Recently I cared for a man suffering from gastrointestinal bleeding related to his gastric bypass surgery, which had been performed about eight months previously. The medical problems he suffered prior to the surgery indicated his obesity was becoming fatal before he embarked on the journey involving bariatric surgery. He was hypertensive, diabetic and suffering from cerebrovascular disease. His response to the therapy was awesome. He lost one hundred and sixty pounds and expected to lose more. His diabetes disappeared, his blood pressure fell, his sense of well-being improved. His GI bleeding was fixable.
It was his personal performance in a complex program that began nine months before his surgery which impressed me most. It included intense nutritional coaching, group psychotherapy, weight loss and preparation for dietary restrictions that would follow the surgery. He was restricted for months following the surgery to protein “shakes,” then gradually advanced to other foods. He found that some of his favorite foods now had no appeal, that foods he formerly disliked he now preferred, but he continued to lose weight. He had good follow-up care. As he described this journey to me he seemed a man on a mission. He had more weight to lose, a new job to enter that excited him, a new house to move into. He wanted out of the hospital quickly.
This was a team approach. He was appreciative of his surgeon’s skill but he spoke of his nutritional counselor as though she were his personal life coach and guru. So this was a success story. The patient had entered, armed with his own determination, into a systematic therapeutic endeavor.
The social facts of this man’s life, the fact that he was employed and had medical insurance that made his journey affordable were foundational to his experience and to his assertion of his own agency to change his health status and life expectancy.
In a room across the nursing station from him at the same time was another obese patient whose care I assumed, a lady who had been declining for months. In spite of some chronic arthritic problems she had until a few months prior been active and outgoing, but she noted progressive weakness and found that walking and lifting, just getting out and about, were becoming impossible tasks due to weakness. Unemployed, unable to afford medical insurance and age sixty-four, she promised herself that she would see a physician when she turned sixty-five in eight weeks and became eligible for medicare. And then she fell. And she could not get up. She lay on her floor, embarrassed for most of the day until she summoned help via her cell phone. Understanding how precarious her financial situation was I can imagine her not calling the squad because she knew how expensive that would be.
Due to the fall she suffered a nerve injury that left her with a foot drop. From lying on the floor she had rhabdomyolysis and a kidney injury. At first, with typical prejudice, I must admit I thought that she remained on the floor due to the sheer bulk of her person. We assume things about very obese people at our own, and their own, peril. We screened her thyroid and discovered, low and behold, that she was seriously hypothyroid.
So the clinical puzzle pieces fell into place. Over the previous months she had gradually become hypothyroid but its manifestation was mostly a hypothyroid myopathy, a muscle affliction causing her gradual and progressive muscle weakness. This had progressed to the point that she was no longer ambulatory. After her kidneys improved and we began to replace her thyroid she required transfer to a skilled nursing facility.
These patients are a tale of two medical economies. One patient had insurance that gave him agency to tackle his medical problems even though the therapy is costly. The other fell through a hole. For one the medical machinery functioned well, for the other it was a goat rodeo.
The patient, without medical insurance could not have contemplated the bariatric journey of the first. Even when she developed a problem that can be solved by a few office visits and simple thyroid testing she could not afford even this. In her case we see the extreme costs of the medical care avoidance that has been noted and written about in people with no insurance or insurance with such high deductibles that even a bit of medical care can cause them to miss a car payment or fall behind in the rent.
And we all, when these easily treated disorders progress to disasters, pay for it.
When I was caring for these two individuals during the same week I was reminded of what is or used to be presented to most school children as a poem by John Donne, For Whom the Bell Tolls. In the poem, Donne asserts that we are all connected to one another. The bell tolling due to the disease and death of any human he asserts is of concern to him, because we are all “part of the main.”
In fact, Donne did not write it as a piece of poetry but rather as part of a prose work he called “Devotions Upon Emergent Occasions, and several steps in my Sickness.” At the age of fifty-one Donne, a poet, lawyer and Anglican priest, developed a severe and prostrating illness which he clearly feared would be fatal. Some historians assert that it was recurring typhus as there appeared to be an epidemic of this at the time in London. His illness lasted twenty-three days and for each day he wrote a “devotion.” Each devotion includes a “meditation,” an “expostulation” and a prayer. The seventeenth mediation includes what many know as the famous poem:
No man is an Iland, entire of it self; every man is a peece of the Continent, a part of the maine; if a Clod bee washed away by the Sea, Europe is the lesse, as well as if a Promentorie were, as well as if a Mannor of thy friends of thine own were; any mans death diminishes me, because I am involved in Mankinde…
This meditation contains a spiritual thunderclap, an assertion that we are all connected, diminished by the misfortune and death of any other.
In 1623, the year of his illness, Donne, like all others in his age, was incapable of thinking of his illness in biologic terms. In his “Devotions” he asserts that his illness is perhaps a blessing, offering a means of meditating on the spiritual. For many in his age illness was considered a probable message from God and Donne seizes the twenty-three days of confinement to explore his own spirit. The seventeenth meditation appears to assert a spiritual and social contract: we are all in this together.
No matter what one’s spiritual or social reflections, it cannot be a disputed that individual disease burdens, even though ignored and unattended due to a lack of social insurance, spread out and ripple through society. It costs us in many ways. It is a burden to families and businesses, a burden to public costs and hospital revenue. It leads to unnecessary death, a shrinking work force, falling life expectancy and worsening perinatal infant and maternal outcomes. It leads to bankruptcies and contributes to homelessness. If you think that the struggles and illnesses and deaths of the poor, the opiate-addicted or people poisoned by pollution do not spiritually diminish you, they will likely diminish you materially.
…And therefore never send to know for whom the bell tolls: it tolls for thee.