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The Left Atrium
CMAJ 2001;164(2):237-40

• Developmental reading • Uric acid wit • Much ado about cholesterol
• Gout • Home remedy

Developmental reading

Out of poverty and into something more comfortable
John Stackhouse
Mississauga: Random House Canada; 2000
366 pp. $34.95 (cloth) ISBN 0-679-31025-8

See also:Fie on this book review C.M.Godfrey; V.M. Hanlon [Letter]

Not long after John Stackhouse became the Globe and Mail's first "overseas development writer" in the autumn of 1991, I was sitting in a window seat on an Indian Airlines plane readying for takeoff out of Bombay. Just off the runway, clusters of men, women and children were living in makeshift shelters. Later during that same vacation, I travelled in the air-conditioned comfort of our friends' Ambassador sedan in Kerala province. At the side of one highway I saw women and children slowly hammering rocks into gravel to build more roads. These days, when casual conversation turns to foreign travel and, occasionally, to issues like poverty, homelessness, noise pollution and soul-shattering work, I can share a few bleak observations of life in extremis in the "developing" world.

John Stackhouse spent the years from 1992 to 1999 as a foreign correspondent based in New Delhi. Out of Poverty and into Something More Comfortable is a surprisingly optimistic book about his meetings with poor people in more than 40 countries. In contrast to my brief sojourn to visit friends in the south of India, his travels ranged as far east as Indonesia and as far west as the Côte d'Ivoire with many stops in between. He searched out, lived among, listened to and recorded the stories of subsistence farmers, nomadic cattle herders, shrimp fisherman, forest dwellers, shea-nut gatherers and entrepreneurial groups of woman. More than a third of the book is devoted to repeat visits to Biharipur, a hamlet of 700 people in the northeast of India on the Gangetic plain.

His book goes against the grain of many of our preconceptions about the desperate lives of the poor — certainly as presented in the various appeals for donations that fall into my mailbox. His first-person narrative blends energetic curiosity, respect for the people he meets and almost unflagging good humour under trying circumstances. He meets with some of the poorest of the poor: Amma, a Dalit ("untouchable") widow in Biharipur; Abdul Aziz, a farmer turned unsuccessful shrimp fisherman in Bangladesh; Gulabdai, mother of seven, who presents herself at a sterilization camp in Jaunpur in Uttar Pradesh.

The book unfolds in a straightforward series of encounters rooted in geography. The writing is clear and unsentimental; recounted conversations speak with liveliness and authenticity. Photos of the people, taken by himself and his photographer spouse, Cindy Andrews, open each chapter. They provide a two-dimensional identity for some of the names: the sisters Hajera and Badana, Kartar Singh and his family, farmer Sindaiga Sabar. The final paragraphs of each chapter summarize one of the multiple struggles facing the poor: education for girls, equitable division of land, a more bountiful harvest, timely medical care and "something more comfortable" against the larger, unrelenting crush of limited resources, corrupt bureaucracies, caste prejudice and ill-conceived aid.

Travelling with Stackhouse we run repeatedly into the d-word. It first occurs in his introduction, where he summarizes the single most important insight of his eight years of work:

As I traveled from country to country, village to village, it became glaringly clear that human development is not about creating wealth, though income and material assets are important. It is not about outside interventions, whether they are massive government projects or simply the imposition of free-market ideologies. I came to see development as a process, even a struggle, that was internal to a place and deeply democratic in nature. This book is about those struggles, quiet as they are, carried out in hamlets and slums, on riverbanks and mountainsides, by people who until now have been largely excluded from public decision-making.

To some extent Stackhouse could be likened to a doctor recording the stories of many patients and then attempting to draw conclusions about the state of public health in the nation. Development is now recognized as more than aid, debt relief, structural adjustment and megaprojects; similarly, health is more than health services, drugs, CT scanners and massive immunization or sterilization projects. Of paramount importance in both areas are strong families and communities. The difficulty remains that micro efforts in health or economics are inextricably tied up with macro initiatives.

