Upon commencing the eighth decade of life
1999; Elsevier BV; Volume: 354; Linguagem: Inglês
10.1016/s0140-6736(99)90276-3
ISSN1474-547X
Autores Tópico(s)Global Public Health Policies and Epidemiology
Resumo"And the thoughts of mortality touch the mind."–Virgil I am 70 years old and, without insisting on a precise definition of the adjective, healthy. I need spectacles to write and read. I have a hearing aid for committee meetings–if I want to hear what is being said. To get onto my horse, I need to use a mounting block. I no longer like to climb higher than 12 000 feet, either up mountains or in small aeroplanes. I work 10-12 hours a day. So far, I have been blessed with the great gift of the gods–luck. I have had my share of accidents and illness. I have surrendered redundant parts. Thanks to expertise, care, love, and the pillar of homoeostasis–redundancy–I have always recovered. I have many ambitions left. In recent years I have even acquired a new one, which is connected to my ineradicable habit of reading medical journals. To reach my goal will require luck and circumspection, for my new ambition is to avoid blame for my demise. According to my reading, illness and death are caused by social injustice or are self-inflicted by lifestyle. There were years in my youth when I was the victim of deprivation. To be sure, this was not while my mother was looking after me, for she managed, wonderfully, to provide me with food, shelter, hygiene (if we discount bedbugs, an accoutrement of middle-class life in Budapest in those days), warmth, love, and happiness. After I left her, at times I had no food, no roof, and no soap. With determination, luck, and the help of many people, I managed to prevail without lasting damage. Fortunately, I was never short of friends, affection, recognition, and success. Also, I always succeeded in engendering enough hostility to experience a healthy amount of stress. I shall not be able to blame society for any illness that looms ahead. According to statistical evidence, cardiovascular disease or cancer is in store for me. In either case, it will be my fault. When I run on the treadmill, as required by my aviation medical examiner, what stops me is the heat on my soles generated by the rubber belt. Chances are, however, that I shall succumb to a myocardial infarction, in which case it will obviously be due to a combination of Dutch cigars, Hungarian salami, Swiss chocolate, Viennese cakes, Italian spaghetti, my refusal to jog or to use a stationary bicycle, and my combative, domineering, and restless way of life. One would have to add poor weight-control to the list; this is due to beer. I would be similarly accused if I had a stroke, although, in that case, I could make a counterclaim and reintroduce the social dimension–for the greatest risk of stroke in my life occurs during committee meetings. Cancer? The big five? I can deal quickly with the lung. The issue is clear: cigars, notwithstanding the fact that my heirs may succeed in proving, with the help of a contingency-fee lawyer, that it was not mine but the tobacco industry's fault. Colon or rectum then. Bad news for me. Fat (lard in fact), red meat, beefsteak tartar are the obvious causes, as well as my refusal to indulge in fibre and the unforgivable fact that, ever since I left my mother, I eschewed spinach, carrots, and beans. Pancreas? Beer, red wine, Hungarian paprika, raw bacon, onions, coffee in the morning, coffee during the day, Irish coffee in the evening; then there is the Danish cheese, Dutch cheese, and French cheese, the bluer the better. Bladder perhaps? Smoking again, needless to say. Chemicals–I always failed to avoid chemicals. I neglected to read the list of ingredients on my candy. If I did notice a series of coded symbols under the "additives, preservatives, and colouring", I failed to identify them, to ascertain their toxicological characteristics. I, foolishly, relied on the regulatory agencies that are supposed to protect us from poisons. I wish I didn't have to consider the prostate. If my demise resides in that troublesome organ, I shall not escape blame. A few will whisper that I have put this awkward freak to culpably infrequent use. Most will claim, confidently, that on the contrary my fate was brought about by overindulgence, and precocious demands. Or will my skin lose its patience with ultraviolet light; will it wildly mutate, mitose, ulcerate, metastasise, protesting my move to latitudes that require the pigment my enterprising ancestors have lost? If so, it shall be asked: "Why did he have to go there? Why did he, if he had to give in to his love of deserts, not wear protective clothing? Why did he, on his cherished mountains, not cover himself in protective cream?" Oh, irony; my mother paid our doctor to irradiate my pale skin with his quartz lamp winter after winter so that my bones should not bend like those of a Limey … Let's think about infections. Since I grew up I have lost my reluctance to wash myself, so I am protected from many contagions. I would be vulnerable in an influenza pandemic, which surely is brewing