In death everyone is equal: journeys of wounded healers

This week’s blog comes from downtown New York, so I hope I have got the timings right in posting it now! New York is one of my favourite cities and I have been here many times. One of those trips was to present at a conference and visit colleagues at the Mount Sinai Roosevelt (now Mount Sinai West) and Mount Sinai St Luke’s hospitals. Sadly, on this trip I don’t have an opportunity to catch up. It was something I wanted to do, and in particular, to hear how their approach in developing an Accountable Care Organisation (ACO) was working. Although I think their model is slightly different to the ACOs that are beginning to emerge in the UK, the same principles of providing comprehensive and co-ordinated care to individuals underpin both approaches.

  

Quite coincidentally, one of the emails I received before leaving for New York was an invitation to attend the International Practitioner Summit (2018) which this year takes as its focus the notion of the Wounded Healer. It will be the 10th anniversary of this conference, which although heavily featuring the work of medical colleagues, is a great conference for folk from all health care professions to attend. Like many other conferences, the Summit brings together academic and clinical practice, and draws on research as well as experiential knowledge. Unfortunately the Summit dates clash with something I have already agreed to go to. However, when I was reading the draft programme, I couldn’t help but notice that Dr Abigail Zuger, Associate Clinical Professor of Medicine, from the Icahn School of Medicine at Mount Sinai, was one of the key note speakers. 

I am disappointed not to be able to take part, as the programme looks wonderfully diverse and far reaching in terms of promoting, maintaining, and understanding what makes for good mental health and well-being in individuals and communities. There is a clue in the conference title ‘wounded healers’ that points to the recognition that none of us, be we practitioners or patients, are immune from experiencing mental health problems. The term ‘wounded healer’ is one attributed to the psychologist and psychoanalyst Carl Jung. This notion is that the analyst treats patents because the analyst is themselves ‘wounded’. Indeed research has shown that nearly 75% of counsellors and psychotherapists have experienced one or more wounding experiences which influenced their subsequent career choice. The psychotherapist Alison Barr, has undertaken a great deal of research into the relation of early life experiences to mental health problems in adult life. She describes the wounding experiences as most often including abuse (sexual, emotional and physical), personal mental ill-health, and the life-shortening illness of others

Of course, in acknowledging the ‘wounded healer’ there are many implications for all those engaged in therapeutic relationships, both in terms of preparation for practice and the supervision in practice. These implications were really brought home to me when I visited the 9/11 Memorial and Museum last week. I had been to New York a few times before 2001. I have been up the twin towers on each occasion. I have been back to New York since the 2001 attack and have always felt humbled by the way that folk remembered the 9/11 day. However, nothing had really prepared me for seeing the 9/11 memorial, Reflecting Absence.

Reflecting Absence is made up of  two memorial pools that sit within each of the footprints of the two twin towers. Around the sides of each pool are the names of the 2,977 people who lost their lives as a consequence of the attacks. The memorial pools are both simple, yet breathtakingly magnificent with water gently flowing ensuring it remains an oasis of calm amidst the hustle and bustle of neighbouring Wall Street. Michael Arad’s design was equally striking and respectful. Unlike some of the folk that appeared to be there purely to get the best selfie possible. 

I was struck by the name placement – some of which were grouped together to show allegiances, such as the names of people from the different fire and rescue service, or organisations that occupied the offices in the twin towers and surrounding buildings, or the passengers from the four planes involved in the attacks. Edith Lutnick, of the Cantor Fitzgerald Relief Fund, who was involved in the public and family consultations over the name placements, said of the decision over how to order the victims’ names: “Your loved ones’ names are surrounded by the names of those they sat with, worked with, those they lived with and, very possibly, those they died with”.

|In addition, there is an underground 9/11 museum at the memorial site. It is built 70 feet below ground and houses artefacts, message recordings, damaged emergency vehicles and parts of the twin tower and the hijacked planes. Although the museum is designed to evoke memories without causing additional distress, particularly to the family of the victims and the first responders, I chose not to visit it. It didn’t feel right somehow. The two memorial pools sit within a new plantation of some 400 trees, one of which is a Callery Pear that survived the original attack and has now been replanted. It is called the ‘Survivor Tree’, and is a symbol of both the resilience of the city and its residents, but also of all those whose lives were ‘wounded’ by the original attack. I guess some of those wounds, of disbelief and heartache, and hurt might never heal. 

