Maastricht-2019 Earlier this year, I turned 60, not a birthday to bring joyful anticipation for whatever the future may bring, though I am trying to embrace my inner, and increasingly outwardly visible crone. A week after my birthday I received a letter from the Dutch public health authorities reminding me that it was time for my quinquennial cervical smear (sometimes called Pap smear). I dutifully made an appointment with my family doctor, and turned up a few days later for this medical check that is also not preceded by joyful anticipation. It was summer, and having learned from previous experiences, I remembered to wear a dress, no tights - attempting to make the process as quick as possible. It was not my usual doctor, but nonetheless I removed my shoes and underwear without any hesitation, clambered onto the examination table, hoisted up my dress, tried to remember to breathe, and prepared myself for this necessary but usually unpleasant examination. For those who don't know (most men, younger women), a cervical smear involves a metal device, shaped like a duck's bill, inserted into the vagina. It is then widened, so the doctor can have a good look and insert a swab to take a sample of cells from the cervix. This really is not fun - certainly undignified, sometimes painful. Smear tests are perhaps rather like weddings and funerals - each one reminds you of others that have gone before.
I thought back to the first time I lived in the Netherlands, during the 1993-94 academic year. Back then, as a foreigner, even one from elsewhere in the EU, I had to register with the police. I also had to present myself, with my passport and birth certificate, at the town hall so that my details could be recorded on the Dutch population register. I did not need to visit a doctor during that year, and never even registered with one. I turned 35 in May 1994, and a week later received a letter from a private medical laboratory suggesting I arrange to have a cervical smear. All 35-year old women receive such a letter, as testing happens every five years (starting at 30. Many other countries begin routine screening at 20 or 25, and thereafter at two- or three-yearly intervals). I was not so dutiful as I am now, and was horrified by the fact that public authorities, either the police or the town hall, had passed my details to a private health clinic. My Dutch colleagues did not see any problem, finding it an instance of good preventive healthcare, and by the standards of today this is really rather innocent surveillance. I did not avail myself of the opportunity as I was leaving the Netherlands in June, and because I was having smears every two years in England where I lived.
In my early 20s, I suffered a lot from thrush. I tried everything – western pills and ointments, homoeopathy, folk remedies involving live yogurt and cloves of garlic on a string. It was also the tail end of second wave feminism, during which women were fighting for abortion rights and more generally for control of our bodies. I never went in for the full-on self-examination (with speculum and mirror, sometimes undertaken in a consciousness-raising group) but I did attend a women’s self-help health group, and still have my copy of Our Bodies Ourselves, first published in 1971, and still in print). The recurrent thrush alarmed both me and my GP (general practitioner), and I was referred for a smear test. Abnormal cells were found first time round, so I had to go back again quite quickly, this time to an oncology clinic where I was required to remove all of my clothes, don a hospital robe that did not fully cover my body and that had CANCER in large red letters across the back. Nothing serious was found, but thereafter I was invited for a smear test every two years, and this continued until I moved to the Netherlands when I was 40.
Even though a smear test does not really take much time, these recollections of earlier experiences came to the surface while reclining on an examination table in 2019. I breathed slowly in and out, grateful for all that practice at yoga classes. I also chatted to my doctor, and learned the good news that regular check-ups stop at 60. I will not be reminded again. Of course, if I take up multiple male sexual partners or observe unusual discharge, I should let my doctor know. But Dutch medical professionals assume both of those are not very likely at my now advanced age. While writing this, I learned that in some countries screening continues until 65 or even 75. Perhaps this last smear is not such good news, or maybe other countries recognise that older women may still be sexually active.
These recollections are a reminder of the well-known adage of second wave feminism, that the personal is political, and that the personal could be generative of research and of design. Why do countries differ in the ages at which they start and stop routine screening? Why is the frequency different? Do these differences affect the detection and treatment of cervical cancer?
And what about the design of the thing? Plastic is used more frequently now. It is not so cold and hostile as the metal version, though less friendly for the planet. Are specula an instance of what I call ‘hostile technologies’, deliberately designed to exclude or cause discomfort?
