Zealandia?

Sometimes things are not as they seem and we see, as the biblical Paul wrote, ‘through a glass darkly’. Sometimes there is more than meets the eye; it is what makes the world so interesting. Maybe it’s why we wrap gifts –or give them, for that matter. They are such stuff as dreams are made on…

I have always loved New Zealand; to me, it is a gift, and so is what I’ve recently learned about its origins. To think that Aotearoa –the land of the long white cloud- is more than the ribbon I can see today, more than the Maori seafarers could see even a thousand years ago when they first arrived, is astonishing, and not a little intriguing. An article in the Guardian (https://www.theguardian.com/world/2017/feb/17/zealandia-pieces-finally-falling-together-for-long-overlooked-continent?CMP=Share_iOSApp_Other) reports on a paper published in GSA Today -the journal of the Geological Society of America: ‘Zealandia covers nearly 5m square km, of which 94% is under water, and encompasses not only New Zealand but also New Caledonia, Norfolk Island, the Lord Howe Island group and Elizabeth and Middleton reefs. The area, about the same size as the Indian subcontinent, is believed to have broken away from Gondwana – the immense landmass that once encompassed Australia – and sank between 60m and 85m years ago.’

Of course, even with satellite-derived bathymetric data, it’s hard to appreciate. And the skeptics, largely silent in their apathy, still sit in the shadows wondering what difference knowing  this  makes. After all, it’s almost all underwater, some of it way underwater –one edge of it ‘can be placed where the oceanic abyssal plains meet the base of the continental slope, at water depths between 2500 and 4000 m below sea level.’ http://www.geosociety.org/gsatoday/archive/27/3/article/GSATG321A.1.htm Would we be any the worse, the unimpressed might argue, if this remained undetected? Would the ignorance handicap us in some way? Any way…?

In the conclusion to the paper, the authors assert that: ‘As well as being the seventh largest geological continent Zealandia is the youngest, thinnest, and most submerged. The scientific value of classifying Zealandia as a continent is much more than just an extra name on a list. That a continent can be so submerged yet unfragmented makes it a useful and thought-provoking geodynamic end member in exploring the cohesion and breakup of continental crust.’ But it seems to me that questioning the value of this discovery misses the point entirely. Misses, perhaps, the point of gifts and the wrapping in which they are concealed.

Although I am now retired, I am reminded of something that happened late in my career as a gynaecologist and which continues to intrigue me. It makes me wonder just how many other assumptions limit our vision…

Sometimes in medicine, we feel the need to step back from the fray, to attempt an objectivity denied to those whom we treat. It allows us, we explain, to adopt another, more reasoned perspective -one which is unadulterated by their pain and emotion. ‘A thought which, quarter’d, hath but one part wisdom’ as Hamlet said.

And yet, looking out from the forest of my age, I realize that sometimes people don’t want to be treated as patients, but as people. Fellow travelers. What they want is a knowledgeable friend, not a textbook to which they can turn. One has to learn to gauge the needs…

Jean was not a new patient, but her visits were erratic and unpredictable. Sometimes it was for a pap smear, but more frequently it was for what she would only characterize as an ‘infection’ –“The usual one,” she would inevitably add with an embarrassed laugh. But neither I, nor any of the other doctors she had seen were ever able to find the infection, so it had become a sort of standing challenge as to who would find it first.

Jean was a very fit woman then in her early fifties, who taught both English and drama at a nearby high school. Meticulous about her appearance, I would see her in the waiting room sitting bolt upright, shoulders back, head perched on her shoulders like it was suspended on fine wires to keep it from despoiling the immaculately dressed body below. Her hair was brown and short with each strand assigned an immoveable location lest it be chastened with the brush she kept on her lap in a little purse.

That day, however, I noticed she had added another weapon to the arsenal on her lap –a little pump action plastic bottle, the content of which she would surreptitiously spray on her hands from time to time, followed by a vigorous rubbing as if she had just applied some soothing lotion.

She smiled when she saw me and extended a just-sprayed hand in greeting. “I think I’ve solved my problem, doctor,” she said as soon as we were settled in my office. “I just wanted you to check and see if there was any difference –you know, down…” She blushed before she could finish her sentence. She immediately produced the little bottle and sprayed her hands again. “No infection,” she added, regaining her composure after the little entr’acte.

“And the little bottle?” I had to ask.

“Sanitizer,” she answered proudly. “It’s antibacterial,” she added, and dived into the purse to read the label to me. “It contains triclosan… For some reason it’s really  hard to get nowadays.” Her face suggested that puzzled her. “I mean it kills bacteria doesn’t it? And they’re the troublemakers…”

I suppressed a sigh and sat back in my chair. “It also encourages bacterial resistance, Jean. And it doesn’t seem to be any more effective at cleaning than good old soap and water.”

