Tag Archives: Wisdom

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What is the Merit of Originality?

‘I am not young enough to know everything,’ as Oscar Wilde once said, and maybe the rest of us aren’t either. It is often an unquestioned assumption that New trumps Old, that innovation usually leads to improvement, and that by standing on the shoulders of giants, the view is necessarily better. Clearer.

But there is wisdom in both the long as well as the panoramic views. Neither changing  your shoes nor altering your hat, really improves the safety of a voyage -nor does it address the original goal of a safe arrival of everybody on board. Appearing modern, seeming prepared, only helps if it helps –a leak is still a leak, especially if there are only lifeboats for a few…

Let me explain. I happened upon an article in the journal Nature that chronicled the introduction of a new, and highly accurate method of diagnosing TB through genetic analysis.  https://www.nature.com/news/improved-diagnostics-fail-to-halt-the-rise-of-tuberculosis-1.23000?WT ‘The World Health Organization (WHO), promptly endorsed the test, called GeneXpert, and promoted its roll-out around the globe to replace a microscope-based test that missed half of all cases.’ It sounded like a perfect technological fix for a disease that has so far avoided effective control. ‘Some 10.4 million people were infected with TB last year, according to a WHO report published on 30 October [2016?]. More than half of the cases occurred in China, India, Indonesia, Pakistan and the Philippines. The infection, which causes coughing, weight loss and chest pain, often goes undiagnosed for months or years, spurring transmission.’

Unfortunately, ‘[…] the high hopes have since crashed as rates of tuberculosis rates have not fallen dramatically, and nations are now looking to address the problems that cause so many TB cases to be missed and the difficulties in treating those who are diagnosed. […] The tale is a familiar one in global health care: a solution that seems extraordinarily promising in the lab or clinical trials falters when deployed in the struggling health-care systems of developing and middle-income countries. “What GeneXpert has taught us in TB is that inserting one new tool into a system that isn’t working overall is not going to by itself be a game changer. We need more investment in health systems,” says Erica Lessem, deputy executive director at the Treatment Action Group, an activist organization in New York City.’

But I mean, just think about it for a minute. ‘The machines cost $17,000 each and require constant electricity and air-conditioning — infrastructure that is not widely available in the TB clinics of countries with a high incidence of the disease, requiring the machines to be placed in central facilities.’ Sure, various groups agreed to subsidize the tests in 2012, but: ‘each cost $16.86 (the price fell to $9.98), compared with a few dollars for a microscope TB test.’ So which test would you choose if you were a government strapped for cash to provide for healthcare for a broad spectrum of other equally pressing needs?

‘Even countries that fully embraced GeneXpert are not seeing the returns they had hoped for. After a countrywide roll-out begun in 2011, the test is available for all suspected TB cases in South Africa. But a randomized clinical trial conducted in 2015 during the roll-out found that people diagnosed using GeneXpert were just as likely to die from TB as those diagnosed at labs still using the microscope test.’ That seems counterintuitive to say the least.

So what might be happening? ‘Churchyard [a physician specializing in TB at the Aurum Institute in Johannesburg, South Africa] suspects that doctors have been giving people with TB-like symptoms drugs, even if their microscope test was negative or missing, and that this helps to explain why his team found no benefit from implementing the GeneXpert test. Others have speculated that, by being involved in a clinical trial, patients in both arms of the trial received better care than they would otherwise have done, obfuscating any differences between the groups.’

‘Even with accurate tests, cases are still being missed. Results from the GeneXpert tests take just as long to deliver as microscope tests, and many people never return to the clinic to get their results and drugs; those who begin antibiotics often do not complete the regimen.’ Clearly, technology alone, without an adequate infrastructure to support it –without a properly funded and administered health care system- is not sufficient.

And it’s simply not enough to have even a well-funded health system that benefits just those who can afford it, leaving the rest of the population to fend for itself, and only seeking help when they can no longer cope –often when it is too late. Health care is a right, not a privilege –no matter what those in power would have us believe.

I’m certainly not arguing that improving technology is not part of the solution, but sometimes I wonder if it is merely putting new clothes on a beggar. Handing out flowers in a slum.

Let’s face it, real Health Care is more than a sign on a door, more than a few people in white coats. It is a kind of national empathy. A recognition that even the poorest among us, have something valuable to contribute; that even those who have strayed from society’s chosen path, are who any of us might be, but in different clothes.

