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…

Full o’ th’ Milk of Human Kindness?

I used to drink a lot of milk when I was a child. It was 1950ies Winnipeg and milk was still delivered to the house in those clear glass bottles with the little bulge on top to hold the supernatant cream. I never much cared for the cream, but my mother always found a use for it. Anyway, most of my fascination was with the delivery system. If I stretch my memory to the earliest days, I can still hear the clip-clop of the horses hooves, and the tinkling of the bottles as the milk wagon rolled slowly down the street, stopping every few hundred feet to make a delivery and carry away the empties we each left on the front steps.

Looking back, it seems a magical time. A time when parents were told that milk was needed for healthy bones, and felt obliged to insist on its consumption at every meal if they could afford it. I didn’t know there was any controversy then. I had no idea that not everybody felt that way -and there really wasn’t any reason to think otherwise, I suppose. Not then, at any rate…

But more recent advances in historical techniques, and evolutionary genetic studies able to find and interpret DNA from far away civilizations in varying times, are allowing us to understand the cultural differences I could never have suspected in my halcyon years.

I happened across an article in an NPR section called ‘the Salt’ which delved into the issue: https://www.npr.org/sections/thesalt/2012/12/27/168144785/an-evolutionary-whodunit-how-did-humans-develop-lactose-tolerance

‘Most babies can digest milk without getting an upset stomach thanks to an enzyme called lactase. Up until several thousand years ago, that enzyme turned off once a person grew into adulthood — meaning most adults were lactose intolerant (or “lactase nonpersistent,” as scientists call it).’ And, it would seem that ancient European farmers ‘[…] lacked a genetic mutation that would have allowed them to digest raw milk’s dominant sugar, lactose, after childhood. Today, however, 35 percent of the global population — mostly people with European ancestry — can digest lactose in adulthood without a hitch.’

Those groups who became lactose tolerant (over the last 20,000 years) seem to be mainly people of Northern and Central European descent and from certain African and Middle Eastern populations. Also, many other societies were able to tolerate at least some milk by processing it into cheese, butter, or yogurt which removes some of the lactose.

And as I discovered in another article discussing a new book Milk, by Mark Kurlansky (see below) ‘[…] milk was a vital symbol in the mythology of the Sumerians, Greeks and Egyptians. The Fulani of West Africa believed that the world started with a single drop of milk, and in Norse legend, a cow made from thawing frost sustained the world in its earliest days.’

There were some differences between cultures, however, perhaps related to much earlier experiences with lactose intolerance. ‘[…] even with these deep cultural connections, milk held a peculiar status among early civilizations. The Greeks castigated barbarians for their gluttonous desire for dairy, and in Rome, milk was widely regarded as low-status food because it was something only farmers drank. Northern Europeans would earn similar ridicule for their love of reindeer milk, and Japanese Buddhists later rebuked Europeans as “butter stinkers.”’

Much has been written about milk over the years, but perhaps the most worrisome recent chapter in its history concerned the fact that it ‘spoiled’ easily and rapidly. Reliable refrigeration was not available in the early days, nor -at least in the cities- were the cows often kept in hygienic conditions. https://www.smithsonianmag.com/history/surprisingly-intolerant-history-milk-180969056 Milk is an ideal medium for the growth of many types of bacteria, and so it was a huge risk for the population to whom it was fed -largely children.

In France, in the 1860ies, Louis Pasteur pioneered the heating of milk to high temperatures to kill pathogenic bacteria, but ‘pasteurization proved a tough sell in the United States […]. There was little doubt that the process improved milk safety by eliminating the diseases that led to so many deaths, but consumers complained that pasteurized milk was flavorless. Some officials, including Harvey Wiley, then the director of the U.S. Bureau of Chemicals also argued that pasteurized milk lost its nutritional qualities.’

These arguments persisted despite the invention of homogenization of milk in 1899 by Auguste Gaulin. It was a way of breaking down the fat molecules in milk so they wouldn’t separate out -so you didn’t need that little glass bulge on the top of the milk bottles in other words. It is an entirely separate and different procedure than pasteurization, of course -and added yet another cost.

Then, in 1908, the U.S. Surgeon General under president Theodore Roosevelt, ‘released a 600-page report that attributed most childhood deaths to impure milk and argued that pasteurization was the best way to address the ongoing public health crisis.’ But, in the face of continuing public suspicions about cost, flavour, and even attributions of other maladies such as rickets and scurvy to the process, a more or less universal adoption of pasteurization in the U.S.A. was slow. And, ‘The discussion around how to best prepare milk even continues today, evinced in the growth of the GMO-free products and the resurgence of artisanal industries and local dairies.’

Me? I miss the horses most. And the sound of the gently clinking bottles, as distinctive then as the melody of those little ice cream trucks that still drive around some neighbourhoods even now. It’s a shame that none of this exists in the memory banks of most people nowadays. Like the language of many of our indigenous predecessors, or the receding northern glaciers, it should be enshrined somewhere. Saved. Celebrated.

Yes, I know things keep moving forward -I suppose it’s what happens with Time- and yet am I alone in wishing that it could move sideways for a bit? Not forever, mind you -that’s a long, long time- but perhaps it could just slow down a little. Linger in a quieter space, when it was still possible to hear the snuffling of the horse’s breath, and the quiet hiss of the milkman’s curse as he tripped over the bike I’d left beside the sidewalk in my rush to wash my hands in time for breakfast…