I typically do my marketing, as food people like to call food shopping, on Monday evenings. Dallas’ hungry hordes descend on the store over the weekend and on Monday the side-by-side Sub-Zeros are still full. Central Market, the food playground that combines the best of Whole Foods, Trader Joe’s, and a neighborhood specialty importer, has had a little bit of time to try to restock the shelves. In Boston, it seemed that the debate over where one should purchase food was a principal topic of dinner conversation. Fortunately, Central Market has ended that discussion in Dallas. We are free to move on to more important topics, like where our friends will send their kids to school, pedestrian safety on the Katy Trail, and eulogies for the final episode of “Friday Night Lights.”
Last night I steered my full-sized cart (this is Texas) into Central Market’s check-out bay, which looks like something like a branding chute for cattle. To my delight, there was an unoccupied cashier: a diminutive man, maybe in his late 50s, with a mustachioed smile, and a moderate paunch accentuated by his kyphotic posture. Although it was 105 degrees outside at 6:30, he wore a burly flannel under his green apron. His movement was lighter than one would expect, giving him a sprightliness. The nametag said “David” (it didn’t say that, but we’ll call him that) and “Fluent in Russian” (it did say that).
I took up a position at the end of the conveyer belt and arrayed my collection of cloth bags in front of me. Although I lack the skills of a professional, I like to help out with the bagging. At the end of the counter, I avoid the pain of standing at the register watching the total climb as the items go by the scanner.
As you have correctly guessed by now, I’m a talker. Just about all of the Central Market cashiers are more than happy to give the conversational muscles a stretch. I observed that it was not too busy in the store that afternoon. He shrugged, “I could not know this” in an accent almost worthy of Yakov Smirnoff’s “Vhat a country!” He had just started his shift, I was his second customer. He would need a little more time to gauge that evening’s crowd. I said, “Nice, you are just getting started.” David said, “Yes, but I’ve come from my first job.” I wondered if it was appropriate to ask what that might be. My curiosity got the best of me. Turns out that his first day job is at the Dallas Public Health Department. I said, “That’s great, I also work in health. I’m a pediatrician.” His small eyes lit up. He asked about my specialty (I guess I look like a specialist). He really got excited when I tell him that I am a pediatric rheumatologist. He set the white beans or the salad greens back in the cart and moved in closer as he asked, “Do you mean to tell me that children have connective tissue disease?”
Now I was intrigued. I explained that although uncommon, children do present with various forms of connective tissue disease: systemic lupus erythematosus, juvenile dermatomyositis, scleroderma, and others. Fortunately, these conditions are rare, although there are enough challenging kids to keep pediatric rheumatologists busy. David looked at me intently; he was taking this all in. “Now is this connective tissue one disease? Children get this also.” I resumed bagging, eyeing another customer queuing up at David’s register. I did my best to explain that connective tissue diseases are disorders of autoimmunity. Somehow, in these people, the immune system recognizes the body’s own tissues as an invading infection or as out of place foreign material. To counter the perceived threat, the immune system makes inflammation. This misguided inflammation injures tissue and causes organ damage.
David then asks, “So how can there be a treatment for this connective tissue disease?” My cashier distinguished himself by asking this insightful question. I think that he was trying to ask me how there could be just one treatment for so many diseases. I’m sure that I smiled my approval. I told him that he was exactly right. We treat connective tissue disease by suppressing the immune system with non-specific drugs in order to try to stop the damaging downstream inflammation. If we knew more about what causes the autoimmunity, we could hopefully find more specific treatments for each disease.
The bagging is complete and I swipe my card. David paused from loading the straining bags on to the cart. “My doctor tells me that I have this connective tissue disease.” After a beat, I offer, “But you look so well!” David continues, “Every so often I have pain in my legs and my shoulders, my muscles (I’m thinking polymyalgia rheumatica?, not something I typically diagnose). I’ll tell you, I take herbs. There is an herb that they make in Germany that is good for the inflammation. I don’t like to take medicine.”
I tell him that I’m very happy that the herbs are helpful and that the pain is under control. I can’t help but say that sometimes the herbs are not enough to control inflammation and in that case, fortunately, there are stronger medicines.
I come around the counter to shake David’s hand before collecting my cart.
“Yes, but I don’t like to take medicine.”