I heard that word, “fragments”, used by a historian in a podcast recently. He was explaining that history wasn’t fixed, was never “complete”, that in every event, every circumstance involving human beings there are multiple stories to tell, multiple, often entirely contradictory experiences to explore. He used the term fragment, to communicate that. That all of history is fragmentary, and all human stories are too. I liked and disliked the word “fragment” equally at the same time (I don’t think there are any fragments, in the sense that there is nothing which isn’t connected to anything else, but, on the other hand, as it seems impossible to ever know “the whole”, maybe fragments are the very essence of reality), but it’s wormed its way into my mind and I’m turning over this issue of fragments ever since. 
Here’s where I’ve got to so far – I see two different kinds of fragments in the world. There are pieces, like pieces of iron, or pottery, or whatever, that archeologists might find. These are pieces which have lost their connections. And it’s the archeologist’s job to piece the pieces together. Like putting together a jigsaw. Once the pieces start to fit together, the connections become clearer. The picture emerges. We can say, oh, I see now! So there’s that kind of fragment.
But there’s another, something more dynamic, more fluid, almost a kind of perceptual fragment. You know like when you go to the movies with a couple of friends and in the conversation afterwards the experiences can be so different that sometimes you even wonder if you all saw the same movie? Well, that kind of fragment.
And that kind of fragment is what every single story is. It’s what every single relationship is. It’s what every event and experience is. No single story is something called “the whole story”. I don’t know if such a thing as “the whole story” exists, but, if it does, I don’t know how any single human being can know it. For instance, it wasn’t unusual for me to find that several months, or even years, into an ongoing therapeutic relationship with a patient, that they would reveal something fundamental about themselves, tell some story which suddenly explained mysteries about them. This would happen with people who I had really convinced myself I had heard and understood. At times, the new story, previously untold story (commonly the patient would say “I’ve never told this to a single person before”), would be nothing short of a moment of enlightenment. With experience, I grew to understand that even these moments were never the final ones, that there never was something called “the whole story”.
I see the Self like that too. Whether that’s the “community of selves” idea (The Scottish Psychologist, Miller Mair  coined this term – “His 1989 book Between Psychology and Psychotherapy was subtitled “a poetics of experience”, and this theme recurs throughout his written and spoken work. He saw therapist and client as reaching towards understanding through conversation and metaphor, through engaging with the “community of selves” of which they were personally constituted, and through striving to “tell stories” that would illuminate the conditions of their lives.”) 

https://www.theguardian.com/science/2011/aug/08/miller-mair-obituary

or the idea of multiple facets, roles or aspects of the same person – differences which are so different that sometimes that we wonder if there can be a ‘thing’ called “THE SELF” – and, I don’t think there is. Whatever a SELF is, it’s not an object, not a thing. It’s a subject, a complex web of woven threads, a continually changing, evolving, dynamic host of energies. And maybe, just maybe, one of those aspects overwhelms the others, at least for a while, but they all exist, all come into being, all ebb and flow….all “interfere” with each other, in the way that waves and ripples “interfere” with each other.

I guess at times some of the threads that make up YOU pull or rub against each other in uncomfortable ways and you think “wouldn’t it be simpler if I had less threads?”
And maybe it would.
But would the tapestry be as beautiful?
Only you know.

 

 

Here in the Charente, March is a month of emergence. Officially, it’s Spring. Well, I’ve read three ways to determine Spring actually – you can go by the appearance of Spring flowers, like the crocus, or you can take the “meteorological Spring” which falls on the 1st of March, or you can wait till the “Spring Equinox”, one of two days in the year where the number of hours of day and night are equal (that’s March 20th in the Charente). Well, in the Northern Hemisphere, anyway (you guys in the Southern Hemisphere have your Autumn Equinox when we, here, have Spring – and vice versa). Oh, and, it’s not exactly equal day and night, but pretty close.
I think of Spring as a time of awakening. The bare branches of the trees begin to bud and flower, and the Spring bulbs push up their green leaves and unfurl their gorgeous petals. It’s a sort of time of beginnings.
Mind you, I also feel that Autumn is a time of beginnings, but that’s because I started University (Edinburgh) in the autumn, and began my first job as a Junior Doctor on the 1st of August (1978). In those days there were two variations of training doctor contracts, six month ones and twelve month ones, so we all started jobs on 1st August, or on 1st February. It’s probably changed since then. However, that rhythm of new academic years and new training posts over a decade has embedded a sense of beginnings for me every Autumn.
Spring, though, feels like a more Nature-attuned time of beginnings.
So, I went off yesterday on a blossom and bud hunt. I took quite a lot of photos. Up top here is the kind of phenomenon I was looking for.
And here’s one of many cherry blossom photos I took. I love the delicate pink colours against the blue sky, and the delicacy of the stamens reaching for the sky!

Back home I found a tulip which had revealed her red petals since the day before

and the tree peony has five buds this year. Here’s one of them, just beginning to show a hint of her pink petals.

The appearance of the cherry blossom is greatly celebrated in Japan, with daily reports on TV and the front pages of newspapers, showing maps which follow its path from the south to the north of the country, and thousands of people setting off to have picnics under the trees, or to stroll around admiring them and photographing the blossoms.

So, here’s what I recommend for the next few weeks. Take a local safari. Go out, on foot, on your bike, or drive around and see if you can spot buds and blossoms. When you do, take some photos. They don’t have to be works of art. It’s just a great delight to focus in on emergence, to get up close and personal to new signs of life, new expressions of Creation, new beginnings.

What you do after that is up to you. My hunch is that kind of experience changes how you feel about the day.

If you’re in the Southern hemisphere, then its time to capture a different phase of change. Here’s a link for Australia. And here’s one for South Africa.

But you tell me……wherever you are in the world, what changes do you notice this week, as we move towards the Equinox?

