Matula Thoughts May 2, 2014

Endurance

1. May is here at last, a month encompassing the anticipation of summers, vacations, family time, and recreation unfettered by heavy clothing. We have endured another winter in Ann Arbor, this one more challenging than average. Yet our seasonal challenges are nothing compared to those in other parts of the world where climate, geology, society, local economy, and government are less stable. With Independence Day two months away we have to be thankful for the serendipity of our national circumstances. Serendipity is a word defined by two components – luck and sagacity. The United States of America has had the good luck of great resources and sagacious founders with unusual wisdom, although that luck and wisdom were not shared with the indigenous Native Americans and generations of imported slaves.

2. Democratic government, hardly perfect as we exercise it, is a work in progress. Yet for all its flaws it appeals to people around the world who want fair and rules-based government that allow people to speak their minds, have a fair shot at playing out their lives, and creating good futures for their children. Democracies tend to be richer than non-democracies, less corrupt, and less likely to resort to war. Yet for all of its appeal, democracy is under threat through a.) imperfections in its various deployments, b.) failure to “stick” where they have recently been initiated such as after the Arab Spring, or c.) competition from other belief systems of government. The alternatives of oligarchy, military dictatorship, kleptocracy, communism, sectarian rule, despotism, or royal ascendency are hardly preferable to most people. The aspirations we have for government at national scales hold true at the local levels and indeed within nearly all organizations including the University of Michigan and the American Urological Association – two organizations of immediate interest. Academia is no different from other organizations, in spite of its long history and self-ordained privileges. How we govern ourselves at any level matters deeply to the individuals involved and their ability to reach their potentials of performance and happiness.

3. What about the May seconds of the past? Of the many events to consider the following caught my attention. In 1536 Anne Boleyn, Queen of England, was arrested and imprisoned on charges of adultery, incest, treason, and witchcraft. While we have to thank her husband, King Henry VIII for giving the Company of Barber Surgeons the Royal Charter just 4 years later, things didn’t go so well for Anne. Henry’s successor in England, King Charles II on 2 May 1670 somehow felt he had the right and authority to give a permanent charter for the Hudson’s Bay Company to open up fur trade in North America without consideration of the indigenous economies. Friendly fire wounded Stonewall Jackson in 1863 while reconnoitering at the Battle of Chancellorsville on the second of May and he died 8 days later. In 1885 the Congo Free State was established by King Léopold II of Belgium, presaging untold more human misery. On 2 May 1933 Hitler banned trade unions (Gleichschaltung) and on that date in 1945 the US 82nd Airborne Division liberated the Wöbbelin concentration camp finding 1000 dead prisoners, most of whom starved to death – sad bookends to the Third Reich. In 2011 May second was the last day for Osama bin Laden.
4.             May Days have been traditional times of celebration. Many are cheerful festivals of spring. Some are more somber rememberences. May Day in Chicago celebrates the labor movement and is known as International Workers’ Day, in commemoration of the Haymarket massacre of 1886. This occurred (actually on Tuesday May 4) at a labor demonstration when workers went on strike for an eight-hour workday and someone threw a dynamite bomb at police as they tried to disperse the crowd. Seven police officers and 4 civilians were killed, many others were injured. Eight anarchists were accused of the crime and of these 7 were sentenced to death and one to a term of 15 years in prison. Of the death sentences, 4 were hanged, one committed suicide in prison, and the other 2 were commuted by the governor to life in prison. So in terms of life, it wasn’t quite an eye for an eye. May Days show humans at our best and worst. [Pictures from Wikipedia. On left: Mayday festivities National Park Seminary, Maryland 1907. On right: Engraving from Harper’s Weekly]

