Weird, wonderful, fun
I spent November working in a tropical disease clinic, in the comfortable and familiar setting of a wealthy non-tropical country. At this clinic, I saw patients with malaria, dengue, neurocysticercosis, Giardia, amoebae, scabies, and cutaneous larva migrans (Latin for “worms crawling in your skin”). I met people with suspected bat viruses, typhus, lymphatic filariasis, and delusions of parasitosis. I saw lots of monkey bites. I giggled (only inwardly) as I diagnosed a pregnancy at a parasitology clinic: a real-life punch line to a medical joke if ever there was one. Mostly I simply saw people for post-travel symptoms or check-ups, who usually turned out to not have anything tropical. And it was a whole lot of fun. It was a treat, to the point of provoking guilt — and then wondering whether guilt makes sense. Am I really motivated by the needs of others, as I would like to be, or am I just pursuing my own satisfaction? Is it okay to have this much fun? Is it okay not to have this much fun?
We all have an affinity for novelty, but in medicine it feels self-indulgent. Ideally, health care needs and caregiver interests would align perfectly, but novelty-seeking seems to risk seriously distorting this ideal. If my intellectual stimulation depends on encountering the weird and wonderful, who’s going to deal with the more commonplace and therefore more important ailments? And how does a patient with a rare but serious illness feel about their doctor’s delight in finding such a rare bird?
Tropical diseases were always included under the “weird and wonderful” banner in medical school, being rare birds indeed in Canada. While I was preparing a presentation on liver parasites during my rotation, it struck me that, of course, that this perspective is a strictly local illusion, and quite backwards. Over a billion people on this planet are currently infected with one or more tropical diseases (WHO). The prevalence of intestinal worms surpasses 90% in some communities. Really, ‘normal’ is much more accurate than ‘weird’. And they are surely not wonderful in the sense of pleasant. Tropical disease isn’t weird or wonderful. If anything is weird and wonderful here, it’s my own freedom from tropical disease! I happen to live in an environment which, both by nature and by human design, provides me with extremely effective prevention against these conditions, so that I have never had to worry about them. How lucky am I? It seems obvious to me now, but when it first occurred to me in November, it felt like a minor revelation.
Even luckier, this line of thought lets me justify my novelty-seeking. (Cognitive consonance! Excellent!) It’s okay so long as the apparent novelty is an artifact, so long as my interests are well-aligned with global need. Right? Well, do I really need to be that strict with myself though? Should I apply these standards of taste to others?
I do think preferences are malleable, and I often try to use my ethics to modify my tastes (and I believe I have succeeded). But surely this malleability is not infinite, so we should not place “good enough” forever out of reach. If you want to serve for a long time, you need to do what you love. Be open to the idea that you could learn to love new things, and try to be aware of whether pursuing your interests actually does anyone else any good, but trying too hard to contort one’s mind in the name of perfection is probably unhelpful. I wouldn’t like to be a career politician or an early childhood educator or a trauma counselor, no matter how much good I think might be done in such roles. A wise colleague during my rotation at the tropical medicine clinic advised me to find something that makes me glad to get up every morning, excited to go to work, for that is how I will elicit the greatest things from myself. Hard to argue with that!
With this in mind, I tour the country interviewing for training positions in public health. At my first interview, earlier this week, I gushed about how much fun it would be to try to eradicate something tropical, and the interviewers chuckled with me at my ambition (in sympathetic recognition, I’d like to think, and also perhaps at the disease-centric rather than person-centric view of public health that that ambition implies, which might be a little bit naïve and even gauche). Meanwhile, I am reading around schistosomiasis control strategies in advance of my planned trip to Tanzania, and reading the drug distribution and education project proposal written by my Tanzanian medical student colleagues thrilled me to my core. As do lots of other public health issues. If only I had more time to read and write about these things! Residency can’t come soon enough!
These slippery people 
“Is it okay to have this much fun?”
Nope, work should be strictly a job- no fun allowed under any circumstances.
“Who’s going to deal with the more commonplace and therefore more important ailments?”
I wish you had come to Michael Hayden’s talk last week.. he talked about how he was the only person interested in studying these rare neurodegenerative genetic diseases for a long time, but that seemingly obscure work led to *really* important findings about basic biology that are now used to develop drugs for conditions like chronic pain that afflict so much of the world’s population. Therefore, I strongly object to the notion that only commonplace ailments are important. It’s impossible to know what will turn out to be an important finding in the long term.
