Pharmacopoeia

Wieg tot Graf: Cradle to Grave in the Netherlands 2009

Dr Liz Lee

Wieg tot Graf is a new version of the installation Cradle to Grave, created for the exhibition Niet Normaal (Not Normal). It shows the life of ‘everywoman’ and ‘everyman’ living in the Netherlands today. The fabric contains all the pills that they have had prescribed during their life which are knitted into the fabric in the exact order in which they are taken.

Both are healthy children who mainly take paracetamol and occasional antibiotics. From their late teens their medication histories diverge. The woman takes the contraceptive pill before and after having two children. In her middle age she becomes depressed and takes antidepressants for few months. Later she has breast cancer and needs treatment for five years. In general her health remains good until her seventies when she develops diabetes. She is still going strong at 80 years old.

The man has asthma and hay fever in his teens and twenties. He is a smoker and needs antibiotics for chest infections throughout his life. In his thirties he suffers from migraines and intermittent indigestion. Later he gets high blood pressure and cholesterol which means he has to take regular daily medication. At 75 he has a heart attack and a year later suffers a fatal stroke.

“The photographs bear witness to vitality and decay, and to the moments of joy and worry that face all of us at some point in our life. Wieg tot Graf generates feelings of astonishment and fascination, but at the same time asks critical questions about the use of medication, and our views on health and health care.”
— De Collectie (The Collection), A New Context for Art Projects in Care Institutions

Read the typical man’s story

Read the typical woman’s story

Go to Wieg tot Graf in Artworks

‘Cradle to Grave’, In Sickness and in Health 2009

In 2003, Pharmacopoeia received a major commission from the British Museum, leading to the work ‘Cradle to Grave’. The installation tells the story of an average man and woman told through the medication they have taken in their life and accompanied by photographs, documents and objects. ‘Cradle to Grave’ sheds a particular light on a person’s medical history from a medicines’ point of view. Depending on how old the onlooker is, the installation likewise projects a glimpse into a possible future and a thorough reflection on that.

Pharmacopoeia is a medical-art collaboration between the artists Susie Freeman and David Critchley and the family doctor Liz Lee. Over the last ten years we have created a body of work that explores different aspects of health and ill health. Most of our work reflects attitudes and health beliefs that are common in the UK, but we have also worked on projects in other European countries and in Africa. Central to our work are active pharma- ceuticals that we buy from pharmacies using private prescriptions issued by Dr Lee. In this way we access real drugs that are not available to ordinary members of the public unless they are prescribed. In some artworks we also use ‘over the counter’ medicines that can be purchased without a prescription. The only drugs we do not use for legal reasons are ‘controlled’ drugs such as morphine.

The pills and capsules and often their packaging, are incorporated into fabric by a process known as ‘pocket knitting’. By using a fine nylon yarn small solid objects such as pills are captured in pockets in order to create large flexible fabrics.

In 2001, the British Museum commissioned Pharmacopoeia to contribute to their new gallery of ethnography ‘Living and Dying’. We were asked to make a piece of work that reflected how people in our own Western society respond to sickness and ill health and how we also strive to promote and preserve our sense of wellbeing. The art installation we created is called ‘Cradle to Grave’. It focuses on the Western biomedical approach to ill health with its reliance on medicines, which we take in ever increasing amounts as we move from birth, childhood and adulthood into old age and eventually death. Within the gallery this is contrasted with a number of other societies from the Western Pacific, Nicobar Islands, Native North America and Bolivian Andes who all invoke the help of spirits or Gods to protect them from harm and to cure them of sickness.

Cradle to Grave is a 14-meter long installation that runs down the middle of The Wellcome Trust Gallery at the British Museum. Its central theme is the dominance of the biomedical approach to health and illness within Western societies, here focused mainly on the use of medication. Two central ‘Pill Diaries’ made out of pocket knitted fabric, document and reveal all the medicines prescribed to one woman and one man during their lifetime in the UK today. The pills are laid out in the exact sequence in which they would be taken. As most people also employ a variety of other strategies to promote their sense of wellbeing and to combat ill health, several linked narratives explore these complementary themes. These are provided by a series of ob- jects, documents, and personal photographs that run along either side of the Pill Diaries. Together they reflect the ways in which people deal with sickness and try to secure wellbeing in the UK at the beginning of the 21st century.