5.                  A friend recently told me about a provocative short film (8 minutes) by Norman McLaren (1914-1987) that encapsulates the bright and dark duality of the human condition. Born in Scotland McLaren developed a career in Canada as an animator and film director. His 1952 film Neighbours won an Oscar (in 1953) for best documentary. You can find this and watch it via Wikipedia or buy it via iTunes. My appreciation to Harry Cross, fellow Ann Arborite, for turning me on to McLaren, whose other work – particularly the short film Pas de Deux – is equally worth watching. By the way, if you use Wikipedia like I do, you should consider a voluntary donation to help support it. It is an amazing and living library, and although imperfect, it gives you the tools to improve it. One of our newer faculty members, Khurshid Ghani noticed it didn’t contain an entry for Reed Nesbit, our great professor in urology here at Michigan. Khurshid figured out how to get an entry into Wikipedia and got it done. Speaking of Nesbit we will be having our annual AUA Nesbit Society Reception on Sunday, May 18 from 5:30-7:30 PM at the Hilton Orlando in the Sun Garden. We look forward to seeing many of you there and if you haven’t RSVP’d please do so to Sandy Heskett by email at sheskett@umich.edu. [Photo on left – McLaren’s Neighbours. On right – Dow Chemical’s logo for our species]

6. A while back two articles in The Lancet caught my attention. The first was the single-page piece by the editor, Richard Horton called “Offline: Social chaos – the ignored tragedy in global health.” [The Lancet 283:111, 2014]  The second was a two-page article by Arthur Kleinman in The Art of Medicine Section called “How we endure.” [The Lancet 283:119, 2014] The first article talked about the fierce debates regarding universal health coverage, Millennium Development Goals, non-communicable diseases, and social determinants of health. Yet, Kleinman observed: “…almost the entire field that is global health today has built an echo chamber for debate that is hermetically sealed from the political reality that faces billions of people worldwide. That reality is social chaos: the disruption, disorder, disorganization, and decay of civil society and its institutions. Social chaos erodes societies, destroys communities, eviscerates health systems, and eliminates any remaining vestiges of hope individuals might have for better lives. And yet social chaos is nowhere on the global health agenda. It is systematically ignored, marginalized, or censored.”

7. Arthur Kleinman was chair of the Department of Social Medicine at Harvard Medical School and is an MD with an MA in Social Anthropology. A medical anthropologist, he brings personal as well as professional insight to his discussion of “How we endure.” The essential concepts in his essay are missing from standard medical education curricula, indeed they are left out of most formal educations society offers today. Kleinman’s broad view identifies a core element of the human condition, namely suffering. He writes: “ … for billions of poor people in our world, enduring pain, misery, and suffering is not only a description of their everyday reality but the moral message that they share with their children. And this is true as well of many people in rich societies who must endure seriously debilitating illnesses, disabling accidents, terminal organ failure, end-stage neurodegenerative conditions, and the final days of dying.”

8. Kleinman illustrates his article with a single photograph that you will recognize immediately. It is Dorothea Lange’s image in the Migrant Mother series, showing Florence Thompson with two of her children in 1936. Kleinman’s concluding paragraph begins: “Assisting family and professional caregivers as well as patients to endure may not be assessed today as a measure of the cost-effectiveness of health-care systems, and yet it is at the very core of what human experience is about and what caregiving should be about. Our cultural images today seem blinded to life’s limits and dangers. While emphasizing human flourishing and celebrating happy outcomes, they obscure the reality of human conditions. Physicians can work hard at achieving the best outcomes, while still acknowledging that their patients, like themselves, must prepare for lives lived under some degree of constraint. This means that each of us at some point must learn how to endure: the act of going on and giving what we have.”

9. As physicians, especially in our younger years, we buffer ourselves with the binary illusion that disease and disability, may be sitting on the examination cot or operating room table while we stand in our healthy professional space spared from such misfortune. Of course this is a convenient self-delusion. The extent of our ability to imagine that the healer/patient duality is ultimately a singularity is related to our ultimate success as physicians. The additional buffer of our specialization as urologists adds to the delusion. We, no less than our patients, must endure many challenges and burdens though our lives, and our personal and professional successes can be synergistic. If these thoughts intrigue you, read The Lancet paper, or even go a little deeper in the internet to hear and watch Kleinman’s William James Lecture from December 5, 2011 called “The Unfulfilled, Yet Not Unfulfillable, Quest for Moral Wisdom in Academic Life: Why William James Still Matters.” It is an interesting title, “the quest for moral wisdom in academic life.” Then check out Wikipedia on William James who, by the way, was educated as a physician although he never practiced medicine. (Harvard Medical School 1869).

Best wishes, and thanks for spending time on “Matula Thoughts.”

David A. Bloom