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Archive for the ‘from the consulting room’ Category

Sometimes I find threads which connect various, apparently completely different, books. Here’s one such example.

I’m reading Alain Juppé’s “Dictionnaire amoureux de Bordeaux”, and one of his entries is about Jacques Ellul, who was a Professor of Law and wrote about sociology, philosophy and theology, amongst other topics. One of his major themes was what he termed “Technique”. I won’t go into that in any detail here. I’ll write something else about it some other time. But here’s the phrase of his which hit me between the eyes – “Suppression du sujet” – the suppression of the subject. This is what happens when we turn a blind eye to the uniqueness of each human being, or when we reduce a “subject” to an “object”. This is an issue close to my heart and I’m going to explore it more, but what immediately came to my mind when I read that phrase were a few lines in the opening paragraph of Marguerite Yourcenar’s “Memoirs of Hadrian“. Specifically, this –

It is difficult to remain an emperor in presence of a physician, and difficult even to keep one’s essential quality as a man.

When I read that two thoughts jumped into my mind. One was how I had never experienced intimidation when I consulted with a patient. No matter whether or not the person was a celebrity, a Lord, or a Professor. It wasn’t that I felt better than them, but I saw everyone as unique, wounded and suffering. But I only thought about that because this is an emperor speaking. The other thought, which I reckon is more important, was the second phrase in the sentence – “…..difficult even to keep one’s essential quality as a man” – there is something potentially de-humanising about health care. It happens when doctors and nurses refer to a patient by their diagnosis instead of by their name. Indeed, not only refer to them as “a case of X”, but treat them that way too, considering only the “data”, the “results”, as important and not the lived experience of this unique person.

When visiting my mum in hospital recently, I overheard one nurse in the corridor say to another “Have you taken the blood from Bed 14 yet?” I thought, good luck getting blood out of a bed!

Sadly it’s not uncommon to witness health care based on the “suppression of the subject”. Outcomes, targets, measurements, doses, and all the technical paraphernalia of machines, tubes and flashing lights can obscure the human being completely.

When I read the sentence in The Memoirs of Hadrian, I wrote in the margin, some lines from T S Eliot’s “The Cocktail Party” –

In consultation with the doctor and the surgeon

In going to bed in the nursing home

In talking to the matron, you are still the subject,

the centre of reality. But stretched on the table

you are a piece of furniture in a repair shop….

All there is of you is your body

and the “you” is withdrawn.

The subject as the centre of reality – is that basis of our health care? Is it the basis of our politics, our economics, our schools, our workplaces? Because if it isn’t….it should be!

This “subject” which Ellul says is suppressed, this “essential quality” of Hadrian’s, this “you” which Eliot says is withdrawn. What is it?

That’s my thought for the day – how do we get to know the subject, the “me”, the “you”, the “self”, the “person”? And how do we make that REALITY the core of our societies?

Because when we objectify human beings we lose touch with reality, and we open the door to all kinds of cruelties and suffering.

