One of my most favourite sculptors is Antony Gormley, he who made “The Angel of the North” which stands beside the M1 in the North of England. His “The Field”, which I saw in Inverleith House in the Edinburgh Botanic Gardens years and years ago left an indelible mark on me. I recalled it in my mind time and time again as I wrestled with the paradox of what makes every patient unique and what they share with others.
But I was thinking again of his work the other day and I remember “Capacitor” which is what you see in this photo at the beginning of this post. This was one of the works he created from an outline shape of his body. In this case he made it with dozens of metal rods.
Maybe this came to mind because for the first time since I moved here almost six years ago I came across a hedgehog in the garden after dark, as I was out closing the shutters for the night.
I have such a clear memory of being in the same room as “Capacitor”….how awkward and dangerous it felt to be anywhere near this work. Like it could take your eye out, or pierce your body if you got too close.
So, you can see why that’s come back to me now. When I’m out and about now I sometimes think everyone has got on a suit that makes them look like “Capacitor”. Except all the spikes are invisible. Has this become the famous “new normal”? All of us increasing our stand-offishness (is that a word?). All of giving each other “a wide berth”. Everyone now regarded as a potential threat.
Then it struck me…have you seen the images of the coronavirus?
It’s a ball of spikes!
Yikes! It’s turning us all into images of itself!!
The wonders of the everyday. Or “L’émerveillement du quotidien”. It’s normal for me to find myself wondering about something I’ve just seen or heard.
I suppose for most of my working life my days were filled with patients. I never tired of that. I never got bored of that. Every day each patient would present to me a unique a story, a new, and singular problem, puzzle or conundrum to unravel. Each patient would be asking me to help them make sense of what they were experiencing and to support their abilities to heal, to cope, to adapt. Maybe they didn’t quite use that language but that’s always what I heard.
Before I became a doctor, way before, right back as early as I can remember I was driven by curiosity. I wanted to learn, discover and explore. It strikes me now that it isn’t a long way from curiosity to wonder.
People have always amazed me. They still do. Life has always amazed me. This Earth, this planet, the solar system, this universe which we all live in have always amazed me, filling me with an infinite supply of curiosity.
But there’s something else.
Beauty.
Look at this photo of a glorious, immersive sunset, where every single element of the sky and the Earth changes colour. Look at the palette! It is just breathtakingly gorgeous.
I see beauty everywhere. Which isn’t to say I find everything I see beautiful, I don’t. But there is “so much beauty in this world” (do you know what movie that comes from? Here’s the answer).
I am a very visual person. I think visually. I sketch and diagram as I think. I love photography and I think I “have an eye for it”. I see what I find amazing, curious or beautiful and I try to take a photo or two. Then I return to those images again and again, year after year, and I find that, like with this one, the delight, the pleasure, the amazement in beauty like this never fades.
Of course there are other senses and I don’t just experience beauty visually. I love music. I collected “records” long before people starting calling them “vinyl”. I still have them. I still play them. I spent hours and hours ripping CDs onto iTunes and I don’t even know where those libraries are any more! But I stream music now. Every day. Several times a day. I used to discover new music on the radio. I took the back off an old radio when I was a teenager, attached two wires to the speaker using clips, and fed the audio directly into a cassette recorder. I still have some of those recordings…..studio sessions on John Peel’s programme on Radio 1.
I’ve long had a love for movies. I love them for their stories and for their beauty, oh, and I often love them for their music. I compiled short clips of about a hundred movies to teach doctors and other health care workers about our unique human strategies for coping and adapting. I could have taught those strategies without movies but the beauty, wonder and emotional engagement which came with the movies made them much easier to learn and to remember. I probably have a whole vocabulary of coping and adapting based on movie characters, scenes and plots.
There is beauty all around us. I delight in images. I delight in music. I delight in movies.
Where do you find beauty? Where did you find beauty today?
