Assisted dying.

Posted on February 5, 2017 by Elen Samuel

I wrote in my last blog that recent advances in treating dementia have shown promise. I said, “Drugs are being developed to target monoclonal antibodies against amyloid β, the protein that seems to be awry in Alzheimer’s disease”. However since writing that blog, I have read that some scientists think that really this was another false dawn. I wrote, “They have not been universally effective in Phase 3 trials with people with mild, prodromal, or even preclinical AD”. If these treatments are to work, they ought to have been effective, so now scientists are wondering whether the amyloid hypothesis itself is correct. There are other proteins that accumulate in Alzheimer’s disease, and it may be that we should look elsewhere for a cure for dementia. Back to the drawing board again, perhaps. So no magic bullet in the foreseeable future, and it is clear that dementia is going to be a tremendous burden on patients, patients’ relatives and economies for years to come.

And there is the rub. I don’t really want to say this, but my experience of being a GP to many of these patients, was that it could be a wicked, horrible disease that robs them of their dignity and causes a living hell. As patients got more and more confused they understandably got more and more anxious, and sometimes were living in torment. Not always of course, many were quieter and more settled, as is usually portrayed in the many dramas, films and documentaries that have been produced. But extreme suffering there was, and even powerful antipsychotics and tranquilizers (frowned on by many patients’ groups and some professionals), didn’t help much. This is not a nice way to die. In fact it is just about the worse fate that I can imagine. And if a cure is not coming for 20 years, if ever, then for me this is a dreadful prospect. My mother and my aunt developed Alzheimer’s as do 33% of the over 85’s and 60% of the over 90s’, so it is quite possible that I will get it too.

So, once you have been diagnosed as having Alzheimer’s disease, or other forms of dementia, what are your options? The first thing to do is to be absolutely sure that the diagnosis is correct. There is no sure way of diagnosing Alzheimer’s disease in life. Alzheimer’s is caused by neuron death and part of the diagnosis is the presence of deposits of beta-amyloid and the formation of amyloid fibrils, whether these are the cause of the disease or the result of other processes as yet unidentified. Absolute confirmation that this disease affects a person can only be given following a biopsy, which is far too invasive to be done as a diagnostic tool. So specialists use clinical interviews, biomedical imaging (TAC, MRI scans of the brain), and so on. There can be signs of brain failure in the very elderly which are not due to a progressive dementia, so it is important to be sure.

When I was working in general practice, I saw many elderly people with acute confusional states due to infections such as urinary infections or pneumonia, metabolic problems including dehydration, or side effects of medication. Almost any serious illness can affect the proper working of the brain, and in the elderly the brain’s reserves can be quite low, so that when people are ill, or very frail, they become confused and drowsy, sometimes delirious. The good news is that once the cause is treated, they get better. So it is important not to assume that such people are suffering from dementia. In the past some people have been incorrectly labeled, as having Alzheimer’s when they don’t have it, and not only those who want to avoid jail sentences. Diagnosing the exact type of dementia (Vascular, Alzheimer’s, or Lewy body dementia) is also important to give a prognosis, as some types progress much faster than others. Once a diagnosis has been made, you should take out a Power of Attorney if you have not already done so, and make a living will to ensure that everyone knows your wishes, and to make sure someone is going to be able to supervise your care and treatment. But after that, and when the disease is progressing? The options would be very limited. The only solution for me personally would be to end my life, after accurate diagnosis but before the disease has progressed to such a level that I would not be able to do anything about it. But of course it is illegal in this country to help anyone die.

In the Netherlands and in Belgium this is possible for people with incurable painful conditions, and just recently Marike Vervoot, the Belgian Para-Olympian athlete has confirmed that she has signed the papers to allow assisted suicide. She suffers from a painful incurable and progressive spinal condition which has paralysed her and caused epilepsy, and though she has fought long and hard against it, and proved that disability can be overcome by physical effort, she takes comfort knowing that when the time comes she can have a peaceful death. In her words, “With euthanasia, you are sure that you will have a soft, beautiful death, and that you can do it with the people you want who stay with you. It gives [me] a feeling of peace and rest on my body that I can choose myself how far I will go”. That surely is something that should be possible for mental health issues as well. The living hell that Alzheimer’s can produce is something that should not be inflicted on people if they say they want to end it.

Over 80% of the population would agree with that sentiment. So why is it so hard for our lawmakers to actually put this into law? The answer is that there are powerful and influential people who are totally against it.Our society is based on the idea that human life is “sacred”, i.e. that there is something different about human life – all human life – that it should be preserved under all circumstances. It is taboo to think of death in any terms other than in saving lives wherever possible. Yet everyone must die sometime, and we all understand that at some level, even if we don’t want to think about it. Religion is very much a part of it, but I don’t think this idea is only a result of religion – religion is the result of this way of thinking as much as its cause. It has been suggested that there is a gene for spirituality, so that if you have it you are more likely to experience self-transcendence, which includes or a feeling of connectedness to a larger universe, and mysticism. This gene may well be selected for, because societies with the ability to organise its people through shared spiritual experiences, are likely to do better than ones with no such “holding glue”. Religion is a way of expressing the idea of human life being paramount, and in the monotheistic religions the exhortation “Go forth and multiply” makes it explicit. (Interestingly, in Judaism it was considered right for rabbis, the most educated and intelligent people in the community, should have the most children, which ensured selection of genes for upright living and intelligence, while Catholicism made sure its priests, equally educated and upstanding, would have no children, thus losing many highly valued genes. In some countries fertility is openly used as demographic weapon, to ensure that one religion continues to be able to dominate another. This is more common in the monotheistic religions; on the other hand, Buddhism has a much more balanced view.

