Gavin Francis’ book Recovery — GP’s take on the neglected art of convalescence –:
has a brilliant example of what good, or harm, our minds can do as part of our well-being; worth quoting. Francis talks about two middle-aged men who ‘a few weeks apart both suffered a cardiac arrest and collapsed, ostensibly dead, but who were successfully resuscitated with electric shocks. Both were then fitted with portable electronic defibrillators …[that were] about the shape and size of a matchbox’. If either man collapsed again, ‘the portable defibrillator would sense the change and shock the heart back into a healthy rhythm.’
‘For one of the men, the intimate experience of the proximity of death, the fragility of life and his new reliance on the implanted defibrillator was utterly traumatic. He began to suffer panic attacks and fiddled ceaselessly with the swelling beneath his collarbone. He couldn’t find a way to stop fretting that it might fail. At the time of his cardiac arrest he had been working as an administrator but he found himself unable to go on working. He was afraid to be alone, and his nights became a torment of insomnia.
‘For the other man, the almost identical experience of collapse and then resurrection became an epiphany of gratitude. His new life was a gift, he said, for by rights he should now be dead, and all the tedious, niggling irritations that once troubled him seemed to dissolve. It was enough to be able to breathe this air, walk on this earth, see his grandchildren. He had always lived modestly, but now began to emjoy sumptuous meals, fine wine, and booked holidays to places he would never before have considered visiting.
‘He had died, but then he lived again, and that new life into which he was born seemed one of richness, tenderness and gratitude.’
More about the teaching of Walter Wink, as mentioned last week, in his book The powers that be, which was a later summary of earlier work.
Wink teaches that every institution possesses an ‘outer, physical manifestation’ and ‘an inner spirituality, corporate culture or collective personality’ (p24) and combined they correspond to what the New Testament called ‘powers’, which were a tangible part of life back in New Testament times. Materialism has slanted our impression of them, but perhaps they have not gone away.
For our struggle is not against flesh and blood, but against the rulers, against the authorities, against the powers of this dark world and against the spiritual forces of evil in the heavenly realms (Ephesians 6:12).
For in him all things were created: things in heaven and on earth, visible and invisible, whether thrones or powers or rulers or authorities; all things have been created through him and for him (Colossians 1:12).
For I am convinced that neither death nor life, neither angels nor demons, neither the present nor the future, nor any powers … will be able to separate us from the love of God in Christ Jesus (Romans 8:38-39).
Are these ‘powers’ good or bad? It is customary in my part of the church to think of them (or at least the spiritual components) as ‘bad’, spiritual remnants perhaps of an original fall that led to the fall of some spirits into evil; the same worldview as can be found in the Bible and which John Milton used in Paradise Lost. And it is true that Jesus is never recorded as coming across an evil being that he wished to redeem. He apparently wished to expel all of them from his good creation.
In Wink’s view, however, the powers are:
Good
Fallen
Needing redemption.
He argues that:
These three statements must be held together, for each by itself is not only untrue but downright mischievous. We cannot affirm governments or universities or businesses as good unless we recognize at the same time that they are fallen. We cannot face their oppressiveness unless we remember that they are also a part of God’s good creation. And reflection on their creation and fall will seem to legitimate these Powers and blast any hope for change unless we assert, at the same time, that these Powers can and must be redeemed. But focus on their redemption will lead to utopian disillusionment unless we recognize that their transformation takes place within the limits of the fall.
Wink, op. cit., p 32
Whether or not the Powers can be redeemed (or merely expelled), the material, earthly institutions certainly are created, fallen, and can be redeemed. At the moment this is within the limits prescribed by our current fallen world; in the future it will be fully so, as part of New Creation.
This is eye-opening stuff:
Institutions have a spiritual character as well as a material form.
Institutions are good, fallen, and capable of a degree of redemption.
They will be fully redeemed at the so-called eschaton, the full arrival of the New Creation.
How can the Powers be opposed? How can institutions be redeemed, or at least cleaned up a bit, capturing more of their divine vocation?
