Sharks and Waterfalls

At my high school graduation I received a card whose cover ran, “Once, you were a tiny drop of water. Then you became a stream, getting bigger and bigger, and now you are a mighty river, running towards the ocean…” I opened the card and read, “…where all the sharks live.” As fun as it is, of course, the analogy makes as much sense as a gust of wind fearing the birds. For this month’s blog I’m not even going to try to link my two themes, and instead give you two short entries. Waterfalls. Sharks.

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In Pilgrim at Tinker Creek, Annie Dillard writes eloquently of standing on a bridge over the rushing river below. Looking upstream, she writes, is to look at the future. This is the water that has not yet reached you. Perhaps it carries a fallen branch, a floating leaf, a salmon hatchling. It is always new and different. To look downstream is to look at the water that has already passed. The past.

This works beautifully if you are standing on the bridge or riverbank. But for seven summers I guided whitewater river trips, and these rivers have indelibly etched in my brain that the future lies downstream. With the exception of eddies--and, once, an epic poison-ivy bank scramble pulling a swamped baggage raft back up to catch the eddy at Saddle Creek--there’s no going back. Even when we pull over, to camp for the night or to scout the next rapid, the river’s pull draws my attention to what will come next: the water’s flow becomes my own.

To facing upstream is to risk blindly drifting into Wild Sheep or Granite, class IV rapids.

In retrospect, I have been navigating the last 3 months not as a spectator on a bridge looking upwards to the future, nor as a river guide looking downwards to the future, but as a soaked rat on a piece of flotsam, gazing back at the rapids and—oops!—waterfalls I’ve just come through.

In February we moved houses. Rather than take time off, both LL and I worked more than usual in the last three months. We both took on additional extracurricular activities beyond our paid work. But the current did not slow down for us just because we decided to be crazy. There were still bills to be paid, food to be purchased, meals to be prepared, diapers to be changed. I'm thankful to say that we were mostly able to make our two-year-old our top priority, and I don't think he is much the worse for the wear. But eventually such stress will tear apart even the sturdiest raft. We have at least identified the need to seek calmer waters and back-eddies, to rebuild before we go over any even bigger falls.

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A shark need to keep moving in order to breathe. This oft-repeated statement actually turns out to be true, as best as we can tell, for most sharks, most of the time. Those qualifiers might give one pause, yet all science has such qualifiers, whether we articulate them or not. The act of observing changes what is observed. Or, at the least, it is impossible to prove that it does not.

I digress. Sharks, movement, oxygen. I suffer from intermittent sesamoiditis, which sounds like some unbecoming disease contracted south of the border (doubly so), but is actually an inflammation (-itis) of a pair of tiny bones located directly under the ball of the foot. The simple equation is that more pressure causes more inflammation, so one would expect that being on one's feet, on a hard surface, for long hours, would cause inflammation and pain. This is exactly what happened during my residency training. For five non-consecutive months over the three years, I wheeled about the hospital on a "Roll-About"--picture a kid's scooter with the platform padded and raised to knee height--because it was too painful to stand.

The converse, however, is not consistently true: rest has not always healed my foot pain. Similar to the pain of plantar fasciitis (-itis of the plantar fascia running from the heel to the mid-foot), stretching the muscles and tendons that pull on my sesamoids has proved crucial in relief. Stretching requires movement. And whether or not piezoelectricity, the growth-stimulating charge that causes bones to become stronger with weight-bearing, plays a role, I have found that I do much better with daily exercise. It would seem that I need to move to be healthy.

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Perhaps as a shark I can better navigate the waters ahead. If life is a constant reframing of perspective, then maybe I was not nearly so avant-garde as I'd pictured myself with my river-guide-rather-than-brigde-dweller viewpoint. Perhaps, then, I need to stop trying to stay dry and start learning to swim.

The Hobbit : a picture review

I believe that if you click (or double-click?) on the image you'll be able to see it in more detail.

Deadlines

"I love deadlines.
I love the whooshing sound they make
as they fly by."

-Douglas Adams

(if I had to choose only one desert island book,
it would be So Long and Thanks for all the Fish;
if I could bring along four more,
it would be the trilogy [comprising five books] of
The HitchHiker's Guide to the Galaxy)

Seriously!

