Elen Samuel, doctor and writer

Is the patient really ill?

Posted on October 10, 2019 by Elen Samuel

A question that often occurred to me when I was a GP was – Is this patient really ill?

Some people obviously weren’t because they came about something else – for general advice for instance. But of the ones who perceived themselves to be ill, were they? Usually the correct response for a doctor is to say – if the patient thinks they are ill, then they are. But it can be a very difficult question when you are in the consulting room.

Take the patient who is tired all the time, with very low energy levels who gradually becomes disabled, not able to walk far or has to give up work. All the tests are negative and ME is diagnosed. But that seems to be a slap in the face to the patient; though there is a diagnosis; there is no cure, no recommended management pathway and no prognosis. It isn’t a “real illness” and patients don’t get to be under the care of a hospital consultant or treatment plan. Is it all “in the head”?

Well, yes and no. No because the illness is real, something is going on which has real effects. But yes, because new ways of thinking about this have come to the conclusion that the symptoms are the result of unusual neuronal circuitry in the brain. Our eyes, ears, nose, and skin send data to the brain all the time, through the nervous system. But it seems that our conscious selves do not interpret this data in its “raw” state – it always goes through pathways in the brain that have internalized prior experiences and predictions, and this may alter the experience of the raw data. This can be beneficial, as we have memories of similar data sets in the past and these can colour the information that the brain now has to process. So with standard illnesses such as arthritis, different people can have very different reactions to objectively similar levels of illness, and the outcome is correspondingly better or worse, and this may be because of their prior expectations. It might even be an explanation of the well-known placebo theory, where just the expectation of benefit can result in improvement in symptoms.

But sometimes, very rarely, it goes wrong, and our past experiences override the raw data leading to unexpected symptoms, which may not be what the data is actually telling us. This leads to the brain “imposing” on the interpretation of the data so that the patient experiences symptoms such as weakness, paralysis and other neurological dysfunctions.

I’ll use an example from when I was practicing as a GP. A lad in his twenties, a slightly solitary, but very pleasant farm worker came to see me with symptoms in his left arm, below the elbow. He complained of pain in the skin and a dull ache inside his forearm together with some weakness in his hand. It had started he said when he had to do a lot of sheep dipping. (There was an epidemic of a parasite in the area at the time). His left arm was inside the sheep dip for long periods, and he felt the symptoms shortly afterwards. He had looked up the leaflet that came with the liquid, and there were lots of side effects, but none of them fitted his symptoms. He felt that the sheep dip had damaged his nerves, and was very worried about it, understandably. I knew him to be a bit of a worrier, and I took his symptoms seriously, examined his arm, his neurological system and did some blood tests. I found with pinprick testing that sensation was reduced below the elbow. I reassured him that it must be a superficial effect of immersion in a fluid on his skin for longish periods and asked him to come back if it didn’t settle.

But I didn’t think for one moment that his nerves were damaged. This is because nerve damage has to occur along the pathway of the nerve in question. In this case the nerves to the lower arm start in the neck and the fibres within them have crossed and merged several times. If the damage had been to the end fibres in the hand and fingers and had crept upwards there is no way that the cut off line would be the sharp demarcation that he had shown me. So I was surprised to see him back two weeks later with the symptoms having got worse. As his worry was specifically about the sheep dip, I gave him a note to say that he wasn’t to use it from now on. Fortunately, the programme for treating the sheep was coming to an end and it didn’t affect the farm work. But he came back several times, still worried, and asking for referral to a neurologist. I tried to demur, but eventually did so. Waiting lists for neurology were then, as now, very long, and six months later I saw him about something else. I asked him about his arm and he smiled and said the symptoms had all gone. I felt that the fact that he now had a new supportive girlfriend had a lot to do with it! The symptoms had been entirely real to him, but now that his brain’s activity was concentrating on something else more positive, the circuitry could bypass the expectations he had had and allow the true data through.

Another example, not from my practice, was a young woman who had a soft tissue lump on the left side of her head, which was removed by a dermatologist, and was benign. But she became convinced it was cancerous, and after several months she suddenly experienced weakness of her left leg, the same side as the lump. She was admitted to hospital, but shortly after her arm became weak as well, She was thoroughly investigated and no sign of a stroke was found. She was told that it could not be a stroke related to the lump on her head because if it were, the stroke would have affected the right side – the nerves cross over after leaving the brain, so that a right-sided lesion would cause left sided paralysis. She was discharged with intensive physiotherapy, but recovery took years even though she seemed to accept that it could not be cancer due to the lump on her head.

These are examples of what we now call “functional” illnesses, because they cause problems with functionality with no anatomic basis at all. They have been known for centuries; such illnesses were common in the Victorian era and were often considered “hysterical”. But they were very real to the patient and doctors have taken a long time to really appreciate what such patients are suffering.
But many acute neurological events that turn out not to be due to physical illness, come on extremely rapidly when the patient has no expectation at all that something may be not quite right, unlike in the two examples above. The acute symptoms, which could be exactly like an epileptic fit, or a stroke or paralysis, are a great shock to the patient who may have been very healthy previously. And unfortunately the symptoms may not go away and may be completely life-changing, with people having to give up their job, becoming dependent on others and having real problems, including with accessing benefits in order to live. So whatever previous experiences or thoughts that were altering the mind’s interpretation of the symptoms must be buried pretty deep, or be caused by a faulty series of neurological connections which weren’t conscious at all.
Research has been done into what sorts of people were prone to this syndrome. It is common, comprising about 16 % of patients attending neurological clinics; so that neurologists get very expert in deciding which patients have it. It is easier to be sure that there is no anatomical basis for their symptoms in neurology than in other disciplines because neurology pathways are very specific and not often what patients expect, as in the two cases above. Women are more often affected than men – nearly 70% of cases. However, women’s problems have historically been taken far less seriously than men’s so this may not be a true proportion. It can be triggered by physical illness or disease – a car crash for instance where pain or weakness lasts much longer than the injuries themselves. Sometimes stress can cause it. Sigmund Freud believed that it was always due to a past psychological trauma. (Well he would, wouldn’t he)? But a recent meta-analysis revealed that 24 per cent of people with a functional neurological disorder had been abused in childhood, against 10 per cent in a comparison group, so though it may be a factor it isn’t a common or necessary trigger.
The first challenge is to make a positive diagnosis of FND – functional neurological disease. In a case of paralysis or tremor, the neurologist has to rule out diseases such as stroke or MS, both clinically and by doing the relevant tests. But they also have to look for positive signs that might indicate FND. For instance, in a case of weakness or paralysis of one leg, you see a characteristic gait where the patient drags the leg behind the body as a single unit with the foot pointing inwards or outwards. Or the patient may walk with excessive slowness, especially with difficulty starting a movement. These are different patterns from those seen in MS or Parkinson’s. With severe tremor, a key positive sign would be change in the tremor when the patient’s attention is distracted. This is shown by the “entrainment test”, entrainment being a technical term for when the tremor frequency switches to match exactly the frequency of a voluntary rhythmical movement performed by the unaffected limb. If you take someone with a “functional” tremor in their right hand and ask them to hold out the hand, the tremor is more pronounced than when they are resting. Ask them to also hold out their left hand and tap it on the table to a beat and, with attention focused away from their right hand, it may either stop shaking, or it could pick up the same rhythm as their left. If you ask a patient with a Parkinson’s tremor, or benign essential tremor, to do this, it stays the same. There are many such examples where the responses of a patient with FND will differ from that of other neurological diseases, and the neurologists will be certain that this is indeed FND. It isn’t just a matter of excluding all other diseases. So it is definitely not a matter of a patient making it up – if it were there would be no consistency in what the symptoms the patient would get.
But sometimes there may actually be more than one process going on – a patient can sometimes have a functional disorder at the same time as an organic disease. For example a 38-year-old woman came to a clinic with a whispering hoarse voice that doctors decided was definitely a functional symptom. She then developed progressive mobility symptoms with unsteadiness, slowness and a change in personality. Doctors were not at all sure what was going on, and thought it was all functional. Then she developed drooling, unsteadiness, a parkinsonian tremor and finally became completely mute. Eventually doctors discovered she had Wilson’s disease, a genetic disease where copper builds up in the body causing neurological symptoms and liver disease. The original hoarse voice was indeed functional, but everything else was organic. Only then was she able to get the correct treatment.

So what about treatment? There is hope. Many neurologists are now referring their patients to physiotherapy departments, which are trying new methods of re-educating or re-training muscles to work properly and to overcome the faulty messages that the brain is sending out. Some of them are based on that entrainment test, which indicates that functional symptoms tend to decrease when people are distracted. It is possible to show people how their symptoms abate under distraction – sometimes you can film them as they moved their leg, for instance, to help convince them the muscles were working normally. Sometimes people can use their own distraction techniques if symptoms began. One example was of a patient with functional seizures, simply running her fingers over the holes in her walking stick, which provided enough distraction to seem to prevent symptoms and return of seizures. It made her brain thinks of something else, she said.
The inference was that distraction was enabling the “real” data to come through the circuitry in which expectation had become dominant.

So it has become more routine to refer patients with FND to speciality physiotherapy clinics, where patients get one-to-one therapy. There is a U-tube video which shows this being done very movingly.

There is some evidence that it works.
In one study, 60 patients with various functional disorders were enrolled into an experiment where the intervention was done according to a carefully constructed 5-day programme, delivered by a neurophysiotherapist who had undertaken additional specific training.
It took into account events that seemed to trigger symptoms, other concurrent diseases, psychological factors, attention focused too much on the self and unhelpful reinforcement of symptoms. Movement retraining was developed aimed at restoring normal movement by redirecting the focus of motor attention. There was a control group which received more usual physiotherapy; and the results were analyzed after various periods of time. It was found that the intervention group did significantly better than the control group and continued to improve after the programme was stopped.
These all seemed to be sensible methods of helping people to re-programme their muscle activity towards more normal activity.

However the take home point for me was the use of targeted physiotherapy early and to focus on re-training of muscle movement. We all know that lack of use itself is the cause of severe disability. If you don’t use it you lose it and for patients with paralysis it is essential to continue movement as much as possible. The intervention should be done early so that the least damage is done by inactivity. If a patient has been in a wheelchair for years, recovery is going to be very difficult whatever the initial reason for the disability.

These new thoughts about FND fitted with what happened to the patients I saw in my surgery. Most of their symptoms were relatively mild; if there had been symptoms of epilepsy or paralysis they would obviously have to go to hospital. They tended be slightly anxious and to worry about their health. But if they became convinced that they did not have an on-going progressive disease, and believed the results of negative tests, then they did tend to improve, especially if investigated early and thoroughly. However quite a few patients were never convinced that their symptoms were functional. In particular I had patients who were convinced that the real cause was some pollutant in the environment or medications that they had been taking which had hitherto unrecognised side effects. Although none of my patients were diagnosed with this, in some cases neurological side effects of medications were found and published in the literature. Obviously this would be a great tragedy if it had been missed, and presumably compensation would have to be paid. I am sure there are examples of this sort of thing especially with young people and children who can be extra sensitive to pollutants.

I think it is extremely important to distinguish between the group of patients who are likely to have functional illness, which is very real to them and is undoubtedly in my mind caused by a real malfunction even if it cannot be exactly pin pointed by neurologists, and those who are actually faking it in order to get a benefit for themselves, be it financial, extra attention, or true malice. To reassure those who are not faking it that their symptoms are real, as well as to maximise their changes of recovery, they deserve as much attention from doctors, nurses and physiotherapists as if they had a more standard neurological problem. After all it is quite clear that the prognosis without help and treatment for those with FND is even worse in many cases than for those with MS, Parkinson’s and so on. There are an awful lot of such patients– there are many milder cases who remain in general practice and see their GPs on an on-going basis, and the 17% of all neurological referrals who are diagnosed as having a functional neurological disorder. Slowly, the health service in many areas is coming to realise that they deserve better than the treatment they have had in the past.

