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Outcomes and fixes

I took this photo at the “Cote Sauvage” (the wild coast) earlier this year. I hadn’t been to this, one of my most favourite beaches, for over a year because during the pandemic we were forbidden to travel more than a few kilometres from home for many weeks and public spaces including parks, forests and beaches were closed.

I think you can feel the sense of expansive openness I experienced once I got here. But the first thing which struck me was how much this landscape had changed. Storms and high tides had completely changed the dunes. It was no longer possible to walk down into the sand directly from the forest behind. The slopes had been turned into cliffs. And the wooden walkway from the car park had been totally destroyed.

Months later I returned and the walkway had been reconstructed. The new cliff edges of sand, however, are the same.

These large scale changes of landscape caused by the interaction of the sea, the wind and the land are amongst the most dramatic changes I’ve seen over a mere matter of months.

Partly this gets me thinking about the fact of constant change. Even large structures on the surface of the Earth are constantly changing – mostly slowly, but occasionally dramatically. We’ve seen a number of these dramatic events over the last couple of years – floods, forest fires and volcanic eruptions. Melting ice caps, shrinking glaciers, earthquakes. Hurricanes and cyclones and other extreme weather events.

But this image also gets me thinking about our somewhat delusional perspective on outcomes and fixes – in every area of life – but, especially in the context of the pandemic, in the area of health.

There is almost an obsession with so called outcomes in health care. That’s always struck me as odd. Human beings are complex ever developing creatures. Looking at only a small period of time in anyone’s life always runs the risk of failing to really understand them. We need to hear their full story, not just measure a couple of changes over a short period of time.

Choosing to focus on an isolated set of measures in a whole person seems to me to give too much importance to the “outcomes” instead of the lived experience of an individual. It seems precious little research looks at the life time consequences of interventions and treatments.

The focus on measurable outcomes shifts the attention from the long term to the short term, and to data from story.

And what this does is delude us into thinking we are “fixing” things.

There’s been a pursuit of simple fixes in this pandemic – we were told lockdown would fix the problem, then mass testing would, then vaccines would.

In fact, we need to address the factors involved in creating the pandemic and its devastating effects…..from the way we interact with Nature (forest destruction, over consumption, pollution, carbon production), to the way we run our societies (inequality, poverty, overcrowded housing, precarious jobs, run down under-resourced Public Services, lack of adequate safe care of the elderly) if we want to really deal with the pandemic.

Quick fixes don’t last. And they aren’t fixes. Despite what politicians and Big Pharma tell us.

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We have an old well in the garden. Its wall is very worn and covered with lichen and moss. Lichen and miss are strange life forms which seem able to grow on the most unlikely ground. I’m quite used to seeing that.

But a few weeks ago a little plant started to grow in a small indentation in one of the stones. Really this indentation isn’t much bigger than a button and it seems pretty shallow. Honestly I never considered it as a likely place for a flower to grow and I certainly didn’t plant one there.

But over a few days this tiny plant grew and blossomed. Isn’t it beautiful?

Really this is the kind of thing that astonishes me. I don’t know how the seed found its way into this tiny recess….either dropped by a bird, or simply blown in the wind. But having found itself there it sure didn’t need much to germinate, grow and flourish.

It reminds me of why I agree with the view that we live in a friendly universe. What I understand by that is whilst entropy shows us that ultimately everything falls apart, there are powerful creative forces in this universe which provide the conditions for life to emerge….more than that…for life to flourish.

Isn’t that astonishing?

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Innovation

I thought I’d share a couple of innovations with you today. These are just two which caught my eye recently.

On the left is a dispensing machine with a difference. Everything on sale here is an organic vegetable. You can choose a basket of selected veg to make ratatouille or soup or you can just choose some potatoes or other vegetables.

I’ve never seen anything like this selling organic veg and the amazing thing is it was in a motorway service station just south of Saint Malo.

Surprising, huh? I’ve no idea how long it’s been there or if it is successful but it certainly caught my eye.

The one on the right is outdoor tables and seating set up for a festival down by the Charente in Cognac. The stools have been made from old gas cylinders. Looking pretty attractive and what a good use of old cylinders.

Ok, neither of these are a big deal, but they are examples of what gives me hope. We humans are a very creative species and we use that creativity to adapt to changing circumstances. There’s no doubt that in the light of climate change and the pandemic that we need to adapt and maybe this kind of innovation is just a signal that we are in the process of doing that. After all the big changes emerge from the interactions of all the individual ones, even small ones, don’t they?