Out of Poverty is quite a different book from, say, Graham Hancock's Lords of Poverty, a hard hitting attack on the policies of the World Bank and the International Monetary Fund. Stackhouse's reliance on oral histories reminds me of Studs Terkel, while the main setting in India calls to mind V.S. Naipaul's A Million Mutinies Now. Picking my way again through Naipaul's book, I came upon his description of a much earlier book by London Times special correspondent William Howard Russel, entitled My Diary in India in the Year 1858–59. Naipaul's comment pinpoints some of my uneasiness with Stackhouse's work:

The trouble I had with the book was a trouble with history, a trouble with the externals of things he described so well. There was such a difference between the writer and the people of the country he was writing about, such a difference between the writer's country and the country he had traveled to.

Stackhouse is aware of his position of privilege and power, and he lets us know he's thinking about it. He is reminded from time to time by some of the villagers he meets:

As Kartar spoke, a small boy from Biharipur appeared, announcing that we, the foreigners, had come to exploit them. We would take their photograph and offer nothing in return, the boy said ... . I often thought the villagers were right to expect something more than sweets but also feared that if I brought lavish gifts it would change the nature of my visits.

Just what is the nature of his visits? What is the quid pro quo here? Why has he written this book?

To get his stories, or rather to get their stories, Stackhouse laboured under difficult living conditions that temporarily resembled those of his subjects. The heart of his narrative is outside himself; it rests in the hearts and aspirations of the people he meets. At the end of the day there remains something unsettling about a well written book that grew out of the stories, pictures and transient relationships of an overseas development writer and his subjects. It is unsettling if only because part of the original impetus for this writing was to help fill a newspaper (with its particular world view) and sell it for more than the equivalent of a day's wage for many of his subjects. The sticker price of his book would render it unattainable to the people he writes about, were they part of his intended audience.

Out of Poverty invites the necessary comparison between our own lives, families and struggles and those of the individuals described. The men and women Stackhouse portrays demand a response from us. What do we think about them? What is the nature of community? We've heard more than enough about globalization and development; can there be such a thing as global solidarity that cuts across extreme economic inequities? I worry that the reasons for optimism that Stackhouse discovers among some of the world's poor may simply foster among his middle-class North American readers a more comfortable complacency.

In the end, what's to be done? For a start, consider reading this book but not buying it. Support your community lending library instead. And while you're there, have a look at a copy of the New Internationalist, a magazine that "exists to report on the issues of world poverty and inequality." Continue to educate yourself in world affairs. And send the $40 you've saved to a reputable NGO like CalmMeadow Foundation, Interpares or Canadian Physicians for Aid and Relief — but not before you've had a look at their vision statement and annual report. You could change a life, maybe your own. Failing that, you'll still end up with a small tax credit.

Vincent Hanlon
Emergency physician
Lethbridge, Alta.

• Developmental reading • Uric acid wit • Much ado about cholesterol
• Gout • Home remedy

Uric acid wit

Gout: the patrician malady
Roy Porter and G.S. Rousseau
New Haven and London: Yale University Press; 1998
393 pp. $35 (cloth) ISBN 0-300-07386-0
$16.95 (paper) ISBN 0-300-08274-6

Histories of disease have enjoyed a surge in popularity recently. Epidemics, including plague, cholera, smallpox, Ebola and AIDS are the focus of new books. Chronicles of cancer, heart disease, blood disorders, STDs and neurologic conditions such as multiple sclerosis and the slow virus infections have also captured the public eye. So how does a book on gout — that ancient, chronic and relatively benign ailment — fit into this flurry of fascination fixated on sex and death?

Edmé Jean Pignal (1798–1872), Fructus Belli, Docteur! Lithography by Langlumé
US National Library of Medicine, History of Medicine Division

The prolific and inspired Roy Porter, professor of the social history of medicine, and G.S. Rousseau, professor of English literature, have joined forces to produce what will become the standard history of gout from antiquity to the 1930s. With uncommon erudition, they move chronologically through medical texts ranging from the famous works of Hippocrates, Sydenham and Garrod to the more obscure but intriguing accounts of Cadogan, Stuckeley and Scudamore — many themselves afflicted with gout. But they also pay close attention to the words of lay sufferers, especially writers such as Smollett, Dickens, Conrad and Hemingway, whose uric acid infiltrated their fiction and correspondence as well as their tissues. The greatest attention is devoted to the early modern and enlightenment periods, areas of expertise for both authors. The work closes a bit abruptly with a convoluted chapter devoted to the complex ludic personalities of gout, and another to an analysis of its associated images.