I have to skip over a large and brilliant part of his analysis here but the central understanding is that violent overthrow won’t do it. All violent overthrow does is replace one system of spirit-fueled domination with another. A revolution is rightly named: it’s just the turning of the same wheel. What do ‘work’ (and again I am oversimplifying) are the things Jesus taught so directly. Turn the other cheek. Hand over all your clothes if someone takes your cloak. Love your enemies. Do good to those who hurt you. Feed and water your enemies. You want to lead? Be a servant. You want to line up with God’s rule? Be a child. Jesus himself entered Jerusalem on a donkey, not a charger. He won the day by going to his death like a lamb to the slaughter.
The aim is not conquest, but relationship: humanizing the oppressor, so that oppressors are themselves liberated from being oppressed by their own oppressive behaviour: ‘today, salvation has come to this house.’ These same acts also restore dignity and agency to the victim.
That’s how we ‘win’. And the winning may not be seen in this life, or certainly only partly seen, but it is putting a foothold in eternity, it is filling up our storerooms in heaven, it is investing in the future.
Just finished an illuminating book called ‘Recovery’ by practicising GP Dr Gavin Francis. I am drawn back again to the idea of healing (I was in hospital when I wrote this) and really enjoyed how this book taught me things I’d previously groped towards. Some snippets:
Psycho-social
We fall ill in ways that our profoundly influenced by our past experiences and expectations, and the same can be said of our paths to recovery. (p8)
Green and growing
He talks of the difference Florence Nightingale made in the Crimea, how hospitals should have ‘the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet’. (p 13, quoting Nightingale’s own 1859 Notes on Nursing). Windows should look out something green and growing. After her arrival in 1854, the rate of soldiers dying from their wounds fell from 1 in 2 or 1 in 3, to 1 in 50
Convalescence
But in changing times and with new drugs something has been lost:
It’s not possible for me now, as a GP, to admit a frail, elderly patient somewhere for nursing care and convalescence alone – the hospital gates don’t open unless there’s a medical diagnosis, and a plan in place that prioritises getting the patient out again as soon as possible (p15).
You might not find ‘convalescence’ or ‘recovery’ as a heading in the medical textbooks but you will find ‘post-viral fatigue’… Long-term symptoms from viral infections will be different for everyone, but can include varying amounts of breathlessness, difficulty concentrating, forgetfulness, mood changes, insomnia, weight-loss, exhaustion, muscle weakness, joint stiffness and flashbacks.
All these are to be considered normal – not evidence that recovery has stalled or is going (p20) into reverse.
Pacing
He suggests ‘pacing’ as the route forward – not the boom and bust cycle of activity and exhaustion, but steady efforts, frequent rests, small meals, not doing much for an hour after a meal, getting fresh air, sitting down a lot, avoiding exerting. With boom and bust, your world narrows; with careful pacing, it slowly widens.
Work aids recovery
He talks about the world of sick-notes, and that doctors are better coaches than judges. ‘Many of the patients I sign off from the obligation to find a job could undoubtedly work in some capacity, at something, if support were available to help them do it… Work aids recovery in all sorts of ways… If I could sign my patients up to a supportive back-to-work scheme, rather than simply signing them off sick, I would‘ (p27)
A misfortune whose cost should be shared
He notes Aneurin Bevin’s championing of the idea that illness is ‘neither an indulgence for which people have to pay nor an offence for which they should be penalised but a misfortune the cost of which should be shared by the community’ (p 29. Bevan was borrowing his ideas from T H Marshall, a sociologist.)
Photo by Daniel Chicchon on Unsplash. The photo is of San Francisco; note that bridge in the background.
I read a short article by Matthew Taylor, Chief Executive of the NHS federation, in the current Wired magazine (July-August 2023). This is an unashamed abridgement of that fine article.
Taylor points out that the human species is better at developing technology than thinking through its consequences. He sees these issue for the NHS:
A revolution in diagnostics. This really good thing– catching disease early– depends a lot on how willing we are continuously to monitor our health. This is not so simple. Already there are harmless incursions in my life. Under my bed is a device that downloads my pacemaker data and sends it to my hospital in London. One time when I was developing symptoms, they asked for a download, then called me in, then re-timed the pacemaker and fixed the problem: really nice. On the other hand, when I was in hospital recently, nurses were taking observations several times a day. My observations are problematic and sometimes set alarms off. At least twice they sent a more senior nurse to redo the observations as they didn’t believe what a junior nurse had recorded. These constant readings do no good whatsoever to how I feel about myself. They are stressful and discouraging. Heaven forbid that I should have a thing on my wrist that did this to me all the time.
