She wears her faith but as the fashion of her phone.

Everything is a matter of time, isn’t it? Everything changes. Like the apocryphal monkeys typing away infinitely, everything will be written. Everything will be transmogrified somewhere. Some time. Somehow. I suppose that should be a comfort, but I can’t escape the nagging feeling that there is something unrequited in all that: an imbalance between now and then -no bridge to mediate between what is, and what some nebulous future may unfurl for our children’s children.

And yet, an article I found offers some hope that I might have missed the entr’acte, missed a vital link in the ever lengthening chain of progress –or at least underestimated its importance. I’m talking about the smartphone. I grow old… I grow old… I shall wear the bottoms of my trousers rolled, as T.S. Eliot wrote –that, at least, may be a suitable mea culpa for my inattentiveness, perhaps.

I should have seen that with all of the changes occasioned by the phone, other subtle philosophical alterations might well hide within its shadow. ‘He wears his faith but as the fashion of his hat; it ever changes with the next block’, as Beatrice says in Shakespeare’s Much Ado About Nothing. Who would have thought that religion itself might live the same fate? The mobile phone Bible seems to be replacing the book Bible –at least with many of the younger religious crowd. And the result may have been a loss of context –no thumbing through the pages looking for something, just an arrival at whatever nugget was requested –like looking it up in Wikipedia. In other words, an information Christianity, a virtual religion. ‘“A new kind of mutated Christianity for a digital age is appearing,” says Phillips [director of the Codec Research Centre for Digital Theology at Durham University in the UK]. “One that follows many of the ethics of the secular world.” Known as moralistic therapeutic deism, this form of belief is focused more on the charitable and moral side of the Bible – the underlying tenets of religion, rather than the notion that the Universe was created by an all-seeing, all-powerful leader.’

Although I hold neither religious affiliation, nor any particular interest in the Bible, I have to say I am intrigued by the philosophical machinations the smartphone seems to be engendering –the moralistic therapeutic deism, as it is increasingly being referred to. The results of interviews with three thousand teenagers were summarized in (sorry) Wikipedia, and seem to establish the tenets of this theism. First of all, ‘A god exists who created and ordered the world and watches over human life on earth.’ And ‘God wants people to be good, nice, and fair to each other, as taught in the Bible and by most world religions. The central goal of life is to be happy and to feel good about oneself.’ But what I found particularly interesting was the idea that ‘God does not need to be particularly involved in one’s life except when God is needed to resolve a problem.’

And why do I find this  so-called ‘moralistic therapeutic deism’ so interesting? It seems to me it may be the early phases of an evolution of religious thought engendered by the way we are beginning to assimilate information. Or perhaps I should say they are –the millennials. I suspect that we elders –or should I say just ‘olders’- still adhere to the belief that data does not necessarily spell knowledge.

But, as the article points out, ‘[…]a separate strand of Christian practice is booming, buoyed by the spread of social media and the decentralisation of religious activity. For many, it’s no longer necessary to set foot in a church. In the US, one in five people who identify as Catholics and one in four Protestants seldom or never attend organised services, according to a survey conducted by the Pew Research Centre. Apps and social media accounts tweeting out Bible verses allow a private expression of faith that takes place between a person and their phone screen. And the ability to pick and choose means they can avoid doctrine that does not appeal. A lot of people who consider themselves to be active Christians may not strictly even believe in God or Jesus or the acts described in the Bible.’

I doubt that this phenomenon is exclusive to Christianity, either. Any religious doctrine which has a credo that can be digitized, is susceptible -nuggetable into bite-sized digestible portions. Wikipediable.

I think that is what two girls were talking about at the bus stop a few days ago. Both wearing delightfully colourful hijabs, they were huddled around their smartphones giggling.

“Where did you find that?” the taller of the two said shaking her head. She was dressed just like any other teenager –running shoes, jeans, and a bright orange leather jacket- but a dark blue hijab seemed almost tossed onto her head and barely draped over her shoulders. Perhaps it was the wind, but the almost-studied disarray was charming.

The other girl, stouter and wearing a long black coat, also sported a red, hijab-like scarf that barely covered half her head despite her constant readjustments. “It’s Al-Quran [an app, I later discovered],” she answered as if that should have been obvious.

The taller girl tapped on her screen for a moment and then nodded her head. “But, you know that’s not what Abbad said…”

The other girl just shrugged. “He always thinks he knows everything, Lamiya.”

“Well…” I could see Lamiya sigh, even though I was trying not to watch them. “He usually gets it right, Nadirah… I mean, don’t you think…?”

