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- Herausgeber: Hammersmith Health Books
- Kategorie: Ratgeber
- Sprache: Englisch
- Veröffentlichungsjahr: 2014
Medicine is not just about science. It's also all about stories, and about the mingling of narratives among doctors, and between them and their patients.' So writes Cecil Helman after 27 years as a family practitioner in and around London interlaced with training and research as a medical anthropologist, comparing a wide variety of medical systems and other forms of healing. This unique combination of frontline health worker and detached academic informs the many stories that make up this fascinating book. It also informs the author's insights into what human suffering can teach us about ourselves and our own attitudes to health and illness, whether we are deliverers or recipients of health care. With insight and compassion, Dr Helman's stories take the reader on a journey from apartheid South Africa, where he did his medical training, to the London of the early 1970s, where for a short time he foreswore medicine to become an anthropologist and poet; from ship's doctor on a Mediterranean cruise to family practitioner in London; from observing curative trance dances in the favelas of Brazil to interviewing sangomas in South Africa. While trained in the Western tradition and with many years of practice in that system, Dr Helman's anthropological insight leads him to view illness in a wider personal, social and cultural context, considering elements beyond the purely physical. In pleading for this holistic approach he celebrates family medicine which 'in its quiet and unassuming way, and every day of the week, is still at the very frontline of human suffering'.
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‘A marvellous memoir on the human side of GP practice … His resolutely non-specialist memoir may, I think, turn out to be one of the classics which every medical student must read. … I don’t think anyone since AJ Cronin has expressed so strongly what it is to be embedded in the community as a GP.’
Libby Purves, BBC Radio 4 Midweek
‘I simply could not put down this extraordinary mixture of stories from the GP’s surgery in suburban London. … Two clear messages emerge from this book, which should be required reading for every medical student. … First, medicine must relearn its heart and soul … Second, there is no certainty in medicine, and no clear answer as to what it is that cures, or fails to cure people. … Clearly told, and an extraordinary read, this is a passionate cry for humane medicine.’
Dame Julia Neuberger,The Independent
To my daughter Zoe
CONTENTS
ACKNOWLEDGEMENTS
I would like to acknowledge the following sources that I have quoted in this book. Full details of the original publications are given in the Bibliography.
Arthur Conan Doyle’s quotation is from Tales of Adventure and Medical Life (John Murray, 1963). Rachel Naomi Remen’s quotation is from My Grandfather’s Blessings: Stories that heal (Riverhead Books 2000). Saul Bellow’s quotation is from Mosby’s Memoirs and Otrhe Stories (Weidenfeld & Nicholson, 1969). Susan Sontag’s quotation is from Illness as Metaphor (Penguin, 1991). Anaïs Nin’s quotation is from Winter of Artifice (Peter Owen, 1974). Oliver Sacks’s quotation is from A Leg to Stand On (Picador, 1984). I.M. Lewis’s quotation is from Ecstatic Religion (Penguin, 1971). Franz Kafka’s quotation is from the story Ein Landarzt, first published in German in Leipsig in 1919. Roy Portser’ quotation is from The Cambridge Illustrated History of Medicine (Cambridge University Press, 1966). Mircea Eliade’s quotation is from Masks: mythical and religious origins, in Symbols, the Sacred and the Arts, edited by Diane Apostolas-Cappdona (Crossroads, 1986). The quotation from JAMA is from L.D. Grouse’s Editorial, Has the machine become the physician? (Journal of the American Medical Association259, 1891).
Every effort has been made to trace copyright holders. The publishers will be happy to correct mistakes or omissions in future editions.
INTRODUCTION
I come from a family of 13 doctors and not a few hypochondriacs. Among my relatives I can also count a medical librarian, a medical researcher, a medical secretary, a medical social worker, and a technician in a medical laboratory. In fact, the family connection with medicine goes back even farther in time: all the way back to a village practitioner who lived almost 200 years ago.
Most of my adult life I have tried hard to escape from the gravitational pull of this family history, but mostly I’ve been unsuccessful. When I think back on it, my struggle to create an individual orbit around medicine (and sometimes to escape from it) began even before I qualified as a doctor from the University of Cape Town in 1967. And in a way, it still continues today.
