Our Lady of Paris
Our Lady of Paris
Paris is often associated with hearts. The world is full of people wearing T shirts emblazoned with the slogan "I Love Paris", the "Love" part represented by a bright red heart. This phrase is even used, for reasons that I don't understand, as the name of a chain of shoes stores in New Zealand—not that I can say I understand that much about shoe stores anyway. Many people claim to have "left their hearts" in Paris. The city of love. The city of light. The city that has had to restrain people in love from displaying their enthusiasm: couples are now prevented from attaching padlocks to the iconic Pont des Arts as a sign of their commitment to each other; sticking with the heart theme, young lovers have taken instead to enhancing or defacing the bridge with heart-shaped graffiti.
Paris then, it seemed to me, was a perfect venue for the 2019 World Congress of Cardiology conference. Except, of course, that it is on the other side of the world, in the northern hemisphere. That didn’t matter. We have made these long plane trips before. It was an also an excellent opportunity to visit our oldest daughter, who has lived for some years in that part of the world.
In the hospital where I work in Central Otago, we have a lot of heart problems. Of the cardiology type. Many of our patients are retired Southland farmers. As soon as they don't need the rain to grow grass and feed sheep or cows, they move to our part of the world, where the sun always shines, and the views are better. The former farmers, who have eaten mutton and cream all their working lives, once they stop working, become less active, start looking backwards, their coronary arteries fill with plaque, and they have their first heart attack.
From a personal point of view, I was also interested in the sessions on atrial fibrillation. This abnormal heart rhythm, unless you ask my dentist, is the first significant medical condition I have so far developed myself, from a combination of over-eating, over-exercising, and drinking what I would call moderate amounts of alcohol. It is also a leading cause of stroke, a condition in which I am trying to develop a special clinical interest. I also have an interest in not having a stroke myself. I was keen to hear what the cardiologists at the conference had to say.
People have mixed feelings about Paris, as they do about most cities. From my own point of view I like to visit them but prefer to live away from them in the countryside. A rural colleague who knows a thing or two about cardiology, and knows a little bit about more populated localities, while acknowledging that Paris is the most visited city on the planet, reminded me that we already live in a beautiful place. "Earnscleugh," he said, referring to the tiny Central Otago community in which he lives, and is admittedly a lovely part of the world, "is nice at this time of year." It was mid-winter when he told me this, and just before we left on our own travels.
In France, which of course is in the other hemisphere, this meant it was summer, which inspired us, in a choice that was true to our rural roots, to head out of Paris for a couple of days soon after we arrived. Six months before the conference, at home, we had been watching the water lilies in our pond reach their peak and die back. They looked a bit, we thought, like the pictures on the calendar of Monet paintings hanging in our kitchen. Two days before the conference, in France, we were at Giverny, with much of the rest of the world, admiring the real water gardens planted by Monet in the 1880s and immortalised in his paintings. Having seen the real thing, we could no longer claim any comparison with our little pond at home.
Giverny itself is a charming village, obviously attracting people who like to keep it that way. To get there from Vernon, where the train from Paris stops, and where we stayed, tourists enjoy a pleasant walk or bike ride along the river, on a path that follows the banks of the Seine all the way from Paris to the sea. Close to Monet's house and garden, we shared an apple tart with calvados with our morning coffee on a veranda shaded with wisteria. Later in the day, before tackling the walk back to the train, we sat down to a leisurely lunch featuring fresh salad and tomatoes in a garden cafe overlooking the valley.
Our daughter, who grew up with the Monet calendars, studied in Paris, and has learned to love France, took a month off from her work in the Middle East and rented an apartment in Les Batignolles, a smart suburb of Paris between Saint Lazare and Montmartre. We stayed with her and her fiancé for the week of the conference. This was not the same as Earnscleugh; this was a large vibrant city where many different people lived. Much of their life seemed to us to be lived on the street. We enjoyed walking past the many cafes and restaurants—except for the second-hand cigarette smoke—but, when it came to meals, generally bought fresh produce from the local markets and ate at home.
We made a side trip from Paris to Chartres, which is a wonderful old town with good cafes and restaurants, and has an interesting walk along the river, but nobody ever goes there except to see the cathedral. The building is called, predictably, Notre Dame de Chartres—Our Lady of Chartres. In this case, the link with Our Lady, the Virgin Mary, the mother of Jesus, is arguably justified, because a relic believed to have been the iconic lady’s tunic is located at the site, and the large number of pilgrims who have come to see it is the original reason for the cathedral's existence. The current building is the fifth on the site, the earlier versions having been destroyed by fire. But somehow, perhaps miraculously, the item of clothing allegedly belonging to the Virgin Mary has not been destroyed. As recently as 1836 there was a fire that damaged the wooden roof, which was replaced with an iron structure. We didn't get to see the tunic—nobody does—but we did get to marvel with all the other tourists at the mix of architectural styles, the stained-glass windows, and the general hugeness of the cathedral on the top of the hill.
