Author: Gunjan Sharma

GS is a medical student at Cardiff University. She has an interest in Global Mental Health, Medical Humanities, Anthropology and the link between Healthcare and Philosophy (for example, the link between moral responsibility and psychopathy). She is particularly interested in a career in Forensic Psychiatry, and the role of mental disorders as symptoms of society.

In her spare time, GS is an avid reader with a to-read list of over four hundred books long. She reads a wide-range of genres, from Fantasy to non-fiction. She is a strong believer in the spoken word and has an odd habit of memorising poems.

Prizes: Prizewinner of the 2014 Careif Suicide Prevention Essay Competition.
Joint Prizewinner of the 2016 Medical Student Essay Prize of the Forensic Faculty of the Royal College of Psychiatrists.
Prizewinner of the 2016 Medical Student Essay Prize of the Spirituality Faculty of the Royal College of Psychiatrists

Categories
Reflection

The War Against Aging

‘Back in elementary school, I realized we all have a genetic, lethal disease called aging. I remember being frightened that my mother would die and terrified that my existence was ephemeral and meaningless. At the time, it felt like I was being told I had terminal cancer or some other horrible disease. Death was inevitable. No matter how rich or successful I could be in life, it would all be lost in the end. So, still a child, I found an objective, a purpose for my life: to cure human aging.’
Joao Pedro de Magalhaes (1)

Of all the diseases we have left to conquer, one raises its voice above all others: the disease of aging. From anti-wrinkle creams to advertising billboards, from our conceptions of beauty to our desire for youthful skin, our fear of aging is present in all walks of life.

But is aging a disease? Is it a demon that must that be conquered, lurking beneath our skin, crumpling up our genes until our skin sags and our hair turns grey? Or is it a natural part of life – something that needs to embraced with humility? Is our preoccupation with aging a cultural phenomenon, a type of ignorance or obsession that needs to be tackled by changing social attitudes, or is it primarily a problem of medical science?

Eternal Youth vs Immortality

What is it that we are actually fighting for – do we want to live forever, or do we want to be forever young? Most of us would not wish to live a longer life if it meant we continued to age. What we long for is a good quality of life while still holding on to more years. This is best highlighted in the Greek myth known as Tithonus Error. Tithonus was a mortal who was granted immortality by Zeus but was not granted eternal youth. As a result, Tithonus became increasingly debilitated and demented as he aged (2). This is a fate no one would wish to have. The quest, it seems, is to extend one’s years upon this earth while retaining quality of life, looks, and independence. If this is so, we must ask ourselves: is this something worth fighting for?

One argument against the idea of ‘fighting aging’ is the concept that aging is a natural process. For those making this argument, the insistence on limiting aging is uncomfortable; who are we to go against nature? In fact, some would even argue that it is aging that makes us human. Indeed, without the knowledge of mortality placed upon our fragile shoulders, we would never value those things which are so important in our lives and yet so transient – our first kiss, our first day at school, our first date. If we were to extend our lives infinitely, then the value of the present moment may disappear.

As emotively tempting as this argument may be, if one takes a step back and takes a look at the history of medicine, one begins to see that battling nature is something that science has always done; from antibiotics to vaccinations, from the eradication of smallpox to the application of technology, fighting the natural world is an inevitable component of science. Indeed, battling the features of aging makes up a large part of modern-day medicine; we battle stroke and heart disease, insidious cancers, and debilitating degenerative diseases every day within our hospitals and with our surgeries. What makes ‘fighting aging’ any different?

The Cultural Phenomenon

This question ultimately goes back to the cultural phenomenon of aging. Aging is a rather new phenomenon. At the beginning of the 20th century, only 5% of the population was over 65 years of age, while today people are able to lead active and independent lives well into their 90s (3). With this rise in aging has come new prejudices and stereotypes. It has been argued that our negative attitudes against ageing emerged relatively recently, in the 18th century. Prior to this era, the elderly were often held in high regard, seen as carriers of wisdom and knowledge thanks to their years upon this earth. But as more and more people began to survive into their 80s and 90s, the idea of being a ‘nuisance’ began to take hold. Employers felt that the elderly were holding on to jobs that could be taken over by the “young and fit.” This change in attitude is reflected in our vocabulary with words such as ‘codger’ (meaning an odd, old fellow), and the change in meanings of certain words over time, such as ‘fogey’, which previously meant a wounded war veteran but now is used more pejoratively to describe those who are old and thought to hold ‘old-fashioned’ views.

The social role of the elderly has changed dramatically as well. With fewer multigenerational families living under one roof, the role of the elder within the family structure has been lost (3). This gradual change in society is reflected in the way we view age. We equate youth with beauty and aspire to look as young as possible. Yet on a grander scale, the way we view age has also corresponded to a larger shift in our society’s policies, in our public expenditures, and in our healthcare.

Within medical care, conditions such as depression are often ignored in the elderly and often seen as a part of aging itself. From a social perspective, discrimination in social care is evident in the assumptions that people may have about how older people should live their lives and what constitutes a life worth living for the elderly. On a public health level, there is a strong suspicion that the use of Quality Adjusted Life Years, a tool used in the UK to assess the costs of treatments, will often discriminate against treatments for diseases such as Alzheimer’s Disease, Osteoarthritis and Age-related Macular Degeneration, most of which would mainly benefit older people with few remaining years. Within the research sphere, the elderly are often excluded from clinical trials, with this under-representation of the elderly affecting the number of available treatments for them. Most importantly, from the patient’s perspective, older people are more likely to feel talked over compared to other patients when they are in the hospital, often feeling ‘as if they weren’t there’ (5). All of these examples illustrate how our culture of youth has manifested itself within the sphere of medicine, where it is our responsibility to be non-judgemental. Yet this is the world in which we live. If we want to make a change, we must become aware of such uncomfortable realities and understand what has given birth to them.

Even if we wish to view aging as a biological phenomenon, for example by looking for “anti-aging” genes within our laboratories and for drugs that can reverse the damage done to DNA over time, we still have to take into account society’s perception of the elderly. We still have to ask the difficult, philosophical questions. For example, are we battling aging because it will allow us to be healthier and have more fulfilling lives, or because of our modern obsession with youth and beauty? Likewise, how would we evolve or change as human beings if we were able to slow, stop, or even reverse the process of aging?

Perhaps conquering aging is not the same as vanquishing cancer, for growing old is an intricate and natural part of our lives. Indeed, perhaps it is part of what makes us human. These are questions that no one person can answer, and which need to be debated within the public sphere. The discussions that arise from asking these questions will undoubtedly impact the direction medicine takes with respect to its interaction with aging; maybe more resources will be dedicated to ‘diseases of the elderly’. If we are lucky, maybe this will all cultivate an attitude of acceptance and empathy within a culture that sees aging as a part of life. Maybe we can change a culture. Maybe we can even save a life.

“We have added years to life; it is time to think about how we add life to years.”
Robert Kennedy (6)

 

References

  1. Magalhaes, J. P. Fearing Death and Curing Ageing [Online]. Available at: http://www.senescence.info/death_and_aging_fears.html [Accessed: 14th September 2016]
  2. Magalhaes, J. P. Should we cure Ageing? [Online]. Available at: http://www.senescence.info/physical_immortality_myths.html [Accessed: 14th September 2016]
  3. Big Picture. 2014. Ageing and Society [Online]. Available at: https://bigpictureeducation.com/ageing-and-society [Accessed: 30th September 2016]
  4. Jones, R. 2007. A Journey through the Years: Ageing and Social Care. Ageing Horizons. 6: 42-51
  5. Centre for Policy on Ageing. 2009. Ageism and age discrimination in secondary health care in the United Kingdom. Department of Health.
  6. Steinsaltz, D. 2016. Become the New 60;. Nautilus; 36 [accessed 28th May 2016]. Available from: http://nautil.us/issue/36/aging/will-90-become-the-new-60

Featured image:
Age by Iburiedpaul

Categories
Opinion Public Health

Is health a moral responsibility?

L0070041 Public Health Centre

“The preservation of health is a duty. Few seem conscious that there is such a thing as physical morality.”
Henry Spencer (1)

We are in charge of our lives. We choose what job we go into, what friends we invite, what clothes we wear and what food we eat. This is what we tell ourselves every morning as we drag ourselves out of bed, every night when we gaze up at our ceilings and think back on our day with pride. After all, if we were mere puppets on a string, what would be the point of it all?

For the past few decades more and more money has been pumped into public health campaigns (1). Our health is not based solely on our wealth, our family or our doctor, but upon the choices we make, and public health campaigns aim to nudge our choices in healthier directions.

Knowing that we are responsible our health, how does it feel to have such a responsibility? How do we react to this immense control that we hold in our hands; this ability to decide how many years we will live, how quickly we will age – the knowledge that the health choices we make today may well have an impact five years down the line? And how much responsibility do we really have for our own actions, considering all of the external forces acting on us, many of which are acting at a subconscious level?

To illustrate my point, allow me start with an example. If I knew I was going to die of lung cancer in twenty years if I continued to smoke, would I be encouraged to give it up? This simple question illustrates how very complex our lives really are. Giving up a habit – whether it is smoking tobacco or eating fast food – is rarely simple. Some of us may well choose to place the responsibility upon the smoker, but such a simplification masks the more intricate webs of that person’s life: what made them start in the first place, what made them continue and where does their motivation now lie? Are they smoking as a way to escape their feelings? To chase after a certain persona? If we place responsibility at the person’s feet, then we ignore the more subconscious desires that have led them towards their supposedly autonomous choices. We all engage in risky behaviours to some degree. A quick glance at the past few days will highlight many ‘unhealthy’ decisions that we have all made on the spur of the moment. Are we to blame for our decisions?