 

 

 

Let’s talk about death.
Because we don’t.
Somehow it’s not acceptable to talk about death, almost as if it’s bad manners, or maybe just that you’re going to make someone uncomfortable by talking about it because death is something we all hope to avoid. Today, anyway! Maybe we think that if we don’t talk about it, don’t even think about it, then it won’t happen. Which is equivalent to a child covering their eyes to hide and thinking nobody can see them.
Death is certain. It’s inevitable, inescapable, unavoidable.
Yes, yes, I know that, but let’s deal with it when it comes along, and, look, it’s not coming any time soon, right?
I don’t have the impression that death is difficult for the dead, but, then, what do I know? I’ve never talked to a dead person. Or, more accurately, no dead people have ever talked to me.
Dying, on the other hand, can be really difficult. I’ve seen difficult deaths, been present through those final weeks, days, minutes of final struggle. Some of those deaths make the moment of death like a release, a final end to suffering.
And death is difficult for the living. It’s loss, emptiness, sadness, distress, grief….It changes the lives of the living permanently. Life is not the same after death.
But life is never the same anyway. Life is a process of constant change. Even in the midst of our most fixed habits and routines, life changes. Relationships are formed, relationships fall apart, new jobs appear, old jobs go, people enter our lives, and they leave, some temporarily, some permanently. Isn’t death just one of those changes? A kind of ultimate experience of transience?

How many deaths have you witnessed?
I’ll never forget the first time I had to certify someone as dead. As a Junior Doctor working in a hospital, one of my responsibilities was to confirm that a patient had died, and initiate the formal recognition of their death, writing in their case file “Time of death” and entering the time I declared it. The first time for me I was called, as on call doctor, at about 3am, to a ward I’d never visited before. An elderly patient there, whose death was expected, had just died. It was my responsibility to examine him for signs of life. I took my time. I didn’t want to get it wrong! I listened to his chest for a long time, but couldn’t hear any heart beats. I tested for various reflexes and got not response. I stared long and hard into his eyes, using a device called an ophthalmoscope, shining a light onto his retinae to look for the signs of death I’d been trained to see. Finally, I was convinced. Looked at my watch, and retired to the little office at the end of the ward to write the formal statement of my examination and the date and time of his death. As I walked back along the empty main corridor I began to think about what I’d just experienced. I wondered whether or not it was true that we each have a soul, and whether or not that soul hovers around the body for a little time after death, before departing. I wondered if the man’s soul had been hovering around behind me, as I checked his body for signs of life. I wondered if his soul might have started to follow me from the bedside to the office, and maybe, now, as I walked down this empty corridor. I started to walk faster and wondered whether or not a soul could keep pace with a living person. My heart started to beat faster and as I turned into the on call rooms corridor to go to bed I flicked on the light switch in the stair well and “bang!” the light bulb flashed on then immediately went out again. Well, that spooked me! I ran up the dark stairs taking two or three steps at a time, fumbled as I tried to get my key into the on call room door, eventually managing, throwing the door open wide, then slamming it hard behind me. As I stood, breathing heavily, with my back to the door, I suddenly thought. “Hey, surely ghosts can walk through walls!” At that point I realised how absurd it was to be imagining such things. Took me a while to settle though!
I’ve seen many deaths since then. I don’t think it ever became routine. I didn’t imagine souls hovering around me any more, but I always found the experience disturbing. Maybe that’s just normal.
For most of us we won’t have experienced many deaths directly. When they happen, they are significant events. They feel like something has gone wrong. Maybe somebody is to blame. Maybe someone has failed. Maybe we even feel the dead person has failed….failed to rage against the dying of the light.

When you talk to people who have had an encounter with death, a near miss, a sudden, or unexpected one, brought on by an accident or an illness, it’s not uncommon that they will say it’s made them realise how precious life is, how fragile, how maybe until that moment they hadn’t really known that. Well, known it as a sort of fact, but not known it as a person. There’s a difference. Maybe they’ll say they’d have a wake up call. A wake up call to what? To the knowledge of the shortness of life. They might say it’s made them realise that if they want to make the most of life, then it might be a good idea to start now.
Or they might have a heightened sense of reality, of the unpredictability of life, or even of the inevitability of its ending.
Thinking about death because you’ve survived a serious accident, recovered from a serious illness, or have just experienced the death of a loved one, a friend, or a colleague, can make you re-evaluate your life.
Re-value your life.

Feel how precious and fragile it is and decide to make some changes, to stop procrastinating, to stop living this way in the hope that one day, in the distant future, you’ll be able to live a different way.
That’s the gift of death. The gift of life.
Do we have to go through such an experience to get there? Can we only wake up, reassess our choices and values by having personal encounters with death? Or can we make such decisions, initiate such changes, by thinking about death, or talking about it?
If you knew you had one year left to live, what would you do differently?
Stephen Levine, who passed away in January, 2016, wrote a best selling book entitled “A Year to Live” where he describes the process of living as if you have only one year left. Many people have followed his programme since.
But the whole idea of thinking about death as a way to a better, or should I say, more considered, life, goes all the way back to Socrates (there are whole schools of thought on this subject from many other cultures too)

 

In the Phaedo Plato has Socrates claim that in death the soul is released from the impure and contaminated body, and thus becomes able to attain pure knowledge of Truth. In the dialogue Socrates says: “It really has been shown to us that, if we are ever to have pure knowledge, we must escape from the body and observe things in themselves with the soul by itself. It seems likely that we shall, only then, when we are dead, attain that which we desire and of which we claim to be lovers, namely, wisdom…”
Thus according to Plato upon death the philosopher achieves that which he has been striving for his entire life. Because of this Plato has Socrates claim that the practice of philosophy in life is really a dress rehearsal for what comes in death: “…those who practice philosophy in the right way are in training for dying, and they fear death least of all men.”
Since the time of Socrates and Plato philosophy has assisted countless individuals confront their own mortality, and provided consolation in the face of what many consider the greatest of all evils – death.

