July 2011


Gone is the time when people believed that medicine could cure all known illnesses and the doctor was the high priest of the arcane rites. The advent of the internet has meant that patients may be as informed about their diseases as their doctor and the medical consultation is more a dialogue between experts than a trip to the Oracle. It’s more about containment and management than cure. Popular acceptance of the healing arts practiced by alternative and complementary therapists has led to a greater understanding of the core relationship between mind and body in the achievement of well being. 

By far the greatest demand for gastroenterological services comes from patients with recurrent or chronic symptoms of dyspepsia, abdominal discomfort and bowel upset and long term conditions such as Irritable Bowel Syndrome, Chronic Liver Disease, Inflammatory Bowel Disease, Coeliac Disease and Barrett’s Oesophagitis. A modern GI service will not only need to respond rapidly to gastrointestinal emergencies, but also to monitor and facilitate  the self care of long term gastrointestinal conditions. 

In the future, more patients will be encouraged to care for themselves while their condition is monitored with simple blood and stool tests in their local health centre. There will be greater emphasis of self help groups, which could  be facilitated by specially trained health care professionals; practice nurses, dietitians and counsellors, and resourced by the third sector; the patient charities (e.g., Core, Coeliac UK, CC(UK) and The IBS Network). The IBS Network, for example, publishes its own self management plan, operates a telephone helpline and offers medical advice by email.

Patients with long term gastrointestinal conditions crave the confidence of a consistent, responsive and reliable service. This may well be better supplied within the patients’ locality, avoiding unnecessary referrals to hospital and allowing gastroenterologists to focus on the increasingly sophisticated and complex diagnostic and therapeutic procedures required for the more life threatening and complicated conditions. 

Freed up from day to day management of chronic conditions, it could be that specialists will adopt a more supervisory and educational role, monitoring the test results of patients with chronic life threatening GI illness through shared websites, responding to email enquiries from local health services, training local health care professionals, advising patient charities, and  preparing educational videos to be disseminated via local television services.

There will be less separation between primary and secondary care in future.  It seems likely that the bulk of gastroenterological services, including diagnostic endoscopy, will be conducted within local hospitals and health centres, which specialists will visit to advise and consult. For example, dyspepsia could be managed in the community with a test and treat approach to H. Pylori, while health teams will be set up to tackle major public health issues such as chronic alcoholic liver disease and obesity.

Population screening will be increasingly important.  It is already here for bowel cancer and it is likely that simple, sensitive and specific biomarkers will become available for other abdominal cancers; pancreas, ovary, liver, stomach and oesophagus as well as coeliac disease, IBD and viral hepatitis.

And as always, the focus of gastrointestinal research will continue to shift with fashion, establishing evidence for changes in health care, improving outcomes, eliciting patient experience, estimating the nature of well being, developing appropriate biomarkers for screening tests, and seeking insight into the relationship between the gut, the mind and the alien within, the all consuming intestinal microbiome. The future may well be not so much orange but beige or brown!

This was the piece I was asked to write to celebrate Core’s 40th anniversary.  Core, previously the Digestive Diseases Foundation, is the charitable limb of the British Society of Gstroenterology.  

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If only.  If only they hadn’t put the banner on top of the roof at Lower Loxley.  If only Nigel had employed somebody to get it down.  If only David had not suggested that his brother-in-law climb up.  If only David had admitted this when it all happened.  And if only he hadn’t felt compelled to admit it later when Elizabeth was beginning to get over it all.  

Did he expect Elizabeth to understand and forgive him?   Didn’t he realise that the knowledge was bound to shatter the fragile supports she had manage to construct over the weeks since Nigel fell to his death?  Not only would it dismantle the story she had constructed to enable herself and the children to get over it all, but it would also destroy the trust that had built up between brother and sister and leave her without any support at all.  So why did he do it? 

David wanted forgiveness, redemption; he wanted to salve his conscience.  He couldn’t bear the guilt of Elizabeth’s gratitude.  His conscience wouldn’t let her think he was a saint, whereas he felt exactly the opposite.  So he sought absolution from the only person who could give it to him.  But this was such a selfish act.  In admitting his guilt, he was only thinking of his own feelings.  He didn’t think about the consequences of his actions. 

Openness and honesty are not always the best policy. Sometimes you have to bear your own guilt.  Admitting it can only damage the aggrieved.  Let them keep their story; it’s all they’ve got.  Don’t take that away.  Don’t try to justify or explain, only to yourself.  Live with it, understand, don’t attempt to excuse, just understand and in doing so understand your own humanity. 

But this is radio, not real life and in fiction, the best story lines are the most dysfunctional.  So what will happen now?   Will David get so depressed he will take his own life?  Will Elizabeth leave the village?  Will Roy be without a job?  I see a tipping point has occurred and events will take the trajectory that is of most interest to the script writers.

