No one would suggest that we withhold our medical advances from other countries, but it’s perhaps past time to admit that even our most remarkable scientific leaps in understanding the brain haven’t yet created the sorts of cultural stories from which humans take comfort and meaning. When these scientific advances are translated into popular belief and cultural stories, they are often stripped of the complexity of the science and become comically insubstantial narratives. Take for instance this Web site text advertising the antidepressant Paxil: “Just as a cake recipe requires you to use flour, sugar and baking powder in the right amounts, your brain needs a fine chemical balance in order to perform at its best.” The Western mind, endlessly analyzed by generations of theorists and researchers, has now been reduced to a batter of chemicals we carry around in the mixing bowl of our skulls.
All cultures struggle with intractable mental illnesses with varying degrees of compassion and cruelty, equanimity and fear. Looking at ourselves through the eyes of those living in places where madness and psychological trauma are still embedded in complex religious and cultural narratives, however, we get a glimpse of ourselves as an increasingly insecure and fearful people. Some philosophers and psychiatrists have suggested that we are investing our great wealth in researching and treating mental illness — medicalizing ever larger swaths of human experience — because we have rather suddenly lost older belief systems that once gave meaning and context to mental suffering.
????? My daughter is 23 and has been using augmentative communication devices since she was a little girl. We have used devices from several different companies, so we are pretty experienced. This is, by far, the easiest to program. There are lots of preprogrammed categories, so it is possible to start communicating right away, without doing anything other than downloading it. ... After years of dragging around a 4–7 pound communication device that looks sort of ‘clinical’, it’s really cool to have a small iPod touch and a speaker (all of 15 ounces!) to bring with us. ... My daughter has enough things to separate her from her peers. It’s nice to have something for a change that’s the same as other people are using. Can’t say enough good about it!!!
One patient, who was so eloquent on the subject of music, had a great difficulty in walking alone, but was always able to walk perfectly if someone walked with her. Her own comments on this are of very great interest: ‘When you walk with me,’ she said, ‘I feel in myself your own power of walking. I partake of the power and freedom you have. I share your walking powers, your perceptions, your feelings, your existence. Without even knowing it, you make me a great gift.’ This patient felt this experience as very similar to, if not identical with, her experiences with music: ‘I partake of other people, as I partake of music…’
When Dr. Yehonatan N. Turner began his residency in radiology, he was frustrated that the CT scans he analyzed revealed nothing about the patients behind them — only their internal organs. So to make things personal, he imagined each patient was his father.
But then he had a better idea: attach a photograph of the actual patient to each file.
“I was looking for a way to make each case feel unique and less abstract,” said Dr. Turner, 36, now a third-year resident at Shaare Zedek Medical Center here. “I thought having a photo of the patient would help me relate in a deeper way.”
Dr. Turner’s hunch turned into an unusual medical study. Its preliminary findings, presented in Chicago last December at a conference of the Radiological Society of North America, suggested that when a digital photograph was attached to a patient’s file, radiologists provided longer, more meticulous reports. And they said they felt more connected to the patients, whom they seldom meet face to face.
What the great moment in the Ether Dome really marked was something less tangible but far more significant: a huge cultural shift in the idea of pain. Operating under anesthetic would transform medicine, dramatically expanding the scope of what doctors were able to accomplish. What needed to change first wasn’t the technology - that was long since established - but medicine’s readiness to use it.
Before 1846, the vast majority of religious and medical opinion held that pain was inseparable from sensation in general, and thus from life itself. Though the idea of pain as necessary may seem primitive and brutal to us today, it lingers in certain corners of healthcare, such as obstetrics and childbirth, where epidurals and caesarean sections still carry the taint of moral opprobrium. In the early 19th century, doctors interested in the pain-relieving properties of ether and nitrous oxide were characterized as cranks and profiteers. The case against them was not merely practical, but moral: They were seen as seeking to exploit their patients’ base and cowardly instincts. Furthermore, by whipping up the fear of operations, they were frightening others away from surgery and damaging public health.