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I heard that word, “fragments”, used by a historian in a podcast recently. He was explaining that history wasn’t fixed, was never “complete”, that in every event, every circumstance involving human beings there are multiple stories to tell, multiple, often entirely contradictory experiences to explore. He used the term fragment, to communicate that. That all of history is fragmentary, and all human stories are too. I liked and disliked the word “fragment” equally at the same time (I don’t think there are any fragments, in the sense that there is nothing which isn’t connected to anything else, but, on the other hand, as it seems impossible to ever know “the whole”, maybe fragments are the very essence of reality), but it’s wormed its way into my mind and I’m turning over this issue of fragments ever since.
Here’s where I’ve got to so far – I see two different kinds of fragments in the world. There are pieces, like pieces of iron, or pottery, or whatever, that archeologists might find. These are pieces which have lost their connections. And it’s the archeologist’s job to piece the pieces together. Like putting together a jigsaw. Once the pieces start to fit together, the connections become clearer. The picture emerges. We can say, oh, I see now! So there’s that kind of fragment.
But there’s another, something more dynamic, more fluid, almost a kind of perceptual fragment. You know like when you go to the movies with a couple of friends and in the conversation afterwards the experiences can be so different that sometimes you even wonder if you all saw the same movie? Well, that kind of fragment.
And that kind of fragment is what every single story is. It’s what every single relationship is. It’s what every event and experience is. No single story is something called “the whole story”. I don’t know if such a thing as “the whole story” exists, but, if it does, I don’t know how any single human being can know it. For instance, it wasn’t unusual for me to find that several months, or even years, into an ongoing therapeutic relationship with a patient, that they would reveal something fundamental about themselves, tell some story which suddenly explained mysteries about them. This would happen with people who I had really convinced myself I had heard and understood. At times, the new story, previously untold story (commonly the patient would say “I’ve never told this to a single person before”), would be nothing short of a moment of enlightenment. With experience, I grew to understand that even these moments were never the final ones, that there never was something called “the whole story”.
I see the Self like that too. Whether that’s the “community of selves” idea (The Scottish Psychologist, Miller Mair, coined this term – “His 1989 book Between Psychology and Psychotherapy was subtitled “a poetics of experience”, and this theme recurs throughout his written and spoken work. He saw therapist and client as reaching towards understanding through conversation and metaphor, through engaging with the “community of selves” of which they were personally constituted, and through striving to “tell stories” that would illuminate the conditions of their lives.”) or the idea of multiple facets, roles or aspects of the same person – differences which are so different that sometimes that we wonder if there can be a ‘thing’ called “THE SELF” – and, I don’t think there is. Whatever a SELF is, it’s not an object, not a thing. It’s a subject, a complex web of woven threads, a continually changing, evolving, dynamic host of energies. And maybe, just maybe, one of those aspects overwhelms the others, at least for a while, but they all exist, all come into being, all ebb and flow….all “interfere” with each other, in the way that waves and ripples “interfere” with each other.
I guess at times some of the threads that make up YOU pull or rub against each other in uncomfortable ways and you think “wouldn’t it be simpler if I had less threads?”
And maybe it would.
But would the tapestry be as beautiful?
Only you know.

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tree blossom

Here in the Charente, March is a month of emergence. Officially, it’s Spring. Well, I’ve read three ways to determine Spring actually – you can go by the appearance of Spring flowers, like the crocus, or you can take the “meteorological Spring” which falls on the 1st of March, or you can wait till the “Spring Equinox”, one of two days in the year where the number of hours of day and night are equal (that’s March 20th in the Charente). Well, in the Northern Hemisphere, anyway (you guys in the Southern Hemisphere have your Autumn Equinox when we, here, have Spring – and vice versa). Oh, and, it’s not exactly equal day and night, but pretty close.
I think of Spring as a time of awakening. The bare branches of the trees begin to bud and flower, and the Spring bulbs push up their green leaves and unfurl their gorgeous petals. It’s a sort of time of beginnings.
Mind you, I also feel that Autumn is a time of beginnings, but that’s because I started University (Edinburgh) in the autumn, and began my first job as a Junior Doctor on the 1st of August (1978). In those days there were two variations of training doctor contracts, six month ones and twelve month ones, so we all started jobs on 1st August, or on 1st February. It’s probably changed since then. However, that rhythm of new academic years and new training posts over a decade has embedded a sense of beginnings for me every Autumn.
Spring, though, feels like a more Nature-attuned time of beginnings.
So, I went off yesterday on a blossom and bud hunt. I took quite a lot of photos. Up top here is the kind of phenomenon I was looking for.
And here’s one of many cherry blossom photos I took. I love the delicate pink colours against the blue sky, and the delicacy of the stamens reaching for the sky!

cherry blossom

Back home I found a tulip which had revealed her red petals since the day before ….

red tulip

and the tree peony has five buds this year. Here’s one of them, just beginning to show a hint of her pink petals.

tree peony bud

The appearance of the cherry blossom is greatly celebrated in Japan, with daily reports on TV and the front pages of newspapers, showing maps which follow its path from the south to the north of the country, and thousands of people setting off to have picnics under the trees, or to stroll around admiring them and photographing the blossoms.