I don’t think there is much doubt that death as an idea is a very unpleasant, even frightening thought. All religions encompass ideas about death, but the monotheistic ones, Judaism, Christianity and Islam, with their emphasis on an after life in some sort of heaven, take human life to be “sacred” in a religious sense, and this reinforces the idea that it is wrong to die, or at least wrong to die at a time not of God’s choosing. I think this is illogical even in the terms of religious belief itself. Could not God choose to help you to commit suicide if this was the best course of action for you? Why should you not go to everlasting glory sooner rather than later? Whatever the rationale for the idea that it is wrong for a person to choose the time and method of ending his life, it is now causing a lot of unnecessary suffering in the world today.

The people who promote life at all costs against a peaceful death at a time of one’s choosing are not only deluded, in my view, but they are also intent on imposing their views on others in a very patronising way. We are not supposing that people who do not want to do it will have it done to them. There will be safeguards in any law passed which will protect people who feel influenced by pressure to die before their time from whatever source. Yes, I agree there will be some people who are motivated by the desire not to be a burden on others, rather than feeling that life is intolerable. But the way to prevent this feeling is firstly, to actively treat a clinical depression, and then to surround them with people who want them to live and feel that their lives are worth something – their family, friends, and caregivers. If these people cannot persuade them, then what right does anyone have to prevent them doing what they want with their own bodies? It is a form of control from outside that goes so against our feelings of ownership of our own fate.

The people who want to prevent it are usually worthy people – champions of hospices, palliative care specialists, nurses and the religious establishment such as bishops in the House of Lords, and believers in religions which teach against it. They may have chosen this work precisely because they believe in the sanctity of human life, and they do valuable work in easing the paths of many of us with incurable diseases. But as a GP I found that many of my colleagues thought as I did. The few that would not support euthanasia however awful the life and however much suffering there was, were religious people, and I respected their views – for themselves. As assisted suicide continues to be illegal, one cannot ask any doctor to support people in any way at all. I attended several BMA conferences in years gone by when the mood of the majority was supportive of legalizing assisted suicide, but lately the BMA has turned its back on it, fearing that it would put doctors in an invidious position. In any case nearly all specialists in the field – oncologists, palliative care specialists, care of the elderly, have a vested interest in making sure that assisted dying would not happen. Not only would they likely be drawn into the process, for instance in “vetting” people for eligibility, but also their specialities would suffer to some extent, as fewer last ditch treatments might be offered if it became legal and more acceptable. In the last analysis a big part of what they do is to influence their patients in the direction of continued life of whatever quality. I do not think that doctors should have any undue influence on what the law says. The law should be made taking into account what the majority of the people want.

I reject this paternalism. I want to be able to know that if I get Alzheimer’s, just as if I get a painful incurable disease like Marike Vervoot, I will either be able to choose for myself the time and place of my death, or if I have passed that point and no longer have the ability to understand the issues, then someone else will be able to do this for me. There is now a new push to get action on this, as Noel Conway, who has motor neuron disease, is spending some of his final moments challenging the unpopular, broken law on assisted dying. Baroness Meacher, writing recently in PoliticsHome, has said that every poll undertaken in recent years shows that the vast majority of British people are in favour of change and no survey has ever reported a majority of Britons opposed to assisted dying, a fact acknowledged by the Ministry of Justice. The law has been changed to allow assisted dying in many countries; in America, Oregon, Washington, Montana, Vermont and California now permit assisted dying, Canada allows it as well as the Netherlands and other countries in Europe. These are all places where there is excellent palliative and hospice care. There have been no concerns about people being coerced into ending their lives. On the contrary, people have said that they will live longer, knowing that they can control the time and manner of their death. I wish them every success. Of course this would only be a start as the new law would not help people without capacity – i.e. who are no longer capable of making the decision, regardless of how clearly they made their views known beforehand. People with Alzheimer’s disease would be excluded from any of these   proposed new laws. We need a law which allows us to say in advance that we can die at a time of our choosing, with safeguards, whatever our illness, or even no illness at all.

I need this to happen. The world needs this to happen. The world needs us human beings to stop acting as if human life trumps everything else – animal life, the environment, the life of our planet. We need finally, to accept death.

References

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Old Age part 4 – Losing it

Posted on January 7, 2017 by Elen Samuel

– Dementia and its prevention

Having decided that everlasting life is impractical, we can still use existing knowledge to improve our survival. But we want our extra years to be enjoyable, and that won’t be the case if our brains fail us. Just as hearts, kidneys and livers fail in old age, brains do as well. We call it dementia.
Dementia can be caused by several diseases; the commonest are Alzheimer’s disease, and vascular (multi-infarct) dementia.
Our nervous systems – the brain spinal cord and peripheral and autonomic nerves – are infinitely more complex than the heart and circulation, and are very much more specialised so that repair is much harder. We have much less understanding of how the brain actually works, than the heart or the liver for example. But progress is being made.

So what are the risks of getting dementia? The first is obviously getting older -the older we get the more likely we are to get it. About one in 12 people age 65 will develop Alzheimer’s disease and at age 85, one in three will be affected.
But there is not much we can do about this, as the alternative is worse – dying young. So what can we do to lessen the risks to our brains, as we get older?