Research and Methodology

Having received the commission from the British Museum, we started looking at national and international mortality and morbidity data to ascertain major causes of illness and ill health. Strokes and heart disease are the most common causes of deaths both in the UK and worldwide. Other important conditions contribute to morbidity (ill health) rather than mortality (death). For example, depression is rated as one of the top five causes of morbidity worldwide. From this data we began to map out the kinds of illness we wanted to include in the work.

We then looked at the national prescribing figures. The numbers are shocking. For example, currently there are over 40,000,000 prescriptions for antidepressants issued in the UK every year. We discovered other interesting facts, such as on average everyone in the UK takes one course of antibiotics every two years and that we spend more treating indigestion than we do treating cancer. This information provided us with a framework within which to construct the narratives of ‘Everyman’ and ‘Everywoman’.

Both contain over 14,000 drugs which is the current estimated average prescribed to every man and woman in the UK in their lifetime. It should be emphasized that these are only prescribed medicines and so over the counter medicines or pills such as vitamins or minerals are not included. For example, most people do not get a prescription for painkillers when they have a headache; they buy paracetamol over the counter at the pharmacy. Many people take multivitamin tablets or antioxidants daily, which are not prescribed by a doctor. Many take indigestion tablets or laxatives, all of which they buy without a prescription. Although they may make a significant contribution to our health, none of these are included in Cradle to Grave.

Pharmacopoeia’s work is always based on real people’s records and on actual medication. This presented us with a problem. We could not simply use the entire medical record of an 80 year old. After all, they were born before the development of most of our current drugs and so although it might provide an accurate historical record, it would have little relevance to today’s population. In the end we took the pragmatic decision to create a composite ‘Everyman’ from the real medical prescribing record of four different males and an ‘Everywoman’ from four different females.

We were able to use real and accurate prescribing data because as a practicing family doctor in the UK, Liz Lee has access to the computerized prescribing records of the 13,000 patients registered at her practice. In the UK there is a reliable system of transfer of medical records when a person moves from one medical practice to another. Consequently nearly everyone’s medical record accurately documents their medical history and prescribing from birth onwards.

Selection of pills

From the 13,000 records, we selected a 20 year old man who had had a number of common medical illnesses. We documented everything that he had been prescribed since he was born.

We also noted his childhood immunizations. We then chose the record of a 40 year old man and documented everything he had been prescribed from the age of 20 to 40. Again these were mostly treatments for common con- ditions. We ensured that the two patients’ medical history ‘fitted together’ well by selecting suitable patients. For example, they both suffered from hay fever and asthma and this allowed us to ensure some continuity between the two sections of the narrative. We then repeated this process for a 60 year old and completed the record with the medication history of an ex-smoker with a bad chest and high blood pressure who died of a stroke at the age of 76, currently the average life expectancy of a man in the UK. Themes such as chest disease, indigestion and back pain were carried through all the four ages in order to represent the imaginary subjects of our piece.

The same amalgamation of four reasonably well matched patient prescribing records was used for the women’s diary. She took contraceptives regu- larly when she was young. In her twenties and thirties she had two children and one miscarriage, and was treated for an episode of postnatal depression. Later she was prescribed hormone replacement therapy for her menopausal symptoms. After a mammogram in her fifties she was diagnosed and successfully treated for breast cancer. In her seventies she took increasing numbers of painkillers to treat arthritis, which eventually led her to have a hip replacement. Like an increasing number of people she was also diagnosed with diabetes. At the end of the diary she is still alive and reasonably healthy aged 82. In 2003 when we made Cradle to Grave the average life expectancy of UK women was just over 82 years.

Selection of objects and photographs

The pill narratives provide the central structure for the piece but reveal only part of the complex strategies we employ in order to maintain a sense of health and wellbeing. Some of this complexity is captured in two other narrative strands. Running on either side of the pill diaries are personal objects, documents and medical artifacts that relate to daily life. Interspersing these are groups of photographs with captions written by their owners, tracing typical moments in real people’s lives. The photographs are drawn from the albums of family friends and colleagues. We invited a wide spectrum of people to submit photographs that they felt particularly illustrated their own personal experience of health and ill health. The response we got demonstrates very clearly that maintaining a sense of wellbeing is much more complex than just treating periods of illness. Among other things the photographs reveal that it is about family and community, work, weddings and funerals. It is about eating and drinking and smoking and dancing. It is about our relationship with nature. It includes sadness and suffering and loss.

