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The past is in the present

Posted in from the consulting room, from the dark room, from the living room, health, life, narrative, perception, personal growth, philosophy, photography, psychology on July 10, 2019| 2 Comments »

One of my most favourite cities is Segovia, in Spain. Perhaps its most striking feature is the Roman aqueduct. It begins as a pretty average sized wall, then column by column, arch by arch it gets bigger and bigger and bigger, straddling the town below until it reaches the old castle.

In this first part houses have been built on each side of it. I don’t think I’ve ever come across such an astonishing structure running right down the middle a street!

One of the first of the town’s squares lies at the foot of the aqueduct just as it reaches its greatest height.

I find this SO inspiring! Here’s what it got me thinking last time I was there…..

Throughout my career as a doctor I saw time as linear. Perhaps because the second half of my working life was in a specialist centre for people with chronic (long term) conditions, I commonly heard patients tell me of the traumas which they had experienced prior to becoming unwell.

I was never someone who bought into a mechanical, linear view of human beings, or of life. Every patient I met convinced me that all these chronic ailments are multi-factorial. You could never say that “this” caused “all that”. But there was one question I frequently found revelatory.

“When were you last completely well?”

Sounds an easy question, huh? But, actually, it was often difficult, and took some time and conversation to find the time, perhaps even several decades ago, when the patient last felt completely well. I’d then ask about the year the patient moved from wellness to illness.

“Tell me about that year”.

It was often a year of significant trauma, or the culmination of many traumas. I don’t think that meant that the patient’s illness could all be attributed to that trauma, but it was a starting point in making sense of their experience and beginning to find the way forward.

Sometimes patients were clearly stuck with these unresolved hurts. Again and again they’d think about those times, feel bad about them all over again. Others were so traumatised that they were living lives of fear, continually looking ahead and wondering “what if….?” “what might happen?” “how will I cope if….?” and things like that.

In both of these scenarios I’d draw a straight line – and say, the left hand point of this line is your date of birth, the right hand, the date of your death. We know the first, and have no way of knowing the second. But right now, today, you are somewhere along that line. Where is your attention? Where is your focus? Because if it’s to the left of today, it’s in the past, and that doesn’t exist any more, except in your memory. If it’s to the right, it’s in the future, and that only exists in your imagination. You can’t have your attention in more than one place at a time, so what if you draw your attention into the present instead? How might that feel? And we’d then explore ways of living more in the present reality, than in the past traumas and future fears.

I think it was often helpful, but now it seems somewhat simplistic to me. Because I now see time is not as linear as I thought. In fact, seeing cycles and seasons of time makes rather more sense to me now. As I experience a place like Segovia I realise that the past doesn’t go away. It doesn’t disappear into memory. (and memory is not an artificial place anyway….it’s no dusty filing cabinet with the drawers all locked)

Rather the past is always present, always here, and always now. It fashions our every day. It colours our every experience. It sets the tone of today. It constantly challenges us to respond to it, to adapt. In fact, that’s how we learn isn’t it? By having an awareness of the past in the present? If we forgot and discarded everything we experienced how could we learn anything? We adapt by carrying with us the past into the present.

And although this is even more challenging, the future is here now too. Not least because the future is, in one sense, a “multiplicity of singularities” – a set of possible paths, which are, at least in part, fashioned by this present moment, and by each and every decision and action.

I don’t think the past goes away. I don’t think the old “time heals” is true in the sense that it makes the past go away. Instead I think we learn to adapt to it. When we become aware of the past in our everyday we have the opportunities to create new responses, new strategies of living under it’s influence.

OK, so, this is not where I thought this post would go when I pasted in those photos of the aqueduct! But here’s a related thought – how does the presence of the past in today, as we see in this colossal aqueduct stretching over Segovia, shape, fashion, influence, inspire, challenge, stimulate the thoughts, feelings and actions of the people living there?

And so, of course, even when the past isn’t as obvious as this aqueduct, how does it’s presence today influence our experience of today?

Here’s the final part of that story – we don’t heal just by shifting our focus, we heal by becoming aware, aware of the past AND the future IN this present day, and realising we can change how we respond to that. Realising our current patterns aren’t fixed. We can alter them.

