The Patient's Strategy. Column in KomputerraOnline #56

I remember, I remember — my two preceding columns ended with a promise to continue the themes I had begun. But for now I will merely hint at how the abstract life strategies of toads, which I wrote about last time, connect to concrete life. My own. I shall structure this column as follows: first, in the manner of an old man, I will recount my (un)health and its history (a familiar genre, is it not?), and then I will mention the general biological mechanisms reflected in my own ontogeny and, in all probability, reflected in the ontogenies of the readers of this text.
How does one avoid placing anyone I interact with in an awkward position? By emphasizing that all coincidences between what I describe and reality — even if not accidental — are nonetheless coincidences. Dear readers, you surely carried away from your school literature course at least the understanding that the lyrical "I" of a text's author and his actual person are two very different things? The same applies to the columnist's "I"!
I am a product of the Soviet Union, where I managed to be born, to grow up, to serve in the army, to receive a higher education, to marry for the first time, and to be assigned to a position I still hold to this day. My interaction with medicine was very uneven: extensive in childhood and up to my conscription into the army, extremely episodic over the last 25 years, and quite substantial during the past month. Allow me to elaborate — an eloquent picture emerges.
A significant part of my childhood was bound up with illness. At the age of two I suffered a disease that weakened my resistance to everything. I was cast in the role of a sickly child and, over many years of school, missed no less than half of my instructional time (in some years — two-thirds).
My maternal grandmother, a schoolteacher, retired to the weeping of the entire school when I entered the first grade at that very same school. The word "pull" was not then in common use, but despite chronic absences, most teachers treated me well enough. My grandmother helped me learn how to learn, and thereafter I managed it reasonably well. Soviet textbooks were written with solid craftsmanship, and what my classmates mastered in lessons I could understand in five minutes of reading. There were mediocre marks (not from lack of understanding, but from lack of interest), but once I realized they could prevent me from living as I wished (that is, from becoming a biologist), they disappeared. My mode of learning failed only in two subjects: English and physical education.
The English language is wholly insufficient to understand once — it demands a different approach than the natural and exact sciences. I continue to suffer from difficulties with English to this day, even though I have devoted no small effort, time, and money to studying it. Physical education was even worse. After every illness I was excused from it — and I practically never attended those classes. Physical exercises are just as treacherous as English: the principle of "understood it — mastered it" does not work there.
We lived in a private house surrounded by an old garden (my great-grandfather in the 1930s had ordered fine varieties of fruit trees from Europe). The house contained books. To my mother's colossal literary-critical library and my father's concentrated mathematical-cybernetic-engineering library was added my own considerable biological one.
One of my fairly early memories (I was not yet five years old) is the following. My father comes home from work, rejoices that I am recovering from pneumonia, and says that in honor of my interest in animals he has bought me a serious and expensive (ten roubles!) book. A thick "Illustrated Encyclopedia of Animals" by the Czechoslovak publisher Artia.
And in the adjacent part of our house lived my grandfather — my father's father. One of his two rooms was occupied by a grand piano from the late nineteenth century. The piano usually stood with its lid closed, under a thick carpet — to restrain at least somewhat its powerful sound. To maintain his form (physical, technical, emotional...) my grandfather played for several hours each day. At first he explained things to me; then he began to teach me to play — not by method, but immediately whatever I liked. Oh, how wonderful it was...
On the physical education classes I avoided I felt like a weakling, but at times, I suppose, I was quite adequate. My father first had a motorcycle, then a car. We regularly drove out of the city to fish, to hunt, to gather mushrooms, and simply for the sake of it. Even as a schoolboy I could set off alone in a small folding iron boat for kilometers away from my parents, searching, for example, for something in a network of forest lakes in the floodplain of the Siversky Donets.
Where it was genuinely interesting to me and took place against a mobilizing emotional background, I demonstrated entirely adequate health. A wise female physician my parents consulted periodically reassured them: he will grow out of it when he matures. So it turned out. But draft age arrived.
I was examined at a Good Institute and they found many frightening diagnoses, such as chronic sepsis. Time and again, collections of highly pathogenic bacteria were cultured from my blood. I was supposed either to be covered with abscesses or to die — and I continued to live as before. I was supposed to be hospitalized for a long time, but I lost the entire set of Very Important Medical Documents. Then I entered university, and there was no time for it.
I am still amazed that my parents (who were very worried about me) had the wisdom to endure my disregard for the treatment. The direct consequence of this was that I was taken into the army from the first year of university. They were taking almost everyone then. My parents' generation was born during the war years; on the demographic pyramid it corresponds to a deep notch. That notch was so deep that it manifested, more than twenty years later, in my own generation. My contemporaries were insufficient to feed the gigantic moloch of the Soviet army. I was taken in on the day of my eighteenth birthday.
I will not write about the army. The demands (not so much the official ones as those arising from disorder) were serious. I endured them. But when I returned from the army and went for a certificate to visit the swimming pool, the physicians of the student health clinic balked: "Before the army, serious functional disturbances in cardiac function were recorded in your case; physical strain is contraindicated for you." I confronted the chief physician (appealing to the fact that his colleagues had certified me fit for naval service without restrictions and had concerned themselves with my health exclusively in retrospect), extracted the certificate, and thereafter tried to avoid interacting with physicians (except dentists, perhaps).
