Please and Thank you

Please and thank you –isn’t that what we were all taught? Perhaps it was my prairie upbringing, but it seemed the norm when I was growing up. There was no asking why –no need to, in fact- we all just did it. Indeed its absence was noticed and noticeable –like maybe wearing a suit without a shirt. Nothing dangerous, nothing threatening, but just not done, all the same. Maybe in another culture or in a different era, it might have been passed off as an eccentricity, or perhaps mental illness –but not in my youth. And not now either, I had assumed. Polite is polite. Period.

But mores and folkways are fickle creatures, it seems -pragmatic at best, capricious at worst. At times, they seem rooted in tradition and ancestral wisdom, but increasingly, they smack expediency, fashion –borrowed from somewhere else like a hat for an occasion. And as with trends on social media, they are ephemeral –tales told by an idiot full of sound and fury, signifying nothing…

Or am I being too critical? Too unwilling to accept change? Too… old?

*

Judith was an angry person –or maybe I just met her on an awkward day. But she held her body stiffly, as if any movement might reveal a secret. She had an accent I couldn’t place, but her demeanour didn’t really invite my inquiring about it -another secret she needed to conceal, I suppose. The referral note said only that she had pain but had refused to let her doctor examine her. Judith wouldn’t let me examine her either; she was certain it was caused by an ovarian cyst and she just wanted to talk about it.

I could see her peeking at my computer screen with suspicious eyes. The way I’ve had to configure my temporary desk to accommodate both the ability to access the monitor as well as well as the patient’s face, lends a certain intimacy to the little makeshift office. No longer can I afford to write a note to myself that the patient I’ve been asked to see seems unduly anxious or irritable; I dare not suggest that she is being evasive in her answers to my questions; I cannot even intimate that she doesn’t appear to trust me. All is open to scrutiny during a renovation.

And that’s fine. She can have access to her chart; I have nothing to hide. But as well as her answers to my questions, what I write are merely impressions, conjectures: colours. The subsequent consultation letter to her referring doctor is a collation of these -a considered appraisal of what I have observed and heard. The initial chart is a first draft of things that will later become an opinion. An assessment.

But Judith was persistent. Like someone reading my book over my shoulder on a bus, I have to admit I did feel some boundary issues. I toyed with the idea of turning the screen so she could read it more easily, but my long-held prairie rules of decorum prevented me. Instead, I contented myself with an obviously self-conscious stare at her face. She paid no attention to my discomfort except to wrinkle her face at what I had just written.

I was filling out the reasons for ordering a pelvic ultrasound –outlining what questions I hoped could be answered, and what, specifically, I hoped they would address: The patient has complained of right lower quadrant pain for several months. She may have a right ovarian cyst. Please assess ovaries and characterize cyst if present. Thanks. It seemed a perfectly straightforward request, but I could see Judith shaking her head.

“You’ve got to be more forceful in your request, doctor,” she said, her face tight with concern. “I told you I have a cyst so why don’t you just say so?”

Her response took me by surprise. “I was just outlining my suspicions for them to confirm or refute on the ultrasound…”

Her eyebrows stayed lashed to her hairline. She was shaking her head again, but whether in disapproval or disbelief I couldn’t tell. “And why do they have to know about the pain? That seems to be a breach of patient confidentiality, don’t you think?”

I sighed quietly. “It’s not a breach of confidentiality, Judith, it’s a medical document outlining the questions I want answered, and so it has to have pertinent details about the condition. If it is an ovarian cyst, not all cysts cause pain and not all pain is caused by cysts. I need to know the details of what they see.”

You’d think that would have appeased her but I could tell she was still troubled by what she saw. “And why do Canadians insist on using ‘please and thank you’ all the time? It’s just a request for an ultrasound…”

I sat back in my squeaky chair and smiled. “What would you write, Judith?”

She thought about it for a moment, obviously caught off guard. “Well… How about: I’d like you to describe the cyst on her right ovary.”

“ ‘I’d like you to..?’ Isn’t that just a longer way of saying ‘please’?”

Her eyes narrowed and I could almost hear the gears grinding in her head. “Then… why not just: Assess the pelvis?

I squeaked my chair again. “Seems to me that’s just a command to do something without explaining why. The more information they have, the more they are able to tailor their study.”

A little smile fought for the stage on her face. She was getting into this. “Okay, so: Cyst suspected in pelvis. Confirmation and characterization required.”

I nodded, then turned back to the screen to amend it. “I can accept that, Judith,” I said, as I typed her words onto the requisition. “But I can’t say I agree with it.” I looked up at her. “It seems  too impersonal and uncaring, somehow.”

