The myth of normal, p.32
The Myth of Normal, page 32
For all Virchow’s renown, nearly two centuries later many doctors and scientists internationally are still striving in the face of political, professional, and social indifference to impart the broader lessons he derived from his investigations. When the contemporary epidemiologist Sir Michael Marmot[*] began his research into the impact of social stratification on health, he discovered that “inequality and health was completely off the agenda, bar a few trailblazers, writing about the evils of capitalism.”[18] His findings over the decades, published in numerous papers and books, have richly demonstrated the links between social and health disparities.
There’s no need to repeat the science in detail. Both inequality and poverty stir the by now familiar brew of disturbed genetic function, inflammation, chromosomal and cellular aging, physiological wear and tear, hormonal disturbances, cardiovascular effects, and immune debility, all of which combine to bring illness, disability, and death. Biologically embedded in utero, in childhood, and throughout adolescence, all these are further exacerbated by adversity or threat at any stage of life. Stress hormone levels, for example, are much higher among children of low economic status—a biological hazard for future illness of many kinds.[19]
While we Canadians like to pride ourselves on our publicly funded health care system—and rightly so, especially as we peer over the 49th parallel at the law-of-the-jungle morass to our south—research shows that, at most, only about 25 percent of population health is attributable to health care. A full 50 percent is determined by social and economic environments.[20]
In my view there is plenty of reason to think that even this 50 percent is a serious underestimate. “Tell me your zip code,” asserted a speaker at a 2014 Chicago health conference, “and I’ll tell you how long you’ll live.” The life-expectancy gap between Chicago’s poorest and most affluent neighborhoods is close to thirty years.[21] “Basically the difference between Iraq and Canada, within a few miles,” a physician friend of mine commented. Canadians given to patriotic smugness might look at a similar study in our own country, done in 2006. In the city of Saskatoon, people in the poorest neighborhoods were two and a half times more likely to die in any one year. The infant mortality rate was triple in the city center than in its more affluent environs.[22]
In 1974 the anthropologist Ashley Montagu, cited earlier in this book, coined the phrase “sociogenic brain damage.” Technologies since available to us confirm that stressed environments, including penury, do interfere with brain development. More recently, one scientist has called poverty a “neurotoxin.” Brain scans of children and young people from deprived backgrounds have shown reduced surface area of the cerebral cortex, as well as smaller hippocampi and amygdalae—the subcortical regions involved in memory formation and emotional processing.[23] The brain’s serotonin system in adolescents has been seen to be impaired by the stresses of poverty, increasing the risk for emotional turbulence.[24]
Toronto physician Gary Bloch, who serves an impoverished inner-city population, has been waging a campaign within the medical profession and beyond to raise awareness of how penury, race, and gender inequities intersect to promote disease. He wants doctors to recognize poverty as a risk factor for ill health, just as they would regard high blood pressure, smoking, or a poor diet. In practice, of course, these all tend to accompany one another. An affable forty-seven-year-old with an open smile and earnest demeanor, Gary—a long-time family friend of ours—writes prescriptions for diet supplements and refers people to financial aid workers to help with subsidies and tax problems: anything that could help ease their poverty. He shared a telling anecdote he heard from a social worker. “A physician says, ‘Take this antibiotic three times . . . on a full stomach,’ and I always laugh hysterically, and the women I know who are working poor laugh because they know that, ‘Yeah, three meals, like what’s he talking about three meals? A full stomach?’ Another said, ‘I had an old guy that needed diabetes medicine who lived in a shelter in Toronto . . . He was elderly and had mobility issues, and he didn’t take any of his diabetic medication because the side effect it caused for him was diarrhea, and he was living in a shelter with sixty younger men and two toilets . . . He had no chance of getting to the toilet if he needed to quickly, so he wasn’t going to take his pills.’”
“The missing piece I’ve been addressing is the link between knowing how social issues affect people’s health and what to do about them,” Gary told me—a Sisyphean task, given current social conditions. “Societal trauma is something I deal with all the time,” he said. “I honestly cannot remember being taught that when I was in medical school. The traditional body of knowledge, medical culture, hasn’t included interventions into social issues as a core part of what medicine is. Social trauma is a huge beast to come up against, and I can almost tangibly feel how strong and real an entity it is. It is daunting to try to confront it.”
Were health professionals to take to heart information about social determinants, Canadian health expert Dennis Raphael mockingly suggests, they would stop issuing injunctions such as “Stop smoking,” dispensing instead “Don’t be poor” and related prescriptions: “Don’t live in damp, low-quality housing”; “Don’t work in a stressful, low-paying manual job”; “Don’t live next to a busy major road or near a polluting factory”; “Be able to afford to go on a foreign holiday and sunbathe.”[25] In other words, immigrate to a kinder, saner, more equitable parallel universe.
