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Posts Tagged ‘health’

12 DECEMBER, 2014

Being Mortal: A Surgeon on the Crossroads Between Our Bodies and Our Inner Lives and What Really Matters in the End

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How dying confers upon living “the courage to act on the truth we find.”

“I am not saying that we should love death,” wrote Rilke, perhaps humanity’s greatest sherpa of befriending our mortality, in a 1923 letter, “but rather that we should love life so generously, without picking and choosing, that we automatically include it (life’s other half) in our love.” In Being Mortal: Medicine and What Matters in the End (public library | IndieBound), second-generation surgeon Atul Gawande grants Rilke’s undying words a new dimension in his sublime contribution to the canon of befriending mortality, which stretches from Montaigne’s meditation on death and the art of living to Sherwin Nuland’s foundational treatise on how we die to Alan Lightman’s wisdom on our paradoxical longing for immortality. In his part-memoir, part-manifesto, Gawande sets out to shed light on our contemporary experience of dying — an experience that, it warrants remembering, begins at birth — and on “what it’s like to be creatures who age and die, how medicine has changed the experience and how it hasn’t, where our ideas about how to deal with our finitude have got the reality wrong.”

Gawande opens by noting the profound rift between anatomy and mortality in his medical education, bespeaking medicine’s general failure to prepare physicians for the most difficult yet deeply humanizing part of human life: our exit from it. “How the process unfolds, how people experience the end of their lives, and how it affects those around them,” he recalls, “seemed beside the point.”

But one particular work forever changed Gawande’s worldview as a student — and it wasn’t a medical text. It wasn’t written by a doctor, but by Leo Tolstoy, whose contemplation of the meaning of existence remains among the most important pieces of human wisdom ever committed to words. The work that so moved Gawande, however, was Tolstoy’s The Death of Ivan Ilyich and the following passage in particular:

What tormented Ivan Ilyich most was the deception, the lie, which for some reason they all accepted, that he was not dying but was simply ill, and he only need keep quiet and undergo a treatment and then something very good would result.

Illustration from 'The Flat Rabbit,' an unusual Scandinavian children's book that helps make sense of death. Click image for more.

His tuition, Gawande suggests, went toward a similar deception — medicine’s insistence on isolating the inner workings of the body from the rich and often difficult inner life it houses, especially when that bodily abode begins to fall apart. He writes:

Modern scientific capability has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.

Pointing out that over the past seven decades we have shifted from a culture where most deaths take place in the home to one where more than 80% occur in hospitals and nursing homes, Gawande laments our malignant attitude that casts death as a failure of both doctors and the dying:

Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things.

[…]

You become a doctor for what you imagine to be the satisfaction of the work, and that turns out to be the satisfaction of competence. It is a deep satisfaction very much like the one that a carpenter experiences in restoring a fragile antique chest or that a science teacher experiences in bringing a fifth grader to that sudden, mind-shifting recognition of what atoms are. It comes partly from being helpful to others. But it also comes from being technically skilled and able to solve difficult, intricate problems. Your competence gives you a secure sense of identity. For a clinician, therefore, nothing is more threatening to who you think you are than a patient with a problem you cannot solve.

There’s no escaping the tragedy of life, which is that we are all aging from the day we are born. One may even come to understand and accept this fact. My dead and dying patients don’t haunt my dreams anymore. But that’s not the same as saying one knows how to cope with what cannot be mended. I am in a profession that has succeeded because of its ability to fix. If your problem is fixable, we know just what to do. But if it’s not? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity, and extraordinary suffering.

This experiment of making mortality a medical experience is just decades old. It is young. And the evidence is it is failing.

[…]

You don’t have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit. They are spent in institutions—nursing homes and intensive care units—where regimented, anonymous routines cut us off from all the things that matter to us in life. Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need. Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers.

Piece from Candy Chang's global art project 'Before I Die.' Click image for more.

And yet Gawande extracts the promising potential beneath this cultural failure:

I have the writer’s and scientist’s faith … that by pulling back the veil and peering in close, a person can make sense of what is most confusing or strange or disturbing.

To be sure, Gawande brings a singular lineage of perspectives to this issue — an accomplished practitioner of Western medicine, he was born to parents, both doctors, who immigrated to America from different parts of India. He recalls visiting his paternal grandfather in India — “a dignified man, with a tightly wrapped white turban, a pressed, brown argyle cardigan, and a pair of old-fashioned, thick-lensed, Malcolm X-style spectacles” — when he was older than a hundred. Gawande paints the stark contrast between how his grandfather’s culture handled human finitude and how his own does:

He was surrounded and supported by family at all times, and he was revered — not in spite of his age but because of it. He was consulted on all important matters— marriages, land disputes, business decisions — and occupied a place of high honor in the family. When we ate, we served him first. When young people came into his home, they bowed and touched his feet in supplication.

