- Email: [email protected]
TOTAL DEAFNESS
375 3. Coronary atherosclerosis probably reflects the person’s lifetime history. Can anyone contend that Japanese men with a serum cholesterol level today of 240 mg/dl had the same lifetime serum cholesterol levels as their Framingham contemporaries with the same level today? 4. Serum cholesterol is
not a
It is now cholesterol in the low density lipoproteins (LDL-C) is positively related to CHD risk, serum cholesterol in the high density lipoproteins (HDL-C) is inversely related to CHD risk. There is also reason to suspect that subfractions of the HDL, and perhaps of the LDL as well, differ in their relations to CHD risk; and that other aspects of the lipoprotein structure may also be important risk factors. Moreover, the Framingham Study data show that the ratio of LDL-C to HDL-C is a better indicator of CHD risk than either alone-and much better than serum total cholesterol. t2 We continue to speak in terms of serum total cholesterol because most of the available epidemiological and experimental data refer to that lipid alone. But clearly (without prejudging what data from differing populations will finally show), we need to consider more than that. To cite a case in point, one rural Yugoslav population has no gradient ofCHD risk by serum cholesterol level. 13 We might attribute this to the very low average level of serum cholesterol in this population, arguing that the level is below that at which serum cholesterol is a risk factor. However, if we have reason to suspect (as we do) that the level of HDL-C in that population is high, then the conclusion could be quite different. Since Japanese men with an average level of serum cholesterol as low as that of the Yugoslavs show a distinct gradient of CHD risk by cholesterol levels the suggestion of 14,15 a critical level for CHD risk becomes even less plausible. We must admit to a certain regret that there does seem to be a gradient of CHD risk at low levels of serum cholesterol. If there were none we might be able to argue (if we could agree between ourselves) that it would be prudent for men with very low levels to raise them and equally prudent for men with very high levels to lower them. This would preserve an Aristotelian mean, while maximising the intensity of healthrelated activity. Fortunately perhaps, the facts-at least the epidemiological facts-do not allow us such a temptation.
point
TOTAL DEAFNESS
pure CHD risk factor. Its effect will
depend on its lipoprotein composition. The last
Disabilities and How to Live with Them
warrants
believed that although the
slight amplification. serum
Correspondence should be addressed to W. B. K., Department of Preventive Medicine, Boston University Medical Center, 80 East Concord Street, Boston, Massachusetts 02118, U.S.A. REFERENCES 1. Oliver MF. Serum-cholesterol-the knave of hearts and the joker Lancet 1981; ii: 1090-95. 2. Dayton S, Pearce ML, Hasimoto S, Dixon WJ, Tomiyasu U. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis. Circulation 1969; 40 (suppl. II): 1-63. 3. Ederer F, Leren P, Turpeinen O, Frantz ID. Cancer among men on cholesterollowering diets. Lancet 1971; ii: 203-06. 4. Kagan A, McGee DL, Yano K, Rhoads GG, Nomura A. Serum cholesterol and mortality in a Japanese-American population: The Honolulu Heart Program.Am J Epidemiol 1981; 114: 11-20. 5. Garcia-Palmieri MR, Sorlie P, Costas R, Havlik RJ. An apparent inverse relationship between serum cholesterol and cancer mortality in Puerto Rico. Am J Epidemiol 1981; 114: 29-40. 6. Williams RR, Sorlie PD, Feinleib M, McNamara PM, Kannel WB, Dawber TR. Cancer incidence by levels of cholesterol. JAMA 1981; 245: 247-52. 7. Kozarevic DJ, McGee DL, Vojvodic N, et al. Serum cholesterol and mortality-the Yugoslavia Cardiovascular Disease Study. AmJ Epidemiol 1981; 114: 21-28. 8 Committee of Principal Investigators. Report on a cooperative trial in the primary prevention of ischaemic heart disease using clofibrate. Br Heart J 1978; 10: 1069-118. 9. Anonymous Cholesterol and noncardiovascular mortality. JAMA 1980; 244: 25.
