Is Kindness Key to Happiness and Acceptance for Children?

The study “Kindness Counts: Prompting Prosocial Behavior in Preadolescents Boosts Peer Acceptance and Well-Being” published by Layous and colleagues in the journal PLOS One on December 26, 2012 was cited by multiple websites as proof of how important it is to teach children to be kind. NPR commented on the study in the blog post “Random Acts Of Kindness Can Make Kids More Popular“, and the study was also discussed in ScienceDaily in “Kindness Key to Happiness and Acceptance for Children“, Fox News in “No bullies: Kind kids are most popular” and the Huffington Post in “Kind Kids Are Happier And More Popular (STUDY)“.

According to most of these news reports, the design of the study was rather straightforward. Schoolchildren ages 9 to 11 in a Vancouver school district were randomly assigned to two groups for a four week intervention: Half of the children were asked to perform kind acts, while the other half were asked to keep track of pleasant places they visited. Happiness and acceptance by their peers was assessed at the beginning and the end of the four week intervention period. The children were allowed to choose the “acts of kindness” or the “pleasant places”. The “acts of kindness” group chose acts such as sharing their lunch or giving their mothers a hug. The “pleasant places” group chose to visit places such as the playground or a grandparent’s house.

At the end of the four week intervention, both groups of children showed increased signs of happiness, but the news reports differed in terms of the impact of the intervention on the acceptance of the children.


The NPR blog reported:

… the children who performed acts of kindness were much more likely to be accepting of their peers, naming more classmates as children they’d like to spend time with.

This would mean that the children performing the “acts of kindness” were the ones that became more accepting of others.


The conclusion in the Huffington Post was quite different:


The students were asked to report how happy they were and identify classmates they would like to work with in school activities. After four weeks, both groups said they were happier, but the kids who had performed acts of kindness reported experiencing greater acceptance from their peers  –  they were chosen most often by other students as children the other students wanted to work with.

The Huffington Post interpretation (a re-post from Livescience) was that the children performing the “acts of kindness” became more accepted by others, i.e. more popular.


Which of the two interpretations was the correct one? Furthermore, how significant were the improvements in happiness and acceptance?


I decided to read the original PLOS One paper and I was quite surprised by what I found:

The manuscript (in its published form, as of December 27, 2012) had no figures and no tables in the “Results” section. The entire “Results” section consisted of just two short paragraphs. The first paragraph described the affect and happiness scores:


Consistent with previous research, overall, students in both the kindness and whereabouts groups showed significant increases in positive affect (γ00 = 0.15, S.E. = 0.04, t(17) = 3.66, p<.001) and marginally significant increases in life satisfaction (γ00 = 0.09, S.E. = 0.05, t(17) = 1.73, p = .08) and happiness (γ00 = 0.11, S.E. = 0.08, t(17) = 1.50, p = .13). No significant differences were detected between the kindness and whereabouts groups on any of these variables (all ps>.18). Results of t-tests mirrored these analyses, with both groups independently demonstrating increases in positive affect, happiness, and life satisfaction (all ts>1.67, all ps<.10).


There are no actual values given, so it is difficult to know how big the changes are. If a starting score is 15, then a change of 1.5 is only a 10% change. On the other hand, if the starting score is 3, then a change of 1.5 represents a 50% change. The Methods section of the paper also does not describe the statistics employed to analyze the data. Just relying on arbitrary p-value thresholds is problematic, but if one were to use the infamous p-value threshold of 0.05 for significance, one can assume that there was a significant change in the affect or mood of children (p-value <0.001), a marginally significant trend of increased life satisfaction (p-value of 0.08) and no really significant change in happiness (p-value of 0.13).

It is surprising that the authors do not show the actual scores for each of the two groups. After all, one of the goals of the study was to test whether performing “acts of kindness” has a bigger impact on happiness and acceptance than the visiting “pleasant places” (“whereabouts” group). There is a generic statement “ No significant differences were detected between the kindness and whereabouts groups on any of these variables (all ps>.18).”, but what were the actual happiness and satisfaction scores for each of the groups? The next sentence is also cryptic: “Results of t-tests mirrored these analyses, with both groups independently demonstrating increases in positive affect, happiness, and life satisfaction (all ts>1.67, all ps<.10).” Does this mean that p<0.1 was the threshold of significance? Do these p-values refer to the post-intervention versus pre-intervention analysis for each tested variable in each of the two groups? If yes, why not show the actual data for both groups?