The fact that diagnostics are usually probablistic, not black-and-white. In any case, diagnostics don’t help as much you’d like. If you might develop cancer, or might not, but will develop side effects to treatment, whaddya do?
Inequality. Matthew Taylor points out that technology empowers people, but usually it is only some people, and inequality increases given that other people, already disadvantaged, don’t benefit. (This actually is a slightly curious argument when things are on average getting better, but let it pass.)
Finally he talks about care. He makes some fascinating observations: ‘Medicine is technocratic and scientific; care is human and relational‘. Medical expertise is sort-of expected by us patients; care is what makes the difference to how we feel about our treatment. That is very true in my experience.
Medicine is technocratic and scientific; care is human and relational
He points out this issue is especially important in end-of-life care. End of life treatment is usually the most expensive medical phase in a person’s life, but still ‘a lot of people don’t get the end of life care they want. They might receive expensive care, when they would rather have cheaper care that’s more humane, at home, with loved ones.‘ This is fascinating. Having watched friends die both in government hospitals and in our local (charitably run) hospice, I know which of the two I would choose. Give me the lovely hospice every time.
Perhaps a contribution that people of Christian faith can offer in their last days is choosing not to have every possible intervention to keep us hanging on, but to decide our time’s up, go home, or to a hospice, to face the end of life in peace? It is oddly the opposite of euthanasia, realizing our time has come and accepting it. Interesting.
I’m struck (but then I’m a slow learner; it’s obvious when you think about it) how much health and social justice are linked. For churches, it’s fascinating how important this ‘pre-healing’ ministry is. And any church interested in ‘healing’ ought to be fascinated by the possibilities of pre-healing people before they ever get sick. The good we can do! The changes we can make! Look at this from the current Wired magazine 1, which finds its way to us among articles about virtual wards, remote robotic surgery, and unlocking the NHS’ troves of digital records.
… about one in five people live in poverty in the UK. Poverty has an awful impact on physical and mental health: it is associated with higher infant mortality, lower adult life expectancy, poorer mental health, asthma, diabetes, cardiovascular disease and obesity. It has been estimated that getting your daily calories from healthy foods costs three times more compared to buying poor quality food.
Housing is another big problem. According to the Health Foundation, one in three people reports a problem with the affordability, security, or the quality of their housing. Issues such as mold and damp can lead to respiratory problems and headaches…
Green spaces are another massive issue. There’s a lot of evidence now proving that exercise is like a miracle drug. There is also plenty of evidence that if you provide more open, free, green spaces to people, you end up with higher levels of physical activity in the population, and improved mental health. In 2020, the government itself estimated that if every citizen had access to green spaces, it could save the NHS billions of pounds a year.
… We need to realize that almost all policy has an impact on population health, and think more holistically about what our health priorities are for the longer term.
The wonderful ‘MD’ from the magazine ‘Private Eye’ is cheaper and quicker than any number of inquiries into the National Health Service. One of his main points is that the NHS suffers when society suffers. It is free, like schools, the police, and even the prison service. Hospital doors are always open. So if people can’t get the help they really need, they seek out the hospital or the doctor.
Or to put it another way, there is a link between poverty, unstable homes, abuse, poor living conditions, poor nutrition, generally not being able to cope with being an adult; and ill-health. But ill-health is the easiest to address because all you have to do is troll up to the accident and emergency department.
With all the other things, if the state can fix them at all, there’s the problem of finding whom to ask, and then a process, delays, bureaucracy, forms to fill, queues to be at the end of, and if you reach the front of the queue they may not have what you need.
Schools are the same; they have to take the kids even if their lives elsewhere are crumbling. And prisons have to take whomever the courts send, so they find space for the mentally ill who, if other parts of the state were working effectively, wouldn’t be there at all.
An issue for politicians, then, and perhaps for the Christian community: the main way to fix the NHS, and schools at the same time, and with a side order of reducing the prison population, is to fix everything upstream that leads to people crowding towards the easily-accessed freebies. And the way to fix national budgets, perhaps, is to shift them towards the slow: stable, warm homes, good nutrition, fitness, and friendship and social support that stops people falling ill (and incidentally keeps them happier and more fruitful) in the first place.