So broad is its scope that this book could serve as an introduction to a cultural history of medicine before 1900. A list of gout's notable victims reads like a biographical dictionary of Western civilization. The languid writing, with its alliterative wit, thick description and penchant for apt citation is reminiscent of 18th-century prose.

Porter and Rousseau claim to have a "post-Foucauldian" perspective and nod in the direction of the social construction of disease concepts, as articulated by Ludwik Fleck, Georges Canguilhem and Michel Foucault. But underlying that receptivity to social construction is a positivistic view of gout as an entity increasingly elucidated by science. They take issue with Susan Sontag's work on tuberculosis, cancer and AIDS: they agree that metaphors are attached to diseases; they disagree that metaphors are bad.

Gout, say Porter and Rousseau, is loaded with metaphors. Debates over its many meanings reveal traces of social unrest and cultural revolution. It was "genderized" as a male disease, an emblem of patrician comfort and a political symbol of swelling and of rank. Sometimes it was a blessing in disguise, a protection from more dangerous conditions. A controversy in the 1770s over its cause attracted partisans on opposing sides of arguments over temperance, politics and religion, who advanced their own agendas in viewing gout either as an inherited affliction or as a punishment for laziness and overindulgence. Metaphors in disease may be inevitable; it serves nothing to tilt against them, Porter and Rousseau feel, when we can learn so much by studying them.

The authors also claim that the history of gout has been ignored. Perhaps this is true of social historians, but doctors have long been interested in the history and images of this cruel but kind ailment. In fact, gout is one of the few diseases that readily invokes historical thought in the medical mind, providing one more reason to welcome this authoritative new book.

Jacalyn Duffin
Hematologist and medical historian
Queen's University
Kingston, Ont.

• Developmental reading • Uric acid wit • Much ado about cholesterol
• Gout • Home remedy

Room for a view
Much ado about cholesterol

I'm just off to my pharmacy to pick up my prescription for Lipotor. Given my age, my cardiologist has decided that this retired obstetrician–gynecologist needs to have his "cholesterol numbers" reduced. You might infer that since I am being treated by a cardiologist there is something wrong with my heart. 'Tain't necessarily so. A few years back a "routine" ECG at the behest of my KOFP (kindly old family physician) showed a "possible irregularity." A lot of investigation at that time failed to prove that I had a bad heart. But suspicion remained. Indeed, it does not require a towering intellect to suspect that there might be plaque in the coronary arteries of a 78-year-old man. Hence the cardiologist.

Yesterday, he punched into his hand-held calculator my age, weight, blood pressure (normal, presumably as a result of the medication I'm on already), my nonsmoking status (for 15 years now), the fact that I am not diabetic and my "cholesterol numbers." He did not include the fact that my father died at age 85 of coronary artery disease, or that my mother died at age 99 of not really wanting to live any more.

The little calculator told him that my risk of dying in the next 10 years of heart disease was increased by 32%. (Over what?) I did not fall into a dead faint at this announcement, since I had already guessed that the odds of my dying in the next 10 years were pretty high anyway. (Say, 50–50?)

However, the cardiologist felt that I should take an anticholesterol medication. My wife takes a similar drug and, according to my pharmacist, so does a high percentage of the over-65 population. He said there was only about a 2% chance of the medication "blowing out" (his words) my liver or kidneys. Since exploding my liver or kidneys didn't sound like a bad way to go, I agreed. Also, I am supposed to let our Westie, MacDermott, take me for a walk every day. And I must not eat anything I enjoy.

But I need to clarify this whole cholesterol thing. Before my retirement, when we lived in the city, the favourite conversational gambit when we dined at other folk's houses seemed to be cholesterol one-upmanship. "You think that's high! My cholesterol is twice as high, and my bad cholesterol is even worse than yours!" But, now that we've moved to the country, we attend many of the roast beef suppers put on by the local churches. We often sit across from a grizzled, horny-handed old farmer who pours gravy with reckless abandon over his mashed potatoes and generous helpings of meat. Nor is he fazed by the carrots swimming in butter. His wife, no slouch herself in the avoirdupois department, turns down a fourth helping of pie in favour of cheesecake and, for her coffee, produces a packet of Sweet 'n Low from her pocket rather than use the sugar that the church sinfully provides.

