views & REVIEWS Not even a dog’s life PERSONAL VIEW Raymond Towey
P
TRENT PARKE/MAGNUM PHOTOS
erhaps I should put it down to culture shock from re-entry into Britain. In the past 14 years of working in East Africa as a medical missionary I have had many opportunities to experience that special bittersweet sense of detachment you have when arriving back in your own country, and you realise that you are a stranger to it and see your own culture through the eyes of an alien. With practice, you can overcome this feeling in a short time, before you make too many social gaffes that leave your friends and family glancing at each other in embarrassment. Africa’s rural areas must be among the poorest in the world in terms of medical resources, and statistics indicate that life expectancy in sub-Saharan Africa is equivalent to that in 1840 in England and Wales. This has a particular poignancy for me as an anaesthetist, because 1846 is generally regarded as the year when anaesthesia was discovered. So I think I am entitled to some degree of medical culture shock when I return to Britain. However, re-entry shock is not an altogether negative experience. As in any crisis situation, it’s also a time of opportunity and reflection. So now I am left with one word that alone
sums up my assessment of the amazing practice. Invasive monitoring in theatre, advances in the United Kingdom and the the fundamentals of intensive care and appalling comparison with medical care cardiorespiratory support, assessment in sub-Saharan Africa: obscene. The gap of patients, and the management of between the quality of medical care in the arrhythmias were the foundations of a developing world and that in new era. We knew the developed world is widening that this was the future with every modern advance, but Perhaps in time I will of modern hospital it’s not the advances in medicine learn to accept this medicine and that we that this time put me into a kind appalling disparity would be a better part between care of domestic of that future after our of shock—it’s the advances in veterinary medicine that have animals in the developed cardiac rotation. I am shocked me, and I can only sure that today’s young world and humans in conclude that the comparison is sub-Saharan Africa veterinary surgeons obscene. Open heart surgery is and anaesthetists must now available for domestic dogs be relishing open heart and cats in the developed world, whereas in surgery for dogs and cats in a similar way. sub-Saharan Africa most patients needing In the 1960s and 1970s the development such expensive care are sent home to die, of hospital intensive care units was given assuming they even reach a hospital in the a major boost as open heart surgery first place. Will doctors in years to come progressed, and I am sure the same process wonder at how we could tolerate such an will take place for animal intensive care obscene disparity? units now. The late 1960s and 1970s were an exciting In 1846 the first successful anaesthetic to time for me as a young hospital doctor in the be publicly demonstrated was ether, and this specialty of anaesthesia. Cardiac surgery was agent is the mainstay of anaesthetic practice taking off, and intensive care units had been in rural sub-Saharan Africa now, as its safety established as a facility in the big teaching and cost make it the best choice. For open centres but had still to make an impact heart surgery in domestic animals a newer in the districts. As a young anaesthetic generation of anaesthetic agents is available, resident I found which for me accentuates the obscenity. the cardiac Perhaps in time I will emerge from this rotation a prized culture shock and learn to accept with experience. My equanimity this appalling disparity between colleagues and care of domestic animals in the developed I knew that on world and human beings in sub-Saharan this rotation we Africa—or perhaps this article is a sign of my would learn so underlying inability to adapt. Do I have a much that would right to be at ease in my home culture, given benefit our own such a reality? At the moment, though, I professional am hoping that I do not adapt, because development either I am suffering from a severe form and give us of “speciesism,” or a global underlying much experience racism exists that allows this obscenity to be to manage tolerated. critically ill Raymond Towey� is ��� consultant ������������������������� anaesthetist, patients better Department of Anaesthesia and Intensive Care, in other areas St Mary’s Hospital Lacor, Gulu, Uganda Open heart surgery is now available for dogs and cats in the developed world of hospital
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A personification of evil? p 641
review of the week
Watching the detectives A new book plunges the reader into a Victorian urban nightmare, charting in novelistic fashion the 1854 cholera epidemic, writes Wendy Moore The story of cholera is as much the story of human waste and its disposal as the discovery and defeat of a disease. It is fitting, therefore, that Steven Johnson’s book The Ghost Map opens with a gripping description of the army of scavengers that once roamed London to rummage through the rubbish and detritus the city’s dwellers left behind. Recreating this Dickensian world of “excrement and death,” Johnson describes the toshers who scoured the river for saleable metal, the mudlarks who salvaged the rubbish even the toshers discarded, the night soil men who emptied household cesspits in the hours of darkness, and the “pure finders” who possessed perhaps the least enviable job of all—collecting dog excrement for use in the leather