A related train of thought is wondering what you would do differently if somebody you knew had only a year left to live. What if that somebody was your mum or dad, a brother or sister, a lover, partner or friend?
And what if it wasn’t a year? What if it was five years, or, ten? Would that change anything? Would either of those scenarios lead to different choices?
So, a little contemplation on death from time to time, might have a serious impact on both the way we live, and the way we are with others.
You know, I think there’s an awful lot more we could consider down this road, but maybe that’s enough for now.

Before I finish, though, when I was researching life expectancy figures for the articles I was writing about health, I discovered that a male Scot aged 65 (that’ll be me in a few months time!) has a life expectancy of a further 19. 7 years. When I read that I had mixed feelings. I mean twenty years seems quite a long time, right? But on the other hand, it feels as almost no time at all! But what I realised I was doing with that figure was considering it as an end point. I thought, well I might just see the start of 2040 then! But then I read what “life expectancy” is. It’s a median. That means that in 19.7 years time, 50% of male Scots, aged 65 today, will be have died. But 50% will live beyond that timescale. It’s not an end point. It’s the 50/50 point!
Hey, how human is it to grasp at offer of hope?! (Well, that’s another subject to consider….the importance of hope)

OK, this is like a PPS but I must tell you about the patient I saw one day. I knew her from previous visits, but this day she seemed particularly out of sorts. I asked her what was bothering her and she said “My husband’s been diagnosed with cancer. He’s been told he’s got six months to live”
I sympathised with her and asked how that news had made her feel. Her reply took me completely by surprise.
“I’m angry. Really angry. I mean how come he gets to know how long he’s got and I don’t get to know how long I’ve got?!”
We had an interesting conversation about uncertainty after that!

 

 

This is my last article in this series about health. I started by addressing the needs of health services,

then continued with an exploration of how to move towards healthier communities so that more people might expect more years of healthy life. I began with shelter, exploring housing, then, food, education, and the environment.

Finally, I want to address the issue of inequality

In Scotland, in 2008, life expectancy figures revealed that men living in one part of Glasgow could expect to live 28 years more than those in another part. This was publicised as the plight of “Shettleston man”, named after the area with the poorest male life expectancy.

Twenty eight years of difference in two areas a mere 15 minutes away from each other.
Shocking? Of course. This wasn’t the full story. The number and severity of illnesses suffered by the men in poor Shettleston, were far greater than those living in the more affluent, Lenzie.
Since 2008, that picture has changed somewhat, partly because that dramatic figure was a result of high numbers of drug deaths. Ten years later the figures still show huge differences between the richest and the poorest parts of Glasgow. One area has a male life expectancy of 82, whilst in another it’s 66 – still a difference of 16 years.

This huge inequality in health experience and in life expectancy are closely linked to other inequalities, from income, employment, and housing to education.
For many years Richard Wilkinson and his partner, Kate Pickett have produced research evidence for inequality itself being one of the most significant factor in the production of these shocking statistics. It’s not just poverty, it’s inequality.
They’ve recently published more findings which explore the links between mental health, wellbeing and inequality.

What they demonstrate is some of the potential mechanisms of the links between inequality and illness, through the psychological impacts which are part of the daily lives of the poorest communities.
We don’t live in isolation.
We can’t just exhort people to eat more healthily, smoke and drink less, and move more and expect the population to suddenly become healthier. We have to address the conditions in which people live. Unless we tackle inequality it’s going to be hard to bring better health to the majority of the population.
Many reports have shown how inequality around the world is on the increase. This article, in The New Yorker neatly summarises the findings of the French economist Thomas Piketty on this issue.

The famous “elephant graph” (so called because of its shape) shows what’s happened over the last four decades.

Is this inevitable?
Surely not. It wasn’t always the case, and it’s actually changing. If we want to change it in a different direction we’ll need to get to grips with ways in which the richest manage to grab and hoard their wealth.

A recent story reported that, in the US, Amazon, despite making a profit of $11.2 billion, they’ll not only be paying zero Federal tax, but will actually receive a tax rebate of $126 million

It’s not only the richest corporations who work hardest to pay as little tax as they can. Individuals do too. The CEO Ineos, the UK’s richest man, is moving to Monaco to save £4 billion in tax. His two wealthiest executives are following suit.

The “Panama Papers”, leaked from the offshore law firm, Mossad Fonesca, revealed, amongst other things

“the myriad ways in which the rich can exploit secretive offshore tax regimes. Twelve national leaders are among 143 politicians, their families and close associates from around the world known to have been using offshore tax havens. A $2bn trail leads all the way to Vladimir Putin. The Russian president’s best friend – a cellist called Sergei Roldugin – is at the centre of a scheme in which money from Russian state banks is hidden offshore. Some of it ends up in a ski resort where in 2013 Putin’s daughter Katerina got married. Among national leaders with offshore wealth are Nawaz Sharif, Pakistan’s prime minister; Ayad Allawi, ex-interim prime minister and former vice-president of Iraq; Petro Poroshenko, president of Ukraine; Alaa Mubarak, son of Egypt’s former president; and the prime minister of Iceland, Sigmundur Davíð Gunnlaugsson.”

