Monthly Archives: April 2011

Yet another election – is it still 2008?

No self-respecting curmudgeon would consider the current (federal) election a worthy topic of conversation (the superficial nonsense on health care alone is enough to put one to sleep), nevertheless given the ridiculous fact that it is even happening seems to require some kind of reaction.

Mine is mostly boredom. Well, I do confess a that those appalling conservative attack ads do vex me – ah, Ignatieff didn’t come back for me? Why would he have to? Was I lost? (Perhaps there is some subliminal religious theme here that I’m missing: “I once was lost and now I’m found, etc.” )

Four old white men, desperately trying to seem relevant – tweeting, eating hot dogs, hanging out at Tim’s drinking some weird concoction called a double-double (and you call yourselves coffee drinkers, pah) – wandering around the country in a repeat of 2008. Women my age apoplectic at the sexism and waste of money; young people completely disengaged and why shouldn’t they be when the one time a bunch of them try to get into a Harper rally they are turned away, and older people the only ones paying attention lest anyone go anywhere near their various entitlements. Touch my senior discount sonny and I’ll bean you with my walker.

Sorry. That was uncalled for. Particularly from a person of my advancing years. As, incidentally, we all are.

So, in keeping with the spirit of this corner of the cybersphere, I will focus on one small aspect of the discussion, one that I know a thing or three about, health care. Notably that dastardly phrase in the Canada Health Act, namely that all “medically necessary” services will be provided, ad infinitum and ad nauseum.  For aye, there’s the rub.

What, in this age of in vitro fertilization and knee replacements, full body MRI’s to “rule out” any serious hidden condition and various and sundry (highly expensive) drugs that will prolong life for a few weeks, is actually medically necessary? According to whom? CNN? The magazine you’re reading? The specialist? Your Aunt Sadie?

Things were a lot easier 50-odd years ago. Your grandmother knew when she was sick and needed to go to hospital (well, most of the time, if she didn’t decide she was too busy and couldn’t afford the time). Nobody was breathing down her neck insisting she had all kinds of risk factors that needed treating or pointing out that type 2 diabetes was the “silent killer” and surely someone her age needed to be on a biphosphonate for her bones. Oh, after a bone scan of course. Ah, the good old days.

Today, on average, women live past 80 and men about 78. In all likelihood anyone that age has a few things “wrong”, the question really is whether or not all of these need intervention and whether these treatments and drugs and so on end up often doing more harm than good.

What we need is a genuine, difficult discussion on what “medically necessary” means. For everyone, not just my Uncle Joe or me down the road (which of course must only be the best). Hell, why don’t we go all out and have a discussion about science policy as well. Rather than just the blather – science good, health care, good, oog oog. (For a more nuanced and informed discussion on science policy in Canada, visit my friend frogheart’s blog here.  ( Or you can listen to her being interviewed on Peer Review radio.)

In terms of health care, which everybody wants in on (versus science policy which makes most people run shrieking – forgetting that without policy we remain the commodities market we always were and that, boys and girls, is finite – those forests and minerals eventually will give out – the basics are as follows: Any national health care program has to navigate carefully between being all things to all people (and going bankrupt) and being most things to (almost) all people (there will always be people who end up getting better care than others, that’s life) but then we have to de-list somethings. We can’t do everything all the time. So that means we all have to give up a few things, like getting that MRI right this instant.  In any event, most of the time later on is good enough.

Take a painful knee.  Whether you’re a weekend warrior or a professional athlete, the reality is that joints take time. With or without that MRI your knee needs rest, ice, elevation, an anti-inflammatory and tincture of time. You may never need the MRI, the knee will probably get better. If it doesn’t, well, eventually you’ll need surgery. Again, MRI optional. But our belief in technology is so extreme that we transpose screening technologies with treatments. Simply knowing what something looks like isn’t a solution. But we always want “more”, like that Dickens kid.  And if we don’t get surgery next week? We end up complaining to the media that our health care stinks and all is lost. Like that woman, a gazillion pounds overweight, who whinged to the Globe and Mail a few years because she didn’t make it to the top of the surgical list. Or the alcoholic who’s peeved that his new liver can’t be had on demand.

My prejudices and curmudgeonly asides aside, this is a discussion Canadians need to care about and engage in. What constitutes medically necessary care? It’s not enough to think health care is just the greatest thing since sliced bread. We have to define what it is, what it means – and we all have to be prepared to give up a few things for the good of the all. That’s what ‘public” means.

But that’s the conversation nobody wants to have, which is why this election is really about individual (male) ego. And that’s boring.

Physiology 2.0

An older woman of my acquaintance misplaced her watch recently. Not a big deal, you’d think. She found it a few days later with the help of a friend – unbeknownst to her it had slipped off the television and into a drawer. What got my attention was her extreme secretiveness, so convinced was she that people would suspect she had Alzheimer’s or dementia or what-have-you (because of her age).

Somewhat in the same vein I am often asked – in strictest, pain-of-death confidence – about a pain here, a twinge there; a slow-to-heal cut or some bleeding that my interlocutor is convinced is something dire, cancer probably. Almost always with some judicious questions I can reassure the person; the pain is probably a pulled muscle (if it doesn’t improve over time then perhaps further investigation might be called for), the blood loss benign (and common), the cut merely infected and in need of antibacterial care. The relief is inevitably palpable. Terror had literally been keeping the person up nights.