I couldn’t help but smile when Nadirah rolled her eyes. “He only gets it right when you don’t know! If you don’t check on it…”

Lamiya seemed to pout. “I just, like, took his word for it…”

“You can’t do that blindly, Lami… Not anymore.” She made another attempt to readjust her hijab in the biting wind. “Not when you can look it up!” She shivered deeper into her coat and I could see her breath whenever the wind died down. “Things just aren’t what they used to be for our parents… We can actually, like, check,” she said as their bus pulled up and they got on, leaving me still informationless in the cold.


The Science of Answering

I suppose in this suspicious age, everything is open to scrutiny. But some things are examined at one’s own risk risk -like turning over a familiar log in the garden only to find unexpected and sinister-looking creatures lurking quietly beneath. This is fine, of course, but it can be hard to know what to do with the results of such investigations without some attributions -either positive, or more likely, negative. And, depending on our experience, a vacillation between the two.

Science by encouraging unbridled curiosity has often not been neutral in this. With some trusted and unsuspecting products that have been on the market for years, subsequent studies have occasionally determined similarities of structure, or function, with other, more bothersome effects. Aluminum in cookware was one famous example. Aluminum was found in some plaques in the brains of patients with Alzheimer’s disease so of course products containing aluminum went into a precipitous decline from which they never really recovered despite subsequent studies that failed to substantiate the risk. Or think of the autism scare after a since-repudiated 2004 article suggested that thimerosol, a synthetic form of organic mercury which has been used for many years as an antimicrobial agent and preservative in many vaccines, was the cause of autism spectrum disorder.

Once these doubts have been cast, suspicion often lingers that is hard to eliminate. Conspiracy theoreticians emerge from the shadows to sew their seeds, flaunting the seemingly obvious and intuitive conclusion that there must have been something that made the scientists find what they did. The fact that science actually encourages refutation -that nothing is ever known for certain and that they’re rather happy with that- escapes those who would rather believe there is a cover-up.

And now, there is another study –one among many- that suggests that even low amounts of parabens –preservatives used in, among many other things, the cosmetic industry- might increase the risks of breast cancer! Researchers from the University of California, Berkley have published a study in Environmental Health Perspectives that seems to demonstrate this: Environ Health Perspect; DOI:10.1289/ehp.1409200

‘Existing chemical safety tests measure the effects of a chemical on human cells in isolation. However, as these tests fail to consider that compounds might interact with other signalling molecules, the tests are insufficient, explained the researchers.

Using the naturally occurring growth factor in breast cells, heregulin, the researchers stimulated the HER2 receptors in breast cancer cells and exposed the cells to parabens. The chemical caused the oestrogen receptors to activate genes, which led to the proliferation of the cells. Moreover, the effect was significant: parabens in the HER2-activated cells stimulated breast cancer cell growth at concentrations 100 times lower than in cells lacking heregulin.’

Is nothing safe? It’s difficult to know what to do with information like this. Surely there is a middle ground between merely shrugging our shoulders and accepting that the world is a dangerous place, and railing against Science for trapping us here. Do we sometimes just use our indecision as a reason to worry? Change seems to spawn unintended consequences no matter how hard we try to anticipate them. As an enthusiastic user of modernity I suppose I am closer to the shrug camp, but I recognize that there are different world-views out there and I dare not gainsay them. Especially if they are first time patients who are a little wary of me to start with.

Jona did not trust me; I could tell by her eyes as soon as I introduced myself in the waiting room. While her face said hello, her eyes threatened me with silence if I so much as stepped on the boundary. The hand that shook mine was aggressively firm and it was all I could do to keep from wincing. I hate that. I’ve always felt that the first contact should be a greeting, not a contest. A sign of mutual respect, not a dare. I don’t feel at all competitive at that stage, but from her expression, I could see she felt it was a form of sport. I was surprised she let me lead her into my office.

When I was finally allowed to sit and open up my computer, I saw that her referral to me was for dyspareunia –code word for pain with sex. She sat on the other side of my desk with everything on guard: face, posture, fists… Everything dared me to ask her why she was here. So I didn’t. I just let her talk –debrief, as it were. Her eyes –at least the ones that she had trained to pin doctors to their chairs- were hovering around my face, waiting for me to provide the excuse for an attack.

“I know that Maria has listed my problems in the letter she Emailed, doctor, but before you start on me, I just want you to know that I refuse to take, insert, or inject any medications.” She proceeded to cross her arms tightly across her chest, as if something was trying to escape from under her blouse. “Maria wanted to put me on estrogens, but as you know, they can cause strokes, heart attacks and cancer. Sex isn’t worth that risk.” She glowered at me, still holding off the eye-attack until I said something. “Then, she suggested the low-dose variety that you merely put in your vagina… Merely?? It’s hardly a little thing to put an uninvited foreign body in there, doctor! She thinks my vaginal skin is too thin and that’s why it hurts.” She thought about it for a moment. “And how would she know? She couldn’t even get a speculum in there, so how could she say that? I’m 48, not 68 for God’s sake. I’m still having periods and tampons have never hurt.” She sighed theatrically and continued. “I’ve tried lubricants and stuff, but if you look at what they contain and then Google the contents, it’s like playing Russian roulette with your vagina. Some of them even print disclaimers and suggest medical consultation before using them. They can cause allergies, skin irritation, infections… Some are even carcinogens when you look up the pharmacology. And then there’s that article saying that the parabols might even cause breast cancer…”

‘Parabens,” I corrected her and then closed my mouth, smiled sympathetically and waited for permission to say something more. Anything.