The objects are more diverse still. These were selected by the artists in order to reflect the complexity and sophistication of our thinking and actions. They included choices we can make about healthy living as opposed to risk taking behavior. An apple to illustrate a healthy diet, condoms for protection against sexually transmitted disease, a glass of red wine, which is protec- tive against heart disease, but in excess can damage our social and physical functioning. Conflicting feelings about ‘healthy behaviors’ are addressed by the inclusion of an ashtray filled with fag butts suggesting the dangers of smoking while the photographs acknowledge the pleasure and sociability associated with smoking.

Medical artifacts fill the gap created by our tight focus on medication. The contribution of technology and surgery to the biomedical approach to health is represented by x-rays, a pregnancy scan, a mammogram showing a breast cancer, and a prosthetic hip joint. The existence of a National Health Service, which undertakes to provide care that is free at the point of delivery to all residents in the country, is important to citizens’ sense of wellbeing. It is represented by a blood donor collection bag and a long service enameled badge. In the UK, ordinary people donate blood as volunteers. They are not paid for their altruism but instead are rewarded for multiple donations with a blood donor’s badge. Acupuncture needles and homeopathic medicines represent complementary therapies and a bible is included to acknowledge the importance of faith to many people. Finally there is the documentation, which in the case of the birth certificate acknowledges our arrival into our society and the death certificate, which marks our departure.

The pills

Cradle to Grave focuses on ordinary people suffering from the common ills of our society. Most of the medicines present in the two pill diaries are prescribed either for the primary or secondary prevention of disease. Primary prevention is treatment taken before a disease has developed. For example, for some years the man takes antihypertensive medicine to treat his high blood pressure. High blood pressure is not itself a disease, but if you suffer from untreated raised blood pressure it increases your likelihood of having a stroke or a heart attack. In spite of his years of treatment, he does have a heart attack at the age of 76. After this his pill regime changes to one of secondary prevention. This means treatment is now aimed at preventing a second heart attack. This includes continuing to control blood pressure, taking a drug to reduce circulating cholesterol and taking an aspirin to thin the blood. These actions together will statistically reduce his likelihood of a recurrence.

The woman represented has breast cancer treated with surgery. After this she takes a pill every day for the next five years to reduce the likelihood of a recurrence of the cancer. Again this is secondary prevention. When trying to get pregnant and in the first three months of pregnancy she takes the vitamin folic acid to reduce the chance of her baby being born with the condition spina bifida. This is primary prevention.

Some of the medication is prescribed in order to cure, for example, both take antibiotics to cure infections of the chest or the throat. As well as primary or secondary prevention and cure, many pills are taken to control distressing symptoms such as indigestion or the pain of arthritis. Most of the early sections of the woman’s diary are dedicated to the control of fertility. Thousands of contraceptive pills are taken in order to prevent the ‘natural’ act of conception.

There is also evidence of the medicalization of ordinary life: of the menopause, of unhappiness, of obesity and of smoking addiction. These more controversial areas of treatment are perhaps more susceptible to prescribing fashions. For example, hormone replacement therapy (HRT) was widely used in the UK five years ago. But now there is new evidence about its harmful as well as its beneficial effects and if we were remaking Cradle to Grave in 2008, HRT would not be included.

Other evidence based changes have also taken place. In 2002, by the age of four, children in the UK were immunized against nine infectious diseases, but this has now increased to 10. There are new guidelines on the most effective treatment of high blood pressure and changing trends in the medicines used to treat childhood pain and fever. Because of the speed of change in prescribing patterns, the pill narratives in Cradle to Grave have already become a historical record.

Looking into the future

Some people, including doctors, are therapeutic nihilists; others are committed pill takers. Each individual’s response to Cradle to Grave reflects not only this natural preference but also their personal experience of illness. The tendency is for younger people to say ‘this is not relevant to me as I hardly ever take any medication’. In this they are correct. Young people take very few prescription medicines and if they look more closely they will see that this interpretation is clearly reflected in the work. Age tags sewn into the margin of the 14-meter strip of fabric reveal that by the age of 20, the amount of pills representing the intake of an average man, is only two meters long. One of the astonishing aspects of Cradle to Grave is that it not only allows a 20 year old to reflect on their present and past state of health, it also asks them to look into their future. It is at the other end that the real pill tak- ing starts. ‘Everyman’ takes as many pills in the last 10 years of his life as he has in his previous 66 years.