The idea of being in charge of our health has become particularly popular in the mainstream media. A quick Google search will uncover articles on how to build the perfect body, ten-minute guides to eating more fruit and vegetables and quick tips to help us lead more healthy lives (2). Even closer to healthcare, the idea of patient-centeredness has become almost an ideology within healthcare circles; words that are repeated ad infinitum to both students and professionals. This idea of being responsible for our own bodies illustrates our desire to place the power to determine our health back into our own hands, as opposed to relying wholly on the modern medical apparatus to do everything for us.

The numbers back this up even more. The World Health Organization (WHO) has stated that lifestyle-related diseases accounted for 86% of deaths and 77% of disease burden within the WHO European Region. This includes diseases such as cardiovascular diseases, cancers, chronic respiratory problems and mental illnesses (3). Furthermore, leading geneticists have pointed out that the “current increase in obesity has nothing to do with genes and everything to do with how we live” (4). These statistics are further supported by the fact that prevention is far more cost-effective than any intervention that healthcare professionals can undertake; from health education within our schools to exercise regimens into our forties – these are the most impactful activities we can do to positively impact our health. And because these are activities that we choose to participate in, it follows that we are sitting in the pilot seat; we have the power to get off our sofas and put on those Lycra shorts.

So what would it mean if we believed that we are all 100% responsible for our bodies? On one end of the spectrum, it may encourage people to lead more healthy lives – to perhaps avoid that drive to McDonald’s on the way home, or to insist on an early morning run despite the rain pattering on the window outside. But at the other end of the spectrum you have those people who have simply stumbled down the black hole of unhealthy lifestyle, whether it is drugs, fast food or a sedentary lifestyle. And the more we push for a culture of individual responsibility, the more needless blame we may place upon those who ultimately need help and not judgment. Do you think you would treat a person differently if you believed their illness was entirely their choice?

By placing responsibility on individuals, we walk down the road of assuming that to be ill is to be guilty, thereby further stigmatizing the unwell. A good example of this is mental illness, which has a long history of blame ranging from the relationship with the mother to the relationships within an entire family, until eventually we decided to fall back upon neurobiological theories in an attempt to absolve people of blame altogether.

As human beings, we are creatures of habit; as much as we would like to believe that becoming healthy is as simple as creating a New Year’s Resolution, half of all individuals who begin an exercise regimen quit within six months (4). The environment in which we grow up as children has a profound influence upon our behaviours. The habits we learn from our parents and those closest to us, whether they be about smoking, exercise or eating unhealthily, can stay with us subconsciously (3). When we decide to stay at home and watch another episode of Game of Thrones rather than go out for a run, how much of that decision was ours? How much control do we have over our personalities, whether they be impulsive or habitual?

Health is more than just a decision. It lies at the center of many threads: genetic, environmental, social and psychological. Although we live in a world where six of the ten leading factors contributing to the burden of disease are lifestyle related (5), we must appreciate the fact that these are indeed factors, not a solid line that we can draw across other peoples’ lives to claim that they are wholly responsible for what happens to their bodies and mind.

So what do we do about these opposing forces acting on us? On one end of the spectrum lies the idea that we have a dictatorial control over and responsibility for our decisions, while on the other end there lies the more deterministic way of viewing things, where ‘whatever happens, happens – I can’t do anything to change it’ is the prevailing belief. Which one is right? Which one should we accept?

The answer, I believe, lies not within abstract philosophical questions about morality and free will. Rather, I believe the answer is different for each and every one of us. It is up to us to decide how we view our bodies, our minds and the world in which we live. Do we want to live healthily? Why? Are we doing it for ourselves? To be able to fit into our new wedding dress? To allow our children to live in a smoke-free house? We all have our own reasons for the choices we make, and no doctor can make these decisions for us. Instead, we need to take a step back and think about what is most important in our lives, and do what we can to realize our goals with that in mind.

“Freedom is but the negative aspect of the whole phenomenon whose positive aspect is responsibleness. [..] That is why I recommend that the Statue of Liberty on the East Coast be supplemented by a Statue of Responsibility on the West Coast.”
Viktor Frankl (6)

References

  1. The Lancet. Is health a moral responsibility? The Lancet; 1996. 347:1197
  2. Cappelen, A.W., Norheim, O.F. Responsibility in health care: a liberal egalitarian approach. Journal of Medical Ethics; 2005. 31:476-480
  3. Brown, R.C.H. Moral responsibility for (un)healthy behaviour. Journal of Medical Ethics; 2012. 10.1136
  4. Minkler, M. Personal Responsibility for Health? A Review of the Arguments and the Evidence at Century’s End. Health Education & Behaviour; 1999. 26:121-141
  5. Resnik, D.B. Responsibility for health: personal, social, and environmental. Journal of Medical Ethics; 2007. 33:444-445
  6. Frankl, V. Man’s search for meaning: the classic tribute to hope form the holocaust; 2013. Ebury Digital.

Featured image:
L0070041 Public Health Centre by Wellcome Images

Categories
General Psychiatry Psychology

The Case Against Global Mental Health

‘We have become not a melting pot but a beautiful mosaic. Different people, different beliefs, different yearnings, different hopes, different dreams.’
– Jimmy Carter

Western culture is taking over the world; from supermodels on television screens, to fashion accessories in shopping outlets around the world, to the movies made in Hollywood and disseminated worldwide online. Globalization has opened new doors. It has allowed us to build new relationships and learn about new cultures. It has opened our eyes to the worlds beyond our borders – to different languages, religions and beliefs. It has had an impact on every aspect of our lives, including medicine and healthcare.

The pathophysiology of most disease is similar throughout the globe. The diagnosis of a myocardial infarction will have similarities across different continents; an ECG that is normal in the UK will likely be deemed normal in the USA. But when it comes to our inner thoughts and our minds, a similar comparison cannot be made. The Western model of mental illness, of the divisions of neurosis, psychosis and personality disorders yields more than just mere categories. It also produces a set of values and beliefs – namely, that these thoughts and behaviours are outside the remit of social norms. Does a person with a diagnosis of Major Depressive Disorder in the USA show the same symptoms as someone in South Africa? Does this diagnosis hold the same meaning on the other side of the continent? My answer: no, it does not.

Mental health problems go beyond human anatomy and pathophysiology, and treating them like they do not leads to inappropriate therapies. Culture and mental health have close ties that are not addressed when treatment involves only the prescription of a drug. Our mental health colors how we view the world around us; how we view ourselves, our failures and our successes. It defines our identity. In the West our society is based upon science and rational thought. Such a focus has placed a large emphasis on the ‘biomedical model,’ i.e. that symptoms can be clustered together into categories, leading to a diagnosis and a form of treatment. Yet in other countries the idea of being labeled with a ‘disease’ seems bizarre. In many cultures, mental distress is explained through a spiritual lens, based upon the power of one’s ancestors or a curse placed upon one’s family. Who are we to step into this other world and banish such beliefs in the name of the ‘superior’ Western thought?

It can be argued that by placing people within a scientific category, one is filtering out a person’s lived experiences. Sure, a diagnosis may be appropriate in certain circumstances, allowing appropriate support and treatment to be offered to those who are in distress, but we must remember that the diagnoses written in the textbooks do not always correlate with the chaos that is human life.

What is it that makes someone ‘mentally unwell?’ More than anything else, it is a social judgment; it is based upon the idea that everyone over this line is unwell, while those of us who are able to follow the norms of our society are deemed ‘sane.’ Every society is different, and every society has its own ideas of what an illness is and is not. We can often be so determined to get out there and ‘save lives’, that it can be easy for us to forget that when it comes to mental health, it is they (the patients) who have the far superior knowledge of what they are going through. They are the ones who know what emotions they are feeling, what thoughts skip through their mind, what fears drench their hearts. They are the masters of their lives. What is needed is not a rush to produce pills, to prescribe, to diagnose and to medicalize – no, what is needed is humility. The appreciation of our own ignorance in a culture that is different from our own – an understanding that human beings are different. Only then can we begin to take that step to alleviate the distress of mental health problems worldwide.

If we were to take out our Diagnostic Statistical Manuals and set about drawing boxes in other countries, we would find that such a rigid classification system does not translate well to other cultures; a person who fits the criteria for Major Depressive Disorder in London, UK does not necessarily experience the same illness as someone in New Delhi, India. We need to go beyond the symptoms and think about the person’s suffering and pain; what is it that has led them to feel such despair? For some it may be the loss of a job, or status, or wealth. For others, it may be a fall within their social circle, the death of a spouse, or the belief that they are being cursed or punished. We need to be able to understand another person’s suffering if we want to help them. A setback within someone’s life needs to be seen within its context. This involves sitting with people, attempting to understand their lives, eating their food, conversing in their language and understanding what it means to be a citizen in their country. It is not a process that can be ticked through in a few minutes based on a checklist of symptoms. Such arbitrary methods do not capture the emotional and spiritual parts of mental distress, nor do they take into account the vastly different cultural contexts in which patients may live.

Remember that the labels we put on our patients are often value-laden. These criteria we use from our diagnostic manuals are often drawn from the concept of right and wrong – what each society chooses to accept and reject as the norm. When it comes to mental health, what is most important is not the structure of the neurons, nor the actions of their neurotransmitters; it is the effect on the individual, the person within, the person who breathes and feels and cries and laughs.

All of these issues can be illustrated with the worldwide response to the Tsunami in 2005. Following the disaster, many NGOs provided ‘mental health assistance’ by using the Western psychological models of distress, particularly to describe the response to trauma. Most of the workers were ignorant of the local cultural beliefs and traditions, which resulted in a set goals that were more in line with the charities than the victims.

“We are fishermen and we need space in our houses – not only to live but also to store our fishing equipment. After the tsunami we have been living in this camp, which is 12 kilometers away from the coast and in this place for reconstruction. When the international agency came and started building a housing scheme, we realized that they are building flats, which is not suitable to us. But when we try to explain this to the foreigners who are building this scheme, they looked at us as if we were aliens from another planet. What are we supposed to do?”
[..] We have lost our families, now we are having our homes stolen too.”
– Action Aid International 2006 (8)

Such interventions have raised questions as to whether this ‘external mental health aid’ is actually harmful, leading to a division between the ‘superior’ external workers with their Western knowledge, and the locals who have been left helpless and vulnerable.