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Reality is relationships

Posted in from the dark room, from the living room, life, perception, philosophy, photography on July 5, 2019| Leave a Comment »

This made me stop. It looks like two trees who got together a long time ago, and have continued to grow, relate, entwine, even dance and kiss together ever since!

The physicist, Carlo Rovelli, says “the universe is made up of networks of kisses, not stones”

He also says

I think that quantum theory can make sense as it is: we just have to give up some cherished metaphysical prejudices and accept the deep relational aspect of nature that the success of the theory has revealed

Another physicist, Lee Smolin, says “the universe is a network of events”.

Asked about his theory he says

It’s a theory about processes, about the sequences and causal relations among things that happen, not the inherent properties of things that are. The fundamental ingredient is what we call an “event.” Events are things that happen at a single place and time; at each event there’s some momentum, energy, charge or other various physical quantity that’s measurable. The event has relations with the rest of the universe, and that set of relations constitutes its “view” of the universe. Rather than describing an isolated system in terms of things that are measured from the outside, we’re taking the universe as constituted of relations among events. The idea is to try to reformulate physics in terms of these views from the inside, what it looks like from inside the universe.

 

Aside from physicists, daily life begins to take on a different flavour altogether when we shift our focus from things to events, from objects to relationships, from separate items to connected contexts.

Try it for yourself, see what’s it like to focus more on kisses, relationships and events than on “stuff”.

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Waves and pieces

Posted in from the dark room, from the living room, life, neuroscience, perception, philosophy, photography on June 30, 2019| Leave a Comment »

I reckon I come across something amazing every day. Maybe I’m easily amazed! But in French, the phrase, “l’émerveillement du quotidien” (the amazement of the every day), is one which has made its way to the core of my being. I don’t know if you’d call it a value, or a principle, but it shapes my life, moment by moment, day by day.

This photo is of something I noticed the other day, something which attracted my attention, then stimulated my thinking. That’s the kind of amazement I like best!

What I saw first was the sky. Just a bit of the sky between two buildings. The clouds looked unusual and pleasing, so I framed the shot, taking in the silhouettes of the buildings on either side of the patch of sky. I liked it the moment I saw it. And I clicked.

When I looked at the shot later it pleased me even more. Not least, I think, because of the contrasts. There’s the contrast between the blue and white of the sky, and the dark browns and grey/blacks of the buildings. But there’s another contrast too.

Look at the shapes.

There’s the shape of the stepwise construction of the building, the bricks laid, one by one, each one separate from the other. It’s like a stair case, isn’t it? A stair case you climb one step at a time. The shape, it seems to me, is typical of what we’d call “discrete”. Each step is distinct from, separate from, the others. And each one adds in a pretty linear, arithmetical way to the others.

But then there is the shape of the clouds. They look like waves. They emerge out of the invisible, out of the blue, each one becoming less distinct, less separate, than the other, till at the top of the image the waves merge into a patch of cloud, almost like waves disappearing into the sea.

I find that pleasing.

I find that appealing, attractive and it make me wonder. Isn’t that the essence of amazement? Of “émerveillement”?

I find that thought-provoking. It seems to me that the left hemisphere of the brain is great at seeing patterns, great at breaking the whole down into individual, discrete parts, great at constructing, building, step by step. Whilst the right hemisphere is busy seeing the whole, seeing the context, seeing the connections, great at finding what’s new, great at engaging with waves which emerge from the whole, (from the sky, from the sea, from the Earth) and dissolve back into it again.

How amazing. To have two brains working away at the same time, enabling us to see and appreciate this universe so uniquely.

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What’s in a name?

Posted in creativity, from the dark room, from the living room, life, narrative, perception, photography on June 29, 2019| Leave a Comment »

This small street in Segovia doesn’t look like much but up on the wall is this plaque –

Now, my knowledge of Spanish is very limited but I can see this is the name of the street – it’s the street of the door of the moon. The “Door of the Moon”! Oh, now, doesn’t that change things? What a name!