The “Paradise Papers” are another big data leak related to a separate company showed many, many, similar examples

“Key revelations include:
Millions of pounds from the Queen’s private estate has been invested in a Cayman Islands fund – and some of her money went to a retailer accused of exploiting poor families and vulnerable people.
Prince Charles’s estate made a big profit on a stake in his friend’s offshore firm.
Extensive offshore dealings by Donald Trump’s cabinet members, advisers and donors, including substantial payments from a firm co-owned by Vladimir Putin’s son-in-law to the shipping group of the US commerce secretary, Wilbur Ross.
Twitter and Facebook received hundreds of millions of dollars in investments that can be traced back to Russian state financial institutions.
The tax-avoiding Cayman Islands trust managed by the Canadian prime minister Justin Trudeau’s chief moneyman.
The Formula One champion Lewis Hamilton avoided taxes on a £17m jet using an Isle of Man scheme.
Oxford and Cambridge and top US universities invested offshore, with some of the money going into fossil fuel industries.
A previously unknown $450m offshore trust that has sheltered the wealth of Lord Ashcroft.
The man managing Angola’s sovereign wealth fund invested it in projects he stood to profit from.
Apple secretly moved parts of its empire to Jersey after a row over its tax affairs.
How the sportswear giant Nike stays one step ahead of the taxman.
The huge tax refunds given by the Isle of Man to the owners of private jets.
Offshore cash helped fund Steve Bannon’s attacks on Hillary Clinton.
The secret loan and alliance used by the London-listed multinational Glencore in its efforts to secure lucrative mining rights in the Democratic Republic of the Congo.
A former UK minister who defended tax avoidance has a Bahamas trust fund.
The complex offshore webs used by two Russian billionaires to buy stakes in Arsenal and Everton football clubs.
Stars of the BBC hit sitcom Mrs Brown’s Boys used a web of offshore companies to avoid tax.
British celebrities including Gary Lineker used an arrangement that let them avoid tax when selling homes in Barbados.
Prominent Brexit campaigners have put money offshore.
The Dukes of Westminster pumped millions into secretive offshore firms.
A tax haven lobby group boasted of “superb penetration” at the top of the UK government before a G8 summit that was expected to bring in greater offshore transparency.
The law firm at the centre of the Paradise Papers leak was criticised for “persistent failures” on terrorist financing and money laundering rules.
Seven Republican super-donors keep money in tax havens.
A top Democratic donor built up a vast $8bn private wealth fund in Bermuda.
The schemes used to avoid tax on UK property deals.
The celebrities, from Harvey Weinstein to Shakira, with offshore interests.
How a private equity firm tried to extract £890m from a struggling care home operator by making it take out a costly loan.
Trump’s close ally Robert Kraft, the New England Patriots owner, is the longtime owner of an offshore firm.
One of the world’s biggest touts used an offshore firm to avoid tax on profits from reselling Adele and Ed Sheeran tickets.”

It’s only the wealthiest individuals and companies which go to such lengths to contribute less of their wealth to the societies in which they made their gains.

Meanwhile, at the other end of the scale, there is a growing evidence that increasing minimum wages is a great way to make positive impacts on populations.

A 2011 national study showed that low-skilled workers reported fewer unmet medical needs in states with higher minimum-wage rates. In high-wage states, workers were better able to pay for the care they needed. In low-wage states, workers skipped medical appointments

“Studies have linked higher minimum wages to decreases in low birth-weight babies, lower rates of teen alcohol consumption and declines in teen births. A 2016 study published in the American Journal of Public Health found that between roughly 2,800 and 5,500 premature deaths that occurred in New York City from 2008 to 2012 could have been prevented if the city’s minimum wage had been $15 an hour during that time, instead of a little over $7 an hour.”

None of these issues can be tackled in isolation. They need co-operation and collaboration. That should encourage us, because these are two of the greatest strengths of the human species.

 

 

 

 

 

 

 

 

How do you have a healthy population of human beings without a healthy environment? Isn’t it pretty obvious the two issues are linked? Because there are no human beings who live outside of the environment. You could even say that it’s a false distinction. There is no “us” here, and an “environment” over there. It’s not like the environment is a foreign country you can visit with a tourist visa.

But what do I mean by environment? I often find I’m tempted to write environment in the plural, to talk about “environments” rather than a singular object called “THE environment. Because the environment is just the circumstances in which we live. It’s that vast web of connections which weaves every single individual into the whole.

There’s a physical environment of earth, air, water and fire. There are the cyclical environments of energy, of heat, cold, wind and rain.

There are the geographic environments of place. There’s a long running French TV series called “Rendez vous au terre inconnu” (Meeting in unknown places), where someone spends two weeks with a remote tribe and a camera crew capture the experience. I love it. It’s done with great sensitivity and compassion. Every episode opens your eyes to other ways of living and it is frequently surprisingly moving. It’s very human. In one episode they did return visits to three places and showed each group the original films of both their own place and the places of the other two. One group lived high in the mountains, one in a region of permanent snow and ice, and a third on houses built on poles in the sea. It was startling to see such diversity and to see each group express their astonishment that other people could choose to live so differently. There’s no doubt that the physical places where we live influence our daily habits, our diets, our whole outlook and our patterns of disease and health.

City dwellers face different challenges from rural ones. Coastal communities different ones from desert dwellers. And so on.

But there are other, less visible, environments. Our social environment of family, friends, colleagues and neighbours. Our cultural environment of values, practices and beliefs. Our political environment of laws, limits and agreements. And so on.
We live embedded in all of these and more. We are influenced by them, and we influence them.

In the books as “Linked”, by Barabasi, “Connected”, by Christakis, “The Bond”, by Lynne McTaggart, and “The God Problem”, by Bloom, we can see how we live in networks of relationships which influence everything from or chances of becoming obese, or catching certain infections, to the daily choices we make. We are not as “individual” and separate as we think we are.
Look how “memes” spread, how videos become “viral”, how quickly behaviours and attitudes spread across cultural and physical borders through social media.
If we want to create healthier populations we have to address these environments.

I was going to write about things like the number of industrial chemicals which can be detected in the blood of new born babies in Paris, or the insecticides, fertilisers, herbicides present in everyone’s urine, or the number of prescription drugs which are present in our drinking water, or the amount of plastic washing up on remote islands, or even the estimated 400,000+ people who die every year in Europe from disease caused by air pollution.
But I’m not going to.

You can read any of these kinds of details any time. If those sorts of stories don’t appear in your newsfeeds, you can search for them online. They really are not hard to find.

No, the only point I want to make here is that we do not live separate lives, so if we want to create healthier societies we need to pay attention to our multiple environments. We need to understand them better, then make some different choices. Together.