I am not suggesting that we place a hold on Global Mental Health. I am not suggesting that we stop giving aid. What I am suggesting is that when it comes to mental health, we acknowledge the diversity of the human race. We accept that to be mentally unwell means more than to have an imbalance of chemicals. And by accepting that mental illness affects not just a brain but a person, an identity, a family and a society, we are able to put on our boots and trudge deep into the mud alongside those who we are hoping to help, and perhaps we may even help ourselves along the way.

References

  1. Gilbert, J. 1999. Responding to mental distress: Cultural imperialism or the struggle for synthesis? Development in practice. 9:287-295
  2. Aggarwal, N.K. 2013. From DSM-IV to DSM-5 an interim report from a cultural psychiatry perspective. British Journal of Psychiatry. 37:171-174
  3. Alarcon, R.D. 2009. Culture, cultural factors and psychiatric diagnosis: review and projections. World Psychiatry. 8:131-139
  4. Canino, G., Alegria, M. 2008. Psychiatric diagnosis – is it universal or relative to culture? The Journal of Child Psychology and Psychiatry. 49: 237-250
  5. Harpham, T. 1994. Urbanization and mental health in developing countries: A research role for social scientists, public health professionals and social psychiatrists. Social Science & Medicine. 39:233-245
  6. Kirmayer, L.J. 1989. Cultural variations in the response to psychiatric disorders and emotional distress. Social Science & Medicine. 29: 327-339
  7. Thakker, J., Ward, T., Strongman, K.T. 1999. Mental disorder and cross-cultural psychology: A constructivist perspective. Clinical Psychology Review. 19: 843-874
  8. Gilbert, J. 2007. Mental Health: Culture, Language and Power. Global Health Watch 2.
  9. Gilbert, J. 2007. What is it to be human? Finding meaning in a cultural context.
  10. Gilbert, J. Cultural imperialism revisisted. Counselling and globalization. Critical Psychology.
  11. Gilbert, J. 2006. Cultural imperialism revisited: Counselling and Globalisation. International Journal of Critical Psychology, Special Issue: Critical Psychology in Africa. 17:10-28
  12. Gilbert, J. 2000. Crossing the Cultural Divide? The Health Exchange. April 15-16

Featured image:
Mental Health Conditions by amenclinicsphotos ac

Categories
Empathy Humanistic Psychology Patient-Centered Care Psychology Reflection

Applying Humanistic Psychology to Medical Practice

“People are just as wonderful as sunsets if you let them be. When I look at a sunset, I don’t find myself saying, ‘Soften the orange a bit on the right hand corner.’ I don’t try to control a sunset. I watch with awe as it unfolds.” –Carl Rogers1

We as human beings love categories. We enjoy dividing the body into its constituents, from the bones to the muscles to the skin, from the heart to the vessels to the blood cells. The more we can break something down, the more we can dissect it, understand it and build from it. It can be argued that this method of reductionism is what has led to many of the insights of the present day. It is by becoming so specialized within one area that one is able to build upon one’s expertise and develop novel ideas.

This method of classification, however, cannot be used to explain everything around us. While insightful in some areas, it can be destructive in others; namely, the human mind.

Look back at the history of Psychology and we see ourselves jumping through the same hoops of categorization, attempting to reduce our inner worlds into hierarchies and models. From the psychodynamic theories of Freud to the behavioristic perspectives popularized by Pavlov and Skinner, we are led to believe that if we can merely slice apart the human mind into chunk-sized pieces, perhaps we can gain insights into humanity itself.

But unlike the heart or the lungs, the way we choose to see a particular human mind can have profound effects upon that person. Tell someone that they are a mess of electrical impulses and chemicals, and they may see themselves and the world around them far differently than a person who believes that it is they themselves who have control over their lives.

There is a reason Psychology and Psychiatry garner so much criticism from the general public in a way that no other specialty does.  There is a reason that an anti-psychiatry movement exists, but there are no anti-surgery or anti-cardiology movements. It is because these theories, these categories, have an impact on how we see ourselves. They touch upon what it means to be human.

The argument I wish to propound is to urge us all to go beyond these categorizations, be they biomedical, psychological or social, and to take a more holistic approach, which I believe can best be viewed through the lens of Humanistic Psychology.

What is Humanistic Psychology?

Humanistic Psychology arose in response to the more mechanistic views of human behaviour that were gaining popularity in the 1950s2. Rather than focusing on one aspect of a person, be it our childhoods or our innate animalistic needs, Humanistic Psychology proposes that what is important is how the person themselves experiences the world around them. The human being is central. It is not the objective measurement of chemicals, electrophysiology or set questionnaires that lies at the heart of humanity, but how we think and feel.3

There are many contributors to the Humanistic canon, but I wish to focus on just one aspect of it: Carl Rodgers’ person-centered therapy. Although the word “therapy” implies a form of treatment for those with mental health problems, I wish to apply these principles to the arena of healthcare as a whole. I believe the therapeutic relationship between therapist and client can teach us much about our own relationships with patients within hospitals, emergency rooms and clinics.

Person-centered therapy is built upon three principles4:

  1. Congruency
  2. Unconditional Positive Regard
  3. Empathy

I will go through each of these in turn and focus on how they can transform our relationships with our patients.

Congruency

Congruency refers to genuineness, that is, displaying ‘your actual self’4 when dealing with a patient. This involves letting go of one’s mask and revealing one’s true feelings as they come and go. It requires a level of self-awareness, which allows us to fully experience the moment instead of remaining walled-off from our true inner state.

Do not think of yourself just as a doctor, a medical student or a healthcare professional. Undoubtedly there are professional boundaries that must always be maintained, and a profession that you represent every day. But be careful that you do not let this professional façade get in the way of your relationship with your patients. Remember that you are only human and the last thing a sick patient needs is a robot. By displaying an open and trusting character, you give your patient the opportunity to relax, to feel at ease and to be open about what is truly troubling them.

Congruency takes us back to our humanity, reminding us that there is little difference between ourselves and the patient sitting opposite. If we can come to terms with our own thoughts and emotions as we deal with the chaos that occurs in the world of healthcare, then we will be able to display a level of respect and understanding that will allow our patients to appreciate that they are speaking to a human being and not just a title.

Unconditional Positive Regard

Unconditional Positive Regard refers to the belief that people should be accepted as they are. For the professional, it involves displaying a non-judgmental attitude that is provided unconditionally, i.e. without limitations or expectations.

Although this is a concept well known to most of us, it can be difficult to put into practice. We all have our prejudices and our own rigid lines that we draw across our horizons. The expectation is not to get rid of all prejudice, but to be aware of how they impact our behaviour towards others.

Do we at times place blame on our patients?
Does our heart sink when we go to speak to certain people?
Do we have certain beliefs about people based on their clothing, their lifestyle, or their occupation?

Of course we do. Think back to a time when any of these thoughts have come to your mind and think about their effects. It may not necessarily mean that you throw everything in the air and scream your prejudices out loud. But it does mean that the way you regard your patient may be subtly altered; you may show less enthusiasm towards certain patients or display less sympathy than you would for someone else. It is by being aware of these little discrepancies that will make us all better clinicians.

Undoubtedly, healthcare places us all into positions where we come face-to-face with lifestyles that we disagree with and behaviours that we feel uncomfortable around. The idea is to go beyond these actions and see the human being lying beneath the layers. We must accept them as they are, and may be surprised to find that the patient responds with gratefulness at being treated as an equal.

Empathy

Perhaps the term most popular out of the three, empathy refers to the ability to understand what the other person is feeling. It involves having an understanding of the other person’s beliefs and values, and being cognizant of why they care about the issues that are important to them – in other words, it involves fully stepping inside another person’s private world.

Within healthcare, it is important that we do not go through a list of tick boxes and forget that our versions of events are not the same as theirs. All too often we may accept simple words such as ‘I’m frightened’ with a mere nod of the head and a simple smile on our faces without digging deeper and asking, ‘What is it you are frightened of?’ Our job does not merely consist of diagnosis and treatment, but of going further into our patients’ lives and understanding what their illnesses mean to them. What it means for them to be in hospital, to be a patient, to lose their role as a parent or a provider. Without this aspect, we may well cure a disease with our drugs and our technology, but we will never get to the heart of the matter.

What does it all mean?

These are all terms that most of us are familiar with. They are words we may write time and again upon reflection, sayings that we repeat year after year during our interviews. But the idea is to put this into practice, which can only happen if we first take a step back and think about the times when perhaps these three concepts were not fulfilled. Those times when the relationship broke down, when the patient closed up, when we walked out of the consulting room thinking that could have gone better.

Remember that patients do not always come to us with a collapsed lung or a broken rib. They come to us as a whole. The idea behind Humanistic Psychology is to go beyond the reductionist theories that focused on one aspect of a person’s being, and to appreciate the totality of human experience.

Why do I think these three concepts are important? Because I believe these are concepts that make all of us much better clinicians, and ultimately much better people. I believe that almost all of the problems we face within healthcare, and indeed outside of it, revolve around our ability to relate to others. How differently would we act if we could truly see through the eyes of the person sitting next to us, feel their pain and suffering, think their thoughts as they swirl between their children, their loved ones, their aims and their worries? These concepts, although integral to person-centered therapy, transcend the therapist’s room and can be practiced in every dialogue across every hospital and by every person, including you and I.

