushed the bell for the nurse at the same time. By the time the midwife had arrived with angry eyes, I had transferred it to the bassinet and was fiddling with a suction tube preparing to suction out the baby’s mouth.

When the nurse heard the grunting of the infant and saw what I was attempting she smiled at me and took over.

The mother, in the meantime, was distraught. “Why did he wake my baby up?” she screamed. “We were having a little quiet time when he barged in here and grabbed my baby.”

The nurse handed a screaming infant back to the mother and touched her gently on the arm. “You should be glad that Doctor came in, Emily. Your baby was having trouble breathing with all that mucous in its mouth.”

The husband looked embarrassed. “I think we were too focussed on that weird placenta stuff,” he said and smiled at Emily to sooth things over. She blushed and cast a loving glance at her screaming baby.

“It wasn’t very tasty was it, honey?” she whispered. “Not at all like that book promised…” She reached over and kissed him warmly on his cheek.

He returned the blush. “I… I spit mine out into this,” he admitted and pulled out a little plastic K basin he’d hidden under his pillow. “Couldn’t swallow it,” he said and shrugged. “How about you, sweetheart?”

“Terrible heartburn, dear…” She glanced at the midwife, in case she had transgressed on some sort of midwiffic tradition. “But maybe it just needed more salt, or something,” she added quickly to try to make the best of a bad situation.

The room filled with the cries of the baby. “Maybe it just needed to stay in the metal bowl where the doctor put it,” he said in a brief lull as the baby sucked in a lungful of air and he returned his wife’s kiss.

The midwife was all smiles. “I couldn’t eat mine, either,”she said, winked, and cast a knowing shrug towards them. Then she walked slowly over to a sink in the room, picked up a couple of towels and, ever the nurse, dampened one edge of each.  “Anybody want to clean up a little?”

The Skirt’s the Thing

Skirts are back in the news –this time in France… for being too long

You’re kidding! A skirt’s a skirt, right? They’ve been around for thousands of years it would seem, albeit of multiple lengths and designs that accorded with local customs and –perhaps- fashions. The wearers were, of course, were no doubt sometimes tempted to flout the prevailing dress codes and deviate from what was common practice. This risked social approbrium at first, but eventually, as nowadays, also risked becoming the norm. We all flirt with change. We all want to be noticed on occasion –and, at least in the Western world, unique clothing is often a fledgling’s first dangle outside the nest. An experiment in independence.

But what is this deviation –this anti-Fashion- and can we ever differentiate it from protest? Isn’t it always about change? A statement of belonging –or not belonging- to a particular group? An identification for any who care to notice?

Indeed there is a growing body of evidence to suggest that the brains of teenagers, for example, are not just young, unruly adult brains. They differ in neural connections, and although intellectually comparable to those of adults, lack the impulse control that develops with maturity. http://www.nimh.nih.gov/health/publications/the-teen-brain-still-under-construction/index.shtml And this is not all bad. For example, Scientists believe that the loss of synapses as a child matures is part of the process by which the brain becomes more efficient. Although genes play a role in the decline in synapses, animal research has shown that experience also shapes the decline. Synapses “exercised” by experience survive and are strengthened, while others are pruned away. From a societal –but mainly, an evolutionary­- standpoint, this is probably a good thing: it encourages new thinking, new perspectives. Innovation.

But what has all this to do with long skirts, I hear you mumbling? Well:

http://www.bbc.com/news/world-europe-32510606­

What bothers me is that a girl in France, along with several of her friends, was sent home from school for wearing a long (black) skirt –a 15 year old, Muslim girl no less…

In 2004, France introduced a ban on ‘conspicuous’ religious symbols at state schools in an attempt to enforce its secular version of separation of religion and state. The orginal issue seems to have been Islamic headwear.

But the girls had already removed their Islamic headscarves before entering the school! So what was the issue? The Toronto Star reported that: “It was a concerted action… with a will to put a (religious) identity on display,” Patrice Dutot, inspector of the Ardennes Academy, which oversees the schools in the area, commented by telephone: “It is not the long skirt that is the problem,” Dutot said. The issue is that the girls “had agreed to wear the same skirts… to display their belonging” to a religious group.

Stuff and nonsense! They are teenagers striving for an identity in a society that is bent on a futile quest for homogeneity. If they had decided to dye their hair green, or worn rings in their noses instead, they may well have been tolerated. But even if they were admonished it would not have had the same effect as stigmatizing an entire segment of society –France has about 5 million Muslims which is the largest Muslim minority in Western Europe.

I think it is a policy gone recklessly wrong! While I do not agree with their ban on conspicuous headscarves, if the argument was that the very ostentatiousness of a niqab identified the wearers as members of a religious group, surely the decidedly unpretentious length of a skirt is an individual prerogative –a fashion statement, even. Witness the popularity of the hashtag #JePorteMaJupeCommeJeVeux (I wear my skirt how I want)!