I’ve had a bit of a hunt online but I can’t find out much information about this street, or about the “door of the moon”, but I did discover there is also a “door of the sun” (of course!). When Segovia was a fortified town it had a wall around it, and to gain entry there were a number of “doors”, some of which were I think just wooden gates, and, as best I can tell, “the door of the moon” was one of those gates.

I haven’t come across any stories associated with these doors yet, but if any Spanish speaking readers here are inspired to do a bit of investigating I’d be delighted to hear what you discover!

For me, this is just such a romantic name. It inspires. It activates my imagination. Does it active yours?

See what a name can do? Doesn’t it whet your appetite for some stories? The stories which explain, or give meaning to, whatever has been named.

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The necessary distance

Posted in from the dark room, from the living room, life, perception, personal growth, philosophy, photography on June 28, 2019| Leave a Comment »

There’s a very human tendency to view ourselves as outside the world. What I mean is that we feel we are IN the world, but we remain APART from it. We are dualists. We think “there’s me” and “there’s the world”.

How did we get here? Just parachuted into it? Dropped down from outer space? We talk about “Nature” or the “the natural world” as if that’s something other than ourselves. As if it’s a place we can visit, and then leave again.

But that’s all a sort of delusion, isn’t it?

There is no “me” separate from “the world” or from “Nature”. We didn’t land on Earth from an alternate universe, we emerged within it, live within it, die within it. There is nowhere else. (Or if there is, we have no way of knowing that)

Yet, this sort of division persists, doesn’t it?

In fact, it seems this is a crucial and necessary part of being human. Our brain has evolved the ability to create what some call, “a necessary distance” between the flows of energy, information and materials pouring through ourselves and the planet we live on.

We are great pattern spotters, we humans. We see patterns, analyse them, name them, categorise and label them, then we can re-cognise them very quickly. We create maps in our minds. We create a “you map”, a “me map” and a “we map”, as Dan Siegel says in “Mindsight”. These maps contribute greatly to our sense of self, as well helping us to recognise others and develop confidence and belief in our relationships.

Our linguistic abilities are used to create the names and labels and to think about whatever we are applying them to, as well as enabling us to communicate about them. We use words, symbols and metaphors to take these processes of analysis and recognition to whole new levels. These are some of our super-powers as humans. They enable us to literally, and metaphorically, grasp the world in which we live.

To do all those things requires us to step back from the flow of experience. We use this “necessary distance” to momentarily step aside, to enable us to see more clearly, understand more deeply. With this comes this sense that we are “apart”. That there is “me” and “The Other”. When, in reality, there is only ONE, and we live inextricably IN the flux and the flow.

I don’t like judgements. They stop thought. But we need them. It’s just we need to be able to let them go more easily than we make them as our understanding deepens, as we see more and more connections, envisage the contexts in which whatever we are examining exists.

So, it’s interesting to me, to take the old school philosophical spiritual practice of “the view from on high”, literally from time to time. To climb up somewhere, to take the time to gaze towards the horizons, to see the landscape unfolding in front of me. To see the “bigger picture”.

This photo is one I took the other day when standing outside the Alcazar in Segovia. I’m pretty sure that what caught my eye was the church. It seems to stand alone. Almost in the middle of nowhere. But as I framed the shot my eye was led from the church to the winding road which my mind then followed to the top of the hill. Up on the ridge I could see buildings. A lot of buildings. So not a church in the middle of nowhere at all. But still, a church set apart somehow. The curve of the road was immediately appealing and I made sure I included it in the camera frame.

Now that I look at this image I see, yes, the church, that physical symbol of the spiritual connected to the village at the top of the hill by a winding, beautifully curving road. You could argue the road leads to the church. Or you could see the road as leading from the church to the town where people live. In other words, you can see the church, the town AND the connection all at once. I find that immensely pleasing.

I don’t know if that will get you thinking about the place of the spiritual in human life. It might. Or maybe it will get you thinking about connections, contexts and the illusions of separateness?

Ah, before I go, one other thing……see the wall someone has built just to the left of the church and the road? Someone has claimed this piece of the Earth as their own and built a wall around it to strengthen their feeling of separateness. Most people live in the village on the ridge, or so it seems to me. Not many live behind the wall.