AT the age of seven meningitis made me totally deaf and blind. Life up to then had been just like that of any little boy-going to school, playing football in the street with my pals, and getting on in normal family life. Brian, my little brother, had been born the previous year so my mother had plenty on her hands already. All I can remember at the time was being drowsy and ill in bed. My last memory of those days was seeing my mother’s anxious face as she looked down at me. When I woke up a long time later everything was dark and silent. Life in hospital was very lonely because nobody knew how to talk to me, although Lcertainly talked, hoping someone was there to listen. My solace during that time came during visiting hours and from the kind nurse who, at my pleading, brought me shredded wheat during the long hours of the night! My mother soon learned to converse with me by "writing" capital letters on my palm. My father came when he could, but Home Guard duty and his job made it difficult for him; this was during the early days of the war.
Fortunately, my eyesight began to come back, and it was pure joy one day when I took offthe dark glasses and could see my mother’s face again. It took about eighteen months before I could see properly. My homecoming brought the first real problem. Totally deaf and partly sighted I could not face meeting my old pals again. They would think me nuts when I did not know what they said to me, forcing me to stay stubsilent in fear of answering right off the point. However, my mother encouraged me to face up to them and more or less pushed me out into the street to meet them. It was hard but it was for the best, and over the years we gradually slipped back into the old routine of football and games in the
bornly
neighbourhood. They were real pals, patiently repeating what they said until I understood. Later on, after I had learned sign language, they all learned finger-spelling. Lipreading is extremely difficult because so many words look alike or are invisible. Even now, over forty years later, I find lip-reading an untrustworthy method of communication, but finger-spelling is a quick and easy way to clarify difficult words. All my family and friends quickly adopted this system. Communication was a matter of speaking carefully and I would lip-read what was said, with the occasional word fingerspelt. I, of course, still had my speech so that others had no difficulty in understanding me. I had to go to a special school for deaf children. The nearest one at that time was in Margate, Kent, 130 miles from home.
10. Gordon
T, Kannel WB, Castelli WP, Dawber TR. Lipoproteins, cardiovascular disease and death: The Framingham Study. Arch Intern Med 1981; 141: 1128-31. 11. Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, relative weight and ECG abnormalities to incidence of major coronary events: final report of the pooling project. J Chron Dis 1978; 31: 201-306. 12. Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High-density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. Am J Med 1977; 62: 707-14. 13. Kozarevic D, Pirc Z, Dawber TR, Gordon T, Zukel WJ. The Yugoslavia Cardiovascular Disease Study: 2. Factors in the incidence of coronary heart disease. Am J Epidemiol 1976; 104: 133-40. 14. Johnson KG, Yano K, Kato H. Coronary heart disease in Hiroshima: report ofa sixyear surveillance, 1958-64. Am J Pub Hlth 1968; 58: 1355-67. 15. Hyams L, Segi M, Archer M. Myocardial infarction in the Japanese: a retrospective study. AmJ Cardiol 1967; 20: 549-54.
B, Racic
376 The early years at school were traumatic-separation from the family for three month periods except for the Easter, summer, and Christmas holidays. Life was so dull and routine and lacking in family affection. The sparkle was almost completely absent. The staff were decent, friendly people who did their best, but all children need their families and will pine for them. No doubt it taught me to be tough, to accept that life can be hard, and to depend on my own resources. Being both deaf and partly sighted made things worse at the beginning, but my dread of school remained up to my early teens. When able to see better I soon realised that I was with children whom I could not understand. They all conversed in
sign language, hardly using speech. Sign language was not taught but all were bound to learn it living in a "signing" environment. None of the teachers used sign language. That is the strange thing about the education of deaf children, even today; few schools officially accept sign language because they think deaf children will learn to speak and lipread if the teachers stick to oral communication. It rarely works out that way; the children find oralism far too difficult and lifeless for them, so they converse in sign language. Nowadays, some enlightened schools are using sign language as well as speech and lip-reading-it has taken 100 years of oralism to convince them. Deaf adults have always proclaimed that sign language and speech are the best ways to communicate with profoundly deaf people, but educational authorities never wanted to take any notice of them-even though they are the people with the disability! I have found that deafness is essentially a communication problem. The many deaf