The “eureka moment” of anesthesia, like the seemingly sudden arrival of many new technologies, was not so much a moment of discovery as a moment of recognition: a tipping point when society decided that old attitudes needed to be overthrown. It was a social revolution as much as a medical one: a crucial breakthrough not only for modern medicine, but for modernity itself. It required not simply new science, but a radical change in how we saw ourselves.
A deep problem is the replacement, in the medical profession as in the legal profession, of a professional model of service with a business model. In the professional model, the service provider is assured a good but not extravagant income by limitations on competition, and in exchange he is expected to avoid exploiting the ignorance of patients as he could do by performing unnecessary or low-value procedures. In the business model, the service provider endeavors to maximize his net revenues. In the case of medicine, the disparity of knowledge between provider and patient, coupled with the fear and desperation that serious illness (or just the possibility of it) engenders, enables the profit-maximizing provider often to convince the patient to undergo costly low-value treatments. Certainly the profit-maximizing health-care provider will be very relucant to refuse to provide a treatment that the patient insists upon, his insistence being made convincing by the fact that insurance will pay all or most of the cost. Insurers do try to limit their costs by refusing to approve low-value procedures—but in the face of combined pressure by provider and patient, the insurer is often forced to back down.
To return to the initial puzzle of why our peer nations are able to provide what seems, judging by outcomes, a level of health equal or superior to that of Americans at far lower cost, the only convincing answer is that the health-care providers in those nations limit treatment. I am not sure of the explanation, but the possibilities include: the professional model is more tenacious in societies less committed to free markets and a commercial culture than the United States; more of their hospitals are public and more of their doctors are public employees, who are therefore salaried rather than entrepreneurial; and Americans, being less fatalistic than most other peoples, have a more intense demand for life-extending procedures.
D: So the problem isn’t small-town Kansas—it’s a toxic mixture of small-town Kansas plus adolescence?
R: I think so. I like the small-town Kansas where we are now but, believe it or not, small-town Kansas is very heterogeneous. The town where we live now and where I grew up have a lot of significant differences in culture.
D: Tell me more…
R: Mainly it has to do with how people treat each other and how people approach problems. Here, problems are meant to be solved and people have a lot of respect for one another. We have “community conversations” when there’s something that impacts the whole town, and everyone who wants to speak can have their say. Where I grew up, on the other hand, people say all manner of things about other people, and if there’s a problem that affects the town everyone just complains to everyone else. The population even since I left has declined really sharply and everyone just says, “Oh, poor us, look at our dying town, who will save it?” Whereas here they formed an economic development commission and went out looking for new businesses to bring to the community. Some problems are similar, but by and large I think this is a positive place to grow up, and the graduating seniors we know well have said so too.
The other great example of small-town heterogeneity is to look at the counties to the north and south of us. To the north we have County A, where people routinely farm well into their 80’s, have active sex lives into their 90’s, and there has not been a teen pregnancy in almost 10 years. These are the ruddy-cheeked insanely healthy country folk you may have read about. To the south, then, we have County B, where everyone over 40 has diabetes, the obesity rate seems like it’s about 90%, STI’s are rampant and there are currently 8 pregnant girls in the high school. What’s the difference? I have been trying to figure this out. The medical care is exactly the same (it’s our group). The physical infrastructure is not that different. But culturally, people in County B have this victimizing, back-biting mentality.
D: It’s that stark a difference, huh? That’s astonishing.
R: It really and truly is.
Behavior | From eating vultures to clear up syphilis to treating H.I.V. with garlic and beetroot, quack medicine persists in folk remedies around the world, writes Ewen Callaway in New Scientist. Now an Australian study describes the cascades of human gullibility that help explain why.
Put simply, person X uses snake oil to treat her goiter, arthritis or what have you. Seeing this, friends assume snake oil works and more follow suit. Since it doesn’t work and X persists in using snake oil, more gullible people are exposed to the folly and fall for it than if X had been quickly cured with effective treatment.
Four out of five hucksters couldn’t have done better. [New Scientist]
I can tell you from my experience in Beijing that having an entire city of masked people is devastating to the social fabric. It is hard to have conversation through a mask—you can’t see smiles or frowns. Also, not all masks are equal. A good mask, well fitted and worn properly, is uncomfortable and hard to breathe through. And wearing a mask casually draped over your ears is more of a totem against disease than a scientifically valid form of protection.