I know there’s a colour called “sea green” but I must say that most times I look at the sea, I don’t think “Look how green the sea is!” But on this particular day, I did. In fact, the singular most striking feature of the sea in this photo is how green it is. Growing up in Scotland I’m used to seeing the land as green….the hills, glens, fields and forests. There is a lot of green in Scotland. I associate those greens with Nature, and with Life.
When I think of a calm, soothing landscape, I usually envisage one which is green, but this green seascape isn’t calming at all. The fact that the wind is whipping up the waves and causing them break far from shore tells me this is a day of a more “active” form of weather…..not a day of peace and ease. And there’s something else in this scene which makes it a bit disturbing….the lighthouse.
The lighthouse? Why should that be disturbing? Well, what’s a lighthouse for? For warning people sailing in this area. Why this area? Because there are dangerous rocks, and/or dangerous tides here. If you’re not careful around here then you could run aground, and even lose your life.
Noticing the lighthouse and realising that I was feeling unsettled as I looked at this image reminded me that we are constantly bombarded with warnings these days – “yellow weather warnings” (what is yellow weather by the way?), “red weather warnings”, “danger to life”, “virus warnings”, “health warnings”, “safety warnings”…….there’s no end to it.
What do all these warnings do? Keep us safe? Maybe. But one thing they certainly do is trigger our inner warning systems. There’s a part of the brain which is called the “amygdala” which has a key role in our alert system. It sets off the famous “Fight or flight” response, flooding our bodies with adrenaline, speeding our hearts and our breathing, tensing our muscles, tightening our stomachs, preparing us to take action. What kind of action? Survival actions.
This essential survival system comes with a problem however….when it’s constantly triggered it sets a higher level of body defence…..that’s the inflammatory system…..and a chronically alerted, activated inflammatory system is at the basis of most chronic disease – from heart disease, to any form of “-itis”, to autoimmune diseases and chronic psychological problem states like chronic anxiety, phobias and depression.
So, I think it’s important to be able to do something about that, and here’s a simple, but helpful exercise – take three very deep breaths, slowly one after the other, completely filling your lungs, then gradually letting all the air out bit by bit. Repeating that big, deep breath three times.
That’s it.
Sure, there are loads more things you can do, but, believe me, this is a good start! Firstly by consciously choosing to do these three breaths you’re taking your attention away from the alarm state. Secondly, this form of breathing changes the chemical balance in your body, changing the oxygen/carbon dioxide ratio in a way which triggers cascades of anti-inflammatory change in your whole system. Thirdly, it triggers the vagus nerve, slowing the heart and pretty much literally steadying your nerves. Finally, this all breaks the loops, helping your break out of stuck hyper-activated circuits….a kind of “re-set” if you like.
If you want to extend these benefits and deepen them, the next thing to do is call to mind a calming, safe, relaxing scene…..preferably one you once experienced. Re-create that event, or that circumstance for a few moments and the emotions which arise with it will begin to dilute the alarm state and deepen the benefits of the three breaths.
You might want some help with this. I find a sunset helps. Here’s one taken from garden on a night where the crescent moon sat above the plum tree and the planet Venus hung in the depending night sky just above the moon.
You might well have a photo of your own somewhere on your phone…..a peaceful, pleasing, calming scene, which you, yourself witnessed. If you do, mark it as a favourite and keep it handy. It could be just what you need.
This is a photo of a small part of something called a “Scratch Patch”. It’s an area about the size of a large room. The floor is covered with polished stones. You pay for a container/jar and can then spend as long as you like filling it with the particular stones which attract you most.
I shared a photo of a pumpkin stall at a farmers’ market the other day to demonstrate the beauty of diversity but then I came across this photo which shows exactly the same thing in the mineral world.
We have a bit of an ambivalent attitude towards stones I think. Maybe because they are inanimate we don’t often value them as much as we do plants or animals, but on the other hand, “precious” stones are considered to be amongst the most valuable objects in the world.