people I know are otherwise normal, but life is made more difficult because deafness is’ rarely understood. The lack of understanding means people just do not know what to do when they meet a deaf person. They find communication slow and strained and the deaf person does not know what has been said. Even repetition is often no help. So people tend to avoid talking to a deaf person because they know it will be difficult. Naturally, the deaf also tend to avoid talking to those whom they know it will be hard to understand. Since my speech is quite good, and because my job entails conversing with hearing people all the time, I probably manage quite well. Even so, I had to learn to accept that I would miss the conversation at social gatherings and understand very little of television programmes. Cultural and educational interests cannot be pursued locally simply because I cannot follow the conversation. In fact, all things which depend on hearing what is going on are a dead loss for a deaf person. There are so many such activities that I can understand the terrific shock of going deaf in the prime oflife. The sudden removal of a large chunk of the activities which make life worthwhile is a shattering experience. Having grown up deaf, I have had the chance to build up a mode oflife which is thoroughly satisfying. Deafness is not a burden at all for those who are able to adjust their lifestyle to suit the circumstances. When I left school I decided to spend most of my free time with other deaf people. With them there is no communication difficulty, we converse freely and fluently. However, there are relatively few deaf people in the community so it is difficult to meet every day. So, much of my free time was spent at the youth club where I could join in the various games without much difficulty. Some games, such as football and cricket, were not so satisfying because I missed the social side of the game. I could not talk freely with the others before and after the match, which made me feel isolated despite the friendliness of my team mates. Deafness
always brings this sense of isolation when you cannot converse easily with others. Finding a job was not difficult at that time, but I could not get work of the kind I wanted. At school, trade
training had
taught me the basics of printing and engineering, yet no local employer wanted a deaf trainee even though this one already knew quite a lot about the job! This has always been a problem-convincing others that deafness does not hinder you from doing most things. People confuse the situation; just because communication is difficult it is imagined that everything else is also a problem. In fact, deafness is a positive advantage for concentration and coordination undistracted by sounds. Sign language and the need to be watchful condition a deaf person to be adept in coordination of eye and mind. My problem, and that of other deaf people, is sometimes to convince others that I can do many things as well as, perhaps better than, they can. Since I spent most of my free time with deaf people I naturally looked out for a deaf wife. I had some hearing girlfriends at first, but it soon became apparent that deafness created difficulties in deaf-hearing relationships. The deaf person feels uneasy and lonely when with the hearing friends of the hearing partner. He does not know what is being said and can easily become frustrated at being left out of the conversation. Exactly the same thing happens to the hearing person when with the deaf partner’s deaf friends. Thus most deaf people feel more at ease married to another deaf person. Anyhow, I married Anne, who was born profoundly deaf and have a son who is also totally deaf. However, I should mention that it is comparatively rare for deaf parents to have deaf children. My wife has no family history of deafness and both she and our son are probably victims of rubella in pregnancy. Life in our family is just the same as in any other. Deafness makes no difference to us. Peter, our son, has always played with the children living nearby and still does. He now goes to a boarding school for deaf boys; this is the only technical school in the country which caters for deaf children, so he has to board. This is a common problem for parents of deaf children because the number of such children is too small to make day schools a feasible proposition. While we miss him a lot, he can usually come home for weekends every fortnight. He is making many new deaf friends which will give him contacts in many areas when he leaves school. There is much talk about integration of deaf people with hearing people, most of it by well-meaning hearing people. The deaf know from experience that integration is impossible in many social situations because deafness excludes the possibility of easy communication and lipreading is no substitute. I, like all other deaf people, do have many happy friendships with hearing people, but these are all on a one to one basis-such as at work, in a pub with a friend, and in our own homes. As soon as more people become involved the deaf person is quietly, although unintentionally, cut out, unless those present are willing to enter into one to one conversation. It is difficult to do that at most social gatherings.
