Book Review: The One Memory of Flora Banks

I read The One Memory of Flora Banks (Author: Emily Barr at www.emilybarr.com)  last weekend when I was on call at the Children’s Hospital of Eastern Ontario. On a day when I was providing service to a busy emergency room, it grounded me to be considering the plight of a young person who had suffered considerable trauma and had lost her memory because of it.

This is the adventure of a 17 year old girl named Flora Banks who has anterograde amnesia, which means that she cannot remember anything that happened after the event which caused the amnesia. To help her manage her life, Flora writes down every important thing that she must remember. Many, many things she wants to remember are written into notebooks, but the most important things are written on her hands. Of the important messages, one is prominent and it is a tattoo that says: Flora be brave.

Flora’s memory problems, we are told at the beginning, are the result of a brain tumour that was removed at age 10. The book is written in Flora’s voice and so the reader can experience what it is like to live inside Flora’s brain. To an observer, it would seem as though Flora has lost a lot of her capacity. But from inside Flora’s brain, the reader realizes that this is not the case. One of the most important messages of this book is never to underestimate a person’s abilities.

Even though Flora is capable of more than is evident, she is very hopeless about what she has lost and worries about what her life holds. One evening this changes when a boy kisses her and Flora remembers this kiss for longer than her usual several hours. Immediately, Flora is hopeful that this boy, or his love, holds the answer to her regaining a functional memory. She sets off to find him, despite the limitations of her memory and without anyone supporting her.

There are many days in my work as a psychiatrist for youth that I see young people coping with having a chronic medical condition that could limit what they might achieve. Like Flora, they have periods of hopelessness when they sadly wonder what their lives will bring. But many of them, like Flora, refuse to be defeated by despair. I don’t care if they disagree with me about their medications, or their symptoms or their diagnosis. I hope that I am true to the spirit of hope that lives in them, and I work to be worthy of that positivity.

This is an important book because we can all benefit by knowing Flora. Not all of the people who love Flora trust her hope any longer, but she meets a lot of new people in her voyage to find love and her memory and they do trust Flora’s hope. Please read about Flora and resolve to help at least one person stay hopeful.

(Note: I read the 2017 Penguin Random House edition of The One Memory of Flora Banks. The photo is the cover of that edition.)

Game of Thrones Madness?

For the past few weeks, I have felt as though my husband and sons, not to mention many friends and acquaintances, have joined a cult. As a matter of fact, I often spend Sunday evening with my family, but tonight and for weeks to come everyone I know will spend Sunday evenings with characters from a fictional land.

Here are some of the comments I have heard in the past few weeks leading up to the 7th season of Game of Thrones which starts tonight on HBO:

Question: “What if we tape the whole series and binge watch them all at once for a kind of party?”

Answer: “You can’t do that because you’ll definitely have the plot spoiled by everyone talking about what has happened.”

Question: “If I go away for a week, do you think I should stop following the Twitter feeds and other social medial?”

Answer: “OMG I never thought of that.”

Question: “Do you think we can find out in advance who’s going to be live tweeting during the show and stop following them?”

Answer: “Good idea – and put up warnings for your followers not to post.”

Question: “Dr. Beck, will we be allowed to watch Game of Thrones on the unit?”

Answer: “Is there no escape?”

I know exactly why the series does not appeal to me. I find too much graphic violence disturbing. It’s perverse, but I am more fascinated by trying to understand why certain television series can develop cult-like followings. How does it happen that certain shows can become so popular that there’s no point in even inviting anyone over on a certain day around a certain time unless you’re holding an event related to a certain series. My gourmet dinner club held a Downton Abbey event. I know of people holding Game of Thrones parties as the new season starts.

The research on why certain cultural phenomena become popular indicates that the capacity to identify sympathetically with characters, especially when the story line allows us to struggle with concepts of good and evil, can be cathartic. It can help us to resolve our own conflicts safely, especially if, in discussing a show’s dilemmas with others, we can begin to understand how our friends or family members are themselves resolving conflicts.