At a simple level many of delight in spotting and picking up a few “interesting” stones when we are out walking – whether it’s through the vineyards, or along a beach. You probably have some favourite stones of your own. Maybe in your pocket, at the bottom of a bag, or on a shelf somewhere in your house.
We must know, instinctively, that stones are not all the same. Otherwise how would we notice some but not others? Why would we choose to pick up and keep certain ones?
I think the attraction of uniqueness runs right through everything in this universe. We humans, each of us unique in our own right, are delighted by uniqueness, whether we find it in our gardens, the paths we walk along, the flowers and trees which grow around us…….
I have often said that what I looked forward to most on a Monday morning was the first clinic of the week. Every single week I knew I’d meet unique patients. Every single day I knew I’d hear unique stories which I’d never heard before. Every single consultation was unique, never to be repeated.
For me, good Medicine couldn’t be reduced to protocols, guidelines and algorithms because every single human life is a unique one. Every single human being is “extraordinary”, not reducible to a class, a type, or a disease. Every encounter occurs only once.
Here’s where I’m for “efficiency” – in machines and in situations where you can accurately predict the outcomes.
Here’s where I’m against “efficiency” – in human situations. Human beings, all other living creatures, Nature and the environment are all complex, open systems. You cannot predict the outcomes with accuracy and certainty from any starting point. For three reasons – change is constant (nothing stays the same), everything is connected so subject to unpredicted influences, and the phenomenon of “emergence” where a complex system develops new characteristics and behaviours which couldn’t have been predicted from its prior state.
Everywhere you look in Nature you find something called “redundancy” – natural systems have more checks and balances, more options in play, than logic would lead you to believe was either necessary or “efficient”. This is the key to their robustness.
As Professor Margaret Heffernan, author of “Uncharted”, points out, aircraft are built with more control systems than they “need”. They have more engines than they “need”. It’s these backups, alternatives and “redundancies” which make a plane robust. She clarifies the difference between “resilience” which is the ability to recover, and “robustness” which is the ability to avoid failure in the first place.
Austerity economics plus managerial philosophies of “efficiency” plus neoliberal politics created the perfect conditions for the pandemic to be a disaster. In many, many countries the health care services had been cut to the bone. They weren’t robust. In many countries social care services had been cut to the bone. They weren’t robust either. In many countries industry, employment conditions, education…..you name it, had all been pared back, trimmed down, downsized, made “more efficient” by under-resourcing them, failing to replace staff who left, and, in fact, doing the exact opposite of developing and strengthening any of them.
How do we cope better with the next pandemic?
Well a good place to start would be to set our sights on “robustness” instead of “efficiency”. After all, in human beings and in all of Nature, the future cannot be predicted, the exact outcomes cannot be known. We are not machines.
Ok, you’re asking, what’s all that got to do with a table of pumpkins at a market? Well, that photo is from a fabulous Saturday morning farmers market in Capetown, and I love this display of diversity and abundance. I love how DIFFERENT they all are! No standardisation by size, shape of colour. Nature is like that. Diversity, abundance and redundancy are key features of healthy natural systems.
I see two symbols of hope in this one image – a cloud with a silver lining, and the beginnings of a rainbow (or, if you prefer, the emergence of colour out of monochrome)
We human beings need hope. I’m not sure if it’s possible to live without it. That might sound dramatic but I expect you’ve heard tales of seriously ill people “turning their face to the wall”, and dying. Or, maybe the opposite, maybe you’ve heard those who recover from serious illness described as “fighters”, which doesn’t mean they have defeated an enemy, it means they have dug deep, found wells of hope and belief, and have healed.
Whenever I saw a patient with a serious disease I knew there were roughly three possible future paths – improvement, deterioration and something inbetween (a kind of continuation of the present). You can see that with common, acute infections, such as a cold or flu, and you can see it with this COVID-19 virus too. Some people make a complete recovery, some go downhill quickly and die, others recover well enough to leave hospital but continue to have disabling symptoms (people are calling them “long haulers”).