The history of the speculum does not make for comfortable reading. References to something resembling the speculum date back to the first century, but James Marion Sims is usually credited with the invention of the modern version in the mid-19th century (Eveleth 2014), developed from his experiments on American slave women, some of whom he bought for the purposes of experimentation. The basic design has not changed very much over the past 170 years. Despite some efforts to innovate – curved duck bill, three-sided, self-insertion, inflatable – the traditional design prevails. Arielle Pardes (2017) suggests this is at least in part because of the slow pace of change in medical education. Others, such as Mary Daly (1978) might suggest it represents the continuing misogyny of western medical practice.
What do these recollections of smear tests at 25, 35 and 60 mean for the ‘Making Clinical Sense’ project? How do doctors learn to insert a speculum? After the speculum has been widened, the doctor does a visual exam – looking for what? Even though some men sometimes have problems identifying women’s sexual organs, I hope doctors know a cervix when they see one. I guess it is not hard to take a swab. My amateur view is that it would be considerably more difficult to find the right vein for taking blood, or to feel for an enlarged spleen. Maybe the most difficult part is dealing with nervous women, embarrassed and tense as they anticipate immediate discomfort coupled with fear about results that only arrive two or three weeks later. Some doctors don’t seem to worry too much about any of this, or have become desensitized to something that is a routine part of their work. Doctors have learned a few things since I was young, perhaps because there are now many more women doctors. For example, specula are now routinely warmed or lubricated, and one only needs to remove a minimal amount of clothing (though that may not be the case in many clinical settings). Clearly there is still lots more work to be done to understand the design of the speculum and its use in clinical contexts.
Boston Women’s Health Collective/Angela Phillips and Jill Rakusen (1971/1978) Our Bodies Ourselves. A Health Book by and for Women. Harmondsworth, UK: Penguin Books.
Daly, Mary (1979) Gyn/Ecology. The Metaethics of Radical Feminism. London, UK: The Women’s Press.
Eveleth, Rose (2014) ‘Why no one can design a better speculum’, The Atlantic, 17 November.
Pardes, Arielle (2017) ‘The speculum finally gets a modern redesign’, Wired, 5 October.
10th JANUARY 2019, MAASTRICHT – On my desk at work is a small wooden box. It was a present from a student, given to me in the mid-1990s when I still worked in London. I quite often receive presents from students – bottles of wine, flowers, books or book tokens. One of the best was a voucher for ice cream. My philosopher partner rarely received anything from his students. I always thought it was gendered until discussing this with another heterosexual academic couple where the man frequently received presents but the woman never did. Leaving aside the workings of the academic gift economy, this small wooden box is particularly special.
It is special because you have to know the trick to open it. There is always something rather magical about a secret box with a hidden compartment. It is also special because of what it contains. This is a box of its time. There is chalk inside. Not just any chalk but special German chalk that has paper around it so your fingers don’t get covered in chalk dust. Now we have computer screens onto which we project the presentations we prepared prior to class, and maybe a white board or even a smart board for more immediate ideas and explanations. But when I started teaching, we still used blackboards, and hand-drawn overhead sheets. Chalk is very visceral, plus you had to think about what you were wearing. Black is never good with chalk dust. I don’t remember ever receiving any health and safety instructions about using chalk, but I do remember that it severely aggravated sore throats. I was glad to find that my German colleagues had found a way of alleviating the chalk dust problems, and stocked up on this when in Germany. My English colleagues were envious.
There is also a tiny screwdriver inside, with the Case Electronics logo on it, something I received from a conference. The company is still around offering computer and telecom services, including repair. Personal computers had started to appear on academic desks in the 1980s, but probably only became standardly available in the mid- to late-1990s. This was before they had become completely black-boxed. Sometimes you needed to open them, to adjust or replace the motherboard. If you tried that now you would have the ICT service people or the US security services down on you like a ton of bricks. Apple’s CEO recently admitted that while repairing iPhones is the environmentally responsible thing to do, it is bad for Apple’s profits. A colleague was stopped recently when entering the US because his laptop looked as if someone might have been tampering with it in some suspicious way.