Cradle to Grave incorporates evidence of the medicalization of ordinary life. We take pills to treat unhappiness, obesity, smoking addiction, to control natural events such as the menopause and these are important issues that our society needs to debate. Perhaps even more importantly, Cradle to Grave demonstrates our commitment to the medicalization of old age. As the body begins to fail, we turn to pharmaceutically active chemicals to preserve and extend life. We minimize the suffering of old age by medicating it. But this does raise questions on the earlier years when we are not considering long-term health, nor being concerned with health itself and only reacting to acute and crucial situations.

In the end we are asked to consider the deeply complex relationship we have with prescription drugs. They are both wonderful and dangerous. They allow us to live longer, they allow us to suffer less, but they may also offer false promises of happiness and health and immortality that they cannot possibly deliver. In this they are more like the spirits and gods of other cultures than we care to believe.

Go to Cradle to Grave in Artworks

Dose at Holloway Prison 2009

Katie Lloyd Thomas

The installation of Dose in the prison chapel at HMP Holloway, which was at the centre of the 4-day workshop I participated in with Pharmacopeia, had three very particular and profound effects. First, although I could only recognise some of the pills knitted into it like treasures, many of the prisoners could identify and name most of them – from aspirin to contraception to anti-psychotics – and some could directly read its narrative of erratic use of medication prior to a stay in Holloway to a controlled and helpful use afterwards. As an artwork it spoke directly to the prisoners and prompted immediate and lively discussion. Second, Dose became a work table, a place to gather round and talk, finding common ground in our experiences, and a space to map all of our lives. On day one we marked significant events on post-its and mapped a collective past. On day four when visitors came to our final exhibition we all contributed our hopes and predictions for our futures.

This theme – of a life – carried through for those that were there on the first day into the two days we spent in the textiles room making bags – sewing, printing, chatting – around a table once again. Some women took pleasure in the gorgeous fabrics and ribbons Susie brought in and made something beautiful they could keep. One prisoner made a bag in turquoise satin with a print of a cat she had drawn to send to her daughter. Another materialised painful aspects of her past she found difficult to verbalise, with images of flames and the words ‘fire is powerful’. For me it was, perhaps, most moving to sew alongside a young prisoner who told me she was so quick to anger that she could never usually concentrate on anything. She astonished herself by working for two days solid, making a very intricate bag although she had never sewed before and was constantly frustrated. A gauze pocket at the front held drawings of scenes and memories that she took from a map of her life she had drawn on day one. That first morning the road that represented her life was marked by needles, alcohol and the death of her father and ended at ‘jail’. But then she added a future, beyond Holloway, which was going to be ‘Quality Street’. Her bag held the past and symbolised her hopes for the future in gold beads and ribbon. Dose mapped out a life in medications and brought difficult issues to the surface, but it also provided a structure for us all to think about our own lives, and in ways I never expected when I apprehensively stepped ‘inside’, to consider our commonalities even more than our differences.

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Behind ‘White Pain’ 2007

White pain is made from the pill packaging that remains after one man’s lifetime of taking painkillers. It starts with the medications he took as a child, paracetamol for earache, toothache and sore throats. When he was twelve he got mumps and needed several days of analgesia for pain in his swollen face. As he grows into early adulthood he takes occasional aspirin, paracetamol or ibuprofen after footballing injuries and for hangovers. He falls off his bike and breaks an arm so needs to take eight paracetamol a day for two weeks the pain is so bad.

In his thirties he has very little trouble, just occasional headaches and one bout of tonsillitis. However, in his forties he needs many more pills as he starts to suffer from recurrent low back pain. For two or three weeks at a time he needs large numbers of both paracetamol and ibuprofen taking up to eleven tablets a day. In the UK back pain is the most common cause of time off work.

After several months of particularly bad pain he suffers from depression and is teated with seroxat. Chronic pain can make you depressed but also when you are feeling depressed it is harder to tolerate pain.

As he moves into his sixth decade he has a painful bout of shingles. The rash lasts for three weeks and is very painful so treated with coproxamol. After this he continues to have pain in the nerve that was affected by the shingles. This is called post herpetic neuralgia and it lasts for six months. The pain of neuralgia does not respond to ordinary pain killers. Instead he tries gabapentine for a month but is more successfully treated with amitryptyline, taking one tablet a day for six months until the pain naturally subsides.

