Tag Archives: medicine

The Brain and the Doppelgänger

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From David Biro at the Literature, Arts and Medicine blog:

One of the most exciting, recent discoveries in science has been the mirror neuron. First isolated in monkeys and later found to exist in human beings, these neurons (and groups of neurons) are active not simply when we are moving and emoting but when we observe others moving and emoting. Our brains, as it were, re-enact or mirror the movements and emotions of other people as we watch them. Although scientists are still working out the implications of this extraordinary finding, it is almost certain that the brain’s mirroring system contributes to the profoundly social nature of human beings and may well be responsible for many of our greatest collective achievements: language, social institutions, and culture (4).

Many scientists also believe that neuronal mirroring can reflect in two directions, illuminating both the external world (of others) and the internal world (of self). By constantly observing and imitating others, we not only learn about them but about ourselves: How we see and think of ourselves; the meanings we ultimately give to our most intimate and “unsharable” experiences like pain; indeed the ongoing project of human creation in general as it works to fill the world with things that possess the capacity to reflect our humanity (5).

Thinkers like Sartre, Foucault and Lacan may have been exquisitely prescient. Mimesis may well turn out to be a prerequisite or stepping stone to self-knowledge. We observe, reproduce, impose patterns, and thereby understand. We can do this with objects that happen to cross our field of vision…  But we could also do this on a more sophisticated level. If a potential doppelganger doesn’t exist we can invent one … as many artists do in their poems and paintings. After finishing his masterwork, Flaubert is famously reported to have said of his creation: Emma Bovary, ces’t moi. The re-production leads to recognition. The same thing that painters do perhaps more self-consciously in their self-portraits and in the case of Frida Kahlo, her double self-portraits. Here the dictum of philosopher Nelson Goodman is most transparently realized: Comprehension and creation go on together (6).

Read the whole thing here

Women, Politicians & Doctors

Posted on by elizabeth
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Why don’t more Canadian women run for public office?  Try division of labour:

So what’s the problem? Getting us to run, of course.

Isabel Metcalfe, who was in charge of recruiting women to hit Stéphane Dion’s target of one-third female Liberal candidates, told me that women need to be convinced. “There’s always some guy who thinks he’d be terrific,” but women are “reticent.”

Family is usually what’s holding them back. Provincial or federal politics means weeks at a time away from home, and that conflicts with the larger share of domestic baggage women still carry.

It happens in the best of families. In this week’s New York Times Magazine, Kerry Kennedy — daughter of Bobby and Ethel — was asked if she has ever considered running for office. She said she has thought about it, but her children are 13 and 11, “and as a single mother, I think that would be just too tough on our family. Their father is a politician.” (Kennedy was very publicly divorced from New York’s attorney general, Andrew Cuomo, in 2003.)

If a daughter of the U.S.’s most storied political family thinks running for office is too hard on the home life, there seems little hope for the rest of us.

So how do we get women to chuck the hubby and kids for life in a fishbowl? If we wait until men are willing to take up the domestic slack before women take a bigger role in public life, well, we’ll be waiting a long time.

But perhaps Baby Boomers, women of Penny Collenette’s vintage, will start answering the call in greater numbers. In their 50s and 60s, they’ve had their careers, raised their families, done fine charity work, had enriching life experience, and sure understand what’s facing everyday families.

Come to think of it, just what we want in our politicians.

Let’s face it, the job isn’t made for men or women who have families.  The numbers of women who have entered previously male professions and taken on men’s jobs in the last several decades have not changed to nature of the work itself very often.  On that theme, it’s interesting to look at what’s happened to the nature of family practices in medicine over the same time period.

Over the last several decades, Ontario has experienced a severe reduction in the number of family practice doctors available to take on new patients such that the lack of doctors has caused a crisis in rural and even some suburban areas.  To a certain extent, this crisis can be attributed to short-sightedness about the number of doctors who would be needed – the government of Canada understood the rapid increase in cost of running the health care system as being physician driven and, in their wisdom, reduced the number of available places in Canadian medical schools by 10%.  Brilliant.  It’s a little more complicated than that, but suffice to say, there would now seem to be about 5 million people in Canada with no primary care physician – count me as one of them.

