For patients who have had their road in life wash away, we do not ask for a history with all of the nuances, vicissitudes, and emotional upheavals. Instead, we administer brief questionnaires and come up with a number like a Health Assessment Questionnaire of 1.3 or visual analog scale of pain of 4. Although these metrics are fine for scientific study, in the real world of patient care, they can be distancing. By reducing life to a number, they depersonalize and dehumanize. As providers, we may not be able to query patients about life’s details, but it would be very informative if we did.
One the themes of the Mandelieu meeting was the debate about nature versus nurture in disease pathogenesis, as if these two influences were equivalent. Look at what the volcano—a prime example of nature at its most furious and majestic—did to our society. When it erupted, it overwhelmed just about every modern artifice and electronic doodad—nurture at its apogee—in our world. Nature is very, very powerful.
As my wife said upon getting home from Europe the Sunday after the meeting, we dodged a bullet. While we completed an arduous trip reasonably unscathed—albeit groggy and dysphoric—we didn’t really dodge a bullet. Dodging implies action, but in reality we were passive—tired, frazzled, in need of a shower, and staring, frightened, with a deer-in-the-headlights look. Of course, in this case, the headlights were a screen from Expedia’s website.
If nothing else, Mother Nature is a gunner, prone to spraying bullets our way. The targeting and weaponry are variable, including sniping, strafing, and a full-out barrage—like a volcano—in which she blasts away. In such circumstances, just like catastrophic illness, you don’t dodge bullets. The bullets dodge you, for whatever reason.
To me, the venerable statement, “There, but for the grace of God, go I,” has never made much sense. To the extent that I got off relatively easily in the volcano’s ash shower, I do not think that God’s grace had anything to do with it, any more than a lack of God’s grace left some of my friends stranded for a week or hopscotching around the globe to get home sweet home. Although it may be comforting to think that God has shined his light down to give good fortune—whether a quick escape from the volcano or a remission from serious disease—it is all a mystery.
Comparing Stories
When I got home, I was reluctant to call or email friends who were still in transit from Mandelieu. I did not want to share my good luck, knowing they were still sleeping on the floor of an airport, cramped in the confines of a motor coach, or buffeted on the high seas in a British battleship. While misery loves company, a turn in fortune upsets the dynamics. Two people with active RA can share their troubles, but the conversation takes a distinct turn when one person hits the remission jackpot and the other languishes with a Disease Activity Score of 6.