Neurologists do actually have to get over their own preconceptions. Comparing MS and FND from a neurologist’s perspective, it was estimated that the “popularity” of MS with neurologists is about 90% while with FND it is about 5% – in other words neurologists don’t really like seeing patients with FND. They often think it is not their business. And public understanding of MS is 95%, while FND is about 2%. Very few people know about FND, let alone understand it.

Considering that new diagnoses of MS in a neurology clinic are about 6%, while FND is much commoner at 16%; and the disability level for both is the same at 7%, you can see that the FND patient does not usually get a fair crack of the whip. I do hope that attitudes in the medical profession, and in the public at large continue to change in the right direction so that such patients get a much better service in the future.

References

New Scientist: The illnesses caused by a disconnect between brain and mind
https://www.newscientist.com/article/mg24232240-100-the-illnesses-caused-by-a-disconnect-between-brain-and-mind/#ixzz63HVJkdZl
Health 3 April 2019 Clare Wilson

FUNCTIONAL SYMPTOMS AND SIGNS IN NEUROLOGY: ASSESSMENT AND DIAGNOSIS
J Stone, A Carson, M Sharpe J Neurol Neurosurg Psychiatry 2005;76(Suppl I):i2–i12. doi: 10.1136/jnnp.2004.061655

Functional symptoms in neurology: mimics and chameleons
Stone J, Reuber M, Carson A. Pract Neurol 2013;13:104–113.
Neuropsychiatry: Research paper
Randomised feasibility study of physiotherapy for patients with functional motor symptoms
G Nielsen1,2M Buszewicz3, F Stevenson3, R Hunter3, K Holt2,4, M Dudziec2, L Ricciardi1, J Marsden5, E Joyce1, MJ Edwards1,4

How to use the entrainment test in the diagnosis of functional tremor
http://dx.doi.org/10.1136/practneurol-2013-000549
Louise S Roper1, Tabish A Saifee2, Isabel Parees2, Hugh Rickards3, Mark J Edwards2
U tube video : My Functional Neurological Disorder (FND) Recovery Story
Jamie Lacelle

Posted in Health Delivery, Medicine, science | Tagged FND functional neurological disorder, Multiple Sclerosis, physiotherapy, psychology | Leave a comment

Managing addiction to drugs – my experiences over the years.

Posted on August 2, 2019 by Elen Samuel

Addiction is unfortunately part of the human condition. It is due to the reward system hard wired into our brains, giving us the feeling of pleasure, which is essential to keep us functioning. Emotions, reproductive drive and the instinct to eat and survive are all part of this. And it can easily be hi-jacked by substances like nicotine, drugs, alcohol, and certain foods, and it is extremely difficult for humans to fight against it. If you develop something to stop people experience pleasure, they may well not want to live. A drug to combat overeating which did just that by blocking cannabis receptors was found to increase depression and suicide rates and therefore its licence was withdrawn. However, addiction causes much misery, increases crime rates, and damages health, both mental and physical.

This is well known. Over the time that I practiced medicine, drug addiction in particular mushroomed into a major problem for society. But when I started practicing as a GP, the culture of management of addiction was very different from how it is today.

In the 60’s, while I was training to be a doctor in London, nearly all addicts were treated medically, in the same way, as they would be for any other illness. Any doctor could prescribe maintenance therapy, usually heroin and later methadone, and so patients had the benefit of one-to-one care by a sympathetic doctor. (Usually doctors who weren’t sympathetic didn’t do it, as they didn’t have to, and the patients just went to someone else). It was known as “the British system” and was almost unknown in other countries. Addiction here was thought of a medical problem with social effects, and there wasn’t a stigma attached to it nor were patients expected to stop the drug. There were punishments for illegal use and supply but these were separate from treatment. Patients had to register for treatment, and would then get their drug needs free. At the time most of the supply came from prescribed drugs, with some coming in from abroad, and drug trafficking and dealing was not a big problem. For over 40 years this system had resulted in a stable number of patients who did not have to steal or commit crimes to get their drugs. I treated a middle-aged man with oral methadone for years. He had become addicted to heroin while living abroad, but managed to get a job when he returned and held it for years until his health deteriorated with problems unrelated to his addiction.

Things changed though. We all knew in the 70’s and 80’s that there were some doctors who prescribed heroin and methadone privately in large amounts, and everyone was worried that these drugs would then get out for recreational use. In America there was a growing problem with drug dealing and severe addiction, and it was treated as a sign of weakness, so a punitive system had quickly grown up. Criminal gangs made huge amounts of money by importing drugs from countries like Afghanistan and Mexico, which were sold to Americans. This boosted the crime rate as addicts had nowhere to go for their drugs but the black market when they were desperate for the their fix. The resulting social problems meant that pressure was put on all countries to change laws to try to reduce the availability of drugs. In 1961 a convention set up to try to control global drug trading had recommended that countries should not treat addicts by prescribing illegal substances, and should allow only scientific and medical uses of drugs. It was not itself binding on countries, which had to pass their own legislation. Britain didn’t do this for quite some time, but in 1964 it did introduce penalties for possession and supplying drugs and in 1971 it classified drugs into various categories depending on how dangerous they were perceived to be – class A B or C. By the 1980’s most clinics were restricted by a lack of staff and support services. Patients were treated as “problem drug users” rather than people with a medical need. From 1991 there was more separation of medical treatment versus punitive responses by the authorities. Most treatment now went on in clinics (drug treatment centres) which were available both privately and under the NHS, but the concept of addiction, as an illness had waned, and the aim of treatment now became to get people off the drugs quickly. Policing for possession and dealing in drugs became more aggressive with “stop and search” becoming very common, so the concept of the “British method” finally died.

Increasing availability of recreational addictive drugs made the problem very difficult to manage. Then central government became more involved with more and more laws (the Misuse of Drugs Acts) were passed for the criminal justice system. In America they have had their “War on Drugs” with some extreme penalties, but the problems only got worse.

New dangerous drugs flooded the market, and the death rate rose. However the drug scene is constantly changing and over time In America, heroin became a problem mainly for middle-aged and elderly and addiction fell slightly in poor communities. But a new problem arose there from the late 1990’s on and currently the groups who are now suffering most are middle class people who have been prescribed synthetic substances such as OxyContin, an opiate.

From 2000 on we GP’s in the UK noticed that we were being encouraged to use opiates and other really strong painkillers, not for terminal cancer or really severe neuropathic pain as before, but for non-life threatening chronic illnesses such as arthritis, and after operations, when it was often self-administered. It was about the same time as evidence showed that many painkillers we doled out weren’t really working very well, so it appealed to our compassionate side. But there were quite of few of us, me included, who were very worried about the possibility of addiction. And indeed, opiate drugs such as fentanyl and OxyContin have been very aggressively marketed and their propensity to cause addiction downplayed. This has resulted in huge sales and enormous profits for some companies, so much so that now there are many lawsuits on-going against them. Excess prescription drugs were sold on and more people became addicted, with people getting them on-line without prescriptions. The increase in deaths from opioid overdose has been dramatic, and opioids were responsible for 47,600 of the 70,200 deaths from overdose in the US in 2017. Whole communities of white middleclass Americans, such as in Appalachia, are being decimated. There is now a backlash against the pharmaceutical companies that have misled people about the addictive properties of the drugs, and the huge profits they have made. And the problem, as ever, is crossing the Atlantic. It is more difficult for patients to get hold of a large supply here than in America as prescription drugs are more tightly controlled, but patients can get them on the black market. And they are just as heavily addicted. I treated a man who was addicted to a drug which had been prescribed for intermittent abdominal pain in hospital, and he was highly dependent on it. Everyone in the practice treated him because he was highly manipulative. He was a very successful businessman with plenty of money, but he wasn’t content with paying privately in London for his supply. He wanted it on the NHS as well, so we had to register him with the Home Office in order to do this. He would never stick to the dose which was prescribed and used to tell the most brazen lies in order to get his fix. Once he phoned reception saying that he was on a business trip to Paris and that he had to stay an extra 2 days to finish a deal. He wanted his next weeks supply to be ready for him when he returned the next day even though it wasn’t yet due. The receptionist was about to instruct the dispenser to do this when our nurse told us that she had seen him in town that day. It was a real try on. But he was very difficult to resist. He caused a lot of trouble in the practice, and on several occasions had to be sent on to other practices in the area. It was a shame really because a lot of people in his business knew about his problem and he didn’t get the respect he deserved. However he did continue to work at a high level for many years despite his addiction. But of course in Britain he did have recourse to a free, safe supply.

Most workers in the field have known for a long time that criminalizing drugs and harsh penalties do not work and result in more drug addiction, more drug deaths, trafficking and a huge increase in crime. Right wing groups especially in America are very opposed to liberalising drug laws because of their mind-set of free trade and because the usual victims do not vote for them. But now their own voter base in rural white communities is suffering, republicans might care to readdress the situation.

The cannabis situation has also changed. Its use is widespread at all levels of society in all countries, and the market, worth at least £1bn per year in the UK, is dominated by criminal gangs. It results in huge levels of violent crime on our streets. So some countries are experimenting with de-criminalising cannabis and taxing it, just as we do with tobacco, which immediately reduces the power of the criminal gangs. In Canada for instance cannabis is grown locally and sold in licensed stores. The levels of two main cannabinoids, THC and CHB (THC is the one which gives the highs) are marked on labels like the alcohol content on beer. People are therefore legally able to choose to buy cannabis. However the black market still exists as it can undercut the price in the stores, so it isn’t as yet a complete solution. But another difficulty you have when cannabis is illegal is that it can then be unavailable for treating patients who might benefit from it. Cannabis has been legally supplied for many years in the UK; I used Sativex, which contains both THC and CBD, several times to painful spasms in MS, although it wasn’t very effective. Clinical trials showed a very valuabe 30% reduction in pain levels for some sorts of chronic pain. Dronabinol, another cannabinoid, can also be used for nausea and vomiting during chemotherapy. Recently after a lot of publicity the law was changed to allow patients to be treated with a cannabinoid for treatment resistant epilepsy after a family campaigned hard for it to be available for their son. Sadly, due to the paucity of clinical trials showing benefit, and the fact that it seems only a very few people would actually benefit from the drug; it hasn’t made getting treatment any easier for patients. So would it not be better to remove restrictions altogether?
Several countries and states in the US have done this, with generally beneficial results. Usually, such countries find that the amount of violent crime goes down; there are savings due to sale of drugs, and less money is spent on enforcement of the law and prisons. There are downsides though; more people use cannabis, with a risk of psychosis in susceptible people, often the young; and hospitals have to treat more cases of intoxication.

The main problem though is that legalization does not tackle the social inequity that surrounds drug use and drug markets in many countries, and drugs are still produced by poor farmers all over the world who depend on the trade to survive. Powerful drug cartels do not go away.
But actually it may not be de-criminalizing cannabis that helps. It is how you treat patients that makes the difference. Portugal seems to be taking over the “British system” with some success. After the overthrow of the dictatorship of Antonio Salazar in 1973, the country was wide open to drugs especially heroin. Under the dictatorship even coca cola and cigarette lighters were banned, and as the gates were lifted, heroin and cannabis flooded in. It became a big problem, affecting all families, rich and poor. Like parts of America today every family had had a death from drugs. But in 1973 doctors in the north of the country treated addicts with methadone in clinics similar to those in Britain at the time. Needle exchange programmes were established and gradually the ethos changed – probably because it wasn’t only a radicalized minority that was affected. Rather than being arrested, those caught with a personal supply might be given a warning, a small fine, or told to appear before a local commission – a doctor, a lawyer and a social worker – about treatment, harm reduction, and the support services that were available to them.
Social attitudes changed and clinics continued to operate and expanded, and full decriminalization of drug use was enacted in 2001. Portugal’s policy rests on three pillars: one, that there’s no such thing as a soft or hard drug, only healthy and unhealthy relationships with drugs; two, that an individual’s unhealthy relationship with drugs often conceals frayed relationships with loved ones, with the world around them, and with themselves; and three, that the eradication of all drugs is an impossible goal.
We will never get rid of drugs. There is a world wide industry which makes billions in making sure some people will get addicted, But treating addicts in a harm reduction environment offers the best way of dealing with the worst of the dreadful effects. To go back to what I said in the beginning of this blog, addiction is a biochemical pathway causing a compulsion that to get whatever it was that had triggered the biochemical process in the first place, whether the stimulus was a drug, or what we consume such as nicotine, alcohol or food. If any other biochemical pathway in the body goes wrong or is overloaded, we in medicine will try to put it right. There is absolutely no benefit to be had by punishing people or criminalizing people. That way lays disaster for the sufferer and terrible effects on the whole world. I hope public opinion is going in this direction and lawmakers will see sense. But in the meantime, it would help the whole of society if we tried to help addicts, not punish them. After all, it might be our son or daughter, or our friends who are affected.