But, I can empathise with feeling a little strange when you realize you’re really excited about a disease state. I say you can be intellectually excited about a disease while retaining compassion for the patient. My guess is that clinician-researchers manage to find a balance between the two.
“Try to be aware of whether pursuing your interests actually does anyone else any good”.
Define “any good”. Is good only measured by the immediate relief of symptoms? Does spending time in meetings ever do anyone any good? What about on planning? Or on research? Even if the intervention doesn’t work? Even if the results are inconclusive? My answers to those (as you might guess) are yes, yes and YES, as long as you’re passionate enough about the subject that the setbacks don’t turn you off the work completely, and as long as you spend enough time thinking about what you can learn from what hasn’t worked.
How does thinking about eradicating a tropical disease ignore the people afflicted by it? I’m confused.
Have fun in Tanzania!
“I strongly object to the notion that only commonplace ailments are important.”
They are more important in that they cause more suffering, so more preventative and therapeutic resources should be directed at them, and that’s all I meant to discuss in this post. Research resources are a different issue, and I agree that they should not be so tightly tied to public health or any other long-term outcomes, but only because such outcomes are much harder to predict for basic research.
“Any good”: no, you don’t have to see the actual concrete result of your efforts for them to do good. Meetings and such are means, not ends (except to the extent that people like having meetings), but of course they can do good as one necessary step in a larger effort. I suppose I use “do good” as shorthand for “contribute towards an effort which you can reasonably expect to eventually have a net-positive impact on people’s lives”. For any given positive outcome, imagine all the innumerable things that a group of people working together could potentially collectively do to bring it about, and then try to do at least one of those things. Then re-evaluate and repeat.
And of course, a focus on disease does not equate to ignoring patients, but I think it does miss the mark slightly. Disease eradication is a means, and subjective well-being/overall health is the end. Instead of picking the means a priori, it seems to me as though a more effective approach would be to first look at all the things that cause ill health in a population, and then work backwards to choose the optimal means to address that.
By “commonplace” did you mean “with a large global disease burden” or solely measured by the # of afflicted patients? Because I can think of many commonplace ailments that cause less suffering on an individual and societal level, compared to more rare diseases. E.g. common cold vs. HIV.
Your definition of doing any good is rather broad. I’m struggling to think of any human endeavor that it wouldn’t encompass, except for the most extreme cases of torture and gross environmental destruction.
I also don’t understand how or why you would work backwards to fix ill health in a population, it seems like such a broad and inachievable goal. Why not start with “babysteps” (e.g. disease eradication), that have already been proven effective, and once those are done re-evaluate and see what else needs to be fixed (now with a healthier, more productive, parasite-free etc. population)
Yes, I meant large global disease burden. Thanks.
Hmm. I’m afraid I’m unable to think of a non-broad definition of doing good! So I am comfortable with being rather broad.
If targeted disease eradication is the only thing we know how to do that’s going to be helpful, then by all means we should go ahead and do that. If we have more than one option and can’t do them all, we shouldn’t just pick the most fun option. We should try to get some sense of overall health needs and then start with the things that seem most likely to have the biggest impact.
I don’t think I ever said we should pick the most fun option, although I am likely to see anything that gives exciting and measurable results as fun.
So, can you give me a scenario of ill health you’ve seen where the targeted eradication of a disease (I’m assuming infectious disease) wasn’t likely to have a bigger impact on the health of the population, compared to other approaches?
No, you didn’t – I did. I was tempted to pick the most fun option (disease eradication) without stopping to consider whether something else might do more good. Also I don’t have an example of the inferiority of disease eradication close at hand, but I don’t think I need one because I’m not making that claim: rather, I’m claiming not to know what’s best, so I think the burden of proof is the other way around. The claim that eradication of one disease is the best approach to health improvement is the claim that needs verification. There are lots of ways for a ministry of health/philanthropist/donor government to spend money on health: maybe training birth attendants plus merely controlling malaria would save more young lives than spending all your money on trying to eradicate malaria, so let’s evaluate the evidence for the various possibilities before picking one, as I failed to do when I said “eradication would be fun”. (insert here: standard Paul Farmer-acknowledging caveat about also not accepting the supposed resource constraints you’re told to operate under, and standard warning against false dichotomies/all-or-nothing thinking in service planning.)