In America, he would almost certainly have been placed in a nursing home. Health professionals have a formal classification system for the level of function a person has. If you cannot, without assistance , use the toilet, eat, dress, bathe, groom, get out of bed, get out of a chair, and walk — the eight “Activities of Daily Living” — then you lack the capacity to live safely on your own.

Gawande turns to Plato’s dialogue Laches — a text written nearly two millennia ago — for enduring guidance on how to cultivate a healthier relationship with our mortality. In the ancient text, Laches and Socrates go on to propose, then dismiss one by one, a series of definitions of courage, from “a certain endurance of the soul” to “knowledge of what is to be feared or hoped, either in war or in anything else.” They come up with no definitive answer, but Gawande argues that the reader arrives at an implicit one, which he synthesis beautifully:

Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength.

He considers how the notion of courage illuminates the ultimate act of showing up that is dying:

At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality — the courage to seek out the truth of what is to be feared and what is to be hoped. Such courage is difficult enough. We have many reasons to shrink from it. But even more daunting is the second kind of courage — the courage to act on the truth we find. The problem is that the wise course is so frequently unclear. For a long while, I thought that this was simply because of uncertainty. When it is hard to know what will happen, it is hard to know what to do. But the challenge, I’ve come to see, is more fundamental than that. One has to decide whether one’s fears or one’s hopes are what should matter most.

Gawande’s most emboldening point is that reframing our relationship with death, as well as our treatment of the dying, confers greater freedom upon life and more dignity upon the living:

Being mortal is about the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bone. Medical science has given us remarkable power to push against these limits, and the potential value of this power was a central reason I became a doctor. But again and again, I have seen the damage we in medicine do when we fail to acknowledge that such power is finite and always will be.

We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive. Those reasons matter not just at the end of life, or when debility comes, but all along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?

[…]

If to be human is to be limited, then the role of caring professions and institutions — from surgeons to nursing homes — ought to be aiding people in their struggle with those limits. Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person’s life.

In the remainder of Being Mortal, which lives at the intersection of science and philosophy, Gawande goes on to illustrate these ideas with practical examples of better, less limiting, and more dignified models of caring for the elderly and easing our exit from being. Complement it with philosopher Joanna Macy on how death helps us dial up the magic of life.

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28 AUGUST, 2014

Darwin’s Battle with Anxiety

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A posthumous diagnosis of the paralyzing mental malady that afflicted one of humanity’s greatest minds.

Charles Darwin was undoubtedly among the most significant thinkers humanity has ever produced. But he was also a man of peculiar mental habits, from his stringent daily routine to his despairingly despondent moods to his obsessive list of the pros and cons of marriage. Those, it turns out, may have been simply Darwin’s best adaptation strategy for controlling a malady that dominated his life, the same one that afflicted Vincent van Gogh — a chronic anxiety, which rendered him among the legions of great minds evidencing the relationship between creativity and mental illness.

In My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind (public library | IndieBound) — his sweeping mental health memoir, exploring our culture of anxiety and its costsThe Atlantic editor Scott Stossel examines Darwin’s prolific diaries and letters, proposing that the reason the great scientist spent a good third of his waking hours on the Beagle in bed or sick, as well as the cause of his lifelong laundry list of medical symptoms, was his struggle with anxiety.

Stossel writes:

Observers going back to Aristotle have noted that nervous dyspepsia and intellectual accomplishment often go hand in hand. Sigmund Freud’s trip to the United States in 1909, which introduced psychoanalysis to this country, was marred (as he would later frequently complain) by his nervous stomach and bouts of diarrhea. Many of the letters between William and Henry James, first-class neurotics both, consist mainly of the exchange of various remedies for their stomach trouble.

But for debilitating nervous stomach complaints, nothing compares to that which afflicted poor Charles Darwin, who spent decades of his life prostrated by his upset stomach.

That affliction of afflictions, Stossel argues, was Darwin’s overpowering anxiety — something that might explain why his influential studies of human emotion were of such intense interest to him. Stossel points to a “Diary of Health” that the scientist kept for six years between the ages of 40 and 46 at the urging of his physician. He filled dozens of pages with complaints like “chronic fatigue, severe stomach pain and flatulence, frequent vomiting, dizziness (‘swimming head,’ as Darwin described it), trembling, insomnia, rashes, eczema, boils, heart palpitations and pain, and melancholy.”