While on the subject of cathedrals, of which Paris is developing something of a shortage, but more about that later, we also made a short trip from our accommodation in Paris to Saint Denis, which happened to be at the end of our Metro line, to see the basilica there. The suburb was named, and the cathedral was built, in honour of Saint Dennis, a Bishop of Paris in the third century. He was decapitated on the hill of Montmartre—possibly an origin of the name; the mount of the martyr—and is said to have carried his head, which continued preaching as he went, until he reached the spot where the basilica now stands.
The cathedral is historically important, being the first gothic cathedral in France, and most of the French kings, starting from more than a thousand years ago, are buried there. It is still possible to see their graves and effigies, though many of the associated relics were melted down as scrap metal during the French Revolution. The cathedral was also visited in the fifteenth century by Joan of Arc, who hung up her white armour on the alter there, as a gesture of resignation, after her army was defeated in Paris in 1429. One of the spires, damaged in the nineteenth century, has been pulled down, and has been waiting for more than thirty years to be rebuilt, at a cost of millions of Euros. Good luck with that.
Part of the fun is practising the language. The French people we met, contrary to the usual stereotype perpetuated by English-speaking tourists, seemed to understand this. Waiters and shopkeepers who spoke some English would generally give us a choice and would helpfully correct us if we didn't know the word for something in French. The only exception was a lady in a wine shop who said she conducted wine-appreciation seminars and wanted to practise her English, which admittedly was not very good, for the purpose of talking about wine, and was happy to learn from us. She knew about New Zealand wines. We asked her to recommend a French wine to share with our daughter that evening. The lady asked us what we were going to eat. “Probably a salad,” we answered. She was lost for words, shocked that anyone would consider a salad to be a meal. “It doesn’t matter,” she eventually advised us. “Just drink water.”
In Paris, we continued with the Monet theme, which apart from cardiology and the cathedrals, had become the focus of this trip. Paintings and churches, and hearts. A wonderful mixture. We spent most of an afternoon in the Orangerie, only five minutes' walk from the Louvre, but much less crowded and much more peaceful, surrounded in the main gallery by Monet's massive paintings of the lily ponds at Giverny, then into another section of the same museum giving an historical perspective of his other work in other locations. On another day, we made a long walk through town, with a compulsory photo stop at the Arc de Triomphe, to the Musée Marmottan on the edge of the Bois de Boulogne to see more paintings by Monet and his contemporaries.
But, you will remember me saying, I was here to learn about cardiology. To get to the conference, I made a short walk to the Brochard Metro station at the end of the street, pushing in with the other commuters in the crowded train on line 13, looking out for pickpockets, changed at Montparnasse, enjoyed a compulsory stop at the croissanterie between the first and second escalators for a quick pastry and coffee, then joined a different crowd on line 12, where many of my fellow travellers by this stage were wearing their conference badges, to the final stop at Porte de Versailles, and up the last steps to the conference venue.
The conference was huge; a city in itself. There were 30,000 delegates, a small army of staff to organise us, and seemingly every pharmaceutical representative in the world with something to sell that may or may not have had the potential to help someone's heart. At each time of any day the programme offered 27 separate sessions to choose from. I was not completely overwhelmed: I was able to rule out over half of them as too technical; or promoting some expensive treatment that our public health system in little far-away New Zealand was never going to be able to afford. Other sessions, especially the ones with a free lunch, I could see were simply advertisements.
What did I learn? Well, mainly that other developed countries, especially in Europe and North America, at least in the big teaching hospitals, spend much more money on health care than we do: earlier adoption of the newer drugs, more enthusiastic use of expensive technologies, and a greater emphasis on life-prolonging interventions at a stage where these are probably futile. A Belgian study presented as part of a session on palliative care, showed that patients with end-stage heart failure were more likely to die at home if they chose, which was the goal of care, if they were visited daily by a nurse, dispensing inotropes through a central line. There was no group in the study of patients who were visited daily by a nurse at home without the expensive interventions. This palliative care session, labelled as a "nursing" session, was almost empty. A concurrent presentation on mechanical left-ventricular assist devices, used in a similar group of patients, was overflowing.
I met with a few other New Zealanders. Rod Jackson got the opportunity to debate the affirmative for the concept that risk scoring is essential for cardiovascular disease prevention. Ralph Stewart was given twelve minutes to present the findings of the New Zealand Oxygen Therapy in Acute Coronary Syndromes trial. In another session, a presenter from Houston was very complimentary about the studies from Christchurch on ruling out acute coronary syndromes in emergency departments using clinical scores and Troponin I testing. We are involved at Dunstan Hospital in a follow-up to this research, employing the same test in rural settings. However, the presenter has been unable to get American emergency department doctors to use this evidence to reduce hospital admissions, mainly because of the perceived risk of being sued, which is disappointing. He obviously saw the screening of patients in the emergency department, to reduce unnecessary hospitalisations, as the way of the future. It was early afternoon in Paris. "In New Zealand," he said, "it is already tomorrow."