Sticks and stones may break your bones — but if you need surgery, the right words used in the operating room can be more powerful than many drugs. New research published today in the New England Journal of Medicine found that when surgical teams heeded a simple checklist — as pilots do before takeoff — patient-mortality rates were cut nearly in half and complications fell by more than a third. . . .
Whether these changes can be sustained over time is another question. Gawande and his colleagues note in the study that a phenomenon called the “Hawthorne effect” may be largely responsible for the checklist’s success. The effect was named for a series of experiments designed to determine how to increase productivity at a factory in Chicago. All of the tactics implemented by the study leaders improved worker output during the experiments — but researchers realized that the effect they were really measuring was a boost in motivation among workers who knew others were watching.
“The checklist is kind of an effort to produce a consistent Hawthorne effect,” says Gawande. “It is intended to make people aware that other people expect these things to be done.”
Some 30,000 pairs of his spectacles have already been distributed in 15 countries, but to Silver that is very small beer. Within the next year the now-retired professor and his team plan to launch a trial in India which will, they hope, distribute 1 million pairs of glasses. The target, within a few years, is 100 million pairs annually. With the global need for basic sight-correction, by his own detailed research, estimated at more than half the world’s population, Silver sees no reason to stop at a billion.
If the scale of his ambition is dazzling, at the heart of his plan is an invention which is engagingly simple. Silver has devised a pair of glasses which rely on the principle that the fatter a lens the more powerful it becomes. Inside the device’s tough plastic lenses are two clear circular sacs filled with fluid, each of which is connected to a small syringe attached to either arm of the spectacles.
The wearer adjusts a dial on the syringe to add or reduce amount of fluid in the membrane, thus changing the power of the lens. When the wearer is happy with the strength of each lens the membrane is sealed by twisting a small screw, and the syringes removed. The principle is so simple, the team has discovered, that with very little guidance people are perfectly capable of creating glasses to their own prescription.
In truth, experts say, the developing world doesn’t need more incubators. It needs incubators that work. Over the years, thousands have been donated from rich nations, only to end up in “incubator graveyards” — most broken, some never opened. According to a 2007 study from Duke University, 96 percent of foreign-donated medical equipment fails within five years of donation — mostly because of electrical problems, like voltage surges or brownouts or broken knobs, or because of training problems, like neglecting to send user manuals along with the devices.
To compensate for this philanthropic shortsightedness, medical staffs either crank up the temperature in “incubator rooms” to 100 degrees or more, or swaddle babies in plastic to hold in body heat. Such makeshift solutions led the Boston team to ask: How can we make an incubator for the developing world that will get fixed? . . .
In his discussions with doctors who practice in impoverished settings, Dr. Rosen learned that no matter how remote the locale, there always seemed to be a Toyota 4Runner in working order. It was his “Aha!” moment, he recalled later: Why not make the incubator out of new or used car parts, and teach local auto mechanics to be medical technologists?
The larger point of my argument with your claim is that we cannot (I use the term advisedly) know what to expect of children with Down syndrome. Early-intervention programs have made such dramatic differences in their lives over the past few decades that we simply do not know what the range of functioning looks like, and therefore do not rightly know what to expect. That, Professor Singer, is the real challenge of being a parent of a child with Down syndrome: it’s not just a matter of contesting other people’s low expectations of your child, it’s a matter of recalibrating your own expectations time and time again—and not only for your own child, but for Down syndrome itself. I’ll never forget the first time I saw a young man with Down syndrome playing the violin—quite competently, at that, with delicacy and a sense of nuance. I thought I was seeing a griffin. And who could have imagined, just forty or fifty years ago, that the children we were institutionalizing and leaving to rot could in fact grow up to become actors? Likewise, this past summer when I remarked to Jamie that time is so strange that nobody really understands it, that we can’t touch it or see it even though we watch the passing of every day, and that it only goes forward like an arrow, and Jamie replied, “except with Hermione’s Time-Turner in Harry Potter,” I was so stunned I nearly crashed the car. I take issue with your passage, then, not because I’m a sentimental fool or because I believe that one child’s surprising accomplishments suffice to win the argument, but because as we learn more about Down syndrome, we honestly—if paradoxically—don’t know what constitutes a “reasonable expectation” for a person with Down syndrome.