 

This is one in a series of articles about health. There’s an almost unspoken belief that the way to make people healthier is through Medicine, and the Health Services through which Medicine is delivered. I’m not sure that’s true. Some of the most striking improvements in population health throughout history have come through the provision of clean water, effective sewage systems, and making such changes as housing the population in better houses, reducing malnutrition, and tackling poverty.
I think it’s important to deliver good health care, and, for me, that means both adequately resourced health care, and, perhaps more importantly, human-scale health care.

What do I mean by that?

Health care where the day to day, hour by hour, minute by minute focus is what human beings do together. It’s caring, compassionate, staff who are well educated in engaged and committed relationships with those who are suffering.
But one thing is clear. The demand for health care is increasing, and shows no sign of tailing off. The higher demands rushing fast down the pipeline come from demographic change with many more people reaching old age, and, consequently, many more with chronic illnesses, complex needs and, ultimately a requirement for good, end of life care before they die.
If we want to tackle the rising demand, we have to deal with the causes of ill health, and if we restrict our focus to individual behaviours, we’re going to fail. We have to deal with the economic, social, and environmental causes of ill health if we want people to live more of their lives in good health.
I’ve written about housing and food so far, and here I’d like to explore education.

Some people claim that education is THE most powerful way to make an impact on population health and it’s a hard claim to refute. Education can improve health in many, many ways, some more obvious than others.
For example, education can reduce poverty and improve incomes, enabling people to find more adequate shelter and to eat more nourishing diets. Education is particularly effective when focused on women and girls. Educated girls and women tend to be healthier, have fewer children, earn more income and provide better health care for themselves and their future children. It reduces maternal deaths and helps to combat infectious diseases, including HIV and AIDS.
Did you know that a child whose mother can read is 50% more likely to live past the age of five?

Don’t you think that’s stunning?
If you want to explore this further have a look at the United Nations 17 Sustainable Development Goals.

But there is another aspect to education I’d also like to consider. It’s the education embedded in the ordinary doctor-patient consultation. Or at least, it could be. One of the first tasks of a doctor is to make a diagnosis, which is a way of saying to arrive at an understanding. The doctor tries to make sense of the patient’s story, of their symptoms and of the signs of disease in their bodies. A diagnosis unlocks the door to effective treatment, and by effective treatment I mean whatever encourages a restoration of health (though, sadly, many treatments don’t do that, they just either maintain the status quo, or slow the progression of the illness, but with less suffering).
Why shouldn’t diagnosis be a shared experience? Not just a label applied by the professional. One of my favourite diagnoses to illustrate this labelling behaviour is “Idiopathic Urticarial Syndrome”. A patient goes to the skin specialist with an itchy rash. They don’t know why they’ve got it. They don’t know what it is. But the skin specialist does. It’s “Idiopathic Urticarial Syndrome”. Well, here’s a secret. “Urticarial” means an itchy rash (OK, it’s a particular kind of itchy rash, one with “weals”, which is another word for “urticaria”). “Idiopathic” means in this particular case we don’t know what is causing it. If we knew what was causing it, it wouldn’t be idiopathic. It’d be an allergy to washing powder or whatever. “Syndrome” is a trick word. It’s sounds like the name of a disease but actually it’s a collective word for a group of symptoms (and maybe some signs). So, having sought help with an itchy, urticarial, rash whose origin is unknown to you and which you don’t understand, you now know you have an itchy, urticarial rash, whose origin nobody knows, and which nobody actually understands.

There is a different way.

Rather than seeing a diagnosis as an end point, it I can be thought of as a level of understanding. Then the doctor can take it as a step forwards, not a job done. A step towards a better, deeper, broader understanding of the patient. They can explore some of the mystery, the when, where and even the why of the illness. I think this is a form of education. It’s the doctor educating themselves about this particular patient.
An exploration of the circumstances of an illness, probing the when, the where and the possible why questions, is an opportunity for education for the patient too.
If somebody understands better what is going on, and what the initiating and maintaining factors might be, they can make other choices. Choices which might well lead to restoration of health.
One of my most favourite questions in a consultation was to ask the patient when they last felt completely well. It might take a bit of encouragement to get there, but most people can identify the period of their lives before this illness began. Having identified the time around the change from health to illness, I’d then explore what was happening in the patient’s life around that time.
I can’t tell you how many times that was like a light bulb going on. “Do you think my mother’s death might have had something to do with getting ill?” “Do you think losing my job, getting divorced and the death of my brother all in the same month might have had something to do with this?”
Of course, I could never answer a simple yes. It was just a helpful way to begin to explore the potential factors, their impacts, and what someone could do to tackle the ongoing effects.
I’m sure this isn’t possible in every single encounter, but it’s something to bear in mind. Ideally, all doctor-patient consultations can be therapeutic ones, and perhaps the best way for them to be therapeutic is when both the doctor and the patient learns something from the experience.
Learning from experience is definitely a powerful education.

One of my friends says “If everything that goes wrong is a learning experience I’d have a bloody PhD by now!”

 

 

 

How do we reduce demand on over-stretched health services? Well, it might help to work towards a healthier society. Whilst it’s important to give health services enough resources to look after the sick, it’s not Medicine, not drugs, nor vaccines, nor “gene therapies” which have ever made the greatest contributions to population health. And it never will be.

As best I can see there are a number of issues to consider and all of them involve we human beings working together to create healthier societies. It’s what we can achieve when we work together that really impresses me. Sure, individual choices, personal behaviours and so on can result in valuable improvements for each of us in our own lives, but we don’t live in isolation. We are embedded in complex webs of environments and societies. If we don’t pay attention to those environments, our personal choices run the risk of being overwhelmed by the noxious factors outwith our individual control.

The first issue I explored was housing. After all, without adequate shelter, human beings perish. And with over-crowding, poor sanitation, inadequate supplies of clean water and power millions suffer from poor lives and are vulnerable to the ravages of acute infections, trauma and a growing number of chronic inflammatory conditions.