For the last month I've been hoping to finish a pictorial review of Peter Jackson's 2nd Hobbit installment. It got started over Christmas break, but instead of finishing it, I've chosen to do other things with my time…

I serve on our state's board of directors for family physicians, and one of the things on my mind a lot in this role has been food and nutrition. (See "Leonardo and GMO", 9/29/13). Since last fall I've started reading "Food and Western Disease", by Staffan Lindeberg, and am interested in reading "Nutrition and Physical Degeneration" by Weston Price. Both recommend a return to a more natural and whole-foods diet, rich in vegetables but also, depending on location, incorporating a moderate amount of meat such as wild fish and game. By moderate amount I really just mean more than the zero amount argued for by T. Colin Campbell in "The China Study", which I read a few years ago. All three of these books are, as best I can tell, well-researched. All three, regardless of amount of animal protein they recommend, conclude that our modern diet of highly processed grains and feedlot-raised meat is unhealthy.

There are two major points I am struggling with right now, in considering this conclusion. (It is a conclusion with which I agree, and which more popular recent books such as "Grain Brain", "Wheat Belly", and Campbell's new work "Whole" also come to.)

The first is that none of this work is being taught to either new medical students or current physicians. In medical school I had one-half of one day on nutrition. On my drive over to Seattle from Omak for this quarter’s board meeting, I listened to five straight hours of CME (continuing medical education) covering a wide range of topics—not one of them nutrition. Nutrition is relegated to “alternative” medicine, while drugs and surgeries, which really should be the last “alternative” when lifestyle changes fail to achieve health, are the definitive focus.

My second struggle is with the disparity between the nutritional recommendations that I am or should be giving my patients, and what they can afford. Calorie for calorie, nutrition-dense food comes in at 10 times the cost of junk food: $36.32 per 2000 calories of healthy foods vs $3.52 per 2000 calories of junk food according to a 2007 University of Washington study.

When one considers that the U.S. has the highest income gap among the 30 most-developed nations, these data on foods costs help explain why we have the worst health statistics to match—and why, in addition to having overall worse health (e.g., the richest cohort in an unequal-income country like the U.S. is less healthy than the richest cohort in a more-equal country like Sweden or Japan), countries with a greater income gap also suffer from a greater health gap between rich and poor. If you’re rich, you can buy walnuts and kale and pomegranates and wild Alaskan salmon. And if you choose not to and only eat Big Macs, you can still buy yourself the statins and insulin injections and coronary artery stents.

In moments of such consideration, I have to step back and remind myself to not take myself too seriously. Yes, I will do what I can in the quest to right such wrongs, and do my best. But I am only one little hobbit, and the orcs are many and fierce. Look for a more light-hearted post next month. ☺

cold November rain

One month and twenty years ago tomorrow, I walk into the front doors of our 100-student high school to learn that one of my best friends, Matt Halley, has taken his own life with a gun over the weekend.

I am there now like it was yesterday, the halls quiet for a Monday, the bounce in my step collapsing as my sister’s friend Kindra tells me the news. I do not have words. There are no words, there is no air, the walls suddenly loom close. Somehow my feet carry me back outside. Without thinking I drive back up to the forested mountains above our house, five minutes from the front door of the Pine Eagle High School, where the scream that has building inside me can escape and lose itself in the ponderosas.

It is not raining. The sun is bright and the day is warm for the first of November. I ask the pine trees, “Why? Why? WHY?!” The tears stream down my face and all that I can do is follow my legs as they climb up and up.

Matt Halley. One grade younger than me. Great jumpshot from the upper left corner of the key. A smile and a laugh that catch you off guard and then catch you up in a contagious delight at the world. We got to ski together at Brundage Mountain, once, on a rare break from the all-consuming winter basketball schedule, and it was all I could do to keep up in speed, never mind form. Matt was the kind of kid who everyone wanted to be, precisely because he was comfortable being himself. I had a crush on his sister Miranda, who was in art class with me, but I don’t think Matt ever knew that. I would never get to tell him now. I would never get to go skiing with him, or shoot hoops, or suffer another long bus ride together. Was there a note? Was there a phone call? Was there something that could have been done, differently, by any of us? All I knew was that there was a gun.