Considering vascular dementia first, over time damage to the brain is caused by interruptions n the blood supply, due to damage to the walls of arteries. The resulting lack of blood supply to brain tissue means it is starved of oxygen, and so the brain tissue is damaged. This is the same sort of damage which causes heart attacks, where heart muscle is damaged due to blockage of arteries in the heart. In the brain it shows up as a series of small strokes. The area damaged by lack if blood supply in both cases (brain and heart) is called an infarct, and hence vascular dementia is sometimes called multi–infarct dementia, and may be prevented to some extent by lowering cholesterol, treating high blood pressure, good control of diabetes and keeping weight down, in the same way as heart attacks can be prevented. Statins, well known in preventing heart attacks and some strokes, should help.

However, more often, dementia is due to Alzheimer’s disease, which is a specific disease not due to any form of hardening of the arteries. It is associated with plaques of a tissue called amyloid building up in the brain especially the amygdala (a part of the brain associated with putting down memories). Alzheimer’s disease is usually the late onset or “sporadic” type, which usually develops after age 65, but there are some inherited forms which occur earlier, sometimes as early as the mid fifties. I had a patient once who had it in her fifties, and as it progressed she had to go into the community home where she had worked as a social worker. She thought she was still going there to work even when she did not know who her husband was and completely incapable of managing on her own. The staff that had worked with her before were very caring but it was gut-wrenchingly sad. She died in her early sixties. The familial type of Alzheimer’s disease has certain genetic markers, and there are clinical trials are now going on with some families, looking for specific changes that can be made while the patient is still in the asymptomatic phase of the illness.

We know that some genes, such as Apo E, may influence Alzheimer’s disease risk. Apo E-4 has been found in around 40% of people with Alzheimer’s disease, and may lower the age at which it starts. But many with the gene never develop Alzheimer’s disease and many who do develop it do not have the Apo E-4 allele. Also there may be additional risk factor genes for Alzheimer’s disease. So most of us have no way of knowing at what age we will get Alzheimer’s, or if we will get it at all.

So can we try to prevent it happening?

If you have high blood pressure, high cholesterol, diabetes, or have had heart problems, you should already be taking medication for these conditions, including statins. All these should reduce the risk of getting vascular dementia. And the lifestyle choices you make should be obvious too – not smoking, healthy diet, plenty of exercise. However Alzheimer’s disease is not related to problems with your blood vessels and atheroma. So what lifestyle measures should you take to reduce your risk of developing this?

Alzheimer’s disease takes many years to develop – possibly 10-20 years or more, so there is plenty of time for individuals to try to reduce their risk. The good news is that the simple things I have been talking about in this blog can help. This isn’t just wishful thinking. In a recent study in the Lancet it is estimated that up to 1 in 3 cases of Alzheimer’s disease maybe preventable by lifestyle changes. According to this report, there are eight potentially modifiable risk factors that have consistent evidence of an association with Alzheimer’s disease; lack of exercise, diabetes, high blood pressure in middle age, obesity in middle age, depression, smoking, low level of education, and traumatic brain injury.

The importance of each individual risk factor depends on where you live. Worldwide, the highest estimated risk in populations was for low educational attainment, 19·1%; but for the USA, Europe and the UK it is for physical inactivity: USA 21·0%, Europe, 20·3%, and the UK, 21·8%,

So for western countries the most crucial risk factor is undoubtedly lack of exercise, and this in theory should be easily remedied.
It is amazing how sedentary people can be. Watching TV, using the computer, doing games, all mean sitting around, and going anywhere often means using the car. We know that taking exercise, at least 2 hours every week (walking, cycling, swimming) is key to preventing diabetes, high blood pressure, and obesity. But it is also associated with better brains – one study reported that there was a 50% reduction in the risk of dementia in older persons who maintained regular bouts of physical activity.

Several studies have followed up groups of older patients, some who had healthy lifestyles and some of who did not, and measured their physical and cognitive abilities over time. Evidence over the last 5 years suggests that modifying these behaviours can affect brain adaptability (plasticity) in both humans and animals. Other positive benefits may include a decrease in the risk of falls, improved mood, and potentially, perseveration of brain function. These can be long lasting.

Eating healthily with plenty of fresh fruit and vegetables is very important. Recently, there have been several meta-analyses of studies on diet and the development of dementia, although unfortunately the articles do not distinguish between vascular dementia, which should theoretically be reduced by a healthy diet anyway, and Alzheimer’s where there is no theoretical reason why diet should help, so the benefit such healthy eating may mainly come form the effect on vascular dementia. There again, Alzheimer’s disease accounts for about 80% of all dementia, so a decrease overall it would indicate that Alzheimer’s too might be reduced. Published results are that higher consumption of unsaturated fatty acids and antioxidants decrease the risk of dementia, while smoking and higher consumption of aluminium increase the risk. Supplementation with B vitamins may have an effect – they do in one series and not in another. The Mediterranean diet had a small effect on reducing dementia, and the effect of fish, vegetables, fruits, and alcohol was said to need further investigation. Low levels of vitamin D were associated with cognitive decline, although this may well be an association rather than a cause as low vitamin D levels are a marker for poor health.

