Heroes Not Zombies

Human beings are complex, dynamic, constantly changing organisms. To understand a single person you have to consider them within their multiple contexts – temporal, spatial, social, cultural and so on. Changes in any of these contexts can profoundly change our understanding of an individual.

Medicine tends to divide all illness into two types – acute and chronic. These terms have the flavour of being defined solely by time – acute is short and chronic lasts longer. But in fact, it’s not that simple. First of all, there is no definite period of time when an acute problem becomes a chronic one. It’s not defined in hours, days or weeks. And there is no transition point, where suddenly a problem is no longer acute, but has become chronic. Secondly, the same disease might at some time be termed acute and at others termed chronic. The taxonomy becomes confusing. There is even talk of “acute on chronic” where a chronic problem , temporarily becomes acute. Sometimes this is termed “relapses and remissions”, but you might think of it as really bad spells within an ongoing illness. In all these definitions, the assumption is what is important, definitive even, is the duration of the problem. The longer the duration, the more likely we will term it chronic. But this tricks our minds into thinking it’s just the same thing, and the only difference is how long the problem lasts.

Here’s a slide I made up to teach medical students and which I share with patient groups too –

What this slide shows is a graph. If we move from left to right, we consider longer duration of symptoms. If we move from below upwards we consider a greater number of symptoms. There are two circles, one inside the other. The greenish circle represents the set of symptoms which are characteristic of a specific disease – say, for example, asthma. The yellow circle represents the set of symptoms which are experienced by an individual patient and are therefore not characteristic of the disease.

On the left we see the typical “acute” scenario. In the example of asthma, this might be what is termed “status asthmaticus” – a severe, life threatening episode of wheeze. Imagine a series of a hundred children admitted to the emergency department of a hospital with this problem. Almost all of them will have the same symptoms and signs. The variation (as represented by the yellow circle) will be tiny. Such a situation does not require much individualisation of care – they ALL need pretty much the same treatment. Although every one of those hundred children is totally unique, in the “acute” situation, that matters little. They all need the treatment which will open up their airways and allow them to breathe again.

Further along to the right we see the typical “chronic” scenario. Let’s say this represents a series of a hundred children who have had asthma for ten years. They will still all have a set of symptoms characteristic of the disease “asthma” (represented by the greenish circle) but now they will all have a great number of different symptoms and experiences of the disease (represented by the large yellow circle). Some, over the ten years, will have symptoms only when they run, others only in the winter, yet others only in the summer. Some will have found that sitting up in bed eases their cough, others will have found only lying flat on their stomach eases it. Some will have found a glass of cold water will set off a fit of coughing, whilst others will have found that only a glass of cold water settles their coughing. Some will become very irritable when wheezy, others afraid and clingy. In short, the more of the story you listen to you, the more you realise that every single one of these children is unique.

This is the key difference between “acute” and “chronic”. It’s not just a matter of time and we can treat all children with asthma the same way and get the same result. As time passes the individual brings more of themselves into the picture. We all cope differently. We all experience the world differently. We are all impacted differently by the “same disease”.

This is one of the ways the biomedical approach falls down. It’s been fantastic at developing techniques and technologies to deal with acute, life-threatening disease. But the same tools are not enough in chronic illness because chronic is not just long-last acute – it’s fundamentally different.

The management of chronic illness will always be inadequate if it fails to consider the uniqueness of every individual and focuses instead on the small number of symptoms which people with the same disease have in common.

As we move our gaze from the short term to the long term we need to change our focus and our priorities – from the disease to the person.

In essence, the longer term requires a greater emphasis on understanding the individual and tailoring a complex of interventions and supports to bring about the greatest benefits for every single human being considered as unique – not as just another example of disease “x”.

Yesterday I posted about Seth Godin’s comments about making money.

Today I read an article by Desmond Morris about living to a grand old age. Remember Desmond Morris? He’s the zoologist who wrote “Manwatching“, a book I read as a teenager and found utterly fascinating. Well, he’s 80 years old now and he was writing about ageing. He tells us about Madame Jeanne Calment who lived in Arles until she died aged 122 (at 121 she was the world’s longest living human being). He wondered about her longevity. I’m sure you’ve read articles like that before, where people are interviewed to try and figure out what they were doing that contributed to their experience of health and longevity. Well, the amazing Madame Calment was still cycling and gardening at 121, and had tried to give up cigarettes at the behest of a local doctor a few years before but didn’t manage, and she enjoyed daily cheap, red wine, ate well of a typical French diet including rich stews, fois gras, and chocolates. She joked that her name, Calment, was very appropriate because she was always calm. And this, Morris thinks, was a key characteristic –

Had she worried about her health and taken steps to improve it, the anxiety caused by stirring up fears about ill-health would themselves have reduced the efficiency of her immune system.

Worrying about your health can make you sick! He mentions other long living people who shared this characteristic of not worrying about their health –

The oldest man who ever lived, Mr Izumi of Japan (who made it to 120), enjoyed his daily saki (rice wine) and said his secret was “not worrying”. Eubie Blake, a U.S. jazz pianist, said at his 100th birthday party: “If I’d known I was gonna live this long, I’d have taken better care of myself.” The irony is that it was probably his not worrying about his health that enabled him to live that long.

Regular, gentle exercise, like walking, cycling and gardening are common features of the lives of those who are over 100 years old and Desmond Morris makes an extremely interesting point about the place of exercise in these peoples’ lives. He noted that, when it came to exercise –

Cycling, walking and gardening were three of the most popular – done not to keep fit but for pleasure.

What’s Morris’s conclusion?

It seems that if you wish to live an unusually long life, you need to eat and drink what you fancy, keep as mobile as possible, have a lively interest in the world around you, avoid introspection and, above all, do not waste time worrying about your health.

I like his summary on the place of food in our lives too –

1. There are three truths concerning human feeding behaviour.
2. The first recognises that we evolved as omnivores, succeeding where others failed because we consumed a wide range of foods. One of the reasons we are now living longer than we did in the past is that the shelves of supermarkets display a truly astonishing variety of food from all over the world.
3. The second truth, which renders all diet books superfluous, is that the more you eat, the fatter you get, and the less you eat, the thinner you get. End of story. But whether you are eating more in order to put on weight or eating less in order to lose it, it is always important to keep the range of foodstuffs as wide as possible.
4. The final food truth is that you should enjoy what you eat and take time to relax while eating it. Speed and anxiety ruin digestion.