I don’t blame them. Everything they hear about health, and there is a lot of it around, is about something horrible. In truth, we are all so inundated health “news” these days, so saturated with medical “updates” – in every medium possible – that it’s virtually impossible not to become a hypochondriac at one point or another. Especially since medical problems are presented not in terms of real physiology which is messy, unpredictable and slow (but often very resilient) but in entertainment terms: Monster tries to eat New York, hero rises to vanquish monster, stuff happens, the end.

The heroic angle is ever present. We will discover the gene that “causes” cancer (Really? How’s that working out?), tweak it and presto! Problem solved. Well, not right this instant of course. Oh, and did we mention there are these fibres in those bags you now use to carry groceries that can cause beri beri? Oopsy woopsy.

That’s not how physiology works.

From the immune system to neurons, our physical selves advance, retreat, retrench; go forward one step and back two (even with something ostensibly simple like a flu virus). Age on the one hand creates fragilities, on the other speaks to great endurance (hey, there are a lot of chances to die before you hit 75). Physiology is complex, dynamic and infinitely changeable, even in the same person, from one moment to the next.

The root of this reductionist thinking came after the second world war when money and attention, not to mention serious institutional support, went towards medical research, the National Institutes of Health, Health Canada and the like. And our focus, as the late Yale epidemiologist and physician Alvan Feinstein wrote, turned away from the person (patient) and towards disease. Plus, we started flinging large sums of money at medical research which, in turn, began singing its own praises, which is hard to do unless you create a bogeyman you are battling.

So, nobody mentions that we live longer, healthier lives (in the developed world) than any generation ever. That over half of all people over 65 are alive today and doing very well thank you very much. What we do hear is that there are umpteen dreadful diseases out there, skulking, lurking.

So we freak out over minor aches and pains and mumble “Oscar material” when some fellow played by James Franco heads into some canyon and gets stuck. Look, I’m glad the fellow saved himself and yes it must have been dreadful but the real story is not dramatic but in the day-to-day lives of all those amputees who have to cope with getting on with their lives. The real story isn’t in the escape but life after that idiotic daredevil stunt. Except life with a disability is painfully difficult, often humiliating and can make even a grown man cry from frustration. Boring. Not at all Oscar material.

Is it any wonder real life, only too often – when it hits, as it always does – comes not only as a rude shock but as a personal affront?

Take another curmudgeonly peeve of mine. Violence. Movies, television shows, games – the level of gore has steadily increased even as our ability to emphasize or react in any appropriate form has gone down. Sure, I enjoy watching the evil genius get his or (more rarely) her comeuppance; I like a watching a building blow up and cops shooting at bad guys. What I do not enjoy is the inevitable desensitization these increasing levels of violence have on our collective psyches. (Or the noise: I seem to be the only person in the western world with intact hearing.)

It seems that we have all become so immune to the ugly impact violence has that even an essentially comic-book hero like James Bond is portrayed not as the suave Sean Connery straightening his cuff links after a dustup but is rife with fake blood and cringe-worthy torture scenes that make one feel vaguely ill.

Then. Then. (Here we have to pause for me to give a heavy sigh.) Then, the victim of aforesaid torture or flying bullet gets up and carries on. If he’s the hero, that is. Later, we hear that he was lucky, the bullet “grazed” the skin, it was just a flesh wound.

Pardon me?! What flesh would this be? Um, human? Frankly, I have yet to meet a real human being who was able to recover from even a kitchen accident in a day. (Hey, you try it. Make a deep slice in your finger as you’re chopping carrots or a slice of bread and you tell me how long it takes to heal. More often than not you’ll take the bandage off way too soon, the cut gets infected and starts to throb and the whole process starts all over again.[1]) The consequences of violence are so rarely seen as to be invisible.

No doubt this is why we get those news items of seven-year-olds firing on one of their pals in jest without realizing that real guns do real damage.

Physiology is hard. Healing takes time. Bodies are fragile yet amazingly resilient. It all depends on the person, the situation, the amount and place of the damage. Even a broken ankle can lead to a lifetime of causalgia (you don’t want to know – major, lifelong pain) and someone can fall off a cliff and survive with minimal injuries. It’s not possible to predict and it’s probably better not to try that last one. Politically, such attitudes end up reflected in the acceptance for President Bush’s redefining torture in defiance of the Geneva Conventions and in our nonchalance around so much global suffering – even as it convinces us that we’re dying from some dreadful disease – when all we’ve got is a hemorrhoid.

[1] (First Aid note: when you’ve cut your finger or hand and the skin has healed over but it’s red, swollen and painful, what’s happened is that bacteria are trapped and your immune system is responding, but slowly. To help the macrophages along, you need to clean out the bacteria physically by making a tiny incision and letting the blood and pus ooze out. Sounds horrible but there’s physiology for you. Then soak in hot water with a drop of disinfectant, e.g. Dettol, or just water in a pinch.  Cover with antibacterial cream and bandaid.)