What about low educational attainment, which has the biggest association with Alzheimer’s disease in the world as a whole? The association has been known for a long time, since 1988 in fact. One American study (the well known Framingham study) found that it may be a spurious connection – that people with lower educational attainment smoke more, and have a worse diet, and this is reflected in a higher incidence of vascular dementia, and that there is no effect on true Alzheimer’s disease. But if you take a code for overall dementia such as ICD-9 or ICD-10, and correct for these factors, then the association is very clear. A meta-analysis in the World Alzheimer Report 2014 on Dementia and Risk Reduction, suggested that the reduction in risk may be around 40%.
So what could cause this?
There are several hypotheses. People with higher educational attainment are likely to have a higher socio-economic status, to enjoy a healthier and more advantaged lifestyle, and to have greater access to superior healthcare. There is undoubtedly something in this explanation, which is related to the explanation of poor diet and smoking in those whose education is limited. But a further explanation may lie in the “brain reserve theory”, which is that a bigger reserve function has been built up over years of intellectual effort, developing a greater complexity and/or efficiency of neural network. Then as dementia-related pathology occurs in the brain, people with higher levels of education may actively compensate by drawing on a greater reserve of cognitive processing approaches – getting round problems of cognition as they occur. This might happen in people who happen to have bigger brains too.
Then there is the ‘use it or lose it’ hypothesis: Lifelong cognitive activity may be necessary to help prevent cognitive decline, and those with higher education may be more highly motivated to pursue intellectual stimulation throughout the life course. Other scientists say that the testing of people with low educational skills is not accurate enough to distinguish between early dementia and a basic inability to do the tests. Or that low educational attainment is a function of low intelligence, which may be associated with other pathologies. So more research into what exactly is causing this association with educational attainment and reduced risk of dementia is definitely needed.

But at the very least, keeping mentally active seems like a good idea, with activities such reading and writing for pleasure, learning foreign languages, playing musical instruments, taking part in adult education courses, being both pleasurable and good for you. Sports such as playing tennis, walking, golf, swimming and group sports, such as bowling will help you keep your muscles from wasting as well improving your brain and co-ordination. It seems that bilingual people who use both languages do better if they do develop Alzheimer’s because their brains have more “pathways” which can be used to get around damaged areas.
Interventions such as “brain training” computer games have been shown to improve cognition over a short period, but research hasn’t yet demonstrated whether this can prevent dementia.

All this may be a little bit comforting for those of us with an intellectual bent. But I always remind myself that the end of the process of dementia of whatever cause, is that everything goes, all memories, all skills, and all personality. It is a devastating disease however brilliant you may have been. Even code breakers at Bletchley can get it, despite an impeccable lifestyle, and constant honing of lifelong learning and skills. These risk factors and benefits are only associations with changes in the risk of dementia, and at the most one could expect these efforts to slow down the effects of dementia or delay them; they cannot completely prevent it.

So we hope there will be some treatment if we do get it. Certainly this would be a game changer. An effective treatment for AD is perhaps the greatest unmet need facing modern medicine, preventing so much anguish and suffering as well as saving vast amounts of money that could be put to more productive use. Even a five-year delay in the onset of symptoms of Alzheimer’s disease could greatly reduce the number of people with the disease.

As with research into ageing more generally, there are lots of different ways of tackling the problem.
The first medications specifically for treating Alzheimer’s, the anti-cholinergics, came out in the early 2000’s, and I do remember all the fuss. They were very expensive and so a way of rationing them had to be found because so many patients were clamouring for them, not surprisingly. So clinics were set up so that patients would be treated only if they were at certain stages in the disease. Patients and their relatives got very angry when they were denied them because they thought the drugs were a real advance which could stop the progress of dementia. But soon I realised that this was really a triumph of hope over experience, or alternatively an example of how the pharmaceutical industry overplayed its hand). As their doctor I couldn’t see any benefit in my patients who took the medication, though sometimes relatives said they saw a difference. But the drugs didn’t alter the overall trajectory of memory loss and loss of function. Eventually the demand died down and they eventually became quite cheap as the patents ran out, but it had been a completely false hope.

Very recently it has been confirmed that statins, these wonder drugs that have prevented many cases of heart disease, can also be associated with a reduction of risk of getting Alzheimer’s. One would expect that they would have an effect on multi-infarct (vascular) dementia and all patients at risk of this should already be taking them. But this study shows that there is a small association between taking some statins (not all) and a decrease in the number of patients getting Alzheimer’s. Researchers reviewed 400,000 patients and say the effect of statins may be explained by an interplay between cholesterol and beta-amyloid, which plays a role in dementia, or that statins’ anti-inflammatory properties could be preventing the disease. Or there may be other reasons for the association. The way to test this is to look at prospective trials, following up patients who are taking them and comparing the rate of development of Alzheimer’s with those who don’t, after controlling for other factors. I don’t know whether this is being done. It is a small decrease and is not seen in all people, but some people might want to take the appropriate statins

In 2016 several more drugs, monoclonal antibodies, have been tested. Monoclonal antibodies are a huge development in many diseases because they can accurately target and destroy specific proteins, and are used in cancer, auto-immune diseases and many more. Research is progressing in development of monoclonal antibodies against amyloid β, the protein that seems to be awry in Alzheimer’s disease. They have not been universally effective in Phase 3 trials with people with mild, prodromal, or even preclinical AD, but some have shown good effect. Many other novel drug treatments are being studied, but the time for data analysis and confirmation is typically 4 to 10 years.

It isn’t the magic bullet we are hoping for. Indeed, pharmacological interventions have been disappointing so far, but we can but hope.