tanning industry. From this headlong plunge into the Victorian urban nightmare, where dirt and disease worked a profitable partnership, Johnson unrolls the story of the 1854 cholera epidemic, which led the physician and anaesthetist John Snow to solve the mystery of how cholera was spread. The story of Snow’s dogged determination to link the cholera outbreak centred on Golden Square with the water from the Broad Street pump is a classic narrative in the history of medicine. Johnson retells it vividly with a day by day—almost breath by breath—account of the disease’s ferocious progress through the wretched slums around Broad Street while Snow quietly and methodically worked to pin down the epidemic’s cause. Snow’s calm collection of data to show that the vast majority of cholera victims had drunk from the Broad Street pump provides a brilliant and timeless example of scientific method combined with sheer hard graft. It is well known that the cholera epidemic had already peaked before Snow persuaded the parish authorities to remove the handle of the offending pump, but Johnson rightly points out that this action may well have prevented a second outbreak. The original source of the cholera Vibrio had disappeared with the death of the first victim, the Lewis baby, but when the baby’s father later succumbed to the disease this could easily have unleashed a fresh epidemic. It was not Snow but his friend and fellow campaigner the Reverend Henry Whitehead who identified Baby Lewis as the index case and pinpointed how the family’s cesspool had leaked into the Broad Street well, and this BMJ | 24 MARCH 2007 | Volume 334
fact is rightfully given prominence—though not, as Johnson says, for the first time. Recreating the stench and oppressive heat of the vile Victorian summer of 1854 in novelistic style, Johnson’s tale generally makes compelling reading, although his diversions into the development of cities, fear of terrorism, and significance of the internet occasionally detract. Like the noxious River Thames of Snow’s era, the story is mostly fast moving, occasionally meandering, and sometimes finds itself lost up a creek. Some of these off-course wanderings provide thought provoking insights. The fact that part of Victorian Soho was more densely populated than modern Manhattan, for all its skyscrapers, gives a poignant perspective to the reality of 19th century overcrowding, for example. Johnson’s rallying call to trust in science and invest in public health infrastructure as our best bet for human survival is well argued and welcome—but do we need to know that “My wife and I are passionately committed to the idea of raising our kids in an urban environment”? More seriously, Johnson overplays the Broad Street story to the extent that it becomes almost meaningless. The partnership of Snow and Whitehead in applying cold hard logic to solve a public health disaster of appalling scale—while working sensitively with their local community—stands for all time as a powerful example of scientific triumph. To overegg that by arguing that the pair “helped make possible” a planet of cities, or that Broad Street marked “the emergence of a metropolitan culture,” is unnecessary and unhelpful. After all it was Edwin Chadwick, civil servant and relentless miasmatist, believing disease emanated from smells, who championed the building of sewers; and it was the “Great Stink” of 1858 that pushed parliament into ensuring sewage did not enter the Thames above tidal reaches, before Snow’s evidence of waterborne transmission had been fully accepted. Ultimately it is unclear what The Ghost Map adds to the literature on John Snow. Better researched popular narratives have already been published—all the “primary” sources Johnson cites on Snow’s life are actually secondary sources. Vast amounts of academic commentary and theory already exist. Attempting to combine the two seems to satisfy the interests of neither. Wendy Moore is a ������������ journalist, ������������������������������ London
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The Ghost Map Steven Johnson Allen Lane, £16.99, pp 320 ISBN 10: 0713999748 Rating:
****
Johnson retells the story vividly with a day by day—almost breath by breath— account of the disease’s ferocious progress through the wretched slums around Broad Street 639
VIEWS & REVIEWS
Belated Homemaker Day greetings My mum is a failure—she doesn’t even have a degree! She will never be a professor of medicine or prime minister, and a Nobel prize doesn’t prop up her bed. The closest she’s been to a glass ceiling is banging her head in her windswept greenhouse. Power dressing means a clean smock and cords. She carves soapstone into animals and sells them to pale Londoners who see Orkney as an “organic” hideaway. They “smile” at her—she “smiles” at them. Mother’s Day saw the usual run on stale boxes of chocolates from garages and belated telephone calls explaining once again that “the card is in the post.” But isn’t motherhood defunct? Isn’t it just society’s instrument of oppression of the sisterhood? Women want real jobs so they can make a real difference to people’s lives, rather than wiping snotty noses and doing the kids’ homework—don’t they? Depending on who you believe, being a parent is either the ultimate ego trip or a selfless act of servitude to the future of humanity. My wife and I share the misery of rearing four children; we are lashed to a treadmill of cleaning, tidying, homework, and talking loudly to the kids (aka shouting). This is all interspersed with the occasional social event, where other social pariahs (parents) counsel each other over wine and beer.
