Beauty is bought by judgement of the eye?

Isn’t it interesting how differently we look at things? How the same bridge crossed by ten people becomes ten bridges? How beauty is so subjective? So ephemeral? Just think of how Shakespeare opened his second sonnet: When forty winters shall besiege thy brow and dig deep trenches in thy beauty’s field, thy youth’s proud livery, so gazed on now, will be a tattered weed, of small worth held.

And yet to some, beauty -however evanescent- seems a prize worth having, no matter the sacrifice. It seems unfair that it should have been doled out to some, but not to others. There are cultures where the inequity of this disparity is taken seriously; there are countries where beauty is felt to be a right to which all should be entitled no matter their social strata.

So accustomed am I to my own cultural mask, I have to admit that I had not realized that Brazil was such a place until I came across an article in the Conversation that addressed the issue. It was written by Alvaro Jarrin, an Assistant Professor of Anthropology, at the College of the Holy Cross in Massachusetts. https://theconversation.com/in-brazil-patients-risk-everything-for-the-right-to-beauty-94159 ‘Brazil considers health to be a basic human right and provides free health care to all its citizens. […] In Brazil […] patients are thought of as having the “right to beauty.” In public hospitals, plastic surgeries are free or low-cost.’ But, ‘public hospitals remain severely underfunded, and most middle-class and upper-class Brazilians prefer to use private medical services.’

Jarrin feels there is a darker side to this medical largesse however, in that the surgeries are frequently performed by more junior surgeons, just learning their techniques (albeit likely under the supervision of more experienced surgeons as is frequently the case even in the USA).

He goes on to say, ‘Yet these patients, most of whom were women, also told me that living without beauty in Brazil was to take an even bigger risk. Beauty is perceived as being so central for the job market, so crucial for finding a spouse and so essential for any chances at upward mobility that many can’t say no to these surgeries.’

‘Plastic surgery is considered an essential service largely due to the efforts of a surgeon named Ivo Pitanguy. In the late 1950s, Pitanguy […] convinced President Juscelino Kubitschek that the “right to beauty” was as basic as any other health need. Pitanguy made the case that ugliness caused so much psychological suffering in Brazil that the medical class could not turn its back on this humanitarian issue. In 1960, he opened the first institute that offered plastic surgery to the poor, one that doubled as a medical school to train new surgeons. It was so successful that it became the educational model followed by most other plastic surgery residencies around the country. In return for free or low-cost surgeries, working-class patients would help surgeons learn and practice their trade.’

The author seems to feel that the reconstructive aspects of plastic surgery -techniques for the treatment of burn victims and those with congenital deformities, etc.- have taken a back seat to techniques geared to aesthetic enhancement, however. ‘Since most of the surgeries in public hospitals are carried out by medical residents who are still training to be plastic surgeons, they have a vested interest in learning aesthetic procedures – skills that they’ll be able to later market as they open private practices. But they have very little interest in learning the reconstructive procedures that actually improve a bodily function or reduce physical pain. Additionally, most of Brazil’s surgical innovations are first tested by plastic surgeons in public hospitals, exposing those patients to more risks than wealthier patients.’

As a retired (gynaecological) surgeon myself, I have to say that I take issue with the naive view Jarrin seems to have about the training of the resident surgeons he reports. After all, clearly it would be better for the young surgeon to learn techniques under the careful guidance of an experienced mentor, than to suddenly be expected to possess the required expertise once she has passed her exams. Indeed, a selection bias is perhaps equally applicable to the anecdotes Jarrin quotes to demonstrate his contention. But, in fairness, I may be guilty of an insidiously perverted form of cultural relativism myself: I see my own world even when it’s not…

Cultural relativism, first popularized in the early twentieth century, attempts to understand and judge other cultures not by our own standards, but by theirs. It is a contextually rooted approach that can be devilishly difficult to achieve. We are all inherently cultural solipsists; we learn customs from the cradle and mistrust or actively disavow any deviations from those to which we have become habituated.

Even beauty itself is fraught. What is beautiful? Surely it is an ill-defined shadow on a rather large spectrum, its position tentative and arbitrary, depending as it must, on time and measurement. Shakespeare knew that. We all know that… Or do we? Are there unequivocal, objective criteria that must be met, or are they entirely subjectively defined? Culturally allotted? Surgically assigned?

No one has defined beauty more bewitchingly, in my opinion, than the poet, Kahlil Gibran, a Lebanese-American writer and artist in The Prophet. When the prophet is asked about beauty, he replies:

… beauty is not a need but an ecstasy.
It is not a mouth thirsting nor an empty hand stretched forth,
But rather a heart enflamed and a soul enchanted.

It is not the image you would see nor the song you would hear,
But rather an image you see though you close your eyes and a song you hear though you shut your ears.
It is not the sap within the furrowed bark, nor a wing attached to a claw,
But rather a garden for ever in bloom and a flock of angels for ever in flight.

… beauty is life when life unveils her holy face.
But you are life and you are the veil.
Beauty is eternity gazing at itself in a mirror.
But you are eternity and you are the mirror.

I cannot criticize the cultural ethos of Brazil, or its need for beauty; I can only wonder whether they will ever find what they are so desperately seeking. Who can touch a rainbow just by reaching?