Perhaps one of the silver linings from this latter group is the growing recognition in Medicine that some viral infections can produce seriously disabling chronic states. Sadly, in my own work, I saw patients with diagnoses from “Post Viral Syndrome”, to “ME”, to “Chronic Fatigue Syndrome” who had been dismissed and/or not believed by other doctors. These patients were hit by a double whammy – illness and disbelief. That was always hard. I hope this pandemic might have changed the mindsets of some physicians who have dismissed such chronic states as “psychological”, “depression”, or “fraud”.
But to return to the issue of hope. What makes the difference? What influences which of these three paths lie ahead for you when you get sick? The improvement path, the decline path, or the chronic illness path? The truth is we don’t know. But I sure hope there are people invested in research projects to try to shed a light on this issue. The other truth is that nobody can accurately predict which of these paths lie ahead for any single patient.
Yes, of course, we can use statistics and probabilities, but when it comes to an individual, those generalities don’t determine the outcomes. I’d be explicit about that with patients, and I’d say, the truth is that for this individual, their path may well be the improvement path, so why not take on board that truth? Taking that on board is a kind of hope.
A little further down the road things might look very different. Someone who was getting better might decline. Someone who looked as if they had no chance might make a stunning, and unexpected recovery….and so on. But as the story proceeded, so did the three options. At every point, every day, those three paths lie ahead – improvement, decline or staying much the same. Is it ever helpful, then, to give up hope? If we hope, then don’t we try our best? Don’t we put in our greatest efforts? If we don’t hope, the danger is that we give up.
Because, here’s the other piece – the self-fulfilling prophecy. How often does it seem that what we anticipate, what we expect, comes to pass? Is it possible that hope can contribute to improvement and that despair and hopelessness can contribute to decline?
What do you think?
I think we human beings need hope. And I think hope contributes towards improvements. And even when things don’t improve, we can always change what we are hoping for. Changing what we hope for keeps us realistic, but being realistic doesn’t mean we have to give up all hope.
I’m convinced that the Self isn’t a thing. There is no entity, or measurable, directly observable object, called “the Self”.
Some say the Self is an illusion, but I was always impressed by the philosopher, Mary Midgely’s response to that…..which was to ask if the Self is an illusion who, or what, is having this illusion? I’m not convinced that the Self is an illusion.
Some say the Self is multiple, that there is a “community of selves”, or that the Self is multidimensional. Different dimensions, or aspects, of the Self are activated and expressed in different relationships, and different contexts. I’m convinced that the Self is multiple.
Some say the Self is a narrative, a story. I’ve got a lot of time for that idea. I’m pretty sure we weave together the events and experiences of our lives into our personal story both to make sense of life, but also to have a sense of Self, a sense of identity.
But that isn’t enough.
There’s more to who I am than my story. There’s my body. There’s my unconscious and subconscious reality, all the breathing and heart beating, and organ and cell and tissue function that is vital to me but of which I normally have zero awareness so can’t weave into a story.
I’m convinced of a Life Principle, a Life Force, or a “Vital Force”, not as an entity, not as an object, not as something “outside” of the body and the Self, but as something manifest AS the body and the Self and probably more besides….
There’s a red thread runs through life…..the thread of the Self as more than a construct, a narrative, an illusion, a force…..isn’t it just wonderful to experience that, to savour that, to enjoy that, to get to know that?
There’s a stretch of coastline about an hour directly west of here. It’s known as “La côte sauvage” – the wild coast. It’s beautiful but a bit dangerous. There are rip tides and ever changing flows within the Atlantic Ocean which can trap and carry off a swimmer.
This photo captures something of that unpredictability. If you look at the lines of the breaking waves you can see the water is arriving from at least three different directions at once, and there are layers of water running in several directions.
Actually, I think life is like this. There are forces, attractions, repulsions, triggers and stimuli influencing us from multiple origins in every waking moment. We are complex creatures, we humans. And the world we live in is complex too. That’s why I doubt simplistic analyses and confident predictions.