So, here’s what I recommend for the next few weeks. Take a local safari. Go out, on foot, on your bike, or drive around and see if you can spot buds and blossoms. When you do, take some photos. They don’t have to be works of art. It’s just a great delight to focus in on emergence, to get up close and personal to new signs of life, new expressions of Creation, new beginnings.

What you do after that is up to you. My hunch is that kind of experience changes how you feel about the day.

If you’re in the Southern hemisphere, then its time to capture a different phase of change. Here’s a link for Australia. And here’s one for South Africa.

But you tell me……wherever you are in the world, what changes do you notice this week, as we move towards the Equinox?

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IMG_1130

Let’s talk about death.
Because we don’t.
Somehow it’s not acceptable to talk about death, almost as if it’s bad manners, or maybe just that you’re going to make someone uncomfortable by talking about it because death is something we all hope to avoid. Today, anyway! Maybe we think that if we don’t talk about it, don’t even think about it, then it won’t happen. Which is equivalent to a child covering their eyes to hide and thinking nobody can see them.
Death is certain. It’s inevitable, inescapable, unavoidable.
Yes, yes, I know that, but let’s deal with it when it comes along, and, look, it’s not coming any time soon, right?
I don’t have the impression that death is difficult for the dead, but, then, what do I know? I’ve never talked to a dead person. Or, more accurately, no dead people have ever talked to me.
Dying, on the other hand, can be really difficult. I’ve seen difficult deaths, been present through those final weeks, days, minutes of final struggle. Some of those deaths make the moment of death like a release, a final end to suffering.
And death is difficult for the living. It’s loss, emptiness, sadness, distress, grief….It changes the lives of the living permanently. Life is not the same after death.
But life is never the same anyway. Life is a process of constant change. Even in the midst of our most fixed habits and routines, life changes. Relationships are formed, relationships fall apart, new jobs appear, old jobs go, people enter our lives, and they leave, some temporarily, some permanently. Isn’t death just one of those changes? A kind of ultimate experience of transience?
How many deaths have you witnessed?
I’ll never forget the first time I had to certify someone as dead. As a Junior Doctor working in a hospital, one of my responsibilities was to confirm that a patient had died, and initiate the formal recognition of their death, writing in their case file “Time of death” and entering the time I declared it. The first time for me I was called, as on call doctor, at about 3am, to a ward I’d never visited before. An elderly patient there, whose death was expected, had just died. It was my responsibility to examine him for signs of life. I took my time. I didn’t want to get it wrong! I listened to his chest for a long time, but couldn’t hear any heart beats. I tested for various reflexes and got not response. I stared long and hard into his eyes, using a device called an ophthalmoscope, shining a light onto his retinae to look for the signs of death I’d been trained to see. Finally, I was convinced. Looked at my watch, and retired to the little office at the end of the ward to write the formal statement of my examination and the date and time of his death. As I walked back along the empty main corridor I began to think about what I’d just experienced. I wondered whether or not it was true that we each have a soul, and whether or not that soul hovers around the body for a little time after death, before departing. I wondered if the man’s soul had been hovering around behind me, as I checked his body for signs of life. I wondered if his soul might have started to follow me from the bedside to the office, and maybe, now, as I walked down this empty corridor. I started to walk faster and wondered whether or not a soul could keep pace with a living person. My heart started to beat faster and as I turned into the on call rooms corridor to go to bed I flicked on the light switch in the stair well and “bang!” the light bulb flashed on then immediately went out again. Well, that spooked me! I ran up the dark stairs taking two or three steps at a time, fumbled as I tried to get my key into the on call room door, eventually managing, throwing the door open wide, then slamming it hard behind me. As I stood, breathing heavily, with my back to the door, I suddenly thought. “Hey, surely ghosts can walk through walls!” At that point I realised how absurd it was to be imagining such things. Took me a while to settle though!
I’ve seen many deaths since then. I don’t think it ever became routine. I didn’t imagine souls hovering around me any more, but I always found the experience disturbing. Maybe that’s just normal.
For most of us we won’t have experienced many deaths directly. When they happen, they are significant events. They feel like something has gone wrong. Maybe somebody is to blame. Maybe someone has failed. Maybe we even feel the dead person has failed….failed to rage against the dying of the light.
When you talk to people who have had an encounter with death, a near miss, a sudden, or unexpected one, brought on by an accident or an illness, it’s not uncommon that they will say it’s made them realise how precious life is, how fragile, how maybe until that moment they hadn’t really known that. Well, known it as a sort of fact, but not known it as a person. There’s a difference. Maybe they’ll say they’d have a wake up call. A wake up call to what? To the knowledge of the shortness of life. They might say it’s made them realise that if they want to make the most of life, then it might be a good idea to start now.
Or they might have a heightened sense of reality, of the unpredictability of life, or even of the inevitability of its ending.
Thinking about death because you’ve survived a serious accident, recovered from a serious illness, or have just experienced the death of a loved one, a friend, or a colleague, can make you re-evaluate your life.
Re-value your life.
Feel how precious and fragile it is and decide to make some changes, to stop procrastinating, to stop living this way in the hope that one day, in the distant future, you’ll be able to live a different way.
That’s the gift of death. The gift of life.
Do we have to go through such an experience to get there? Can we only wake up, reassess our choices and values by having personal encounters with death? Or can we make such decisions, initiate such changes, by thinking about death, or talking about it?
If you knew you had one year left to live, what would you do differently?
Stephen Levine, who passed away in January, 2016, wrote a best selling book entitled “A Year to Live” where he describes the process of living as if you have only one year left. Many people have followed his programme since.
But the whole idea of thinking about death as a way to a better, or should I say, more considered, life, goes all the way back to Socrates (there are whole schools of thought on this subject from many other cultures too)