The second (and final) paragraph of the Results section described acceptance of the children by their peers. Children were asked who they would like to “would like to be in school activities [i.e., spend time] with’’:


All students increased in the raw number of peer nominations they received from classmates (γ00 = 0.68, S.E. = 0.27, t(17) = 2.37, p = .02), but those who performed kind acts (M = +1.57; SD = 1.90) increased significantly more than those who visited places (M = +0.71; SD = 2.17), γ01 = 0.83, S.E. = 0.39, t(17) = 2.10, p = .05, gaining an average of 1.5 friends. The model excluded a nonsignificant term controlling for classroom size (p = .12), which did not affect the significance of the kindness term. The effects of changes in life satisfaction, happiness, and positive affect on peer acceptance were tested in subsequent models and all found to be nonsignificant (all ps>.54). When controlling for changes in well-being, the effect of the kindness condition on peer acceptance remained significant. Hence, changes in well-being did not predict changes in peer acceptance, and the effect of performing acts of kindness on peer acceptance was over and above the effect of changes in well-being.


This is again just a summary of the data, and not the actual data itself. Going to “pleasant places” increased the average number of “friends” (I am not sure I would use “friend” to describe someone who nominates me as a potential partner in a school activity) by 0.71, performing “acts of kindness” increased the average number of friends by 1.57. It did answer the question that was raised by the conflicting news reports. According to the presented data, the “acts of kindness” kids were more accepted by others and there was no data on whether they also became more accepting of others. I then looked at the Methods section to understand the statistics and models used for the analysis and found that there were no details included in the paper. The Methods section just ended with the following sentences:


Pre-post changes in self-reports and peer nominations were analyzed using multilevel modeling to account for students’ nesting within classrooms. No baseline condition differences were found on any outcome variables. Further details about method and results are available from the first author.


Based on reviewing the actual paper, I am quite surprised that PLOS One accepted it for publication. There are minimal data presented in the paper, no actual baseline scores regarding peer acceptance or happiness, incomplete methods and the rather grand title of “Kindness Counts: Prompting Prosocial Behavior in Preadolescents Boosts Peer Acceptance and Well-Being” considering the marginally significant data. One is left with many unanswered questions:

1) What if kids had not been asked to perform additional “acts of kindness” or additional visits to “pleasant places” and had instead merely logged these positive activities that they usually performed as part of their routine? This would have been a very important control group.

2) Why did the authors only show brief summaries of the analyses and omit to show all of the actual affect, happiness, satisfaction and peer acceptance data?

3) Did the kids in both groups also become more accepting of their peers?


It is quite remarkable that going to places one likes, such as a shopping mall is just as effective pro-social behavior (performing “acts of kindness”) in terms of improving happiness and well-being. The visits to pleasant places also helped gain peer acceptance, just not quite as much as performing acts of kindness. However, the somewhat selfish sounding headline “Hanging out at the mall makes kids happier and a bit more popular” is not as attractive as the warm and fuzzy headline “Random acts of kindness can make kids more popular“. This may be the reason why the “prosocial” or “kindness” aspect of this study was emphasized so strongly by the news media.


In summary, the limited data in this published paper suggests that children who are asked to intentionally hang out at places they like and keep track of these for four weeks seem to become happier, similar to kids who make an effort to perform additional acts of kindness. Both groups of children gain acceptance by their peers, but the children who perform acts of kindness fare slightly better. There are no clear descriptions of the statistical methods, no actual scores for the two groups (only the changes in scores are shown) and important control groups (such as children who keep track of their positive activities, without increasing them) are missing. Therefore, definitive conclusions cannot be drawn from these limited data. Unfortunately, none of the above-mentioned news reports highlighted the weaknesses, and instead jumped on the bandwagon of interpreting this study as scientific evidence for the importance of kindness. Some of the titles of the news reports even made references to bullying, even though bullying was not at all assessed in the study.

This does not mean that we should discourage our children from being kind. On the contrary, there are many moral reasons to encourage our children to be kind, and there is no need for a scientific justification for kindness. However, if one does invoke science as a reason for kindness, it should be based on scientifically rigorous and comprehensive data.