Oh yes, walls again. We are hearing a lot about them these days. Both literal walls, to separate Americans from Mexicans, or Palestinians from Israelis, and the toxic and divisive “US AND THEM” walls which divide “natives” from “immigrants”.

But it’s all one world, huh? We share the same planet, the same air, the same water, the same place in the evolutionary path of Life.

It’s a bit of a challenge isn’t it? To see differences and separations but to see them as inextricably connected in a bigger picture.

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Fast and slow – dual speed photography

Posted in from the dark room, from the living room, life, perception, personal growth, photography on June 21, 2019| Leave a Comment »

I’ve recently realised I have a dual speed approach to photography.

First of all, something catches my eye and I stop to take a photograph. Normally, I don’t spend long over this part. I see something. I stop in my tracks. I get my camera or phone out of my bag, frame the shot, and click. Photo taken. That’s the fast part.

Secondly, I upload all the photos I’ve taken that day, or that week, onto my computer. Then I make a first pass, deleting the ones which are just awful, and adjusting others, cropping, straightening, lightening, deepening…whatever seems to need done. That takes time. It’s the first phase of the slow part. As I do that, certain images strike me more than others do, and I mark them as “favourites”.

Thirdly, and this might happen, days or even weeks afterwards, I browse through them, or find myself searching out a particular photo because I’ve been thinking about something and that image has come to the front of my mind. I pick out the one I’m looking for, or I pick one that strikes me in that moment, and begin the fourth stage.

Fourthly, I upload the photo to my wordpress account and paste it into a new post. Then I take my time to look at it more closely and write what thoughts arise. This is the final slow part.

Here’s an example. I was in Paris for a few days a couple of weeks ago and one of the days as I was crossing a road I noticed this huge mural above the shops. I stopped (deciding not to cross with the green man yet!), took out my camera, framed the shot and clicked, then I continued on my way. Once I returned home I uploaded all the photos and when I saw this one I cropped it a bit to focus on the artwork itself. Then I inserted it into this post. The thoughts which have arisen included what I’ve just written about the dual speed nature of my photography, which, strangely, are a set of thoughts about thinking about this photo…..a kind of meta-view……an overview, if you like. Then I returned to the image itself.

This image intrigues me. It’s a huge flight of stairs. I was exploring Paris at the time and that always involves a LOT of walking and a LOT of stairs if you use the metro. I checked my phone and it told me I’d climbed 14 flights of stairs that day! Wow! In that sense, this image was a great motif – this is what a visit to Paris entails – lots of steps! By the way, have you ever climbed the steps up to Sacre Coeur? That’s quite a climb. Or made your way up the crowded Spanish Steps in Rome? Or have you climbed any of the long stairways in Edinburgh up to the Old Town? (You’ll have figured out by now I’m remembering some of the long stairways I’ve climbed. I could add a lot more, but I’ll leave you to add your own).

I’m of a certain age, so a particular piece of music pops into my mind at this point. Yep, Led Zeppelin, ‘Stairway to Heaven’.

And then I return to the image…..

Could the musicians be playing ‘Stairway to Heaven’? If not, what might they be playing?

What other characters are in this mural? There’s a young girl at the top. She’s looking pretty happy and welcoming, and there’s the central character, the man with the suitcase. I realise I’ve immediately identified with the man with the suitcase. Isn’t that something we do quite a lot? Identify with the hero? The central character in the story? Isn’t that how we make sense of our lives actually? Telling ourselves the stories where we are both the author and the main character? Which gets me wondering about the stories we tell. Maybe the man’s suitcase is full of stories? Maybe he’ll be telling some of them to his child (that is his child at the top isn’t it?) once he gets to the top. I suppose there are a lot of life stories about uphill struggles. And lots which are about things “all going downhill” too!

One of my greatest joys throughout my working life was to hear people’s stories, the stories of the patients who came to see me. I never heard too many. Maybe I could even say I never heard enough of them? I loved to sit and listen to them.

Hey, the other night there I watched the movie “Hector and the Search for Happiness“. Seen it? I recommend it. I laughed! And it’s gently thought provoking too. Well, one of the lines in that movie is “Listening is loving”. I liked that line.

I get the feeling that this man is coming home, don’t you? The girl looks like she’s gesturing “welcome back!”