References
The psychiatric side effects of rimonabant
NCBIhttps://www.ncbi.nlm.nih.gov/pubmed/19578688
Fat Chance – the hidden truth, Dr. Robert Lustig
Drug Legalisation
BMJ 2014;349:g5233 doi: 10.1136
British Drug Policies in the 1980s
British Journal of Addiction (1987) 82, 477-488

Opioid epidemic in the United States – Wikipedia

Portugal’s radical drugs policy is working. Why hasn’t the world copied it?
Susana Ferreira
Guardian long read, 5th December 2017

Posted in Addiction, drugs, Health Policy | Tagged cannabis, crime, heroin | 2 Comments

Lessons from Orkney.

Posted on May 30, 2019 by Elen Samuel

Like many other people, I read a huge amount of stuff on environmental matters every day, such as on the climate disaster-in-the-making, overconsumption, pollution of the environment by plastic and other man-made materials, extinction of animals and insects, and, at the root of it all, overpopulation. It is a very worrying scenario. which threatens to bring civilized life as we know it to an end.

But last week I have been brought up short by confronting the other end of the progress of humanity, while on holiday in Orkney. Here I, along with many other tourists, saw the evidence of the challenges our species faced at the time humans first reached Northern Europe, arriving in a pristine world of fertile soil, abundant fish in the ocean, an abundance of stone, and a few trees. It made me think of the journey humanity has made, the achievements in material things, in thought, in the richness of human life all over the globe. The ultimate success of the vast expansion of human numbers must have been quite unimaginable to that tiny number of humans in those early times, who faced daily existential challenges which often must have made them think they would not survive as a group at all. But since then, a multitude of civilizations have grown and died, and technical and scientific wonders have been created. But to what purpose? And how will it all end?

The first evidence of humans in Orkney was just after the last ice age, around 9,000 years ago, during the Mesolithic period (middle stone age).
At that time what is now known as the British Isles was joined to the continent by a flat plain known as Doggerland, now deep under the North Sea. Orkney was joined to the mainland further south, and so the first inhabitants probably got there on foot from Doggerland, which was a rich area, with a coastline of lagoons, marshes, mudflats, and beaches, where there were rich hunting and fishing grounds. The people lived in small nomadic bands, and most or all of their food was obtained by picking wild plant, fishing and hunting wild animals.

But the long cold winters must have been very difficult to survive, and they left little trace – a few tools, ornaments, bones. Gradually (as is happening again now), the climate warmed and the ice caps melted, so that the water released from ice sheets and glaciers, raised the sea level, breaking off Ireland on the west side and Britain from the continent on the other side. This happened gradually but the final inundation of Doggerland and the separation of Britain from Europe happened with the Storegga Slide, a huge tsunami off the coast of Norway around 6,100 years ago.
Eventually Orkney broke off too at the north end, and was then a single landmass, rather than a collection of islands. As global warming continued Orkney became a good place to live, with temperatures about 7 degrees higher than now, fertile soils and seas teeming with fish, because it was in the path of the Gulf Stream. So when Neolithic farmers, who came from a completely different grouping of people from the earlier nomads (with separate maternal DNA), arrived around 6,000 years ago, they found an excellent area where they could farm and keep animals. It was so rich that there was plenty of food, so they could afford to build houses to live in, and also build some of the amazing structures for burial and ceremonial purposes that can be seen on the island.

The oldest that I saw were dated 5,500 years ago and were cairns – tombs for the burial of their ancestors, which was so important to their culture. They were quite elaborate stone built structures showing great skill in manipulating huge slabs of heavy stone.

Skara Bray – possibly a prehistoric toilet (or a cupboard!)

But we also saw the remains of a farmstead, villages and individual houses, (Knap of Howar, single farmhouse 5,500 – 5,000 years ago; Barnhouse village 5000 years ago) which showed how they lived with complete shelter all those years ago. Skara Brae, the most complete village of them all, was occupied between 5,100 and 4,500 and was abandoned by 4,000 years ago.
Farming revolutionized human society, and allowed populations to grow for the first time. But it wasn’t a quick fix, and populations grew and then were decimated by famine, disease, and in Orkney especially, the long winters. Child mortality was huge in these villages that we saw, newly restored by archeologists, in Skara Brae and Barnhouse. Just think of how winter in warmer countries can kill young babies nowadays when conditions are poor, such as in refugee camps. Fertility rites were very strong, and the survival of children must have been the most important goal for the whole society. Pronatalism – encouraging child-bearing and elevating fecundity above all else – was absolutely essential then. (Although it was also promulgated by old men, who, as now, saw many descendants as a source of power). Life itself was very precious, and people tried to prolong it in their minds by venerating their ancestors – hence the huge emphasis on burial rites with the building of cairns, brochs, etc.

Skara Bray

People must have dreaded the winter, when death stalked constantly, but conversely the winter solstice, the turning of the year heralding the coming of spring, would have been a signal for great rejoicing. So they built Maes Howe – a huge stone monument to that important time so that they could know exactly when it came. They designed it so that they captured the first sign of the winter solstice, when the rays of the setting sun over the hills of Hoy, came down over the top of the Barnhouse stone, so that it illuminated the wall of the back chamber and the back cell. Once this appeared, people would know that the shortest day had arrived, and there was hope for next spring. What a feat of engineering, for our forebears 5,000 years ago. Life was hard, and people had to be energized by community acts and beliefs.
Maes Howe was started 5,000 years ago and was certainly in use by 4,700 years ago so it was among the first of its kind in human existence. The earliest Egyptian Pyramids were built around 4,600 years ago, and Stonehenge 4,500 years ago. What a treasure we have in Britain.
Global warming and rising sea levels eventually continued until 4,000 years ago when Orkney became an archipelago and the golden age disappeared. There was pressure for resources as the land disappeared, and many people left their villages abandoning these monuments. But a later people, the Picts, arrived with iron age technology, bronze, iron , jewelry and ornaments, in successive waves from the mainland where they had set up a kingdom, and there is documented evidence of this from 2,000 years ago (1st century AD). The Romans never came to Orkney although some Roman artifacts were found, showing that the Neolithic farmers traded with them. Then suddenly the Picts disappeared and were taken over by Vikings, destroying their culture. And so on, one culture after another throughout the following two millennia.
So fast-forward to modern times. We now have an unprecedented level of comfort and security, when nearly all children survive, old people’s lives can be prolonged, and there people think there should be a cure, as of right, for every illness. But the cult of the sanctity of human life still takes precedence above all other forms of life, through religion or cultural myths. This has all been hard-wired in all of us for at least 5,000 years. There is now no acceptance of the inevitability of death, just an all-pervading sense of our own well-being and, within many groups, that God, or some other non-human power, will continue to ensure this.

Those of us who put the population explosion at the heart of the causation of the coming destruction of the planet’s resources, and hope to stem the tide of pro-natalism, need, I think, to remember that it is only in the last 50 years – a twinkling of an eye – that human lives have improved so much so that almost all children survive to reproduce and lifespans are increased sometimes by 50%. To expect humanity to suddenly realise that we are now the problem is unrealistic.

There won’t be a feeling of thanks that we, who have been given so much, should accept some reduction in comfort or lifespan so that the natural world can continue. We, as selfish human beings, won’t give up anything even though death and destruction are staring us in the face. We started out all those years ago in a world of terrible challenges, with a huge drive to survive. This took us, through innumerable wars, famines and natural disasters, to a point when we now don’t realise that our sheer numbers are destroying the planet. No wonder we can’t escape our early conditioning. The intelligent ape is a prisoner of his own history.

That is the lesson of Orkney for me. Our success at dominating the world, against all the odds, was because of our single-minded imperative to make sure we go forth and multiply, and this has to be recognized now as our greatest threat. Yes, we need to empower women to take control of their own fertility, as women bear the cost of this drive to multiply and it has been proved time and time again that women will make rational choices to have smaller families if given education and contraception. But I’m not sure that it won’t be necessary to inject some old-fashioned fear (as of Hell) into our leaders to make the right choices for ourselves and our planet. It seems that our children are now experiencing that fear, and agitating for better policies (although I haven’t seen any signs that they are agitating for fewer children to be born). But all power to them. They are the ones to direct humanity to a better future. Our planet will survive. But we, and our civilizations, won’t unless we start to control this age-old urge to go forth and multiply.

Posted in Anthropology, Archeology, Food, Global warming, Populaion growth, science | Tagged fertility, Maes Howe, Mesolithic, Neolithic, Orkney, Vikings | Leave a comment

Politics, Health and Devolution.

Posted on April 24, 2019 by Elen Samuel

I don’t usually discussed politics at all in my blog, unless absolutely essential to make a point. However, politics is now intruding on almost every aspect of our lives, all over the world.

In the UK, Brexit is affecting the NHS for the worse, and we haven’t even left yet. The lies told in the referendum about the Brexit dividend for the NHS have quickly been rebutted, and the service is haemorrhaging staff from the EU, resulting in shortages in all parts of the health service. In the USA Donald Trump has withdrawn financial support for women’s health services all over the world, and has his eyes on taking over the British NHS by buying up privatised services to make a profit. The right wing Brexiteers in the Conservative party want to turn the UK into a Singapore style free market economy, in so doing lowering standards in food, services and finance.

I haven’t yet met a doctor who supports a hard Brexit. There may be some out there, but on the whole doctors are aghast at what is happening. But the change in people’s political choices has meant that in England at least, there has been a Tory majority, albeit small, for quite a few years now, and there is not much evidence that a left wing government, even a coalition of different parties, will be elected next time round.

I spent my career in general practice and medical management in Wales, and I now live in Scotland, so I don’t have an Anglo-centric view of health services in the UK. Although all countries of the UK have similar problems, brought about by austerity, and a disinclination of the Westminster government to invest in health for ideological reasons, health is a devolved matter and each country can put a different emphasis on its priorities. For instance, the privatization mantra has not really been supported outside England

Recently Labour has warned that the UK Government’s agenda of privatising the NHS has come one step closer, after the Tories tendered £35m in new contracts to private companies in just six weeks since mid-February. Further analysis reveals that a total of 21 NHS contracts, worth a staggering £127 million, are currently out to tender. Some people believe the mantra that private companies are more efficient than public bodies. But many people in medicine, and I am one, believe that you lose too much – the goodwill of those who now see profits being syphoned off, the lack of morale in a low paid workforce, and the potential for decisions being made that are antithetical to public service.
So one big concern I have is how far devolution will allow Scotland, Wales and Northern Ireland to diverge from this nightmare scenario of the NHS being sold off to American firms after Brexit.
I recently read an article about how the republic of Ireland has managed to influence the Brexit debate. It seems that over a year before the 2016 referendum, the Irish government, appalled by the way things were going, set up a task force to see how Ireland would be affected. They soon saw that Ireland would be affected almost as much as the UK, and that the border with Northern Ireland would be real problem. So they started planning how to respond even before the referendum, and made sure that the important players in the EU were well briefed. It seems that intense lobbying went on so that all countries in the EU were aware of Ireland’s position, and that all supported the joint effort to make sure that the EU was on the side of Ireland, the state that was staying, not the UK that was leaving. Certainly, smaller states on Russia’s border appreciated the benefit of having the EU on their side. Since the beginning therefore the EU has been clear that it would make preventing a hard border a priority. It seems that none of the UK negotiators ever believed that this would be the case, thinking that the EU would give in at the last minute.