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl Rogers6

References

  1. Culture of Empathy. Carl Rogers Empathy Quotes. [Accessed: 28th May 2016]. Available from: http://cultureofempathy.com/references/Experts/Carl-Rogers-Quotes.htm [Accessed: 27th May 2016]
  2. com. Humanistic Approach in Psychology: Definition & History. [Accessed: 29th May 2016]. Available from: http://study.com/academy/lesson/humanistic-approach-in-psychology-definition-lesson-quiz.html
  3. McLeod, S. Humanism; 2007. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/humanistic.html
  4. McLeod, S. Person Centered Therapy [Online]; 2008. [Accessed: 27th May 2016]. Available from: http://www.simplypsychology.org/client-centred-therapy.html
  5. Gillon, E. A Person-Centred Theory of Psychological Therapy. In: Person-Centred Counselling Psychology: An Introduction. SAGE Publications Ltd; 2007. p.43-67.
  6. BrainyQuote. Carl Rogers Quotes. [Accessed: 28th May 2016]. Available from:                          http://www.brainyquote.com/quotes/quotes/c/carlrogers202206.html

Featured image:
Genetic inheritance by Patrik Nygren

Categories
General Public Health

The Doctor as the Advocate

Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.
– Margaret Mead

Doctors are at the forefront of society. They see the dark pits and abysses of humanity that the rest of us try to forget – those depths of despair that many of us will never experience.

As Medicine continues to change, so too does its definition of illness and what it means to be ‘sick.’ Illness means more than just a set of symptoms or a mark upon an X-Ray; it resides within the choices we make every day, the people we welcome into our lives and the jobs we labor for decades at a time. As medicine continues to encompass more and more of our everyday lives, so it takes on greater responsibility.

Advocacy was defined by Earnest et al. in the January 2010 issue of Academic Medicine as an ‘action by the physician to promote those social, economic, educational and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise’ (3).

An article written in the 2014 edition of the AMA Journal of Ethics further divided the definition into two: agency which refers to working on behalf of a specific patient, and activism which is directed towards changing social conditions that impact our health (6). Although many doctors are comfortable with the direct care of their patients, what can often be forgotten is our social responsibility. Not only do we need to treat patients as individuals, but also as a group – as a community.

The doctor’s role goes beyond the hospital walls. The patient is not just the person sitting in the clinic, but the person next door, the young lady who goes to the shops, the schoolboy who drags his bag over his sullen shoulders every morning. Illness takes place in more than the patient’s body; it takes place in society, in the neighborhood, in the schools that cannot provide support and the families that can no longer cope.; what impacts our health? Is it a parasite within our bodies, a virus that has entered so far into our habitat? Or is it unemployment, poor housing, discrimination, social isolation, loneliness, and abuse? These types of vulnerabilities lead to much higher rates of both morbidity and mortality in those affected (4).

The doctor is the voice of those who do not have one. The status of the medical doctor has been respected throughout the centuries; the curer of ills, the bringer of life. While this is gradually changing in the new era of patient-centered care, it is still a prevalent idea.

The doctor should use this privilege and rank within society to fight for those who cannot. As a group, doctors can hold a lot of power within society. Here in the UK, several Royal Colleges have voiced their opinions in the mainstream media over a number of issues already; in 2015 the Royal College of Psychiatrists spoke out about the long distances many of their patients had to travel for support (8), while in 2013 the Royal College of Physicians highlighted the need to tackle obesity more rigorously (9).

These days it is much easier to be an advocate. All it takes is a few clicks on the laptop and you can enter into the sphere of social media. A quick search on Twitter will highlight numerous debates that are occurring amongst patients and doctors, nurses and pharmacists, families and politicians. The battle is no longer held in the debating arena, but within the public sphere.

There is another side to advocacy. Once one decides to expose themselves to the public sphere, they open the door to a hailstorm of criticism and disapproval. By stepping outside of their niche practice and showing their faces to the world, they invite a whole host of attacks. To counter such negative experiences, many medical organizations have offered advice for healthcare professionals who wish to take a bigger role within society.

For example, the Canadian Medical Protective Association (2) recommends doctors:

  • Approach the issue with transparency, professionalism, and integrity.
  • Work within approved channels of communication.
  • Discuss concerns, suggestions, and recommendations calmly.
  • Provide an informed perspective, and attempt to include the perspectives of patients and other healthcare professionals.
  • Persuade rather than threaten or menace others.
  • Remain open to alternative suggestions or solutions, and try to build on areas of consensus.

Another critique against advocacy is the question of the doctor overstepping her boundary. Is advocacy within the remits of the doctors’ role? There is after all a social contract between medicine and society; it is society that holds up the profession to the highest esteem, expecting them to abolish disease and alleviate suffering. A person does not take off their professional cloak the minute they leave the hospital grounds – rather, its presence can be felt in every setting, whether it be the local shop where they grab their newspaper or the primary school where they pick up their children; it is a type of respect that is rarely be found in other professions (4). Medicine and society are intricately linked, and to claim that the doctor’s job ends once the patient leaves the room is to be blind to the role of healthcare in people’s day-to-day lives.

Yet the role of advocacy is not a role that every doctor may wish to take on. Some doctors may fall into advocacy with burning desire to change the world, while others would prefer the calming atmosphere of the hospital room, with just themselves, their patient and a piece of paper in between. I believe advocacy was described best in 2011 when Dr Huddle, Professor of Medicine at the University of Alabama Birmingham, said that it “must remain an occasional and optional avocation in academic medicine, not a universal and mandatory commitment” (3).

On another level, we must be careful not to politicize medicine too far (5) – medicine is for the public and not just a puppet dancing on the strings of politicians. Medicine must speak for those who cannot, yet still maintain its autonomy. Certainly many of the issues that impact our health are heavily politicalized areas – from housing to employment to funding cuts. Doctors must be careful when speaking for their patients. They must not allow their words to become blinded by their biases. We must remember that the doctor’s duty is first and foremost towards her patients – to the public.

There are plenty of examples of advocacy out there –doctors who blog about the daily struggles of their patients, Twitter discussions about mental health and social care, and the clinicians who write books and articles pursuing public policies with an aim of building a more just, equal and ultimately healthier society.

So, how can you get involved? Grab a book, read a newspaper; join the debates on Twitter, pen an article, start a discussion – go out there and let your voice be heard.

Below are some examples:

The Seven Social Sins:
Wealth without work.
Pleasure without conscience.
Knowledge without character.
Commerce without morality.
Science without humanity.
Worship without sacrifice.
Politics without principle.
– Gandhi, 1925 (7)

References

  1. Oxford Dictionaries. Advocacy [Online]. Available at: http://www.oxforddictionaries.com/definition/english/advocacy[Accessed: 4th January 2016]
  2. The Canadian Medical Protective Association. 2014. The physician voice: When advocacy leads to change [Online]. Available at: https://www.cmpa-acpm.ca/-/the-physician-voice-when-advocacy-leads-to-change[Accessed: 4th January 2016]
  3. Kanter, S.L. 2011. On Physician Advocacy. Academic Medicine. 86:1059-1060
  4. Dharamsi, S., Ho, A., Spadafora, S., Woollard, R. 2011. The Physician as Health Advocate: Translating the Quest for Social Responsibility Into Medical Education and Practice. Academic Medicine. 86:1108-1113
  5. Huddle, T.S. 2011. Perspective: Medical Professionalism and Medical Education Should Not Involve Commitments to Political Advocacy. Academic Medicine. 86:378-383
  6. Freeman, J. 2014. Advocacy by Physicians for Patients and for Social Change. AMA Journal of Ethics. 16:722-725
  7. Easwaran, Eknath(1989). The Compassionate Universe: The Power of the Individual to Heal the Environment. Tomales, CA: Nilgiri Press.
  8. Buchanan, M. 2015. Mental health patients sent ‘hundreds of miles’ for care [Online]. Available at: http://www.bbc.co.uk/news/uk-33535864 [Accessed: 17th January 2016]
  9. BBC News. 2013. NHS obesity action plea by Royal College of Physicians [Online]. Available at: http://www.bbc.co.uk/news/uk-wales-20878210 [Accessed: 17th January 2016]

Featured Image:
Speak up, make your voice heard by Howard Lake

Categories
General Literature

Frankenstein: A tale for the Modern Age

“I succeeded in discovering the cause of generation and life; nay, more, I became myself capable of bestowing animation up on lifeless matter.”
– Dr Victor Frankenstein, Frankenstein (2)

Frankenstein is a science fiction novel published by British author Mary Shelley in 1818 that has become an integral part of modern day culture. It follows a Swiss scientist named Dr Victor Frankenstein who becomes obsessed with alchemy and the idea of creating life. His indelible curiosity gradually leads him down the path towards atrocious experiments in the name of science, to the point where he creates a creature – a ‘monster.’

This novel, which has captured our imaginations since its release almost two centuries ago, has led to several famous film adaptations and has become one of the cornerstones of the Horror genre even to the present day.

The inspiration for this novel came from the early 1800s when scientists awed audiences with their ability to use electricity to stimulate the nerves of dead animals, a process called galvanism (1). In 1803 the body of murderer George Foster was attached to a large battery, and witnesses tell us that ‘the adjoining muscles were horribly contorted, and the left eye actually opened’ (3).  It was during this era that science started to take over the reins, stepping onto its pedestal as the fountain of knowledge.

Interestingly, the subtitle of Frankenstein is ‘Modern Prometheus’ (3). Prometheus is the Greek God who brought knowledge to humanity, and later paid for his ‘crime’ through eternal torment. In a similar fashion, Victor Frankenstein brings further knowledge to humanity through his obsession with the life sciences, leading to his creation of a ‘monster’ that ultimately torments him to his dying day. The novel, despite being written at a time when science was just learning to walk, is as relevant today as it was when first published. Yes, it may just be a work of fiction, but the deeper warnings contained within its fine pages speak to us in a way that no scientific journal can.

Frankenstein reminds us that the humanities are the seat belt for the sciences. They have been there to remind us of our morals when all we want to indulge in is our supreme power as human beings. They remind us to stay humble, to think and to question, and not merely to set fire to everything that surrounds us.

History is littered with examples of how scientific discoveries can lead us astray. From the splitting of the atom, which led to the creation of nuclear weapons, to the rise of technology, which has led to the dehumanization of everyday life. But of course, this is a simplification. Science has also given us so much that we now take for granted: organ transplants, heating, the latest iPhone, the very roof over our heads. Science has given us our healthy years, filled with food, shelter, safety and comfort. What Frankenstein highlights is our human desire to go further; to extend our years beyond our imagination, so that not only do we never die, we never grow old either. This hubris is perhaps part of human nature.