I attended the sessions on heart failure with preserved ejection fraction, a condition that I find nebulous and confusing. I learned that cardiologists find the condition nebulous and confusing. I attended the sessions on atrial fibrillation. My very own condition. Again, there was an emphasis on procedures such as ablation, or surgery to close the left atrial appendages, interventions that are not readily available to most of our patients, are expensive, and not all that effective. There was a presentation from a British sports medicine specialist on atrial fibrillation in athletes, which I found was a useful update of the emerging evidence of the increased risk of atrial fibrillation in people who over-exercise, a factor that appears to be most relevant in younger athletes, and so far, a link only discovered in men and not women. Some of the information in this session not directly related to sports medicine, such as the influence of caffeine, seemed to be out-of-date.
The most popular sessions were the presentation of new trials and particularly large trials of new drugs. The exhibition hall, in which these were held, was not big enough to hold all those wanting to attend, and there were video presentations outside the doors where those unable to get in could see and hear at the same time the information being presented. Copies were available of the major medical journals in which the related articles had just been printed. The presenters of the day sat at stands outside wearing their finest suits and ties, like celebrities, available to answer questions. It was pure theatre. There was even a red carpet leading into the hall. Behind the presenters was a light show, with changing colours, of the skyscape of Paris, including the Eiffel Tower, which in fact was not far away.
Delegates could obtain a view of the real Eiffel Tower, as it happened, out the window from the third floor of the conference. No need for a fancy light show. You could walk or take the escalator to the third floor and see it. The tower was distracting; too iconic to be ignored. This was my fourth trip to Paris, but I had never been up the Eiffel tower before. I decided to have a look at it, to see what all the fuss was about.
On one of our walks through the city we strolled past the base of the tower. Our daughter left us there on our own to play the part of tourists. She told us where to buy ourselves a crepe on the street, another not-to-be-missed experience when visiting Paris, and gave us directions as to how to return from the tower to the apartment when we had finished. We shared the queue, which didn't take that long, with an Australian family. We were lucky to get right to the top of the tower, something that is not always possible when it is crowded or windy, and the two of us shared a glass of champagne—it was too expensive, we told the unimpressed man who sold it to us, to have one each—while we looked across at the city spread out beneath us, like a map. Afterwards, we found our way back to Rue Brochard on the Metro.
We found time for some enjoyable walks, which seemed to have become our favourite mode of transport, along the river Seine. One day, we walked across to the Isle Saint Louis. A band was playing on the bridge, dressed in military uniforms, fronted by a young woman in a brightly coloured dress, playing wartime jazz numbers. At the end of the bridge was a popular restaurant, also brightly coloured with green wooden walls and gold lettering. We had taken photos of it on another walk. There was a table available outside. We sat down, deserving a rest, we thought, and some food, after our walk, and enjoyed a long slow lunch. We had become the people in the photograph.
We walked to another Paris icon—Shakespeare and company—the famous English language bookstore, on the left bank, opposite the Isle de la Cité. An earlier version of the shop, in a different location, had been a meeting place for writers such as Ernest Hemingway, F Scott Fitzgerald and James Joyce. The new version features as a part of the Paris landscape in movies such as Before Sunset and Midnight in Paris. It is, unsurprisingly, full of books; ones that you would want to read. I came out with a volume of Hemingway short stories, suitably stamped, in one of the store's iconic canvas bags, to meet the others who were waiting in the nearby rose garden.
Last I need to introduce another character, missing in action, that we had so far avoided in our sightseeing, and I have not previously mentioned in this story, although I have mentioned its cousins and alluded to it in the title. Directly across the river from the bookstore, on the island, there is supposed to be a view of the cathedral—Notre Dame de Paris. It was there when I visited in 1979, and 1981, and 2012. It has been there in some form since the 4th century. Like the Basilica of Saint Denis, it was looted during the French Revolution, was deconsecrated, then further damaged during the Napoleonic wars, and almost demolished in the 19th century. Fortunately, it somehow managed to recapture the imagination of the French people. This was partly because of the success of Victor Hugo's novel The Hunchback of Notre Dame. The cathedral was saved by the book. For local Christian worshippers, and those lucky enough to visit Paris, at least until recent times, it was fully restored in the 1900s and opened to the public. It became one of the most visited and most photographed buildings in the world.
In April 2019, a fire started in the attic and burnt out most of the roof. This in turn led to the collapse of the spire, which crashed into the interior of the cathedral, destroying most of the structure. The French have a plan to restore the cathedral, not with an iron roof like Chartres, but using copies of the original materials, including the oak ceiling. In the meantime, the building looks, and is, a wreck, surrounded by orange plastic barriers. Piles of rubble cover the surviving walls, with only the two towers, which were saved by French fire fighters, defiantly poking through. We still encountered a few tourists, on the day we were there, taking selfies with the view across the river as a background, ignoring the fact that the real subject of the photo was effectively missing. I kept my camera in my pocket.
Our lady of Paris. The heart of the city; the heart of France. "And," as the English poet William Wordsworth said about another city, at a different time, and for a different reason, "all that mighty heart is lying still." To repair the damage in the way the French government has planned will cost more than a billion Euros and take up to twenty years. France spends, we learned at the conference, almost 40 billion Euros annually on heart care for its human population, sometimes for dubious benefit. A significant fraction of this amount, rightly or wrongly, is going to be spent on repairing the architectural heart of their capital city.