“Whatever. My husband doesn’t understand, either. All he wants is something quick before he goes to sleep. Of course, he thinks I’m making up the pain stuff…”

The short pause, and a brief journey of her eyes to a picture on the wall gave me an opportunity to ask her something: “Do you talk to your husband?” I said, and waited for the eyes.

“He won’t even talk to me when we’re eating dinner…” She said slowly and looked down at her lap, caught off guard by the question, I think.

“How long has it been since you were able to talk?”

Jona withdrew her eyes and they disappeared into her face along with her anger. Then she shrugged, and a few words spilled out. “It’s been so long, I can hardly remember when…” She suddenly stopped talking and stared at me. “But why did you ask about him, doctor? Do you think our…?” she said in a whisper. “My GP never even asked…” Her expression changed from one of defence to one of curiosity. “Why did you wonder if I talked to my husband?” she repeated.

“Are you a Shakespeare lover?”

Her face tightened for a moment in puzzled irritation, but then she laughed. “Double, double boil and bubble; Fire burn and cauldron bubble,” she said, obviously pleased with herself. “The witches, in Macbeth, I believe.”

I nodded, then grinned. “Well, let me quote from the play-within-a-play in Hamlet –Gertrude answering Hamlet’s ‘Madam, how like you this play?’… ‘The lady doth protest too much, methinks.’ she answers…”

A little smile –the first real smile she’d shown me- blossomed like a flower on her lips. “Maria said you were good, doctor… You’re smarter than you look,” she said with mischief in her eyes this time, and her body relaxed into the chair. “What do you suggest I do?”

I readied my fingers over the keyboard and chuckled warmly. “I suggest we start by making sure there is nothing you need to worry about.” I thought of another memorable phrase, this one uttered by Hamlet himself: ‘There is nothing either good or bad, but thinking makes it so.’ But I didn’t say anything; she’d had enough Shakespeare for now I realized.

Medical Revisionism

Words -that’s all they are: sounds that by their very presence magically communicate meaning. They are more than mere noise or background. They are not the wind rustling through the leaves, nor the sounds of a frog in a pond; in a way, they are entities that resolve uncertainty, and in as much as they can be interpreted, contain information. Data. So, in a sense, they transcend Time: the information in the words of an ancient document still exists. But information is subject to interpretation; the same data may be seen as having different meaning as time and societal norms change. But does that change the information conveyed? I think not.

I’ve covered this topic in previous blogs (for example: ) but the topic is a source of continuing intrigue for me, so I was once again interested in seeing it broached in an article in the BBC News last fall:  It seems we are constant and insatiable revisionists. It’s as if by changing the descriptor, we somehow alleviate the pejoration its ancestor accumulated. And yet the information remains; only the colour changes.

I suppose that this is useful, but I can’t help but wonder if there is some other way of doing it. Of course, some words seemed to have been coined originally with a belittling intent -Cripple springs to mind- and even without our penchant for viewing the machinations of history through modern eyes, the word is disparaging; it is simply not fair. It derives from the Old English word crypel which has the suggestion of creeping. It was a condition in clear need of a new term.

Other words were more naively-attempted descriptions –designations that were no doubt thought to help others picture what was being named. There was unlikely to have been any attempt at denigration -despite how they might now offend or upset us. Mongolism is one such term. According to the New Oxford American Dictionary:mongol, or Mongoloid, was adopted in the late 19th century to refer to a person with Down syndrome (named after John L. H. Down [1828–96], the English physician who first described it), owing to the similarity of some of the physical symptoms of the disorder with the normal facial characteristics of eastern Asian people. The syndrome itself was thus called mongolism.’ But the problem remains –what happens when the term ‘Down Syndrome’ itself also becomes offensive?

Sometimes, it seems to me, the words will also change for no apparent reason. Think of the various expression changes for sexual diseases over the years and the somewhat clumsy attempts to strip the prejudice out of them. When I first started medical school, the expression was ‘venereal disease’ –or VD. Then, when that became too pejorative, or at least discriminatory, it morphed into STD (‘sexually transmitted disease’), and currently STI for ‘sexually transmitted infection’… Or am I already out-of-date? The reason for any of these transformations, however, is totally beyond me.