Armchair Psychiatry and Violence

Following tragic mass shootings such as the one that unfolded in Newtown, Connecticut, it is natural to try to “make sense” of the events. The process of “making sense” and understanding the underlying causes is part of the healing process. It also gives hope to society that if we were able to address the causes of the tragedy, we could prevent future tragedies. It is not unexpected that mental illness is often invoked as a possible reason for mass shootings. After all, the slaying of fellow human beings seems so far removed from what we consider normal human behavior. Since mental illness directly affects human behavior, it seems like the most straightforward explanation for a mass shooting. It is surmised that the mental illness severely impairs the decision-making capacity and perceptions of the afflicted person so that he or she is prone to acting out in a violent manner and causing great harm to others. Once evidence for “mental illness” in a shooter is found, one may also be tempted to stop looking for other factors that may have caused the tragedy. The nebulous expression “mental illness” can appear like a convenient catch-all explanation that requires no further investigation, because the behavior of a “mentally ill” person might be beyond comprehension.

The problem with this convenient explanation is that “mental illness” is not a homogeneous entity. There are many different types of mental illness, and specific psychiatric disorders, such as major depression, anxiety disorder or schizophrenia represent a broad spectrum of disease. These illnesses do not only vary in their severity from patient to patient, but even within a single patient, mental illnesses vary over time in severity. Just because someone carries the diagnosis of schizophrenia does not mean that the patient will continuously have severe manifestations of the disease. Some patients may show signs of withdrawal and introversion, others may act out with aggressive behavior. Making a direct causal link between a person’s diagnosis of mental illness and their violent behavior requires a careful psychiatric examination of that individual patient, as well as other circumstances, such as recent events in their lives or possible substance abuse.

When shooters kill themselves after the murders they commit, it is impossible to perform such a psychiatric examination and all that one can go by are prior medical records, but it becomes extremely difficult to retrospectively construct cause-effect relationships. In the case of Adam Lanza, the media and the public do not have access to his medical records. However, soon after the shooting, there was frequent mention in the media that Lanza had been diagnosed with either Asperger syndrome, autism or a personality disorder and potential links between these diagnoses and the shooting were implied. Without carefully perusing his medical records, it is difficult to assess whether these diagnoses were accurate, how severe his symptoms were and how they were being treated. To make matters worse, some newspapers and websites have resorted to generating narratives about Adam Lanza’s behavior and mental health based on subjective and anecdotal experiences of class-mates, family friends and in perhaps the most ridiculous case, Lanza’s hair stylist. Snippets of subjective information regarding odd behaviors exhibited by Lanza have been offered to readers and viewers so that they can perform an armchair evaluation of Lanza’s mental health from afar and search for potential clues in his past that might point to why he went on a shooting rampage. Needless to say, this form of armchair analysis is fraught with error.

It is difficult enough to diagnose a patient during a face-to-face evaluation and then try to make causal links between the symptoms and the observed pathology. In the setting of cardiovascular disease, for example, the healthcare professional has access to blood tests which accurately measure cholesterol levels or biomarkers of heart disease, angiograms that generate images of the coronary arteries and even ultrasound images of the heart (echocardiograms) that can rather accurately assess the strength of the heart. Despite all of these objective measurements, it requires a careful and extensive discussion with the patient to understand whether his shortness of breath is truly linked to his heart disease or whether it might be related to other factors. Someone might have mild heart disease by objective testing, but the shortness of breath he experiences when trying to walk up the stairs may be due to months of physical inactivity and not due to his mild heart disease.

In psychiatry, making diagnoses and causally linking symptoms and signs to mental illness is even more difficult, because there are fewer objective tests available. There are, as of now, no CT-Scans or blood tests that can accurately and consistently diagnose a mental illness such as depression. There are numerous reports of documented abnormalities of brain imaging observed in patients with mental illness, but their reliability and their ability to predict specific outcomes of the respective diseases remains unclear. The mental health professional has to primarily rely on subjective reports of the patient and the patient’s caregivers or family members in order to arrive at a diagnosis. In the case of Adam Lanza, who killed himself as well as his mother, all one can go by are his most recent mental health evaluations, which could provide a diagnosis, but may still not reliably explain his killing spree. Retrospective evaluations of his mental health by former class-mates, hair stylists or family members are of little help. Comments on the past behavior of a mass shooter will invariably present a biased and subjective view of the past, colored by the knowledge of the terrible shooting. Incidents of “odd behaviors” will be remembered, without objectively assessing how common these behaviors were in other people who did not go on to become mass shooters.