There are other factors that have contributed to the problem but the increasing numbers of female medical school graduates are part of it.  It’s now well-documented that women practice differently than men.  For one thing, they work shorter hours:

Female doctors constitute half the graduating classes, further reducing capacity, as female doctors, on average, work shorter hours during the child-rearing years.

However, it’s not quite as simple as it looks.  For one thing, it’s in the years before their children are in school full-time that female family doctors work fewer hours than their male counterparts.  For another, though the fall in numbers of hours worked per week is greater in the case of women, male family doctors are also working fewer hours than their predecessors:

The hours worked per week decreased slightly for all physicians, both male and female. Preferred hours of work in 1999 were 37.2 for males and 31.0 for females. Preferences for hours worked and satisfaction with the balance between work and home life were important in predicting the hours worked. Those who were satisfied with the balance in both 1993 and 1999 worked 35 hours a week in 1993 and 33 hours in 1999. Those who felt the balance was not good at either time were working 48 hours in 1993 and 47 hours in 1999. Physicians without children, and women having a physician as spouse, or having a child under six, worked fewer hours. Women with all children at school worked longer hours. [download pdf]

While men have become increasingly less likely to enter the medical profession than women – some attribute this to the remunerative and status appeal of computer science and business careers – those who do become family doctors don’t find the 80-hour work weeks of older doctors any more appealing than women.  Watching women transform practice to allow themselves time with family just may have rubbed off on their male counterparts, making the entry of women into the profession a factor that has actually changed the way the work is done.  However, when male physicians work fewer hours, the explanation is a little different than it is for women:

… we could see it as taking our role as healers seriously, making time for our own inner lives, trying to achieve a balance between an active and a more contemplative life.

Hmm.  women are taking time off to raise their children and men are taking time off to find themselves.  In that way, it doesn’t seem likely that the change in workplace dynamics has changed much with respect to the division of labour within the home.

In addition, there’s evidence that the focus of family practitioners has changed and that the change appears to have originated with women, who provide fewer services but spend more time with their patients. [download pdf]  That’s not necessarily a bad result.  As one analyst notes

It’s not all bad if more time with a patient means fewer visits in the end …

A physician urges us to consider another factor:

Considering the complexity of so many of the health problems in family practice – chronic pain, occupational traumas and stresses, the so-called somatoform disorders, family dysfunction, anxiety/depression and so on – this [increased focus on counseling] is encouraging, especially if it signifies more time with patients and improving counseling skills. Counseling can be shared with nurses, social workers, and other more specialized counselors. But in the assessment and therapy of complex disorders, counseling skills are clinical skills. It is also significant that the great majority in both surveys offered psychotherapy. We do not know what form this takes, but it does suggest that the respondents regard it as important to family practice. There will be some that do not welcome this trend. I urge them to think again. Of all fields of medicine, family practice can show medicine how to transcend the artificial division between mind and body, which runs through medicine like a fault line. It is the kind of relationship we have with patients that distinguishes us more than anything else, and “psychotherapy” may be another word for the emotional intelligence we need in our relationships and our clinical judgements.

For reasons of decreased supply, women have found it possible to maintain practices wherein they are able to control both their hours and the way they work and thus, arguably, to change the way medicine is practiced and their working conditions.  In order to attract increasing numbers of women, other areas of work, like politics for instance, will likely have to show themselves capable of allowing this kind of change and flexibility.  Short of the revolution, such a change will require a change in economic conditions.  But likely not the kinds of changes we’re seeing today.

Equal Voice is tracking the numbers of women nominated, by party, and the numbers of women in “winnable” ridings, as compared to 2006.  Keep an eye out.

Humane Medicine & the Poet

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From an interview with poet Berwyn Moore by Elizabeth Glixman:

EG     You’ve worked in hospitals. Please tell us what your jobs were.