we
Integration may become more of a reality if sign language became more universal. Children in schools can learn it in much the same way as they learn a foreign language. The more people are trained how to talk clearly to the deaf, the more integration will be possible. Mind you, my family gets on very well and is contented as things are, but our horizons would expand if people from all walks of life could talk fluently with us. CLIVE M. DAVIS
not a
It is now cholesterol in the low density lipoproteins (LDL-C) is positively related to CHD risk, serum cholesterol in the high density lipoproteins (HDL-C) is inversely related to CHD risk. There is also reason to suspect that subfractions of the HDL, and perhaps of the LDL as well, differ in their relations to CHD risk; and that other aspects of the lipoprotein structure may also be important risk factors. Moreover, the Framingham Study data show that the ratio of LDL-C to HDL-C is a better indicator of CHD risk than either alone-and much better than serum total cholesterol. t2 We continue to speak in terms of serum total cholesterol because most of the available epidemiological and experimental data refer to that lipid alone. But clearly (without prejudging what data from differing populations will finally show), we need to consider more than that. To cite a case in point, one rural Yugoslav population has no gradient ofCHD risk by serum cholesterol level. 13 We might attribute this to the very low average level of serum cholesterol in this population, arguing that the level is below that at which serum cholesterol is a risk factor. However, if we have reason to suspect (as we do) that the level of HDL-C in that population is high, then the conclusion could be quite different. Since Japanese men with an average level of serum cholesterol as low as that of the Yugoslavs show a distinct gradient of CHD risk by cholesterol levels the suggestion of 14,15 a critical level for CHD risk becomes even less plausible. We must admit to a certain regret that there does seem to be a gradient of CHD risk at low levels of serum cholesterol. If there were none we might be able to argue (if we could agree between ourselves) that it would be prudent for men with very low levels to raise them and equally prudent for men with very high levels to lower them. This would preserve an Aristotelian mean, while maximising the intensity of healthrelated activity. Fortunately perhaps, the facts-at least the epidemiological facts-do not allow us such a temptation.
point
TOTAL DEAFNESS
pure CHD risk factor. Its effect will
depend on its lipoprotein composition. The last
Disabilities and How to Live with Them
warrants
believed that although the
slight amplification. serum
Correspondence should be addressed to W. B. K., Department of Preventive Medicine, Boston University Medical Center, 80 East Concord Street, Boston, Massachusetts 02118, U.S.A. REFERENCES 1. Oliver MF. Serum-cholesterol-the knave of hearts and the joker Lancet 1981; ii: 1090-95. 2. Dayton S, Pearce ML, Hasimoto S, Dixon WJ, Tomiyasu U. A controlled clinical trial of a diet high in unsaturated fat in preventing complications of atherosclerosis. Circulation 1969; 40 (suppl. II): 1-63. 3. Ederer F, Leren P, Turpeinen O, Frantz ID. Cancer among men on cholesterollowering diets. Lancet 1971; ii: 203-06. 4. Kagan A, McGee DL, Yano K, Rhoads GG, Nomura A. Serum cholesterol and mortality in a Japanese-American population: The Honolulu Heart Program.Am J Epidemiol 1981; 114: 11-20. 5. Garcia-Palmieri MR, Sorlie P, Costas R, Havlik RJ. An apparent inverse relationship between serum cholesterol and cancer mortality in Puerto Rico. Am J Epidemiol 1981; 114: 29-40. 6. Williams RR, Sorlie PD, Feinleib M, McNamara PM, Kannel WB, Dawber TR. Cancer incidence by levels of cholesterol. JAMA 1981; 245: 247-52. 7. Kozarevic DJ, McGee DL, Vojvodic N, et al. Serum cholesterol and mortality-the Yugoslavia Cardiovascular Disease Study. AmJ Epidemiol 1981; 114: 21-28. 8 Committee of Principal Investigators. Report on a cooperative trial in the primary prevention of ischaemic heart disease using clofibrate. Br Heart J 1978; 10: 1069-118. 9. Anonymous Cholesterol and noncardiovascular mortality. JAMA 1980; 244: 25.