 

 

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The Caesarian Path

The Caesarian section has a fascinating, if largely apocryphal history. In all likelihood it was probably a procedure of last resort to save the unborn child when its mother was already dead or near death. That the famous Julius Caesar –like Shakespeare’s MacDuff- was ‘from his mother’s womb untimely ripped’ seems unlikely, however appealing the etymology. In fact, the name may well derive from the Latin verb ‘caedere’ –to cut- and hence the cognomen (originally a nickname). Pliny the Elder, according to Wikipedia, ‘refers to a certain Julius Caesar (an ancestor of the famous Roman statesman) as ab utero caeso, “cut from the womb” giving this as an explanation for the cognomen “Caesar” which was then carried by his descendants.’

At any rate, before the days of appropriate antisepsis let alone adequate analgesia, the survival rate for both the mother and baby would have been dismally low. And despite isolated reports of its use throughout recorded history in such diverse countries as India, China, and even Babylon, it was always a procedure of desperation. A triumph, as Samuel Johnson once wrote in another context, ‘of hope over experience.’

Unfortunately it has now become merely a triumph of experience -a default position assumed at what seems to be the slightest provocation. The fact that it is an operation that can be booked in advance under some circumstances, and therefore superimpose a degree of predictability on the scaffolding of the anticipated chaos of labor, has been seen as desirable in some quarters. And in fairness, there are those for whom labor carries undue risks for either mother or baby and its avoidance would be prudent if not lifesaving. The issue, I think, is in the interpretation of risk.

The other, perhaps more problematic concern, is that of choice. At least in a system of limited resources, or one in which the public purse is providing medical coverage, one could ask whether an elective Caesarian section for no other compelling obstetrical reason than patient choice, is a sustainable option. Or even a desirable one.

So, what about in a user-pay system? Is it merely a matter of supply and demand: build more hospitals to accommodate the needs and whims of those who can afford them? Is that an efficient use of their resources? Is it even an ethically defensible position? The matter has finally prompted the Brazilian government to wade in, as an article in the July 7/15 BBC news reports: http://www.bbc.com/news/world-latin-america-33421376

Of course, there are many reasons for elective Caesarian sections –some of which are the result of previous and unsuccessful attempts at vaginal delivery that necessitated Caesarian deliveries at that time. The desire to avoid a similar and frustrating trial of vaginal delivery is certainly understandable –if not always necessary- under those circumstances. These are the so-called elective repeat Caesarians. Others, as I indicated, are obstetrically mandated because of developing or pre-existing risk factors –once again, hard to argue against. There is an interesting and informative article that attempts to put the Canadian experience (2007-2011) into perspective –a classification system (the Robson Classification System) that can be used to make international comparisons in Caesarian section rates: http://www.jogc.com/abstracts/full/201303_Obstetrics_1.pdf

But getting back to the situation in Brazil. As the BBC article suggests, ‘Eighty-five per cent of all births in Brazilian private hospitals are caesareans and in public hospitals the figure is 45%’. And the new government rules ‘…oblige doctors to inform women about the risks and ask them to sign a consent form before performing a caesarean. Doctors will also have to justify why a caesarean was necessary. They will have to fill in a complete record of how the labour and birth developed and explain their actions.’ That they may not have been doing this routinely before is troubling, to say the least.

Also, ‘Each pregnant woman will now be assigned medical notes which record the history of her pregnancy, which she can take with her if she changes doctors.’ I would have thought this practice would have been universal and intuitive -without the need for a government fiat.

But, as worrisome as all of this seems, there is another, perhaps more subtle pressure on the woman to opt for a Caesarian delivery in Brazil: ‘Women who want to give birth naturally in a private hospital have reported finding all the beds are reserved for scheduled deliveries. There have been numerous reports of women going into labour without a caesarean scheduled and being forced to travel from hospital to hospital in search of a bed.’ And as Pedro Octavio de Britto Pereira, an obstetrician and professor at the Federal University of Rio de Janeiro, said in an interview with BBC Brazil last year, “The best way to guarantee yourself a bed in a good hospital is to book a caesarean.”

Of course the blame does not wholly fall on the medical profession there –nor even, perhaps, on their preferred management strategies in pregnancy. ‘Researchers say many women also see caesareans as more civilized and modern, and natural birth as primitive, ugly and inconvenient. In Brazil’s body-conscious culture, where there is little information given about childbirth, there is also huge concern that natural birth can make women sexually unattractive.’

It is always dangerous to judge another country and another culture by our own standards. Our own sensibilities. And yet the risks are transnational and universal. They do not disappear simply because of a differing national mythos. Surgery is surgery; complications are inevitable co-travellers with it in spite of all precautions, and good intentions -the hidden, unwanted occupants of every operating theatre. And while we may never be able to stem the tide of primary elective Caesarians –even education on the subject has challenges overcoming fear or fashion- we may be able to convince women that their choice does not come without baggage. Unintended risks. To journey through a new geography, it helps to have thought about it first; planned the route to avoid unnecessary problems; consulted a knowledgeable guide –someone who will travel along with you. And remember what Seneca wrote: ‘Be wary of the man who urges an action in which he himself incurs no risk’.