Non-white medical students are more likely to embrace orthodox medicine and reject therapies traditionally associated with their cultures. That is one finding from an international study that measures the attitudes of medical students toward complementary and alternative medicine (CAM). While seemingly counter-intuitive, white students view CAM more favorably than their non-white counterparts, the study authors say….
n the first study, U.S. medical students wanted more courses about CAM than students in Hong Kong, for example. (The Hong Kong school was not included in the 2nd survey of fourth year students.) The second study continued to support that trend with the least interest in CAM measured in Asian and black students.
That is why the Great Plague of 1665 has been largely understood as a London phenomenon. The sites of old plague pits are now pointed out with understandable pride. Richard Barnett reveals that the escalator at Camden Town Underground station passes through a vast grave for plague victims, and that a “massive plague pit” is responsible for the low ceiling of the basement of Harvey Nichols. It would be fair to say that he takes a certain, rather morbid, pleasure in compiling this Baedeker of disease and suffering. But why not? This is London’s real heritage. Together with this volume are a glossary and six maps, so that the reader can make his or her way down the various roads to oblivion. If you wish to follow the course of tropical disease as it ate its way to the heart of the metropolis, you can do so; you can follow the route of the plague, or the life of an 18th-century medical student. All human life, and human death, is here.
Does the nature of psychotic delusions change over the centuries? Or are “crazy” people crazy in the same ways regardless of where and when they lived and died?
Slovenian researchers analyzed more than 120 years’ worth of patient reports from the Ljubljana mental hospital, and their findings suggest that psychotic delusions are profoundly shaped by contemporary society, with the technology of the day—be it the telegraph or the television—playing a prominent role. The researchers also found that the “persecution delusion” (a paranoid narrative in which the subject feels hounded by evildoers) is a relatively modern phenomenon: a reaction to the possibility of nuclear war and to Cold War conspiracy flicks like The Manchurian Candidate. In this sense, schizophrenic delusions are a twisted mirror to the world we live in.
Late in the book, when Kidder begins — and very skillfully too — to draw together the threads of his narrative and to sum up (as best he can) his understanding of Farmer, he notes Farmer’s fondness for a particular phrase: “the long defeat.” At one point Farmer says to Kidder,
“I have fought the long defeat and brought other people on to fight the long defeat, and I’m not going to stop because we keep losing. Now I actually think sometimes we may win. I don’t dislike victory. ... You know, people from our background — like you, like most PIH-ers, like me — we’re used to being on a victory team, and actually what we’re really trying to do in PIH is to make common cause with the losers. Those are two very different things. We want to be on the winning team, but at the risk of turning our backs on the losers, no, it’s not worth it. So you fight the long defeat.”
In an interview Kidder gave earlier this year about the book, he commented on the phrase, and says that Farmer “probably picked [it] up from reading Camus.” But that’s not right: he got it from what we learn in Mountains Beyond Mountains is his favorite book: The Lord of the Rings. Galadriel says it: “Through the ages of the world we have fought the long defeat.” And Tolkien himself, in letters, adopted and endorsed the phrase: “I am a Christian, and indeed a Roman Catholic, so that I do not expect ‘history’ to be anything but a ‘long defeat’ — though it contains (and in a legend may contain more clearly and movingly) some samples or glimpses of final victory.”
It seems to me that this philosophy of history, if we may call it that, is the ideal one for anyone who has exceptionally difficult, frustrating, even agonizing, but nevertheless vitally important work to do. For such people, the expectation of victory can be a terrible thing — it can raise hopes in (relatively) good times only to shatter them when the inevitable downturn comes. Conversely, the one who fights the long defeat can be all the more thankful for victories, even small ones, precisely because (as St. Augustine said about ecstatic religious experiences) he or she does not expect them and is prepared to live without them.