In the Phaedo Plato has Socrates claim that in death the soul is released from the impure and contaminated body, and thus becomes able to attain pure knowledge of Truth. In the dialogue Socrates says: “It really has been shown to us that, if we are ever to have pure knowledge, we must escape from the body and observe things in themselves with the soul by itself. It seems likely that we shall, only then, when we are dead, attain that which we desire and of which we claim to be lovers, namely, wisdom…”
Thus according to Plato upon death the philosopher achieves that which he has been striving for his entire life. Because of this Plato has Socrates claim that the practice of philosophy in life is really a dress rehearsal for what comes in death: “…those who practice philosophy in the right way are in training for dying, and they fear death least of all men.”
Since the time of Socrates and Plato philosophy has assisted countless individuals confront their own mortality, and provided consolation in the face of what many consider the greatest of all evils – death.

A related train of thought is wondering what you would do differently if somebody you knew had only a year left to live. What if that somebody was your mum or dad, a brother or sister, a lover, partner or friend?
And what if it wasn’t a year? What if it was five years, or, ten? Would that change anything? Would either of those scenarios lead to different choices?
So, a little contemplation on death from time to time, might have a serious impact on both the way we live, and the way we are with others.
You know, I think there’s an awful lot more we could consider down this road, but maybe that’s enough for now.
Before I finish, though, when I was researching life expectancy figures for the articles I was writing about health, I discovered that a male Scot aged 65 (that’ll be me in a few months time!) has a life expectancy of a further 19. 7 years. When I read that I had mixed feelings. I mean twenty years seems quite a long time, right? But on the other hand, it feels as almost no time at all! But what I realised I was doing with that figure was considering it as an end point. I thought, well I might just see the start of 2040 then! But then I read what “life expectancy” is. It’s a median. That means that in 19.7 years time, 50% of male Scots, aged 65 today, will be have died. But 50% will live beyond that timescale. It’s not an end point. It’s the 50/50 point!
Hey, how human is it to grasp at offer of hope?! (Well, that’s another subject to consider….the importance of hope)
OK, this is like a PPS but I must tell you about the patient I saw one day. I knew her from previous visits, but this day she seemed particularly out of sorts. I asked her what was bothering her and she said “My husband’s been diagnosed with cancer. He’s been told he’s got six months to live”
I sympathised with her and asked how that news had made her feel. Her reply took me completely by surprise.
“I’m angry. Really angry. I mean how come he gets to know how long he’s got and I don’t get to know how long I’ve got?!”
We had an interesting conversation about uncertainty after that!