This gives us an insight into the situation that we are all in. If England doesn’t consider the position of Ireland, its biggest trading partner, to be important when negotiating with the EU, what hope is there for Wales or Scotland?

I think the Union is on the ropes. The most pressing problem is Northern Ireland, as it would suffer most from Brexit whatever form it takes, and is highly likely to join southern Ireland after Brexit because of the effect it will have. And the people there voted to remain. But after that, Scotland would likely want to consider its position. I voted in the Scottish referendum and I voted for Scotland to stay in the UK, at least partly because if Scotland left it might have to leave the EU. I have put remaining EU as a priority, because my mindset is that of subsidiarity – that powers should be devolved downwards as far as possible. I would support a completely federal union within the EU, because that way smaller regions can get the support of the EU when larger ones are bullying them. But to my horror, when Scotland voted to stay in the EU, the Westminster government ignored the vote completely and is still committed to taking Scotland out of the EU against the will of its people.

For Wales, which voted to leave, the situation is dire.
The following table shows the difference between May’s Stronger Town Fund and the EU structural Funds per region, so this is how much each region is losing out on because of Brexit.
Scotland -£895m
Wales -£2413m
South West – £1462
North West – £851
North East- £634
Yorks & Cumberland £597
South East £249.

The Welsh people were promised by the Leave campaign many times that Westminster would make up the money Wales would lose from EU funds. People who believed that were very gullible – the Tories have never invested in Wales, at least partly because the Welsh people never vote for them. It is a vicious circle of course.
Wales is rich in energy – it is the fifth largest exporter of electricity in the world. In 2016 Wales generated 38.8 TWh of electricity and only consumed 16.1 TWh. This means that we exported 22.7 TWh – that’s just less than what the whole of Scotland consumes in a year. But profits from these assets – water, hydroelectric, wind energy, nuclear, don’t go to Wales. Further investment, could increase this wealth, but it will never come from Westminster. The tidal lagoon in Swansea, and electrification of the rail network come to mind, as examples of investment that never happened.

For the NHS as a whole, we know that staff shortages and lack of investment is damaging the NHS. The private sector is growing and is now as big in proportion as in many other European countries with an insurance-based system. Staff shortages are worse in Wales and Scotland; they both depend on immigration, even more than England does, to support the NHS and other industries. Depopulation has long been a concern in Scotland, not overpopulation as in England. Wales loses many of its young people each year – often the most talented, because of lack of opportunities. The cost of their education has been born by the Welsh Government, as education is devolved, and the countries that receive them, mostly England, get a free gift. But a large proportion of immigrants to Wales – from Birmingham, London, Europe or wherever are elderly retirees, who expect (rightly) to use the NHS and to get the same service they would have got in England. This means that the Welsh health service gets a double whammy – it loses the young people who don’t need health services so much and imports the elderly who do. Sadly there is no extra bonus to Wales – the basis of health service funding is per head, with a small addition for the elderly which does not cover the huge extra cost of looking after them. Culturally, the effect on Welsh speaking communities of a huge influx of people from outside Wales has been much worse than having a lot of Polish speaking immigrating to English towns – at least English is not likely to ever be a threatened language!

This all pre-dates Brexit, but when you then add up the loss to Wales of EU funding, then Wales is stuffed.

So, post devolution, how will the health services of Scotland, Wales and Northern Ireland fare? Up to now, they have been able to avoid the worst of the English drive for competition and privatization. PFI is hardly known in Wales, and happened much less in Scotland than in England. Outright privatisation is much less; for instance the GP back-services (which deal with their pay, premises, staff reimbursements and patient records) which were handled extremely badly by Capita, have remained in house, much to the relief of GPs. Where possible both devolved governments have tried to keep the ethos of the NHS as a public service.

The future does not look bright. One of the first acts of the conservatives after Brexit was to take back powers of devolution to Westminster in order to have a “UK –wide” system of funding after Brexit. Both devolved governments objected (NI doesn’t have a government at all at the moment) and protested fiercely. Wales eventually caved in given certain reassurances that the powers would be “given back” after 7 years (by which time everything important will have been sold off, with none of the benefit going to Wales and Scotland). Scotland has never agreed to this and a court case has now indicated that the Conservatives have acted illegally. So the battle for Wales and Scotland to run their services the way they want is not over yet. But if there is either a deal such as Mrs. May’s or no deal then the aim of the Westminster government is to allow further privatization, and we can be sure that this will result in Scotland and Wales having no control over privatization, and devolution going out of the window.

As a result of Brexit, many people believe that Northern Ireland will get a plebiscite on whether to join the republic of Ireland (as is their right under the Good Friday agreement) and may well do so. Scotland will then certainly want another referendum. I, voting in Scotland, and many like me, would definitely vote to leave the UK this time, rather than stay with England. England always was more right wing, and seems to be becoming more hard right and controlling. Wales may not get a choice and its views may be ignored, resulting in it becoming just an appendage of England, getting poorer and poorer and losing its rich culture and language which goes back to Brythonic times. Survey after survey shows that people in Wales want more powers devolved to the Welsh Government; a Federal state is popular and the NHS is even more of an iconic establishment than in England. As with Brexit, youth also favours one side. The BBC’s recent St David’s day poll showed that 63% of 18-34-year-olds wanted either independence or more powers, compared to a measly 7% who wanted to abolish the Welsh Parliament. If Brexit doesn’t happen it will likely inflame the far right throughout the UK, and their representation in the Senedd could increase. The Welsh language and culture are fighting back hard, especially in places where it had previously been almost dead, and nobody wants to get poorer. Plaid Cymru is now openly asking for independence, and its support is growing. So who knows?

I would hate to see the UK break up, although if truth is told I think that ultimately Northern Ireland must join the Irish republic, because of demographic trends and the fact that immigrants are unlikely to join either group of the religious divide. But I have heard that the NHS is a big attraction for Northern Irish people to continue their membership of the UK. Ireland does not have an NHS such as exists in the UK. You have to pay to see a GP and for many hospital services, and it can cost €100 for a visit to the Accident and Emergency department. (People receiving welfare payments, low earners, and with certain other diseases do receive free care). GPs are often single-handed and can charge quite a lot for visits, so many people have private insurance. Brexit could change everything for Northern Ireland.

For me, living in Scotland, and travelling to Wales frequently would be a nightmare if Scotland left the Union. But the thought of creeping Americanization of our Health service is equally horrifying. While American healthcare can be the best in the world, it is the most inefficient system in the world on a population basis, and for Scotland with a long history of poor health outcomes this would be a disaster for those who care about everyone’s health, not just the wealthy. If England really does leave the EU without a deal or a very poor one, and we continue with a hard right wing government I think there is no doubt that the NHS would be dismantled.

I believe in meaningful devolution, and would very much support a more Federal solution. Whether Scotland could rejoin the EU after Brexit is an open question –its health system could continue to develop separately as it has been doing if so.

Whatever happens to Brexit now a lot of damage has already been done to our country’s social cohesion. Who knows what the future will bring?

Posted in Health Delivery, Health Policy, Medicine, Private health care, science | Tagged Brexit, Northern Ireland, Privatisation, Scotland, UK, Wales | Leave a comment

Our children’s future

Posted on January 21, 2019 by Elen Samuel

Global warming and population growth.

The Anthropocene. This is the official name for the epoch we are now living in and it means “the age of humans”. It is named this because we humans are causing global change everywhere that can be seen in geological structures.

We have become aware, all too slowly unfortunately, of the effect humanity is having on our planet, with loss of other species, floods, fires, storms, water shortages, and movement of people because of famine or war. Programmes such as David Attenborough’s “Dynasties” have shown the dire effect of loss of habitat and plastic pollution on other species; and we have just had a conference in Poland on global climate change, and which has had some success in promoting the reduction of harmful emissions, thanks partly to close collaboration in Poland between the U.S. and Chinese delegations (despite Mr. Trump not believing any of it). These delegates worked closely to foster a remarkable consensus that all countries must follow uniform standards for measuring emissions and tracking the achievement of their national targets. But is it enough? It hardly mentioned the fact that there is already 9 billion of this and us could rise to over 11 million in 2050. This must surely be the main driver behind our problems.

But it could be so good. There are obviously far too many of us but in most of the world fertility is falling. Fertility in all European countries is now below the level required for full replacement of the population in the long run (around 2.1 children per woman), and in the majority of cases, fertility has been below the replacement level for several decades. Eastern Europe shows the biggest projected drop; Bulgaria, Croatia, Hungary, Latvia, Lithuania, Romania, Serbia, and Ukraine, all are struggling to grow their populations, especially with migration of the young and healthy to wealthier countries; and in Asia, the drop in population in South Korea and Japanis projected to be even bigger. This is due to women having more choices in life and choosing to have fewer children. It is an ideal situation because fewer children per family means a better upbringing for them; women are happier, and no one need be dragooned into having children when they don’t want them. If you follow the UN projections of population growth, you can see that even in the most pessimistic scenario the fertility rate of the world would be at replacement level, even for the least developed countries, in less than a hundred years (2099). The population would have stabilized, with birth and deaths being approximately equal. But of course the actual numbers of people on this earth could be as many as 15 billion by then, so we are reducing our numbers by too little and too late. No one thinks 15 billion would be sustainable.

Despite the drop in fertility rates, the population is still increasing because people are also living much longer, so the number of deaths has been decreasing. Our health has improved immensely due to higher standards of living, better diet, better treatment of sewage, fewer infections and much better treatment with all the advances of modern medicine. Old people do not reproduce but they certainly consume – often in a big way. So the effect on our climate and resources will still be unsupportable.

The main danger at the moment as we all know, is global warming due to rising amounts of CO2 in the atmosphere. We have to reduce our consumption now and change our ways right now in order to safeguard our environment. We need to turn to renewables instead of burning fossil fuels, eat less meat, stop using plastic – all these things which have had such a bad effect on our planet, and the other living organisms, which share our planet with us. But don’t think we in the rich world don’t have to reduce our population even further. Each extra child in the west will consume more than 12 times the earth’s resources than a child in a developing country.

The changes we have to make will have consequences for our prosperity and our economic system, because that depends on growth and increased consumption. We have to work towards a stable system, and this is likely to mean reducing the huge profits that are made by the few at the moment, and find ways of managing the economic consequences. Otherwise we will destabilize the natural world so that extinctions of plants and animals continue inexorably; and we will pollute the land, the oceans and our atmospheres so that our children and grandchildren will inherit a terrible legacy. So if people in the wealthy countries don’t also reduce their fertility rates even more, there is very little chance of saving the planet and our descendants. Social attitudes help; people without children are no longer considered odd or selfish, although many feel pressurized by parents to have grandchildren.

What about other parts of the world especially those that haven’t so far enjoyed the benefits which the rich world has had for many centuries? Looking at Asia, India and China are the two countries with the biggest populations; China is the biggest but India is forecast to overtake it in the next five years. China of course had its “one child policy” – which was supported by over 70% of Chinese people, but was much criticized in the rest of the world. (Actually over 50% of couples were allowed two children so it wasn’t as draconian as we thought). It is said that China’s low fertility was achieved two or three decades earlier than would be expected given its level of development, and that more than 500 million births were prevented between 1970 and 2015, some 400 million of which may have been due to one-child restrictions. In addition, by 2060 China’s birth planning policies may have averted the births of as many as 1 billion people in China when one adds in all the eliminated descendants of the births originally averted by the policies. So we do have to thank China, though no one now wants to be – or perhaps needs to be – quite as draconian as that. There is no doubt that the improvement in China’s economy has been dramatic since they also embraced the market instead of using a state directed economy.

India has a higher fertility rate overall than China, America or Europe and so is projected to be the most populous country in the world in the next 10 years. India is a huge heterogeneous country, and there is a vast difference between educated city dwellers where women have fewer than 1.5 children on average, and some rural illiterate populations which still have more than four children. The key here, as in all areas, is education of women, and this is rapidly improving in India, but its neighbour, Pakistan, has a population growth completely out of control, with dire consequences for water, food sustainability and risk of war over resources. Its government is belatedly, recognizing that and trying to do something about it. Bangladesh however with a similar mix of people has made great strides in enabling women to control their family sizes and now has a fertility rate of 2.1 down from 6.6 in 1960, due to education and availability of birth control.