BM     I graduated from high school at 17, but didn’t attend college until much later. I had a variety of jobs, including one as a respiratory therapist at the Babies Hospital in Wrightsville Beach, North Carolina. I was trained on-site and was even head of the department for a while. I also worked as a pharmacy IV technician, mixing formulas, at the New Hanover County Hospital in Wilmington. I had an interest in medical issues growing up, because of my father’s influence, and even spent hours poring over his medical books–including the horrific photographs of various diseases. (They were frightening!) Once I finally got to college, I first majored in nursing, but switched to English in my senior year. I teach at a university now and love teaching. It’s interesting how the medical component has continued through the years–as a subject in my poetry and also in a medical humanities course I developed and teach called Literature and the Healing Arts. Students learn about the humane side of medicine in the context of stories, poems, essays and films. It’s exciting. I also worked as a photographer’s assistant for a few years.

EG     Please name a few stories, poems, essays and films that are part of the curriculum.

BM     I use two anthologies in this course. One is called On Doctoring, edited by two doctors, John Stone and Richard Reynolds, and contains stories, poems, essays, and a play by writers such as William Carlos Williams, Lucille Clifton, Richard Selzer and Kurt Vonnegut. The other anthology, Between the Heartbeats, is edited by Cortney Davis and contains prose and poetry all written by nurses. I have shown movie clips from Patch Adams, Awakenings, One Flew Over the Cuckoo’s Nest, and Philadelphia. My syllabus for this course is posted at the New York University School of Medicine Database: http:endeavor.nyu/lit-ed/syllabi.for.web/inst.gannon.html. [new link]This web site is a wonderful repository of literature, art, films and syllabi in the medical humanities.

EG     Why is it important for your students to learn “about the humane side of medicine” and/or why was it important for you to teach this?

BM     A few years ago a friend and fellow teacher and I had discussed the possibility of developing such a course when she was being treated for cancer and I was diagnosed with MS. Our experiences with illness and also with a slew of health care workers–at times confusing and frightening–framed our interest in medical humanities. After she died, I pooled our ideas to design the course, which uses literature as a context for exploring ethical issues, the patient-physician relationship, that sort of thing. Some might not think that compassion can be taught; I am absolutely convinced it can be fostered.

Drugs, Race, Crime, Science & Women

Posted on by elizabeth
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At Health Beat, Maggie Mahar and Niko Karvounis discuss how a science-based view of the use of illegal substances could lead to more enlightened methods of dealing with related individual and social problems than that currently used in the US and increasingly, Canada: criminalization of those who buy, possess and use them:

… rather than engaging in yet another political argument about personal responsibility vs. society’s responsibility to help its poorest citizens, it might be helpful to take a look at what medical science has been learning about drug addiction over the past few decades.

Addiction Treatment: Science and Policy for the Twenty-first Century (Johns Hopkins U. Press, 2007) does just that, and in the process “highlights the amazing discord between scientific knowledge and public perception,” according to a review by Stanford University’s Dr. Alex Macario in the June 4th JAMA.

In this collection of short, incisive essays, the authors don’t always agree on specifics, but they do reach a consensus of sorts: the scientific community needs to educate the public about drug addiction—and our approach to treatment should be based on medical evidence rather than personal ideology.

Today, medical technology allows scientists to observe first-hand what happens inside the brain when it is, in the words of William R. Miller, a psychiatrist at the University of New Mexico, “hijacked by drugs.” Thanks to brain imaging, for example, we know that regular drug use disrupts the frontal cortex, which regulates cognitive activities like decision-making, planning, and memory. In other words, drugs affect an individual’s capacity to make the choices that the Reaganites insist addicts “should” be able to make (Just Say No!). Undoubtedly the drug user could have said “no” the very first time he let desire over-ride good judgment. But after that, Miller notes, “neuroadaptation involves biological changes in response to drug use that increase the likelihood of repetition and escalation, undermining the person’s capacity for volitional control.”  Recent studies have even shown that drug addiction changes our brains at the genetic level, influencing how our DNA is translated into enzymes and proteins.

As a result of this new information, experts are increasingly incorporating the recognition that addiction is, in part, a “brain disease” into their treatment recommendations. This perspective has even made headway in the halls of power. Last year Congress introduced the Recognizing Addiction as a Disease Act, which would institutionalize the disease model by changing into the name of the National Institute on Drug Abuse to the National Institute on Diseases of Addiction and change the name of the National Institute on Alcohol Abuse and Alcoholism to the National Institute on Alcohol Disorders and Health.