Human life cannot be reduced to “cause and effect”, to “rationalism”, to “measurements”, “categories” and “data”. Life is full of surprises and every single experience emerges within multiple contexts with us responding, mostly unconsciously, to an almost infinite number of factors.
Somehow, that makes life all the more beautiful, all the more mysterious, all the more engaging……
There was a craze hundreds of years ago for “chimera” – originally an idea from Greek mythology, medieval peoples took it a whole stage further and created all kinds of bizarre animals.
The chimera is an invented animal made up of the parts from other animals…so maybe a human head, a lion’s body, wings, a serpent tail etc. You can see lots of them carved onto the sides of old churches, and they illustrated old texts as well.
What do you think of them? Are they horrifying? (I think they were often intended to be so) or are they fun? Fascinating?
They just aren’t “natural” are they? You would never imagine that a creature like this existed anywhere. Maybe, once upon a time, some people did. Maybe they believed that they lived in unexplored regions…..remember the old maps with the unmapped areas labelled “Here Be Monsters”?
Probably the commonest reaction to them is a sort of disgust. We find them a bit repulsive….even the more beautiful ones!
I wonder if both chimera and genetically modified plants and animals touch that same core discomfort in us. There’s something a bit unsettling about cutting some DNA out of one creature and splicing it into another, don’t you think?
I think it’s no surprise that many people want GM foods labelled so they can choose not to buy them if they don’t want to. I think it’s not a surprise either that many people think there are complex ethical challenges to be addressed, and a need for intense oversight and control of the whole business of mixing DNA from creature into another……
There’s something which really bothers me about modern management theory and practice – “efficiency”.
“Why should that bother you?” you ask.
Well, because it seems to me that it usually means getting the greatest return from the least input or effort. And I’m not sure that’s always a good idea. I’m coming from the perspective of health care. I despaired of the annual cuts after cuts after cuts in the NHS. Every year I saw colleagues who retired or moved away, not replaced. Every single time someone left the remaining staff were asked to “absorb” the missing colleague’s workload. Every year there were more budget restrictions, more closures of beds and services, all in the name of “efficiency”.
So what has happened now that a pandemic has hit? Not enough beds, not enough equipment, not enough staff. Even now, weeks into the crisis, frontline staff lack adequate amounts of PPE (Personal Protective Equipment). All the pressure to “protect the NHS” was due to the fact it had been pared down to the bone over at least a decade. There was, and there is, no, or little, resiliency in the system. Yes, they redirected staff and reallocated beds to deal with the COVID-19 patients, but did so at the expense of the care and services which those staff and beds were normally employed for.
Is it really a good idea to have “just in time” ordering and delivery systems for something like the NHS? It doesn’t look like it. Is it really a good idea to have as few beds as possible, as few hospitals as possible and as few staff as possible? It doesn’t look like it.
Nature doesn’t do it this way.
Nature goes for abundance. Look at the seedhead in the photo at the start of this post. How many seeds are there from that single plant? Way more than you’d “need” for reproduction and spread you might think. Would it not be more “efficient” for the plant to produce, say, half that number of seeds? Or maybe only ten percent? It doesn’t look like it.
Complex adaptive systems are Nature’s way of enabling adaptability and resilience. All such systems have what scientists call “redundancy” – by which they mean there are “belt and braces” approaches, there are several pathways to achieve the same thing. It’s by drawing on those “extra” resources and methods that Natural living organisms survive and thrive.
I think we need to learn that from Nature. There’s been way too much paring back, stripping down, and minimising going on. If we want resilient services, and resilient societies we aren’t going to get there by “efficiently” going for the least, the cheapest, the quickest and the meanest.
I welcome constructive criticism and suggestions. I will not, however, tolerate abuse, rudeness or negativity, whether it is directed at me or other people. It has no place here. ANYONE making nasty comments will be banned.
Heroes Not Zombies 