From Rochdale to Karachi in 7 Days

Last Tuesday I attended a celebration dinner to mark the 71^st Pakistan Independence Day. It was a fantastic night. The colour green was everywhere (yes the green clogs came out), the music was foot-tappingly good, and the smiles and happiness were infectious. Iron-Bru, Coke and water were the only drinks to be had, but the wonderful food more than made up for there not being any alcohol! There was a serious side to the celebration too. Prayers were said, and beautifully sung, and although I couldn’t understand Urdu, my table companions told me the prayers centred on peace and continued security for the country. Gaining freedom and independence from the British Raj (the British run system of governance in what was called British India) was remembered. The British Raj had lasted from 1858 – 1947.  

These days of course, that region is now divided into the sovereign states of Pakistan, India and Bangladesh. Pakistan got its name from the Urdu words ‘Paak’ which means ‘pure’ and ‘stan’ meaning ‘land’ or ‘place’. I have only been to Pakistan once, and that was to Karachi. With a population of 21 million people, it’s the most populous city in Pakistan, and the sixth most populous city in the world. I got a sense of this when I arrived at the airport. The queues to get through passport control ran into literally thousands of people – it was a completely mesmerising sight. Fortunately, I was met by colleagues of my host, Professor Adibul Hasan Rizvi. They seemed to know the officials at the airport and before I knew it, I was on my way out and into the city.

The city streets teem with people. Some of the city’s infrastructure is very poor. For example since 2015, when the city’s sewerage system failed, Karachi residents have been discharging 100% of their raw sewage into the nearest coastal waters. It is also not one of the safest places in the world. Everywhere I was driven during my stay was in a locked car, with a guard armed with a Kalashnikov in his hand. Every time we returned to the hotel, the car was searched for bombs, before it was allowed through the hotel’s formidable defences. However, like the Independence Day Celebrations, the food was absolutely fantastic, and especially so for vegetarians! 

I was in Karachi to visit the Sindh Institute of Urology and Transplant (SIUT). This fantastic institute is run by Professor Rizvi. He has been the director of SIUT for some 40 years. Over this time he has slowly built this organisation into one of Pakistan’s largest public health organisations. Pakistan’s health system suffers from corruption, mismanagement and a lack of resources. Many people in Pakistan simply cannot gain access to or afford even basic health care, let alone the specialist health care provided at SIUT. The SIUTs mission is to provide ‘free public health with dignity’. If this mission statement sounds a little familiar, it may well be because Professor Rizvi came to Britain after he finished his medical education and training in Karachi. He undertook a surgical fellowship and remained in Britain for the next 10 years.

An interesting connection for me was that he undertook the surgical fellowship at Salford Royal Hospital and worked in many of the Greater Manchester hospitals. The work of the SIUT is both pioneering and carefully based on contemporary research. Education and training form a big part of the way in which SIUT undertakes its work. Doctors come from all over the world to learn and share knowledge. However, other professions, such as nurses, do not have the same skill level or autonomy as nurses in the UK. SIUT carried out the first Pakistan cadaver kidney transplant in 1995. They quickly established a reputation for making cadaver organ transplantation a reality. They have become the ninth Islamic country after Saudi Arabia, Turkey, Iran, Egypt, Kuwait and others to carry out cadaver organ transplants. These are all countries often known for other more undesirable reasons.

My trip to SIUT was an extraordinary experience. If I compared some of the things I saw there with what we expect in the UK, I probably would have been horrified. Patients were nursed in corridors, there was often little privacy other than a thin curtain and the rest of the ward, the medical records system and storage was reminiscent of what I imagine the tower of Babel to be like. Yet out of all this confusion and apparent chaos, goodness came about. There was no doubting the high esteem many of the patients and their families had for the staff who cared for them. There were many elements of the Independence Day Celebrations last week that reminded me of this visit. A catalyst for this was an appeal for donations for a cancer charity made at the event. Whilst I am undoubtedly sure that many donations will be made, and vital equipment and drugs will be purchased, what they really need is a skilled, knowledgeable and experienced health care workforce. 