The beast of inequality has many tentacles with which to squeeze the life out of people’s lives. For one thing, inequality’s biological imprint doesn’t affect only the very poor. In societies dominated by materialist principles, your relative position on the social ladder is a predictor of health across all strata. The linking of social rank with health is known as the social gradient, a slope that runs through all segments of society. It is easy to see why. Status grants people higher or lower degrees of control, the absence of which we already know to be a trigger for physiological stress and illness. This was shown in Michael Marmot’s famous Whitehall studies, which found that people’s rank in the British civil service correlated with their risks for heart disease, cancer, and mental health diagnoses.[26] The further down the position on the ladder, the higher the risks, independent of behavioral factors such as smoking or blood pressure. And this among a cohort of people with relative economic security and respectable, middle-class employment! “It is easier to vacate contaminated buildings than to change social structures,” another leading chronicler of inequality, the British epidemiologist Richard Wilkinson, has commented. “We could speculate on how different the response would be if the slope of the social gradient in death and disease ran in the opposite direction, so that the highest-status people did the worst.”[27]
Finally, amid a culture grounded in values of competition and materialism, we confront not only actual material conditions, pertinent as they are, but also how people are induced to see themselves. When people judge themselves or are judged by others according to financial achievement, being lower on the pyramid—even if in a relatively stable position—is itself a source of stress that undermines well-being. In the neuroscientist Robert Sapolsky’s tart phrase, “Health is particularly corroded by your nose constantly being rubbed in what you do not have.”[28]
Racism, poverty, inequality—in this society, people’s faces are constantly rubbed in what they do not have and what the system daily reminds them they do not deserve.
Chapter 23
Society’s Shock Absorbers: Why Women Have It Worse
Many of my female patients have no idea how to express their anger in healthy ways. Their suppressed anger contributes to their depression and, I believe, other medical symptoms as well.
—Julie Holland, M.D., Moody Bitches
This chapter aims to pierce an apparent medical mystery: Why do women suffer chronic illness of the body far more often than men, and why are they far more likely to be diagnosed with mental health conditions? I say “apparent,” because from all that is known about the bodymind unity and our biopsychosocial nature, the answers are staring us in the face and are entirely predictable. That we don’t recognize them has everything to do with our taking for granted the “normal” way of things in a culture of patriarchy, which, despite centuries of female resistance and progress, is ruled as often by subliminal male concerns as by overt power dynamics.
By “we” I’m referring not only to my profession of medicine and to society at large but to my own membership in the dominant sex class and the conditioning that such an affiliation has instilled in me. The truth is, I talk a much better gender-equality game than I sometimes play. It has taken, and continues to take, a very strong and determined woman—my wife, Rae—to keep alerting me, far more frequently than she should have to, to such realities in our own personal relationship. Looking around me, I sense that Rae and I are far from unique in manifesting how unconscious transactions between men and women play out daily in our culture, to the detriment of both sexes but especially at the cost of women’s physical and emotional well-being.
The gender gap in health is real, if underappreciated. Women are more subject to chronic disease even long before old age, and they have more years of poor health and disability. “Women have it worse,” a leading U.S. physician wrote recently, pointing out that women are at much higher risk of suffering chronic pain, migraines, fibromyalgia, irritable bowel syndrome, and autoimmune conditions like rheumatoid arthritis.[1] As noted in chapter 4, rheumatoid arthritis strikes women three times more often than it does men, lupus afflicts women by a disproportionate factor of nine, and the female-to-male ratio of multiple sclerosis has been rising for decades. Women also have a higher incidence of non-smoking-related malignancies. Even when it comes to lung cancer, a woman who smokes has double the chance of developing the disease.[2] Women also have double men’s incidence of anxiety, depression, and PTSD.[3] “We are creating a new normal that isn’t normal at all,” the New York psychiatrist and author Julie Holland said when I interviewed her. “Perhaps one out of four or more American women right now are taking psychiatric medications, but if you add in things like sleeping pills and antianxiety meds, it’s even higher. At any given staff meeting or PTA meeting, you’ve got about a quarter of the people, maybe more, who are taking daily medicines to moderate the way they feel and the way they behave.” Alzheimer’s dementia, too, seems to affect women disproportionately, just as it does Black people in the United States.[4]
That last fact alone ought to give us pause, containing as it does a significant clue as to the sources of such conditions. This book has, after all, been tracing the physiological impacts of developmental needs not being met, of stress and trauma. A consistent theme, beyond scientific doubt, has been that such emotional disturbances frequently trigger inflammation and other forms of physiological and mental harm. We might ask ourselves what burdens, what stresses, could women of any color and class share with Black people as a group? To me the answer is clear: they are both especially targeted by a culture that does not honor but demeans, distorts, and even impels people to suppress who they are. If that is an accurate assessment, we would expect that as these pressures intersect and compound each other, so would the incidence of disease rise. And it does, hugely.[5]
In the previous chapter we examined the biological embedding of racism and inequality and the resulting health disparities. Here we take the logical step of looking at the stresses of being female in a patriarchal society. These, too, get under the skin, playing havoc with all systems of the body, including the immune system.