What Frankenstein teaches us is that we must take responsibility for our creations, and remember that every gleam of hope also betrays a darker path; ultimately, it is not the ‘monster’ that leads to his masters’ demise, but the lack of empathy and responsibility that is displayed. By continually digging deeper and deeper, searching for a way to transform the cells that create us and the organs that give us life, we must not forget the power that lies in our hands, the ever-human desires of greed and selfishness that can take over our quest.

“I might in process of time, renew life where death had apparently devoted the body to corruption”
– Dr Victor Frankenstein, Frankenstein (2)

Many may question how relevant such warnings are in the present day. Perhaps these messages do not apply to our times. Very few of us would turn our backs upon science, casting our technologies aside and turning to the fire to heat our food and the rock to give us shelter. The issues that Frankenstein brought up, of using nature to bring about life, can be found within any hospital across the world. The use of the defibrillator – a device that uses electricity to shock the heart back into rhythm – could be described as the answer that Frankenstein worked so hard to find – to bring people back from the dead, to introduce life so to speak. Would one call this abominable?

Perhaps we are being unfair to Frankenstein – looking at ourselves as medical students and doctors, how many of us would not do the same as him; sitting hours within a cramped room, reading textbook after textbook, trying discover the intricacies of the human body: how does it breathe, how does it sleep, how does it eat, how does it live? Isn’t this what we do every day – delve deep into the human body so that we can learn how to shock it back to its original state?

We can choose to see both ourselves and Dr Victor Frankenstein as lights that shine onto pathways of future knowledge, discovering new cures and assembling fresh treatments along the way. But we must remember that we cannot rely on science alone to answer all of our problems. Ultimately, science cannot work in a lab by itself. It must work within the context of our greater society, and it must be made morally accountable for its actions. By continuing one’s endeavors out of pure selfishness and greed, one may tread down a path from which there is no return. In the end, it is the monster created from Frankenstein’s obsessions that kills him, and this can serve as a warning to us all.

References

  1. Brown, A.S. 2010. How early experiments with electricity inspired Mary Shelley’s reanimated monster [Online]. Available at: https://www.insidescience.org/content/science-made-frankenstein/1116 [Accessed: 8th January 2016]
  2. Shelley, M. 2010. Frankenstein. William Collins.
  3. Pires, V.M. 2013. Shelley’s Monster: A Lesson on Scientific Hubris [Online]. Available at: http://piresphilosophy.blogspot.co.uk/2013/07/shelleys-monster-lesson-on-scientific.html [Accessed: 8th January 2016]

Featured image:
Frankenstein by Khánh Hmoong

Categories
Emotion General Lifestyle Reflection

Loneliness: The Epidemic of the Modern Age

“God, but life is loneliness, despite all the opiates, despite the shrill tinsel gaiety of “parties” with no purpose, despite the false grinning faces we all wear .. Yes, there is joy, fulfillment and companionship – but the loneliness of the soul in its appalling self-consciousness is horrible and overpowering.”
– Sylvia Plath (1)

Who amongst us has not felt the hand of loneliness? The first breakup as a teen, the rejection letter lying on the kitchen table, children moving away for the first time, the little cracks in a marriage beginning to show. If loneliness is so widespread, so ‘normal,’ why do we need to talk about it? Aren’t we generally attracted to the more rare and wonderful aspects of life? Aspects like the documentation of  odd and wonderful medical conditions, the extremes of human behaviour that we can analyse with such voyeuristic enthusiasm. The topic of loneliness has instead been taken over by the arts; a subject for novelists and philosophers to dissect rather than scientists and clinicians.

Loneliness can be defined in a couple of different ways: emotional and social loneliness. Emotional loneliness occurs in the absence of an attachment figure, while social loneliness occurs in the absence of a social network. Emotional loneliness has been compared to a child’s feeling of distress when they feel abandoned by their parent, while social loneliness is the feeling of exclusion by a child whose friends have left. Thus, loneliness can be described either as a devoid outer world, or an empty inner world.

On the other hand, the cognitive approach suggests that loneliness stems from one’s social expectations not being met. Could it be that through our reliance on social media, our expectations for relationships have become exaggerated? As we scroll through our Facebook feeds, we become an outside observer to the fruitful lives around us; to parties we have missed, weddings we have declined. And so we draw a comparison to our own lives, thinking of ourselves as hollow shells in comparison to these roaring waves we see around us.

But what is the opposite of loneliness? Is it social connection? Is it the number of contacts we display on our phones? The number of parties we are invited to every month? Or the feeling we have of being valued? Is it being able to share a chuckle while watching a movie, reading a novel with a soft hand by your side, or simply being present in another’s life and being acknowledged?

Loneliness is different from solitude. Solitude can be an enlightening experience, leading to increased creativity and growth. Some of the best ideas have come through hours of sitting at an office desk, staring at a piece of paper. Just because more people in today’s society are living alone, does not mean that loneliness is on the rise. We must be careful not to mix these terms together. Loneliness is very different from solitude. Loneliness is the feeling of despair and alienation. It develops from the need for intimacy, and from the feeling of rejection when one fails to find it. It is described as a social pain; what is the equivalent of morphine for the pain of loneliness?

The power of loneliness can be illustrated through the effects of solitary confinement. It has been suggested that prisoners who have been through solitary confinement develop psychiatric disorders such as depression and anxiety, often turning to self-harm as a means of escape. Solitary confinement is described as a form of psychological torture, with one Florida teenager describing his experience as “the only thing left to do is go crazy.” Humans are social creatures. Without stimuli and control, is it any wonder that depression, hypersensitivity, and psychosis develop? This isn’t just an abstract concept that we are talking about, something for the philosophers to discuss at their round tables. It has implications with regards to disease, happiness, and relationships. It can be found in every aspect of our lives, in every infant and every adult – it is something that needs to be examined more closely through our microscopes.

“The most terrible poverty is loneliness, and the feeling of being unloved.” 
― Mother Teresa (2)

The topic of loneliness has fascinated novelists, poets, theologians, and philosophers, all attempting to give meaning to this beast. Yet psychoanalyst Shmuel Erlich suggested that the meaning of loneliness remains “an enigma” (3).

The concept of loneliness looks deep at the need for human connection. Through the rise of science and technology, a result on our emphasis on empirical modes of thought, we have gained considerable scientific knowledge and a whirlwind of medical technology. Yet what has happened to the conversation involving spirituality, social customs, and personal relationships? What has happened to the human perspective? Dig as deep as you like into the functions of the human body, the junctions between the cells and the DNA mutations – just remember that the knowledge that is discovered needs to be applied to a living, breathing human being. Can we quantify the despair of loneliness, the cracks of a thirty-year marriage, the grief of a mother who has lost her child? We may spend our lives pursuing wealth and status, but ultimately it is meaning that we all search for in the end.

“Existential aloneness is necessarily a part of serious illness.”
– S. Kay Toombs (4)

How does it affect us as doctors?

As healthcare professionals, we are trained to be objective, to look at the statistics, and arm ourselves with the jargon of relative-risk and correlations. But walk into any hospital, and you will not see wards filled with numbers and graphs. You will see vulnerability, the eyes of loss, of angst and fear. You will see people tested to their limits, people whose lives are cracked and crumbling – people who have entered the threshold of loneliness.

Is loneliness a pathological condition? Intolerance for being alone was once a criterion for the diagnosis of Borderline Personality Disorder in DSM-III, while more recently, loneliness was found to increase risk of mortality by up to 26% (5). It can be argued that loneliness can have a purpose in our lives; it can form the path towards self-acceptance, growth and spiritual transcendence. The existential perspective goes so far as to say that loneliness is what it means to be human. It argues that through loneliness, one can begin to question one’s own existence, and thereby create meaning for oneself in a world that has lost all meaning. Western literature paints loneliness as a vital part of being human. It is seen as an obstacle one must climb through during the various experiences of life – through change, bereavement, love and loss. It has been argued that just as joy is made brighter through the experiences of sorrow, loneliness shines a light on the meaning of our life. Yet loneliness has also been linked to alcoholism, depression and suicidal ideation. At what point do we as healthcare professionals need to step in and help someone climb out from this abyss? Where do we draw the line between self-discovery and pathology?

Loneliness can also manifest itself through illness, both physical and mental. The feeling of a broken body, of being a burden on one’s family, can lead to helplessness. Roles that were once worn with pride are now cast aside: the mother, the carer, the provider. These can lead to a loss of self-identity and raise questions about how one can contribute to society. Ultimately, being ill can be an isolating experience, raising questions about one’s reasons for existence and the value of one’s life. As healthcare professionals, it is our duty to guide our patients through this journey. It is our responsibility to help them discover their own meaning for this loneliness, to help them affirm their identity. It is not always distraction or drugs that a patient needs, but an open conversation, which can help patients to gain new perceptions on what it means to be human. The role of the professional is not to provide answers or interpretations, but to listen, to share and to understand. It is a difficult task, filled with uncertainty and anxiety for both practitioner and patient, but it is also human.

We often cast aside people who are deemed lonely; they are the shy recluses, the self-pitying. We suggest that the cure for loneliness is simple: join clubs, create hobbies, meet new people.

By following such advice, we forget something vital: you do not have to be alone to be lonely. It is more than just being independent or respectful of others’ privacy; it is a feeling of distress. Loneliness illustrates our need for human intimacy. So where can we find this painkiller to drug us against such distress? Which specialist will take away our aches and pains? You do not need to be a trained medical professional to combat loneliness. Just remember, Hello is the most powerful word against loneliness.

As a final thought I want to leave you with this person’s experience of loneliness: https://www.youtube.com/watch?v=6-usOHfSQuA#t=23

To the one who set a second place at the table anyway.
To the one at the back of the empty bus.
To the ones who name each piece of stained glass projected on a white wall.
To anyone convinced that a monologue is a conversation with the past.
To the one who loses with the deck he marked.
To those who are destined to inherit the meek.
To us.