As the BBC reports: In 2011 France became the first European country to ban the full-face Islamic veil – the niqab – in public places. Most of the population – including most Muslims – agree with the government when it describes the face-covering veil as an affront to society’s values.

You’ve made your point, France. Don’t push it too far, though: the lion only slumbers.

The Polarization Bias

Okay, I have to admit to living an unbeknownst lie –unbeknownst to me, at any rate. Sometimes it is easy to coast, to accept help where it is offered and feel almost foolishly grateful for suggestions that foster the dependence. Advice is seductive, guidance addictive. But more importantly, it is insidious. Critical thinking -critical analysis- suggests that we process whatever information we are offered by considering its validity when compared with other sources, other viewpoints, other contexts. It is what we should do; it is not what we usually do. Time constraints, biases, laziness –they all conspire to let us float on the tide. Drift.

I suppose my awareness of the current may have started when I was casting about for a book to read. Like many of us, I have a passion for reading that is naively open to recommendations. The online Amazon book store is an almost limitless cornucopia of books. And when you click on one, a section appears just beneath your choice that says: Customers who viewed this item also viewed… And a list of similar books on similar subjects is just a click away: a topic-specific, yet unrequested bounty spilling onto the screen. And all with seemingly different approaches but eerily similar viewpoints to the book you’ve chosen. A coincidence? Or a recognition that you have a particular worldview whose advocates you are more likely to read? And buy.

At first, I was both pleased and amazed that Amazon could find so many different authors and topics that I found compelling and place them before me like a waiter with a dessert tray. So easy to choose from only what is offered –too easy… What I initially thought of as a diverse array of well-considered opinions, I began to realize was an artfully arrayed selection that fostered my already-held biases. A compass that always pointed north, no matter the coordinates.

I suspect that most of us, even offered the choice, would find no compelling reasons to change allegiance, or flirt with opinions we have been taught to mistrust. We feel uncomfortable accepting that the opposition feels the way it does on grounds that are equally persuasive for it. Rather than being open even to thought-provoking alternative ideas, we rust into positions that further restrict our ability to move.

But what if the news we so avidly ingest nowadays could be similarly sorted to our tastes and presented to us as a fair representation of what is really happening? How would we know of the manipulation? How could we become aware of the slanted viewpoint when it so closely agrees with our own –when it is what we want to hear? Confirmation bias is difficult to resist even at the best of times.

http://www.huffingtonpost.com/2015/05/12/facebook-study-polarization_n_7245192.html?utm_hp_ref=world&ir=World

I hadn’t realized that many people actually read those snippets on Facebook that purport to inform. I had thought most of them were not terribly well disguised ‘infomercials’, but perhaps that is my bias -the boreal plain to which I am unwittingly confined. But that our serving of news should be chosen for us according to our likes and dislikes is anathema. And that our meal of information should be expurgated and mashed into a small, more easily digestible aliquot of words smacks of propaganda. Control. Handling… I would like to digest unchewed information in my own way, thank you. I can deal with heartburn; I’m not good with starvation.

http://www.bbc.com/news/technology-32707014

The dilution of mainstream media and its as-yet relatively unfettered ability to pretend to present both sides of an argument is worrisome. Similarly, the accretion of our sources of information into a few huge monolithic blocks with their own interests to serve is dangerous. Especially when they presume to know what opinions will keep us quiet.

“Let every eye negotiate for itself and trust no agent,” says Claudio, in Shakespeare’s Much Ado About Nothing. Bravo!

Nudging Childhood Obesity

When I was a kid, obesity was not the norm. Admittedly, this was a long time ago, and no doubt I only remember brief and highly selective snippets of the time –modified, no doubt, to serve whatever demands are required in the present. But in these unexpurgated, sketches, I have memories of labeling the occasional child in the playground as ‘fat’. Whoever it was stood out from the rest –ex gregis in the true etymological sense of the word ‘egregious’- and so through the insouciance of childhood, were forever condemned to wear the epithet like a poorly fitting sweater.

Maybe we just didn’t have enough to eat in those halcyon days of early Winnipeg; maybe the winters were too severe and the necessary clothes too heavy to allow the accumulation of excessive girth. But let’s face it, normal is what we see around us. It is parochial. It is the statistics of one box. And yet, isn’t that how we judge: by what we know? If I am obese, and my child is too, then what’s the problem? And if all his friends, and all my friends are large, then how am I to adjudicate another norm? Thin is aberrant, not fat.