Growing up in South Africa in such an overwhelmingly medical environment was always a mixed blessing. For one thing, it introduced me early on to an exotic, inverted world – unknown to most people outside it – in which the usually grotesque and shocking all seemed to have become familiar and domesticated. It was the type of world where suffering and death were close acquaintances and not the usual distant strangers, and where the talk around the dinner table, or the barbecue, was often all about Interesting Cases, with their bizarre symptoms, gross swellings, unusual cures or inexplicable deaths.
This background also taught me that medicine is not just about science. It’s also all about stories, and about the mingling of narratives among doctors, and between them and their patients. As Dr Foster, the general practitioner in Arthur Conan Doyle’s story A Medical Document, puts it: ‘There’s no need for fiction in medicine, for the facts will always beat anything you can fancy.’ In fact, the art of medicine is a literary art. It requires of the practitioner the ability to listen in a particular way, to empathise and also to imagine – to try to feel what it must be like to be that other person lying in the sickbed, or sitting across the desk from you; to understand the storyteller, as well as the story.
Suburban Shaman is about medicine, and about many of the different types of medical practice. It is written from the perspective of a doctor who is also an anthropologist. It’s a view from the inside, from the other side of the doctor’s desk, and is based on the 27 years I spent in family practice, before taking early retirement some time ago in order to concentrate on teaching and writing.
This book is not an autobiography. It’s a mosaic of memories rather than a single story. It aims to take the reader along on a series of journeys that I’ve been privileged to make through the various different worlds of doctors and patients – from medical school in South Africa during the darkest days of apartheid, via ship’s doctoring in the Mediterranean, to a spell doing research at Harvard Medical School in the USA, to medical aid programmes in the Third World and encounters with shamans and folk healers in different countries, and finally, to the practice of family medicine in various parts of London and surrounding towns. Along the way, each of these different worlds has taught me a specific lesson about the nature of healing and of medical care. Those lessons form the basis of this book.
Much of what follows is a defence of old-style family practice, and a celebration of it. It’s a type of medicine that people often take for granted, or even ignore – except when disasters happen. In Britain, the local National Health Service general practitioner or family doctor is still the first point of call for the vast majority of people who seek medical help. In its quiet and unassuming way, and every day of the week, family medicine is still at the very frontline of human suffering.
My own professional life has been spent mainly at this less glamorous end of medicine, in suburban family practice, far from the great fluorescent laboratories of the medical schools and the teaching hospitals, far indeed from the newspaper headlines about the latest wonder drug, or the latest tanned and white-coated celebrity surgeon. Family practice in Britain is a rushed, unglamorous life and the effects of its heavy workload can be grinding and corrosive. Yet, for all of this, I think there’s a quiet and unacknowledged heroism about it all. And it may well be one of the last survivors (though not the only one) of a long tradition of ‘real’ medicine, the type of holistic approach to health care that has always tried to treat the person as well as their disease, and to do this within the context of their own home, their family and their community.
What fascinates me particularly about it are the extraordinary human situations into which people (doctors as well as patients) find themselves propelled by illness, especially sudden, unexpected illness. Medical life provides endless examples of these situations, and they supply some of the tales that follow: brief glimpses through the half-opened doorways of many thousands of lives, revealing moments of drama that are poignant, tragic, bizarre or even comic.
Family practice is a long-term business. Gradually, over time, family doctors need to build up a picture of their patients and their backgrounds: from visiting their homes when they’re ill, from treating other members of their families, from consulting their medical records (which follow them from birth, wherever they move), and from seeing them not only in sickness but also in health (for routine examinations, health advice and immunisations). From all of this, they should acquire a deep knowledge of a particular individual and their family. Of course, to achieve this, it helps to be embedded within a particular community, to be a part of its daily life and of its local identity. Although in Britain this type of continuity is much truer of rural rather than urban practice, in the suburbs I have still often encountered my patients in the supermarket or in the street, as well as in the consulting room. Overall, their family doctor is more familiar to them than the white-coated strangers who interrogate and examine them at the local general hospital.
Family practice also involves (or at least, should involve) an understanding of patients’ belief systems, the ways they understand how their bodies function, and how they have got ill. And as far as possible, family doctors need to try to work within those beliefs in order to make their interventions most effective. Above all, family practice involves understanding the ways that illness can upset not only a body’s internal equilibrium but also the harmony of the patient’s relationships with the world they live in – and therefore how treatment should not only treat a diseased organ, but also aim to restore to the patient’s life that previous sense of equilibrium.