But wait, there are two other characters in the image. Near the top of the stairs there are two statues, both of which seem to have just come to life, and are about to step out from their little platforms. Doesn’t it look like that? I mean, they could just be two statues, each captured in an action pose, but I don’t get that impression. It looks like they are starting to move. Are these two goddesses? If they are, then what are they about to bring into this man’s life, into his story?

What do you think?

……well, this is what I mean by dual speed photography – from noticing to contemplating.

I recommend it.

 

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The scenes which make us think

Posted in from the dark room, from the living room, from the reading room, from the viewing room, life, philosophy, photography on June 10, 2019| Leave a Comment »

Do you get those experiences where something catches your eye, then when you stop to reflect on it, its significance gets deeper and deeper?

Last week I was in Paris, and on one of the rainy days was heading for a restaurant at lunch time but this scene caught my eye. Despite the fact it was raining, I stopped and took a photo. In fact, I took two….the first time my camera slipped as I pressed the shutter and I only caught the top of the scooter!

These electric scooters are everywhere in Paris just now. You can hire one using an app and drop it off anywhere you like. In fact, that’s become a bit of a problem. People are falling over them on the pavements and sustaining injuries, so the authorities are starting to consider new regulations to control them.

I took the photo because I thought it looked funny. To see this serious gentleman either looking down at the scooter somewhat disdainfully made me smile. Then I thought maybe he’s actually thinking about jumping down onto it!

When I got home, I decided to find out who this man is – turns out he is “The Marquis de Condorcet”, a leading Enlightenment thinker and writer, a mathematician and philosopher. One of his most deeply held beliefs was “progress”. He thought we humans, through learning and communicating with each other, would steadily increase our understanding of the natural, social and political worlds, continuously progressing and improving society. “However, Condorcet stressed that for this to be a possibility man must unify regardless of race, religion, culture or gender”

The wikipedia entry on him goes on to say this –

Condorcet was concerned with individual diversity; he was opposed to proto-utilitarian theories; he considered individual independence, which he described as the characteristic liberty of the moderns, to be of central political importance; and he opposed the imposition of universal and eternal principles.

He was a champion of diversity, equality and individual freedom. But he was also a champion of thinking – that progress required us to deepen our understanding of the world and of each other, comparing and reflecting on our individual experiences. He campaigned against slavery and for women’s civil rights.

So, it took an electric scooter to get my attention, but I’m glad I’ve discovered Condorcet. I think we could learn something from him about the importance of values, diversity and justice.

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What is it to be human?

Posted in art, books, creativity, education, from the consulting room, from the dark room, from the living room, from the reading room, health, life, philosophy, science on June 3, 2019| Leave a Comment »

I recently visited the Chateau de Clos Lucé in Amboise, in the Loire valley. This is where Leonardo da Vinci spent the last years of his life. He was invited to live there by François I in 1516. The king provided Leonardo with a place to live, 700 gold ecus a year, and financed his works, in turn for the pleasure of his company and daily discussions with him. Leonardo only lived three more years, dying in 1519, which is why, on this 500th anniversary year of his death, the chateau is hosting a major exhibition of his work. (As an aside I find it fascinating and inspiring that Leonardo was given free range “to dream and work” – what kind of society could we have if we funded creatives and academics to “dream and work” together, without goals, funding applications or publication demands?)

There are a number of Leonardo quotations around the chateau and the gardens. This one caught my eye –

You know that medicines when well used restore health to the sick: they will be well used when the doctor together with his understanding of their nature shall understand also what man is, what life is, and what constitution and health are. Know these well and you will know their opposites; and when this is the case you will know well how to devise a remedy.

After a lifetime career in Medicine, I’m less sure now that medicines do “restore health to the sick”. I think it’s biology which restores health. Human beings are complex adaptive systems, and all such organisms have both “self-healing” and “self-making” capacities. The best medicines stimulate those natural processes of healing. The next best support the processes. Many of the ones we use reduce symptoms, or reverse an imbalance in the body, both of which are reasonable goals and acts, but are they directly involved in restoring health to the sick? Do you think that’s just semantics? I don’t. I’d have a hope for the future that we’d develop the treatments which really do support and stimulate the natural processes of healing, and that’s what Leonardo says, in other language, at the end of that quotation – “when this is the case you will know well how to devise a remedy”.