An article written by Liza Long with the sensationalist title “I Am Adam Lanza’s Mother” was widely circulated after the shooting. Long was obviously not the mother of Adam Lanza, and merely took advantage of the opportunity to describe her frustration with the mental health care system and her heart-wrenching struggles with the mental health of her son who was prone to violent outbursts. In addition to violating the privacy of her son and making him a likely target of future prejudice and humiliation, Long implied that the observed violent outbursts she had seen in her son indicated that he might become a mass shooter like Adam Lanza. Long, like the rest of the public, had no access to Lanza’s medical records, did not know whether Lanza had been diagnosed with the same illnesses as her own son and whether Lanza had exhibited the same behaviors. Nevertheless, Long’s emotional story and the sensationalist title of her article caught on, and many readers may have accepted her story as a proof of the link between certain forms of mental illness and predisposition to becoming a mass shooter.

Instead of relying on retrospective analyses and anecdotes, it may be more helpful to review the scientific literature on the purported link between mental illness and violence.


The link between mental illness and violence

There is a widespread notion that mental illness causes violent behavior, but the scientific evidence for this presumed link is not that solid.  “Mental illness” is a very heterogeneous term, comprising a wide range of disorders and degrees of severity for each disorder, so many studies that have tried to establish a link between “mental illness” and violence have focused on the more severe manifestations of mental illness. The 1998 land-mark study “Violence by People Discharged From Acute Psychiatric Inpatient Facilities and by Others in the Same Neighborhoods” by Henry Steadman and colleagues was published in the highly cited psychiatry journal Archives of General Psychiatry and focused on patients whose mental illness was severe enough to require hospitalization. The study followed patients for one year after they were released from the acute psychiatric inpatient units, and assessed how likely they were to engage in violence. At one of the sites (Pittsburgh), the researchers also compared the likelihood of the psychiatric patients to engage in violence with that of other residents of the same neighborhood.  Steadman and colleagues found that there was a higher rate of violence observed in psychiatric patients, this was associated with the higher rate of substance abuse. Psychiatric patients without substance abuse had the same rate of violence as other residents of the neighborhood without substance abuse.

The recent large-scale study “The Intricate Link Between Violence and Mental Disorder” was published in the Archives of General Psychiatry by Elbogen and Johnson in 2009 and also found that severe mental illness by itself was not a strong predictor of violence. Instead, future violence was more closely associated with a history of past violence, substance abuse or contextual factors, such as unemployment or a recent divorce. A 2009 meta-analysis by Fazel and colleagues was published in PLOS Medicine and reviewed major studies that had investigated the potential link between schizophrenia and violence. The authors found an increased risk of violence and homicide in patients with schizophrenia, but this was again primarily due to the higher rates of substance abuse in the patient population. The risk of homicide in individuals with schizophrenia was 0.3%, and the risk of homicide was also 0.3% in people with a history of substance abuse. All of the studies noted a great degree of variability in terms of violence, again reminding us that mental illnesses are very heterogeneous diseases. An individual diagnosed with “schizophrenia” is not necessarily at higher risk for engaging in violent behavior. One also has to assess their specific context, their past history of violence, their social circumstances and especially their degree of substance abuse, which can refer to alcohol abuse or alcohol dependence as well as the abuse of illegal substances such as cocaine. The data on whether Asperger syndrome, one of the conditions that Adam Lanza is said to have been diagnosed with, is far sparser. Stål Bjørkly recently reviewed the studies in this area and found that there has been no systematic research in this field. The hypothesized link between Asperger syndrome and violence is based on just a few studies, mostly dealing with case reports of selected incidents.

It is quite noteworthy that multiple large-scale studies investigating the association between mental illness and violence have come up with the same conclusion: Patients with mental illnesses may be at greater risk for engaging in violence, but this appears to be primarily linked to concomitant substance abuse. In the absence of substance abuse, mental illness by itself does not significantly increase the likelihood of engaging in violence. Richard Friedman summarized it best in an article for the New England Journal of Medicine:

The challenge for medical practitioners is to remain aware that some of their psychiatric patients do in fact pose a small risk of violence, while not losing sight of the larger perspective — that most people who are violent are not mentally ill, and most people who are mentally ill are not violent.