Then there are the countries of the Middle East.
They have a different mindset. They are, like Pakistan, in the grip of fundamentalist religious teaching, which at bottom seems to me to be based on getting demographic advantage, as it was undoubtedly so in Old Testament times. The age old imperative – go forth and multiply – is still at the root of religious teaching, It is interesting to note that before the advent of oil wealth, Islam as a religion was much more tolerant. It was Saudi Arabia which used its wealth to promote its particular hard line Wahhabism. Iran, which until recently could be commended for its success in educating girls to the point that they too wanted fewer children and the fertility rate dropped, is now trying to compel women to have more children. Thy think it is a way to increase the population at a time when Iran is surrounded by Sunni Muslim countries which are increasingly hostile, and are themselves increasing their populations – although it has to be said that this is as much as a result of immigration from poor countries as increased indigenous fertility rates. Yet the middle East is arid and becoming even drier, and their consumption of energy, mostly oil, is huge as they have so much of it. Using air conditioning is even more energy intensive than heating homes. There were many causes of the war in Syria but climate change and lack of water, partly as a result of damming rivers for agriculture further up, led to a rise in young men from farming areas pouring into the cities and finding no work.
Another case in point is poor, suffering Gaza. It is the third most populated country in the world (after small rich countries like Hong Kong, and Monaco) yet contraception is illegal and in 2014 had an annual population growth rate of 2.91%, the 13th highest in the world. Most people blame this on Israel, which is of course responsible for the fighting and the economic blockade and for the fact that people cannot leave. But even so, how can you justify forbidding contraception on religious grounds in such a situation? Historically people in Palestine wanted to make sure they outnumbered Jews so that they would ultimately inherit the land. It was also the country that gave women almost no rights. Though literacy is now high in Gaza and Palestine, thanks to the UN, girls still cannot choose how many children they can have. There seems no way out – if modern religions insist on fighting to get more and more followers regardless of the well-being of our shared planet then fight to the death they will – our deaths.

Other regions where things also look bad are South America and Sub-Saharan Africa. South America is suffering already from poverty, water shortages, and farmers can no longer make a living. It is difficult for governments to make a difference, and many are totally corrupt anyway. Hence the migration towards the Mexican border. Africa is experiencing a population boom, and this is what is striking fear into European and Western hearts. It isn’t only racists who don’t like this idea; lots of people don’t necessarily like the idea of people so different from them taking over the population growth. Culture does matter.

But the effect of extra people in South America and Africa on global warming and the Earth’s survival on will be small, initially at least. Burning of fossil fuels causes global warming and all the associated dangers, and even in the big African cities, fossil fuel use is low. But even now many poor people in some parts of Africa feel that they have no hope of a decent life, and have fallen victim to organized gangs of people traffickers and try to come to Europe. Fortunately countries bordering the Sahara have now clamped down on the people smugglers and the flow of people northward has slowed to a trickle. But the fertility rates in many central African countries are sky high. All attempts to try to improve their standards of living founder on this. If you manage improve the yield of agriculture by 50 % (by technology for instance) you still can’t feed people if they reproduce by 200%. In many areas women still don’t have access to contraception. But even when they do, it is often not used . Why?

Historically population in Africa has been very slow to rise, compared with Asia. East Asia was the first area to increase rapidly in population, in the centuries before Christ, presumably because climate supported agriculture. Europe’s population increase came much later and is still way below Asia’s. But after the industrial revolution Europe’s population began to rise, and colonization of Africa (and the rest of the world) began. But Africa’s total population was still way behind, and it is only in the last 50 years that the massive rise in population has happened. Why did it take so long? Colonization, disease prevalence, slavery, theft of resources, subjugation as well as difficult climatic conditions all contributed to slow growth of populations in Africa.
Now the huge child mortality that was common in Africa has been reduced, due to higher standards of living and modern medicine, and the population has finally risen. You can understand why people who have lived with such high infant mortality rates (as well as high rates of maternity deaths) for so long would have a culture of wanting more babies, and resistance to contraception. Reliable contraception has only been available for 60 years, and it has taken some time for contraception to be used widely. There is still determined resistance to it in educated affluent societies, driven mostly by religious beliefs, so one can understand how people in rural and traditional societies which have never even thought of contraception because so few children survive anyway. distrust it. And these populations are poor, and depend on their children to support them in their old age. No wonder they see contraception as a trick by the West to try to exterminate them. Religion holds things back here too. The Catholic church has a lot to answer for, although it has to be said that more and more Catholics show a very healthy distrust of its teaching and the fertility rate has fallen all over some areas of Africa and South America as a result of education. We need a wholesale and determined effort to educate girls in Africa. This is the tried and tested way of reducing fertility and allowing standards of living to rise. With pro-natalist policies in America and other countries now it gets harder to provide the resources to do this but a determined effort needs to be made by world governments and charities to do this. Our survival depends on it.

If the modern western countries do achieve the goal of reducing their populations by natural means, and also manage to reduce consumption so that the world does not totally fry in the next 50 years, what happens next? At present people in rural Africa and South America contribute virtually nothing to global warming, however many children they have. The wealthy North has produced it all. Perhaps these under-developed countries could grow gradually wealthier by using solar and wind power, bypassing the terrible effects of coal and oil consumption, now that the technology is there. And they do show signs of doing just that. And natural justice should mean that underdeveloped countries should themselves get the chance to get wealthy enough to voluntarily use contraception to reduce their populations to a sustainable level. Many economists argue that there is a demographic dividend in those countries in Africa with a very large youth bulge due to high fertility rates, and this would kick start economic growth But a demographic dividend for the economy is not just the number of workers, but how educated they are. If a worker cannot read what job can he do? Fewer children means higher education spending on each child, which leads to a higher education level.

But as such countries get richer, as one would hope, the existing population would impact even more on their local environment and wildlife, and there would still be problems of water shortage in most areas. And if global warming then makes their agriculture unsustainable, then this extra glut of young people will not be able to survive, let alone reach their potential. There is already a threat of mass migration of people from very poor countries leading to loss of the brightest and best, further diminishing chances of a better life locally. If large number of these young people do reach the west and manage to increase their prosperity their extra consumption will of course further exacerbate global warming.

So, now at a pivotal point in our planet’s history, with global warming threatening to engulf everyone, we have Europe and most of its diaspora (USA Australia etc.) in a demographic clash with Africa and South America; with so many countries doing their best to try to stop the tide of humanity rushing towards them to escape poverty and stagnation.

I do totally understand why Europeans are not very keen on welcoming millions of poor people from sub Saharan Africa. Germany is to be commended by admitting 1m Syrians, but they are educated people fleeing a dreadful war caused mostly by wealthy rulers, (including western meddling), and by climate change as drought increases in the middle east due to population increases there. And Germany has been successful, by and large; but look how that was viewed and how it has led to the rise of populism and the far right. Racial differences may things worse, and some European people feel totally threatened by these immigrants; in the USA as well, where Donald Trump has stopped the government functioning in order to bring about a huge wall. In the long run Africa has to become a place where its population wants to stay.

Nobody knows if civilization as we know it, will survive through the next 50 years. But these actions might help.
1. Provide free contraception throughout the world, giving long acting contraceptive implants to every woman who wants it (and is allowed it by their society) but prioritizing young girls who have not yet got pregnant. If you can give them 5 years to grow up and get educated then they will know when they are ready to have children, who will in turn be healthier and more intelligent. Early marriage should not be tolerated.
2. A drive to allow women to choose and to decrease the power of male dominated religions (we all know which they are). Buddhism has an excellent record of tolerating women’s choice. If procreation strains the ability of resources to support life, then procreation is against the basic principles of Buddha.
3. Big corporations should be forced by their shareholders and governments to improve the welfare of their workers in poor countries so that fewer feel the need to leave.
4. Wildlife and rainforests should be protected until such time as the pressures of diminishing space and resources can be reduced
5. A total drive to eliminate fossil fuels and to switch to renewable energy all over the world including poor countries which can then leap frog over rich countries in developing technology.

I think it is very possible that we will continue to reduce our fertility with beneficial effects on consumption. Those countries which want to maximize the demographic advantage, usually for political reasons, have a hard time of it. South Korea is trying to boost its fertility rate but failing; Japan has probably given up and is adjusting to the economics of “steady state” consumption. Germany has also given up the struggle and that is probably why they could countenance welcoming 1 million refugees. For the world as a whole, we need to understand that people are not special in any way, except for the damage we can cause. We don’t need to go forth and multiply any more – that has been done. Human life is not sacred. When we have had enough of living, or are ill, or feel guilty at being a burden, we should be able to make a mature decision to end our lives.

The alternative to lowering fertility and consumption is hardly something we can contemplate.

Posted in Global warming, Health Policy, Populaion growth, Sir David Attenborough | Tagged child mortality rate, CO2, consumption, fertility, Religion, renewables, sustainability | Leave a comment

Sexism in Science

Posted on October 9, 2018 by Elen Samuel

There is currently a bit of a storm in scientific circles about sexism in science. Again. An article in New Scientist recently highlighted yet another male scientist who thinks that women can’t or shouldn’t do science – in this case physics. It happens regularly – the last male scientist to do this was James Damore, who was fired from Google last year for holding similar views. This time it happened at a scientific workshop on gender and high-energy physics being held at the CERN particle physics laboratory, in Geneva that aimed to look at gender issues in science. A professor, Alessandro Strumia from the University of Pisa, Italy, who is a long-standing member of the CERN collaboration, gave a presentation purporting to be on “a historical look at women’s representation in academic publishing”. Instead of giving an evidence-based account of gender issues in physics, he used poor evidence to claim that women weren’t as good at physics, were promoted too early and received disproportionate funding given their ability. He got a lot of stick for this and CERN has suspended him from any activities, pending an investigation.

It resonated with me because there are lots of men who think like this. Last week I was talking with a good friend, a retired scientist, about the problems women had in politics, and he said exactly the same thing – that the reason why there aren’t many women in high positions in politics or science is that they really aren’t as good as men in either discipline. He inferred that women are good at empathy, and communication and have no real interest in science.

There are two parts to arguments like this; firstly whether women’s brains are configured differently so that they really aren’t as good in thinking scientifically, on average, as men. That is a question for science itself to answer, and I will go into this a bit later. But the other question is – are women put off by the scientific culture and is there still gross sexism in science today?

So I told him about something that happened to me when I was in the sixth form in a co-ed valleys grammar school in 1962. There were 7 girls and 22 boys in the A level physics class, and for the first term we had an excellent experienced teacher who we all liked. Then in the second term he took promotion at another school and left, and we got a young teacher, who had been teaching for about 3 years. The difference was astounding, and the girls soon began to feel very undervalued. He would never ask girls to answer his questions; he would make snide comments to them and he picked on them. I say “them” because I didn’t feel that so much. As it happened I was the daughter of the deputy head in the same school, so I got treated a lot better. But after several terms of this, and after trying to talk to the teacher about it, the other girls wrote a petition and asked me to take it to the headmaster. I was a little unwilling to do this at first as it didn’t really seem to be my problem, although I could see what was going on, but I realised that I was the only one who would be able to do this. So I went to see the Head taking the letter. He was very fair and understanding and assured me that he would try to deal with it. Indeed he did, and the teacher was obviously made aware of the problem and did try to be fairer towards the girls. Of course he wasn’t at all happy with me and ignored me as much as possible for the rest of the course.