The second issue I’d like to explore is food.
Patients often asked me if I had a “diet sheet”. I didn’t. Maybe that was naive of me, but I don’t believe that one “diet” fits all. We are all different. Not only in our tastes, but in our tolerances, and even our needs. I think healthy diets can be as varied as human beings are. Yeah, sure, too much this, and too much that, is rarely healthy, but trying to single out a particular food or food group as “good” or “bad” always struck me as foolish. No single food is a miracle cure for anything, and no natural foodstuff is just downright bad.
I’ve always admired the work of Michael Pollan. Two things he has said are especially helpful. The first is “Eat food. Mainly plants. Not too much.” That seven word dietary advice seems very wise to me. Starting at the end, the “not too much” captures the need for both moderation and variety in a healthy diet. “Mainly plants” points to the fact that too much meat can be a problem. And “eat food”, although that sounds strange advice, actually captures one of the most important points. Why should we eat anything that isn’t food? Isn’t everything that we eat food?
Well, what he means by this is that the less processed a foodstuff is, the more likely it is to be nutritious. That connects well to the second point he makes, which is captured by asking yourself, “who made this food?” Because if it was made by human beings it’s more likely to be nutritious than if it was made by machines in a factory.
The more a foodstuff is processed, the more chemicals which are added to make it last longer, look a different colour, artificially change its flavour, the chances are, the less nutritious it’s likely to be.
This simple advice to “eat food” pushes us towards eating what is produced locally and seasonally. It’s one of the things I enjoy most about life here in the Charente since I moved here from Scotland. There is a local market every day except a Monday in Cognac, and within a short distance from here there are a large number of other interesting weekly markets. The markets regularly have stalls of locally produced, seasonal foods. The “locally” bit doesn’t mean only whatever is produced within the surrounding countryside. But it’s a sort of tendency. Yes, you can get what local farmers produce, but you can also get what’s grown in France, rather than what’s arrived from boats and planes over thousands of kilometres. And if you don’t see what you fancy from the local farms, or from France, then you can go a little further, and buy fresh produce from Spain or Portugal. Everything is labelled clearly. You can see how far it’s come.
I look forward every year to the Corsican clementines, the white and the green asparagus, the locally grown strawberries and raspberries, the various types of French apples and pears, the season of the walnuts, chestnuts, truffle. I swear that eating whatever is “in season” just tastes better. Is it healthier? I don’t know, but I want to eat food which is more than just “healthy food”, I want to eat food that is delicious.
The photo I’ve used at the start of this post is an example.
There is a network throughout southern France of Spanish orange growers and traders. They claim the time from tree to the stall in a local town car park is a matter of days. I have no way of verifying that but I can tell you I’ve never tasted orange juice quite this delicious.
Well, that’s me, and my personal circumstances. Yours will be different. But here’s my point.
The more we industrialise food production, the more we reduce its potential nutritious value, and the more we run the risk of non-food consumption of a mind-boggling list of man-made chemicals. This goes all the way back to the farming methods. Factory farming of cattle, pigs, chickens, and of plant crops, demands huge inputs of energy and chemicals, from antibiotics, to growth hormones, pesticides, fungicides, insecticides and so on. All these additives in the food chain aren’t food.
Even without considering the ethics of rearing animals in these conditions of mass overcrowding, one of the biggest problems is that these factory farms mainly feed other factories…..the ones which “process” the original plants and animals so much that you often can’t be sure what you are eating by the time it arrives on your plate. Is that beef, or horse? What part of the animal is used to make those nuggets? The label shows a list of substances you struggle to pronounce, and you sure don’t know what they are doing there, and whether or not they are at least not harmful, or, at best, good for you.
So can we apply these principles to food? The basis of all health? Good, nutritious, delicious food?
What if we prioritised, favoured, both personally, but also at the level of society through economic and political policies and controls, the following qualities –

  1. Less added chemicals – at all stages – from the farm to the shop
  2. Less processing and more transparency – so we can know what we are eating
  3. Less transporting – which will favour more local, more seasonal, fresher food
  4. More variety – every study I’ve ever read shows that populations which have more variety in their diets, often because they eat more seasonally, have longer, healthier lives.

The food economy of a society impacts the planet and its climate, the soil and the oceans, all forms of life, and, in particular, the health of whole populations.

 

 

There’s a lot of talk about the increasing strain on health services, something I’ve addressed here.

One of things that bothers me about these discussions is the assumption that increasing funding and resources to the health care system will result in a healthier population, which will, in turn, reduce the demand on the health services. This has never happened. And it’s not likely to happen.
The health of a population mainly comes down to how we live, not to the medicines we swallow or how quickly we can get an operation. Let me just clarify that I’m not arguing against more resources and funds for the health service, we need that to improve them. It’s just that this isn’t a way to create a healthier population and so reduce demand.
To create a healthier population we need to invest in what creates better lives. Better lives for as many people as we can.
There are many ways to do this. But let’s start with housing. Because decent housing, warm, weather-proof, houses with enough living space, clean, running water, an efficient sanitation system, and affordable, reliable power, is a foundation for healthier lives.
Would anyone argue otherwise?
If people are homeless, or living in insanitary, unsafe, overcrowded conditions, then they are more likely to get sick – both in the short term, with infections, and in the longer terms, with chronic, inflammatory conditions. I’m not going to list references here. Google these issues for yourself. But I am going to claim that adequate shelter is a necessary first step to better health for a population.

There are many factors and problems to consider here, but I just want to focus on one – waste – the number of abandoned and/or unused dwellings in every town and city.
When I think about this I can’t help also becoming aware of “high streets” full of empty, abandoned shops and offices. So, let’s take that into consideration too. Because when the town centres empty of commerce they aren’t only dying, depressing and, possibly, dangerous, but they represent a huge waste of opportunity for people to work and live together. We need shops, offices, workshops, cafés, restaurants, exhibition and performance venues, to have a healthy community. It’s no good just building lots of apartments in streets which are devoid of the possibilities for people to meet, share, and work together.