If we think that in the NHS we have a workforce shortage, it’s nothing compared to what is being experienced in Pakistan. I am not sure what the answer might be to solving the workforce issues in either the UK or Pakistan, but unless we do, sooner or later the quality and availability of what we have come to expect from our health services will become impossible to provide. Perhaps the implementation of the ambitious Health Education England (HEE) ‘earn, learn, and return’ scheme for overseas nurses could be accelerated. Now that really would be worth the reported increase of HEE boss Professor Ian Cumming’s salary (now somewhere between £200,000 – 205,000) and the reported increase in his bonus pay range to (now up to £10,000 - £15,000). Just saying… 

People Watching Post 1984: A Brave New World for the NHS

Over the years, one of my favourite pastimes has been people watching. From Spain to Singapore, France to Finland and Australia to America, I have sat at pavement cafes and bars and watched the world go by. It’s better if there are two of you. Sitting together, you can wonder why that man has a frown, that woman a smile, that young couple walking but not talking, and so on. This kind of people watching might also include commentaries on clothes, shoes, hair styles and guesses as to where they might have come from or are going to. Of course, some readers might see this pastime as somewhat voyeuristic and intrusive, and I guess up to a point it might be so. However, my people watching is simply observing everyday folk doing everyday things, and I think I do this without any infringement of their privacy. 

Of course this is not always the case. The usual explanation of voyeurism is the sexual interest in or practice of spying on people engaged in intimate behaviours that are usually considered to be of a private nature. Voyeurs generally observe others in private and not in a public place. I was surprised to find that voyeurism is classified as a mental disorder in the Diagnostic and Statistical Manual (DSM). There is another more sinister type of people watching, and that is the type often portrayed in stories of dystopian societies. 

Now I have yet to see the TV adaptation of Margaret Atwood’s The Handmaid’s Tale, but I guess I will at some stage do so thanks to catch up television. I have, however, read both Aldus Huxley’s Brave New World (first published in 1932) and George Orwell’s Nineteen Eighty Four (first published in 1949). These are all examples of dystopian novels. They are all set in some fictitious future, and all three books feature real-world issues such as politics, religion, ethics, society, technology and psychology. These same world issues are as pertinent today, as they were when these books were first published. 

Today many of the terms used in these books, particularly 1984, are part of contemporary language: Big Brother, thought-crime, newspeak, and Room 101. Indeed I used the term Big Brother just last week when I went to collect my new car. I was taking out some finance to cover the value offered for my old car and the cost of the new one. Long gone are that days where you were required to produce three recent pay slips, and proof of address and so on. Now it is all done by computer – even the signing of the contract was done electronically. What piqued my anger was to get onto the finance form and complete the application, I had to first answer five questions. I was asked for the first two initials of someone who I might have a mortgage with; the last five digits of one of my bank accounts; length of time living at my current house; and a couple of others.

Each of these questions had five answers for me to choose from, and only one was right of course. The salesman thought my irritation at being asked these questions was strange. He said they (the finance company I hope) could see everything about my finances, where I banked, mortgage, shopping bills and any and all aspects of my financial health and well-being. In these days following the recently updated General Data Protection Regulations (GDPR), I was appalled that anyone should have unauthorised access to personal data in this way. It really did feel like Big Brother was watching me. As I wanted to take my new car home, I had no real choice but to go along with it.

The experience made me ponder a couple of things. What other information about me was being held without my knowledge? Amazon send me recommendations based on my recent browsing history, with everything from books to garden furniture. Every month Tesco send out money saving coupons for me to use based upon what I had purchased in the months before. If I use certain hashtags, the number of followers on twitter goes up (or down). Which when you stop and think about how much of our lives is lived through online and smart technology, is a very frightening thought. The other thing to cross my mind was given the financial sector could collate, analyse and act on my personal finances and spending habits, why hasn’t the NHS managed to do the same with my health records and life style choices? Or maybe they have, and simply not told me! 

Way back in 2016, a five-year allocation of £4.2 billion was made available for information technology development. 50% of this was ring-fenced for existing programme up-grading or replacement; the other half for new programmes. It is not enough money of course, but it is enough to make a start. There is a NHS IT Strategy which has five aims: empowering people to maintain and manage their own health, illness and recovery; supporting clinicians in delivering high quality care at all time, particularly developing electronic records to help share patient information; to integrate services across health and care; managing the health care system in a way that reduces the burden of data collection, supports quality improvement and enables complex modelling for health and care planning; to create a future where the NHS becomes world leading in genomics, big data analysis and keeps the British public’s confidence.

To deliver all of this, there is the small problem of having a secure network infrastructure, which can support data collection and dissemination, and an ecosystem for folk to control their own data and as such allow the NHS to access this data in much the same way as the banking sector does. With such an IT enthusiast as the new Secretary of State for Health and Social Care Matt Hancock, I might just get Amazon to send him a copy of Orwell’s 1984 – he might find it a useful reminder of what to avoid.