I arrive at a clearing, where in spring the arrowleaf balsamroot explodes in yellow. Now their leaves are dry and brown, awaiting winter’s insulating snow. For the first time I feel the ache in my legs. My breath comes in ragged gasps. My screams have been spent but the tears will not stop.

From here I can look out over our little town, our little houses, our school. The already-white peaks at 10,000 feet hide behind the wooded ridge immediately above me. Another winter will come, another basketball season, another ski trip. The tears continue to slide down my face.

At this point I cannot know that Matt Halley will not be the only, or the closest, loss I will experience to suicide. I can only feel the raw ache of a life torn away too soon, a thread ripped out of the fabric leaving jagged edges and holes where before was a pattern. And I cannot know, hopefully will never know, the loss that his parents experience.

Mark and Gail, wherever you are, I am thinking of you.

It is late and I am tired

Everything I've ever read about writing emphasizes the importance of just that--writing. Writing every day. Writing whether or not one feels creative or inspired. Writing, perhaps, in hopes of finding creativity and inspiration. Writing even if it is late and one is tired.

To that general premise (to which I can only say that I aspire; even the effort of maintaining a blog monthly is something I can't always muster) I would hold up the contrarian perspective that the world is filled with those who have something to say and never do and those who have nothing to say and keep on repeating it. And that I would hope to avoid falling into the latter company.

And yet, what truly marks a work of genius? Simplicity. The ability to take a complex idea and put it into words that make the reader say, "Obviously. Even I could have written that." Daniel Quinn and Patch Adams come to mind, as does Malcolm Gladwell. At the other end of the spectrum is Salman Rushdie, though for me his linguistic trapeze act is a delight unto itself.

Which then raises the question of whether it is possible to ever fully delight in an idea with which one does not already agree. Quinn and Adams, for me, speak truths that seem self-evident. I am well aware of my biases (I see!, said the blind carpenter to his deaf wife, and picked up his hammer and saw), yet I wonder the extent to which these biases color not only how I read what I read, but in fact what I read. In other words, am I predisposed to only see that which I already believe?

It is late and I am tired. As my dad would astutely observe, I have managed to fill four paragraphs with words without saying anything. Each keystroke is one more pixel of non-renewable energy, another toe in my already large carbon footprint. For all you writers out there--and I'm including myself in this admonition--write, yes, please write, and also maybe think, beforehand.

Leonardo and GMO

What would Leonardo da Vinci have to say about GMO?

At our recent Washington Academy of Family Physicians Public Health meeting we debated GMO foods, specifically, “Yes” or “No” on 522, the Initiative to label GMO. The question had been raised no less than 4 months earlier. Though against GMO (and thus in favor of the public’s right to know), I had managed little in the way of objective research. Then, during the 5-hour Omak-Olympia drive, I listened to a compelling audiobook build the case against one specific GMO crop, wheat. I used this example, in the broader context of human-manipulated food, to argue for “Yes” on 522. Our Board ended up deciding not to be “neutral”, which would have implied that both sides were equally compelling; our position of “no position” suggested insufficient evidence for either. Or that we hadn’t taken the step of due diligence to ferret out what evidence there might be.

The whole affair left me unsettled. Not because I disagreed with our decision or the process by which we’d reached it. I agreed with both. Nor because my arguments weren’t given a fair hearing. At the time of our meeting, I had not yet synthesized my thoughts into a coherent argument, yet my fellow physicians graciously heard me out. In the 72 hours after the meeting I scrambled together a position statement for our online journal. I regretted not having invested the effort months earlier, which might have allowed me to state my case more effectively and respected my colleagues’ time by letting them ponder it pre-meeting.

Only a few weeks later was I further able to put a finger on the pulse of my disquiet. Ironically the insight came while while relaxing on a family vacation in Port Townsend, from a book my father-in-law had left on the coffee table: Fritjof Capra’s “The Science of Leonardo”.

What could the 15th-century “Genius of the Renaissance” have to say about 21st-century GMOs, due diligence, and disquiet of the heart?