Her face softened with bewilderment and I could feel her eyes searching my face for an answer. “What do you mean?” she asked after sifting through my words for clues.

I shrugged, not at all sure I could explain. “I guess it’s sort of like the Golden Rule: If a person is standing in a doorway talking to a friend and I want to get past, I could say ‘Get out of my way!’ or I could smile and say something like ‘Would you mind if I squeezed through?’ Experience tells me I’m likely to get more cooperation with the second way. Maybe even a smile…” My chair squeaked again. “I like smiles, even if I’m not there to see them.”

Suddenly her whole body relaxed and a laugh lit the room like the sun coming out from behind a cloud. She reached out in the tiny room and touched my arm. “When I said I didn’t want to see a male gynaecologist, my family doctor said you were different…” She sat back in her chair looking the most relaxed I’d seen her. “Put the ‘Please and Thank you’ back in the form if you want. I think I’d like to see the smile on the technician’s face when she reads it, too.”

The prairie in me sighed. I suppose she meant well- meant it as a compliment… Thought she had gained a unique perspective on a world she had never trusted and maybe never thanked. And yet I don’t think she really understood. What I considered thoughtful, she saw as weak. Not polite. And it bothered me. Am I really so different in being accommodating and respectful when I request a service from someone? Is the concept now so unusual that it draws attention to itself? Attention to me? Thank you, but I cannot let myself believe that. Please let me be right…

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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.

Are We There Yet?

There are some things you just have to get right -or else. But, or else what..?  Continuing exposure, even to the most egregious injustices risks dulling the senses; eliciting not indignant shouts but shrugs, excuses not action. Accommodation.

There are benefits that accrue to adaptation, of course –if one lives next to a pulp mill, the objectionable odours soon fade into the background; if one lives in a dangerous neighbourhood, one discovers ways of staying out of danger; these are mechanisms for survival. We can grow accustomed to the most outrageous things, we can attempt to normalize the abnormal. And yet…

And yet that which is abnormal to one culture may be the norm in another. But here be dragons –as ancient cartographers used to say about unexplored territories on maps. One has to differentiate between cultural relativism –accepting that there are many ways of being in the world- and injustice or cruelty meted out in the pursuit of a majority-held social belief system. One that has perhaps been practiced by a population for uncounted generations –so long, even, that it is no longer considered aberrant. No longer noticed.

And the territory is heavily mined –to criticize it, or attempt a change, however laudable, can be seen by those affected as ill-informed at best, and intrusive at worst. Let’s face it, for some issues the dissent is over ideology. Political systems. America, for example, has a thing about spreading its own version of participatory democracy and can’t seem to understand the objections to its imposition –by force if necessary. Others, less convinced of the superiority of the American interpretation, resent the interference, attributing other more venal reasons for its meddling. And who is right? It evidently depends on where you live. Truth defines itself.

But some things do seem to transcend culture and are difficult to defend no matter what the historical cultural practices –torture, physical abuse, murder, to name but a few examples. Whether by outside example, domestic protests, or perhaps even token acquiescence to seem compliant, there is some progress in that regard. For example, I was pleased to see that ‘China has drafted its first national law against domestic violence.’ http://www.huffingtonpost.com/2014/11/26/china-domestic-violence_n_6225876.html The drafted legislation ‘creates a formal definition of domestic violence for the first time and streamlines the process of obtaining restraining orders.’ There are several parts of it that could be improved of course; still, it is a start. A recognition that there was a grievous injury in the body politic. A wound that was long overdue for surgery.

The recognition of defects such as domestic abuse, long tolerated in cultural folkways, is perhaps a natural progression as a society develops. But I worry that the legal protection that is put in place may occasionally overshoot its mark and end up as oppressive as the practice it replaces. It requires thoughtful consideration and sober second thought to prevent unintended injustice. Prejudicial enquiry. Discrimination. As my daughter used to keep asking any time she sat in the car: “Are we there yet, daddy?” “Pretty soon,” was the only answer that seemed to satisfy her -if only briefly. But in this case, soon is not at all satisfying.

In the case of domestic violence –sexual, or otherwise- investigation of the alleged abuse must balance the difficulty of the aggrieved partner in coming forward with the information –the danger to her both physically and emotionally, not to mention the social and legal stigma that might ensue- with the right of the accused to be fairly adjudicated and the evidence impartially considered. I recognize that in this type of situation, it is difficult to progress from a ‘He said, she said’ situation to a balanced appraisal of whatever information is available without seeming to impune the word of either party. And I also understand that, no matter the guilty party, reputations of both, and perhaps even standing and subsequent acceptance in the community, might be at stake. Merely acknowledging the need for a remedy does not necessarily create one.

