Insecurity in health

We live in insecure times. We watch how the world has embraces war yet again (at this time Ukraine-Russia, Israel-Hamas) with dictators nearby, intent on the misuse of power. Employment is an issue, and the monthly pay-cheque doesn’t go as far. Politicians seem to let us down (so we are led to believe) more than not. COVID put a wedge between social remedies, and we all became more isolated than ever. Crime on the rise. Gun violence migrating north. Bastions of democracy are pilloried by those who put self-reward ahead of ‘liberty, equality and fraternity.’ It all plays out on the National News every night, and we go to bed feeling the buzz of caffeine without the caffeine.Glenda Roberts saw me last month. She is 73, a retired office manager, widowed with three adult children. She presents for review of palpitations, breathlessness and dizziness. “My life has changed so much in the last year, ever since Jack….” Her voice trails off, and she looks for answers on the floor.I make a mental note: this will take longer than the average consult. Once physical disease is ruled out, there will be a need for empathy, understanding, explanation, counselling - and maybe drug therapy. I’ve seen a hundred Glendas this year. You know, multiple diary entries on her Holter monitor (with 4 PACs, and a ventricular couplet underneath). You recall she has mild hypertension, treated with Ramipril 5mg daily. Her EKG shows sinus rhythm, with borderline voltages for LVH.I welcome her, and try to establish trust and open communication. “I am sure these symptoms are real, and distressing for you. My job is to look for a cause, which isn’t always physical. Hopefully we can check out your heart and circulation and give you some good news today.” Glenda doesn’t want to be brushed off: she just wants to feel well. She willingly answers questions about stimulant use (caffeine, inhalers, amphetamines, etc.), possible hyperthyroidism (goitre, tremor), cardiac malaise (exertional chest pain, syncope, previous heart mischief and failure), pain, fever and organ dysfunction, etc.“My mother had a pacemaker at 88…” she tells me. Yes, but in the setting of advanced age, valvular heart disease and COPD. Glenda has a normal cardiovascular exam, other than systolic blood pressure of 145mmHg (“Oh, it’s less when I take it at home…”). I peruse the bland panel of bloodwork, and conclude - she is well. Physically. Oh, sure, I’ll book her for a stress test, and review last year’s echo. But I’m not going to chase down urinary catecholamines, serum zinc or a brain MRI.“How are things with the family?” I ask, casually. “Well. Eh. They keep in touch.” “In touch? So where are they now?” I hear mention of several cities around the globe.“Jane is having job troubles, as usual. Would be different if she had a husband, but she’s all on her own, in Sudbury. I contact her every day. I guess she has been a concern from the get-go. Just unlucky, both at work and now her health.” I sense this lonely, intelligent widow carries stress like a cross, hiding it from friends (of which she has few). I open up a bit. “Yep, been there. Changed days. Your children will always call mum for advice, eh?” “Cancer,” she says, her anguished gaze capturing mine. “How do you get ovarian cancer?” She doesn’t cry.Her sense of ‘insecurity’ was intense. Her coping mechanisms, minimal. Sure, she had a home and food, money and social stability. But her symptoms, which were real and distressing, were generated by fear, isolation, uncertainty and the lack of . . . an understanding ear. This meeting was more therapeutic than diagnostic: her excellent GP knows the score, and wants to help as best she can.What percentage of a medical practice deals with the consequences of such insecurity? A substantial amount, I think. And the ‘just-to-be-sure’ blood-work and imaging tests that become the more-and-more-routine - are not without cost.This topic is covered comprehensively in Astra Taylor’s book, ‘The Art of Insecurity.’1 In it, she identifies our social order as having been built on a foundation of insecurity, now challenged by the near-impossibility of home ownership, progressive global warming, increasing health challenges—and the dissolution of moral values we associate with stable government and social democracy.Some of this ‘insecurity’ comes from the innate nature of humanism, but other forms are manufactured by advertising, the media and government. She quotes Franklin Roosevelt’s remark (1935):‘The civilization of the last one hundred years, with its startling industrial changes, has tended more and more to make life insecure.’ More than ever we live in a world where we need protection—whether it be locks on our doors, passwords on our computers, or circumspection when answering strangers on the phone. Of course, those less fortunate (the poor, unemployed, homeless) are the most vulnerable to such malaise.What does insecurity have to do with health? A great deal. When Public Health measures are taken care of, it’s the tough stuff that’s left. Our frail and isolated elders are often poorly equipped to cope with calamity. Sure, this isn’t wartime, or a global famine, or another Great Depression, which our parents and grandparents navigated. But expectations were different then. Families supported families. Children looked after parents, in their homes. Seventy-three-year-old mums were quiet, mostly.Glenda agreed to counselling—for now. And a sleeping pill when her insomnia becomes troublesome. She knows that frank depression and anxiety are diseases that are treatable with a variety of drugs, and she’s coming back for follow-up. Jane will come with her next time. Her care-givers will be more prepared. Mental health services should be more accessible, don’t you think?Thomas Hobbes, the 17th century philosopher, moved away from the Stoic image of mental calm to one of physical security (forfeiting some personal liberty in lieu of strong governance). Fortunately, the concept of ‘security’ has been recognized as an inalienable right, and is included in several important documents.1 Freedom, as we know it, is a material benefit of security: that sounds like a major plus to me.What is the significance of patient insecurity as it relates to health? We recognize that access has become compromised; increasing complexity has compartmentalized care; costs of getting care are hidden and not so hidden; and of course, COVID (and restrictions pertaining thereto) has generated panic and anxiety of huge proportions. Maybe if we stopped for a moment and acknowledged our mortality, and celebrated our freedoms and successes, we would be less insecure and more appreciative of what we have (rather than what we don’t). I think this is an educational challenge. We have vaccines and antibiotics, surgeries and nutritional diets, housing and protective institutions—we just have to make them work together. Co-production means patients are active partners in this effort. They judge the indices of quality outcomes, they help plan distribution of care, they are the instrument of measurement and feedback.We must all work to reduce ‘manufactured’ insecurity whenever possible (the media, the internet, government, etc.)As for caregivers, Taylor states “Taking care of others rewards and replenishes us, and helps ensure we are cared for in return. By giving the gift of care, we take care of ourselves.”1 I think this is mostly true: as long as we have the respect and understanding of our patients, and appropriate resources to do good work, maybe we can make this Medicine lark work. With some degree of security.Reference:The Age of Insecurity. Astra Taylor (Massey Lectures). Anasi Press Inc (2023) ISBN-978148701932The Universal Declaration of Human Rights. The International Covenant on Economic, Social and Cultural Rights. The UN Declaration of the Rights of Indigenous Peoples (ratified into Canadian Law 2021)

Casebook of a Community Internist

Insecurity in health

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Hector Baillie

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