– Flood: Years of Solitude by Dionisio D. Martinez (6)

References

  1. Plath, S. 2002. The Unabridged Journals of Sylvia Plath. Anchor Books.
  2. Silouan, M. 2011. The Poverty of Loneliness [Online]. Available at: http://wonder.oca.org/2011/11/16/the-poverty-of-loneliness/ [Accessed: 8th January 2016]
  3. Erlich H. Shmuel, “On Loneliness, Narcissism, and Intimacy,” American Journal of Psychoanalysis58, no.2 (1998): 135-162.
  4. Toombs, S.K. 2008. The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Springer.
  5. NHS Choices. 2015. Loneliness ‘increases risk of premature death’ [Online]. Available at: http://www.nhs.uk/news/2015/03March/Pages/Loneliness-increases-risk-of-premature-death.aspx [Accessed: 8th January 2016]
  6. Dionisio, D., Martinez. 1992. Flood: Years of Hope; Years of Solitude; Years of Reconciliation; Years of Fortune; Years of Judgment; Years of Vision; Years of Discourse. 22: 159-162

Featured image:
Maré vazia no mar de Wadden by Luis Estrela

Categories
Clinical Disability Issues Reflection

Asperger’s & Neurodiversity

“He who is different from me does not impoverish me – he enriches me. Our unity is constituted in something higher than ourselves – in Man… For no man seeks to hear his own echo, or to find his reflection in the glass.” 

–  Antoine de Saint-Exupery (11)

We live in a world of increasing diversity and acceptance. With more efficient travel, greater connections and more robust discrimination laws, never before have so many opportunities been laid out for us to endeavor. Women can vote, same-sex couples can marry; we are on the cusp of entering a new era. Yet amongst all these historical, cultural and economical changes, what we often forget is the psychological. If we are to accept people for who they are, with respect and dignity, then why do we then choose to label them with terms such as ‘Asperger’s’ or ‘Autistic’ and to then reduce the paths they may be able to follow?

What is Neurodiversity?

‘My brain is a jewel. I am amazed with the mind that I have.’ – Muskie, diagnosed with Asperger Syndrome (2)

In the late 1990s, sociologist Judy Singer invented the term neurodiversity; a term that described conditions such as Autism and ADHD (5). This neurodiversity movement was born out of the autistic civil rights movement in the 1990s, and has grown rapidly thanks to the internet. The movement consisted mainly of members who had been diagnosed with Asperger’s, but did not wish to be ‘cured.’ This perspective, a step away from the mainstream method of  categorization, led to books (12) and articles (13) being written, the launching of groups such as the Autism Self Advocacy Network, and a novel  perspective of human thinking.

Neurodiversity is a term very similar to cultural or biological diversity; it takes into account the wide variety of human experiences, and respects people for their differences. Such an approach steps away from the medical model of viewing disability, instead focusing on the talents and perspective that each person can bring to the world. The implications of such a movement are widespread; the right to be treated with respect and dignity, regardless of the way one thinks.

What is Autism?

‘Autism is pervasive, colors every experience, every sensation, perception, thought, emotion, and encounter, every aspect of existence’ – autistic activist Jim Sinclair, 1993 (2)

Autism is found under Pervasive Developmental Disorders in the International Classification of Diseases-10. The criteria listed include impairment in social communication and social attachments (6). First used in 1910 by a Swiss Psychiatrist named Bleuler, it was transformed into its modern-day meaning in 1944 by the Austrian paediatrician Hans Asperger, when he published its first definition. The disorder has been termed Asperger’s Syndrome ever since (7).

Since its first use, the incidence of Autism has increased, leading to increased public attention both in the media and within the medical circle (1). This gradual increase has often led to the question: is this a disease of biology, or of society? Indeed, as our society has become more medicalized, Autism has entered into an era fixated with treatment and cure.

What is ‘normal’?

By continuing to medicalize a different way of looking at the world and of interacting with others, we must first define what it means to have a ‘normal’ perspective of such things.

This question brings to light the very fact that no one is normal. From the way we dress, to the jobs we undertake. From our hobbies to our distractions, our loves to our hates, our desires to our ventures, we are all different. How do we then take out our marking pen and draw a line between those who are ‘normal’ and those who are not? In fact, from an ‘autistic’ point of view, people who are non-autistic are easily distractible, obsessed with social interaction and suffer from profound deficits in attention to detail. The idea of normality changes with time, place, date and gender; what is normal here in the UK may well be considered unacceptable in Sub-Saharan Africa.

Rather than focusing on the normal, we should be focusing on individuality; on what each person can contribute to our society, and to themselves. This boundary between normality and disability is an artifact, a division drawn by man that merely reflects the values of the society in which he resides. For example, dyslexia is based upon our value to read sufficiently, something that would  not have been as significant hundreds of years ago. So what does our medicalization of Autism tell us about ourselves?

As the modern era continues to be transformed by technology, perhaps what we build in the future –with the internet in our laps and a screen at every corner – will become a haven for those who have difficulty with eye contact and with body language. The diagnosis of Autism today may well be different from the diagnosis tomorrow.

Is Autism an identity or a disease?

In the absence of any biomarkers for diagnosing psychiatric illnesses, psychiatry often utilizes behavioural deviations instead (4). Using this argument, one could suggest that psychiatry may end up ignoring advantageous behaviors that are outside the ‘norm’ (4). What we may see instead are the difficulties that entrench a person. Rather than encouraging a young child to develop their interests and their hobbies, instead we may focus purely on their intense obsessions on the minutest details. Imagine what this means for a child. Instead of being seen as a building block of opportunities for ideas and growth, these children may instead see themselves as having un-breakable boundaries.

Yet, a label can have a lot of power. A diagnosis places upon the person a special status within society. It opens the doorway to specialist interventions and support from multiple sectors, helping the individual to succeed in certain areas of life that they may find more demanding than others.

There are clearly many things that children with Asperger’s have difficulty with; areas where they require intensive support and management. It is through these interventions that children may then be able to better integrate with society and feel valued. But the idea of finding a cure seems a step too far. As science continues to delve into our lives, we gradually begin to see everything with a different lens; that there must be pathology in everything that is different, and there must be an answer – a pill, an operation, a test.

But it is not all bad. The medical model has brought with it huge shifts within science – new drugs, new insights and a new life for many, many people. By medicalizing something, by using physiology to explain a condition, you are then able to destigmatize it. Thus, a person is no longer a schizophrenic, but instead suffers from schizophrenia – a disease entity of its own.

Whether or not such a viewpoint can be used for a diagnosis such as Autism is a difficult question to answer. For some, the explanation that Autism is an ‘atypical wiring of the brain’ (2) may help them to understand the difficulties that they face. Yet others may strongly identify with such a diagnosis, claiming that it is a gift that allows them to view the world through a different lens, giving them the opportunity to appreciate the depths of the human mind. They may choose to see themselves not as pathological, as wiring gone wrong, but as privileged beings who have been granted a gift of insight that others cannot fully appreciate.

Different vs Defective

As with many things in life, Autism falls on a spectrum. One could argue that by focusing on those who are high-functioning, and therefore able to have this debate, you are minimizing the true suffering of those who do not have this privilege. Indeed it can be argued that because it is on a spectrum, one should be careful not to blanket everyone with Autism as either having a ‘disability’ or simply being ‘high-functioning.’ The aim is to view Autism with a more open mind, rather than as something that requires a gene to be unlocked. This has received appreciation by the American Psychiatric Association, who recently converted the diagnoses of ‘Autism’ and ‘Aspergers’ into one simple diagnosis of ‘Autism Spectrum Disorder.’ Through the creation of this diagnosis, the emphasis has been placed on the idea that people do not fit into boxes, but lie upon a continual line that can encompass a wide range of behaviour.

Neurodiversity is the idea that neurological differences such as Autism are due to normal variation, rather than a sign of pathology. This point of view emphasises the fact that these people do not necessarily need to be ‘cured’ but helped and accommodated. If we look at the progression of science and the humanities, we see that the breakthroughs have been developed by minds that think differently; create links where others have drawn their blinds. If we are to grow as human beings, then this is the approach that is required; not just to grow scientifically, but also morally. Unfortunately, we are currently drawn towards questions of causation and cure – the link between Autism and MMR by Wakefield being just one example (8); an attempt to find blame, and ask the question: why is my child the way he/she is?

And to people with these conditions themselves, surely the idea of being part of a natural variation is much more appealing than being seen as something that is broken and needs to be ‘fixed.’ To describe someone as defective is to take away the essence of who that person is, and what they can bring to the world, to their family, to themselves.

Instead of creating a world focused on finding cures, on ridding the world of autism, we should be building the foundations to allow people to receive the support they deserve, to have their rights heard. Such efforts include early interventions for speech and behavior therapies, and building more accommodating home and work environments.

If we are to accept the fact that equality has been applied to race, religion, gender and sexual orientation, then why can it not be applied to people with different ways of thinking and interacting as well?

We are already seeing glimmers of this in our current society. Mark Haddon’s novel, The Curious Incident of the Dog in the Night-time, written from the point of view of a young boy with Autism, helps readers to transcend their lives and view the world from eyes that see differently, a mind that whirs at a different tone. This novel  is studied by English students across the UK (9), and perhaps by encouraging these types of empathetic endeavours, rooted in the humanities rather than the sciences, a new way of thinking can be formed, where we can focus on acceptance rather than on cure.