She blinked, but whether in surprise, or disbelief I couldn’t tell. “But…” She gathered her thoughts before continuing. “We pick up bacteria from our environment and dirty hands are how we transmit a lot of diseases. We have to keep them clean… Bacteria” –she said it as if the word itself were dirty- “Bacteria are everywhere.” She pointed to an alcohol-based hand sanitizer I kept on my desk. “And I see you don’t take any chances either. ”She relaxed in her chair as if she’d proved her point.

I allowed myself the sigh I had avoided earlier. “An interesting dichotomy, isn’t it?” She raised an eyebrow. “That we live in a world jam-packed with so many bacteria that they are virtually ubiquitous…” I continued, “…and yet so few cause us trouble.”

“But…” She leaned forward on her seat.

“But we seem to want to malign them all; we act as if they were all our enemies. And yet, our own microbiome –the bacteria living in our intestines- are absolutely essential for our health in ways we are just discovering. And apparently the number of bacteria normally living in and on a healthy human body outnumber our own cells by ten to one.” I stopped and smiled at her incredulous expression. “We –our cells- are only the tip of the iceberg.”

I suppose I thought I’d just be reminding her of something she already knew, but her eyes were saucers. “Zealandia,” she said after a moment’s reflection.

“Pardon me?” I’d never heard the word, and wondered whether she was referring to the title of some obscure novel she was teaching at school.

“Zealandia,” she repeated as if she were surprised I didn’t recognize the term. “You know, doctor, the continental landmass of which New Zealand is a part? It’s 95% underwater so you can’t see it and therefore don’t appreciate it’s importance. We usually only judge what we can see, don’t we…?” she added with a wink and a big winning smile.

We all have our blind spots.

Vehicular Obstetrics

Here I am in New Zealand, land of narrow roads, one lane bridges, and at least for us North Americans, the necessity of switching our cultural allegiance from the right to the left hand side of the road. Personally, my greatest struggle is remembering to get into the car through the correct door. Everything seems mirror-imaged, including the controls on the dashboard –you can tell tourists at a crossroad because their windshield wipers start up before their turning signal.

But of course, that’s what I love about the country; I drive a lot when I come here, so traffic always is in my mind, if not in my heart. The ever-distracting scenery seems to require more attention than back home, despite the smaller population .

It all reminds me of a Canadian study reported in the Canadian Medical Association Journal (CMAJ) of July 8/14  http://www.cmaj.ca/content/186/10/742.full  which  ‘compared the risk of a serious motor vehicle crash during the second trimester to the baseline risk before pregnancy.’  It was a large study which used the women themselves as their own controls before and during pregnancy. Interestingly, the relative risk of motor vehicle accidents rose by 42% in the second trimester of pregnancy. As the authors state: ‘The increased risk extended to diverse populations, varied obstetrical cases and different crash characteristics. The increased risk was largest in the early second trimester and compensated for by the third trimester. No similar increase was observed in crashes as passengers or pedestrians, cases of intentional injury or inadvertent falls, or self-reported risky behaviours.’

In other words, there seems to be something, not so much about pregnancy per se, as about the second trimester. It’s obviously only one study and more research has to be done to substantiate the findings, but there is some corroboration mentioned in a Commentary on the report in the same issue: ‘A population-based study from North Carolina found that the highest risk of a motor vehicle crash during pregnancy occurred at 20–31 weeks’ gestation, with a marked decline in the risk of a crash thereafter,3 which is similar to the current study’s results.’  http://www.cmaj.ca/content/186/10/733.full

Pregnancy has long been coloured by reports of altered memory, concentration, sleep deprivation and fatigue, but why does the second trimester seem to be the time of greatest risk? The authors recognized the difficulties and used an interesting set of criteria to help explain it: ‘with all observational studies, it is difficult to make causal inferences. In this article, we assess the associations shown in the study in light of the criteria proposed by Hill:2 temporality, consistency, biological plausibility and evidence of a dose–response effect.’ In other words, do the study findings satisfy these conditions? By and large, they feel they did, with reservations you can address through the links.

As an obstetrician of many years, I can’t remember being asked about the act of driving while pregnant. About being more careful, yes; about where to position the seatbelt, yes; and even about whether or not to report to the hospital if there is a relatively minor accident –more of a bump than a crash. If asked, I’m sure I would have pointed out the altered anatomy and how it might not fit as comfortably behind a steering wheel as pregnancy advanced, but I don’t think I would have singled out the second trimester as being the time of greatest concern. So I’m intrigued by the findings.

The authors have been diligent in pointing out the limitations of their study –such things as distance travelled, frequency of travel, and that after an accident, a pregnant woman might be more likely to report to a hospital because of worry about her foetus even if she weren’t injured herself. It still doesn’t explain the seeming preponderance of risk in the second trimester, however.

I shall certainly be watching for any further analysis of the data, or any follow-up studies this engenders. And with my now heightened curiosity piqued, I may even include a warning to my pregnant patients to be extra careful behind the wheel. I’ll  certainly be more careful if I see one of them get into a car…