FROM THE FRONTLINE Des Spence
We have one last remaining pleasure—watching the “parental make over.” The young, golden couple— tanned, slim just back from skiing—delight in their first pregnancy. A year later their clothes are heaving at the seams, their hair is uncut and frizzy. They trudge the streets at 7 am on a Sunday morning—long lie-ins are a painful memory. Their transparent smiles belie the hollow “We are just great.” I have two recurring dreams about my medical career. The first is of wandering the aisles of supermarkets when retired, with juniors and colleagues blanking me, no longer forced to respect me or to talk to me. The second is of donning a smock, buying a goat, taking up painting, and “smiling” at pale Londoners. Both dreams are becoming ever more frequent, as I increasingly realise that the things we can’t possess are the only things worth owning. I reflect that my mum brought up six children, and that all of us are reasonably happy and contented. Her contribution to life is more important and significant than anything I will ever do. So thanks, Mum, for being such a good failure. In turn, I hope one day to receive a box of stale chocolates and lame excuses about the card being in the post from my children. Des Spence is a general practitioner, Glasgow
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Confessions of a collaborator IN AND OUT OF HOSPITAL James Drife
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Listen, I was just doing the regional specialist training committee a favour. They’re good people. They care about trainees. I happened to be there when they asked for volunteers, that’s all. I didn’t even know what “MTAS” stood for. Sure, I smelled a rat when shortlisting was postponed. Yes, I could have walked away when they said there were 500 candidates. But I felt committed. We all did. So we spent the best part of a week on line, scoring the answers to those dumb questions. It drove us crazy, but we met the deadline. Afterwards we felt dirty. But by then, young doctors were coming for interview. We couldn’t let them down. Hey, meeting them was a breath of fresh air. It restored our will to live. Too bad they have to wait so long for the results. We’ll go back and find the ones we missed.
We’ll sort it out. That’s what doctors do. Colleagues are saying we should have boycotted it, taken a stand, caused chaos. They’re calling us collaborators. That’s rich, coming from a profession that’s been collaborating en masse for 20 years. In the 1980s the government set out to take us over. We let them do it. I can remember when the Hospital Consultants Committee took decisions. Did anyone start a protest march when the managers eased us out? No. And these days, when politicians reorganise general practice, do doctors write to the papers? No sir. We shrug and let them get on with it. We prefer seeing patients. So when they set up new bodies to replace key functions of the royal colleges, who resisted? Not the colleges or faculties, all 27
of them with their 28 opinions. Certainly not the quango-loving doctors who jumped on the bandwagon. I heard them, you know, in trendy committees, patronising their clinical colleagues. It made me sick. I could name names. But so could you. We all read them in the journals, those non-practising doctors being pompous about medical scandals. Or maybe we stopped reading and turned the page. It had to end, and now it has. We turned on our own young. The public can’t believe it. The politicians are scared. This is when people start shooting collaborators. Let’s hope they shoot the right ones. They’re spoilt for choice. James Owen Drife is professor of obstetrics and gynaecology, Leeds
[email protected] BMJ | 24 MARCH 2007 | Volume 334
VIEWS & REVIEWS
Tr i u m p h a n t s u c the destruction BETWEEN cess—in others, I of his home city, THE LINES hasten to add; I’ve Coventry—its transnever experienced it formation from Theodore Dalrymple myself—intimidates medieval city firstly me and makes me to rubble and then feel stupid. Why am I to modernist urban not similarly successwasteland, not to ful, though quite intelmention hell—had ligent enough to be something to do so? I suppose it boils with the bleakness down to character, of his vision? or what these days is Only something, called personality. of course, because I know a banker man is incalculable: who has made hunnot every citizen of dreds of millions who, Coventry born in while outwardly polite 1922, after all, wrote Now we know that to us starvelings, must lines such as: “Man all human problems think us fools. I don’t hands on misery to are caused by serotonin dare admit to him man. / It deepens we ought to have that I haven’t a clue like a coastal shelf.” what bankers actuDoes it? I suspect conquered neurosis ally do: I now have it is more like an less idea than when I extended plain than was a student, when they wrote to me, a plunging geological declivity. “Dear Mr Dalrymple, Your account is In the year of my birth Larkin wrote now £3 17s 4d overdrawn, and I trust a poem about neurotics. Of course, you will rectify the situation as soon as now that we know