There are also some items of sentimental value. I visited Berlin a few times in the 1990s, not too long after the collapse of the Berlin Wall (1989). These little pieces of painted concrete allegedly come from the wall, but I suspect it might be like the pieces of the cross. All those little pieces of concrete, now for sale in Berlin tourist shops, would make for a very big wall. Also from that period of my life is a tiny rubber stamp for making sheep images, and an ink cartridge for a very beautiful Pelikan pen. I have absolutely no recollection as to why I have saved a few marbles and push pins.
Because of other commitments, I was due to arrive somewhat later than other participants. Given my anxiety about publicly making a bad omelette, I was somewhat relieved to receive a message during the morning saying they had enough participants, and I did not need to attend, but of course was welcome to come along. I was keen to see how it was going, so I turned up after the other volunteers had made their omelettes and were already sitting down to a nice lunch.
This part of the experiment involved an expert omelette maker (hereafter referred to as ‘chef’) describing to the volunteers how to do it (on other days, volunteers watched a video or read a recipe). But I had missed that as well. So during the debriefing, I asked one of the volunteers to repeat what she remembered being told by the chef, and how she had done it. On the basis of that second-hand description but first-hand experience, I attempted to make an omelette a few days later, in my own home, to be consumed by my partner and myself.
I gathered together the ingredients (see photos) – three eggs for the omelette, plus the ingredients for a potato salad and a green salad. I cracked the three eggs into a bowl, using my traditional method of banging them on the side of the bowl. Suddenly cracking them with a knife was an experiment too far. I beat the eggs, and added a little bit of salt and pepper at this stage. There had been some disagreement between the chef and the volunteer about when to add seasoning. We recently acquired a new frying pan which was a huge improvement on the old one, so I was already feeling more confident. I melted some butter in it, and poured the egg mixture into the pan. We have a gas hob, but I kept the gas very low. As the egg started to cook around the edges, I used our wooden spatula to gently move the egg towards the middle, repeating this until the egg was mostly cooked. I had read in the past that egg continues to cook, even after you remove it from the heat, so it’s best to stop a bit earlier than you think is necessary, otherwise it could end up too dry. Plus, I was doing some experimenting of my own, by adding cheese and parsley after the omelette was mostly cooked, and putting the pan under the grill briefly to melt the cheese.
To my great surprise, the resulting omelette was better than anything I had ever produced. I even managed to roll it up, which I first thought was a bit ostentatious. The resulting roll was cut in half, and divided between the two of us. We had a very tasty meal, I have overcome my omelette anxiety, and maybe we have learned that skills can be transferred in this way. Though of course I did have a lot of prior (bad) experience to build upon.
I explained the problem – in my best Dutch – offering also both of the explanations above. To my immense surprise he pulled a tuning fork out of his desk drawer, and stood behind me. He struck the tuning fork against his desk and held it a short distance from my head. He repeated this, holding the tuning fork in different positions, and asked me what, if anything, I could hear. After this short test of only a minute or two, he sat down and informed me that I had minor hearing loss on my left side, and advised me to go to a specialist hearing centre. A week or so later, I did just that, where I was asked to sit in a soundproof cubicle with headphones on, while another young man sat behind a computer in a different room but in my line of sight. He generated various sounds and I had to press a button if I could hear them, on the left or the right. This lasted much longer, maybe 10-15 minutes. At the end, he too informed me that I had minor hearing loss on my left side. Not yet serious enough to warrant a hearing aid, but something to check again in two years. I left with a booklet about hearing loss, a copy of the graph generated by the test, the advice to come back in two years, and permission to ask people to stop mumbling, in both English and Dutch.
This experience was, for me at least, a wonderful example of the issues being explored in this project. In 2016, in Amsterdam, a young doctor had somehow learned how to use a tuning fork to test a patient’s hearing. At the same time, not far away, another specialist was using a computer with sound and recording software, to generate a graph indicating which frequencies I could hear on both left and right. How are these very different skills being learned? How do you test if a young doctor is capable of using a tuning fork correctly? What happens to the data generated by the computer? Do all doctors have to learn both, or can they choose?