AT the age of seven meningitis made me totally deaf and blind. Life up to then had been just like that of any little boy-going to school, playing football in the street with my pals, and getting on in normal family life. Brian, my little brother, had been born the previous year so my mother had plenty on her hands already. All I can remember at the time was being drowsy and ill in bed. My last memory of those days was seeing my mother’s anxious face as she looked down at me. When I woke up a long time later everything was dark and silent. Life in hospital was very lonely because nobody knew how to talk to me, although Lcertainly talked, hoping someone was there to listen. My solace during that time came during visiting hours and from the kind nurse who, at my pleading, brought me shredded wheat during the long hours of the night! My mother soon learned to converse with me by "writing" capital letters on my palm. My father came when he could, but Home Guard duty and his job made it difficult for him; this was during the early days of the war.
Fortunately, my eyesight began to come back, and it was pure joy one day when I took offthe dark glasses and could see my mother’s face again. It took about eighteen months before I could see properly. My homecoming brought the first real problem. Totally deaf and partly sighted I could not face meeting my old pals again. They would think me nuts when I did not know what they said to me, forcing me to stay stubsilent in fear of answering right off the point. However, my mother encouraged me to face up to them and more or less pushed me out into the street to meet them. It was hard but it was for the best, and over the years we gradually slipped back into the old routine of football and games in the
bornly
neighbourhood. They were real pals, patiently repeating what they said until I understood. Later on, after I had learned sign language, they all learned finger-spelling. Lipreading is extremely difficult because so many words look alike or are invisible. Even now, over forty years later, I find lip-reading an untrustworthy method of communication, but finger-spelling is a quick and easy way to clarify difficult words. All my family and friends quickly adopted this system. Communication was a matter of speaking carefully and I would lip-read what was said, with the occasional word fingerspelt. I, of course, still had my speech so that others had no difficulty in understanding me. I had to go to a special school for deaf children. The nearest one at that time was in Margate, Kent, 130 miles from home.
10. Gordon
T, Kannel WB, Castelli WP, Dawber TR. Lipoproteins, cardiovascular disease and death: The Framingham Study. Arch Intern Med 1981; 141: 1128-31. 11. Pooling Project Research Group. Relationship of blood pressure, serum cholesterol, relative weight and ECG abnormalities to incidence of major coronary events: final report of the pooling project. J Chron Dis 1978; 31: 201-306. 12. Gordon T, Castelli WP, Hjortland MC, Kannel WB, Dawber TR. High-density lipoprotein as a protective factor against coronary heart disease. The Framingham Study. Am J Med 1977; 62: 707-14. 13. Kozarevic D, Pirc Z, Dawber TR, Gordon T, Zukel WJ. The Yugoslavia Cardiovascular Disease Study: 2. Factors in the incidence of coronary heart disease. Am J Epidemiol 1976; 104: 133-40. 14. Johnson KG, Yano K, Kato H. Coronary heart disease in Hiroshima: report ofa sixyear surveillance, 1958-64. Am J Pub Hlth 1968; 58: 1355-67. 15. Hyams L, Segi M, Archer M. Myocardial infarction in the Japanese: a retrospective study. AmJ Cardiol 1967; 20: 549-54.
B, Racic
376 The early years at school were traumatic-separation from the family for three month periods except for the Easter, summer, and Christmas holidays. Life was so dull and routine and lacking in family affection. The sparkle was almost completely absent. The staff were decent, friendly people who did their best, but all children need their families and will pine for them. No doubt it taught me to be tough, to accept that life can be hard, and to depend on my own resources. Being both deaf and partly sighted made things worse at the beginning, but my dread of school remained up to my early teens. When able to see better I soon realised that I was with children whom I could not understand. They all conversed in
sign language, hardly using speech. Sign language was not taught but all were bound to learn it living in a "signing" environment. None of the teachers used sign language. That is the strange thing about the education of deaf children, even today; few schools officially accept sign language because they think deaf children will learn to speak and lipread if the teachers stick to oral communication. It rarely works out that way; the children find oralism far too difficult and lifeless for them, so they converse in sign language. Nowadays, some enlightened schools are using sign language as well as speech and lip-reading-it has taken 100 years of oralism to convince them. Deaf adults have always proclaimed that sign language and speech are the best ways to communicate with profoundly deaf people, but educational authorities never wanted to take any notice of them-even though they are the people with the disability! I have found that deafness is essentially a communication problem. The many deaf people I know are otherwise normal, but life is made more difficult because deafness is’ rarely understood. The lack of understanding means people just do not know what to do when they meet