The cultural phenomena that are television shows or movies have never been as cathartic for me as those I read and, of course, there is research on that as well. This research considers the reasons why some people are drawn to stories told via one medium over another. Again, this research shows that we are drawn to the medium that most engages our emotions, that allows us to enter the conflict of the story safely, so that we are not overwhelmed. I don’t mind imagining a bloody conflict, but I find it overwhelming to watch. I will also admit that I skip over parts of tv shows or movies that I find too difficult to tolerate, but I never have to do this when I’m reading a story.

Finally, whether you watch or read or listen to a story, stories show us how difficult it is for humans to live in the present, to “enjoy the moment”. We flip to the back of the book. We watch every episode. Do we not all want to know the end of the story, even when the story is good all the way along?

Not Just Any Village

In recent months, I have come to learn more and more about the difficulties indigenous youth have in obtaining mental health services. In part, this is because local, provincial and federal news reports are calling attention to these difficulties but I am also very much aware of the needs of these young people in my own community and practice.

It is especially distressing that, despite the goodwill of governments and their financial investment, all the measures that have been taken seem to have no impact. How can this be?

I have come to understand this only in the context of being a mother myself and it is only using this reference point that I can make sense of why our efforts have been so ineffective. Let me see if this helps you to understand what is missing.

Imagine that your child has serious mental health problems. She is twelve years old and started using substances like cannabis, or alcohol, or solvents. (I have seen indigenous youth who started using substances, especially solvents, as young as seven years old.) School is a struggle and because of this, the child feels hopeless about the future. Perhaps as a parent, you can understand this because you were in the same situation at her age. You are desperate for your child to get help and so you agree that she should travel hundreds of miles away from home to get that help. You agree to this even though you will miss her desperately, and worry about her all day, every day. You know she is anxious and will cry because she misses you and her family, but you know that you cannot travel with her because there are other children to care for, or your job, or even because you yourself do not have the emotional strength to support her. Who cannot relate to the desperation of this situation? Of this parent? Of this child?

The research evidence is overwhelming that children’s health depends on family support. It takes the first year of our life to be able to walk. It takes us until we are two to utter a few words. We begin to have the skills to read, and write, and do math around age five. The evidence says that our enormous brains can take until age 25 to fully develop. We clearly need personal support to grow and develop and every culture relies on families to provide that support. When we are unwell, we need that support even more.

How do we expect these children to heal when we send them away from their families? If we must do this, could we not at least set up those sophisticated telehealth networks and facetime for parents and children and grandparents and brothers and sisters to stay in touch? “It takes a village to raise a child” is an African proverb that recognizes the universal truth that we need our families and kin – our village.

When I am having a hard day, I will often count my blessings and the blessings I remember first are the people of my personal village: my children and husband and family and friends.

Do we really believe that indigenous youth (or any youth) will become stronger mentally away from their families? Have we really learned nothing from the experience of those sent away to residential schools? Are we really not listening?

If those African philosophers will permit, I do have one slight modification to their proverb. I agree that it takes a village to raise a child, but not just any village will do. Each child deserves the support of their own village: their own family, their own friends, their own people.

(Photo credit: Family Ties sculpture by Kevin Barrett)