References.
Journal of Alzheimer’s Disease, vol. 22, no. 1, pp. 205-224, 2010
Molecular Neurobiology November 2016, Volume 53, Issue 9, pp 6144–6154 Dietary Patterns and Risk of Dementia: a Systematic Review and Meta-Analysis of Cohort Studies
The Lancet Neurology DOI: http://dx.doi.org/10.1016/S1474-4422(16)30356-8
The Lancet Neurology Volume 13, No. 8, p788–794, August 2014
Potential for primary prevention of Alzheimer’s disease: an analysis of population-based data
33. Mortimer J. Do psychosocial risk factor contribute to Alzheimer’s disease? Etiology of dementia of Alzheimer’s type

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Cheating Death

Posted on December 24, 2016 by Elen Samuel

Ageing
Most people do not want to talk about death and human life is held up to be absolutely sacrosanct; any death is a tragedy. There seems to be a taboo about admitting that we will all have to die one day. I think it is quite likely that lots of people think that it is possible we won’t have to. After all, it is remarkable how longevity has increased in the last 50 years. We have made such strides in achieving a long and healthy life for so many people, that we are beginning to think that we might in the end cheat death. That is, that there might be a cure for old age, and that people in the future can live very long lives without showing the signs and symptoms of ageing that I have been talking about for the last few blogs.

Might this be possible?

It should be obvious that all life forms do show signs of age and ultimately die, though some do it at faster rates than others. There are some animals that live a very long time, and we already live longer than most similar size animals, so it is as legitimate a subject as any other for scientists to try to work out what is happening to us, as we get older, and to prolong life.

Almost all the work done to date has been on laboratory animals such as mice and rats, and most of the scientific enquiry going on in this field is in America. Very few European institutions are studying it in detail, and there is a good reason for this – the global market in anti-ageing products is worth probably more than £190bn annually. A lot of money can be made out of old age health in a completely market run economy even if there aren’t any measurable improvements in overall population health. It is true that there is vast scope for snake oil salesmen here. It is also a field in which the safety of any medicines would be paramount. After all, if you were going to take new drugs for long periods of time to prevent ageing, they would have to be absolutely safe. It is a bit like common disorders like irritable bowel syndrome. Some promising drugs, which cure this, have been discovered in the past, but they had side effects. There is no chance of such drugs getting to market, as IBS is not going to cause serious disease. But that does not stop scientists looking.

There are many theories of ageing – apparently at least 300. Most assume that over time our tissues are damaged by something in the environment. For instance we know that free radicals, atoms or molecules with a single unpaired electron which makes them chemically very reactive, can break down intracellular molecules, so that junk accumulates in our cells that can’t easily be broken down and eliminated. So scientists look at how and where that damage happens and how it leads to the organism’s death.

Many theories look at our DNA – the building blocks of life – to see how death happens. For instance, if the DNA in the nucleus of the cells is damaged by oxidation, this causes errors in the copying of the cells when they divide, so that they are not so long lived. But such damage, if it occurs in one DNA strand, can be repaired each time the cell divides by the other complementary strand, if that is undamaged. So the damage is more likely to lead to long-term deterioration in cells which do not divide often. There is good evidence that such long term DNA damage is a cause of the changes seen with the ageing process.
What is not thought to be the cause is chance mutations occurring in our DNA, not specifically due to damage. The reason for this is that mutations in a particular cell which give that cell an advantage in dividing tend to cause cancer rather than normal ageing.

More recently, attention has focussed on the telomeres in DNA. Telomeres are short segments of DNA which cap the ends of every chromosome, acting as ‘buffers’ against wear and tear. They shorten with every cell division, eventually getting too short to protect the chromosome, causing the cell to malfunction and the body to age. In fact this theory has got as far as the experimental stage, as a lady in the USA (who had shorter than usual telomeres) has received gene therapy to reverse the process and lengthen the telomeres in her white cells. It appears that this has been successful in the white cells in her blood, but of course we won’t know for many years whether this has an actual effect on how this lady ages. The therapy is supposed firstly to protect against loss of muscle mass with age, and also to prevent stem cell depletion responsible for many age-related diseases. so we may be able to see if this actually occurs, at least in one person.

It has also been noticed (in rats) that a calorie restricted diet can be effective in prolonging life spans under certain circumstances, due to the diet’s effect on an insulin-like growth factor signalling pathway. This responds to an animal’s nutritional intake, matching growth and reproduction to food availability—and also, it seems, affecting health and longevity. But in my limited experience of the 90 year olds and centenarians I looked after, they all seemed to enjoy their food and none of them gave a history of restricting their food intake deliberately in order to live longer.

Another theory looks at the enzymes in cells responsible for repair mechanisms. Most scientists agree that free radical oxidative damage would be impossible to prevent, so they turn to cellular repair mechanisms to see if these can be boosted. The maximum lifespans of humans, naked mole rat and mouse are respectively, 120, 30 and 3 years, and when the DNA repair mechanisms of the liver of these animals were compared it was found that the longer-lived species, humans and naked mole rats had more effective DNA repair genes, than did mice. In addition, several DNA repair pathways in humans and naked mole-rats were up-regulated compared with mouse suggesting that increased DNA repair facilitates greater longevity. But no-one has succeeded in this yet.

All in all therefore, despite a lot of research, you won’t be surprised to learn that there are no magic bullets to postpone death which are coming on stream any time soon, and some scientists argue that it is impossible to prevent the sort of damage to cells mentioned above that cause ageing. Consider the fact that everything in the world wears out in the end. Until we can stop mechanical machines, which are composed of much simpler molecules, from wearing out, we are not likely to be able to do this in animals. After all we know that cancer is a simple problem – the overgrowth of cells which causes tumours, and spread. These cells need to be killed off, but despite huge amounts of money and decades of research there’s a lot of cancer we still can’t cure. More hopefully, other scientists say there’s no law of physics that says we can’t alter the process of ageing.

