Breathing health into a stone?

Are my emotions mine? That is, do they live inside me, or are they things that are shared -exist between me and others, in other words? Are they more the combination of genetic predisposition and situational features which are dependent on societal norms that we were taught from our early years at home and in the community?

It seems to me that it is an important point: where should we direct our efforts if we feel  emotions are getting out of hand? Is simply treating me sufficient, or am I the fabled canary in the coal mine? I’ve been retired from specialist medical practice for some years now, and I can feel my loyalties shifting. It’s not that I have joined the dark side, or anything -more that I can see both sides better from the border.

If we are to confront medical skepticism, it is a good idea to examine it from a historical perspective. I found a helpful essay by Bernice L. Hausman, professor and chair of the Department of Humanities at the Penn State College of Medicine in Hershey, Pennsylvania: https://aeon.co/essays/what-explains-the-enduring-grip-of-medical-skepticism

Early in her explanation, she writes that ‘while medical therapeutics have advanced considerably, many current treatments are also aggressive… Consider the expansion of disease categories to include personality quirks and body types, side-effects that demand further medications, drug interactions that are deadly, and medical supervision of things left well enough alone. If 18th-century medicine lacked a scientific basis, our problem might be too many therapies for our own good. The expansion of treatment has led to a critical response – ‘medicalisation’, which describes a skeptical approach to mainstream medicine’s social role in defining health.’

Indeed, what is ‘health’? Is it merely a state of being free of injury or illness, or is there something else involved as well? Something that medicine often fails to address: who has the social authority to decide what constitutes health -not so much for society as a whole, but for the individual? And how it should best be treated, for that matter?

Take an old example: TB. The proximate cause, of course, is the tuberculum bacillus, Mycobacterium tuberculosis, but in some sense the bacterium is merely opportunistic. The ultimate, or distal cause may well be something like impaired immunity from malnutrition or poverty. So, which cause should be addressed -the proximate one, of course, but should we leave it at that? Is it enough to rub our hands and say ‘done’? For that matter, to whom should we look for a remedy?

But, the problem is still with us -for example, the current pandemic of Covid 19 with its massive social and economic upheavals. From time to time, there has been promulgated the exculpatory mantra that the virus knows no boundaries; the virus does not discriminate, unlike our political borders. But of course it does. The communities of colour -African American and Latino, in America at least- seem to be disproportionately affected. Why? Well, there are a few obvious factors at play. ‘African-Americans have higher rates of underlying conditions, including diabetes, heart disease, and lung disease, that are linked to more severe cases of COVID-19′. And, ‘They also often have less access to quality health care, and are disproportionately represented in essential frontline jobs that can’t be done from home, increasing their exposure to the virus,’ according to a report (May30/2020) from NPR.

And, from the same report, ‘Latinos are [also] over-represented in essential jobs that increase their exposure to the virus… Regardless of their occupation, high rates of poverty and low wages mean that many Latinos feel compelled to leave home to seek work. Dense, multi-generational housing conditions make it easier for the virus to spread.’ Of course, by now that is old hat… isn’t it?

I suspect I saw it differently when I was in practice, but perspective is often beguiling -the old aphorism about the hammer and the nail, perhaps? ‘In Medical Nemesis (1975), Illich [the intellectual iconoclast, Ivan Illich, a Croatian-Austrian Catholic priest] made a starkly prescient argument against medicine as a dangerous example of what some call ‘the managed life’, where every aspect of normal living requires input from an institutionalised medical system. It was Illich who introduced the term ‘iatrogenesis’, from the Greek, meaning doctor-caused illness. There were three levels of physician-caused illness, as far as he was concerned: clinical, social and cultural. Clinical iatrogenesis comprises treatment side-effects that sicken people. Social iatrogenesis describes patients as individual consumers of treatment who are self-interested agents rather than actively political individuals who could work for broader social transformations to improve the health of all.

But, cultural iatrogenesis is the one that interests me the most, I must admit: that ‘people’s innate capacities to confront and experience suffering, illness, disappointment, pain, vulnerability and death are [being] displaced by medicine.’

Illich thinks that ‘medicine takes a technical approach to ordinary life events, hollowing out the rich interpersonal relations of caring that defined being human for millennia.’ But to be fair, Illich still felt that ‘Sanitation, vector control, inoculation, and general access to dental and primary medical care were hallmarks of a truly modern culture that fostered self-care and autonomy.’ He was more concerned with the impersonal bureaucracy that surrounded medicine. An interesting criticism, and one that I also share -albeit one that seems to stem from the medical system as he saw it from south of our Canadian border.

And yet I think the thrust of Hausman’s essay was more a reaction to the disillusionment that followed the initial promise of modern medicine. Things like delegating the definition of health to professionals who have a vested interest in defining it in a way that seems to mandate the continued need for them. I think this view is unfair, but, given Illich’s iatrogenesis concerns, I can see how that attitude might seem plausible.

Have we doctors been -are we still- sometimes too aggressive in our treatments, too arrogant in our knowledge, too certain of our advice, and too resistant to alternative approaches? I’m not suggesting that we cave to pseudoscience, or acquiesce to theories just because they are currently fashionable; Science is never perfect, and is open to change. But still, primum non nocere is a good aphorism to guide us: First of all, do no harm. I seem to remember promising something like that in my medical oath…

Bad Samaritans?

I suspect this is an incredibly naïve, not to mention unpopular, opinion, but I suppose in these times of plague, I should be grateful we have borders -fences that keep them out, walls that keep us safe. But I’m not. I’ve always mistrusted borders: I’ve always been suspicious of boundaries that artificialize the denizens of one region -that privilege residents as opposed to non-residents, friends versus strangers, our needs compared to theirs.