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sinking boat

This is my last article in this series about health. I started by addressing the needs of health services, then continued with an exploration of how to move towards healthier communities so that more people might expect more years of healthy life. I began with shelter, exploring housing, then, food, education, and the environment.

Finally, I want to address the issue of inequality.

In Scotland, in 2008, life expectancy figures revealed that men living in one part of Glasgow could expect to live 28 years more than those in another part. This was publicised as the plight of “Shettleston man”, named after the area with the poorest male life expectancy. Twenty eight years of difference in two areas a mere 15 minutes away from each other.
Shocking? Of course. This wasn’t the full story. The number and severity of illnesses suffered by the men in poor Shettleston, were far greater than those living in the more affluent, Lenzie.
Since 2008, that picture has changed somewhat, partly because that dramatic figure was a result of high numbers of drug deaths. Ten years later the figures still show huge differences between the richest and the poorest parts of Glasgow. One area has a male life expectancy of 82, whilst in another it’s 66 – still a difference of 16 years.

This huge inequality in health experience and in life expectancy are closely linked to other inequalities, from income, employment, and housing to education.
For many years Richard Wilkinson and his partner, Kate Pickett have produced research evidence for inequality itself being one of the most significant factor in the production of these shocking statistics. It’s not just poverty, it’s inequality.
They’ve recently published more findings which explore the links between mental health, wellbeing and inequality. What they demonstrate is some of the potential mechanisms of the links between inequality and illness, through the psychological impacts which are part of the daily lives of the poorest communities.
We don’t live in isolation.
We can’t just exhort people to eat more healthily, smoke and drink less, and move more and expect the population to suddenly become healthier. We have to address the conditions in which people live. Unless we tackle inequality it’s going to be hard to bring better health to the majority of the population.
Many reports have shown how inequality around the world is on the increase. This article, in The New Yorker neatly summarises the findings of the French economist Thomas Piketty on this issue.

The famous “elephant graph” (so called because of its shape) shows what’s happened over the last four decades.

elephant graph

Is this inevitable?
Surely not. It wasn’t always the case, and it’s actually changing. If we want to change it in a different direction we’ll need to get to grips with ways in which the richest manage to grab and hoard their wealth.

A recent story reported that, in the US, Amazon, despite making a profit of $11.2 billion, they’ll not only be paying zero Federal tax, but will actually receive a tax rebate of $126 million.

It’s not only the richest corporations who work hardest to pay as little tax as they can. Individuals do too. The CEO of Ineos, the UK’s richest man, is moving to Monaco to save £4 billion in tax. His two wealthiest executives are following suit.

The “Panama Papers”, leaked from the offshore law firm, Mossad Fonesca, revealed, amongst other things

“the myriad ways in which the rich can exploit secretive offshore tax regimes. Twelve national leaders are among 143 politicians, their families and close associates from around the world known to have been using offshore tax havens. A $2bn trail leads all the way to Vladimir Putin. The Russian president’s best friend – a cellist called Sergei Roldugin – is at the centre of a scheme in which money from Russian state banks is hidden offshore. Some of it ends up in a ski resort where in 2013 Putin’s daughter Katerina got married. Among national leaders with offshore wealth are Nawaz Sharif, Pakistan’s prime minister; Ayad Allawi, ex-interim prime minister and former vice-president of Iraq; Petro Poroshenko, president of Ukraine; Alaa Mubarak, son of Egypt’s former president; and the prime minister of Iceland, Sigmundur Davíð Gunnlaugsson.”