Take a walk around the streets where you live, both the residential streets where you dwell, and the town streets you visit most often for shops, offices, cafés, restaurants, and so on.
How many properties are sitting closed up and seemingly abandoned?
At the same time, are there homeless people in your locality? The homeless might be obvious sitting or lying on the pavements, in the doorways of closed shops, or they might be invisible to you, struggling to get by in bedsits, guest houses or hostels. What about decent housing? Is there anyone living in sub-standard, even unsafe properties? Is there anyone housed in overcrowded conditions with landlords maximising their income by minimising the personal living space of their tenants? Are the streets of your town vibrant, filled with people socialising and satisfying their daily needs and desires, for material , social and cultural goods?

I’m asking because it seems to me that it’s very common to find so many shops, offices and houses that look abandoned that a whole area feels either unsafe or unhealthy. The French have a word for it – désertification…..where a once vibrant locality becomes a desert. What could we do to turn this around? Here’s one idea.

A policy of compulsory purchase and leasing.

What if the local authority, the Council, or the Commune, had the right to compulsorily purchase, in its area of jurisdiction, any property which was uninhabited or unused for at least five years? What if all such properties could be compulsorily purchased for the current independent valuation price, then leased out to new tenants?
Residential properties could be rented out to those on housing benefit, paid for directly from the tenants’ housing benefit, instead of the current situation where these benefits go straight into the pockets of private landlords. Some properties could also be rented at commercial rates to either individuals or groups of individuals, encouraging a healthy social mix in the community.
Additionally some could be offered for sale, either directly at market rates, or using co-ownership schemes, where part of each month’s rent is allocated towards the final purchase of the property by the tenants. In a co-ownership scheme, an additional idea could be to agree a contract of improvement and renovations of the properties which would be paid for by the initial rental payments. For example, a property requiring £50,000 of work, and valued at a monthly rental of £1000, could have the works paid for by the first 50 rental payments.
Commercial properties, shops, workshops and offices could be offered rent-free for new tenant businesses. Instead of paying rent, the Council or Commune could be empowered to collect the VAT generated by these businesses, keeping that element of taxation for local use, instead of it disappearing into national funds.
The income streams to the councils from the housing benefits, domestic rents, co-ownership contracts, sales and locally ring-fenced VAT could then be used to make more compulsory purchases.
I’m sure somebody else will be able to take this idea and refine it considerably, but the basic idea is to favour circulation of property and wealth in the local economy and environment, instead of the current picture of stasis and decline.
Community associations, and co-operatives could be included in such schemes. In other words, it’s not just something for independent businesses and entrepreneurs, but something which could also encourage community led activities. Workshops, recycling services, training and education courses, as well as libraries, galleries, theatres and music venues.

Bringing life back to our existing communities by prioritising decent housing for everyone and supporting the daily opportunities for people to live, work and play together, would be a good beginning, if we want healthier populations who have less need of health services.

I’ll explore some other factors in later articles, including food, education and inequality. But maybe you’d like to share your own ideas? If you do, on your blog, your youtube channel, your instagram feed, or wherever you express yourself, please let me know. I’ll include links to your ideas in my posts.

Last time I was in Paris I saw these beautiful, thought-provoking photographs hung on the fence around the Jardins du Luxembourg. They were displayed as part of an attempt to raise public awareness about Climate Change.
This photo, which I took, of a woman walking past them made me think about powerlessness. It’s one thing to become aware of a problem like Climate Change, but it’s another to feel that you can do much about it personally. Actually, I’m sure lots of people will tell you all kinds of things you can do, from reducing the waste you produce, to recycling more, cycling more, or eating less meat. And who’s to say these aren’t good things to do? But, the thing is, global problems need human beings to work together to tackle them. Individual, isolated actions might contribute to bigger changes, but they’re not enough. Perhaps it’s one of the defining characterises of being human – that ability to work together. We are brilliant at making connections, and having huge effects by collaborating. It can be easy to forget that, but just pause for a moment and think how many other human beings have contributed something towards you being able to sit down today and eat a meal. Start with what’s in front of you and see how many connections you can imagine. You can’t know them all, of course, but you can imagine them. Include the table and chairs, the plates and cutlery, the food…..just follow as many of the threads as you can. We don’t live alone. In isolation. We didn’t evolve that way.
At the level of society we humans have tried a huge number of ways of organising ourselves. One of those ways is democracy. We elect a small number of us and give them responsibility to solve certain problems, enact certain laws, develop particular policies. Democracy is designed to hold that minority accountable.
You could argue that one of the objectives of democracy is to achieve the greatest possible consensus in a population for a particular set of laws, practices, limits and freedoms in a society.
Sadly, many of the Western democracies run a rather simplistic “winner takes all” variety of democracy. The person elected, or the policy voted for, in such a system usually only has the support of a minority of the population.
If a representative is elected by less than 50% of the electorate, then, at best, they are representing only that minority. It is common in Western democracies for representatives to gain their positions with around only a third of their electorates.
69% of the electorate voted in the UK 2017, General Election, with 42% of those who voted, voting Conservative and 40% Labour. Under this system the Conservatives “won” with only 29% of the electorate voting for them. Maybe it’s easier to see this with the raw numbers. At the time, the UK electorate was 46,843,896 people, 13,636,684 of them voted Conservative, 12,877,918 voted Labour.
You can easily do your own calculations for the country you live in. I’d be surprised if the general conclusion wasn’t much the same. This isn’t a way to achieve the greatest amount of agreement amongst the greatest number of people. It’s a way to enable an elite of winners to wield power over the majority of the population.
It gets worse. Within parliaments there is a similar skewing of democracy towards rule by minority. When all that is required is a “simple majority” for a policy or law in a parliament, then the emphasis is on competition rather than co-operation. The “Brady amendment” in the House of Commons won by 317 votes to 301. A simple win, but is it reasonable to then refer to this as “the clear majority of MPs”? Or to say that “Parliament has expressed a clear wish for…..”?
Referendums are very poor tools for the creation of consensus, or even broad support. A simple binary choice referendum that achieves just over 50% in favour, and just under 50% against, is more likely to increase division than spread consensus. In the British parliament, on the issue of Brexit, the Leave side claims complete authority to act without reference to anyone on the other side, despite a referendum result that delivered only a small majority in favour amongst those who voted, and a significant minority amongst the electorate as a whole. 51.9% voted Leave, 48.1% Remain, and turnout was 72.2%. That means 17,410,742 out of 46,500,001 people voted Leave, yet politicians call that the “Will of The People”. Which begs the question – “which people”? Not the electorate, just the minority who voted Leave.