Human behavior and mental illness

One rarely encounters armchair diagnoses in cardiovascular disease, neurologic disease or cancer. Journalists do not usually interview relatives or friends of cancer patients to ascertain whether there had been early signs of the cancer that had been missed before the definitive diagnosis was made or a patient died of cancer. If medical details about public persona are disclosed, such as for example the heart disease in the case of former vice-president Cheney, journalists and TV viewers or readers without medical expertise rarely offer their own opinion whether the diagnosis of cardiovascular disease was correct and how the patient should be treated. There were no interviews with other cardiovascular patients regarding their own personal history of heart disease and they were also not asked to comment on how they felt Cheney was being treated. In the case of the 2012 US meningitis outbreak, which resulted in the death of at least 35 people, many questions were raised in the media regarding the underlying causes and there was understandable concern about how to contain the outbreak and address underlying causes, but the advice was usually sought from experts in infectious disease.

When it comes to mental illness, on the other hand, nearly everyone with access to the media seems to think they are an expert on mental health and one finds a multitude of opinions on the efficacy of psychoactive medications, whether or not psychiatric patients should be institutionalized and warning signs that lead up to violent behavior. There are many potential reasons for why non-experts feel justified in commenting on mental illness, but remain reticent to offer their opinion on cardiovascular disease, cancer or infectious disease.  One reason is the subject matter of psychiatry. As humans, we often define ourselves by our thoughts, emotions and behaviors – and psychiatry primarily concerns itself with thoughts, emotions and behaviors. Our personal experiences may embolden us to offer our opinions on mental health, even though we have not had any formal training in mental health.

The psychiatric profession itself may have also contributed to this phenomenon by blurring the boundaries between true mental illness and the broad spectrum of human behavior. The criteria for mental illness have been broadened to such an extent that according to recent studies, nearly half of all Americans will meet the criteria for a mental illness by the time they have reached the age of 75. There is considerable debate among psychiatrists about the potential for over-diagnosis of mental illness and what the consequences of such over-diagnoses might be. The labeling of mildly “abnormal” behaviors as mental illnesses not only results in the over-prescription of psychoactive medications, but it may also take away mental health resources from patients with truly disabling forms of mental illness. For example, the upcoming edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM – which establishes the diagnostic criteria for each mental disorder) will remove the bereavement exemption for the diagnosis of depression. This means that people suffering from severe grief after the death of their loved ones, such as the parents of the children that were murdered in Newtown, could conceivably be diagnosed with the mental disorder “Major Depression”. 

Romanticizing and vilifying mental illness

The topic of mental illness also lends itself to sensationalism. Occasionally, mental illness is romanticized, such as the idea that mental illness somehow fosters creativity for which there is little scientific evidence. More often, however, patients with mental illness are vilified. Broad generalizations are made and violent tendencies or criminal behaviors are ascribed to patients, without taking into account the heterogeneity of mental illness. Wayne LaPierre of the National Rifle Association (NRA) recently called for the creation of an “active national database of the mentally ill” and on a subsequent event, LaPierre referred to mentally ill patients as “monsters” and “lunatics”. Such sensationalist rants may make for good publicity, but they also help further undermine an objective discussion about mental health. Especially the call for a national database of mentally ill people comes seems somewhat counter-intuitive since the NRA has often portrayed itself as a defender of personal liberty and privacy. Are organizations such as the NRA aware of the fact that nearly half of all Americans will at some point in their life qualify for mental illness diagnoses and would have to be registered in such a database? Who would have access to such a database? For what purposes would the database be used? Would everyone listed in the database be barred from buying guns? How about household members living with a patient who has been diagnosed with a mental illness? Would these household members also be barred from buying guns?  If indeed all patients with at least one psychiatric diagnosis were registered in a national database and if they and their household members were barred from owning guns, nearly all US households would probably become gun-free. If one were to follow along the logic of the NRA, one might even have to generate a national database of people with a history of substance abuse or a past history of violence, since the above-mentioned research showed that substance abuse and past history of violence may be even stronger predictors of future violence than mental illness.