The myth of Baucis and Philemon tugs at my memory: They were an old married couple living in a small village in Anatolia (part of Asian Turkey nowadays) who, unlike everyone else in the town, welcomed two peasants at their door who were seeking refuge for the night. The couple, of course, were unaware that they were actually welcoming two gods, Zeus and Hermes, disguised as humans. A common enough trope, perhaps, but an instructive one, I think -one that transcends virtually all cultures, and borders: the idea of helping others without any expectation of reward. It is not an exchange -a transaction- so much as an action. Agape, in fact.

Health care is like that. Or should be… It’s not about the glittering display in the shop window –there to impress the passersby- it’s about the people in the shop.

 

 

 

 

 

 

 

 

 

 

 

 

 

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Fairness Which Strikes the Eye

Sometimes it seems we cannot help ourselves –the pull of the tide is just too strong to resist. And sometimes an argument, when considered too quickly, too uncritically, captures us with its ostensibly intuitive wisdom. We have no need to question it. No need to probe the basis of its logic.

The rhetoricians of old were well versed in this form of argument –the art of persuasion and how to best achieve it. Aristotle, for example, suggested three essential features of a convincing argument: ethos –the credibility of the contention; pathos –understanding the needs and emotions of the audience; and logos –the patterns of reasoning and the words chosen. His wisdom, although modified and woven into the contemporary tapestry, has not been lost in modern times.

What could provoke a greater sense of outrage in a population than the 1% contention? That is to say, in at least one of the iterations fostered by the Occupy Movement, that in the United States, 1% of the population controls 40% of the wealth. And to many, that unequal distribution of wealth, is symptomatic of what is wrong with Capitalism. It certainly resonates with those of us in the 99% who hear it. It begs for remonstrance; it demands rectification.

And yet there are usually many sides to a story –or at least this one, at any rate. There are times  when we need to move back a step or two in order to appreciate the different perspectives. Even so, I have to admit that an article in the BBC Future series came as an intriguing surprise: http://www.bbc.com/future/story/20170706-theres-a-problem-with-the-way-we-define-inequality It allowed me to entertain an alternative that I had not even considered.

As they tease at the beginning, ‘Some researchers argue that income disparity itself may not be the main problem. The issue, they say, is not the existence of a gap between rich and poor, but the existence of unfairness. Some people are treated preferentially and others unjustly – and acknowledging that both poverty and unfairness are related may be the challenge that matters more […] While many people may already view inequality as unfairness, making the distinction much clearer is important.’

They go on to say that ‘In a paper published in April in the journal Nature Human Behaviour called ‘Why people prefer unequal societies’, a team of researchers from Yale University argue that humans – even as young children and babies – actually prefer living in a world in which inequality exists. […] Because if people find themselves in a situation where everyone is equal, studies suggest that many become angry or bitter if people who work hard aren’t rewarded, or if slackers are over-rewarded.

‘“We argue that the public perception of wealth inequality itself being aversive to most people is incorrect, and that instead, what people are truly concerned about is unfairness,” says Christina Starmans, a psychology post-doc at Yale who worked on the paper.

“In the present-day US, and much of the world, these two issues are confounded, because there is so much inequality that the assumption is that it must be unfair. But this has led to an incorrect focus on wealth inequality itself as the problem that needs addressing, rather than the more central issue of fairness.” And as Mark Sheskin, one of the co-authors remarks, ‘“People typically prefer fair inequality to unfair equality”’.

In a way, a lot of the argument hinges on definitions. There are, after all, several ways to look at inequality: equality of opportunity, equality of distribution of benefits, and of course, equality of outcome. Must all of them be addressed, or is there a priority? Is the existence of a super-rich 1% the problem, or would it be more helpful ‘ to concentrate more on helping those less fortunate, who via a lack of fairness, are unable to improve their situation’?

‘Harry G Frankfurt is a professor emeritus of philosophy at Princeton University. In his book On Inequality, he argues that the moral obligation should be on eliminating poverty, not achieving equality, and striving to make sure everyone has the means to lead a good life.’ Poverty, in other words, is the problem; it is unfair…

I suppose, when considered practically, it would be unrealistic and unduly Utopian, to think that we could ever dispense with at least some degree of income disparity. People ‘don’t typically work, create or strive without the motivation to do so’. It seems to me that the unfairness does not lie in the money fairly accumulated for work done, so much as in the fact that ‘not everyone is afforded the same opportunities to succeed, even if they put in that hard work.’