Words, it seems –or maybe it’s me– just can’t keep up. Maybe, like Fashion, they’re bound to change because of user-boredom or a need for novelty, but I think it’s probably deeper than that. I suspect that it relates more to societal attitudes than societal ennui. And I think that it may be a lost cause to expect consistency of usage. As we change our approach to issues and our opinions, so we change our words to describe them. It starts off with the more curmudgeonly amongst us –usually those for whom tradition provides a stable and secure platform- proclaiming the changes to be ‘political correctness’- to use the current phrase. But then, gradually, sometimes imperceptibly, the expression achieves a common parlance and not using it courts sideways glances, or even incomprehension. It is, perhaps, an aurally measurable example of society’s changing attitudes, if not its mores.

My biggest complaint, however –although minor in the scheme of things- is that it seems a waste of perfectly good words. One of my favourite ones ‘awe’ and its brother ‘awesome’ which used to bespeak a form of reverence, was ripped from my useful vocabulary only a few years ago and I’ve never really gotten over it. The words now have little value -they’re the scrapings from a different, grander time. Crumbs. Leftovers.

I am reminded of the words of Moth, the page of the soldier Don Armado in Love’s Labour’s Lost by Shakespeare: ‘They have been at a great feast of languages, and stol’n the scraps.’ 

A Medical Chinese Curse?

Change. We are condemned to live in interesting times, as the Chinese Curse purportedly observed -although there seems to be no evidence that there ever was such a curse, nor does anyone appear to have any idea what it means… But I have always assumed that it had to do with change, and our sometime antipathy to it. Of course things have always been in flux but its only over the last hundred years or so that it has seemed exponential. We’ve had to accustom ourselves to a continuing and accelerating change and have come to expect that next year -if not tomorrow- may be significantly different from today. But although gradual change is readily assimilable, when the difference is abrupt or requires a significant adjustment we often rebel. Habits die hard. After all, an assumption of predictability and stability is what allows civilizations to function, groups to cohere.

It is under just such conditions that a fundamental dichotomy arises, however: knowledge is the enemy of stasis and progress requires modification, however incremental –a sea change into something rich and strange, as Shakespeare wrote. Change often comes upon us like contagion on the wind: pollution with an unknown virus. An unexperienced plague for which we have no defence. No immunity. And yet like the Siren’s song that lured ancient mariners onto rocks, it is seductive.

It’s hard to know what to make of Change. Not all of it is good; some of it is mere revision. As the poet Robert Frost once observed: ‘Most of the change we think we see in life is due to truths being in and out of favor’. Some of it, however, inevitably represents real advances, or even revolution -think of the concept of the paradigm shift popularized by Thomas Kuhn in his nineteen-sixties book The Structure of Scientific Revolutions. Something is conceived that is so new, so different from what we had come to believe, that it turns our belief system inside out.  The change, to be adopted, has to offer distinct advantages over the old, of course; it has to be worth making the effort. Reinvesting. But it is not without a struggle from those with vested interest or careers dependent on the old knowledge…

There are many such changes occurring in Medicine. Some are lauded and universally appreciated: a new treatment for cancer, say, or a fresh insight into the cause of a disease. Others, seemingly trivial, go unremarked -or at least unflagged until pointed out. And yet they may represent paradigm shifts in their own right. For example, new ways of looking at the problem of hospital infections and the spread of resistant bacteria. Hand washing and alcohol-containing lotion dispensers situated outside each patient room along the corridor are being universally adopted and are an important component in the containment attempt.

But there is another approach that, now that I think about it, should have been equally obvious. I first read about it being mandated in some UK hospitals and filed it away somewhere as being a good idea. Now it is being considered here in North America, and none too soon:

Hang Up Your Lab Coat (What Not to Wear — for Patient Care) 

It’s so obvious when you stop and think about it, isn’t it? What is worn from room to room, brushing against patients, rubbing on bedclothes, and stained by anything and everything that it touches? The white lab coat, of course! We see them so often in our hospitals, we’ve come to expect them. And we all know who wears them: lab techs shuffling along the halls, doctors hurrying from room to room, senior nurses… its a virtually ubiquitous sight in a hospital. An expectation. And yet, no matter how often and diligently the doctor -or whoever- washes his hands between patients, no matter how devoted to cleanliness, no matter how motivated, if he drags his lab coat -his uniform– from room to room, he’s like a germ duster. A fomite. A Johnny apple-seed for our times. And the admonishment of Bare-below-the-elbows, as the link suggests, makes sense too: it assumes the lab coat has been hung up outside the door. But it’s also one of those things that is clear in retrospect, but almost invisible unless pointed out.

Consider it pointed out.