From sixty-five he starts to get the beginning of arthritis in his hands and knees. Slowly he takes more and more analgesia such as co-codamol and kapake until eventually in his mid seventies he needs to take four or more tablets every single day.

After his wife dies unexpectedly at sixty-nine he suffers from a second bout of depression, treated with the anti-depressant efexor.

He is diagnosed with cancer of the prostate when he is 78. At the time of diagnosis the cancer has spread to his bones and these secondary deposits are very painful. Initially he takes the anti-inflammatory drug diclofenac for this bone pain but with treatment for the cancer the pain subsides. It returns later as the cancer spreads and in the last year of his life he takes both diclofenac and the strong opiate drug tramadol. Finally in the last three days of his life when he can no-longer take tablets by mouth he is given diamorphine (heroin) as a continuous infusion under the skin to keep him pain free and comfortable until he dies.

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Malaria and the creation of Veil of Tears 2007

We have based this piece on the experience of people living in the small town of Maseno on the shores of Lake Victoria. It is an area where malaria is so common that by the age of two nearly every child will have been infected. The consequences of recurrent infection throughout life are profound as can be seen in the health of the population many of whom have resulting chronic anaemia.

In children under the age of five, malaria is the commonest cause of death in this region of Kenya. The adult wards are full of patients with HIV related illness but the children’s wards are full of babies and infants being treated for malaria.

The child in Veil of Tears is modeled on a baby in the children’s ward of Maseno hospital. Her mother and father talked not only of the fear they experienced when their child was ill, but also of the economic consequences of bringing her to hospital. This included a day’s pay for the bus fare, the equivalent of one month’s pay for the hospital treatment, and the expense of missing work. The survival rate for children with severe cerebral malaria has a direct correlation with the likelihood that they are treated in hospital and this depends on the distance the family live from the nearest hospital, and whether they can afford to go.

The Veil of Tears installation considers the burden of malaria in the first five years of the life of a child living in Maseno. It is based on academic research carried out in the local region and on our own observations and interviews.

The first net demonstrates the number of mosquito bites infected with Plasmodium Falciparum sporozites that a five-year-old child will have had. This is known as the Entomological Inoculation Rate (EIR) and in the Maseno region the daily EIR average is 0.6 infective bites per person. Sleeping nets impregnanted with permethrin reduces the EIR considerably but often people could not afford nets, or when they had them did not always use them.

Research in the region also suggests that one in thirteen of these sporozite inoculations or bites is likely to to result in infection. The second net contains eighty-four finger prick blood films, which represent the number of times this child might be infected with malaria before she is five years old.

Most cases of malaria are treated at home and people buy antimalarial drugs in the nearest pharmacy if there is one, or at the local shop. There is increasing resistance to the drugs used to treat malaria. The more money you have the more effective drug you can afford. Most people take a course of three antimalarial tablets for each episode of malaria. Many take a course every time they get a temperature whatever the cause. The drugs in the third net increase in price and in efficacy as they rise up the fabric.

The final net partially covers a sick child receiving the drug chloroquine into a vein in her scalp. Her mother sat with her day and night. She eventually made a complete recovery but is very likely to be ill with malaria again before she reaches five years old.

Go to Veil of Tears in Artworks

HIV and making Table Talk 2004

Susie Freeman

In 2004 I was awarded an Arts Council grant for Slim – a study of HIV in the UK. With additional research by Dr Liz Lee and support from the charity Crusaid, we developed a large installation in the form of a table setting.

“Making Table Talk was particularly challenging. Unlike previous work which was based on our own personal and professional experiences, we knew little about HIV. Starting from a relatively small knowledge base we set about trying to learn what it is like to be HIV positive today and to compare this to the experience of having HIV in the earlier phases of the epidemic.