In 1865 — six years after the completion of The Origin of Species — a distraught 56-year-old Darwin wrote a letter to another physician, John Chapman, outlining the multitude of symptoms that had bedeviled him for decades:

For 25 years extreme spasmodic daily & nightly flatulence: occasional vomiting, on two occasions prolonged during months. Vomiting preceded by shivering, hysterical crying[,] dying sensations or half-faint. & copious very palid urine. Now vomiting & every passage of flatulence preceded by ringing of ears, treading on air & vision …. Nervousness when E leaves me.

“E” refers to his wife Emma, who loved Darwin dearly and who mothered his ten children — a context in which his “nervousness” does suggest anxiety’s characteristic tendency to wring worries out of unlikely scenarios, not to mention being direct evidence of the very term “separation anxiety.”

Illustration from The Smithsonian's 'Darwin: A Graphic Biography.' Click image for more.

Stossel chronicles Darwin’s descent:

Darwin was frustrated that dozens of physicians, beginning with his own father, had failed to cure him. By the time he wrote to Dr. Chapman, Darwin had spent most of the past three decades — during which time he’d struggled heroically to write On the Origin of Species housebound by general invalidism. Based on his diaries and letters, it’s fair to say he spent a full third of his daytime hours since the age of twenty-eight either vomiting or lying in bed.

Chapman had treated many prominent Victorian intellectuals who were “knocked up” with anxiety at one time or another; he specialized in, as he put it, those high-strung neurotics “whose minds are highly cultivated and developed, and often complicated, modified, and dominated by subtle psychical conflicts, whose intensity and bearing on the physical malady it is difficult to comprehend.” He prescribed the application of ice to the spinal cord for almost all diseases of nervous origin.

Chapman came out to Darwin’s country estate in late May 1865, and Darwin spent several hours each day over the next several months encased in ice; he composed crucial sections of The Variation of Animals and Plants Under Domestication with ice bags packed around his spine.

The treatment didn’t work. The “incessant vomiting” continued. So while Darwin and his family enjoyed Chapman’s company (“We liked Dr. Chapman so very much we were quite sorry the ice failed for his sake as well as ours” Darwin’s wife wrote), by July they had abandoned the treatment and sent the doctor back to London.

Chapman was not the first doctor to fail to cure Darwin, and he would not be the last. To read Darwin’s diaries and correspondence is to marvel at the more or less constant debilitation he endured after he returned from the famous voyage of the Beagle in 1836. The medical debate about what, exactly, was wrong with Darwin has raged for 150 years. The list proposed during his life and after his death is long: amoebic infection, appendicitis, duodenal ulcer, peptic ulcer, migraines, chronic cholecystitis, “smouldering hepatitis,” malaria, catarrhal dyspepsia, arsenic poisoning, porphyria, narcolepsy, “diabetogenic hyper-insulism,” gout, “suppressed gout,” chronic brucellosis (endemic to Argentina, which the Beagle had visited), Chagas’ disease (possibly contracted from a bug bite in Argentina), allergic reactions to the pigeons he worked with, complications from the protracted seasickness he experienced on the Beagle, and ‘refractive anomaly of the eyes.’ I’ve just read an article, “Darwin’s Illness Revealed,” published in a British academic journal in 2005, that attributes Darwin’s ailments to lactose intolerance.

Various competing hypotheses attempted to diagnose Darwin, both during his lifetime and after. But Stossel argues that “a careful reading of Darwin’s life suggests that the precipitating factor in every one of his most acute attacks of illness was anxiety.” His greatest rebuttal to other medical theories is a seemingly simple, positively profound piece of evidence:

When Darwin would stop working and go walking or riding in the Scottish Highlands or North Wales, his health would be restored.

(Of course, one need not suffer from debilitating anxiety in order to reap the physical and mental benefits of walking, arguably one of the simplest yet most rewarding forms of psychic restoration and a powerful catalyst for creativity.)

My Age of Anxiety is a fascinating read in its totality. Complement it with a timeless antidote to anxiety from Alan Watts, then revisit Darwin’s brighter side with his beautiful reflections on family, work, and happiness.

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23 JUNE, 2014

Rethinking the Placebo Effect: How Our Minds Actually Affect Our Bodies

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The startling physiological effects of loneliness, optimism, and meditation.