I came across an interesting article in Forbes magazine reporting about a study –several studies, in fact- demonstrating the inability of parents to judge whether or not their child was overweight: http://www.forbes.com/sites/alicegwalton/2015/03/30/can-you-tell-if-your-child-is-overweight-most-parents-cant-study-finds/

This is worrisome, to say the least -unless of course you change the definition of what weight is normal… But no matter the norm, health risks for diabetes, hypertension and cardiovascular disease generally increase with increasing BMI (Body Mass Index -which is the weight in kilograms divided by the square of the height in meters: kg/m2).

And it is difficult to rationalize the increasing prevalence of corpulence in the population as an evolutionary process. It’s hard to understand how plumpness would be of any survival benefit, or why it would be selected for in a gene pool. There exist islands of controversy in this, of course: http://www.bbc.com/news/magazine-28191865  But I think most analyses would suggest that obesity (BMI >30 -at least in North American population studies) adversely influences health and life span. So it would make sense to attempt to correct the issue as early as possible.

As an obstetrician, I am drawn to the idea that management of pregnancy and birth weight are important. I was intrigued by a prediction model I saw reported in the BBC from 2012 suggesting the risks for subsequent obesity of a child could be predicted at birth with about 80% accuracy: http://www.bbc.com/news/health-20509577  I haven’t seen much about this recently, so I don’t know how well it has stood the test of scientific scrutiny, but at least it was an interesting thesis. A start.

Recently, the Canadian Task Force on Preventive Health published an update on childhood obesity guidelines: http://www.cbc.ca/news/health/child-obesity-charts-open-door-to-treatment-1.3014832  It contains the usual admonitions against junk food and physical inactivity, of course, but advocates some innovative strategies, I think. For example, because the circadian rhythms of teenagers have been found to differ from the adults who are teaching them, it recommended starting classes later in the morning and suggested breaks in each class. And walking to school, where feasible, as part of the exercise regime… Dr. Brian Goldman, host of CBC’s ‘White Coat, Black Art’ program, while agreeing with the guidelines, detected some downsides to the recommendations however: http://www.cbc.ca/radio/whitecoat/blog/the-cure-for-childhood-obesity-parents-will-hate-1.3014981

The contributing factors to obesity –let alone childhood obesity- are legion: genetics, dietary habits, social milieu, parental influences, environmental conditions, Media, socioeconomic status, and peer group expectations, to name a few. None are solely responsible, but unless there are some counteracting forces –incentives- all are important. Behaviour, habits, and expectations are learned phenomena and it may be something as simple as imitation of parents or friends that starts it off and then sustains it.

When faced with uncountable opponents and overwhelming odds, how can Society possibly succeed in changing things? Well, simplistically, it needs to change attitudes. Change what the majority considers acceptable. Change the mythos. It is slowly changing the acceptability of smoking as a norm; even the legitimacy of drinking and driving is under scrutiny –not only in the courts but also in the minds of drinkers. Some things are just not seen as cool nowadays.

But, given the importance of preventing childhood obesity for the health and well-being of future generations and given the relative lack of success so far, I think we need a new (old?) approach. There is a freshly-named, although age-old practice, termed ‘Nudge Theory’. It is a euphemism that my mother would have simply called manipulation because, although cleverly disguised, that’s really what it is. Wikipedia has succinct explanation: Nudge theory (or Nudge) is a concept in behavioral science, political theory and economics which argues that positive reinforcement and indirect suggestions to try to achieve non-forced compliance can influence the motives, incentives and decision making of groups and individuals, at least as effectively – if not more effectively – than direct instruction, legislation, or enforcement. Here are two introductions –take your choice:  http://www-2.rotman.utoronto.ca/facbios/file/GuidetoNudging-Rotman-Mar2013.ashx.pdf or http://www.businessballs.com/nudge-theory.htm

Education, and early identification and treatment of those at risk of becoming obese are obviously important and desirable, but I think we need something more. Something with a proven track record, albeit in different fields. Maybe ad campaigns and directed manipulation –sorry, nudging– would be valuable adjuncts. We are media savvy nowadays, and used as a tool for change, it seems ideal. As long as we are certain of our goals, and the science is correct, I think it is an ethically acceptable approach, and one with great potential.

I did, though, run across a light-hearted, but nonetheless cautionary article about nudging in the Toronto Globe and Mail: http://www.theglobeandmail.com/globe-debate/im-an-adult-stop-nudging-me/article20925672/

However, we have to take advantage of all the tools at our disposal. My mother’s manipulation was unsubtle and in my face; nudging is not. If we are going to be successful in stopping the steadily increasing tide of obesity, we need to revise expectations, and change what we accept as normal. We have to alter folkways and mores –in other words the rules that society uses to guide behavior. Nudge them, I suppose…

We need the courage to try novel approaches. There is a quote by Erasmus that is germane: A nail is driven out by another nail. Habit is overcome by habit. Okay, so let’s change them. Nudge them. No! I hate the verbal evasion. Let’s mold them.