#endpolio

There is nothing in medicine more elegant than a public health strategy, especially one that is well-planned and conducted efficiently. One of the best examples of such a strategy can be found in the Global Polio Eradication Strategy. The hope is that such a strategy will do for the world what a similar strategy did for Canada.
In 1953, polio peaked in Canada and, in a one year period, there were 9,000 new cases and approximately 500 deaths. The Salk vaccine was introduced in 1955 and the Sabin oral vaccine in 1962 and within 20 years of the 1953 peak, polio was under control in Canada. In 1994, Canada was declared “polio free”. In its peak years, the disease was so widespread that everyone knew a child who had developed limb paralysis because of polio. Of those who developed paralysis, 5-10% could develop paralysis of the respiratory muscles which could result in their death. It was for these people that the iron lung was developed.
Polio was a major worry for Canadian parents in the 1950’s. For many children, polio would cause fever, fatigue, vomiting, neck stiffness, headache and limb pain. I had two aunts who were pediatric nurses and I remember them speaking about the helplessness they felt nursing a child who had seemed to have a mild illness and then suddenly began to develop paralysis. My aunts have spoken about how much parents would dread whenever their child developed a fever.
When the Global Polio Eradication Strategy was initiated in 1988, there were still 350,000 cases of polio worldwide. The strategy was launched in response to a Resolution passed at the World Health Assembly. Within 20 years, thanks to 3 million volunteers worldwide, there has been so much progress toward eradicating polio that the World Health Organization believes it might be possible to eradicate polio by 2018.
The last bastion for polio is in three countries: Nigeria, Afghanistan and Pakistan. The challenges that perpetuate polio in these countries include insecurity, weak health systems and poor sanitation. It is possible for polio to migrate from these countries to other countries whose health systems are weakened by the same factors. For example, cases of polio are now being tracked in Syria.
The public health professionals and advocates involved in the efforts to eradicate polio are determined and diligent, and they will succeed. From the offices of the World Health Organization in Geneva to the grassroots volunteers around the world, there is a hopefulness in their websites and statements that is undeniable. What must be done to achieve their goal is simple: every child must be vaccinated against polio. It takes a lot of work to ensure that this is happening but many countries, and not just countries as rich as Canada, are managing this.
It is easy to understand why this can be managed. Anyone who has witnessed the suffering of a child with polio will want to prevent it. These witnesses will work to ensure that every child can be vaccinated. It is simple and elegant. You can watch the progress on social media by watching #endpolio. You can watch public health at work. You can watch the end of polio.
(Credit: This image of an iron lung is taken from the website of the Canadian Public Health Agency.)

A Lesson in Resilience

Here in Eastern Ontario, the weather is beginning to get to me. We have had a cool, wet, rainy spring with long periods without sun and I find myself contemplating the emotional impact of poor weather, especially at a time of year when we are used to being outside, enjoying the first picnics, hikes and patio activities of the summer season. A few years ago, however, I read The Idle Traveller by Dan Kieran, a travel writer from England. I truly enjoyed this book that emphasized focusing on the journey and one of the best lessons I learned from this was not to let the weather affect your outdoor plans. This is one lesson anyone can learn from the British and I saw it in real life just last month when I visited London.
Just after I arrived, there were 3 days of sunny weather and everyone was out in the parks, sunning themselves in shorts and tank tops. Now, lest you get the impression that it was also warm, let me tell you that it was sixteen degrees centigrade out. Sixteen degrees!! I was chilly in the wind and was certainly not in shirtsleeves as many were, but it was a vivid reminder that the British do not let a little cool weather get in the way of spring.
The lesson about the weather is not the only reality check you can get from the people of Britain. In the last three months, there have been three terror attacks in England: two in London and one in Manchester. They were deadly, and frightening, and there is every reason to believe there will be another one. But no matter the level of terror alert, the parks are full of people on sunny days and everybody goes about their business as if it’s been just a regular three months. They even went to a concert with the very same artist, in the same city where two weeks earlier 22 people had been killed and many more injured. Even children had been killed or injured and still people went with their children.
The determination of the people of Britain not to let weather or terror disturb their days is evidence of their resilience, and that resilience can be cultivated. The personal qualities that are evident in resilience include a positive attitude, optimism, an ability to manage emotions and an ability to learn from setbacks.
Let’s think about some of these qualities. Positive attitude can be found in all those BBC sitcoms whose characters keep stressing “mustn’t grumble”. The entire British attitude toward weather is typical of the national optimism. Second World War posters telling citizens to “Keep Calm and Carry On” are just as popular today as they were 75 years ago. As for learning from setbacks, the Angles, Saxons, Danes and Normans were able to invade Britain but in modern times a determination to “fight on the beaches…on the landing grounds…in the fields and in the streets” has kept Britain’s enemies at bay.
Having just returned from London shortly before the attack at a Manchester concert and the attack on London Bridge, I find I have a great admiration for the extraordinary courage that manifests itself so ordinarily, as if it only what is expected. If only I could be that brave!