Physics wasn’t my subject as I was intending to study medicine, but I found it very interesting and not difficult. I have no idea whether any other girls went on to do Physics in university but I doubt it.
I went on to read medicine at Cambridge, and at that time there were 9 lads to each girl. It was very disconcerting to be completely overwhelmed with boys. It is not a comfortable situation to have such an unequal gender mix, and I am sure boys would feel just as uncomfortable if they were in a situation of being always in an extreme minority.
I found that throughout my career as a GP. At the beginning of my career in the seventies, female doctors were very scarce and while the patients were very happy with us, our colleagues often weren’t. When I joined the practice I was eventually to stay in for 37 years, one of the male partners said he didn’t think I should have been appointed because women wouldn’t stay and would leave to have babies. He left general practice 10 years later, and became a farmer instead! I knew I had to be very disciplined to survive and when I did have to have occasional flexibility to deal with childcare emergencies I would always say I had to take the car to the garage. That was always so much more acceptable. Sometimes there was outright prejudice, not so much in the practice but in medical management, which I did a lot of. All the usual gripes – I would make a point in a meeting, which was ignored, then a man would make the same point 10 minutes later and it was immediately taken up as an important contribution. The successful projects for improving quality in health care that I started were ignored by my male colleagues even though they were picked up by think tanks (such as the King’s Fund) and by the Welsh Assembly. They managed to ignore my work even when there was a trail of health service managers coming to our Health Board for information on how to copy it.

So if men in science or medicine think that women are only suited to “female” jobs is not surprising that for so long women thought these jobs were just too uncomfortable? And that is without the sexualizing and indecent behaviour that so many women seemed to suffer from. And the undoubted fact that in high-pressure jobs where women want to give their best but also have a family, childcare and housework will fall on them in most cases. It will weed out all but the most energetic, disciplined and brave young girls.

So, back to the question of whether there are differences between male and female brains that might account for differing ability aptitude and attitude towards science.
It has been said that from a very young age baby boys and girls are different, boys being more interested in objects and mechanics and girls are interested in people and emotions. But this has been disproved by evidence from scientific papers
over the last 30 years. It appears that male and female infants are equally interested in objects; make the same inferences about object motion at the same time in development. The small differences that are found are just as likely to show girls learning skills earlier as learning them later.
It has then been claimed that formal maths and sciences don’t bear any relationships to these early learning skills, and males are better at these skill subsets. From the evidence there is a biological foundation to mathematical and scientific reasoning. We have core knowledge systems that emerge prior to any formal instruction and that serve as a basis for mathematical thinking. But these systems develop equally in males and females.

However, it seems there are differences in cognition between older children, starting at puberty. They manifest themselves more in the ways that children solve problems using different strategies. Girls perform better at some verbal, mathematical and spatial tasks, and boys perform better at other verbal, mathematical, and spatial tasks. But it is very subtle; manifesting itself in the choices children make that will speed up or slow down solving the puzzle. It does not mean women are “verbal” and men are “spatial.” In formal testing, it is possible to construct tests that can give an inherent advantage to boys or girls depending on which tests are used, so you have to be very careful in interpreting IQ scores, for instance.

So why have boys done better on maths tests than girls? They certainly used to but the gap has been getting smaller over the years with more girls studying the sciences. And now in many cases girls are doing better than the boys. The age at which girls have improved has been gradually rising and now both sexes tend to perform similarly right up to University. So while there are sex differences, they don’t add up to an overall advantage for one sex over the other.

Why do so many more boys than girls become “high flyers” in maths and science? The usual explanation is that men show a greater variability so that there are more men at the top of the ability scales (as well as more in the bottom sets). This is certainly possible, but given the different expectations of boys and girls and the amount of encouragement and opportunities they have had in the past, this can’t be proved at the moment and it may well be that in future this gap will narrow as well.

So we have now had 3 Nobel prizes for women in Physics. Attitudes towards women in science may have changed, but only slowly. Jocelyn Bell didn’t get a Nobel Prize for the discovery of Pulsars because her supervisor took it, despite the fact that not only did she do all the work but also he even disbelieved her results in the beginning. He may have been within his rights, and it may have happened to young men as well, but it still seemed unfair. Rosalind Franklin didn’t get a Nobel Prize for her part in the elucidation of DNA despite the fact that the solving of the structure was based on her crystallography pictures, which had been stolen from her without her knowledge. It is true that she died tragically young, and Nobel prizes are only given during one’s lifetime, but even in the early years her work wasn’t acknowledged. That there always was gross discrimination and discouragement of women in Science is indisputable, but the tragedy is that some men cannot see that this will have an effect on the numbers of young women making a career in science and think that it is because women are not up to it. There are however plenty of men especially those who have daughters and granddaughters of their own, who do support young women, and who want to change things for them. And it is reassuring that when men with such dated and sexist opinions do speak out there are consequences for them, often leading to them losing their jobs. Perhaps they will get the message sometime soon.

References
New Scientist Daily news 1 October 2018
1. Physicist sparks gender row after claiming women are worse at physics
2. It is 2018, so why are we still debating whether women can do physics?
3. THE SCIENCE OF GENDER AND SCIENCE
PINKER VS. SPELKE A DEBATE 5.16.2005]

Posted in Medicine, science | Tagged gender inequality, human development, IQ scores, Mathematics, Nobel Prize, quality in healthcare | Leave a comment

Is the Savannah hypothesis of human evolution really, really dead?

Posted on May 18, 2018 by Elen Samuel

Yes, I am back on anthropology rather than medicine.

Remember this theory? Man evolved in Africa from a chimp like ancestor which lived in trees, about 6 million years ago (mya). For some reason (climate change perhaps?) he came down from the trees, went into the savannah where he immediately learned to walk upright, and proceeded to develop hunting skills. These required a bigger brain, and so his skull enlarged too. The rest is history. All palaeo-anthropologists had to do was find the relevant bones in the right places and construct an evolutionary tree.

BUT THEY HAVE FAILED TO DO IT.

The three things that make a modern human are: – a big brain, and hence a big skull; a smaller mouth and teeth, indicating a softer diet; and longer leg bones with pelvis and leg bones adapted, not only to walking, but running long distances. So, to fill in the gaps scientists would need to find a neat line of skeletons in various parts of Africa which showed the development of the brain case, evidenced by the skull and face shape, gradual loss of limb adaptations to living in trees such as prehensile big toe, and changes in the knees to allow modern walking and running.

At first all went well, with the discovery of Lucy, Australopithecus afarensis, in 1974. She lived at the right time, 3.2 mya, and place, in the Afar region of Ethiopia, to be considered the ancestor of us all. She was partly bipedal, so possibly on the way to becoming completely so.
If you go to any museum in the world that gives a history of the evolution of human beings, this is what it will say.

But discoveries of three separate hominid bones in the late 20th century and 21st century have not been kind to this theory, and now many scientists are saying that they are incompatible with the savannah hypothesis, and so it must be discarded.

These three discoveries are;
7 mya – an ape skull with some human like features found in Chad; therefore named Sahelanthropus tchadesis. It was found in 2002;
6 mya – a species the size of a chimp with human like teeth, found in the Tugen Hills, central Kenya, named Orrorin Tugenensis which lived 6 mya (nickname: Millenium Man). This was found in 2001 and had an upper femur, showing evidence of bone build up typical of a biped. So these individuals climbed trees but also probably walked upright with two legs on the ground.
5.5 mya – Ardipithecus, found in 1997, which was an almost complete skeleton of early ‘proto-human’ sharing traits with chimps and gorillas, which was also partly bipedal.

All these finds were of skeletons which had some traits that were more human than Lucy, yet were much older (Lucy dates from 3.2 mya). This was very confusing, and cast doubt on the molecular clock dating mechanism which had given the split between apes and hominids at about 6 mya. None of these three earliest skeletons could have shown these human changes by then if the split was so late. So the dating mechanism had to be tweaked. Lo and behold, some of the assumptions in that calculation were found to be suspect, and scientists decided that the split could have been any time between 13 mya and 7 mya. We may have begun our journey much earlier than the 6 million years ago that has been accepted for many years

It was clear years ago that the savannah theory had serious flaws – quite apart from the fact that the savannah came and went and wasn’t there at the time humans were supposed to be evolving. But now we have archeological evidence that there is no linear development of skulls and limb bones which show that hominids came down from the trees, started hunting, walking on two legs and developing skills which needed a large brain. Other recent finds have confirmed that individual hominid remains could have a mixture of primitive and advanced features previously thought to belong to different species, so that there was no tidy sequence of human skulls, teeth and leg bones indicating the transition of humanity in this way. These other species were
Kenyaanthropus platyops found in 2000, contemporary with Lucy, but seemingly closer to modern humans,
Homo Naledi, 2.36 mya, found in 2015, which has a tiny brain but otherwise morphologically human,
And two Australopithecus skeletons dated at 2.2 mya .”In reality, there may have been a variety of evolutionary branches, each developing unique suites of advanced human-like features and retaining a distinct array of primitive ape-like ones.” said Lee Berger at the University of Witwatersrand in South Africa, who led the analysis of two of the most recent finds. So we cannot be certain (if we ever could) that any of these skeletons were our direct human ancestors and so we cannot use anatomical differences to trace our human journey in Africa or anywhere else. Many of the recent discoveries may not have been our ancestors and we don’t know which ones are.

I am delighted that the Savannah hypothesis is now on its deathbed. Scientists, apparently, are still arguing over this, trying to reconcile the findings with a sensible theory. But I don’t know that they ever will if they confine themselves to the study of archeological remains. Yes, paleo-anthropology has inevitably meant the study of bones. Until recently that was all scientists had. But the study of bones would never tell us how we functioned so differently from apes. To me, as a doctor trained to look at how people functioned, it is physiology, the functions of the body which tell the real tale. When and how did we get the ability to speak? Was this ability the cause or the result of our increasing brain size? Why do we get so obese? Yes, we store fat under, and linked to, the skin unlike any other apes, but why? Why and when did we lose our hair? How did our ancestors get enough protein to enable brain development? Does the theory of why we sweat, rather than pant, when we are in danger of over heating, really stand up? (It involves early man having to go out and hunt in the mid day sun amongst other things).
These are all questions not generally considered by anthropologists (and certainly not answered by them), but are just as important I think to understand how Homo sapiens evolved. To my mind, what makes us human has never been the fact that we walk upright. It is the fact that we can communicate with each other with a sophisticated tool – language, that separates us off from apes.

I think t is clear that it will have to be DNA that tells the true story, which may finally give some answers to the physiological questions above.

So if we consider that the split between the ancestor of chimps and the ancestor of man could have been as long as 15 mya ago, we would have to look at the conditions on earth at that time. We know that 15 mya, called the Mid-Miocene Climate Optimum, was when the climate was as much as 4 to 5 degrees Celsius (or 7 to 9 degrees Fahrenheit) above today’s average temperatures. (This also seems to be where the earth is heading after humans became the most successful species on earth in terms of being able to alter the environment). There were many species of large ape around at the time, and we need to find out why the two branches split. What changed? Even if you don’t go along with my mini-obsession with aquatic apes, the theory that some apes had spent time in the water, resulting in changes to their physiology in order to adapt to a more aquatic way of life, we will have to find another theory that explains the fact that hominids diversified into a whole new series of anatomical changes which did not relate in any way to the story of man the hunter in the savannah.

After that split in DNA, which ultimately led to a talking, intelligent ape, that group of human ancestors could have gone into a number of new habitats. They could have been living at riversides, with nearby forests, they could have been on more open plains, they could have lived in caves, or by the seaside. We can’t be certain. But whether they habitually walked on two legs or not would have been irrelevant. It would depend on where they were living, and some would still have adaptations for living in forests. Some of the later finds have smaller brains than the early ones we have assumed were human. Are they human? In many ways they are. Does that mean that language growth and skull size aren’t related either? It could be. The original change of starting to speak would not necessarily have led to a bigger brain – the language area is only one small part of the brain, and the bigger brain could have come from what we then did with our brains as we developed further skills. Or it may reflect better nutrition.

It is a very exciting time for those interested in human evolution. Of course many scientists will carry on supporting the savannah theory despite the new evidence. I hope new breakthroughs will come thick and fast, in DNA and paleo-anthropology, to make further progress in this fast moving field.