Our first lesson was that HIV affects a whole spectrum of ordinary people. The only significant difference between patients in the waiting room of the HIV clinic and patients in a GP surgery is that there are less old people in the HIV clinic. The second lesson was that HIV remains predominantly a hidden or secret condition. The rising number of HIV positive people go unnoticed because they choose to keep their diagnosis quite private. Initially this made it difficult to gather information, but gradually we were able to find people willing to talk about their personal experiences”

Liz Lee

A table is set for guests, all of whom will have either been HIV positive or personally affected by the disease. These are all people that as a result of our research we felt we would like to meet. Each guest has a place at the table, marked by a mat and napkin; the images and writing on these reflecting something of each personal story. They also have a place-card with first name only, year of birth and sometimes year of death.

The history of the HIV pandemic is also the history of its drug treatment. These medications form a central table runner showing chronologically the development of retrovirals as well as an indication of treatments for opportunistic infections.

I interviewed people who are HIV positive along with relatives, friends and carers of others who had died of AIDS. Liz met with professionals working in the field, following their work in clinics and talking to patients.

Our illustrated guests include a haemophiliac, a pregnant woman, a Terrance Higgins Trust buddy volunteer and David Carr, who died in his mid-twenties in 1957 following a complex medical condition which mystified doctors during his five month stay in Manchester Royal Infirmary. Known as the Manchester Sailor, David Carr was the earliest known confirmed case of HIV in the UK at the time we made Table Talk. Tissue samples preserved from his death were subsequently tested from 1983 to 1987 revealing he had HIV infection. It is now thought that HIV existed for hundreds of years but remained undiagnosed.

The youngest person included is Susan, a twelve year who is not yet fully aware of her diagnosis. When she visits the GP surgery a sign flashes up on the computer screen to alert and remind the doctor to her HIV positivity.

The napkins on the table are printed with the stories of the guests, but most of these are exhibited rolled and tied, concealing some of the information just as the diagnoses are kept private. Four people agreed to have their full interviews on display, and these napkins are laid out so the whole story is visible.  In Susan’s case, the account comes from one of her carers:

I work as a nurse specialising in the care of children who are HIV positive. Because of the social stigma associated with HIV and because the public still have a real problem with it, you can’t tell very young children their diagnosis because they might blurt it out…
Click here to read the rest of Susan’s story

In 2007 for the exhibition Medical Mesh in Bergen, we expanded the installation to include 2 people living in Norway. We continue to collect information and welcome opportunities to broaden the piece for other countries.

We would like to thank all those who contributed their experiences and assisted with our research.

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‘Pharmacopoeia’ in Feminist Review 2002

Dr. Liz Lee (published in Feminist Review, no.72, 2002)

Abstract

In this article I describe the development of my collaboration with the textile artist Susie Freeman in the production of the visual arts project Pharmacopoeia. Over the past 3 years we have created a body of work that aims to provide information about common medical treatments in a way that engages the public imagination.

The work is dominated by the use of active pharmaceuticals, both pills and capsules, which are incorporated into dramatic fabrics by a process known as pocket knitting. These fabrics are then made into clothing and accessories, making their individual messages easier to ‘read’.

The work aims to encourage people to think about their own medical and pharmacological history, and to reflect on their relationship with commonly prescribed drugs. It also reveals how dependent our society is on pharmaceuticals, how ambivalent we feel about them and yet how casually we use them.

Full article available on www.palgrave-journals.com

Osteoporosis & Mrs. Patel 2001

Dr Liz Lee

General Information

Osteoporosis is the thinning of bones and is the most common risk of fractures in people under the age of 70. Throughout life there is a constant removal and replacement of bone cells and our bones are at their strongest in early adult life. Following the menopause bone reabsorption exceeds the formation of new bone and bone density is gradually reduced. There are no symptoms from low bone density but osteoporosis can be suspected if women show rapid loss of height or rounding of the spine. It becomes a problem if fractures occur. Bone density is influenced by lack of exercise, smoking and intake of dietary calcium. Genetic factors are also important and some families are more likely to develop problems than others. People who have taken corticosteroids for long periods of time are also at risk. There are several approaches to treatment. Giving hormone replacement therapy reduces bone loss and may even improve bone density. Biphosphonates are a class of drug that reduces the turn over of bone and can also produce an increase in bone density. Thirdly calcium supplements given with vitamin D are prescribed particularly where the diet is low in calcium and and where there is a risk of vitamin D deficiency. Sunlight on the skin is essential for the synthesis of vitamin D and so housebound elderly patients are at risk. It is also more common in Asians who eat unleavened bread.