(Photo credit: This photo was found on Facebook after the attack in London in March 2017.)

One Hundred Years of Women Doctors

Over the next ten years, various women’s medical organizations from around the world will be celebrating their centenaries. I was contemplating this while attending the Centenary of Britain’s Medical Women’s Federation last week. The American Medical Women’s Association celebrated its Centennial in 2015. The Federation of Medical Women of Canada was founded in 1924 and the Australian Medical Women’s Federation formed in 1927 even though Australia’s first medical women’s society was founded in 1896. In 2019, the international body to which all these associations belong, Medical Women’s International Association, will celebrate 100 years of operation, the oldest international medical association. Many of these organizations took as their inspiration the women’s suffrage movement – the theme colours of Britain’s Medical Women’s Federation are exactly those of Britain’s suffragette movement.

This means that there have been one hundred years of women physicians’ influence on medicine and health care. What has this meant for health and for the status of women physicians?

From the beginning of medical women’s organizing activity, women doctors have concerned themselves with the health of women and children and with advocating for opportunities for women doctors. All told, most of these women doctors’ organizations would likely believe that they have been more successful on behalf of their patients than on their own behalf.

Despite growing numbers of women in medicine, women continue to be underrepresented in the highest paid specialties, in university professorships, in clinical leadership positions and in most other medical leadership roles. This is true even in those countries in which women have formed the majority of the medical workforce for many years, such as China and Russia. The underrepresentation of women in powerful medical roles is of such concern in most first world medical women’s organizations that advancing the position of women doctors has become a primary concern for most of these organizations. “Equal pay for work of equal value” has its own meaning for women doctors!

As for health and healthcare, medical women and medical women’s organizations have championed women’s and children’s health, and especially women’s reproductive health. A look at the websites of any of the national organizations listed above will demonstrate this important work. The work of the members of Medical Women’s International Association (MWIA) has been so noteworthy that its projects have ensured that it has official working relations with the World Health Organization (W.H.O.).  MWIA also maintains Category II Status with the Economic and Social Council (ECOSOC) and is involved in the Immunization Programmes of the United Nations Children’s Fund (UNICEF). MWIA is represented in all three of the United Nation Centers, New York and Geneva by Permanent Representatives. MWIA is a Founding Member of the Council for International Organizations of Medical Sciences (CIOMS) and continues to be actively involved in that organization. MWIA also sends representatives to the European Women’s Lobby.

The projects of the various national organizations and of MWIA itself are as varied as its members. In recent years, MWIA has worked with ZONTA to distribute birthing kits to those women in poor countries who have their babies at home, often without any birth attendant – not even a neighbour. As well, one Past President, Dr. Gabrielle Caspar of Australia has collected ultrasound machines in that country to deliver to African countries. MWIA members from around the world are compiling a series of typical cases of intimate partner violence into a training manual for use around the world. The cases will cover an unprecedented example of cultural and social impact on intimate partner violence.

One hundred years ago, at the time that women around the world began to insist on a role in government by means of the vote, women doctors began to insist on a role in medicine that would allow them to have the impact on health, and especially women’s and children’s health, that was needed to improve health standards in general. These pioneering women physicians realized that healthcare must be equal for all. They fought for it then and continue to champion the same goals today.

(Note: The above photo is of the original members of MWIA in Geneva, Switzerland at the time of their founding meeting.)

My Predictable Clinical Life

In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.