Much easier, of course, said than done, not least because it is long-term and even if done well only addresses part of the ‘problem’ of the NHS. (Another part of its ‘problem’ is the Health Service’s ability to keep many of us alive, which requires a lot of maintenance, rather than dead, which doesn’t. The NHS’s successes poisons its own well.)
This affects healing in the Christian context too. A lot of the best healing ministry is, or perhaps should be, not healing at all but pre-healing: the network of love, the care, the personal disciplines, the pursuit of joy and vocation and indeed the pursuit of God himself, which save us from being ill. Real healing restores these; but really real healing prevents us from becoming sick in the first place, at least sometimes.
Of course all this is simplistic, obvious, easy to point out, hard to do, and is anyway only a temporary fix. The Second Law of Thermodynamics is coming for us. We will disassemble soon. The only permanent solution is the Christian hope. But I’m reminded how much healing should have a wide focus –the whole person in a loving network–not a narrow one — such as increasing the anti-depressant dose.
It’s interesting to watch — from the safe vantage point of vast ignorance — cracks in the gleaming exterior of Western mental health care. To say the least, it’s not like flying a plane, where highly trained people, following international standards of safety and expertise, successfully take people to places they want to go. Psychiatry and psychology are not like that. They may want to look like that, but they are not like that. 1 Here are some of the cracks:
The standards aren’t, well, standard. The American Psychiatric Association publishes a thing called the DSM (the diagnostic and statistical manual of mental disorders), currently on its fifth edition, DSM-5. It’s widely referred and accepted and is the product of much scholarly endeavour. But it changes, and practice changes with it. After DSM-4 was published, ADHD diagnoses tripled, autism diagnoses increased 20-fold and bipolar diagnoses 40-fold. 2 This was not a sudden epidemic of mental illness, it was a consequence of widening the categories. So, beware, with the next edition of the book, your illness could become a variant of normalcy, or your normalcy be re-categorized as illness.
It’s subjective, not objective. Physical medicine is at least a mixture of both, blood tests and MRI scans complementing the doctor’s own judgement. Mental illness appears not to be independently testable. This subjectivity on the part of mental health professionals has consequences: I have seen people bounced between diagnoses of Borderline Personality Disorder, PTSD, Bipolar, and schizophrenia in a process that seems a bit like different practitioners sticking random Post-It stickers on people’s heads. (Though it’s worth remembering that people who practice mental health care all are there to do something good for the broken and damaged people whom they meet every day and they want to help them thrive. They are not dabbling with words; getting it right matters. The bitterness of the debate is because everyone cares, not because no-one does.)
Commercial interests are involved. As one kept alive by various drugs, I am very fond of big pharma, but I do acknowledge that they have a commercial interest in selling drugs for mental health, and that must influence their own influence in this subjective area. Certainly different groups of all stripes campaign to change the DSM in their favour, which must mean each DSM is a product of power struggles as well as pure evidence.
It victimizes people. Telling my liver that it is abnormally swollen does not upset my liver too much; telling my head I have a personality disorder, and that, no, they haven’t really found a cure, affects my whole sense of who I am and what I am to do about it.
It oversimplifies, or at least wrongly frames, the problem. Have mental health problems rocketed, powered by social media, relationship breakdown, unwise romantic choices, and covid-19 exclusions? Or have otherwise normal people across our communities been battered by exceptional stresses? Are they, at root, diseased or injured? That matters a great deal for how, and if, you can get well again.
It’s not been great for children. Apparently (according to my source article again) as late as the 1990s it was ‘unusual to prescribe medication or give diagnostic labels to under-18s.’ That is no longer the case. It would be good to know what the evidence is for this change. I hope it’s solid. I can’t help thinking that diagnosing children -a subjective process and one that is inconsistent across practitioners- on the basis of the child’s own grasp of the problem, is a shaky place from which to start chemical intervention or medical labelling.
Can it mean that problems are treated here in the West as primarily medical, rather than, say, primarily to do with relationships, poverty, trauma, abuse, poor choices, or just the kind of ennui that doesn’t know what to aim for or what to aspire to be, or what the point of living is; that we are attempting to treat medically a kind of lostness?