The text of the act embraces the disease model, noting that “the pejorative term ‘abuse’ used in connection with diseases of addiction has the adverse effect of increasing social stigma and personal shame, both of which are so often barriers to an individual’s decision to seek treatment.”

All extremely interesting and helpful.  But since we are still arguing the merits of scientific theories of evolution versus faith-based adherence to the myth of creation by a divine deity, I’m afraid it may take too many hundred years to convince people that the possession and use of illegal drugs is a medical rather than moral problem.  Much as it might be more interesting and less troublesome to escape to the world of science, it’s just not a good idea to try to de-politicize a highly political problem.  I’m not denigrating the science.  It’s important.  It provides informative ammunition.  It just won’t ever be a sufficient replacement for organized action on political grounds.  The brain medicine that leads to good rehab practices is only available to rich people or those with good private health insurance anyway.  Even in Canada.  Yes it is!

Recently, certain Canadian laws with respect to drug possession and trafficking were struck down as unconstitutional by the B.C. Supreme Court.  InSite is a safe-injection site in Vancouver’s downtown east side.  It’s been in operation since 2003 under an exemption from the drug laws, granted by the Federal government of Liberal P.M. Paul Martin.  The exemption was due to expire on June 30th of this year and it was pretty clear that Health Minister Tony Clement wasn’t going to extend it, so Insite, along with several habitual drug users, challenged the drug prohibition laws in the courts.

In May, Justice Ian Pitfield found that sections of Canada’s drug laws are inconsistent with section 7 of the Charter of Rights and Freedoms:

Pitfield says in his ruling that denying access to the site ignores the illness of addiction.

“While there is nothing to be said in favour of the injection of controlled substances that leads to addiction, there is much to be said against denying addicts health care services that will ameliorate the effects of their condition,” he wrote.

“I cannot agree with the submission that an addict must feed his addiction in an unsafe environment when a safe environment that may lead to rehabilitation is the alternative.”

Sometimes, logic does creep in to judicial decision making.

Pitfield’s decision gives the Feds till June 20, 2009 to bring the law into accord with constitutional principles of fundamental justice.  Neil Boyd, a criminologist at Simon Fraser University, points out that the decision is in line with the trend toward understanding the use of addictive drugs as a health problem rather than a problem for criminal law.  However, he pointed out on the day of the decision that it wasn’t likely the end of the story, as several levels of appeal were and are still available to the Feds.

Sure enough, a day later, our illustrious Health Minister indicated Ottawa’s intention to appeal Pitfield’s decision.  Of course. 

“We have been offering drug maintenance rather than drug treatment,” said Clement. “We have been sending a message [to addicts] that says we have given up on them, and that we do not expect them to recover.”
Clement said that Insite only saves about one life per year, and that up to 97 percent of injections occur outside of Insite. But he refused to answer whether or not the research he was presenting had been peer-reviewed.
Thomas Kerr, a research scientist at the British Columbia Centre for Excellence in HIV/AIDS, and the chief researcher for Insite, has actually conducted a series of peer-reviewed studies on supervised injection sites.
In his studies, Kerr concluded that Insite does in fact lead to a reduction of syringe sharing and the number of overdoses resulting in deaths.
“How many peer-reviewed papers does the government need before they believe us?” said Donald MacPherson, the City of Vancouver’s drug policy coordinator.
“The only negative result we’ve found from these safe injections sites is that there aren’t enough of them to really make a big impact.”
Clement argued that a decision about harm reduction should be based on public policy, and referred to the scientific evidence around the facility as “mixed.”
He said that he instead wanted to focus government spending on treatment and prevention programs, as well as increasing the number of beds available to sex workers in Vancouver’s downtown eastside.
“Injection drug users are not dying — there is still hope for them,” said Clement. “Even if they fail treatment the first time, we can help them to get up and try again.”
Many MPs were frustrated with the fact that Clement did not seem to understand the importance of harm reduction programs for drug addicts.
Few drug addicts will move to abstinence overnight, they argued. This is why harm reduction programs are essential in terms of getting those addicts in the door first, and then gradually moving them towards treatment.
“To have low threshold programs is a critical policy, and I don’t know why you don’t get that,” said NDP MP Libby Davies, voicing her frustration towards Clement.
“It must be because of an ideological reason that you can’t move on,” she said. “Practically everyone else on this committee is on board with [Insite] except for you.”