‘An autistic child can only be helped if a serious attempt is made to see the world from his point of view.’ (10)

References

  1. Baker, D.L. 2006. Neurodiversity, neurological disability and the public sector: notes on the autism spectrum. Disability & Society. 21:15-29
  2. Ortega, F. The Cerebral Subject and the Challenge of Neurodiversity. 4:425-445
  3. Jaarsma, P., Welin, S. 2012. Autism as a Natural Human Variation: Reflections on the Claims of the Neurodiversity Movement. Health Care Analysis. 20:20-30
  4. Kapp, S.K., Fillespie-Lynch, K., Sherman, L.E., Hutman, T. Deficit, Difference, or Both? Autism and Neurodiversity. Develeopmental Psychology. 49:59-71
  5. Silberman, S. 2013. Neurodiversity reqires conventional thinking about brains [Online]. Available at: http://www.wired.com/2013/04/neurodiversity/ [Accessed: 1st January 2016]
  6. World Health Organisation. 2016. ICD-10: International statistical classification of diseases and related health problems. Geneva: World Health Organisation
  7. McGuinness, S. 2015. History of Autism [Online]. Available at: http://www.autismuk.com/home-page/history-of-autism/ [Accessed: 1st January 2016]
  8. Godlee, F., Smith, J., Marcovitch, H. 2011. Wakefield’s article linking MMR vaccine and autism was fraudulent. The British Medical Journal. 342:c7452
  9. 2013. Subject Content [Online]. Available at: http://www.aqa.org.uk/subjects/english/aqa-certificate/english-literature-8710/subject-content/why-choose [Accessed: 1st January 2016]
  10. Stanton, M. 2006. What is Neurodiversity? [Online]. Available at: https://mikestanton.wordpress.com/my-autism-pages/what-is-neurodiversity/ [Accessed: 1st January 2016]
  11. Evans, T. 2015. Counselling Skills for Becoming a Wiser Practitioner: Tools, Techniques and Reflections for Building Practice Wisdom. Jessica Kingsley Publishers.
  12. Silberman, S. 2015. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. Avery
  13. Solomon, A. 2008. The Autism Rights Movement [Online]. Available at: http://nymag.com/news/features/47225/ [Accessed: 28th January 2016]

Featured image:
Diversity by Séb

Categories
General Reflection

Culture and Medicine

Culture binds together the building blocks of our identity. It defines the paths we choose to walk, the people we seek to befriend, and the meaning we place upon our lives.

It is present at every job interview, every birthday, every heartbreak and every wedding. It is the voice in our ear that cautions us when we go against our values, the shoulder that nudges us with soft hands towards tradition. Whether we choose to acknowledge it or not, the fact remains that something so vital to our being also forms the roots of nourishment and support during the most trying times of our lives: ill health.

Think of the word “culture”, and many definitions come to mind. For some, it is a cage; bars that stow rigid beliefs and deep lines of division in the sands. For others, it is a sweet reminder of their childhood, their distant family. A link to their ancestors perhaps, or a nod to the countless sacrifices that so many generations past have made.

Clearly, culture is not a gleaming jewel in itself. There are walls that culture can build – stereotypes, divisions, segregation and war to name but a few. And we must be aware, in this ever-increasingly globalized world, that cultures are not typically singular. Families immigrate and pick up traditions and values as they plant their new lives upon fertile soil. Our beliefs about ourselves and those around us continue to change and transform as we step outside of our boroughs and breathe in new air. It is this mixing of values and beliefs that can help form ties with traditions long lost, offering diversity and different ways of looking at life. For example, Bhui (2011) found that there was a high risk of suicide in South Asian women, but this risk was attenuated when these women were born in the UK. What is it about growing up in the UK that has an impact upon such a profound decision? Or indeed, what is it about growing up in South Asia that directs people down the path of self-destruction? If culture can have an impact on such a deep level, perhaps it is something worth examining.

Are we looking after a sick body or a sick society?

Culture teaches us how to speak, how to act, how to think and how to breathe. The range of emotion we express to our friends, our family and to the public at large is limited by the boundaries of by our cultural habitats. Some cultures place emphasis on dignity and self-reservation – of being stoic in times of difficulty. Others may open arms wide, taking in grief and self-loathing, pity and joy, stirring these feelings into a melting pot of human life, rich in colour. The more we learn about our culture, the more we learn about ourselves – the way we think, what we think, why we think the things we think. Not only is this important for us as individuals, allowing us to grow and change, but it is also important for us as clinicians, when we are charged with the task of rebuilding and restoring these things when they inevitably fall apart.

We, as healthcare professionals may continue to learn from our textbooks about drugs and their effects, but in a world transformed by increased living, both quantitatively and qualitatively, perhaps it is no longer drugs that matter to our patients, but how we choose to approach our decaying bodies.

It is culture that shapes the way we face our woes and despairs. During the moments of agony, of aches and pains, it is culture that provides the lens through which we view ourselves. Do we remain stoical, chuckling heartily at the jokes juggled around by the nursing staff, or do we sit down with our head in our hands, so consumed by our grief that our need to wear a mask is but a luxury of a world far away. In the end, it is up to the doctor, the nurse, the healthcare professional to explore and understand how it is the patient views themselves, their body and the world around them. We can do this gently, by probing into the innermost recesses of our patients’ lives – encouraging a conversation, engaging in questions that touch at the heart of the person:

What do you do to stay healthy?

What does illness mean to you?

Who are your social supports?

How do you view doctors and medications?

We must remember that medicine is not a dogma upon which we pontificate. People may have differing beliefs about their illness, and in the end, these may be the only things left to tie their hopes to. For example, some people in India may use karma to explain illness, underlying their deeply religious and spiritual background (Fernando 2012). In the Western nations, where society has gradually built its walls between thyself and thy neighbours, people may return to their GP again and again with vague complaints, when the underlying problem may be psychosocial. This idea is illustrated beautifully in the following blog post: https://abetternhs.wordpress.com/2013/05/04/loneliness/

Although bodies have signs and symptoms, only people become sick.

Nichter 2010 described five expressions of idioms of distress:

  • Medicine-taking behaviour: requests for prescriptions, self-medication
  • Biomedical disease nomenclature: associating distress with disease
  • Diagnostic tests: expressing distress to others by taking tests
  • Healthcare-seeking: searching for a practitioner and a diagnosis
  • Changes in consumption patterns: e.g. increased smoking – distress communicated nonverbally

As we can see, people seek help for a variety of reasons. It may not be as simple as a quest for a prescription, for a scan or a blood test. By focusing only upon these rigid scientific measurements, you lose what it means to be a patient – to suffer. This is a loss not only for the patient, but for the clinician and for the healthcare system. When the physician becomes a robot, with an ever-increasing checklist to tick through, or list of procedures to complete, the vital relationship between doctor and patient is lost. This is the relationship upon which lies the patient’s hopes, fears, trust, and beliefs. When this relationship begins to wither, with it goes compliance and faith in the healthcare system – the willingness to step in front of a clinician and say ‘I need help.’

Of course, taking into account such a colossal term as ‘culture’ and applying it to each and every patient, one after another, day in day out, is not an easy task. Try as we may, the largest part of our curriculum is based on the medications we administer, the scans we perform, the blood tests we order. Our training in the scientific and technical fields gives us our title and our role. It takes a lot of courage, determination and compassion to go beyond these components of the therapeutic relationship, and explore our patients as whole persons with equal parts body, mind, and spirit. To help expand upon this, Blumhagen (1962) cited in Parry (1984) compiled some sample questions:

What do you think has caused your problem?

Why do you think it started when it did?

How severe do you think your illness is?

What do you fear most about your illness?

What are the chief problems your illness has caused for you?

What are the most important results you hope to get from treatment?

The Culture of Healthcare

I have spoken much about the cultures in which our patients present themselves. However, we too are human beings, which means we too are subject to cultural conditioning. We are part of the culture of healthcare, which has biases all its own. In a world that has become and continues to become transformed by multiculturalism, it can be easy for doctors to feel alienated from patients. After all, we cannot hold the same beliefs as every single one of our patients. It is not similarity of beliefs that is required, but an understanding and an appreciation. What patients want isn’t a parrot to recite back their own ideals, but a person who is able to accept the world in which they reside, respecting the decisions they make with an appreciation of the diversity of human life. And perhaps, through this understanding, a truly patient-centered approach can be adopted, in which it is the patient’s belief that takes precedent, and not those written down in a textbook by a retired professor. To reach this level, there is but one obstacle: ourselves. We need to become aware of our own biases –what makes us tick, what prejudices we hold, what makes us squirm, what opens our heart and makes it beat. Once we begin to learn more about ourselves, we can then take the step to learn more about our patients and the lives they lead.

If we do not take these steps to gain a greater understanding of our own being, then the outcome can only be confusion, unease and distress. One example of this is the release of the National Mental Health Program in 2002 by the Indian government, which placed emphasis on psychotropic medication. Jain and Jadhav (2009) argued that this focus on medication silenced the voices of the community. They noticed that social workers in rural villages took histories of patients, decontextualizing the symptoms into a list from which the doctors could make a diagnosis. The symptoms of the patients were seen through a biomedical lens, and clinical dialogues were structured around compliance. The medication eventually served as a boundary, with psychologists and social workers seen as assistant doctors– the power lying in the hands of the prescribers. The clinicians were alienated from the daily lives of their patients, ignoring the idioms used by their patients to describe their suffering.

What do we do?

Although physicians may memorize lists of cultural attributes, we must not forget the individuality of each patient. Families can adopt new values that may not always be tied to their heritage. Alas, culture is an ever-sticky concept – yet if it were anything else it would not be human.

So what can we do? We can acknowledge the person sitting in front of us in their entirety. We can become aware of any judgments that may cross our mind, and fix our eye on the person with open curiosity. We can learn from our patients, and allow them to teach us how we can best help them. They are the experts in the room.