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Relationships

I was tempted to post this photo with no words. I mean who doesn’t like a photo of duckling? It’s just a charming, delightful, heart warming image, don’t you think?

But I do think this image says something about the way not only ducks, but many other creatures including we humans, need the care of others, learn by copying, and gain security by sticking together.

In other words relationships are fundamentally important.

Does that need to be said?

I think it does. For two reasons. First, because we have moved into an increasing separated, transactional society. Health care, for example, should be centred on relationships. Health is about people, individual unique people in relationship with the others. Anything which degrades or impairs the quality of the relationship between patients and doctors, between patients and nurses, between patients and carers or between team members should be addressed and changed. Just the other day I heard the U.K. Health Minister laud as innovation and improvement a centre which was doing twice as many cataract operations in half the time. I’m sorry, Minister, but innovation and improvement would be improving the quality time spent between patients and professionals. We need to build long term kind and caring relationships into the heart and core of our services, just as Victor Montori says in Why we Revolt.

Secondly paying more attention to relationships will help address the imbalance between competition and co-operation in our societies. Some of the most impressive stories of the pandemic have been the kindness and care of neighbours, strangers and families for each other, as well as the impressive scientific and clinical co-operations which have improved our ability to treat those who get sick from Covid.

So, yeah, this is a lovely photo of ducklings, but it reinforces my desire to contribute towards the creation of a different world.

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Order and chaos

I took this photo a few years ago because I was struck by the contrast between the two areas of the landscape I could see.

To the left are rows and rows of vines, all well tended, individually pruned, (and sprayed multiple times!) – a managed area of land, impossible without intense human effort.

To the right is a field of wild flowers, a whole range of diverse species each flourishing in a part of the land left untouched (for this year) by human hands.

I find both beautiful.

What this image stirs in me are the writings of two medical writers – Iain McGilchrist and Dan Siegel.

Iain describes the different ways our two cerebral hemispheres engage with the world. The left seeking structure and order while the right seeks to explore difference, novelty and betweenness.

Dan describes the mind as an integrative process managing the flow of energy and information. It integrates order and chaos. Too much of either is unbalanced. The mind seeks to integrate them.

Search this site for either of these authors and you can find a number of posts I’ve written about their insights.

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Remember TINA?

Do you remember TINA?

That was one of Margaret Thatcher’s slogans. Well I’m not sure she ever used the acronym but she sure believed the statement which led to it – “There Is No Alternative”.

What she meant, of course, was that she was determined she was right and would entertain no criticism.

I hated that from the first time I heard. It struck me as both arrogant and ignorant.

At best it was a delusion, and at worst, a deliberate lie.

Almost a couple of years ago the ancient, high stone wall separating the garden from our neighbours’ property fell down. A huge, sudden crash and down it went. If you look back through my blog you’ll find lots of photos of the wall….or more specially of the glorious false vine which grew on it. Some experts have blamed the fall on the ivy, and maybe it did contribute but it was beautiful all the same.

The wall still hasn’t been repaired (don’t ask!) but the neighbours did chop down the remains of the ivy plant to stop it regrowing.

Well look at this – it hasn’t given up yet!

I listened to an excellent episode of the onbeing podcast the other day. It featured an interview with the forest scientist, Suzanne Simard. I recommend it. Her work on the interconnectedness of trees and fungi in the forest is mind expanding. Yet she had to fight to have it accepted as the dominant orthodox model was based on Darwinian competition, not collaboration and cooperation.

In that interview she says

You know, I’ve learned through my work, in studying how systems work, that they are regenerative systems. You know, they’re built that way. They’ve evolved that way — that the old help the young, that the large helps the small, and it’s reciprocal, and that this network, this system, will grow. And out of it emerges incredible stuff, like the ability to sequester carbon in our ecosystems, for example; the productivity of a beautiful cathedral forest; the sense of wonder and health and vitality and health you get — that we get when we interact with that incredible place.