Is it any wonder that ordinary people have lost faith in this particular flavour of democracy? This loss of faith is commonly cited as one of the reasons for the rise of populism. Government by minorities in competitive systems creates a sense of distance between the elected and the electorate. And as individual politicians turn their positions into careers, those minorities evolve into elites.
So how can we make democracy work more in favour of a greater number of the population? How can we heal the divide between the governed and the governors?

There are a number of ideas around.

Limitation to years of service
A simple way to mitigate against the creation of political elites would be to limit the number of years any individual could serve on any elected body. Democratic countries which have a President already limit his, or her, possible years of service in that post. It’s usually a sign of a slide into autocracy when a particular President changes a constitution to remove that limit.
Limiting the number of years which any individual can serve in parliament would make it harder for them to become career politicians, and therefore, a separate, elite, class. It would also make it harder for lobbyists to buy political support (although there would need to be a lot more than that to tackle the issue of lobbyists. Who was it who said they’d “drain the swamp”? How’s that going?)

Proportional representation with minimum level bars
Proportional representation for all elections, with the setting of minimum levels of support necessary to be elected could also contribute to decreasing the gap between whole electorates and their representatives. With an electorate of 100,000 people, a representative could be required to achieve a minimum number of votes, say 50,000, in order to be elected. This might require more than one round of voting, as is currently the case in several European countries.
Minimum level bars could also be set within a house of parliament, demanding a higher level of consensus than the current first past the post system allows for.

Election by lot
The House of Lords in the UK is a completely unelected chamber. One possibility would be to replace it with individuals drawn by lot, in the same way as people are selected for jury duty. Such a chamber could then have the responsibility for scrutinising plans and policies of the House of Representatives (or Commons, in the UK) with the intention of achieving as much consensus as possible within practical time limits. The House of Consensus would then make recommendations back to the House of Representatives.

Two chambers – a House of Consensus and a House of Representatives
What if one chamber of government, the one of elected representatives, had the responsibility for governing on the basis of the greatest degree of consensus achievable, rather than one of governing group versus opposition working against each other in their own Party interests? The use of committee systems to explore, challenge and analyse policies could be developed further. Across the chamber working groups and a voting system requiring minimum level votes to pass laws might lead to greater consensus and less conflict.
A second chamber, elected by lot, could have the responsibility for the scrutiny of proposals, policies and laws developed by the House of Representatives, then returned there for further discussion, debate and votes.
The first chamber makes decisions and laws, the second one problem solves and makes suggestions.

Preferendum
In relation to referendums, a recent French article laid out the idea of a “preferendum”. To avoid the binary trap of “yes” or “no” which only perpetuates division, each question asked on the ballot paper could be presented in the form of preferences. This involves asking the voter to state a level of preference for each of a number of options. From “strongly agree” to “strongly disagree”. The option with the greatest overall preference is the one taken forward.

Devolution and decentralisation
This is an idea which has been around for a long time, and has been carried out to different degrees in different countries, but the basic principle seems reasonable – that the closer an elected body is to its electorate, the more easily representatives can be held to account. Again, there could be limits to the number of years any individual can serve in any elected position. At any level of government, minimum voting levels and some selection by lot can be used. So local bodies could employ such principles as well as the national ones.

Citizens assemblies
Citizens assemblies have been used in a number of countries to help develop policies. These are locally gathered groups of people who debate, discuss and deliberate on an issue to put forward policy suggestions. They would probably never replace other democratic pathways but might be a useful way of broadening engagement.

It’s only the 17th of February but this week, here in the Charente, it feels like Spring. It’s chilly in the mornings, sometimes only a degree or two above freezing, but by the afternoon, after a few hours of bright sun shining down from a blue, blue sky, the air has warmed up to 14 degrees, or more.
Under the mulberry tree, for the last few years, we’ve been planting crocus bulbs every autumn. The first of them appeared this week. I mean, just look at the richness of those purple petals opening up to reveal the golden treasure within!

At first there were just half a dozen of them, but day by day, more have appeared, purples, yellows, whites, little petals, big, bold, look at me petals! They are delightful.

Look at them when the sun sets their golden stamens and pistils on fire! When those delicate little triads cast those shadows on the veined purple petals!
Here’s another one, this time, white

Two sets of three petals, one behind the other, and in the middle, three yellow stamens at the base of a deep, orange, pistil. The gorgeous shadows stretching up from the splash of yellow at the base of each petal, up towards its milky white peak.
This is a flower in all it’s glory. That central female pistil, it’s three stigma (what’s the plural of stigma?) opening to the highway down to the ovary, surrounded by three male stamens.
Is three the magic number?
I see it repeated, layer after layer, here.
As I sit under the mulberry tree reading a book in the afternoon sun, I hear a deep buzzing sound and look up to see a huge, jet black, carpenter bee, flying from crocus to crocus, collecting delicious nectar and pollen, flower by flower. The sun catches the bee’s wings which shine with an iridescent purple sheen. Stunning.
There’s something deeply entrancing, delightfully awe inspiring, about the simplest, smallest, everyday events.

It feels like Spring.