They were best mates, soldiers, adventurers; they had shared danger, drink, women, the best of times together.  Iago was married, he had children, but domestic bliss was not the mainspring of his life.  He lusted after excitement, adventure, the comradeship of like-minded men and loose women.   Life was good.  He and Othello had pitched up in Venice, where they intended to have a good time.  But then Othello appointed Cassio as his lieutenant and fell in love with Desdemona.  These were the contingent events that instigated the disaster.  Iago,  who had long enjoyed the stable though unrequited love for Othello that male comrades in arms enjoy, felt excluded and plotted his revenge.  First Cassio and then Desdemona had got in the way.  Iago was furious; the dark powers of his personality were released and he plotted his revenge.  

Othello was naive and vulnerable.  He had not married and had little experience of women.  He came from a ’Taliban’ culture that kept their women covered up, out of sight and temptation. Throughout history, men have feared the power of women and sought to control them;  their sexual appetites, once released, could destroy a family, a tribe a Kingdom.  We might wonder whether Othello’s mother was sexually incontinent, but for whatever reason, Othello had never previously had a woman he could not control until he met Desdemona, the Venetian beauty, who came from a culture where flirtation and intrigue was a way of life. 

Othello was out of his depth and feeling very vulnerable.  He was overwhelmed by the romance, the experience of being in love.  Those we fear, we put on a pedestal; to Othello, Desdemona appeared  chaste and virtuous but he did not trust her sexuality, even when it was focussed purely on him. Her youthful lustfulness was a contaminant. 

Iago was more the politician, the schemer, the spin doctor who could manipulate other people.  To him everything that was good was just a weakness; something to be exploited.  Iago was so envious of his friend’s infatuation.  How he wished he could experience that kind of all consuming love.  But he was trapped in a loveless marriage and now he was in danger of losing the only real friend he had in the world.  How much he hated Desdemona, how furious he was at being passed over for Cassio.  In the cynical, loveless world he inhabited, he did not care what others thought of him, he had to destroy the one he loved and in so doing destroy the only thing in himself that was good and vulnerable.  He hatched a plot to ensnare both Cassio and Desdemona; he invented an intrigue between them and slowly dripped petrol onto the embers of Othello’s suspicions.

Othello, so courageous in battle, so wise in council, was vulnerable in love and thus susceptible to Iago’s insinuations.  He was the heroic fool; it did not take much to infect him with suspicion.  

But Iago  was not a sophisticated man.  He really didn’t know his own mind;  he just projected his feelings out into others and encouraged their baser motives.  Iago sensed his friends weakness, his corruptibility, his terrible addiction to the pain and pleasure of sexual jealousy.  He was playing with fire, but he did not appreciate the explosive nature of Othello’s fear and rage and thus did not anticipate the disaster that would ensue.  Nevertheless he was responsible; he infected his friend and made him do it.   As the play winds to its dreadful conclusion, he feels nothing but contempt for himself.    

Iago on the Couch is the topic of an after dinner discussion at The Freud Museum between the actor,Simon Russell Beale, director Terry Hands, and psychoanalysts David Bell and Ingres Sodre and produced in DVD by The Institute of Psychoanalysis. Freud and Shakepeare are natural partners, such amazing observers of human nature. They provide moral luminescence without moral judgement. Shakespeare acts out the pain and the doubt; Freud lives with it.    

At the age of 14, Rene witnessed his mother, being pulled out of the river;  her lower body was exposed and her nightdress was over her head concealing her face.  Was it her, and if it wasn’t where had she gone, what had happened?   But Rene never talked about it;  he didn’t trust words.  He just expressed it through the medium he had control of; painting.  He was an artist philosopher.   Perhaps all ‘creative’ artists are.  What is art, if not visual metaphor?   

Rene Magritte just took it further.  His painterly skill allowed his imagination the freedom to use the image to describe the thought.  His images express the way the mind connects ideas.  They have a dream like quality because that’s how our mind sees things when we are not fixed by the consciousness of real time and space and the rules of language.  So like dreams, his images break the rules, size is relative, shape distorted, there are impossible associations.  In The Dominion of Light, he merges light and day, street lights illuminate a street against a bright afternoon sky,  a bird flies over a dark sea, its shape filled in by a bright cloudy sky.   A crescent moon is placed in painted in front of the dark tree,   the artist creates the woman by painting her, the landscape on the canvas becomes the view, the window pane breaks up into pieces of the landscape viewed through it, a  couple kiss with cloths over their heads, an act of intimacy between two people who are concealed from each other.   

The theme of concealment dominates his work.  He creates illusion by representation.  Magritte liked a mystery, the anonymous detectives in bowler hats coming to arrest and assailant, the woman’s body on the operating table, the same bowler-hatted figures of differing sizes descending like rain in front of the buildings of his home town.   

