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.

From the Mouths of Babes

We take a lot for granted, don’t we? As parents we assume responsibility both for the wellbeing of our children and also their voice. Somebody has to, and obviously we, as their adult guardians, are better able to decide what’s best for them than they are –especially when they are young and inexperienced. It’s hard to argue with that, of course… At least I thought so until I happened upon an article in The Guardian newspaper that started me wondering whether the arrogance of age blinds us to a conceit that should be re-examined. https://www.theguardian.com/lifeandstyle/2016/sep/26/should-children-be-able-to-give-consent-for-medical-treatment?CMP=share_btn_link

I’m not advocating the abrogation of our responsibility to make the decisions –especially in the very young- nor to neglect to act in what we consider to be their best interests. I think it’s more about soliciting their opinions and perhaps incorporating these, where feasible, in the ultimate decision. Clearly, age is a major factor in how engaged the child will be –in the UK, at least, ‘Anyone over the age of 16 can consent to treatment, but so can younger children if doctors think they can understand and are competent to make medical decisions. Neurobiological research shows that the prefrontal cortex, home of balancing risks and rewards, is the last area of the brain to mature. So can adolescents – who are often impulsive risk-takers – be trusted to make decisions about their health?’

There was an interesting 1982 study that addressed the issue of the competency of children and adolescents to make informed treatment decisions: https://www.ncbi.nlm.nih.gov/pubmed/7172783?dopt=Abstract   In it, ‘9-year-olds appeared less competent than adults with respect to their ability to reason about and understand the treatment information provided in the dilemmas. However, they did not differ from older subjects in their expression of reasonable preferences regarding treatment.’

And indeed, there has been some effort to accommodate the child’s wishes in the latest policy statement on Informed Consent of the American Academy of Pediatrics: http://pediatrics.aappublications.org/content/pediatrics/early/2016/07/21/peds.2016-1484.full.pdf  For example: ‘When defined as agreement with proposed interventions, assent from children even as young as 7 years can foster the moral growth and development of autonomy in young patients. This consideration is based on an understanding that, starting around 7 years of age, children enter the concrete operations stage of development, allowing for limited logical thought processes and the ability to develop a reasoned decision.’

Of course, I am a gynaecologist with an adult practice, so I rarely have occasion to delve into the ethical minefield of paediatric consent, but occasionally I am exposed to its intricacies vicariously. These are frequently related to childhood vaccinations. In my Canadian province of British Columbia, vaccinations for hepatitis B and chickenpox as well as HPV (to females only –at the time of this writing) are offered to all children in grade 6 –in other words, to 11 year olds. https://www.healthlinkbc.ca/healthlinkbc-files/grade-6-immunizations Of course, ‘It is recommended that parents or guardians and their children discuss consent for immunization.’ But under some circumstances, even an eleven-year old might be considered a ‘mature minor’ and could potentially consent to the vaccination on her own: ‘In B.C., immunizations for school aged children are given in grade 6 and grade 9. Most of the time, the vaccines are given by nurses at immunization clinics held at schools. Children may also get vaccines at a health unit, youth clinic, doctor’s office, or pharmacy. In all of these settings, a child can consent to the vaccine on their own behalf if the health care provider has determined that the child is capable of making this decision.’

Ruth, a thirty-six-year-old woman whose daughter I had delivered eleven years ago, returned faithfully to my office each year for a pap smear. She had a history of several increasingly abnormal smears, eventually necessitating a minor excision procedure three or four years ago for an HPV-related pre-cancerous lesion on her cervix. Fortunately there had been no evidence of recurrence since then.

She’d always been a nervous woman -her pregnancy no exception- and the subsequent abnormality on her cervix had done nothing to alleviate her anxiety. Even her clothes seemed adjectival to the noun of her angst. Exquisitely ironed white cotton sweatshirts and similarly fussed black jeans over highly polished black leather pumps were her inviolable uniform on each visit. She wore her long blond hair tied in a pony-tail so tightly pulled from her forehead, I imagined I could see tiny fissures opening up on her scalp where it was tearing. And she constantly clenched and unclenched her fists as if she were training for some hand-shaking marathon.

Everything about her usually screamed stress. And yet, when I saw her recently, she had relaxed her hair so it danced freely on her shoulders, and was actually wearing a pale blue silk blouse and a pretty black skirt. At first I didn’t recognize the smiling woman who seemed so comfortable as she sat chatting with one of my young pregnant patients. But as soon as she saw me, she stood and grinned at me as if I were a cherished friend. I suppose I was…

“Doctor,” she said, even before she sat down as I closed the door to my office. “Remember Trish?” she pronounced the name slowly, in case I didn’t remember delivering her.

I nodded and tried not to roll my eyes. She was always telling me about Trish –every visit she had something new to report –and A in spelling, or a Silver in some race she’d entered.

“Well, she’s in Grade 6 in school now…” She stopped and scanned my face to see if I could guess what she was about to tell me. She often played this game and, sadly, I never succeeded.

This time, however, she prolonged it sufficiently long that I began to wonder if she’d forgotten what she was going to tell me. “…And you’ll never guess what happened,” she finally added -probably to tease me.

I knew it would continue like this until I said something. “What?” It wasn’t a very profound response, and I think she was a little disappointed –especially in my evident lack of excitement.

“My little Trish has grown up,” she bubbled with obvious pride. And then, when I didn’t say anything, she continued. “This is the year they all get their vaccinations…” She fixed me with a suspicious stare as she tried to decide whether or not I knew that.

I held my expression to an anticipatory smile and a nod.

“Well, she decided to have the vaccination, doctor!” I could hear the exclamation mark as it rebounded off the walls. “I mean, I’d discussed it with her beforehand and everything, but it was her decision!”

I took a deep, but silent breath. “Was there ever any question about it, Ruth?”

I could see her withdrawing into her face as her eyes took turns jousting with mine.

“She had a lot of questions at first.”

“Questions…?”

She nodded –warily, I thought. Carefully. “Mainly about the HPV one, though.”

“What did she want to know?”

I felt another probing jab with from her eyes before she called them off and sighed. “It was about the boys.” I waited patiently. “She wanted to know why they didn’t have to get the HPV vaccination.”

It was a common complaint, and one that I shared. Although several weak arguments have been made for male exclusion, none of them are convincing.

“She thought boys would have the same risk as girls, and it was so unfair she wondered whether she should refuse to be vaccinated as a protest,” Ruth said proudly.

I wondered where that idea had come from –Ruth was a zealous supporter of HPV vaccinations, I knew. “So you convinced her to change her mind?”

She shook her head. “I tried, believe me. I even phoned the school to make sure they knew I wanted her to have the vaccination.” But I could tell she was pleased that her daughter had evaluated the matter so carefully. I was certainly impressed.

“So what changed things?”

She rolled her eyes and smiled. “One of the boys in the class made a face at her.” Then she sighed. “Perhaps not the most persuasive of arguments…”

All I could do was nod. If someone makes the right decision for the wrong reasons, it’s not really a teaching moment, I suppose…