When what’s the case?

Oh, yes, understand “what man is, what life is, and what constitution and health are”.

Ah! Well, there lies both the problem and the signposts to the solutions…..

A couple of years into my work as a General Practitioner I started to wonder what health is. Nobody taught us what health is at university, and the clinical training of a young doctor focuses on learning diagnostic and therapeutic techniques – identifying pathologies and treating disease states. I went back and looked at my Clinical Medicine textbooks. I searched the index for “health” – no entries. Nope, not one. That set me off on an exploration, looking for an understanding of what health is. The medical school textbooks were no help. Oh yes, there was that old World Health Organisation definition –

“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

But all that really does is substitute the word “well-being” for “health”. It does suggest health is multidimensional – physical, mental and social – and it does suggest health is something positive, not just the absence of disease or infirmity. But does it really take us much further that irritating “Brexit means Brexit”?

While researching the issue of the absence of health in medical textbooks, I discovered there was a kind of parallel anomaly….biology textbooks didn’t have a definition of life. Really? Well, yes, it wasn’t uncommon to find a biology textbook without the word life appearing in the index.

So what is life?

One of the more satisfying descriptions I read was from Maturana and Varela’s, living organisms demonstrate a “self-making” capacity, which they termed “autopoiesis” and that lead me down the path of the complexity scientists and their definition of “complex adaptive systems”. I still find that a good starting place.

That leaves us with two more areas to explore, according to Leonardo. What is man? and What is a constitution? Remember he was writing 500 years ago, and we would probably now say “What is a human?”, rather than “what is man?”. Let’s leave constitution aside for just now, as it’s pretty embedded in the issues of what is a human and what is health?

What is a human being?

There have been a couple of books published recently which put this question centre stage again. Douglas Rushkoff’s “Team Human“, and Paul Mason’s “Clear Bright Future“. Both of these books are concerned about the impact of technology on human beings and on our societies. Rushkoff says –

being human is a team sport. We cannot be fully human, alone. Anything that brings us together fosters our humanity. Likewise, anything that separates us makes us less human, and less able to exercise our will.

In other words, he focuses on the innate sociability and need to act co-operatively in human beings. I’ve heard Paul Mason say at least two interesting definitions of what is a human – human beings “use energy to counter entropy” – in other words we are a creative species. And human beings are “co-operative, imaginative and linguistic” – the combination of which makes us a unique species.

All of these ideas are interesting to me. And I find it refreshing that these questions are coming to the fore now. Surely this is a timely and positive response to the mechanical, data and statistics driven reductionism which is so utterly de-humanising.

I continue to explore what it means to be human, and I find some of the more impressive answers in the works of philosophers, from the classical schools to Spinoza, Bergson and Deleuze (to name just a few!)

Of course, I could write about this for hours! Ha! Ha! But I’ll stop here and leave the possibility that these are questions you might like to pursue for yourself.

Let me summarise – because I think this is a lifetime project as well as potentially the basis for a whole curriculum –

  • What is Life?
  • What is a human being?
  • What is health?

The answers which appear from those studies could, possibly, give us the remedies of the future – the ones which actually do “restore health to the sick” – and, yes, more than that, allow us to create healthier societies filled with people who fulfil their potentials, creatively, co-operatively, and artistically…..can I even say “spiritually?”

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It’s not nothing

Posted in from the consulting room, from the living room, from the reading room, health, life on May 5, 2019| Leave a Comment »

I was reading an interview with Harvard historian, Anne Harrington, who has written “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness”.

When I was at university I was taught there were two types of depression – reactive and endogenous – the former occurring in response to specific events, and the latter seen as an illness of internal origin. It was thought that talking therapies, as they’ve come to be called, were the best way of dealing with reactive depression but that endogenous was a biological problem which required drugs. One of the main themes which emerged from that thinking was the serotonin theory of depression which was the basis for the great commercial success of Prozac, a drug which influenced the levels of serotonin in the brain.