Link

https://www.newscientist.com/article/mg23531400-500-who-are-you-how-the-story-of-human-origins-is-being-rewritten/?utm_campaign=Echobox&utm_medium=SOC&utm_source=Facebook#link_time=1525168796

My Previous Blogs on this site

David Attenborough or Alice Roberts – who do you think is right?
Posted on September 18, 2016
Apes and Women
Posted on January 29, 2016
Why are we fat (some of us anyway!)?
Posted on August 19, 2013
Children taught adults the beginning of language, not the other way around
Posted on February 19, 2016 by Elen Samuel

Posted in Anthropology, aquatic Ape Hypothesis, Elaine Morgan, language, Paleontology | Tagged Ardi, bipedal, evolution of man, hominids, Miocene, Savannah hypothesis | Leave a comment

Why do parts of the media really enjoy criticizing the NHS in Wales?

Posted on January 16, 2018 by Elen Samuel

It is generally considered that the NHS in Wales performs much worse than the English NHS. The Daily Mail is always saying so and many other commentators too.
So when Theresa May recently asked – “If the Labour Party have got all the answers, why is it that we see funding being cut and targets not being met in Wales, where the Labour Party is responsible?” she probably thought this was a good way of answering the criticisms of her government’s record in presiding over the current winter crisis.
Normally, as someone who worked in Wales for nearly 40 years and who is aware that satisfaction with the health service is actually higher in Wales than in England1, I just shrug my shoulders, knowing that this is just stupid politics. The conservatives in England run their health service in their way and the Welsh labour party (which is allied to but separate from, the labour party in England) runs the health service in Wales as they think best. Therefore it is fair game you would think that one should criticize the other, regardless of any truth behind claim and counterclaim. But because Wales is tiny compared with England and struggles to get its voice heard, all the publicity goes one way, from England about Wales and not the other way around, and always infers that Wales is doing very badly.
So for once I want to redress the balance a little bit, and explain how Wales does things differently, and in my view better.
Firstly there is no privatisation programme in the NHS Wales as there is in England. Virgin doesn’t get a look in for hospital or GP services so profits aren’t creamed off. There is no contracting out wholesale for mental health services. There is minimal Private Finance Initiative so there are no problems with costs to private providers causing hospitals to go bankrupt. There are no big debts to pay off in the future. As we have seen this week with Carillion, private companies do not always run their empires with competence or honesty.
There is no contracting out to private GPs, or attempts to de-stabilize GP practice. The back end services that GPs rely on to service their practices (pay and rations) remain in public ownership and work well, while they do not in England.
There are no prescription fees in Wales. This is partly because there was a very large proportion of people in Wales who were too poor to pay them so it made sense to scrap them altogether. There is free parking at almost all Welsh hospitals except those that had contracts in place before the rules were changed (very few).
There was no cancer drug fund in Wales (it has now been watered down in England because it made a mockery of attempts to make sure everyone got fair access to drugs). All the stories in the media about how a few individuals people were dying because of the lack of very expensive drugs were very sad, but I make no apology for saying that scarce resources should be directed to where they will make the biggest difference, according to best scientific evidence. Saying that Offa’s dyke was a “wall of death”2 was absolutely crass – see my previous blog https://scepticalgp.wordpress.com/2014/06/02/offas-dyke-and-the-line-of-death/.
Wales uses an opt out system for consent for removal of organs after death, so that there are more organs available for transplanting. Many of those go to England. England is now considering following suit.
But most of all the Welsh government has a consensual attitude to NHS workers, works well with the Unions and tries hard to attract and keep its workforce. There was no junior doctors strike in Wales, nor any other dispute. The Welsh government has been successful in attracting young doctors to train as GP’s in Wales and all places this year have been filled, unlike in England.
Of course there are problems in Wales but considering that there is no level playing field, Wales does surprisingly well. Comparing Wales to England is hardly comparing like with like. Wales is much more rural, and much poorer than England. It has different challenges that have to be addressed by the Welsh devolved government. The GDP per head in some areas of Wales is lower than parts of Bulgaria and Albania and in 2009 West Wales and the Valleys had a GDP per head rating equivalent to just 68.4% of the EU average. If you need to do comparisons, Wales should be compared to a similar region in England such as the northeast.
This matters because there is a linear relationship between greater poverty, and the amount of ill health. The cost of treating the population is higher per head. There is also the legacy of ill health from old heavy industries like coal, slate, and steel.
Secondly, the demography is different; Wales has a much higher proportion of elderly folk who are more likely to have expensive health needs. There are the older people who have always lived in Wales, but there are also a disproportionate number of non-Welsh retirees, usually from England who come to retire to Wales, because house prices are cheaper and it can be a very nice place to live. Wales is not given more money specifically for these people. They replace younger fitter Welsh people who go over the border to England to work because of lack of opportunities in Wales, and who do not use the English health service in the same way. There are also people on the borders who choose to register with Welsh GPs because they can get free prescriptions, but then object because they have to use Welsh hospital services, even though Wales does not get any more money to pay for them.
So the money that Wales gets from the Westminster government for its health service has to go a lot further.
The money for the Welsh parliament comes in a block grant from England according to the Barnett formula. It is higher per capita than in England but not nearly so high as in Scotland, which is altogether richer. Wales can then choose from this amount how much to spend on its Health service as compared to education and other calls on its funds.
So going on to Theresa May’s question, why is it that we see funding being cut and targets not being met in Wales, where the Labour Party is responsible?”
This “funding being cut” statement refers to the fact that between 2009-10 and 2012-13, health spending was cut in real terms by about 3.6% in Wales, while the English health budget was increasing, albeit at under 1% a year in real terms. During those times Welsh government made a decision to cut the funding of the health care sector in order to protect the social services budget, This was specifically because cutting social services leads inevitably to inability to discharge people from hospital, especially in Wales where fewer people can pay for social care themselves. It was an attempt to stop the very things that are now plaguing the English NHS – inability to discharge patients, blocked beds, inability to admit fro A&E, people waiting on trolleys, ambulances piling up outside A&E, and so on. They were then pilloried mercily for spending less on Health. But the strategy did work to some extent and there were fewer bed blockers in Wales as a result.
However, since 2012-13, health spending in Wales has increased from £6bn to close to £7bn in 2016-17. The Wales Audit Office notes an average 2.9% annual increase in real terms during this period.
This tops spending increases in England, which have averaged 2% per year since 2013. In fact, Wales now spends £64 more per person on health than England, according to HM Treasury. However the overall amount Wales has had from the Treasury has dropped from £16bn available to spend in 2009-10, to about £14.5bn by 2016-17. This means a squeeze on all budgets.
The idea that Wales NHS performs worse than England is because of specific problems with targets such as waiting times for operations and diagnosis.
In 2016 England did better on hernia, pneumonia and heart disease diagnosis, and waiting times for some important procedures and operations such as hip replacements are shorter than in Wales. While that is important for patients, it is not a deciding factor in the effectiveness of treatment. Within reason, waiting times are not always bad. My own personal feeling about waiting lists for surgery is that it all depends on when surgeons decide to put patients on the waiting list. In my view it is very easy to decide on a knee operation far too early, before there is significant disability, and as any operation carries some risk this can mean that patients are actually worse off if they do get a complication when they were managing OK without an op. So these targets are only a small part of whether a service is doing well or not. And on other key procedures such as heart bypasses and kidney transplants, the waits were shorter in Wales. Wales is currently doing worse on hitting the 4 hr. wait for seeing patients in A&E, but every country is having problems for these and they have been disregarded in many analyses. Cancer diagnoses were similar in the two countries, so it is unlikely that waits for diagnostic tests are making much of a difference overall.
Finally, all the evidence is that in the round, there is virtually no difference in the performance of the four nations of the UK. In 2005 a report came out from the Nuffield foundation comparing the four health systems (2), in Wales, Scotland, Northern Ireland and England. It wasn’t reported at all in the press, but it said in effect that the gap between the NHS in England and the rest of the UK has narrowed in recent years, so that now no country is consistently ahead of the others, despite all the hype about how England has improved with increased competition and privatisation.
So one has to realise that the Daily Mail and its mates just want to make a political point that the Conservatives run things better than Labour do, using Wales as a scapegoat. What a surprise! Of course that is a matter of opinion and many would beg to differ.

1. http://www.bbc.co.uk/news/uk-wales-27616963
2. http://www.telegraph.co.uk/health/nhs/10760842/Offas-Dyke-is-line-between-life-and-death-says-David-Cameron.html
3. . http://www.nuffieldtrust.org.uk/our-work/projects/funding-and-performance-health-care-systems-four-countries-uk

Posted in Health Delivery, Health Policy, Medicine, old age, Sir David Attenborough | Tagged end=of-life drugs, health, health service, UK | Leave a comment

Virtual Beds anyone?

Posted on January 16, 2018 by Elen Samuel

The current crisis in the NHS is wearingly familiar. There is talk of patients waiting, and occasionally dying, on trolleys before being admitted, ambulances waiting for hours outside hospitals with paramedics before A&E have the space to take over their care, flu epidemics; too many elderly patients with complex conditions becoming ill over the winter periods, patients in hospital who have been treated and could now go home except there are no services available for them to go home; and so on. It seems to happen every year, and every year there is a crisis.
Looking back on a lifetime of being a GP, I can remember (just) a time when this didn’t happen. If you were on call in the 70’s you were very busy seeing acutely ill people, and they were definitely younger, fitter, and would need a week or two in hospital to be treated for their pneumonia, heart attack or acute gastric ulcer (anyone remember that?), and would then go home to their family. Ambulances arrived, not always very quickly and without paramedics, and discharged their patients straightaway into hospital, and there was very little problem with discharging people. There were council-run care homes for the few that needed them.

So what caused the change?
Yes, the population has increased substantially, but undoubtedly it was the very success of medical treatment that made the real difference. To fail to save someone’s life was a tragedy, but it was a cheap outcome. To succeed, on the other hand, was a wonderful achievement and we were all thrilled, but it was very expensive. As each generation went on to survive into their seventies eighties and nineties, people continued to consume medical resources, collecting diseases (now renamed long term conditions), but still surviving. For some individuals, treating these conditions resulted in a near normal life, but others became severely disabled to the point when no spouse or daughter (hardly ever a son) could look after them. Hence the gradual proliferation of care homes, social services help and so on, all costing an awful lot of money provided by the state for those who could not afford to themselves. You would have thought that hospitals too would be proliferating with more and more hospitals being built to cater for the huge increase in treatments available. But all over the world the cost of medical care was rising to a level above that which countries were willing to pay for, and by the early nineties the system was already creaking. The brakes had to be put on somehow.

It was recognized very early that hospitals were the really expensive part of health care, and that they should only be used when absolutely necessary. My older patients in the seventies would talk of “going into hospital for a rest” when things got tough for them, and sometimes it actually happened! As early as the late eighties, health economists in the USA and Europe, with very different methods of providing health care, were working out ways in which bed occupancy could be cut despite the fact that hospital beds used to be the most prized and economically profitable part of their health systems. Hospitals would have to become lean and mean; very efficient at processing their clients and ruthless in pushing them out again.

So fast forward to 2006. After 33 years as a GP in a market town in Wales, I took a job as acting Medical Director of the local Health Board. At that time, it was clear that the old model of district medical hospitals providing care for a local population was creaking badly; so there were plans to build a large super hospital, a Specialist Critical Care Centre, to take over some of the more complex cases. I was immediately thrust into meetings, which were set up to do detailed planning for this.

Hence I was introduced to the concept of “Virtual Beds”. What is a virtual bed then? You may well ask, as there was no clear answer. What it should mean, I was told, was that instead of a hospital having say 400 beds, it could have 320 beds plus 80 virtual beds. Those “beds” represented the cost envelope for the care of the patients who could be cared for in other environments, such as day care, a care home, or, most sought after of all for these planners as it was the potentially the cheapest, the patient’s own home, with staff going in to look after their essential needs. So our job was to price the resources in these other “facilities” and sell it to the public that these “beds” equated to the beds currently in the local hospital. In this way the new hospital could create new beds, but the old beloved DGH would lose far more beds than were created by the new one. A private company was contracted to work out the detailed development and costing of this new model, and they produced wonderful large spreadsheets in which you could put in the number of beds, the cost per bed, number of staff trained to various levels, and so on, so that the ultimate solution would have as few actual beds and as many virtual ones as possible.