Magritte wasn’t so much looking for meaning, he was more interested in the process of how we represent ideas; he wanted to express ideas as he perceived them.  Our mind, as the extension of the vast neuronal network that is our brain, makes connections between ideas and actions and feelings.  Having conceived of a certain way of thinking, we return to it again and again, establishing neural connections like paths through the forest.   But our mind’s reality makes connections which are impossible in the real world.  Magritte shows us the way our mind thinks about things.  So a pipe is not always a pipe but represents something much more potent, a carrot morphs into a bottle, a bird becomes part of the sky, clouds are like object and thoughts. 

Magritte recognised how words condition our thought, fixing and channelling the meaning, so he experimented with different words for objects.  Words tell us what an object is, but our mind sees other connotations.  Poetry plays with this idea.  It explores the power of words, but also their limitations.  Freud and Jung explored the same territory in their papers on symbolism and dream, but at least Freud had the honesty to admit that ‘sometimes a cigar is just a cigar’.    

Magritte, The Pleasure Principle,  is currently being exhibited at Tate Liverpool on Albert Dock. 

 

At the beginning of a love affair, one might ask oneself either ‘what am I getting into’ or ’what am I getting out of?’  Every entrance is an exit.    The only real question is,  ‘Are we going to go through (with it)?’ 

The pivotal moment in Emma and Jerry’s seven year long affair occurred just two years into it.   Emma was sitting on the bed in the Kilburn flat they had bought together, excited to see him again, when wistfully, nonchalantly but not so, she said.  ‘Are we going to change our lives?’  There was a pause.  Then Jerry replied, ‘we can’t’.  That was it; the start of the illness from which the relationship succumbed.    

They were both in their thirties, married, their children were still young; they had their obligations.   The time was crucial.  For Emma and Jerry, thirty plus represented a loss of freedom, the acquisition of responsibility.  No longer, it seemed, would life hold that frisson of possibility; it now stretched ahead, that slow decline of disillusion.   

In the affairs of men and women, time is of the essence. It both offers the opportunity and then snatches it away. That chance meeting, the inventive creation of space, free afternoons, rendezvous snatched between appointments; at the time, it seems their love could last forever; feeling expands time.  But in real time,  such intensity of passion is ephemeral. 

Falling in love is predicated on hope, and hope cannot be sustained forever.  If the affair goes on too long without a resolution, then hope dies.  The fulcrum of reality is followed by the inevitable winding down of the clock to when time together, like the flat Emma and Jerry rented, becomes empty and meaningless.  If an affair doesn’t go anywhere, if it doesn’t change the lives of the participants, it will die and something in them will die too.

The happily married never need consider these issues.  As the philosopher and psychoanalyst, Adam Phillips, comments, for them the future is the same as the past.  ‘Outwitting time and change, they construct a monument to continuity among the promiscuous ruins.  Valuing a relationship because it lasts, they live as if time proves something.’  

It was a poignant and clever device for Pinter to write the play backwards; time running in reverse.  The end of an affair is always there right at the start.  They both knew it was impossible that first time they kissed at the party; that’s what made it so risky and exciting.   They couldn’t!   But why not?  They were in love.  And love skews perception, makes the impossible seem plausible.   

Except it’s not.  Life is not make-believe, however much we may try to make it so.  There are incompatibilities; the taken-for-granted and the precarious, the tedious routine and the impossible risk – the thing that couldn’t be done.  There is safety and danger, habit and passion, love and lust, attachment and desire, marriage and affairs.  Of course we want to have our cake and eat it.  Why not, we protest, we are integrated beings. Isn’t our body but a representation of our meaningful soul and isn’t our mind the way we think about it?  Why can’t we be more honest?  

But in the affairs of men and women, honesty and kindness are at odds with each other, Phillips asserts.  ‘We lie because we can’t admit our desire and we don’t wish to hurt or be hurt. We lie in order to keep our options open, but also to find out what our options are.  The successful lie creates a fragile freedom.  It shows us that it is possible for no one to know what we are doing, even ourselves.  The poor lie – the wish to be found out – reveals our fear about what we can do with words.  Fear of infidelity is fear of language.’  

Monogamy is reassurance. It’s like believing in God.  Not everyone believes, but most live as though they do.  Erotic life, Phillips writes, is political, disruptive; ‘it rearranges the world, it makes a difference to the ways we and other people organise their lives.  Every infidelity creates the need for an election; every separation divides the party.  Friends may share, cooperate and be honest.  Lovers have to do something else. Lovers cannot be virtuous.’  

Rules by which we govern our lives are ways of imagining what to do.  ‘Our personal infidelity rituals – the choreography of our affairs – are parallel texts of our marriages’.   Successful affairs reproduce the loneliness of marriage.   Unsuccessful ones intensify it.  Serial monogamy, it could be argued, keeps us moving on, maintaining the hope, restoring meaning and renewing life.     