A feisty thirty-eight-year-old small-town Manitoba firefighter I will call Liz told me of her health calvary when we met at a health conference in Toronto. By then she had been off the job for nearly a year with Crohn’s disease, the intestinal autoimmune condition we encountered with Glenda’s story in chapter 2, with such symptoms as fatigue, bloody stools, and abdominal cramping. When that condition resolved, she came down with manifestations of post-traumatic stress: debilitating fear, horrendous fantasies, insomnia. “I had shaking every day,” she told me. “I was terrified of things I had no reason to be afraid of. I developed a mistrust of myself, not knowing how I would react in a lot of situations. I would cry at the drop of a hat for reasons I couldn’t explain . . . when I was in public or when I was doing things. I had suicidal thoughts. And I used a lot of alcohol to manage these symptoms; I started drinking every day.”
By now, it will be no surprise for the reader to learn that there was early trauma in Liz’s history. She had been sexually abused at age seven, a violation that recurred throughout her childhood and adolescence. We know that sexual trauma is a risk factor for all manner of conditions of mind and body, and that girls are more likely than boys to be subjected to it. It is no longer a secret that well beyond childhood, females in this culture face the constant menace of sexual harassment in both private and professional life. While the advent of #MeToo advocacy has thrown necessary light on this scourge, it has long been thus. When my wife was sixteen, working at an ice-cream store, she heard her boss, old enough to be her grandfather, snigger to his son as they walked behind her: “I wouldn’t mind getting into her pants.” “I was shocked and disgusted and weirded out,” Rae recalls. “I had never heard that expression before, but it felt gross. It was total objectification. Naturally, I kept silent.” Or unnaturally, as it were—but either way, an experience for women and girls so regular as to be entirely “normal.” And that is the case worldwide.[6] In such a sexualized and threatening climate, how can many women avoid developing that “assaulted sense of self” Dr. Kenneth Hardy identified as one of the deep imprints of racism, along with the damage it does to physiological and psychological well-being?[*]
We are hearing more and more about the hazards women face in traditionally male fiefdoms such as policing and firefighting. Along with the risk of secondary trauma faced by all first responders, an atmosphere of toxic masculinity on the job also took a toll on Liz, helping to trigger her gut inflammation and mental distress. If she showed vulnerability, upset at the tragedies she often witnessed, she was treated with derision and contempt. “It was a very macho scene,” she recalled. “If you have any issues, you’re a liability. Particularly if you are a woman, if you talk about it, you’re considered a ‘pussy.’ They’ll physically do stuff to you, sabotage you in some way. They threw tampons into my bed. I don’t even know why. It was very much a symbol of femininity.” Such bullying, too, assaults the body and the spirit. In a 2017 study of female firefighters, harassment and threats on the job were linked to suicidal ideation and more severe psychiatric symptoms,[7] findings that extend into other, less male-dominated professions as well. Not only mental but also physical health suffers.[8]
One healthy response to assault for any sentient creature is anger, a function of the evolutionary RAGE system in the brain whose purpose is to defend our boundaries, physical or emotional.[*] My friend Dr. Julie Holland’s comment in the epigraph to this chapter about women’s anger being subdued to the detriment of their health tracks invariably with my observation among people with depression, autoimmune disease, and cancer. The ingrained abdication of the natural, spontaneous “no” is not restricted to women in this culture, but it is certainly imposed on them more widely and with greater force. The dynamic goes even deeper than deliberately holding in anger. As I distinguished earlier, repression (as opposed to suppression) occurs with no conscious awareness, as healthy feelings are banished beneath the level of consciousness: out of mind, out of sight. “Sugar and spice don’t make space for anything that’s not nice,” Holland writes. “When we don’t even know we’re angry, we can’t converse with the person responsible or otherwise tackle the problem. We cry; we eat; we soothe ourselves a thousand different ways.”[9]
Early childhood mechanisms of self-suppression are reinforced by persistent, gendered social conditioning. Many women end up self-silencing, defined as “the tendency to silence one’s thoughts and feelings to maintain safe relationships, particularly intimate relationships.” This chronic negation of one’s authentic experience can be fatal. In a study that followed nearly two thousand women over ten years, those “who reported that, in conflict with their spouses, they usually or always kept their feelings to themselves, had over four times the risk of dying during the follow-up compared with women who always showed their feelings.”[10] As at home, so on the job. Another study showed that for women with non-supportive bosses, the squashing of anger—a natural adaptation to an environment in which to self-express would be to risk the loss of employment—increased the risk of heart disease.[11]
Recall from chapters 5 and 7 this array of self-abnegating traits that predispose to disease: a compulsive and self-sacrificing doing for others, suppression of anger, and an excessive concern about social acceptability. These personality features, found across all autoimmune conditions, are precisely the ones inculcated into women in a patriarchal culture. “I was denying myself as a person, denying my own desires, my wants,” the first responder Liz said. “I was not paying attention to what I needed. Everyone else was far more important. My job was way more important than any concern that I had. I wasn’t listening to myself in any regard.”[*]
That “not listening to self” in order to prioritize others’ needs is a significant source of the health-impairing roles women assume. It is among the medically overlooked but pernicious ways in which our society’s “normal” imposes a major health cost on women. More on that below.
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