Call me unworldly, but what makes me special, and you not so? It seems to me the italics I have used to mark differences, are as arbitrary as the differences they mark. We are all the same, and deserve the same consideration.

That said, we seem to be stuck with countries determined only to look after their own -even with the global crisis in which we find ourselves in these special, but frightening times. In a desperate attempt at historical recidivism, we are attempting a re-balkanization of the world.

But what is a country, anyway? And does it have a special providence -or provenance, for that matter? I happened upon an interesting essay by Charles Crawford, who once served as the UK Ambassador to Sarajevo and Belgrade discussing much the same thing: https://aeon.co/essays/who-gets-to-say-what-counts-as-a-country

As he writes -‘There are only two questions in politics: who decides? and who decides who decides? … Who gets to say what is or is not a country? For most of human history, nation states as we now recognise them did not exist. Territories were controlled by powerful local people, who in turn pledged allegiance to distant authorities, favouring whichever one their circumstances suited. In Europe, the tensions in this system eventually led to the Thirty Years’ War which… ended in 1648 with a thorough revision of the relationship between land, people and power. The resulting set of treaties, known as the Peace of Westphalia, introduced two novel ideas: sovereignty and territorial integrity. Kings and queens had ‘their’ people and associated territory; beyond their own borders, they should not meddle.’

Voila, the modern idea of states, with loyalties only to themselves. But embedded in the concept were at least two principles -two problems: ‘The first is self-determination: the idea that an identified ‘people’ has the right to run its own affairs within its own state. The other is territorial integrity: the notion that the borders of an existing state should be difficult to change.’ But borders soon spawned customs and attitudes that were different from those on the other side –theirs were different from ours, so they must be different from us. An oversimplification, to be sure, but nonetheless a helpful guide, perhaps.

Borders can change, of course, but not easily, and often not without considerable turmoil. Think of ‘the separation of Bangladesh from Pakistan in 1971 [which] claimed up to a million lives… Ambiguous ceasefires can drag on indefinitely. Taiwan and its 23 million inhabitants live in a curious twilight zone of international law, recognised by only 22 smaller countries and the Vatican.’ Examples of each, abound.

And not all borders were established to reconcile linguistic, ethnic, or religious differences. There are many examples, but perhaps the most egregious borders in modern times were those largely arbitrary ones in the Middle East drawn by two aristocrats Mark Sykes from Britain, and Francois Georges-Picot from France in 1916. As Wikipedia describes: ‘it was a secret agreement between Britain and France with assent from the Russian Empire and Italy, to define their mutually agreed spheres of influence and control in an eventual partition of the Ottoman Empire.’

A famous quotation that encapsulates the attitude was that of Sykes: ‘At a meeting in Downing Street, Mark Sykes pointed to a map and told the prime minister: “I should like to draw a line from the “e” in Acre to the last “k” in Kirkuk.”’-a straight line, more or less.

Crawford’s essay was intended to explain the continuing tensions in the Balkans, but it raises a pertinent question for these times -namely, ‘Should nations stay within their historical boundaries, or change as their populations do?’ Or, put another way, should boundaries remain impermeable to needs outside what I would term their arbitrary limits?

With the current pandemic, there are, no doubt, many reasons that could be offered for being selective at borders: family-first ones, by and large. We need to close our borders to support our own economy, feed our own people; in the midst of a global epidemic, it is not the time to sacrifice our own needs by offering altruism to others. Actually, it seems to me that the underlying belief is that migration -legal or otherwise- is a large contributor to the spread of the infection. But once a communicable virus is in the country, its own citizens also become vectors -and they far outnumber the number of refugees or migrants.

Rather than being focussed on borders and exclusion, efforts would likely be more intelligently spent on things like temporary isolation of any who may have been in areas where the epidemic may have been less controlled, and enforced social separation (social-distancing) of everybody else. Consistent, and frequently publicized advice and updates about new developments to educate the public -all the public- is key to managing fear. And epidemics -they have a habit of evolving rapidly.

And testing, testing, testing. Unless and until, we know who might have the infection and be a risk to others, we are essentially blinkered. It’s not the strangers among us who pose the risk, it’s those who are infected and either have no symptoms or who are at the earliest stages of an infection that has not yet had time to declare itself.

The World Health Organization (and others) have pointed out that travel restrictions not only divert resources from the containment effort, they also have human costs. ‘Travel measures that significantly interfere with international traffic may only be justified at the beginning of an outbreak, as they may allow countries to gain time, even if only a few days, to rapidly implement effective preparedness measures. Such restrictions must be based on a careful risk assessment, be proportionate to the public health risk, be short in duration, and be reconsidered regularly as the situation evolves. Travel bans to affected areas or denial of entry to passengers coming from affected areas are usually not effective in preventing the importation of cases but may have a significant economic and social impact.’ And, as all of us realize -and expect- by now: ‘Travellers returning from affected areas should self-monitor for symptoms for 14 days and follow national protocols of receiving countries.’ Amen.

Turning away migrants often has some desired political effects, however: diverting attention away from the receiving country’s possible lack of preparedness and foresight. It’s seldom about the Science and more about Nationalism -further stoking fears of the other.

I think that at the moment, we are forgetting, as was immortalized in that ancient Persian adage that, This, too, will pass. The pandemic will exhaust itself, and likely soon become both amenable to a vaccine and other medical therapy. And those affected will not soon forget -nor will those denied entry in their time of need. As our economies rebuild in its wake, we -and they- will need all the allies we can muster. Best to be remembered as a friend who helped, than someone who turned their back.

We really are all in this together. As one of my favourite poets, Kahlil Gibran writes, ‘You often say,I would give, but only to the deserving.” The trees in your orchard say not so… They give that they may live, for to withhold is to perish.’