In 2013, Neil deGrasse Tyson hosted a mind-bending debate on the nature of “nothing” — an inquiry that has occupied thinkers since the dawn of recorded thought and permeates everything from Hamlet’s iconic question to the boldest frontiers of quantum physics. That’s precisely what New Scientist editor-in-chief Jeremy Webb explores with a kaleidoscopic lens in Nothing: Surprising Insights Everywhere from Zero to Oblivion (public library | IndieBound) — a terrific collection of essays and articles exploring everything from vacuum to the birth and death of the universe to how the concept of zero gained wide acceptance in the 17th century after being shunned as a dangerous innovation for 400 years. As Webb elegantly puts it, “nothing becomes a lens through which we can explore the universe around us and even what it is to be human. It reveals past attitudes and present thinking.”

Among the most intensely interesting pieces in the collection is one by science journalist Jo Marchant, who penned the fascinating story of the world’s oldest analog computer. Titled “Heal Thyself,” the piece explores how the way we think about medical treatments shapes their very real, very physical effects on our bodies — an almost Gandhi-like proposition, except rooted in science rather than philosophy. Specifically, Marchant brings to light a striking new dimension of the placebo effect that runs counter to how the phenomenon has been conventionally explained. She writes:

It has always been assumed that the placebo effect only works if people are conned into believing that they are getting an actual active drug. But now it seems this may not be true. Belief in the placebo effect itself — rather than a particular drug — might be enough to encourage our bodies to heal.

She cites a recent study at the Harvard Medical School, in which people with irritable bowel syndrome were given a placebo and informed that the pills were “made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in IBS symptoms through mind-body self-healing processes.” As Marchant notes, this is absolutely true, in a meta kind of way. What the researchers found was startling in its implications for medicine, philosophy, and spirituality — despite being aware they were taking placebos, the participants rated their symptoms as “moderately improved” on average. In other words, they knew what they were taking wasn’t a drug — it was a medical “nothing” — but the very consciousness of taking something made them experience fewer symptoms.

Illustration by Marianne Dubuc from 'The Lion and the Bird.' Click image for more.

This dovetails into recent research confirming what Helen Keller fervently believed by putting some serious science behind the value of optimism. Marchant sums up the findings:

Realism can be bad for your health. Optimists recover better from medical procedures such as coronary bypass surgery, have healthier immune systems and live longer, both in general and when suffering from conditions such as cancer, heart disease and kidney failure.

It is well accepted that negative thoughts and anxiety can make us ill. Stress — the belief that we are at risk — triggers physiological pathways such as the “fight-or-flight” response, mediated by the sympathetic nervous system. These have evolved to protect us from danger, but if switched on long-term they increase the risk of conditions such as diabetes and dementia.

What researchers are now realizing is that positive beliefs don’t just work by quelling stress. They have a positive effect too — feeling safe and secure, or believing things will turn out fine, seems to help the body maintain and repair itself…

Optimism seems to reduce stress-induced inflammation and levels of stress hormones such as cortisol. It may also reduce susceptibility to disease by dampening sympathetic nervous system activity and stimulating the parasympathetic nervous system. The latter governs what’s called the “rest-and-digest” response — the opposite of fight-or-flight.

Just as helpful as taking a rosy view of the future is having a rosy view of yourself. High “self-enhancers” — people who see themselves in a more positive light than others see them — have lower cardiovascular responses to stress and recover faster, as well as lower baseline cortisol levels.

Marchant notes that it’s as beneficial to amplify the world’s perceived positivity as it is to amplify our own — something known as our “self-enhancement bias,” a type of self-delusion that helps keep us sane. But the same applies to our attitudes toward others as well — they too can impact our physical health. She cites University of Chicago psychologist John Cacioppo, who has dedicated his career to studying how social isolation affects individuals. Though solitude might be essential for great writing, being alone a special form of art, and single living the defining modality of our time, loneliness is a different thing altogether — a thing Cacioppo found to be toxic:

Being lonely increases the risk of everything from heart attacks to dementia, depression and death, whereas people who are satisfied with their social lives sleep better, age more slowly and respond better to vaccines. The effect is so strong that curing loneliness is as good for your health as giving up smoking.

Illustration by Marianne Dubuc from 'The Lion and the Bird.' Click image for more.

Marchant quotes another researcher, Charles Raison at Atlanta’s Emory University, who studies mind–body interactions:

It’s probably the single most powerful behavioral finding in the world… People who have rich social lives and warm, open relationships don’t get sick and they live longer.