When it comes to reporting about mental illness it is especially important to avoid the pitfalls of sensationalism. Mental illness should be neither romanticized nor vilified. Potential links between mental illness and behaviors such as violence should always be made in the context of the existing medical and scientific literature and one should avoid generalizations and pronouncements based on occasional anecdotes. Journalists and mental health professionals need to help ensure the accuracy and objectivity of analyses regarding the mental health of individuals as well as specific mental illnesses. It never hurts to have a discussion about mental health. There is clearly a need for the improvement of the mental health infrastructure and for the development of better therapies for psychiatric disease, but this discussion should be based on facts and not on myths.


Image Credit: Brain of MRI scan data for child onset schizophrenia showing areas of brain growth and loss of tissue via NIMH


“It Is An Opportunity For Great Joy”

I was about 12 years old when I found out that my grandfather was born on 12/12/12. If he were alive, he would be exactly 100 years old today. I found out about his birthday, when he came to stay with us in Munich for an eye surgery. He was a diabetic and had been experiencing deterioration in his vision. At that time, it was very difficult to find an eye surgeon in Pakistan who would be able to perform the surgery. My grandfather spoke many languages, such as Punjabi, Urdu, Persian, English, Arabic and some Sanskrit, but he could not speak German. His visit occurred during my school holidays, so I was designated to be his official translator for the doctor visits and his hospital stay.

On the afternoon before his surgery, we went to the hospital and I was filling out the registration forms, when I asked my grandfather about his birthday and he said 12/12/12. I was quite surprised to find out that he had such a wonderful combination of numbers, when the lady at the registration desk saw the date and asked me whether he was absolutely sure this was the correct date. I translated this for my grandfather and he smiled and said something along the lines of, “It is more or less the correct date. Nobody is exactly sure, but it is definitely very easy to remember”. I knew that I was supposed be a translator, but this required a bit more finesse than a straightforward translation. One cannot tell a German civil servant that a date is more or less correct. If we introduced uncertainty at this juncture, who knows what the consequences would be.

I therefore paraphrased my grandfather’s response as, “Yes, it is absolutely correct!”

She then said, “Eine Schnapszahl!”

My grandfather wanted me to translate this, and I was again at a loss for words. Schnapszahl literally means Schnapsnumber and is a German expression for repeated digits, such as 33 or 555. The origin of the word probably lies in either the fact that a drunken person may have transient double vision or in a drinking game where one drinks Schnaps after reaching repeated digits when adding up numbers. I was not quite sure how to translate this into Urdu without having to go into the whole background of how German idioms often jokingly refer to alcohol.

I decided to translate her comment as “What a memorable date”, and my grandfather nodded.

We were then seen by a medical resident who also pointed out the unique birthday.

His comment was “Darauf sollten wir einen trinken!”, which is another German idiom and translates to „we should all have a drink to celebrate this”, but really just means “Hooray!”  or “Great!”

My grandfather wanted to know what the doctor had said and I was again in a quandary. Should I give him accurate translation and explain that this is just another German idiom and is not intended as a cultural insult to a Pakistani Muslim? Or should I just skip the whole alcohol bit? Translation between languages is tough enough, but translating and showing cultural sensitivity was more than I could handle. My Urdu was not very good to begin with, and all I could come up with the rather silly Urdu translation “It is an opportunity for great joy”. My grandfather gave me a puzzled look, but did not ask any questions.



On the day after my grand-father’s eye surgery, the ophthalmologist and the residents came by for morning rounds.  They removed his eye-patch, inspected the eye and told me that everything looked great. He just needed a few more days of recovery and would soon be able to go home. After putting the gauze and eye-patch back on, the doctors moved on to the next patient.


Once the doctors had completed rounds, I made the acquaintance of the head nurse. She seemed to think that the eye ward was her military regiment and was running it like a drill-sergeant. She walked into every room and ordered all the patients to get out of bed and walk to the common area. Only lazy people stayed in bed, she said. The best way to recuperate was to move about.


I told her that I did not think my grandfather was ready to get up.

“Did any doctor forbid him to get up?”

“No, not really”, I replied.

“If he has two legs, he can walk to the common room. If not, we will provide a wheelchair.”

“He just had surgery yesterday and needs to rest”, I protested and pointed to my grandfather’s eye-patch.

“Yesterday was yesterday and today is today!” was the response from the drill-sergeant.

This statement did not seem very profound to me and I was waiting for a further explanation, but the drill-sergeant had already moved on, ordering the patients from the neighboring rooms to get up.