Sexual harassment falls under a similar rubric, but it is a field even more heavily mined. There seems to be an encouraging awareness of the problem nowadays; women are speaking up about it but often only when it has become intolerable. Indeed even our Canadian parliamentarians are not without blemishes in this regard: http://www.cbc.ca/news/politics/harassment-allegations-against-2-liberal-mps-rest-with-secretive-committee-1.2825385

The issues this type of situation illustrates, are in themselves problematic however: http://www.cbc.ca/news/politics/harassment-on-parliament-hill-6-unanswered-questions-1.2826026 There seems to be no easy solution to the fact that it is important that both sides be heard –not condemned out of hand. Allegations are uncomfortable to submit, and often frought with disciplinary actions should they fall prey to power structures. All too often the victims are too frightened of losing their jobs, or of the publicity and possibility of public ridicule to come forward. Hence the appeal of anonymity, or mechanisms for keeping the accusations one step removed from them. Avoiding potentially damaging confrontations.

But while this offers protection for the victim that is unquestionably desirable if the harassment is to be stamped out, it unfairly (perhaps) predjudices the accused. Unless we accept the concept that a person is guilty until proven innocent, then it is incumbent upon whatever authorities are charged with processing the accusation to adopt an equitable appraisal of all the evidence. Hear both sides.

No matter the society, no matter the longstanding traditions, no matter the crime or the accusations, evidence should trump. It is all too easy to form opinions and act on insufficient information, whatever the ideology involved. It is all too easy to assign blame, especially in the field of personal relations.

But I don’t know… I guess in the end, I’m reminded of Claudio in Shakespeare’s Much Ado About Nothing:

Let every eye negotiate for itself

And trust no agent; for beauty is a witch

Against whose charms faith melteth in blood.”

Menstrual Taboos

Culture shapes behaviour, attitudes and beliefs -or is it the other way around? The chicken or the egg? This has puzzled me since I was a child wondering why everybody I knew wore jeans but in pictures the people living in, say, India did not. And the members of my family –uncles, aunts, grandparents, cousins- all went to church and sat in seats. None of them prostrated themselves on little rugs on the ground. Did each of us have to be Protestant? Was there a choice? Or, was there something about my family that made them that way? I don’t remember choosing.

Why do we end up believing or doing something that seems arbitrary when compared with other parts of the world? Why do we often think that only the way we do things is appropriate? Correct? How many correct ways are there..?

Could imitation be something akin to an infection? If everybody we know does the same thing, why would we even suspect it? Maybe it’s contagious and causes a psychological compulsion to fit in –like fashion, or expresssions in language that identify us as a member of a group or region. We seldom question it, but then again, there is no reason to: everybody around us is doing the same thing so it infrequently rises to a conscious concern. It’s an outrageous thought experiment of course and yet such curious congruity does give one pause for thought.

But in our islands of similarity we do notice difference; it makes us feel uneasy –as if perhaps there was a choice. Another way to do something. Another way to be in the world. And depending on the status of the innovator, we may see the novelty as interesting but peculiar –perhaps even something we should adopt for ourselves- or we may consider it simply wrong. Strange. Evil. Something to be shunned, avoided at all costs -even at the expense of the defector. Even if the apostate is tolerated under other circumstances when seemingly adhering more closely to the accepted norms.

I use the word apostate advisedly. Society is a religion, and one that is often disdainful of heretics, aberrations that tug at the pattern in the fabric. Anomalies. Discrepancies sometimes strain cohesion and make us question who we are and why we have come to behave the way we do. We are creatures of custom.

Of course I realize it is difficult, if not impossible, to apprehend difference without judgment. Even curiosity suggests analysis: comparison and evaluation. Some things, however, seem difficult to assign merely to custom; the difference is more appropriately attributable to fear. Unintended ignorance. Naivete.

The menstrual taboo is a case in point. There have been some recent articles in both the BBC News: http://www.bbc.com/news/world-asia-29727875?print=true and the Huffington Post:   http://www.huffingtonpost.ca/sabrina-rubli/menstrual-education_b_5689072.html that discuss problems surrounding menstruation and how it interferes with education for young girls especially. Menstruation is a natural process for renewing the uterine lining every month: shedding the old cells to make way for new ones that may be required to grow a baby. But natural does not necessarily mean acceptable or discussable for everybody.