As well as being a doctor, I have also been trained as an anthropologist. This has given me a certain individual perspective on medical practice, as well as on other systems of healing found elsewhere.
In the early 1970s, I gave up medicine for several years to study social anthropology at London University. I had been wanting to move out of clinical medicine for a while, in order to acquire a fresh perspective on it. Coming from such a medical background, I needed the break.
Anthropologists are people who study many different societies and tribes in depth, and then compare them with one another. They ask questions like: How do they differ from one another? What do they have in common? How do they see their world, and behave within it? Some anthropology graduates, like myself, have also gone on to study the different forms of curing and healing (they’re not necessarily the same thing) found in many parts of the world, especially in more traditional societies. There, the questions to be asked include: How do people explain the causes of illness, and other forms of misfortune? Do they blame others for their illness, or themselves? Do they blame germs or spirits, divine punishment or even witchcraft? And to whom do they turn if they do fall ill? A doctor, a priest, a healer? If so, why? Answering these types of questions often involves interviewing traditional folk healers, as I have done in South Africa, Brazil, Europe and elsewhere.
Anthropology gave me the opportunity to learn in some detail about some of the hundreds of different forms of healing found worldwide, many of them flourishing beyond the boundaries of Western medicine, and then to compare and contrast them with our own system of health care: to see modern scientific medicine’s many strengths, but also its weaknesses. It led me also to an interest – which I’d never had before – in the traditional African folk healers or shamans back home in South Africa, the sangomas, as well as in similar traditional healers elsewhere.
Being both doctor and anthropologist has also given me a different, rather unusual view of the work I was doing (and it’s certainly an advantage when working in London, now one of the most multi-cultural cities on Earth). This double vision has enabled me to observe close up, like some bemused ethnographer, the increasing alienation between the warring ‘tribes’ of patients and doctors – each with its own specific view of illness, its beliefs about its causes, and expectations of how it should be treated. It has thrown some light on the problems of communication between these two groups, and underlined to me, again and again, the crucial importance of understanding the patient’s perspective, as well as the role of family and social context in the shaping of illness, and how it is dealt with. It has also shed light on the two parallel but interconnected forms of health care that exist in Britain – general practice/family medicine on one hand, hospital-based medicine on the other – and to understand the advantages, and disadvantages of each of them.
It took me some time in practice to realise that a fundamental aspect of family medicine was its attitude to uncertainty. After literally tens of thousands of consultations with patients, and many hundreds of house-calls, clinical practice eventually taught me one big, and rather sobering lesson: it’s that the more you know about doctoring and why it works (or doesn’t work), the more you realise how much you don’t know. For despite its patina of science, at its core medicine – and not just family medicine – is not really about certainties, nor ever has been. To the disappointment of some of the new breed of ‘techno-doctors’ as I’ve called them, it’s also about doubt and ambiguity, and ethical dilemmas that are sometimes difficult or even impossible to solve. It’s also about the limits of human expertise, especially with serious, chronic or incurable diseases.
Uncertainty is endemic in medicine, and it’s the inspiration for much of its research and enquiry. But it’s also part of its frisson and what makes it such a fascinating, absorbing profession. For, especially in family practice, you never quite know who, or what, will walk through your door next – the diseases they will suffer from, the stories they will tell.
At the level of daily medical practice it means, as the cancer specialist Rachel Naomi Remen puts it: ‘Perhaps the most basic skill of the physician is the ability to have comfort with uncertainty, to recognise with humility the uncertainty inherent in all situations, to be open to the ever-present possibility of the surprising, the mysterious, and even the holy, and to meet people there.’
Despite Dr Remen’s advice, my own experience is that modern medicine seems to strive increasingly for a world of ultimate certainty. A world devoid of ambiguity, where the wonders of science and technology will provide a clear answer for every human doubt and a clear solution for every human ill; where everything can be measured and everything can be explained, and almost everything can be controlled, even the processes of death and dying. Not surprisingly, one result of this approach is the tendency to see the ill patient’s body as just a malfunctioning machine, one that needs merely a mechanical repair, or a new type of chemical fuel, or just the provision of spare parts. A machine that can best be diagnosed, and monitored (and sometimes treated) only by other machines.