My grandfather and I did not have much of a choice, so we joined the procession of one-eyed men who looked like retired, frail pirates. They were slowly shuffling out of their rooms towards the common area.

The common area consisted of chairs and sofas as well as a couple of tables. I sat down in a corner with my grandfather, and we started talking. He told me stories from his life, including vivid descriptions of how he and his friends proudly defied the British colonialists. My grandfather recited poems from the Gulistan of the Persian poet Saadi for me in Persian and translated them into Urdu. He wanted to know about German history and what I was learning at school. He asked me if I knew any poems by Goethe, because the Indian poet Iqbal had been such a great admirer of Goethe’s poetry.

We talked for hours. Like most children, I did not realize how much I enjoyed the conversations. It was only years later when my grandfather passed away that I wished I had taken notes of my conversations with him. All I currently have are fragmented memories of our conversations, but I treasure these few fragments.

I then pulled out a tiny travel chess set that I had brought along, and we started playing chess. I knew that he had trouble distinguishing some of the pieces because of his eye surgery. I took advantage of his visual disability and won every game. During my conversations with my grandfather and our chess games, I noticed that some of the other men were staring at us. Perhaps they were irritated by having a child around. Maybe they did not like our continuous chatting or perhaps they just did not like us foreign-looking folks. I tried to ignore their stares, but they still made me quite uncomfortable.

On the next day, we went through the same procedure. Morning rounds, drill sergeant ordering everyone to the common area, conversations with my grandfather and our chess games. The stares of the other patients were now really bothering me. I was wondering whether I should walk up to one of the men and ask him whether they had a problem with me and my grandfather. Before I could muster the courage, one of the men got up and walked towards us. I was a bit worried, not knowing what the man was going to do or say to us.


“Can you ask your grandfather, if I can borrow you?”

“Borrow me?”, I asked, taken aback.

“He gets to tell you all these stories and play chess with you for hours and hours, and I also want to have someone to talk to.”

Once he had said that, another patient who was silently observing us chimed in and said that he would like to know if he could “borrow” me for a game of chess. I felt really stupid. The other patients who had been staring at me and my grandfather were not at all racist or angry towards us, they were simply envious of the fact that my grandfather had someone who would listen to him.

I tried to translate this for my grandfather, but I did not know how to translate “borrow”. My grandfather smiled and understood immediately what the men wanted, and told me that I should talk to as many of the patients as possible. He told me that the opportunity to listen to others was a mutual blessing, both for the narrator as well as the listener.

On that day and the next few days that my grandfather spent in the hospital, I spoke to many of the men and listened to their stories about their lives, their health, their work and even stories about World War 2 and life in post-war Germany. I also remember how I agreed to play chess, but when I pulled out my puny little travel chess set, my opponent laughed and brought a huge chess set from a cupboard in the common area. He beat me and so did my grandfather who then also played chess with me on this giant-size chess board which obliterated the visual advantage that my travel set had offered.


Since that time I spent with my grandfather and the other patients on the eye ward, I have associated medicine with narration. All humans want to be narrators, but many have difficulties finding listeners. Illness is often a time of vulnerability and loneliness. Narrating stories during this time of vulnerability is a way to connect to fellow human beings, which helps overcome the loneliness. The listeners can be family members, friends or even strangers. Unfortunately, many people who are ill do not have access to family members or friends who are willing to listen. This is the reason why healthcare professionals such as nurses or physicians can serve a very important role. We listen to patients so that we can obtain clues about their health, searching for symptoms that can lead to a diagnosis. However, sometimes the process of listening itself can be therapeutic in the sense that it provides comfort to the patient.

Even though I mostly work as a cell biologist, I still devote some time to the practice of medicine. What I like about being a physician is the opportunity to listen to patients or their family members. I prescribe all the necessary medications and tests according to the cardiology guidelines, but I have noticed that my listening to the patients and giving them an opportunity to narrate their story provides an immediate relief.