But let us assume that effective methods to control ageing do become available: stem cell implants, gene therapy, whatever. How many of us would be prepared to bear the cost in time as well as money? The first guinea pigs would have a life dominated by a never ending round of medical appointments, check-ups, discomforting procedures, and heaven knows what else. Would the extra years be worth much if mostly taken up with the getting of them?
Some people do live to 110 or more now, and if they continue to enjoy life and society is able to look after them, that is fine. But if you ask people in their sixties and seventies how long they want to live, most say they would like to reach their eighties, and some their nineties, so long as they continue to enjoy good health. But there is no great enthusiasm to live until a hundred and more. People are realists. If only a few people get to live longer, inevitably their friends would be dead. Even if still very wealthy it is unlikely they would be allowed to contribute much to society, as the power and influence have passed, rightly so, to the generation below. Unless of course such a person, very successful in life previously, had gained a great deal of power and managed to hold on to it. Robert Mugabe comes to mind.

And for the world at large, whether finding such an elixir of life would be a good thing or not is very debatable. After all, only the richest would be able to afford it for many years. If it ever got to the state when ordinary people would be able to do it, it would contribute to the gross overpopulation of the planet we have already. It would be totally unsustainable, and would contribute to competition of richer people for the resources with which to continue living and the costs there of, hereby causing all the more inequality. I think we should be very careful what we wish for.

References

Best,BP (2009). “Nuclear DNA damage as a direct cause of aging”
Aging (Albany NY). 2015 Dec;7(12):1171-84.
BMJ 2011;343:d4119
April 22, 2016 | Editor Neuroscientist News First gene therapy successful against human aging

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Old age doesn’t come by itself – part 3

Posted on November 28, 2016 by Elen Samuel

It seems characteristic of older people these days that we think of ourselves as much younger than these old people we see around us. This because inside we still think of ourselves as being youthful if we feel well, even if our looks give our true ages away very quickly! In our society we are lucky that most of us stay fit and well much longer than we used to. We currently think of the “young old” as being around 65 to 74 years of age, the “middle old” 75 to 84 and the “old old” 85 years plus.
When we talk about the problems of older people with multi-morbidity using up so much of the available health resources, we really mean the over 85’s, because this is the age group that is expanding so much as more of us escape or survive the diseases that used to kill us, because of better healthcare and a higher standard of living. Fortunately only a few people younger than that use the health services very much if they do not have specific age-related diseases such as cancer, dementia and so on. Most health care is given in the two years or so before death, and this means that the vast majority of people between 65 and 85 are independent, enjoy life to the full and can contribute to society, sometimes by working for profit, sometimes doing voluntary work, and often by helping the next generation with childcare, education and so on.

Ageing is a process that starts with conception and continues throughout life, and its speed depends on genetic factors, which we can’t alter; and our environment and how we interact with it, which we certainly can. Sometimes the scars of a poor early environment, such as poverty, emotional trauma or neglect will affect our health, as we get older. But more often we harm ourselves with smoking, eating too much (or the wrong things), taking too little exercise or having a negative attitude to things. Apparently, the average lifespan of those with high levels of negative beliefs about old age is 7.5 years shorter than those with more positive beliefs. It does make sense. If one’s self perception of the ageing process is more positive, this can encourage people to do the best they can to stay fit and active. Dealing with these inevitable changes will be that much easier. So it is important to understand a bit more about aging, how it affects us and what we can do about it to prevent problems as much as possible, while we are still in the “young old” stage.

I talked about muscle loss in my first blog. While muscle weakness itself is a problem, muscle tissue also serves other functions. The contraction of muscle fibres produces heat (by burning carbohydrates such as glycogen and sugars) and in time these fibres become smaller in diameter, due to the ageing process. Muscular activity becomes less efficient and requires more effort to accomplish a given task. There is less muscle mass to generate heat and often people can’t be active because of arthritis or other problems. They often don’t want to be active either, because of impaired neurotransmission – their nerves don’t transmit so well. Also their skin provides less protection from heat loss because it has got thinner and there is less subcutaneous fat to insulate them. All these factors put the elderly at risk for hypothermia if they are in environments that younger people would think are quite warm enough. Hence the usual complaint of people visiting their relatives in nursing homes, and wondering how on earth they can put up with this heat.
For the “young old” this is a good reason to keep active, to keep more of these muscle fibres in trim. I don’t think it is commonly understood that even a small increase in activity for the over 85’s can make a big difference to health and survival. Such things as going to the kitchen to cook or seeing to the cat every hour or so, can make a huge difference, yet people often stay for hours just sitting in chairs, and so complain of the cold. Old people will live for much longer in well-heated homes than if they can’t afford to heat their homes of course, but their physical mobility and enjoyment of life would be so much better if they can be persuaded to move around more. There is a common misconception that to reap health benefits, continuous, vigorous exercise (athletics, jogging, or squash) is required, but nothing could be further from the truth. Every little helps.

It is well known that lack of thyroid hormone will cause people to be intolerant of cold. Recently I was at a dinner party, and was sitting next to someone who was complaining of a dreadful cold draught coming from the air conditioner. She asked the manager to turn it off, and the staff did so. But it didn’t make much difference and so I changed places with her. Although there was a draught it didn’t bother me, and when I asked her, she did indeed have a thyroid problem. An increase in her dose soon sorted that one out. Lack of thyroid can also cause dry skin, weight gain and muscle weakness so it is important to get it checked every now and then. That said, many people have marginally low thyroid levels for years before it really becomes a problem.