 

References

Bhui, K. 2002. Explanatory models for mental distress: implications for clinical practice and research. The British Journal of Psychiatry. 181:6-7

Bhui, K. 2011. Cultural psychiatry and epidemiology: Researching the means, methods and meanings. Transcultural Psychiatry. 48:90-103

Campbell, C., Burgess, R. 2012. The role of communities in advancing the goals of the Movement for Global Mental Health. Transcultural Psychiatry. 49: 379-395

Chau, R.C.M., Yu, S.W.K., Tran, C.T.L. 2010. The diversity based approach to culturally sensitive practices. International Social Work. 54:21-33

Fernando, G.A. 2012. The roads less traveled: Mapping some pathways on the global mental health research roadmap. Transcultural Psychiatry. 49:396-417

Ganzer, C., Ornstein, E.D. 2002. A sea of trouble: A relational approach to the culturally sensitive treatment of a severly disturbed client. Clinical Social Work Journal. 30:127-144

Jain, S., Jadhav, S. 2009. Pills that swallow policy: clinical ethnography of a community mental health program in Northern India. Transcultural Psychiatry.46:60-85

Kleinman, A., Benson, P. 2006. Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It. PLOS Medicine. 3:e294

Lee, E. A working model of cross-cultural clinical practice (CCCP). Clinical Social Work Journal. 40:23-36

Nichter, M. 2010. Idioms of Distress Revisited. Culture, Medicine and Psychiatry.34:401-416

Parry, K. 1984. Concepts from Medical Anthropology for Clinicians. Physical Therapy. 64:929-933

Swartz, L. 2012. An unruly coming of age: The benefits of discomfort for global mental health. Transcultural Psychiatry. 49:531-538

 

Featured image:
The palace of culture – Warsaw, Poland – Travel photography by Giuseppe Milo

Categories
Lifestyle Public Health Reflection

Can social justice replace medicine?

‘Social injustice is killing people on a grand scale.’
– Marmot (2)

Despite the leaps and bounds that science has made over the past century, with all its shiny new techno-gadgets and ever-advancing drugs, the primary reason for our good health today lies in something much less sexy: vaccinations, clean water and sanitation- changes that we take for granted.

We live in a world that is changing every second. Bigger cars, faster phones, all the information at our beck and call: from the education that is offered to our kids, to the healthcare that is offered to our decaying bodies.

The hospital of today is a far cry from the one half a century ago. The minute you walk into a hospital your senses go haywire. You have stepped into the world of the future. The full scale of our technological advancement greets you within these four walls. The bizarre beeping overwhelms your ear canals, screaming into your brain as the alarms screech constantly in the background. The reams of wires trail along the floor of the wards, wrapping themselves around their patients like Christmas presents, offering nourishment to bodies overwhelmed with disease. We are living in the world of machines, and it is upon them that we place our hopes of immortality.

Everyone knows of the success story of Science. We are bombarded by the media, informing us of the next new cancer drug, the gene unlocked that will solve all our problems. What we forget is that we are not merely organisms residing within a vacuum. Nor are we machines ourselves, whose very pores can be zapped with electrodes, transforming our very identity. We are human beings living and breathing on this planet Earth. We digest the world around us. We are not merely scientists of the world within ourselves, of the DNA that twirls inside our cells. We are also manufacturers of the world around us; of the houses we live in, the food we eat and the lives we live. Perhaps the answer to a better, healthier life lies here instead.

But, is this the role of the doctor? Shouldn’t we leave this task to the politicians, to those who have the power to make these important decisions? Isn’t the duty of the doctor ultimately towards her patient, towards that individual who is sitting opposite, rather than to humanity as a whole? I believe Virchow, the German Doctor, described it best when he said:

‘Medicine is a social science and politics is nothing else but medicine on a large scale.’ (1)

Of course there are diseases that can only be fixed by looking inside our own bodies – diseases that come from within, that cannot be changed by any amount of control over one’s environment; Huntington’s Disease is one example.

But if you take a quick glance at the causes of mortality in both the USA and the UK, you will find that the majority of these diseases are significantly related to one’s lifestyle. The top leading cause of death in both the UK (3) and USA (4) is Heart Disease, which has very strong links with lifestyle, including smoking (5), a high-fat diet (6) and poor exercise (7).

In the past, when tuberculosis and polio wreaked havoc upon the population, the role of the doctor was to prescribe medication; to act as the priest who offered the gift of life through his knowledge and wisdom. Yet now, this power lies upon the patient. Our lives are no longer cut short by the plague, but by the pathways we choose to make while we are still alive.

The role of the doctor continues to change along with society. The doctor is the servant of the public. As our ailments in life continue to revolve around these pathways that we choose to take, so must the doctor focus her gaze away from the leaves of her prescription pad and begin to question the foundations of such paths; the reasons behind these choices, the thoughts and actions that lead a person towards their own destruction.

It is not enough to simply inform someone by saying ‘you need to do more exercise.’ Anyone who has made a New Year’s Resolution to do so will understand this. Even in the UK, a country where healthcare is free, one’s health is still dependent upon how much one earns. The richer you are, the longer you will live (8). How is it that in this day and age, this is still the case? Healthcare is a right. And as doctors, it is our duty to ensure this edict is followed. The politician may sit upon his throne and hand down his judgments, but it is the healthcare professional who is in contact day in and day out with the most vulnerable and marginalized.

Indeed, there are some excellent examples of attempts to try and balance this injustice within our society; free school meals in the UK which lead to improved nutrition in children (9) and the ban on public smoking to try and reduce passive smoking (10) are just two examples. These changes in legislation lead to the question: how much control should our government have over our own decisions towards our health? If someone wishes to smoke and drink all their life, then that is their right. Autonomy is one of the principles the doctor must follow; today’s healthcare system revolves around the patient and her choices. No longer does the doctor hold authority over the patient’s body. Yet this does not mean we cannot improve the world around us; we are still capable of building a healthier society, a society in which we will not only live longer, but be happier in as well. Free education and housing are two examples of societal changes that do not necessarily impose upon our personal rights, yet can lead to healthier childhoods and happier families.

Let’s say you are a single working mother – you are only just reaching your rent each month. You can only work part-time because you need to pick up your son from nursery every afternoon. You have no family who can look after him. This leaves little money for food, so you mainly feed your son. His diet is very poor, not only because of the little you can afford, but you yourself have never learned how to cook. Your own childhood consisted of fast food and the occasional apple or banana handed to you by a father who you rarely saw. You live in a very deprived neighbourhood. You cannot afford heating, and your son is constantly sniffling and coughing, hiding under his hole-infested jumper that you managed to grab from a local charity shop. You are isolated – your husband has left you, you have no one to talk to and your neighbours scare you. When you’re not working, you stay at home for your own safety, and ultimately for your son’s. You try to remain happy for your son. You want the best for him. But you are scared. You are scared for the future, you are scared about your next paycheck, you are scared about being burgled, being mugged, having your son taken away from you. You are scared about becoming a failure, of disappointing your son. You start drinking a glass of whiskey each evening to help you calm these anxieties. You gradually spend more and more money on alcohol, an attempt to grasp control of these spiraling criticisms that constantly call into question your ability to be a mother. But this does not always help. As the days turn to weeks, your thoughts begin to gain a voice of their own, almost screaming through your ears; you are a bad mother. A failure. Maybe you’d be better off somewhere else. Your son would have a better life without you. He wouldn’t have such an awful mother.
You eye the packet of paracetamol lying on the table. What would happen if you weren’t here? Wouldn’t your son lead a happier life? He would no longer have this dark mark tainting his existence. He might even be happy… What do you do?

In various points throughout this story, one could take out their pen and draw a mark where someone could have intervened. Not necessarily to offer medication or money, but things such as social support; someone to help look after the son in the afternoons, advice on how to apply for jobs, or housing in a more residential area. A helpful hand to hold on to during the darkest periods, a pat on the back, a shoulder to cry on, an ear to listen. How different would this story be if these simple interventions had been available?

It is very easy for us, the next generation, to caress our mobile phones and laptops that fit in both hands. It is easy to see the world as decaying pieces of rubble to improve, gadgets to insert, wires to wrap around and transform. No doubt this way of thinking has changed our healthcare; it has saved many lives. But we must never forget that humanity is not a machine itself. It cannot be controlled by our remote controls and our drugs; we must look further afield in order to truly appreciate the complexity of the human being. When we look at the human body, at a life that has been lived hard and is ending early, we see not genes that have played havoc, but decades of depression, underlying abuse, a cigarette to cope, a bottle of beer to forget. Addressing these problems is a task that requires us to go beyond our scientific skills. It requires us to understand the emotional lives of our patients.

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” 
– Anne Frank

References

  1. (with acknowledgements to Siân Anis), J. R. A. (2006). Virchow misquoted, part‐quoted, and the real McCoy. Journal of Epidemiology and Community Health, 60(8), 671.
  2. World Health Organisation. 2008. Inequities are killing people on grand scale, reports WHO’s Commission [Online[. Available at: http://www.who.int/mediacentre/news/releases/2008/pr29/en/
  3. Office for National Statistics. 2013. What are the top causes of death by age and gender? [Online]. Available at: http://www.ons.gov.uk/ons/rel/vsob1/mortality-statistics–deaths-registered-in-england-and-wales–series-dr-/2012/sty-causes-of-death.html [Accessed: 13th October 2015]
  4. Centers for Disease Control and Prevention. 2015. Leading Causes of Death [Online]. Available at: http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm [Accessed: 13th October 2015]
  5. British Heart Foundation. Smoking [Online]. Available at: https://www.bhf.org.uk/heart-health/risk-factors/smoking [Accessed: 13th October 2015]
  6. World Heart Federation. Diet [Online]. Available at: http://www.world-heart-federation.org/cardiovascular-health/cardiovascular-disease-risk-factors/diet/ [Accessed: 13th October 2015]
  7. Myers, J. 2003. Exercise and Cardiovascular Health. 107:e2-e5
  8. Royal College of Nursing. 2012. Health Inequalities and the Social Determinants of Health. London: Royal College of Nursing
  9. BBC News. 2013. All infants in England to get free school lunches [Online]. Available at: http://www.bbc.co.uk/news/uk-politics-24132416 [Accessed: 13th October 2015]
  10. Bauld, L. 2011. The Impact of Smokefree Legislation in England: Evidence Review. England: Department of Health

Featured image:
Human Genome by Richard Ricciardi