You know, even in our own societies, look at what we’ve achieved, and look at the joy we’ve developed, listening to the symphony, watching our children grow. It’s just full of joy. And we’re built for that. And that’s what gives me incredible hope, and honestly, hope is the only way to go, right? And it’s also — that hope is based on understanding. It’s an understanding that our ecosystems are meant to heal themselves, and yes, there are tipping points, and yes, we do — if we don’t make changes, they can collapse, but they can also go the other direction. The system will respond, if we make those choices, and it will rebuild and re-self-organize again in a way that is going to be healthy for maybe even the human population, the human society, right? I think it’s all there. We have all the tools. We have all the fundamental building blocks. We just need to make the right — make good decisions.

So I look at this photo again and I see resilience, re-growth and the ability of Nature to find another way.

I love that.

Be wary of those who claim “there is no other way” – there always is.

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Nourish and nurture

Whenever I look at this photo I think of the relationship between a mother and her child. We humans have evolved with a uniquely long period of nurture for our newborn. Our species needs more care and attention for many more months than most others do in the earliest phase of life. From the perspective of evolution that must grant us some advantage, and, as best I understand it, the current thinking is that it allows the development of the brain and the capacities for social interaction.

Is there a more stark example of how much individual human beings need others? None of us would have survived on our own, and although we develop much greater autonomy as we mature, we still thrive best when we are nourished and nurtured.

I think within us all are two aspects, themes, or strands of being. You might think of them as energies….like yin and yang. Or you might think of them as feminine and masculine principles, perhaps related to Mother and Father archetypes or gods. Or you might think of them as the right and left hemispheres of the cerebral cortex and the ways in which each engages with the world.

I have four verbs in my mind when I contemplate these two energies, archetypes or principles. Nourish, nurture, provide and protect.

I know we can’t reduce everything to four simple words and I also know that as society and culture evolves we develop a more complex way of understanding these actions….a way which doesn’t limit the feminine and masculine to the genders of female and male. After all, we have all always had both within us.

This particular photo makes me think of the first two verbs – nourish and nurture. It seems to me that that’s how we begin in life. We start within the womb being nourished by our mothers. Then when we are born our mother’s milk is the first, and for many the only, food we receive. Nourishment is mainly about food….it’s about supplying us with enough of the right food that we need to grow our body and brain. Think of how quickly a baby grows into a toddler, and from there into a child, then teenager, and how much they change in those first ten to twenty years. It’s pretty astonishing and we kind of take it for granted.

Nurture involves more than nutrition. It involves care, encouragement, support and education. How we are treated by our significant carers in the first five years affects the size of the brain and the number of connections which are forged between the millions of neurones. You can imagine how important that is for our future abilities and wellbeing.

In my heart, I feel moved by an image like this. This relationship of care, this relationship of nourishing and nurturing, is so important, it really can’t be overstated.

I hope we see more of this in the years to come – better nutrition for all, more care, attention and nurturing for all.

That would be a good start, don’t you think?

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From above

I haven’t been on a plane for a long time. However, here’s a photo I took a few years back. I looked out of the window just before dawn and what struck me was how solid the clouds looked. They look like a landscape on the surface of the The Earth. There even seems to be a deep ravine as if there is a river flowing far below, down in the dark depths of that gap.

Of course, I know that these clouds are simply water and that if I were to try to step on them I’d fall straight through. And I know that the surface of the Earth is not like that. I know that when I stand in my garden, for instance, I am standing on solid ground.

But this last year of extreme weather events in a wide variety of places in the world has shown us that this sense of solidity is based on somewhat shaky foundations. We are witnessing the Earth reshaping itself….glaciers shrinking, ice mountains falling into the ocean, volcanoes covering the land with lava, overflowing rivers sweeping away hillsides, roads and houses in a few minutes, fires razing forests and whole townships to the ground.

Then along comes a pandemic and the entire world is faced with the certainty that nothing is certain. Day after day “experts” make predictions about what’s going to happen next, then something else transpires instead. We’ve even become a bit obsessed with the future….juggling fears, anxieties, plans and “what ifs”.

Maybe we are being forced to learn to live outside of our shared delusions – the delusion that human beings can control Nature, the delusion that Nature is something outside of us, something apart from us, the delusion that we exploit and consume without limits, (add your own favourite delusions here).

Maybe we are going to have to learn new skills, learn that we live in a complex inter-connected world, learn to emphasise adaptation over control, learn to rate relationships more highly than consumable goods, learn to co-operate and collaborate more than we compete.

Maybe if we do respond to these challenges by seeing the world anew, by taking the view “from above” as the old philosophers taught, then a new, bright, dawn lies just over the horizon.

I hope so.