 

The “Paradise Papers” are another big data leak related to a separate company showed many, many, similar examples

“Key revelations include:
Millions of pounds from the Queen’s private estate has been invested in a Cayman Islands fund – and some of her money went to a retailer accused of exploiting poor families and vulnerable people.
Prince Charles’s estate made a big profit on a stake in his friend’s offshore firm.
Extensive offshore dealings by Donald Trump’s cabinet members, advisers and donors, including substantial payments from a firm co-owned by Vladimir Putin’s son-in-law to the shipping group of the US commerce secretary, Wilbur Ross.
Twitter and Facebook received hundreds of millions of dollars in investments that can be traced back to Russian state financial institutions.
The tax-avoiding Cayman Islands trust managed by the Canadian prime minister Justin Trudeau’s chief moneyman.
The Formula One champion Lewis Hamilton avoided taxes on a £17m jet using an Isle of Man scheme.
Oxford and Cambridge and top US universities invested offshore, with some of the money going into fossil fuel industries.
A previously unknown $450m offshore trust that has sheltered the wealth of Lord Ashcroft.
The man managing Angola’s sovereign wealth fund invested it in projects he stood to profit from.
Apple secretly moved parts of its empire to Jersey after a row over its tax affairs.
How the sportswear giant Nike stays one step ahead of the taxman.
The huge tax refunds given by the Isle of Man to the owners of private jets.
Offshore cash helped fund Steve Bannon’s attacks on Hillary Clinton.
The secret loan and alliance used by the London-listed multinational Glencore in its efforts to secure lucrative mining rights in the Democratic Republic of the Congo.
A former UK minister who defended tax avoidance has a Bahamas trust fund.
The complex offshore webs used by two Russian billionaires to buy stakes in Arsenal and Everton football clubs.
Stars of the BBC hit sitcom Mrs Brown’s Boys used a web of offshore companies to avoid tax.
British celebrities including Gary Lineker used an arrangement that let them avoid tax when selling homes in Barbados.
Prominent Brexit campaigners have put money offshore.
The Dukes of Westminster pumped millions into secretive offshore firms.
A tax haven lobby group boasted of “superb penetration” at the top of the UK government before a G8 summit that was expected to bring in greater offshore transparency.
The law firm at the centre of the Paradise Papers leak was criticised for “persistent failures” on terrorist financing and money laundering rules.
Seven Republican super-donors keep money in tax havens.
A top Democratic donor built up a vast $8bn private wealth fund in Bermuda.
The schemes used to avoid tax on UK property deals.
The celebrities, from Harvey Weinstein to Shakira, with offshore interests.
How a private equity firm tried to extract £890m from a struggling care home operator by making it take out a costly loan.
Trump’s close ally Robert Kraft, the New England Patriots owner, is the longtime owner of an offshore firm.
One of the world’s biggest touts used an offshore firm to avoid tax on profits from reselling Adele and Ed Sheeran tickets.”

It’s only the wealthiest individuals and companies which go to such lengths to contribute less of their wealth to the societies in which they made their gains.
Meanwhile, at the other end of the scale, there is a growing evidence that increasing minimum wages is a great way to make positive impacts on populations.

A 2011 national study showed that low-skilled workers reported fewer unmet medical needs in states with higher minimum-wage rates. In high-wage states, workers were better able to pay for the care they needed. In low-wage states, workers skipped medical appointments

“Studies have linked higher minimum wages to decreases in low birth-weight babies, lower rates of teen alcohol consumption and declines in teen births. A 2016 study published in the American Journal of Public Health found that between roughly 2,800 and 5,500 premature deaths that occurred in New York City from 2008 to 2012 could have been prevented if the city’s minimum wage had been $15 an hour during that time, instead of a little over $7 an hour.”

None of these issues can be tackled in isolation. They need co-operation and collaboration. That should encourage us, because these are two of the greatest strengths of the human species.