It is an indeed an  “an opportunity for great joy”, when the patient experiences the joy of having an audience and the healthcare provider experiences the joy of connecting with the patient. I have often wondered whether there is any good surrogate for listening to the patient. Medicine is moving towards reducing face-to-face time between healthcare providers and patients in order to cut costs or maximize profits. The telemedicine approach in which patients are assessed by physicians who are in other geographic locations is gaining ground. Patients now often fill out checklists about their history instead of narrating it to the physicians or nurses. All of these developments are reducing the opportunity for the narrator-listener interaction between patients and healthcare providers. However, social networks, blogs and online discussion groups may provide patients the opportunities to narrate their stories (those directly related to their health as well as other stories) and find an audience. I personally prefer the old-fashioned style of narration. The listener can give instant feedback and the facial expressions and subtle nuances can help reassure the narrator. The key is to respect the narrative process in medicine and to help the patients find ways to narrate their stories in a manner that they are comfortable with.

Can The Heart Regenerate Itself After A Heart Attack?

Some cardiovascular researchers believe that the heart contains cardiac stem cells or progenitor cells which can become mature cardiomyocytes (beating heart cells) following an injury and regenerate the damaged heart. The paper “Mammalian heart renewal by pre-existing cardiomyocytes” published in the journal Nature by Senyo and colleagues (online publication on December 5, 2012), on the other hand, suggests that the endogenous regenerative potential of the adult heart is very limited. The researchers studied the regeneration of cardiomyocytes in mice using a genetic label that marks cardiomyocytes with a green fluorescent protein and they also used the nonradioactive stable isotope 15N (Nitrogen-15) to track the growth of cardiomyocytes. They found that the adult mouse heart has a very low rate of cardiomyocyte regeneration and projected the annual proliferation rate to be only 0.76%. This means that less than one out of a hundred cardiomyocytes in the adult heart undergoes cell division during a one year period. Even though this number is derived from studying the turnover of cardiomyocytes in mice, it correlates very well with the proposed rate of annual cardiomyocyte self-renewal (0.5% to 1%) that Bergmann and colleagues estimated for the human heart in a 2009 paper published in Science. The key novelty of the paper by Senyo and colleagues is that they identified the source of these new cardiomyocytes. They do not arise from cardiac stem cells or cardiac progenitor cells, but are primarily derived from pre-existing adult cardiomyocytes. Does this low rate of cardiomyocyte turnover increase after an injury? Senyo and colleagues found that eight weeks after a heart attack, only 3.2% of the mouse cardiomyocytes located near the injured areas had undergone cell division.


This low rate of self-renewal in the adult heart sounds like bad news for researchers who thought that the adult heart had the ability to heal itself after a heart attack. However, the journal Nature also published the paper “Functional screening identifies miRNAs inducing cardiac regeneration” by Eulalio and colleagues on the same day (online publication on December 5, 2012), which indicates that the low levels of cardiomyocyte growth can be increased using certain microRNAs. A microRNA is a small RNA molecule that can regulate the expression of hundreds of genes and can play an important role in controlling many cellular processes such as cell growth, cell metabolism and cell survival. Eulalio and colleagues performed a broad screen using 875 microRNA mimics in new-born rat cardiomyocytes and identified 204 microRNAs that increase the growth of the cells. They narrowed down the number of microRNAs and were able to show that two distinct microRNAs increased the growth of cardiomyocytes after heart attacks in mice. The effect was quite significant and mice treated with these microRNAs had near-normal heart function 60 days after a heart attack.

Based on these two Nature papers, it appears that the cardiomyocytes in the adult heart have a kind of “brake” that prevents them from proliferating. Addition of specific microRNAs seems to relieve the “brake” and allow the adult heart cells to regenerate the heart after a heart attack. This could lead to potential new therapies for patients who suffer from heart attacks, but some important caveats need to be considered. MicroRNAs (and many other cardiovascular therapies) that work in mice or rats do not necessarily have the same beneficial effects in humans. The mice in the study by Eulalio and colleagues also did not receive any medications that patients routinely receive after a heart attack. Patients usually show some improvement in their heart function after a heart attack, if they are treated with the appropriate medications. Since the mice were not treated with the medications, it is difficult to assess whether the microRNAs would have a benefit beyond that what is achieved by conventional post-heart attack medications. Finally, the delivery and dosing of microRNAs is comparatively easy in mice but much more challenging in a heterogeneous group of patients.

The studies represent an important step forward towards identifying the self-renewal mechanisms in the adult heart and suggest that microRNAs are major regulators of these processes, but many additional studies are necessary before their therapeutic value for patients can be assessed.


Image credit: Wikimedia Commons