But, on the other hand, it’s not all simply a matter of the equality of opportunity, nor even of equality, per se. Fairness is something different. The issue of fairness is in a different Magisterium altogether. I’m Canadian, and I believe that no one should have to live in poverty. Not everyone has the skills, or indeed, the capacity to hold a job, even if an opportunity presents itself. Some are disadvantaged by appearance, or gender; some are discriminated against by virtue of their origins, or life-style; some, even, have succumbed to past failures and have given up trying… It is unfair to give up on them –any of them- simply because of the lotteries of birth or circumstance.

Fairness, it seems to me, is universally available and accessible health care. It is a living wage that allows even the poorest to feed their family. It is safe and obtainable shelter. It is the respect afforded even to those we do not understand. It is toleration of difference, even when the rest of us may not understand, or agree with it.

It seems to me that inequality, by itself, is not what drives revolutions. Inequality is not what causes societies to weaken and their moral fabric to unweave. Inequality is just the chipped and discoloured veneer most easily visible on the surface. What festers directly underneath, sometimes only detectable when the surface weakens or is pulled asunder, is inequity. Injustice. Unfairness… Poverty, unlike wealth, offers little protection. And that is the iniquitous thing.

For some reason, I’m reminded of Shakespeare’s King Lear: Through tattered clothes great vices do appear; Robes and furred gowns hide all. Plate sin with gold and the strong lance of justice hurtless breaks. Arm it in rags, a pigmy’s straw does pierce it.

Prove me wrong…

 

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Recycling the Old

For everything there is a season, and a time for every matter under heaven…

Really? It made sense when I was young, I suppose -when all of Time was ahead. When I needed to think there was some order to things. That past and future meant old and new. But as the years slip past, I find myself wondering about disparate things. Opposites. Like what, really, is the difference between new and old? Is it merely a temporal distinction? A nudge along a spectrum? Or a more fundamental change -a conceptual shift? I suspect it can be any of these, of course, but it still begs the question: does any change, any difference qualify? What if there is no change in form at all, but rather a change in function? In Purpose? Would that be new, or merely a rose with another name?

The concept of recycling has been with us from the dawn of time. When materials were scarce or unavailable things were used again, either in their original roles, or repurposed for something else their makers had not anticipated -a new situation, a new need. And so the old rises from its ashes like a Phoenix, but this time in a different play as another, unfamiliar actor.

The tradition of respecting the wisdom of elders and retelling their stories is also an honoured tradition. But as stories do, they alter over time and are often interpreted in new and unexpected ways. The knowledge is not lost, it’s just explained in different words. Understood in a new context. Reconstituted. Society has learned that there is often a benefit that accrues to re-examining the old and looking at it from an altered perspective. So has Science: http://www.bbc.com/news/health-33635575 Bisphosphonates have been around for a while as treatments for osteoporosis, a condition in which there is decreased bone mass. They help to prevent bone loss and so strengthen the bones themselves. It is most frequently used in the post menopausal woman when she no longer produces bone-protective hormones from her ovaries.

Bone is a common site for breast cancer cells to travel to (metastasize) however, and they can lie dormant there for years after the primary tumour has been removed from the breast. And yet, interestingly, those women who were already being treated with the bisphosphonates in the menopause and later developed breast cancer, showed a 28% reduction in cancers developing in their bones. http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60908-4/fulltext And because the patents on bisphosphonates have expired in many jurisdictions, the cost of these bisphosphonates is minimal when compared to other ‘new’ treatments on the market.

But there’s more. A medication originally designed for diabetes –glitazone- has been found to decrease the likelihood of developing Parkinson’s disease. http://www.bbc.com/news/health-33608725 Of course this is just a comet in an otherwise cloud-filled night because glitazone is not without its own serious side effects –bladder and heart problems, to name just two- but it is a promise whispered emphatically, albeit quietly, to anyone working in the field. A starting point for future research…

So I suppose we should keep poking about in the ashes. Stirring embers to see if there is a Phoenix hiding somewhere in the cinders, fast asleep and dreaming of another job. We affix labels to things –categorize, then name them for all time. It’s a way of keeping track. Knowing what to expect. The problem, of course, is that things change. Evolve. Mutate. And as Jiddu Krishnamurti, a philosopher, once said of the disadvantage of naming god, it constrains the concept. Limits it. Doesn’t allow for growth and development. I think it is sort of like naming and classifying something when it is only a seed and we are still unaware of its potential. Maybe old is something like that. Where there is life there is always a seed and its age is beside the point. Meaningless.