Adam Phillips would claim that ‘guilt, by reminding us what we mustn’t do, shows us what we may want.  It shows us our moral sense, the difference between what we want and what we want to want.  Without the possibility of a double life, there is no morality.  Because we are always being sexually faithful to somebody, every preference is a betrayal.’  

He continues, ‘what is coupledom, but a sustained resistance to the intrusion of third parties.  The couple needs to sustain the third parties in order to go on resisting them.  The faithful keep an eye on the enemy, eye them up.  After all, what would they do together if no one else was there.  How would they know what to do?  Two’s company; three’s a couple.  Everyone feels jealous or guilty and suffers the anguish of their choices.  No one has ever been excluded from feeling left out.’ 

Betrayal by Harold Pinter is currently playing at the Comedy Theatre,  London. Kristin Scott Thomas is  wonderful as Emma; she was sexy, playful and very attractive; how could Jerry ever resist her.    The programme included  notes from Adam Phillips Book, Monogamy (Faber and Faber, 1996).

(please don’t read this as a moral statement, more an attempt at analysis)

The idealistic Konstantin, humiliated by his famous mother, the actress Irina Arkidina, his play publicly dismissed as ridiculous, tries to shoot himself but instead shoots a seagull and presents the corpse to Nina, the daughter of a neighbouring landowner, whom he adores.  Nina is disturbed and disgusted, but shows it to the sinister Trigorin, a famous writer and house guest, who notes down the metaphor for future use.   Nina is in thrall to Trigorin.  She sees in him an opportunity to escape the cage of the family estate and take flight as an actress.  She follows Trigorin to Moscow, becomes pregnant and is rejected by the writer who is being kept by Irina. The baby dies, her family lock their gates against her, and she is transformed into the kind of tragic heroine that the painter, George Frederick Watts depicted in his allegorical studies of hope and poverty. She becomes the seagull.    

Watts had taken as his child bride the teenage actress, Ellen Terry, in order to protect her from the same fate, or so the story goes.  The marriage failed.   It was supposedly never consummated. According to the amusing fiction by Lynne Truss, Watts just wasn’t interested in her that way.  Released from Watts’ protection, Ellen soared upwards to become the most famous actress of her generation. 

The Seagull possesses the usual Chekhovian themes; the country house, a self indulgent Russian bourgeoisie, decadent, bored and in decline,  the threatening clouds of the oncoming revolution  And the actors have the same familiar roles, the ageing actress and matriarch playing to the balcony while the theatre crumbles around her,  the elderly and ailing uncle, the owner of the estate, representing old Russia about to vanish forever, the frustrated and bullish farm manager, fed up with the old ways and wanting progress,  the desperate young author, the naive and fragile girl, and the doctor, perhaps Chekhov himself, a reflective observer, not entirely engaging with it all.  Soon all will be scattered.  Seen from this perspective, the seagull presents a broader perspective on the oncoming crisis,  a fragile but beautiful way of life soon to be chopped down like The Cherry Orchard.  Of course, the characters seem hysterical and self centred, they are all in love with love as a form of escape, the end of their world is coming; what else can they do?  It wouldn’t be theatre if they all behaved sensibly and worked together. 

The Seagull is currently playing at the Arcola Theatre in Stoke Newington; not an area I know well but accessible via the London Overground.  The theatre is a converted warehouse.  The set and seating are rough and ready but the cast and direction is as accomplished as many productions you might see in the West End.  Geraldine James plays the actress and matriarch.  The doctor is played by Roger Lloyd Peck, recently seconded from the Dibley parish council.  Chekhov billed the play as a comedy but nobody in Stoke Newington was laughing.

The Watts Gallery opened at Compton on the North Downs outside Guildford on June 18th.  It is said to be the only major gallery in the country devoted to a single artist.  Watts was immensely popular in his heyday; two rooms were devoted to his paintings in the newly opened Tate Gallery at Millbank but the fashion for Victorian art changed and by the nineteen fifties you could pick up his paintings for less than a hundred pounds.  His museum at Compton fell into disrepair but was rescued by coming second in the BBC’s Restoration programme and then getting a 4 million pound lottery grant.  Watts’ paintings are not exactly cheerful.  The most famous are allegories of themes like hope, poverty and despair.  They are sombre and intense; Watts saw his mission to produce work that encourage young people to think about moral issues.   

Lynne Truss didn’t treat Watts kindly.  In her novel, Tennyson’s Gift, which described with humour the characters that circled the bard of Farringford, she portrayed him as self obsessed and sexually repressed.  Who knows, if he had been more responsive to Ellen’s allures, she may never have felt the need to escape to the stage.