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Seeing the invisible

Most of the time the light of the Sun simply illuminates the world distinguishing day from night. The light is invisible. We don’t notice it. But then occasionally we see something like this and the sky appears to be filled with obvious, even spectacular rays of light.

A scene like this grabs our attention. In that moment we see the sunlight.

Of course this phenomenon isn’t due to light alone. It’s an interaction between the Sun and water molecules in the Earth’s atmosphere.

But there’s something magical about this.

We feel we are seeing the invisible.

Saint Éxupery wrote in The Little Prince that what is invisible is essential. That’s one of my favourite passages in the book.

I often thought of myself as a doctor of the invisible. Because what interested me most about a patient was their experience as a subject. Sure, being able to know them objectively was often important ….. to be able to elicit the signs of disease in the body, or to measure the levels of certain molecules in their blood, or their organs etc. But I usually started by listening to their story.

As a patient told me their story, they told me of their experiences, of their symptoms, of events in their lives, of their thoughts, emotions and of what sense they were making of it all.

In doing so they revealed themselves as unique subjects. They revealed their personality, shared their innermost selves. They showed me what was invisible.

This getting to know the person who had the disease was a lot more important than getting to know just the disease. Important for diagnosis, for treatment and for healing.

It takes relationships, it takes connections, it takes interactions to reveal the invisible.

When the invisible becomes visible it’s always amazing, it’s always full of discovery and wonder, and it creates an invisible bond.

Isn’t that amazing? I think that’s what I experienced again and again in the consulting room. The creation of an invisible bond, a relationship, between two invisible subjects, the patient’s self and my self. That always felt special. That always felt like a gift.

I think we miss all that if we reduce people to objects and healing to procedures and processes. Human beings are more than that. What is invisible is essential.

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Movement and change

You might need to zoom in to look at this photo more closely. It’s more than an image of blue sky. It’s one of many photos I’ve taken over the years of migrating birds. In this case, they are geese. Those Flying V formations always catch my eye, although to be honest, I usually look up because I hear them rather than them catching my eye.

There’s two things here which I believe are fundamental characteristics of Life – movement and change – in this example bringing these together to witness migration.

Life moves. Is any creature which shows no internal or external movement alive? I think it was perhaps the General Semanticists who first claimed the essential characteristic of Life was a “self-moving capacity”. A stone won’t move unless someone or some other force moves it. A heart beats by itself, a bacterium moves by itself, all living creatures manifest this ability to move without the application of external forces. Maybe the General Semanticists were not the first to coin this term but that’s where I first came across it.

Perhaps it’s a variation of that idea which led to the concept of homeostasis – the ability of living organisms to self regulate and maintain a balanced internal environment. Perhaps Varela and Maturana’s “autopoiesis” or “self making capacity” comes from there too? These abilities to adapt, change, repair and grow are all forms of movement.

But these birds speak to a larger form of movement – migration.

Many, many species migrate. Either in annual cycles or in spreading from their place of birth to new lands, often distant lands.

I was thinking about that as I watched the finals of the Women’s US Open Tennis tournament at the weekend. Those two simply awesome young women performing at the peak of their sport. Emma Raducanu, born in Canada to a Chinese mother and Romanian father, and living in the U.K. since she was two, playing Laylah Fernandez, also born in Canada, but with a Filipino Canadian mother and Ecuadorean father, and now living in the USA.

Wow, now there would be a couple of truly fascinating “Who Do You Think You Are?” episodes? Following the migrations, the movements and changes of those two teenagers ancestors would be quite a trip, wouldn’t it?

I’m just back from Scotland where I was visiting family. Although I can trace my dad’s family back a couple of hundred years in Stirling, my mum’s ancestors came from further north – Perthshire and the Orkney Islands.

When I retired in 2014 I decided to experience the next part of my life in a different land, a different culture, a different language, and emigrated to France. I’ve done that with the clear hope that this movement and change will develop me, enlarge my experience and consciousness, and keep sparking my “vital force” and, so far, it’s working out exactly as I’d hoped.

I’m not a fan of restrictions on movement. I’m not a fan of all the rules and bureaucracy which surround the modern concept of citizenship and how it creates an “us and them” with different rights and responsibilities. I’d prefer a system based on habitation. I think all the inhabitants of the same place should be treated equally, have the same rights and share the same responsibilities.

Maybe only then will we undermine toxic xenophobic hatred and prejudice which I find so anti-life.

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