Can it be that we are underplaying the social, the relational, the physical, and the spiritual and overemphasising the medical? This I find really intriguing because I think I have learnt that healing in any sphere is basically about shalom, peace and contentment; that’s the mark of the healed, even if those same healed ones limp around in broken bodies and perhaps with damaged minds. To thrive before God and people, in all circumstances, that’s healing.
Feels better already. (This is a photo of Singapore by lee junda on Unsplash)
Again I’m writing about healing, partly because I’m living it, partly because what I picked up from many years as a Christian now seems so wrong and there is so much rethinking to do.
I’m still rethinking, and I’m still breathing, both of which I feel are important.
The last few weeks: we bought a disabled buggy, a wonderful little thing, and took it on holiday. (It folds into the car.) We were with our daughter and son-in-law and grandchildren and there was much walking on the prom and the cliff-tops, all of it now painless and easy. Nor was anyone needed to push me around in a wheelchair. And I could give the kids rides. So now in God’s riches I have an electric bike for longer journeys around Cambridge and an electric buggy for when I am with others.
Then yesterday I took the train down to my specialist heart centre in London where they retuned the pacemaker in my chest. A week or so before that, after phone calls from me, I had downloaded the pacemaker data and sent it to the hospital via a piece of kit that lives under our bed. The hospital looked at it and called me in and did the necessary reprogramming. Amazing. It is early days for this treatment but I feel less breathless and my wife tells me I am no longer blue to look at. Those guys at the hospital (both female guys as it happened) don’t just measure your ECG; they modify it and tweak it. They don’t take an ECG lying down. They press buttons and see what happens. Such fun!
This techno-assistance, though, seems a far cry from the New Testament where the Lord Jesus or the apostles did their stuff and immediate physical transformation appears to have happened. My electric buggy and the retuning of the extraordinary electronics that supply my heartbeat seem a different order of a thing to that. Why can’t (as Naaman asked) a prophet just wave his hands over me and make me well? Does this techno-medical intervention really count as ‘healing’ at all? Or is it a second-best solution for those whose lives are so cold and lacking in faith and zeal that the real healing stuff never happens to them? What is healing after all?
The New Testament contains hints that what I have heard doctors call the ‘psycho-social’ parts of healing are important, just as are the physical deliverance parts. Ten lepers were cleansed: only one came back to say thank you. Was there a lingering psycho-social unhealing among the healed lepers? Body fine, head in wrong place. Demons are driven out of the Gaderene demoniac. He is seen sitting clothed and in his right mind. But Jesus tells him to go home to his family, rather than joining the band of disciples. Is that to complete his healing? To address the pyscho-social roots of what got him in such a state in the first place? As it is, Mark records that the former demoniac takes up a speaking ministry in the Ten Towns, and Mark is silent over whether or not that was what Jesus really intended for the man. Interesting.
Then I watch friends, with a cancer diagnosis say, put their lives on hold until the treatment is completed. I observe, I think, I might be wrong (I hope I am), that they are putting all their eggs in the physical healing basket. Zap the cancer, go back to the life we had before. Nothing else matters.
I am so not so sure that this is right. (Of course I have to allow for the fact that I am sitting in my garden, at my ease, contented, writing this, not suffering some medical emergency or hospitalization which would indeed require a lot of effort and focus.)
But still. I am coming to believe more and more that healing is life today, bread today, thriving today and that it is entirely God’s business how he delivers that. All good gifts come down from the Father of lights who does not change as the shifting shadows: buggies, pacemakers, holidays, instant miraculous physical transformations, play, vocation, nice food, people you love and good relationships with God and others.
I am coming to believe more and more that healing is life today, bread today, thriving today and that it is entirely God’s business how he delivers that.
Of course, you have to qualify that idea. There are seasons of emergency actions, long wintry paths of mourning, times of brute endurance of the deeply unpleasant. It’s hard to speak of ‘thriving today’ in the face of those. But still. Healing is thriving. Healing is enjoying our lives, nourished by God’s daily bread, despite everything, in these ramshackle tents of ours, before they are replaced for good with the eternal mansions of glory.
