Coincidences are the food of blogs.

Last weekend our media was full of the return to the ring of NZ's favourite heavy weight boxer David Tua, complete with the pre fight hype, posturing and verbal abuse so typical of the sport. This was while I was researching the guidelines for traumatic brain injury diagnosis and management for a medicolegal case. How could I be comfortable watching the glorification of a brawling boxer who would deliberately, in a few hours time traumatise the brain of an opponent for significant personal gain, while before me lay the clinical records of an accidental head injury patient, to be analysed for the possible outcome of shaming and blaming a doctor who I am sure at no point had intent to maim or wound.

My discomfort was aggravated when the fight finished in the 2nd round with the loser clearly suffering significant brain trauma. A GCS of 14, judging from the short clip of the defender's corner after the bout ended. I bet someone did a CT of his head, probably funded by the public accident insurance. I wonder if anything was found?

Drawing parallel between two vastly different circumstances might seem unfair and some friends have railed against me for complaining about the oxymoron of labeling boxing as a sport and then supporting its banning. They point out that air sports, including some I have personally engaged in, have a far higher death rate. But a glider pilot does not fulfill a personal need by causing grievous body harm to a fellow human. Another pointed out that this was only the top echelon of the sport, for amateurs had head protection which presumably allow them to punch the opponent even harder in the head. Good for releasing all that aggression. Somewhat reassuring, until I saw another TV clip of bar patrons fighting over the outcome of the Tua fight! Presumably they were professionals.

Straining my single brain cell, I wondered why the UK had banned fox hunting but professional boxing continues...do humans care more for foxes than fellow humans? Do we need a new species. Homo Sulgerius.

Now this could get silly and the anti-boxing thing has a certain element of being the domain of greenie, libertarian, tree huggers, but didn't the World Medical Association and the British Medical Association call for the sport to be banned, and the national medical associations of Australia, Bangladesh, Canada, Denmark, Finland, Ghana, Ireland, New Zealand, Nigeria, Norway and South Africa have all lent support to this.

Why do nations permit and glorify such deliberate injury (with long term sequelae) to a fellow human for personal gain, both financial and emotional but forbid so things like smoking in public places because there is a small risk of unintentionally causing harm to other humans. Is it just that boxers have effectively given consent to being harmed when they take up the sport? Is that informed consent? Is it before or after the brain injury sets in?

Over that last year Global Family Doctor has reported several studies showing that higher fat content in diets is healthy. The latest one this week by Esposito et al showed that newly diagnosed diabetics who were instructed to follow a Mediterranean diet with 40% fat content had better blood sugar control, better cholesterol reduction, less use of oral hypoglycemic medicines, and more weight loss that those instructed to follow a standard diabetic diet.

In June 2009 we reported the study by Jenkins et al showing that a diet high in plant-based fat lowered cholesterol. A systematic review by Mente et al that we reported in April showed benefit of Mediterranean diet and intake of fish oils for prevention of heart disease. In January we reported a study by Salas-Salvado et al in which Mediterranean diet plus 30 g daily of mixed nuts decreased the risk among people with metabolic syndrome to advance to diabetes type 2 compared with Mediterranean diet alone.

It seems like time to abandon low fat diets and recommend good fat diets instead.

Last week’s New England Journal of Medicine called attention to another emerging humanitarian disaster – Urbanization! (http://content.nejm.org/cgi/content/full/361/8/741) For many the move to the “big city” often seems be out of an expectation of a better way of life – escape from the confinement or isolation of rural life, escape from conflict, or in search of better work opportunities. The editorials’ authors, however, point out some of the unique challenges of urban healthcare: population density and crowding, lack of social support, lack of disease surveillance in slums, and lack of access to care that may be nearby but unaffordable.

Whew! Just listing the challenges of urban health care helps me remember why I choose to practice in the country! The sheer challenge of thinking through possible solutions is overwhelming – so many challenges, so much complexity, and such a large scale. How do I think about the health of an entire metropolis?

In truth, however, such large-scale thinking is vital to both rural and urban medicine. Answers to the challenges of sickness and healthcare in both the country and the city require thinking on the large scale, and thinking creatively. How can we address the healthcare challenges of our local populations, be they urban or rural? We need to think big, think about the system challenges, and try to keep at least one step AHEAD of the next developing disaster.

We also need to be, first off, good family docs. As big as the scale of urbanization is, we need to remember to think one patient at a time about both diseases, and about social constraints and social conditions. What does my patient have? And how is his or her home, family, or life situation making things better or worse.

For most of the world, life is not all brightness and opportunity in the city, neither is it pastoral tranquility in the country. The challenge of doctoring lies in thinking both about my patient in front of me, and my community of patients “out there,” and about how to help both individuals and systems change for the better.