a deaf person. They find communication slow and strained and the deaf person does not know what has been said. Even repetition is often no help. So people tend to avoid talking to a deaf person because they know it will be difficult. Naturally, the deaf also tend to avoid talking to those whom they know it will be hard to understand. Since my speech is quite good, and because my job entails conversing with hearing people all the time, I probably manage quite well. Even so, I had to learn to accept that I would miss the conversation at social gatherings and understand very little of television programmes. Cultural and educational interests cannot be pursued locally simply because I cannot follow the conversation. In fact, all things which depend on hearing what is going on are a dead loss for a deaf person. There are so many such activities that I can understand the terrific shock of going deaf in the prime oflife. The sudden removal of a large chunk of the activities which make life worthwhile is a shattering experience. Having grown up deaf, I have had the chance to build up a mode oflife which is thoroughly satisfying. Deafness is not a burden at all for those who are able to adjust their lifestyle to suit the circumstances. When I left school I decided to spend most of my free time with other deaf people. With them there is no communication difficulty, we converse freely and fluently. However, there are relatively few deaf people in the community so it is difficult to meet every day. So, much of my free time was spent at the youth club where I could join in the various games without much difficulty. Some games, such as football and cricket, were not so satisfying because I missed the social side of the game. I could not talk freely with the others before and after the match, which made me feel isolated despite the friendliness of my team mates. Deafness
always brings this sense of isolation when you cannot converse easily with others. Finding a job was not difficult at that time, but I could not get work of the kind I wanted. At school, trade
training had
taught me the basics of printing and engineering, yet no local employer wanted a deaf trainee even though this one already knew quite a lot about the job! This has always been a problem-convincing others that deafness does not hinder you from doing most things. People confuse the situation; just because communication is difficult it is imagined that everything else is also a problem. In fact, deafness is a positive advantage for concentration and coordination undistracted by sounds. Sign language and the need to be watchful condition a deaf person to be adept in coordination of eye and mind. My problem, and that of other deaf people, is sometimes to convince others that I can do many things as well as, perhaps better than, they can. Since I spent most of my free time with deaf people I naturally looked out for a deaf wife. I had some hearing girlfriends at first, but it soon became apparent that deafness created difficulties in deaf-hearing relationships. The deaf person feels uneasy and lonely when with the hearing friends of the hearing partner. He does not know what is being said and can easily become frustrated at being left out of the conversation. Exactly the same thing happens to the hearing person when with the deaf partner’s deaf friends. Thus most deaf people feel more at ease married to another deaf person. Anyhow, I married Anne, who was born profoundly deaf and have a son who is also totally deaf. However, I should mention that it is comparatively rare for deaf parents to have deaf children. My wife has no family history of deafness and both she and our son are probably victims of rubella in pregnancy. Life in our family is just the same as in any other. Deafness makes no difference to us. Peter, our son, has always played with the children living nearby and still does. He now goes to a boarding school for deaf boys; this is the only technical school in the country which caters for deaf children, so he has to board. This is a common problem for parents of deaf children because the number of such children is too small to make day schools a feasible proposition. While we miss him a lot, he can usually come home for weekends every fortnight. He is making many new deaf friends which will give him contacts in many areas when he leaves school. There is much talk about integration of deaf people with hearing people, most of it by well-meaning hearing people. The deaf know from experience that integration is impossible in many social situations because deafness excludes the possibility of easy communication and lipreading is no substitute. I, like all other deaf people, do have many happy friendships with hearing people, but these are all on a one to one basis-such as at work, in a pub with a friend, and in our own homes. As soon as more people become involved the deaf person is quietly, although unintentionally, cut out, unless those present are willing to enter into one to one conversation. It is difficult to do that at most social gatherings.
we
Integration may become more of a reality if sign language became more universal. Children in schools can learn it in much the same way as they learn a foreign language. The more people are trained how to talk clearly to the deaf, the more integration will be possible. Mind you, my family gets on very well and is contented as things are, but our horizons would expand if people from all walks of life could talk fluently with us. CLIVE M. DAVIS