But this attempt to reduce much of the complexity of human suffering to a graph or an X-ray plate, a scan or a printout, is doomed to failure. It can never work. It has resulted in many patients perceiving the medical system as becoming even more impersonal and standardised every year. They complain that some doctors concentrate more on the diseased body parts, than on them – the people who contain those body parts. Many say further that it largely ignores their beliefs and fears, their individual needs, feelings and desires. Already the signs of this process of alienation are here: increasing patient dissatisfaction with doctors, more frequent litigation and complaints, media campaigns against the medical profession, and a growing resort to the various forms of ‘alternative’ medicine.
In the United States, critics of the medical system are even more vocal, seeing it as being in danger of becoming just another industry, a major corporate undertaking in which profits have become more important than people, an industry over-dependent on expensive technology as well as on the pharmaceutical industry. It was something I saw at close range in the mid-1980s, when I spent a year in the USA, teaching and researching (mainly on psychosomatic disorders) at Harvard Medical School That year confirmed to me that for all its wondrous discoveries, modern medicine really was in danger of entering a cul-de-sac, one that could eventually alienate it from many of its patients, and from its traditional tasks of healing as well as of curing.
But even in Britain, with its proud NHS, the impersonal mass-production factory model sometimes seems to have become predominant, with the key aim (or rather ‘target’) of feeding in the raw material of sick people at one end, and ‘producing’ larger and larger numbers of healthy people at the other – and all in the shortest possible period of time. This is despite major changes and improvements such as the increase in numbers of women entering medicine, and a greater emphasis on consultation skills. In recent years, too, the case of Dr Shipman, the family doctor who murdered many of his patients, has thrown a dark shadow over the relationships between patients and their doctors.
For many reasons then, family medicine itself seems in danger of moving further away from its original roots, from that well-loved (even if largely mythological) figure of the past – the old-fashioned family doctor with his kindly face and little black bag out visiting the sick on some wintry night, urging on his horse-and-buggy through the blizzards or the driving rain – towards an imitation of hospital medicine. Under the relentless pressures of bureaucracy, cost-effectiveness, rushed consultations, the fear of litigation, the decline in home visits and other factors, those words of Arthur Conan Doyle – ‘He goes from house to house’, and his step and his voice are loved and welcomed in each. What could a man ask more than that?’ – sometimes have a hollow ring about them.
This book was written in answer to two inner imperatives. First, a desire for some resolution within myself of an old (and sometimes painful) split between two different worlds: those of science and art, medicine and literature. And secondly, because of a certain unease and sadness that I feel about some of the directions in which medicine is going. However, despite its occasional polemical tone, I should make absolutely clear that the book is not a rejection of scientific medicine. Nor of medical specialisation. Both are necessary, as well as indispensable, but it does make the point that while such specialised skills are necessary, they are not sufficient. Focusing only on a tiny part of the body, but not on the rest – and seeing people only in an impersonal clinic or hospital ward, far removed from their familiar home or family context – is often not enough. Something else is needed.
At medical school, in our textbooks and lectures, diseases were described to us as if they were abstract ‘things’, somehow independent of the people who suffered from them. And independent, too, of their religious or social backgrounds, or the particular and unique circumstances of their personal lives, such as stress, unhappiness, poverty, discrimination, or poor housing. Most importantly, this approach left out the meanings that people give to their illnesses, the sorts questions they ask themselves when they do get ill: ‘Why has it happened to me?’, ‘Why now?’. It left out, too, all the stories they tell – to themselves and to others – the stories you hear in family practice from across your desk, every day of the week: endless cycles of stories, whether poetic or banal, many hidden within other stories, or concealed behind the masks of symptoms or disease.
Sometimes, in criticising this trend towards the increasingly impersonal approach of high-tech medicine, I sound (even to myself) like a sort of Luddite, someone nostalgic for a mythical, long-lost and low-tech Golden Age of Medicine. Then I have to remind myself, forcefully, that in the 17th century ‘nostalgia’ was actually the name of a disease, an extreme and pathological form of homesickness. I also have to remember all that medicine has achieved: its great triumphs of surgery and transplantation, the development of new drugs and vaccines, the conquest of many diseases, the decline in infant mortality, the lengthening of the human life-span. Yet despite all of these achievements, I still feel that something is being lost from medicine today, or is in danger of being lost – some precious, elusive quality of human interaction, something invisible and yet at the same time very real.
