After the sojourn at the Jorvik Centre, which I wrote about in last month’s column, we were off to the York Minster following a route where the traffic sounds differently than it does in the United States. The air fills with the grind and rumble of diesel engines, and the rush of doubledecker buses gives a great thump.
My mind overflowing with images of arthritic skeletons, I peered at the people to detect the imprint of either the NHS or their Viking ancestors. In front of Bettys Tea Room, I had eureka moment about the difference between the people of York and those in the United States. The difference turned out to be the number of people walking with canes.
In life, once a relationship becomes clear, it is surprising how it was previously missed. Suddenly everywhere I looked, I saw older (and not so older) people walking with canes. Some had walking sticks, some had dark wooden canes, and some had shiny metal ones. Many a hand with Herberden’s nodes was gripping a handle as people wobbled and limped.
Impromptu Research
I decided then to do some quantitation. Standing on a street called Spurriergate, I took a convenience sample of cane usage. Convenience samples are prone to spurious results, but I was on vacation and unable to do anything more elaborate. In 30 minutes, ignoring those with umbrellas used as aids, I counted 14 people with canes, four in wheelchairs (two motorized, two pushed), three people with crutches, and one person with a wand. The one with a wand was a cute little kid dressed as Harry Potter and on his way to the movies.
Satisfied that more people in England used canes than back home, the immediate question was why. Did it have anything to do with the difference in the healthcare system, on the one hand, and the people, on the other hand? The Brits are known for their high frequency of arthritis. The weather, of course, could make anyone twisted and gnarled.
My first thought was that the profusion of canes resulted from the often-discussed delay in joint surgery that occurs in the NHS. People in Britain who need joint replacement supposedly queue up and wait two or three years before for their operation. To critics of the NHS, the delay in joint replacement is a poster child for the system’s shortcomings. With the path to the operating room slowed or blocked, those with arthritis would have to make do with assistive devices and painkillers to get around. In this scenario, canes would be the red flags for NHS backlogs.
Satisfied that more people in England used canes than back home, the immediate question was why. Did it have anything to do with the difference in the healthcare system, on the one hand, and the people, on the other hand?
You don’t have to be an epidemiologist to know that other explanations could account for my observations. These include a greater willingness of the British to use canes; a desire to walk outside despite pain or disability; or even a reluctance to undergo surgery that would make an American run for the knife. A more worrisome explanation is that the people with canes had already had their joint operations and the NHS surgeons are not the best.
I was tempted to do man-on-the-street interviews and ask those nice old people in wool sweaters about their pain on a scale of 1 to 10. Alas, I feared arrest for disturbing the peace or worse, conducting research without an Institutional Review Board–ap – proved protocol.
Only later in the day did I figure out the meaning of the canes, which at this point resembled in my mind the procession of brooms in the Fantasia version of the Sorcerer’s Apprentice. When we got to the York Minster, my daughter, who is 23, announced that she wanted to climb to its top. The tower at the minster is 190 feet high and is reached by a narrow circular staircase with 275 steps. Being fit, I agreed to join her.
At the entrance to the tower, warning signs made the climb sound daunting, if not foolhardy. “Do not attempt it you have any health problems or if you have claustrophobia, vertigo, asthma, angina, or are pregnant.” Suddenly, I felt gripped with fear, as if I was to climb El Capitan without a rope.
I was not alone in my anxiety; the people in the queue began to talk nervously, wondering whether the climb was too arduous or dangerous. Because the narrow staircase allows passage in only one direction, they fretted about what would happen if panic took hold, or someone started wheezing or had his head go spinning.
Cane Revelation
Fear is contagious, and it seemed that more than a few people were having second thoughts about the climb. Just then, at a few minutes before 4:00 pm, people from the last group to the tower emerged from the staircase, uttering reassurances such as, “It’s not bad,” or “You can do it.” Among that group of people coming down from the top were two old ladies who looked to be in their 80s, frail as sparrows with spines curved and shrunken, vertebrae no doubt thin as lace. In the hands of each of the women was a silver metal cane, and as they walked to the exit of the Minster, their canes clicked a zippy tattoo as they struck the ridged and darkened stone that had withstood the steps of worshippers and visitors for over 500 years.
The old ladies smiled and looked jaunty and proud of their accomplishment: 275 steps up and 275 steps down to get a dazzling view of Yorkshire countryside with the green dales rising in the distance. Age, a crumbling spine, and necessity of the cane did not keep these women from scaling the heights.
Stiff upper lip. Definitely. Heart of a lion. You bet.
At that moment, I realized that my discussion with my friend in London could not reach a resolution. As they say, the United States and Britain are two countries separated by a common language, but in truth our separation is greater. At this point in history, the British and Americans are, at most, distant relatives. The British are reserved and conservative. They do not complain. Their plumbing is archaic and their houses stay cold. They are loyal to the Crown and have a fierce sense of country, common purpose, and shared sacrifice that allows them to accept the NHS even if their own care lags.
Americans in contrast are open and optimistic. We love our freedom and modern conveniences and have air conditioners that frost the air in the dog days of summer. We are individualistic, entrepreneurial, and impatient. Distrusting the government, we would rather have an insurer manage our health, even if profit is part of the mission.
At present, it’s Aetna, Cigna, and BlueCross BlueShield for us. It’s the NHS for them. In the future, the healthcare systems in both countries will change. They have to. The economic reasons are strong and the citizens demand it. Will this change increase access to healthcare and make it more efficient?
Like you, I eagerly await the answer.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