Quite a lot, as it happens. From Capra’s careful examination of previous biographies plus thousands of pages of da Vinci’s notebooks, what emerges is a man who above all took a holistic view of nature. Capra argues that Leonardo was centuries ahead of his contemporaries in his use of what would become the scientific method. Even more than that, Leonardo was far ahead of outstanding 16th-through-20th-century figures such as Bacon, Descartes, and Darwin, who, in Capra’s eyes, introduced an artificial and even destructive split that has permeated Western scientific thought ever since. This paradigm would separate mind from body, human from nature, the art of medicine from the science.

“Leonardo’s synthesis of art and science,” writes Capra, “is infused with a deep awareness of ecology and systems thinking.” He quotes Leonardo on “the so-called ‘abbreviators’, the reductionists of his time: ‘The abbreviators of works do injury to knowledge and to love…of what value is he who, in order to abbreviate the parts of those things of which he professes to give complete knowledge, leaves out the greater part of the things of which the whole is composed?’” Capra goes on, “Our sciences and technologies have become increasingly narrow… We urgently need a science that honors and respects the unity of all life, that recognizes the fundamental interdependence of all natural phenomena, and reconnects us with the living earth.”

Whatever Leonardo da Vinci’s vote on I-522, I am inclined to believe that he would see our modern industrial food production, including but not limited to GMO, within the context of the fossil fuel it consumes, the chemicals it unleashes into the environment, the inequality in distribution of our surplus of food (only surplus can result in population growth), and the idea that we can change the genetic code of our own food supply without consequence. This is not to say that Leonardo, the engineer and scientist, wouldn’t be busy designing better irrigation systems, tractor mechanics, and perhaps even techniques of gene splicing. But Leonardo the humanist, the ecologist, and the scientist—the systems thinker—would advocate that we step back and think carefully before each step of change. This step has been grossly lacking in the last 50 years of change to our food technology, not to mention the last 500 years of technologic change overall.

To the question of due diligence, one of the qualities I admire most about our WAFP: just as Leonardo spent hours in dissecting the shoulder muscles of a cadaver and making preliminary sketches of an arm in motion before ever putting paintbrush to easel, so it is our responsibility as physicians and scientists to assemble the best available evidence and share it with our peers for an informed discussion. In reading Capra’s book, I also appreciate differences between myself in 2013 as a physician with a family of my own, and da Vinci in 1490. As far as we know da Vinci had no family to which to devote his energy. He was able to secure positions that let him delve without distraction into his studies, his brilliance allowing him to work as few as two hours daily on actual commissions. While highly regarded by his few peers, Leonardo also seems to have led a highly secretive and even solitary life, so devoted was he to work that went largely unknown for centuries. Reading this, I’m able to forgive myself for balancing my time between personal research projects and my roles as a doctor and father.

At the same time, there are luxuries we enjoy and situations we face in 2013 that should also urge us to act, even when we do not have something like, in this case, hard evidence of direct human harm of GMOs. We enjoy the luxury of free and open exchange of ideas without fear of censure or death. And we have the situation of a world in such rapid flux, and in peril of ecologic and human catastrophe on such a massive scale, that we might recognize a larger systems problem. We might do well to recognize that our food supply has already been radically changed in the last 50 years without any safety trials having been conducted, and that ours is the first generation in history to face higher morbidity and mortality than our parents’.

Because we have the luxury of freely discussing such things—and perhaps, using our leverage as family physicians, the ability to change the broader course of human and global health for the better—we also should seize that chance. Specialists have their place within medicine. Our role, the one role we can fulfill better than almost any other profession on the planet inside or outside of medicine, is to be systems thinkers. We have the chance to be the Leonardos of our time, minus the secrecy and isolation.

This is what makes me proud to be part of an Academy that holds me accountable for reviewing what evidence is available (which I had not done in this case) and still tolerates, in fact encourages, broader thinking and exchange of ideas.

Indeed, if our individual limitations of family and work make it impossible for any one of us to paint a Mona Lisa, we should remember that our strength is in our collaboration, that together we might do work that would make even the Genius of the Renaissance proud.