that all human probpossible.” lems, from depression to pathological It is because success is so intimidating, g ambling, are caused by serotonin I imagine, that I find the poetry of (either too much or too little of it) we Philip Larkin so appealing. It exudes ought to have conquered neurosis, but a reassuring hopelessness, and brings what Larkin had to say about neurotics solace to us failures, who after all are seems all too familiar to me, functional in the immense majority. Dissolution MRI and PET scans notwithstanding. and death are our fates, however self Nothing much has changed really: important we may have been in life. “None think how stalemate in you What, in the end, can we hope for grinds away.” or expect, other than “Ash hair, toad After a time, we doctors grow bored hands, prune face dried into lines”? with neurotics, and blame them for their And which of us, hospital doctors failure to respond to our ministrations: anywhere in the Western world, has not “For interest passes / Always towards experienced what Larkin describes in the young and more insistent, / And “Heads in the Women’s Wards” (except skirts locked rooms where a hired darkthere are no women’s wards now in our ness ends / Your long defence against ultra-efficient brave new world of bed the non-existent.” management): “On pillow after pillow Surely there is just as much neurosis lies / The wild white hair and staring as ever there was? I think Larkin would eyes; / Jaws stand open; necks are have appreciated the acerbic first line of stretched / With every tendon sharply the late Professor Michael Shepherd’s sketched.” We, who still think we are review of a book titled Recent Advances eternal, forget that: “Sixty years ago in Psychiatry. “The title of this book” (I they smiled / At lover, husband, firstquote from memory) “should have been born child.” Recent Activity in Psychiatry.” There’s no denying, though, that Theodore Dalrymple is a writer and Larkin was a bit odd. Could it be that retired doctor BMJ | 24 MARCH 2007 | Volume 334
Medical classics One Flew Over the Cuckoo’s Nest Film released 1975 Set in 1963, this landmark film took viewers into the heart of a typical psychiatric ward and exposed the realities therein. Based on the 1962 novel by Ken Kesey, it tells the story of Randle P McMurphy—an immoral, self centred delinquent who feigns insanity to avoid serving a custodial sentence on a work farm. Not realising that his release from the hospital is dependent on a sound psychiatric report, he instigates his own brand of mayhem to pass the time and “show them who’s nuts!” His antics backfire when his doctors classify him as dangerous, but not necessarily mad, and he is subsequently detained on the ward for further management. During this period, McMurphy continues to taunt the orderly, maternal, authoritarian Nurse Ratched, who seeks to maintain the ward routine that he so desperately tries to disrupt. When a fight breaks out on the ward and McMurphy assaults a staff member, he is sent for electroconvulsive therapy—a scene as graphic as it is disturbing. The central conflict in the drama is between McMurphy and his nemesis Nurse Ratched. Initially she seems caring and sensitive but is shown ultimately to be just as manipulative as McMurphy, especially in the searing penultimate scene after a drunken impromptu ward party. The supporting characters are equally intriguing and include the vulnerable, stuttering Billy Bibbit; the elective mute native American Indian chief Bromden; the misunderstood, suspicious intellectual Harding; and Cheswick, a man unable to face the real world. Thoughtfully filmed in Oregon State Louise Fletcher as Nurse Ratched Hospital, where the and Jack Nicholson as McMurphy superintendent not only allowed filming on an empty ward but also played the role of the consultant psychiatrist, this film is littered with themes of power, autonomy, and consent. It is therefore an ideal film to study with our medical students as it serves as an accessible template for the discussion of these important issues. We debate whether Nurse Ratched is a “personification of evil” (she was named the fifth greatest villain in film history by an American Film Institute poll in 2003) and whether McMurphy is mad. We discuss whether such a character, with features of antisocial personality disorder (irresponsible, impulsive, difficulty maintaining relationships) and who is deemed dangerous (by a panel of psychiatrists), could be detained against his will if the proposed new mental health laws were passed in the UK. However, this film didn’t win several academy awards because of the breadth of ethical issues it covered—it was successful because it is both thought provoking and entertaining. This is a film that can make you laugh, cry, and shout at the screen. It is regarded by many (including us) to be a true classic. Jim Pink, associate academic fellow (
[email protected]) Lionel Jacobson, honorary lecturer, Department of Primary Care and Public Health, Cardiff University
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Comfort for failures
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