I have chosen the title Suburban Shaman because it seems, to me at least, that some aspects of the work of a family doctor have a distant resemblance to those of a traditional healer. To some this might seem absurd. As a modern doctor one should have absolutely nothing in common with these people, with all their superstitions, their feathers and fur, their strange chants and outlandish rituals. After all, our intellectual roots are completely different – ours in Science, theirs in religion and folk tradition. But I’ve come to believe from my anthropological studies that different types of healer, whether medical or not, have more in common than might appear – and so do the patients who consult them. After all, under the masks of culture and custom, suffering people want roughly the same things from their healers, in whichever society they happen to live: relief from discomfort, relief from anxiety, a relationship of compassion and care, some explanation of what has gone wrong, and why, and a sense of order or meaning imposed on the apparent chaos of their personal suffering – to help them make sense of it and to cope.
Healers such as the South African sangoma are usually dismissed by Western doctors as quacks and charlatans, irrelevant or even dangerous – and many of them undoubtedly are. But with all our science, our sophisticated X-rays, MRI scans and other diagnostic gadgetry, I still think we can learn something from them, just as we can learn from the previous generations of family doctors. It is something that today’s rushed, over-specialised, ‘techno-doctors’ are in danger of forgetting. It’s that more holistic view of illness that focuses primarily on a person and not just on their diseased organ; that strives, even if it cannot cure physical disease, then at least to help patients feel better in themselves, more peaceful and more comfortable in their relationships with others, or even with their deities or their natural environment. Such a broader view sees how illness can cause (or result from) an imbalance in a patient’s personal cosmos, particularly their connections to those around them, and how, through talk or ritual, social interventions or other treatments, that balance can be restored.
Like previous generations of doctors, what these healers lack in scientific knowledge they often make up for in a shrewd knowledge of human nature, in impressive bedside skills and in a roughly hewn folk wisdom of their own. For all their obvious limitations (and there are many of them) there are some things modern doctors can learn from them, just as the last generations of doctors would have learned lessons from their old horse-and-buggy predecessors. Over the years, I’ve tried to understand the way they work, the tricks they use. Perhaps most valuable of all, they offer us a window into the past – a glimpse of a more ancient way of healing, now largely replaced by medical science. And it’s worth a glimpse, even if the landscape seems at first so unfamiliar.
The sections of the book that follow this Introduction are arranged, more or less, in chronological order: from medical school in South Africa onwards. Along the way, there are some reflections, based on my own experiences – including some mistakes I have made in practice, in both attitude and action – and some clinical tales to illustrate them.
So the question remains. What are the special strengths of modern medicine, and what are its special weaknesses? What, in recent years, has gone wrong with it? And what – if anything – can we learn from other forms of healing found elsewhere in the world?
I offer these tales in the hope that they may go some way towards answering a few of these questions.
PART 1
Setting Out
CHAPTER 1
Asylums
It is the 1950s, and I am still at school. My father is an astronaut. Every few years he seems to travel to a different planet. Strange, rectangular planets, usually orbiting through small towns or dusty dorps, in the depths of the South African platteland or countryside. Actually, he is a government psychiatrist, who works for the oddly named ‘Department of Mental Hygiene’. He is a staff psychiatrist and later the head or deputy-head (they call it Physician-Superintendent, or Assistant Physician-Superintendent) of several big psychiatric hospitals, one after the other. These are the planets that I reluctantly land on every year. While all the other children spend their summer holidays on the beach, I spend mine in mental hospitals.
Cradock, Pietermaritzburg, Howick, Krugersdorp, Queenstown, Fort England Hospital in Grahamstown, Weskoppies Hospital outside Pretoria (known locally as groendakkies or green roofs). In each place I run barefoot with the other doctors’ children, fight and play bok-bok and other games with them. In each place I am introduced proudly to every individual member of staff: ‘This is my son. He’s at school in Johannesburg. He lives there with his mother. He’s very artistic. Say hello to Dr Geldenhuys, boytjie.’