I’m beginning to see age as a definitional issue, and not in the currently favoured framework of chronological versus biological –or even psychological- age so condescendingly mouthed by those too young to have experienced the ill-disguised discrimination it entails. There is useful wisdom that accretes with years and experience of course. But age is an oven that cooks whatever has been put inside –changes it into something else. Sometimes something entirely new.

I opened with a quote from Ecclesiastes, so let me close with one from the Talmud: ‘For the unlearned, old age is winter; for the learned, it is the season of the harvest.‘

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The Wisdom of Experience

Sometimes, I feel like a fake. I suppose the ability to see oneself from various angles is a gift of age, but I rather enjoyed myself more when I was sure of who I was –or at least didn’t trouble myself with the question. And yet, to dig for the core is to taste the apple on the way.

It was easy to be a doctor when, primed with knowledge, experience was something displayed in a shop window, not something I wore. It was an outfit I didn’t need -an extravagance, really: a luxury you only donned when the facts you’d learned were threadbare and outdated. It was a costume of authority, a camouflage for waning certitude: Moira.

And yet as I plough through the years as steadily as a man walking through waist-high water, I have come to realize that experience is more than subterfuge, more than mere artifice; it is Age. Nothing less. And following in its wake is all the jetsam tossed overboard to lighten the journey, all the flotsam through which we, as sentient beings, must wade in order to progress. A dirty passage protected only by the hull of maturity. But enough metaphor.

All of this somewhat depressing prologue is to introduce an incident that occurred a few years ago when I was teaching a medical student in my office. Stephanie was very good, really –very perceptive and knowledgeable- and she carried herself like someone who had already graduated. It was not hard to integrate her into the chaotic machinations of my busy office.

We were seeing a woman sent to me from a well-respected family doctor who sometimes attracted patients with very dissimilar world-views. She had come to see me for a second opinion about the management of her menopausal symptoms. Or rather, she had been sent to see me by the GP when she refused to accept the treatment offered by the first specialist.

A very well-dressed woman with neatly brushed hair, she sat across the desk from me looking quite confident. She smiled at Stephanie, and then straightened her shoulders and stared at me defiantly. “My doctor wanted me to see you about the menopause…”

I smiled and waited, pen poised to write down her complaints so I could address them later, but she sat back in her chair, obviously finished, and stared at the calendar hanging on the wall behind me. “So, are you having any problems?” I asked after a rather awkward silence.

She shook her head and shrugged. “Am I supposed to?”

I glanced at Stephanie, who was sitting on the edge of her seat, fascinated at the exchange. “No…” I said, looking at the referral letter that just said ‘MENOPAUSE!’ in giant capital letters followed by an even bigger exclamation mark. “But I rather thought your doctor must have had some reason to send you to see me.”

The woman smiled –at least, I suppose that’s what she wanted me to think, but actually it was a smirk. “I’m managing my menopause very well, doctor…” It was a challenge: a dare to be contradicted.

“So… there are at least some symptoms you’re feeling a need to manage.” I said this carefully, not wanting to provoke her.

She immediately straightened in her chair and her eyes hardened. “Why would you say that?”

My turn to shrug. “Well, is there anything I can do for you, then?” I kept the smile on my face.

She took a deep breath to contain her obvious irritation. “My doctor thinks I should be taking hormones… And so did that other doctor she sent me to.”

I started to write in her chart –it often helps patients to think they are saying something important. “Why is that?” A simple question; no sense confusing her.

Silence, and then a prolonged blink. “I told her I wasn’t sleeping and was becoming irritable at work.” She pinned me to the wall with a sudden glare and then, just as suddenly, relaxed the intensity. A little grin crept onto her lips, but she erased it almost before it flowered. “And I mentioned I was having the occasional hot flush.” Her face hardened. “Why do we always medicalize things and make them into illnesses?”