Well, it all changed. Psychiatrists stopped distinguishing between “reactive” and “endogenous” and moved to thinking of all depression as biological and, hence, all requiring treatment with drugs.

But that didn’t last. As Anne Harrington describes, in the late 90s, “a range of of different studies increasingly seemed to suggest that these antidepressants – although they’re helping a lot of people – when compared to placebo versions of themselves, don’t seem to do much better.” As the “gold standard” of drug effect is its performance over that of placebo, and drug after drug was shown not to be that much better, it got harder and harder to bring new drugs onto the market. She says –

“But it doesn’t mean that the drugs don’t work. It just means that the placebo effect is really strong. But the logic of clinical trials is that the placebo effect is nothing, and you have to be able to better than nothing. But of course if the placebo effect isn’t just nothing, then maybe you need to rethink what it means to test a drug”

This is the same observation as Irving Kirsch made in his “Emperor’s New Drugs”. In that book he drew a graph which I found very impressive –

 

 

The point he was at pains to make was the same as Anne Harrington’s – well, actually, he was trying to emphasise that just because the drugs didn’t seem much more effective than placebo didn’t mean that doctors should stop prescribing them. But the main point, I think, is –

Placebo is not nothing

It seems crazy to me that people make decisions about whether or not a treatment should be offered to patients solely on the basis of its statistical difference to placebo if those decisions then lead to the withdrawal of treatments which were helping thousands of patients.

If the placebo effect is not the same as doing nothing (and it is clear that it is NOT the equivalent of doing nothing) then we should be exploring just what it is. That will involve moving on from the stigma of trickery, because that’s how the placebo effect has been portrayed. “Dummy pills”, “inactive pills”, “mock treatments” producing real life changes in the patients who receive them, only to reveal to them that, ha! ha! you got nothing!

I think it’s interesting that it is in the area of psychiatry that this debate has emerged. Because we know something of the power of placebo on our mental states. But as we are whole, body/mind, non-dual beings. What influences our mental states, influences our bodily functions too. Placebo effects are not restricted to changes in mental states, they are seen throughout the body, influencing organs, cells and circulating levels of natural chemicals.

Here’s the other thing – if placebo is NOT the same as doing nothing but a drug doesn’t show a substantial and significant benefit over placebo, then what else can we offer the patient? What else will be at least as powerful as placebo, but less harmful than the drug?

What about exercise, nutrition, the creation of significant social relationships, engagement with natural environments, meditation, learning how to handle our emotions for starters? And not forgetting demanding that we do something about the conditions in which more and more chronic illnesses are emerging – both mental and physical – poverty, poor housing, inequality, polluted environments, industrial, chemical methods of agriculture and food production and so on – have a look at the perspective I described in “There still aren’t enough”, and in “Inequality and health”.

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When there aren’t enough…..

Posted in from the consulting room, health, life on January 24, 2018| 3 Comments »

bandanaEvery day in the UK, we hear stories of ambulances waiting in queues at hospitals. Patients waiting hours to receive attention. Patients waiting hours on trolleys in hospital corridors.

What’s the problem?

Much of the media coverage focuses on the “demand”, by which they mean the sheer numbers of people coming to hospital for health care.

Let me return to the issue of demand in a minute, but let’s start with waiting times. Let’s set targets aside for a moment as well, because targets can be arbitrary and unhelpful.

Why are there queues of ambulances at hospitals?

Part of the answer is there aren’t enough doctors and nurses to attend to the patients’ needs.

There aren’t enough, because if there were, they would be able to devote all the time necessary to each patient but there wouldn’t be a huge queue.

Part of the answer is the staff can’t move patients through from A&E for inpatient care because there aren’t enough inpatient beds.

There aren’t enough inpatient beds.

There are more patients needing inpatient care than there are beds to put them in.

Beds aren’t enough.

Once a patient is in a bed, they need to be cared for….by staff to keep the ward clean, staff to make food for them and feed them, staff to care for their daily needs and staff to manage their diseases and get them well enough again to go home.

So can we fix that first?

  • Increase the numbers of beds available in the NHS to cater for the needs of sick people.
  • Increase the numbers of NHS staff to the level where there are enough of them to meet the needs of sick people.