“You are the only barrier to Insite’s continuation.”

 Since the best available information, and there’s plenty of it, tells us that putting people in prison doesn’t cure addiction and hasn’t put an end to the purchase and sale of banned drugs, what could the problem be?  Is Stephen Harper just an incredible blockhead?  Are the leaders of the free world in the US just as thick?  We like to think so sometimes.  I think not.

In order to understand these hyper-conservative strategies, we have to look at who is hurt by them, and who benefits.

The US has managed to imprison 65% of the male African American population of the country.  I would venture to guess that these men also tend to reside in the lowest of socio-economic brackets, since middle-class and wealthy people are criminalized at a much lower rate.  The numbers of female African Americans in prison, while smaller by 15% than males, is the fastest growing prison population.

In Canada, rates of incarceration are actually falling.  Except among women, and Aboriginal peoples generally.  Indigenous people  represent

  • 3% of the total canadian adult population – (2001 Census)
  • 22% of admissions to provincial/territorial sentenced custody
  • 17% of admissions to federal prisons
  • 21% of male prisoner population
  • 30% of female prisoner population

 

  60% of all those incarcerated in Canada are on remand.  This is a direct result of “law and order” agitation about criminals on the loose and a growing urge among judges, who have been much critisized, to err on the side of caution when dealing with accused (and assumed innocent) people awaiting trial.  There is a high correlation between custodial remand and conviction.  So, the more people imprisoned on remand, the more people convicted.  Remand may not be a direct cause, but it would be disingenuous to say that it has no effect.  Release on bail isn’t necessarily related to the seriousness of the offence.  Rather, to the likelihood that the accused person can be depended upon to return to court for trial.  Having a home, a job, a secure place in a community and mental wellness contribute to the view of an accused’s reliability.  As does freedom from drug or alcohol abuse.

The rate of growth in Canada’s imprisonment rates will also be affected by mandatory sentences that have been introduced for certain criminal offences, another result of that “law and order” agenda.  It is estimated that the sentenced population will increase by 1,000 prisoners per year as a direct result of mandatory sentencing.

Suicide rates in Canadian (and US) prisons are higher than in the general population.  But most people who die in prison die of acute and chronic health problems.  As in the US, many of the imprisoned suffer from a variety of mental illness, which makes them more likely to be held in segregation for long periods of time.  Especially women.  Which means, especially Aboriginal women.  African American women.  See?  We care.

Alchohol and substance abuse is very significantly related to crime in Aboriginal populations.  The stats are similar for Aboriginal crime in the US.  And for African Americans.  Do we know how much white collar crime is committed because of the cocaine or alcohol addled brains of managers and CEOs?  You tell me.  Does a love of single malt scotch contribute to tax evasion?  Does anyone care?

But we have a very hefty investment in the prison industry which, in America, has become the prison industrial complex.  We’re headed in the direction of privatization in prison “services” in Canada too.  Once we get that kind of investment in putting people in prison and keeping them there, it’s hard to take it away.  There’s a real commitment to keeping it going and growing.  There are jobs involved in an economy that is turning into a “service” economy.  There are corporate profits involved.  Stockholders – pensioners and everyday Jill and Joe investors.  Sometimes, the whole economy of rural areas and small towns is dependent on the prison economy.

Stacked against the economic arguments, conveniently buttressed by smug assumptions about the reasons for drug dependence, is the idea that we need to commit society, through our politicians, to solving problems related to the history of slavery, Jim Crow, systemic racism and economic inequality in the US; colonialism, genocide and the destruction of Aboriginal culture and custom in Canada.  It will take a concerted, organized, political effort to convince men like Harper and yes, even Obama, to embark upon that course.  Because the problems are long-standing, endemic and complex.  Collective acknowledgement of root causes and a profound commitment to equality is required; the collective will to begin a journey towards rehabilitation – the rehabilition of us all – and justice is required.

Brain science can give us many things.  But it can’t give us that.