 

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two webs

How do you have a healthy population of human beings without a healthy environment? Isn’t it pretty obvious the two issues are linked? Because there are no human beings who live outside of the environment. You could even say that it’s a false distinction. There is no “us” here, and an “environment” over there. It’s not like the environment is a foreign country you can visit with a tourist visa.
But what do I mean by environment? I often find I’m tempted to write environment in the plural, to talk about “environments” rather than a singular object called “THE environment. Because the environment is just the circumstances in which we live. It’s that vast web of connections which weaves every single individual into the whole.
There’s a physical environment of earth, air, water and fire. There are the cyclical environments of energy, of heat, cold, wind and rain.
There are the geographic environments of place. There’s a long running French TV series called “Rendez vous au terre inconnu” (Meeting in unknown places), where someone spends two weeks with a remote tribe and a camera crew capture the experience. I love it. It’s done with great sensitivity and compassion. Every episode opens your eyes to other ways of living and it is frequently surprisingly moving. It’s very human. In one episode they did return visits to three places and showed each group the original films of both their own place and the places of the other two. One group lived high in the mountains, one in a region of permanent snow and ice, and a third on houses built on poles in the sea. It was startling to see such diversity and to see each group express their astonishment that other people could choose to live so differently. There’s no doubt that the physical places where we live influence our daily habits, our diets, our whole outlook and our patterns of disease and health.
City dwellers face different challenges from rural ones. Coastal communities different ones from desert dwellers. And so on.
But there are other, less visible, environments. Our social environment of family, friends, colleagues and neighbours. Our cultural environment of values, practices and beliefs. Our political environment of laws, limits and agreements. And so on.
We live embedded in all of these and more. We are influenced by them, and we influence them.

 
In the books as “Linked”, by Barabasi, “Connected”, by Christakis, “The Bond”, by Lynne McTaggart, and “The God Problem”, by Bloom, we can see how we live in networks of relationships which influence everything from or chances of becoming obese, or catching certain infections, to the daily choices we make. We are not as “individual” and separate as we think we are.
Look how “memes” spread, how videos become “viral”, how quickly behaviours and attitudes spread across cultural and physical borders through social media.
If we want to create healthier populations we have to address these environments.
I was going to write about things like the number of industrial chemicals which can be detected in the blood of new born babies in Paris, or the insecticides, fertilisers, herbicides present in everyone’s urine, or the number of prescription drugs which are present in our drinking water, or the amount of plastic washing up on remote islands, or even the estimated 400,000+ people who die every year in Europe from disease caused by air pollution.
But I’m not going to.

You can read any of these kinds of details any time. If those sorts of stories don’t appear in your newsfeeds, you can search for them online. They really are not hard to find.
No, the only point I want to make here is that we do not live separate lives, so if we want to create healthier societies we need to pay attention to our multiple environments. We need to understand them better, then make some different choices. Together.

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bouqin

This is one in a series of articles about health. There’s an almost unspoken belief that the way to make people healthier is through Medicine, and the Health Services through which Medicine is delivered. I’m not sure that’s true. Some of the most striking improvements in population health throughout history have come through the provision of clean water, effective sewage systems, and making such changes as housing the population in better houses, reducing malnutrition, and tackling poverty.
I think it’s important to deliver good health care, and, for me, that means both adequately resourced health care, and, perhaps more importantly, human-scale health care.
What do I mean by that?
Health care where the day to day, hour by hour, minute by minute focus is what human beings do together. It’s caring, compassionate, staff who are well educated in engaged and committed relationships with those who are suffering.
But one thing is clear. The demand for health care is increasing, and shows no sign of tailing off. The higher demands rushing fast down the pipeline come from demographic change with many more people reaching old age, and, consequently, many more with chronic illnesses, complex needs and, ultimately a requirement for good, end of life care before they die.
If we want to tackle the rising demand, we have to deal with the causes of ill health, and if we restrict our focus to individual behaviours, we’re going to fail. We have to deal with the economic, social, and environmental causes of ill health if we want people to live more of their lives in good health.
I’ve written about housing and food so far, and here I’d like to explore education.
Some people claim that education is THE most powerful way to make an impact on population health and it’s a hard claim to refute. Education can improve health in many, many ways, some more obvious than others.
For example, education can reduce poverty and improve incomes, enabling people to find more adequate shelter and to eat more nourishing diets. Education is particularly effective when focused on women and girls. Educated girls and women tend to be healthier, have fewer children, earn more income and provide better health care for themselves and their future children. It reduces maternal deaths and helps to combat infectious diseases, including HIV and AIDS.
Did you know that a child whose mother can read is 50% more likely to live past the age of five?