The “science” of health economics was therefore quite well developed 10 years ago, but the problem has been actually implementing the ideas. There have been successes in that more and more beds have been successfully cut, because they really weren’t needed, and so considerable amounts of money have been saved and the system made more efficient.

But for me as a GP looking at their plans, there was one big flaw in their costing. They were assuming that the older, sicker patients, such as the old lady who had had a stroke, or the 90 year old person with diabetes, early dementia and recurrent falls, and so on, did not need super specialist care and could easily be shunted into “beds” with lower staffing levels and so consume less in the way of “resources” i.e. money. Although that sometimes may well be the case, as a GP I knew very well that these people did not have stable illnesses, where the level of care that they needed could be planned in advance, implemented and the cases closed. These are very often people in the trajectory of the end of their lives. It is well known that for every individual in the UK the last two years of their lives will incur about 90% or more of the total spend of the NHS on their care. And it will accelerate until they die. These people oscillate from needing social care only, to needing very complex medical interventions in high tech units urgently, and this goes on for months, may be for years. Virtual beds do not even remotely provide an answer to this problem. You will still need the facilities of the big hospital for everyone, especially the elderly. And even if technically you can get them out of hospital quickly and easily, often the cost of doing this approximates the cost of treating them in real beds.

But the virtual bed concept did have one thing going for it. A “bed” is not just a bed. It represents the costs attached to that bed and a very big part of that is the cost of the staff that treat and look after the patient. Cut that cost envelope too far and you have real trouble. In times of high demand, you will get all the problems we have now – long waiting times in A&E, people treated on trolleys, bed-blocking, (then called DTOCs – delayed transfers of care), ambulances stuck outside hospitals, and so on.

The solution has to involve more money. Any modern system has to have access to money that can make the entry to hospital and discharge from hospital a priority, by having flexible access to fully staffed beds, which will go up and down with demand. Money that can be conjured up really quickly; task forces that will go into hospital buildings, open wards that may have not been needed in the summer, and provide the treatment that these frail elderly people are going to need. It wouldn’t be easy – you need to right skill mix of staff to do this, and staff can lose skills very quickly, so continual learning and updating is essential. But when we have bed occupancy of 95% or more, as we do at the moment in the UK, we have already cut the number of permanent beds too far in my view.

There is no doubt in my mind that part of the problem with political management of the health services is that health economists’ forecasts of what can be done with efficiency savings, lean management systems and so on are far too rosy. Basically they don’t understand how and when people get ill.

And what happened to our brand new hospital? When I left the organisation, planning had been put on hold. Funding of £350m was finally confirmed in 2016, and building started in 2017, 11 years after I was involved in the planning.
Originally it was to have 505 beds, but the final total is 471 beds. There will be reductions in numbers of beds in the surrounding hospitals and I take it this also will mean a lot of virtual beds. It will open (they say) in Spring 2021. I do hope all those spreadsheets had been dusted off and calculations done so that this hospital, and others like it in the UK have the correct number of actual and virtual beds, so that in the future patients on trolleys now can have an actual bed when they most need one.

Posted in Europe, Health Delivery, Health Management, Health Policy, hospital beds, Medicine, old age | Tagged health service, Trolleys, winter crisis | Leave a comment

Breast surgeon guilty of doing unnecessary operations.

Posted on May 10, 2017 by Elen Samuel

How would you feel if you had had an operation or treatment that you thought was necessary and then found out that you never needed this treatment? If you were told you had cancer but you never had it? Pretty let down I would think, even if the operation were “successful”. Think of all the unnecessary worry, the discomfort, sometimes pain, the interruption to your schedule, the insult to your body and body image. If there were complications you would feel devastated. So when I read of the surgeon who was convicted recently for doing just that, I wondered again about his motivation.

It is easy to see why a surgeon might perform extra operations in the private sector – money. The surgeons are paid directly for each operation they perform. They can decide for themselves which operations to do and which not to do, and are constrained only by the concept of “good medical practice”. This is decided and promoted by the Royal Colleges of each speciality, and doctors at the top of their tree, well-respected consultants, look at the evidence for each operation or new therapy. Guidelines are issued, and doctors are expected to follow them, under threat of GMC action if they transgress. However in the private sector they are less constrained by NICE guidance, which gives advice on what would be cost effective for the NHS. So as we have seen, this doctor did not follow the consensus of his peers, and persuaded patients to undergo operations for various reasons. Some of them were told they had cancer when they didn’t – how evil is that? Some of them were persuaded to have operations that he liked to do such as the “cleavage sparing “ operation, despite the lack of evidence. Some of them presumably didn’t mind the inconvenience and discomfort and had operations, which they were told would improve their looks. What ever the reason patients parted with their money, and he assaulted them, banked the money and spent it. Wicked, criminal behaviour.

But this surgeon in fact did most of his unnecessary operations on the NHS, and it is more difficult to see the motivation there. A surgeon is employed by the hospital on a salary, which is set in stone, and he does not get any extra for working harder. The only way of getting more money is through the “merit” system which gives a bonus to those doctors who are considered to do the best quality work in their speciality. Some heavily criticize this system because it is biased towards those in teaching hospitals, but no one can say that doctors getting these awards do not follow guidelines to the letter. On quality you cannot fault the system. It does not reward doctors who have the heaviest workloads, or do most of the routine operations that are boring for the surgeon but are most helpful, and sometimes life changing, for patients. So why would an NHS doctor deliberately persuade patients to have more operations when it will increase their workload for no more money?

Having worked in hospitals and as a manager, as well as being a GP, I can understand the temptation. In a profession such as medicine the route to success, prestige and power is the development and expansion of your speciality and your reputation amongst other doctors. For several years I worked with consultants on a scheme to improve the quality of referrals from GPs, to make sure that each referral made was to the right specialist; for a condition that was according to up to date guidelines; and where all investigations had been done to ensure that the diagnosis was correct. One of the aims was to reduce the vast variation on referral rates from different GPs and so to save patents from having unnecessary treatment. There was also a hope there might be a cost saving for the NHS by making sure that NHS money was only spent on doing essential treatment.

I had naively thought that consultants would be extremely keen on the scheme because everyone expected it to reduce their workload, and make the referrals they got much more focused. I was amazed to find quite early on that some consultants, especially orthopaedic surgeons, were actively against the scheme and would not take part. I had to work extremely hard to get any to turn up for our joint meeting with GPs despite the fact that they had time set aside in their schedules (and therefore paid for) to do so. Yet orthopaedic surgeons had the longest waiting lists, and more unnecessary referrals than any other surgeon, and worked very hard as a result. Why did they not want to reduce referrals?

I eventually realised that waiting lists were far from a problem for the surgeons, but more a source of power. If a surgeon had a much longer waiting list than others it meant that they had more clout with managers whose responsibility it was to clear the waiting lists. They were likely to get more junior staff to help them, and do many of the routine operations while they could concentrate on the bigger more challenging stuff, and more resources that would further develop their speciality. A large proportion of patients referred to them are never likely to get an operation because the solution to their problem is much simpler – lifestyle advice, physiotherapy, podiatry, etc. But if their outpatient clinics weren’t full of patients like these there wouldn’t be a waiting list at all. That would result in managers deciding to put any available extra cash elsewhere, and they might get fewer junior staff in their department. They would lose some of their importance and prestige.

Crucially it would also impact their private practice. If a patient who needed a hip operation could be seen within a few weeks there would be no incentive for them to “go private”. Most private consultations in all surgical specialities result not in a private operation, but in being put on the NHS waiting list, sometimes quite far up the queue. It is perfectly legal. So the patient would pay £150 for a private consultation and would get a quick NHS operation which would have otherwise cost thousands. In our area we found that when the waiting lists came right down in the last years of the labour government, the number of private referrals nose-dived. That did not go down so well.

There were also a few consultants in our area who honestly thought that everyone should be seen by a consultant, even if they did only need a physiotherapist, because only a doctor would be able to pick up on the rare condition that needed further treatment urgently (mostly rare cancers). This is a very old fashioned view now as most physios, podiatrists and other professions allied to medicine are themselves very well trained and know when to refer on. But old habits die hard, and some consultants were very against GPs doing a better job of screening their patients and sending them to the right professional rather than making them go through the hoop of seeing a consultant and then a physio or someone outside their speciality.

I must add that only a few consultants actively obstructed our work and most specialists, especially those with managerial roles, were very keen to help. Breast surgery is also a slightly different case as most breast clinics are tightly managed,, so it has always been more difficult to overtreat. But the culture 10 years ago was very much that consultants would fight for power, prestige and resources, and accurate referral to their speciality was not high on their list of priorities. I doubt if things are much different now.

So this surgeon working extra hard by doing unnecessary operations was not completely outside the mould. He was “shopped” early on by his colleagues who realised that they were all working harder because of his behaviour, but they were probably unaware of how much his work was against patients’ interests. It may have been that the system worked against anyone who really wanted to stop him, and this might have been one of the reasons it took so long to discover exactly what was going on. There must have been other reasons though, and in future the system must ensure that such activity is picked up and stopped immediately it is recognized. The private sector must also be much more tightly regulated so that patients can get recompense as of right. At the moment many of the patients affected will struggle to get any money despite often having been cruelly harmed, as neither the surgeon nor the organisation he worked for had adequate insurance. The NHS has already paid out huge sums, but private patients have no such protection.

This whole sorry tale has an importance beyond one surgeon’s nefarious activity. It goes to the heart of the “privatization” battle in the NHS. The concept of a wholly public NHS, with doctors concentrating entirely on their NHS work, has never worked, and can never work, as private treatment has to be allowed. Where patients are paying either directly or through insurance for their treatment there is little incentive for doctors and private companies not to do operations or provide treatment, even if there is little evidence that patients are actually helped in the long run. This is the main reason for the huge cost of healthcare in the USA – more and more investigations are done, more treatment is provided earlier and earlier and costs rocket. But patients are not better off – in many cases the condition would have got better perfectly well on its own, such is the ability of our bodies to heal themselves if we wait, with much better functional results in the end. A friend in the USA had a series of operations and investigation on his knee, and suffered a lot of pain after them, but in my practice patients with problems like his would get better with physiotherapy – they might have to wait six months but they would not have had to have a painful operation. The overall results of healthcare in the USA are worse, not better, than in other developed countries including the UK because there will always be complications in some cases, and patients’ money is wasted on unnecessary treatment.

There is a big risk we are going this way in the UK with more privatization with big for-profit corporations organizing more and more services. These companies are the reason behind the privatization drive as investors can make huge profits at the expense of patients. The culture in the private sector is that patient choice is paramount so that they can have treatment much more easily if they are paying, but it is imperative that these big corporations are accountable to the patients and shoulder the insurance costs.

My personal view for the future of the NHS is that we should be given a political choice. We can have an increased range of services, with some more risky treatments being allowed if we agree to put more money into the health service. So for instance, we could have a tax on income which would be ring fenced for the NHS, or we could have an increase in national insurance, and with the elderly who use the most services having to pay a graduated national insurance contribution (they do not pay NI at all at the moment.) If the NHS continues to be starved of funds as it is at the moment there will be no option but to streamline treatment so that there is less patient choice, and treatment which is outside evidence based guidelines is completely prohibited. If you are considering a treatment which is only marginally effective in the hope that you will benefit (even though statistically most people won’t) then you would have to pay. At the moment most NHS doctors (and all private ones) will give you the benefit of the doubt, and indeed they have to as they are required to provide “all necessary treatment”, but there isn’t the money available for this to happen at the moment. Unless the general public agrees to pay more, and crucially the government agrees to stop further privatization, the NHS should restrict itself to treatments that are conventional, with an extra fund available for new and exciting developments in a separate income stream. That way those that cannot afford to pay may be ensured that they have unrestricted access at least to those true and tested treatments,

Breast surgeon convicted of carrying out unnecessary-srgery

https://www.radionewshub.com/articles/news-updates/breast-surgeon..

Posted in Health Delivery, Health Management, Health Policy, Medicine, Private health care, science | Tagged breast surgery, evidence based medicine | Leave a comment

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