Thyroid isn’t the only hormone that can cause trouble as the production of all hormones is reduced eventually as we age. This can affect water balance, and mineral, electrolyte, carbohydrate, protein levels; lipid and vitamin disorders are all more common in the elderly. Nutrition and the ability to use food for energy is seriously affected in the very elderly and this can cause weight loss.
Diabetes is common in the elderly. There are many causes but a primary mechanism involves the reduced ability of aging skeletal muscle to absorb glucose.

The very elderly are also at risk for nutritional deficiencies due to anorexia. Age related anorexia has been linked to a lower satiety threshold, but in my experience is more often caused by a loss of interest in food, so that people just eat simple, less nourishing things. One elderly person I knew existed only on reconstituted dried soups and a bit of bread. Also if you feel ill you don’t want to eat, so that by this stage it is highly likely that there are a lot of pathologies going on which should be diagnosed properly. Before that stage, for the younger fitter people, it is most important to eat food high in protein, even if a bit overweight. Reduce the carbs, and increase the protein and fat.

I saw very few fat people in their eighties and nineties when I was in practice. Although many very obese people did not survive that long – diabetes, heart attacks strokes and even cancer are much commoner in such people – it also seemed that people lost weight naturally as they got older. So dieting is something for middle age and the young old and one would need to be very careful in recommending a diet for the over eighties.

Swollen ankles are something not confined to the elderly – many people find their ankles swell ate the end of the day. It is usually due to venous insufficiency – that is that the circulation of blood from the feet back to the heart is impaired. The main problem is gravity – the heart has to pump blood not only to the circulation in the legs but also all the way back up to the heart, and has to work against gravity all the way back. The only thing thong stopping blood and fluid pooling in the lower legs is good valves in the big veins, and unfortunately many people have varicose veins or valves that don’t do their job properly. Varicose veins re often hereditary and then get worse when pooling of blood causes the walls of the vein to bulge, and this stops the valves functioning, Of course the blood itself does not pool for long, but the increased pressure within the vein forces fluids out into the tissues, and this shows itself as swelling of the lower legs. Usually it is worse after standing or sitting for a long time, and exercise such as walking is far the best prevention. However if you do have to sit for long periods as in a plane for instance it is sensible to wear support stockings. Nowadays you will have to go to a health professional to get measured for these, so that would be a good time to check out if there is anything else causing it. Usually if the swelling goes down at night there isn’t much to worry abut but if more severe it may be due to the heart not pumping properly, and early heart failure can cause this. Not only does the heart not pump so well if it is under strain, but the volume of blood in circulation also increases (due to effects on the kidney). When you then lie down at night the fluid does go from the legs because gravity is no longer acting on them, but the extra fluid does not go away – it pools in the small of the back (again under gravity) and in the morning when you get up it comes straight back again into the legs. That would be a real danger signal. Remarkably though the heart, if still healthy, can usually pump adequately well into advanced old age.

When I was working in the surgery, I was quite often asked about sex relationships by elderly people – usually women of course. No doubt my male colleagues got the elderly men. My patients asked about dry vaginas, (especially when they had a new partner, which wasn’t uncommon), and sometimes about a mismatch of desire between them and their partners. It was interesting to see how many of them were enjoying an active sex life. But undoubtedly sexual interest does decline, as people get older. It is not entirely due to falling androgen levels in men it seems, but erectile dysfunction is common for other reasons. Diabetes is a common cause – 50% of men with diabetes have problems, as do many men who have heart problems; and many medications can cause impotence. Lowered sexual drive is also associated with lower attained education, and guess what? – lack of physical activity.

Here is the usual joke then
The manager of a nursing home was addressing the residents. “The female sleeping quarters will be out-of-bounds for all males, and the male dormitory to the females. Anybody caught breaking this rule will be fined £20 the first time.”
She continued, “Anybody caught breaking this rule the second time will be fined £60. Being caught a third time will cost you a fine of £180. Are there any questions?”

At this point, an older gentleman stood up in the crowd inquired: “How much for a season pass?

The next blog will be about mental health problems including dementia and depression – and the search for cures for dementia and old age.

Posted in Backache, Health Delivery, Health Policy, Medicine, old age, Physiology, sexual relationships | Tagged , , , , , , | Leave a comment

Old age doesn’t come by itself – part 2.

Posted on November 2, 2016 by Elen Samuel

There is no doubt that the effects of getting older can be very troublesome. With the insouciance of youth in the surgery I would often joke about it, and sometimes say “well, the alternative is worse”, meaning that at least the elderly person in front of me is alive and able to grumble. I was very aware as a GP of how many of my patients sadly had not lived to get to the point of grumbling. And most of my patients took this in good part, although they didn’t like to remember that some of their contemporaries were now six foot under.

Poor sight, deafness, loss of taste and teeth, are very common, and can now be alleviated by spectacles, hearing aids, dental implants and so on. One wonders what on earth people in the Middle Ages did without spectacles, as the lens in the eye which has to be flexible to allow vision at short distance starts to stiffen in your forties. I suppose only a few people needed to read in those days as many were illiterate, but scribes doing these wonderful manuscripts, craftspeople and needle-workers must have had such a short working span before they had to give it up. Seeing clearly before spectacles must have been a bit of a lottery, because if you were short sighted you would not need spectacles for reading for a very long time, perhaps into your sixties or older, at the expense of not recognizing your old friend in the street for most of your life! Shortsightedness improves with age, whereas if you are long sighted you will need glasses for reading much earlier.