Case Study

Mrs Patel is a seventy one year old Indian woman who lives with her family in Bristol. She has both osteoporosis and arthritis. When she was sixty two she was lowering herself into her bath when she got a terrible pain in her hip and found she was unable to get out. Eventually her family had to break the bathroom door down to rescue her. Their GP came and examined her. Although he did not think she had broken her hip, because after all she had not fallen, he revisited the next day and then diagnosed a fracture. She was sent into hospital where a fracture due to osteoporosis was confirmed. At operation two weeks later the fractured hip was replace by a prosthetic joint. She continues to walk using a stick but gets no pain from her hip. She does however have constant back pain from arthritis which has also been diagnosed in her knees.

For her osteoporosis she takes calcium and vitamin D twice a day. For her arthritis she takes pain killers. At times in the past she has had indigestion and this is a common complication of the non steroidal antiinflammatory drugs (NSAIDS) which are effective in treating arthritic pain. An alternative is to take the paracetamol and codeine based pain killers which do not cause indigestion but can be constipating. If arthritis pain is intractable many patients need to take both the NSAIDS and paracetamol or codeine together as well as medication to counteract their side effects. These include laxitives and indigestion or ulcer healing drugs.

Mrs Patel’s Sari is made from pill packaging and the tablets she takes for her arthritic pain and for her osteoporosis. It also incorporates alternative treatments such as HRT for osteoporosis and NSAIDS for arthritis. Treatment for the common side effects are also included. Many patients are forced to take ten or more tablets of these tablets on a daily basis in order to minimise the pain disability caused by these chronic conditions. Shown with the sari is a prosthetic hip joint as a reminder that there are 60,000 hip fractures a year in the UK.

Go to Mrs. Patel in Artworks

Under Wraps — The Menstrual Narrative 2000

Dr. Liz Lee

When I was at medical school one of my fellow students said to a rather grand surgeon with eight children “Congratulations sir, I hear your wife has had a period”. We thought it was very funny at the time although the consultant apparently didn’t.

Women in the developed world now menstruate many more times than they ever have before. We can expect to have about 400 periods in our lifetime whereas women born in the mid-nineteenth century had about 200. There are several reasons for this. The first is that with better health and nutrition the average age for the onset of menstruation has gradually dropped over the last 150 years from 16 to 13. But more significant are the changes to our patterns of childbearing and breast feeding. Breast feeding inhibits ovulation in most women and so each child born and breast fed for 6 months may prevent about 20 periods. The huge reduction in average family size has thus led to a significant rise in the total number of periods.

As well as the obvious day to day advantages to having fewer periods there are also a number of highly significant medical ones. It has been argued by the contraceptive researchers Couthinho and Segal that the ‘incessant ovulation’ that we now experience is detrimental to our health. Studies show that up to a third of women report heavy periods and slightly more suffer significant pain each month. Premenstrual bloating, breast tenderness, headaches and irritability cause significant morbidity and anaemia as a result of menstruation and is one of the commonest causes of chronic ill health in the world. But perhaps most worrying of all is that an increase in both ovarian and endometrial cancer is linked to ovulation. The more we ovulate the more likely we are to develop one of these malignancies because ovulation causes an increase in cell division in the womb and the ovary.

Few women manage to get through their 400 periods without consulting a doctor at some time. Most problems occur towards the beginning and the end of our fertile years. After the onset of menstruation our ovaries sometimes take a year or two to get into their stride resulting in the erratic ovulation and chaotic periods that are often heavy and painful. Aspirin, paracetamol and neurofen all help the pain, but the only help for the unpredictable bleeding patterns is to put girls on the pill. For many people the pill equals licence to have sex but for me it equals licence not to have horrible periods. If an eleven year old is in trouble with her periods she should not be denied the pill because of this spurious connection.

The pill was developed as a method of family planning and its other uses have always been of secondary importance to the drug companies. It’s introduction a s a contraceptive in the early 1960’s was a major political event. In the hope of getting accepted as a ‘natural method of family planning’ (thus available to the catholic populations of the world) it was formulated in such a way as to give a monthly bleed that mimicked a woman’s normal menstrual cycle. Although the Catholic church was never convinced by this argument the monthly bleed has been retained when in fact there is no medical reason for such long and regular bleeding. OK, so women like to be reassured that they are not pregnant. But give me the choice between a home pregnancy test once a month or a five day bleed and I know which I will choose.