Now, I will admit that if I looked out the window I might well be able to see the farmer's brother slumbering peacefully under the green turf of the churchyard, warmed by the October sunshine.

If so, God bless him. Bless both the brothers, actually.

You see — in company, I suspect, with most folks my age — I am neither worried nor frightened about being dead. Death is inevitable. But I am scared silly about the manner of my going. I want to leave while I can still think. I want to be on my way before the front of my pants is any more stained with dribbled urine than it currently is. I don't want to wear a bib to eat. (My wife says I need one already.) I want to be able to wipe my own bum to the very last. Hey, I wouldn't even mind leaving before I need to pop Viagra.

In short, I am much more concerned about the quality of my remaining years than about their number. So, does lowering my blood cholesterol offer me any assurance about this? The cardiologist didn't talk about that, only about my chances of dying. Is there evidence about quality of life? Or, as seems quite probable, will I have more years during which I need to be cared for — as a result of taking the drug?

I'm not complaining. Indeed, I am grateful to the pharmaceutical industry for contributions to health and happiness that I now enjoy and have enjoyed. And I am grateful that modern research has produced medications that can lower the cholesterol level of my 48-year-old son and, I hope, increase his lifespan. Now, if they could find a drug that would reassure me about the quality of my remaining years, I would thank them for that, too. But they can't.

Can they?

William G. Green
Retired obstetrician–gynecologist
Townsend, Ont.

• Developmental reading • Uric acid wit • Much ado about cholesterol
• Gout • Home remedy

Illness and metaphor

FRANKLIN. Ah! how tiresome you are!

GOUT. Well, then, to my office; it should not be forgotten that I am your physician. There.

FRANKLIN. Ohhh! what a devil of a physician!

GOUT. How ungrateful you are to say so! Is it not I who, in the character of your physician, have saved you from the palsy, dropsy, and apoplexy? one or other of which would have done for you long ago, but for me.

FRANKLIN. ... [O]ne had better die than be cured so dolefully. Permit me just to hint, that I have also not been unfriendly to you. I never feed physician or quack of any kind, to enter the list against you; if then you do not leave me to my repose, it may be said you are ungrateful too.

GOUT. I can scarcely acknowledge that as any objection. As to quacks, I despise them; they may kill you indeed, but cannot injure me. And, as to regular physicians, they are at last convinced that the gout, in such a subject as you are, is no disease, but a remedy; and wherefore cure a remedy? — but to our business, — there.

FRANKLIN. Oh! oh! — for Heaven's sake leave me! and I promise faithfully never more to play at chess, but to take exercise daily, and live temperately.

GOUT. I know you too well. You promise fair; but, after a few months of good health, you will return to your old habits; your fine promises will be forgotten like the forms of the last year's clouds. Let us then finish the account, and I will go. But I leave you with an assurance of visiting you again at a proper time and place; for my object is your good, and you are sensible now that I am your real friend.

From Benjamin Franklin, "Dialogue between Franklin and the Gout," 1780

• Developmental reading • Uric acid wit • Much ado about cholesterol
• Gout • Home remedy

Found object
Home remedy

Going through some old papers in the attic of our family farm near Dundalk, Ont., I came across this handwritten recipe among other, less puzzling, instructions for making apple dumplings, buttermilk cake and dandelion wine. It dates, I would guess, from the first or second decade of the 20th century.

For the kidneys

1 pt. good gin
2 oz. sweet nitre
1 oz. oil of juniper
1/2 oz. turpentine
1 good stick of horseradish grated fine.

Shake them up well. Take a wineglass 3/4 parts full 3 times a day.

The 1946 edition of Stedman's Medical Dictionary gives the following definitions:

Sweet nitre. Spiritus aetheris nitrosi: an alcoholic solution of ethyl nitrate, aldehyde and other substances. A sedative, diuretic and diaphoretic in doses of 20–30 min. [ A minum is 1/60th of a fluid drachm: practically speaking, a drop.]

Oil of juniper berries. A volatile oil distilled from the fruit of Juniperus communis. A carminative, diuretic and stimulant in doses of 5–15 min.

There is no entry for turpentine.

Aileen E. Coates
Retired psychotherapist
Oakville, Ont.



Copyright 2001 Canadian Medical Association or its licensors