Sorry to be writing about healing again. But I keep learning new things. For the longest time I had two ideas about healing, which were complementary if incomplete:
See a doctor, and the result will be somewhere on the spectrum between no cure at all and a complete cure. Quite a lot of conditions can be eased, slowed, ameliarated, sometimes with pills, sometimes with pills and side effects and it’s great. Or at least it’s better than the alternative and it’s pretty good.
Visit the New Testament where there is a quite a lot of instanteous healing, and some instances of progressive healing. This observation influences a lot of Christian practice, both in high-octane mass healing meetings and also sometimes when people are prayed for ad hoc by their Christian peers.
I generally have come to prefer the medical route to (this particular) Christian-inspired paradigm. Each route, doctors or hoped-for miracles, leads to highs and some lows; the Christian route, as described, in my experience, tends to result in more lows than highs. One big reason for this is that doctors are better at managing expectations and describing likely outcomes than Christian pray-ers are. Plus, doctors are less likely to blame people for their sickness (even when they deserve it). Christians in my experience don’t usually blame the patient overtly but do say things like ‘God we don’t understand why you haven’t healed this person,’ while fixing a troubled eye on you. Doctors are professional and Christians are amateur and it rather shows.
Doctors are better at managing expectations and describing likely outcomes than Christian pray-ers are.
I think God is active in both realms. In the week I write this, the much anticipated £1bn Astra-Zeneca headquarters has just opened, a short bus-ride from my home, further cementing Cambridge’s position as a biomedical centre, employing thousands of people, some of whom are friends of mine, busy researching and pioneering further medical cures.
Because of their work, all over the world, mothers will not be parted early from their children, granddads will get to play with their grandchildren, life will be extended and tragedy deferred or defused. God cannot not be in this great project for the common good.
What’s going on inside the head
I feel both these routes towards wellness are incomplete as they stand. And I know that doctors know this too and also talk about the ‘pyscho-social’ aspects of wellness. What is this? Two people can have identical MRI scans, say of their spines. One will say, ‘it’s terrible, my spine is crumbling’ and their disability, and bitterness, will cast a long shadow into their family. They will be a pain as much as their spine is. The other will say, ‘basically I’m fine’ and carry on much as before. Same crumbly spine: different head and heart.
A few weeks ago we visited a National Trust property with my family. I get breathless very easily. For the first time ever (I think) I borrowed one of their electric buggies. This all-terrain craft let me join everyone as we rambled round the gardens. It was wonderful: no pain, no breathlessness, no pretending to be interested in a leaf while my breathing caught up, no struggling to talk, no watching everyone get cold as they kindly adjusted to my slower-than-toddler pace. It felt like healing. It was healing. Of course, physically I was just as before; but in my head, where I live, I was thriving. Healing is thriving, being at peace, content, happy. It happens through Christ. My National Trust buggy was a healing. Really. Miss that and you miss quite a lot.
Look at this from Private Eye‘s wonderful ‘MD’ (aka Dr Phil Hammond) (15-28 October 2021 p 8)
The model of general practice – trying to manage multiple complex risks and needs in very brief encounters – has long been unsafe and unsustainable. You have 10 minutes to help an 80-year-old woman who is arthritic, breathless, recently bereaved and on 12 tablets. It takes three of those minutes to walk her from waiting room to consulting room.She wants to talk about her late husband; you want to ensure her breathlessness was not a red flag for a life-threatening condition or a side effect of the pills you have prescribed.
It takes another three minutes to undress her and get her up on the couch to be examined. And yet her main reason for coming was loneliness.
….
A study of Norwegian health records, published in the British Journal of General Practice, found that — compared with a one-year patient-GP relationship — those who had had the same doctor for between two and three years were about 13 percent less likely to need out-of-hours care, 12 percent less likely to be admitted to hospital, and 8 percent less likely to die that year. After 15 years, the figures were 30 percent, 28 percent and 25 percent.
Healthcare depends crucially on relationships, and staff knowing and understanding you.
Imagine a GP being resourced enough to combine a vocation as a doctor with the time and stability to develop relationships with patients. Vocation and relationships … just like in a book I recently wrote, which I may have occasionally mentioned in this blog. And which is still ‘forthcoming’…