among my friends–the sandpipers, ruffs, godwits, and wagtails in the tundra–to be passed on to Chinese pigs for fortification and flown in Boeings and Airbuses around the globe. One gets influenza by getting too close to people. "He never kept his distance", the verdict would be, "he mingled, shook hands with everyone, and kissed the nurses in the corridor, in the theatre even, in his exuberance after a difficult operation". HIV is a more likely candidate. My lifestyle is risky. I engage myself in frequent encounters with a population of which at least 25% are seropositive. I try to be careful, and I try to use effective barriers, but the risk of an accident is great. Earlier this year, when we attended bomb-blast victims, we had 600 wounded lying on the floor in the hospital, and if one wanted to stop the bleeding, one had to wade in blood. If I contracted the little refugee from the chimpanzee on that day, I am obviously to blame since I did not wear goggles, and I did not wear an apron. If not the vessels, cancer, or infection, there is the possibility of Alzheimer's disease, or another debilitating condition of the ageing brain, against which evolution is unable to select because the disease strikes late in life when its genetic predisposition may already have been passed on to another generation. Experts may detect in this essay signs of dementia. Since smoking is supposed to protect against Alzheimer's disease, I wonder, will it be said that I did not smoke enough? My calculation of the statistically likeliest scenarios with regard to my fate is almost complete apart from trauma, which I must include. The horse, the aeroplane, the mountains are inexcusable. I can hear the murmuring: "The old fool could hardly clamber onto that poor animal of his …" How about an unscheduled meeting with one of the big five (the wild variety) during a walk across the savannah at sunrise? Clearly a sign of recklessness–even if, to advertise my approach, I sing a Gregorian chant or recite Ovid. Also, it will be remembered that smokers are at a higher risk in every pathological situation. If I am killed in a car accident, it will be said that I should have known better than to take part in the Darwinian contest of the Nairobi rush hour. And was I tied in securely? And why did I have no air bags fitted? Or kangaroo bars mounted? Violence is a remaining possibility. I live in a country where income distribution is obscenely extreme and where most of the very rich and some of the poor have been the victims of crime. Carjackings are in vogue now. When called at night to rush to the aid of someone who has been shot in a hold-up, I always muse: what if I were to be the next target? Surely, it would be said that I should have carried a gun. Whatever my fate, since I cannot blame others, I shall be accused of having committed wanton acts and violated the single most important tenet of present-day society, the command to stay healthy! Dying in good health is not an easy task but, should the healthists succeed, its contemplation will become commonplace. One way to avoid illness is to terminate life before disease occurs or, at the latest, when it is recognised. The ultimate of preventive medicine is execution, as a form of hygiene. Such is what we already practise with regard to intrauterine life. All we need to do is to overcome our residual squeamishness and apply the ultimate of health enforcement to ourselves. To rely on suicide would be risky. People would postpone the action, assuming falsely that they are still healthy. Or they would cheat, believing, naively, that illness is natural. Also, unless transported by religious frenzy or a musical debauch, people do not have the courage for anything that smacks of finality. Having written down these thoughts, I now realise that I am no longer worried about being blamed for my end. I shall drop the ambition of impeccable exit. Instead, it seems to me, it is worthwhile to begin the eighth decade of life with a resolution: I shall increase my efforts in resisting the trends and fashions of healthism and the tyranny of the political-correctness ideology. Illness is a characteristic of life. It is a cogwheel of evolution. It is fundamental to ecology. Illness is not something to be ashamed of. It is not a crime. The logic of coercive healthism leads to the criminalisation of illness. Of course we should continue to teach people how they could live healthier, so that they can make informed choices. But we must not continue to pretend that disease can be eliminated, and we must admit that, at best, it can only be postponed. Healthism inhibits the sublimation of illness. Yet the sublimation of illness, of suffering in the widest sense, is the greatest source of creativity. The quest for truth and beauty arises from the realisation of frailty and mortality. I shall continue to try to cure my patients–failing this, to help them make the best of their illnesses. And I shall endeavour to learn from them what I cannot learn from the health-obsessed world–serenity.
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