Wasn’t that the whole point of the NHS in the first place?

To meet the needs of the sick in society.

Let’s turn to demand.

It’s going up.

And there’s absolutely not a shred of evidence to suggest it’s going to do anything other than continue to go up.

The proportions of the population over 60, over 70, over 80, and, yes, over 90 are all rising. All the evidence shows that older people have greater health needs. The demographics of the country tell us that demand will increase.

Life expectancy might be going up, but disease isn’t going down. There are more people suffering from a chronic illness every year. There are more people suffering from two or more chronic illnesses every year. This is what doctors are referring to when they talk about increases in “complex problems and needs”.

All those patients waiting on trolleys for a hospital bed have been assessed as needing the complex care of a hospital to cater for their complex needs.

Not all those patients already in the hospital need the complex care of the hospital. Some of them are elderly, and/or disabled people who are not able to look after themselves at home. They need to be looked after somewhere else.

Here’s the next item on the list.

There are not enough places available in care facilities which are not hospitals.

Places in care facilities, (nursing homes, residential homes etc), need sufficient numbers of trained and support staff to provide the care for their residents. We don’t have enough care facilities.

Let’s think about another aspect of demand. Time and again we hear that many people pitch up at A&E because they can’t get to see their local GP. They are told they have to wait several days, or even weeks, for an appointment so they go to the local hospital instead – with problems which could be, and should be, managed by GPs in the community.

Why can’t people get to see a GP in a more timely manner?

There aren’t enough GPs.

There never have been.

The scourge of General Practice is not having enough time to treat each patient as well as the doctors would like to. Were five minute appointments ever adequate? Are ten minute appointments adequate? Do they give the patient enough time to say what they want to say? Do they give the doctor enough time to listen, to examine, to diagnose, to offer treatment, to give the patient enough information to give informed consent to the treatment, to allow enough time to discuss options and alternatives?

You’ll have a hard time finding someone who can answer yes to that.

There aren’t enough GPs.

And there aren’t enough staff in the GPs’ teams either.

A healthier society

The biggest delusion suffered by those who created the NHS was that the NHS would make the population so much more healthy that eventually demand for it would shrink. That’s never happened. And it’s not likely to happen.

Health care isn’t the biggest contributor to the health of the population.

We need to address the causes of illness if we want to reduce demand. The causes of illness are primarily social, economic and environmental.

  • We need to tackle the isolation of people in our society.
  • We need to tackle poverty.
  • We need to tackle the constant stress of the “precariat” – all those without secure incomes, those on zero hour contracts, short term contracts, those employed for insufficient hours at insufficient levels of pay to meet their daily needs.
  • We need to tackle the food industry, from farming methods, to factory production of foodstuffs, to marketing and sales of food.
  • We need to tackle the chemical industry, to reduce the amount of CO2 in the atmosphere, the amount of plastic in the sea, the number of chemicals found in the blood of every newborn child, the number of chemicals found in drinking water, the number of chemicals in every household.
  • We need to tackle inequality which is rising fast and has been shown time and time again to inflict pain and suffering on millions.
  • We need to tackle conflict, to be able to direct resources towards healthy lives instead of war.
  • We need to tackle our political systems which leave so many feeling disempowered and forgotten. Democracy might be a great idea. Maybe we should try it. Not the pretend democracy of a vote every few years for someone to work in government, but real, relevant, responsive democracy which increases the engagement and autonomy of citizens.
  • We need to find different ways to live together.
  • We also need to tackle the Pharmaceutical industry. That industry which doesn’t exist to produce cures, but profits. There isn’t a drug on the market which increases health. At the very best a drug will support the body’s natural systems of repair and recovery. At worst drugs diminish symptoms without making any impact on the underlying disease.

We need a different philosophy of health care, one focused on health not taking drugs.

That’s an awful lot. Daunting perhaps. But are there better answers?

In summary

This is a toe in the water. There is no way to cover the complexity and extent of the issues in one short article. But can we make a start?

  1. We need more hospital beds, more care facilities, more GPs, more doctors, more nurses and more support and care staff.
  2. At the same time, we need to tackle the causes of the increase in demand – the social, economic and environmental causes.

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