Driving through the high guarded gates, past the small brick bungalows and coiffured lawns of the senior medical staff, you find yourself entering a different world, a volatile place of unexpected moods and hidden rules. There are some men and women in white coats and white uniforms standing around, others shambling by in pyjamas or dressing gowns, withdrawn, frozen, shouting out or crying, or talking volubly with invisible companions. I am forbidden to speak to them.
Like the asylum at Charenton, in Peter Weiss’s play Marat, the hospital is to some extent a distorted mirror image of the world outside. By the 1950s, madness is on both sides of the fence. Apartheid is now powerfully pervasive, and my father hates it. By government decree, the Black patients are rigidly segregated from the Whites in his hospital. They sleep in different wards, are given different (‘more culturally appropriate’) diets, live in different degrees of crowding, and also (though this is seldom spoken of) sometimes given different types of treatment.
One day my father tells me of a rumour about a colleague of his (a psychiatrist, but also the proud possessor of a theology degree), who is said to have given many times the recommended dose of electro-convulsive therapy to his African patients, as part of a post-graduate ‘research project’. But no matter, he is supposed to have said, for ‘their brains are completely different from our own’. It’s odd how soon my memory of this conversation becomes fuzzy, and fades, for no one ever mentions it in my presence again. When I eventually do meet this man, the puzzle deepens. He doesn’t look at all like a Dr Mengele. He is plump, amiable, cheerful and bald, a family man, with a kindly face and a booming laugh, probably a stalwart of his local Dutch Reformed Church or even a lay minister. He gives me sweets and slaps me on the back. But is he mad or bad? Is he just living on the wrong side of the asylum fence, or is he evil? Or maybe neither? How could any doctor behave like that? For years of my boyhood I try to puzzle it out. But however I look at it, the sense of unease remains: the apparently unbridgeable gap in my mind between the person I’ve met and what he’s done. For many years it remained as part of my wider South African mystery. A puzzle, without a solution.
Among themselves, my father and his colleagues speak in a peculiar dialect, difficult for any outsider to understand. They speak of strange creatures they refer to as ‘psychos’ and ‘schizos’ and ‘feebs’ (or feeble-minded), sometimes differentiating between ‘low-grade feebs’ and ‘high-grade feebs’. There are bad people called ‘psychopaths’, people who laugh too much called ‘manics’, people who don’t laugh at all called ‘depressives’, and some who don’t like being laughed at, called ‘paranoids’. After many summer holidays, these words become contagious. I find myself beginning to use them on my friends and my relatives, even on myself. Thus, for much of my childhood I come firmly to believe that sadness is the same as depression, mania a type of happiness, ‘manic-depression’ a combination of the two. And also that being confused is the same as being ‘schizoid’, while disagreeing too strongly with your parents is the clear sign of a ‘psychopath’ – bearer of a terrible, yet ill-defined, Mark of Cain.
In the hospital grounds, several ‘high-grade feebs’ and a heavily-sedated ‘schizo’ or two water the lawns, or weed the flowerbeds in the garden of my father’s bungalow – the one with the white metal burglar-proof bars on the windows, and the large hunting rifle mounted above the fireplace. Part of the peculiar atmosphere of these places comes from the fact that many of them were formerly military camps, their barracks now converted into lengthy wards. Fort Napier Hospital in Pietermaritzburg, for example, where my father worked for several years, was once the base of the British army in Natal from 1843 till 1914, and was especially important to them during the 1879 Zulu War. Later, during the First World War, it was used as an internment camp for German Prisoners-of-War, only becoming a government psychiatric hospital in 1927. It is this atmosphere of high fences, long barracks and straight lines that still signals a place sealed off from everyday life, one where discordant bodies, as well as chaotic emotions, can gradually be brought into line. The atmosphere within it is tense, touchy; the boundaries between ‘sanity’ and ‘madness’ only paper thin, though these pieces of paper, once signed and officially stamped, can have very powerful and permanent effects on any individual’s life.
At first sight each of these hospitals seems to be an inverted, illogical world, a mundus inversus, a world where nothing makes sense. But then, with all the madness of apartheid in full fling outside, you begin to notice a certain quiet peace about them, about their ordered lawns and neat fences, their fixed routines and regular rituals, a certain logical calm. To me, entering and leaving them each summer, they gradually come to seem like a refuge, an asylum.