For many years women have been sorting this problem out for themselves. Most pill takers run packets together over the holidays, exams and special celebrations in order to avoid a period. This is fine for three months at a time but there is a sound medical reason to continue to shed the lining of the womb periodically. If this is not done the risk of endometrial cancer rises.

It is getting the balance that is important. Finally the drug companies have realised how debilitating five days of bleeding every month can be and a new pill is in development. Rather than have a seven day break between packets it will have only three days. Bleeding time will be halved without increasing the cancer risk.

As women approach the menopause their periods often become erratic and heavy as ovulation again becomes sporadic. the most significant recent addition to our vast armoury of medical treatments for these women is not a pill but a coil. The Mirena coil introduced in 1995 is an interuterine contraceptive ‘system’ containing a reservoir of the hormone progesterone which is leaked out in small amounts that are just enough to inhibit the growth of the lining of the womb. Over a period of six months it gradually reduces and then stops the monthly bleed as there is no lining present to be shed. In my own practice the benefits of the Mirena are now becoming apparent as referrals for hysterectomy have dropped by ten percent.

A year ago Sandra Fellows came to see me demanding a referral for a hysterectomy saying ‘I just want it all taken away’. She was pale and exhausted by her frequent heavy periods which confined her to the house for up to three days a month. We talked about the Mirena and she reluctantly agreed to try it on the understanding that I refer her to a gynaecologist if it didn’t work. One year later she is happy with her decision. Although slightly troubled with some irregular bleeding in the first four months she has now completely stopped bleeding. Compared to a hysterectomy with all the attendant risks of major surgery followed by three months convalescence the Mirena is a safe and effective treatment. Provided all goes well she can anticipate very few more periods during her fertile life.

In future years I think those of us who would like to be congratulated for having the occasional period without the trouble of having eight children will be using the pill and the Mirena strategically throughout our fertile lifetimes. We will indeed be more like our great great grandmothers.

Go to Under Wraps in Artworks

Pharmaceutical haute couture 2000

Pharmacopoeia is an exhibition resulting from a 3-year collaboration between Susie Freeman, a textile artist working in London, and Dr Liz Lee, a general practitioner in Bristol, UK. Their work focuses on common medical conditions, with the objective of stimulating thought about the realities of health-care choices. “We particularly want to engage the imagination of people who have little confidence when dealing with doctors, and help them make decisions about their own medical treatment,” explains Freeman…

Full article available on The Lancet website (free, but requires registration)

The Birth of Medico-Political Art 2000

Joe Collier

There can hardly be anything more stimulating than the birth of a new art form, but here we have it. Moreover, how fitting it is that the works are displayed at an exhibition at Contemporary Applied Arts. If the powerful pieces displayed in Pharmacopoeia are not contemporary and applied, what are they?

Art and medicine have long been related. Florentine artists in the fourteenth century were so fascinated by the human body that they became dissectors of bodies at the University. Leonardo Da Vinci almost certainly dissected the bodies he portrayed in his series showing detailed human anatomy (inside and out) a hundred years later. But leaving aside dissection (and the tradition still continues with the recent controversial work of Anthony Noel Kelly), artists have depicted disease as in the famous gouty knee by Raphael in the early 1500s and the pictures of madness by Goya. Applied art too is part of medicine, as art and design are used both to sell medicines in promotional material, and in their product design – surely an artist had a hand in Viagra’s diamond shaped blueness.

The politicisation of medicines is also not new. The concept of political prescribing certainly surfaced in London in the late 1980s. Gradually it was realised that women were being given sleeping pills and sedatives, not because they were ill, but because it offered doctors (and society in general) an easy way of dealing with poverty, noisy neighbours, damp walls and domestic violence.

Pharmacopoeia takes on a new dimension. Here, with beauty, skill an insight, are explicit contemporary commentaries about our relationship with medicines and with treatments generally. The works bring home the enormity of our reliance on drugs, coupled with the power of mechanical help as provided by interuterine contraceptive devices and prostheses such as hip replacements. It also illustrates how wasteful our relationship can be as medicines are unused or abused. With this exhibition, Medico-Political Art is born.

Congratulations to the parents, Susie Freeman and Liz Lee, and to the Wellcome Trust, who through their Sci~Art award revealed their skills in midwifery.

Joe Collier is emeritus professor of medicines policy at St George’s, University of London.