Culture deems some things embarrassing, things best kept private or at least not shared outside a family or circle of friends. Bodily functions and intimate relations probably top the list. And yet necessity sometimes trumps personal feelings; where adequate facilities do not exist, an accommodation, a compromise usually springs up to fill the need. So while communal ablution may never rise to the level of a societal norm, a variation of it may be tolerated under some circumstances. Safety and vulnerability constrains many compromises, with strict gender separation often necessitating extreme measures such as waiting until the relative safety of darkness for a woman to relieve herself. Even this atrocious compromise is fraught with danger, as recent reports of rape and sometimes murder in parts of rural India attest. That the practice should even need to exist is unconscionable to most of us; that those with the authority and power to change it in the region have not managed to remedy it is worse.

But let’s not allow the unreasonable social diminution of women in one area blind us to an even more pervasive inequity in many developing nations around the world: the cultural taboo about menstruation. Femme International has documented some of the more egregious offenders in its website http://www.femmeinternational.org/the-issue.html

Culture is a tricky thing. Both intriguing and covert, it exerts an inordinate amount of influence on thought and action. The sources of its traditions are often historical, bound in a delicate weave with myth and legend, and are at best opaque. To question it, therefore is difficult and usually seen as insulting and provocative –it is what separates us from them, precluding further analysis, further understanding. “It’s just how we do things,” is the usual response to questions from foreigners. “You wouldn’t understand.”

The menstrual taboo is like that… and not. Attitudes are seldom fodder for experimental investigations, and yet occasionally there are aspects that are historically discoverable. The enforced seclusion or restrictions on the activity of menstruating women are usually ascribed to ignorance –lack of education about the function and meaning of menstruation- or fear of some theological punishment.  And yet Femme International, political correctness notwithstanding, has intimated there may be a more obvious, historical reason for the concern, albeit uncomfortable to state.

Traditionally, menses have been a source both of embarrassment as well as inconvenience for a woman –especially if she is required to be in public places such as the market -or school in more modern days- for any extended period of time. How to cope with the menstrual blood? Only recently have effective measures been available, but even these are priced beyond the means of many girls in isolated villages. In Kenya, for example, the BBC article reveals that the cheapest package of sanitary pads costs almost half the average daily wage, so they may be seen as more of a luxury item than a necessity. ‘As a result, girls will resort to using alternative methods of menstrual management, such as rags, leaves, newspaper, bits of mattress stuffing, even mud.’ The Femme International again: ‘Menstruation is the number one reason why girls miss school. Sometimes girls will attend school on their periods, but will refuse to sit down, or once seated, refuse to move. Many schools do not have appropriate latrine facilities, and girls are unable to wash themselves during the day. When latrines are shared between boys and girls, they are teased and mocked during their period.’ Indeed it has been suggested that because of some of these practices, the odour alone may have given rise to some of the fear of contagion and restrictions placed on the menstruating woman.  For example, the BBC reports than in ‘regions of Kenya, girls are forbidden from touching livestock, preparing food or consuming animal products for fear of contamination.’ And in India ‘there is generally a silence around the issue of women’s health –especially around menstruation. A deep-rooted taboo feeds into the risible myth-making around menstruation: women are impure, filthy, sick and even cursed during their period.’

Femme International has suggested at least one acceptable option: menstrual cups. ‘Menstrual cups provide an affordable and sustainable solution to menstrual health management. A menstrual cup is made of medical grade silicone and is worn inside the vagina during menstruation to collect fluid. Menstrual cups are more cost-efficient and environmentally friendly than tampons as they can be washed and reused for up to 15 years. Unlike [expensive] pads and tampons, the cups only need to be emptied every 12 hours. Thus girls can attend school without worrying about the availability of private washroom facilities, or revealing their period to peers.

There are other remedies of course and they, too, need to be pursued. Once again the Femme International: ‘Young women who lack the knowledge and resources to safely and effectively manage their periods not only miss school but face stigma and shame from their male and female peers. When girls do not understand why their body menstruates each month, they easily believe that it is something to feel shame about, something to keep hidden and something that is a source of humiliation. This type of behaviour is strongly influenced by the widespread stigma that surrounds menstruation in the majority of communities. When women are unable to manage their periods, they are less able to participate in daily life. Addressing the issue of menstruation through health education, positive reinforcement and the provision of management materials reduces these gender specific barriers.’

Yes, it’s a step to be sure, but one that may require a generation to succeed. We must not give up because the progress seems slow and the task insurmountable. Attitudes do shift, cultural mores and folkways change, governments fall. And with the almost ubiquitous availability of social media, one hopes the results might be noticeable even in our time. The curtain of mystery that has always separated the two sexes need not be rent asunder, though –mystery, after all, can be a source of awe and wonder. And not all mysteries have to be solved -sometimes just acknowledged and appreciated for their charm and excitement. No, the fabric need not be torn -merely parted enough to reveal that what differences do exist between the sides -between males and females- are nothing to fear. We were made for each other, after all.