education and health

Don’t you think that’s stunning?
If you want to explore this further have a look at the United Nations 17 Sustainable Development Goals.
But there is another aspect to education I’d also like to consider. It’s the education embedded in the ordinary doctor-patient consultation. Or at least, it could be. One of the first tasks of a doctor is to make a diagnosis, which is a way of saying to arrive at an understanding. The doctor tries to make sense of the patient’s story, of their symptoms and of the signs of disease in their bodies. A diagnosis unlocks the door to effective treatment, and by effective treatment I mean whatever encourages a restoration of health (though, sadly, many treatments don’t do that, they just either maintain the status quo, or slow the progression of the illness, but with less suffering).
Why shouldn’t diagnosis be a shared experience? Not just a label applied by the professional. One of my favourite diagnoses to illustrate this labelling behaviour is “Idiopathic Urticarial Syndrome”. A patient goes to the skin specialist with an itchy rash. They don’t know why they’ve got it. They don’t know what it is. But the skin specialist does. It’s “Idiopathic Urticarial Syndrome”. Well, here’s a secret. “Urticarial” means an itchy rash (OK, it’s a particular kind of itchy rash, one with “weals”, which is another word for “urticaria”). “Idiopathic” means in this particular case we don’t know what is causing it. If we knew what was causing it, it wouldn’t be idiopathic. It’d be an allergy to washing powder or whatever. “Syndrome” is a trick word. It’s sounds like the name of a disease but actually it’s a collective word for a group of symptoms (and maybe some signs). So, having sought help with an itchy, urticarial, rash whose origin is unknown to you and which you don’t understand, you now know you have an itchy, urticarial rash, whose origin nobody knows, and which nobody actually understands.

There is a different way.

Rather than seeing a diagnosis as an end point, it I can be thought of as a level of understanding. Then the doctor can take it as a step forwards, not a job done. A step towards a better, deeper, broader understanding of the patient. They can explore some of the mystery, the when, where and even the why of the illness. I think this is a form of education. It’s the doctor educating themselves about this particular patient.
An exploration of the circumstances of an illness, probing the when, the where and the possible why questions, is an opportunity for education for the patient too.
If somebody understands better what is going on, and what the initiating and maintaining factors might be, they can make other choices. Choices which might well lead to restoration of health.
One of my most favourite questions in a consultation was to ask the patient when they last felt completely well. It might take a bit of encouragement to get there, but most people can identify the period of their lives before this illness began. Having identified the time around the change from health to illness, I’d then explore what was happening in the patient’s life around that time.
I can’t tell you how many times that was like a light bulb going on. “Do you think my mother’s death might have had something to do with getting ill?” “Do you think losing my job, getting divorced and the death of my brother all in the same month might have had something to do with this?”
Of course, I could never answer a simple yes. It was just a helpful way to begin to explore the potential factors, their impacts, and what someone could do to tackle the ongoing effects.
I’m sure this isn’t possible in every single encounter, but it’s something to bear in mind. Ideally, all doctor-patient consultations can be therapeutic ones, and perhaps the best way for them to be therapeutic is when both the doctor and the patient learns something from the experience.
Learning from experience is definitely a powerful education.

One of my friends says “If everything that goes wrong is a learning experience I’d have a bloody PhD by now!”

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