Looking back, I understand that had I continued to receive full-course treatment before the army, they would have treated me to death. I do not know whether I would be alive now; I have no doubt that I would not have managed to live a good life. Much of what made me myself — things it is pleasant to remember — was, of course, inadmissible from a medical standpoint. Could I have caught snakes in Central Asia while observing a prescribed diet? Does underwater hunting conform to vascular load norms? Have I, over the twenty years since I acquired my first PC, maintained justified screen-time regimens?
At times ailments appeared. In chance encounters with physicians I received sonorous diagnoses. I ignored them, and developed the principle: "Nothing doing — we'll push through!" And the illnesses somehow disappeared, following in the wake of the chronic sepsis. Where did it go? I do not know. The last time blood sterility was tested on me was nearly thirty years ago. I recalled it while writing this column; once I finish it, I will forget again.
I greatly value Borges's story "Tlon, Uqbar, Orbis Tertius." It describes a world where to exist is to be perceived. We live in precisely such a world — not with respect to physical, natural-scientific reality, but from the standpoint of the reality of our inner world. On the boundary of two realities — the psychic and the physical — lies the zone of psychosomatic phenomena. Believe me (and recall): the more active psychic reality can prevail, reshaping physiology and even, at least on occasion, anatomy to conform to itself.
Why did situations begin to accumulate in my life in which the principle of "Nothing doing — we'll push through!" stopped working? At times it seemed to me that in my fifties the mainspring of the clockwork had run down. You try to get up and push through, and then it rolls over you... It turns out: high blood pressure — so high that it is amusing to watch physicians run and fuss when they measure it. Perhaps it was simply that my faith in the ability to push through had cracked.
And once again I am sent to a Good Institute (a different one, naturally) to see a truly Good Physician. Fortunately, not off the street — at the weighty request of someone. And once again — an examination.
They send me here and there. A CT scan costs, for instance, more than a laboratory assistant's monthly gross salary. Why? Does one need to justify the purchase of the tomograph? No, it has already paid for itself. In fact, there are more tomographs in the city than qualified physicians capable of using them; the reason is unknown. I firmly reject the version that officials earn kickbacks when purchasing tomographs and have no interest in cultivating physicians. One cannot think so ill of people!
The tomograph was indeed necessary. I have three kidneys (this occurs), and the physician suspected that my blood pressure was being driven up by insufficient blood supply to the third, accessory kidney. It turned out that all three are innocent and functioning properly. But both the physicians and I myself could examine the most detailed three-dimensional reconstructions, perfect axial and frontal "slices" of me — still a living person! Very instructive. I would like such a tomograph for the needs of frog science...
At each examination they find substantial deviations from normal (I would like to meet someone in whom they find none). Each physician writes diagnoses, explaining the implications of the deviations found. I search the internet, I investigate... This one is fraught with stroke, that one — with myocardial infarction, another — with cirrhosis, cancer, dementia (oh!), impotence (ah!), stroke again, infarction again... With a heavy heart I go to the physician who is managing my case, and he reads and sets aside paper after paper.
"Let me see... This is not significant..."
"Really? But I was told..."
"Don't listen to that."
"And I read..."
"Don't read."
"So, do nothing about it?"
"As you like. You will not die of this. You may treat it, spend money and energy; you may not bother — the outcome will be the same. But if you address the hypertension (one tablet per day for life; it will need to be changed from time to time) and follow the unburdensome recommendations, you will have a good-sized chunk of active life still before you."
"And can I..."
"Within reason."
"And..."
"You may."
And it dawns on me that the doctor is working against the system, truly for my benefit (thank you!!!). The system is winding me up for treatment and driving me into the self-perception of a chronic patient, maximizing its own profit. The physician seeks the optimum in accordance with my interests. He fulfills the system's requirements. I received a discharge summary describing everything that was done to me, some things that were not done to me, and the prescriptions conforming to strict norms for each of my diagnoses. But most importantly — the physician gives me a small paper square, a standard adhesive memory-note. On it is EVERYTHING that, in his opinion, I need to do.
I have already begun following it — the adhesive note's recommendations. It works — it is as if fifteen years have been lifted from me! And how much the discharge summary would add in terms of self-perception (and subtract in fact from my remaining years) I shall probably not verify.
I began sharing the experience with a colleague. You understand, I said, if the treatment works (and it will work — there is no way out!), I will appear in the documents as statistical confirmation of the life-giving force of the Ministry of Health's protocols. These protocols increase the system's profit and minimize its liability, and my interests, even if taken into account, are treated as residual. And the more abstruse and frightening these protocols, the further the illusory world of documents will drift from actual life. He is surprised: "You didn't know? Well, I understood this long ago — my wife is a physician. Of course, real treatment is described on adhesive memory-notes! The medicine of papers and the medicine of people are weakly connected to each other and develop according to different laws."
One can only rejoice at how the medicine of papers has flourished in recent years. Dr. Shchepetnev writes about how much time filling out forms takes from a physician. Yet what an effect the implementation of all the recommendations contained in them would produce!
And what was it that set a sufficiently low ceiling on my freedom to dispose of myself in childhood, raised it in maturity, and is now beginning to lower it again? Not the illnesses, which arrived and departed with sufficient randomness. Not the successes and failures of medicine (which more often than not exceeded reasonable sufficiency). For better or worse, I am passing through different phases of my own life strategy, belonging to the same category as the strategies of fast-maturing or slow-growing toads. And this strategy depends not on me, not on physicians, but on those vectors of selection that have acted upon my ancestors over the last tens of thousands, hundreds of thousands, millions of years.
So, the column has ended? Well then, some other time...