She was silent for a moment and I put down my pen. She looked at my now dormant chart, for a moment.

“I do not want hormones, doctor,” she said shaking her head angrily. “I’ve solved the issues myself.” And she crossed her arms across her chest as if to ward off any criticism.

I picked up the pen again and her expression softened a little.

“Ginger and lemon juice three times a day…” she said and then stared at me: the dare again.

“It helps?” An innocent question I thought.

“Of course it helps!” Her arms tightened across her chest. “You don’t always need hormones, doctor.”

I tried to keep smiling and sat back in my chair. “I certainly agree with that, Sandra. Sometimes we pathologize things unnecessarily.”

The change in her body language was dramatic and she unfolded her arms and loosened her shoulders. “So you think it’s okay to continue with my lemon and ginger?”

I nodded and wrote something in her chart. “As long as it’s doing the job, why not?” I started to put the pen down and she noticed.

“There’s a lot of stuff in there that you haven’t filled in yet,” she said with an increasing grin on her face and stared at the almost blank history sheet in the chart. “You can ask me some questions –I won’t bite.”

I proceeded with the usual consultation and then looked up at her. She was beaming.

“You’re the first doctor who actually listened to me…” she said, clearly surprised. “Still think I’m okay with the juice?”

I smiled at her -my face was beginning to ache with the effort. “It won’t hurt, “ I said, and sensing she was satisfied with the interview I got up from my chair to open the door for her. “But just let me know if you need to discuss some other options, eh?”

As soon as she was out of the room, Stephanie rolled her eyes; she was obviously troubled.

“So what do you think, Stephanie?”

She took a deep breath and looked at me. “She needs hormones…”

I sat down and waited for her to explain. “I mean, she was obviously describing estrogen withdrawal symptoms: hot flushes, night sweats, sleep disturbance… And did you see how irritable she was? Classic menopausal stuff.”

I smiled patiently. Stephanie was young and enthusiastic. Full of knowledge. “So what would you have done if she’d walked into your office?”

She thought about it for a moment; that she didn’t want to offend me was obvious in her face. “Well… First I would have taken a detailed history like you…” She politely ignored the order in which I had proceeded. “And then I would have told her about how estrogen –and progesterone, I guess, because she still has a uterus- would help alleviate her symptoms.” She looked at me, whether for approval or permission to deviate from my approach I couldn’t tell.

“And if she told you she didn’t want to take hormones? That she felt they were too dangerous, or maybe she didn’t believe she needed them..?”

Stephanie didn’t even blink. “I would have been more insistent…”

“And if she still didn’t agree?”

That stumped her for a moment. “Well… uhmm, maybe I would have sent her to a specialist for another opinion.”

“To validate your opinion, you mean?” I said it lightly and with a grin to defuse the tension I could feel increasing in Stephanie. “She already saw another specialist, who validated her GP’s view… Now what? Give up on her?”

Stephanie stared at me, but it was clear she didn’t have an answer.

“Look,” I started, gently, carefully, so as not to appear to contradict what we both knew to be true: many menopausal symptoms are related to hormonal changes and many of the symptoms do disappear when you prescribe hormones. “Why was she sent to me?”

Stephanie rolled her eyes again –an annoying habit she was prone to use at the slightest provocation. “To treat her menopause…”

“Didn’t she tell us at the very beginning that she was already managing her menopause?”

“Yes, but…”

“Yes, but not the way you would like?”

I could see that Stephanie was becoming exasperated. “But surely you could see that she wasn’t. I mean, she was obviously really irritable and…”

“Wouldn’t you be irritable if nobody listened to your opinion?”

Stephanie’s left eyebrow suddenly took over half her forehead –another trait I had noticed during her time in the office. “But there’s no data on ginger and lemon juice. No studies…”

“She seems to think it’s helping her.”

“Yes, but that’s just a placebo effect. It’s going to wear off…”

I broadened my smile. “And when it does –if it does- who will she decide to talk to about it? The doctors who were unwilling to accept her approach, or the one who admitted she had the right to try another way?”

I’m not sure I convinced young Stephanie, and I’m certain that she’ll succeed in whatever field of Medicine she chooses. But I do hope that she learns that the paths we need to follow are not always straight and that even detours usually end up where we want…