Marchant points to specific research by Cacioppo, who found that “in lonely people, genes involved in cortisol signaling and the inflammatory response were up-regulated, and that immune cells important in fighting bacteria were more active, too.” Marchant explains the findings and the essential caveat to them:

[Cacioppo] suggests that our bodies may have evolved so that in situations of perceived social isolation, they trigger branches of the immune system involved in wound healing and bacterial infection. An isolated person would be at greater risk of physical trauma, whereas being in a group might favor the immune responses necessary for fighting viruses, which spread easily between people in close contact.

Crucially, these differences relate most strongly to how lonely people think they are, rather than to the actual size of their social network. That also makes sense from an evolutionary point of view, says Cacioppo, because being among hostile strangers can be just as dangerous as being alone. So ending loneliness is not about spending more time with people. Cacioppo thinks it is all about our attitude to others: lonely people become overly sensitive to social threats and come to see others as potentially dangerous. In a review of previous studies … he found that tackling this attitude reduced loneliness more effectively than giving people more opportunities for interaction, or teaching social skills.

Illustration by André François for 'Little Boy Brown,' a lovely vintage ode to childhood and loneliness. Click image for more.

Paradoxically, science suggests that one of the most important interventions to offer benefits that counter the ill effects of loneliness has to do with solitude — or, more precisely, regimented solitude in the form of meditation. Marchant notes that trials on the effects of meditation have been small — something I find troublesomely emblematic of the short-sightedness with which we approach mental health as we continue to prioritize the physical in both our clinical subsidies and our everyday lives (how many people have a workout routine compared to those with a meditation practice?); even within the study of mental health, the vast majority of medical research focuses on the effects of a physical substance — a drug of some sort — on the mind, with very little effort directed at understanding the effects of the mind on the physical body.

Still, the modest body of research on meditation is heartening. Marchant writes:

There is some evidence that meditation boosts the immune response in vaccine recipients and people with cancer, protects against a relapse in major depression, soothes skin conditions and even slows the progression of HIV. Meditation might even slow the aging process. Telomeres, the protective caps on the ends of chromosomes, get shorter every time a cell divides and so play a role in aging. Clifford Saron of the Center for Mind and Brain at the University of California, Davis, and colleagues showed in 2011 that levels of an enzyme that builds up telomeres were higher in people who attended a three-month meditation retreat than in a control group.

As with social interaction, meditation probably works largely by influencing stress response pathways. People who meditate have lower cortisol levels, and one study showed they have changes in their amygdala, a brain area involved in fear and the response to threat.

If you’re intimidated by the time investment, take heart — fMRI studies show that as little as 11 hours of total training, or an hour every other day for three weeks, can produce structural changes in the brain. If you’re considering dipping your toes in the practice, I wholeheartedly recommend meditation teacher Tara Brach, who has changed my life.

But perhaps the most striking finding in exploring how our beliefs affect our bodies has to do with finding your purpose and, more than that, finding meaning in life. The most prominent studies in the field have defined purpose rather narrowly, as religious belief, but even so, the findings offer an undeniably intriguing signpost to further exploration. Marchant synthesizes the research, its criticism, and its broader implications:

In a study of 50 people with advanced lung cancer, those judged by their doctors to have high “spiritual faith” responded better to chemotherapy and survived longer. More than 40 percent were still alive after three years, compared with less than 10 percent of those judged to have little faith. Are your hackles rising? You’re not alone. Of all the research into the healing potential of thoughts and beliefs, studies into the effects of religion are the most controversial.

Critics of these studies … point out that many of them don’t adequately tease out other factors. For instance, religious people often have lower-risk lifestyles and churchgoers tend to enjoy strong social support, and seriously ill people are less likely to attend church.

[…]

Others think that what really matters is having a sense of purpose in life, whatever it might be. Having an idea of why you are here and what is important increases our sense of control over events, rendering them less stressful. In Saron’s three-month meditation study, the increase in levels of the enzyme that repairs telomeres correlated with an increased sense of control and an increased sense of purpose in life. In fact, Saron argues, this psychological shift may have been more important than the meditation itself. He points out that the participants were already keen meditators, so the study gave them the chance to spend three months doing something important to them. Spending more time doing what you love, whether it’s gardening or voluntary work, might have a similar effect on health. The big news from the study, Saron says, is “the profound impact of having the opportunity to live your life in a way that you find meaningful.”

Philosopher Daniel Dennett was right all along in asserting that the secret of happiness is to “find something more important than you are and dedicate your life to it.”

Each of the essays in Nothing: Surprising Insights Everywhere from Zero to Oblivion is nothing short of fascinating. Complement them with theoretical physicist Lawrence Krauss on the science of “something” and “nothing.”

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