A big problem causing deterioration of vision, not due to disease, is the fact that the vitreous gel (the clear stuff within the eyeball) tends to get more opaque as it is unable to clear the detritus of old cells, particulate matter and so on which collects as you age. This is the cause of “floaters” which everyone gets at one time or another. As we age this degeneration can also lead to detachment of the retina, and this is more likely in short sighted people. It is said that in over 60’s, much less of the light from outside gets to the back of the eye, so that people in their 60s need three times more ambient light for comfortable reading than those in their 20s. This is why the first thing you need to do, before spectacles even, if you want to see clearly to read, is to ensure a very good light behind you. Nowadays though, a lot of reading and writing is done online with a backlit screen!   Cataracts are caused by opacities within the lens, and these are extremely common. In most parts of the world cataracts can now be cured very cheaply by removing the lens and substituting an artificial one, and in the developed world minor refractive errors are corrected this way. Some of my friends who have had cataracts removed have arranged to have lenses inserted so that they can see well to read with one eye and see at a distance with the other. My own experience has been somewhat different as in my youth I had one quite shortsighted eye and one normal sighted eye. I used the shortsighted eye for reading and the other eye for distance. It is amazing how the brain accommodates to the two different images. However in my case this eventually did cause double vision.

Other common problems are dry eyes, because tear production is reduced, and blepharitis, due to inflammation of the eyelids. People often don’t realize their eyes are dry, and are aware only that that their eyes are irritable and sore. “Artificial tears” – eye lubricant gels and drops, help both. Aging also reduces our field of vision by up to 30 degrees, and this can be very important when driving. It is worth knowing about it and taking extra care especially at night.
There are so many diseases that can cause loss of vision, as we get older, so it is really important to get a yearly check from an optometrist.

Deafness is very common, often hereditary, and very annoying for both the person with the problem and the listener. The usual form of age related deafness should not be called “deafness” at all, because unlike childhood deafness and other sorts of damage, its most obvious symptom is that hearing sounds very distorted, rather than not hearing at all. This is because the reduction of hearing is not spread evenly across the acoustic range, but skewed completely towards the higher range of tones that we use for speaking. So people think they hear but in fact are only hearing the lower register which distorts the sounds that they do hear. Hence the old jokes such as: Three retirees, each with a hearing loss, were playing golf one fine March day. One remarked to the other, “Windy, isn’t it?” “No,” the second man replied, “it’s Thursday.” And the third man chimed in, “So am I. Let’s have a beer.”

When I was a GP and used to visit people in their homes I was often exasperated by the fact that the patient would almost never be wearing their hearing aids, and when I raised my voice to try to get them to understand what I was saying they would say irritably “don’t shout, I’m not deaf”! They had to be prompted to put them on, which took ages because they really often had no interest in wearing them. I now realize that this was because the analogue hearing aids of the time just magnified everything, so that the deeper sounds were even louder and they still often couldn’t hear the upper registers.   I think those aids really helped only a minority of my patients, and were often a complete waste of NHS money. Now modern NHS digital ones are so much better (you would have to spend an awful lot of money on private aids to get ones as good) and can really improve the quality of life,

Other senses such as sense of smell and taste deteriorate too, although not usually to the extent that people find it a problem. One man I saw regularly did complain a lot about the lack of taste, and indeed he lost a lot of weight. He said everything tasted of cardboard. He was seen by specialists, but nothing could be done. He in fact got very depressed, and I am not sure really whether the lack of taste caused the depression or the other way around.

We all know the problems our teeth can cause as we get older. My generation has been very lucky; my parents both wore dentures from their fifties because of poor dental care, and they told me of people who had all their teeth taken out as a 21st birthday present as it was thought that dentures were so much better looking!   They did not know about bone loss in those days. Bone loss is inevitable if multiple teeth are removed, as bone constantly regenerates itself as a result of the pressure and stimulus of chewing. When teeth are lost the bone in the jaw “resorbs” (reabsorbs) into the body – in the first year after tooth extraction 25% of bone is lost, and this continues year on year. . Regular visits to a dentist are essential, but even with the best dental care, teeth sometimes have to be removed, so nowadays many people have dental implants rather than dentures or bridges. They are expensive and not entirely without problems so they are not for everyone.

Sleep problems loom large for many older folk. When I was working such people took up a lot of time. As each wave of sleeping tablets came on stream, from barbiturates, then benzodiazepines, then the Z drugs, and now melatonin, we GPs were told by the drug reps that each new group had none of the problems associated with the older ones – dependence or addiction, sleepiness the next day, dizziness and falls. In fact none of them were risk free, and I found patients often wanted to increase the dose as the “tablets aren’t working”. We were told not to prescribe them by the NHS watchdogs, but patients were often very persistent in their demands. I had some sympathy with them as I had to do night calls once a week, and was often up seeing to urgent problems, and sometimes couldn’t get back to sleep especially if the case had been difficult or upsetting. And f course I had to work the next day. But now I am retired I have a lot less sympathy. If you don’t sleep you can occupy the time listening to radio 4 or podcasts, and often they are uninteresting enough to send you to sleep! Reading does the same thing although the light tends to keep you awake. Language tapes can be useful too. although I don’t think you actually learn very much when half asleep! It all helps to switch off your thoughts, which are going round in your mind and keeping you alert. You can prevent problems with waking your partner by using earphones. And if you don’t sleep you can have a nap the next day. But people in their eighties used to come to me desperate to get some sleep and used to put pressure on me to prescribe stronger tablets. I realized that some of these people were lonely and bored, and some used to go to bed at 8 o’clock, and then wonder why they woke at 2 am. Lifestyle changes are much better, though some people will always want sleeping tablets.

As you have probably gathered I am not trying to give a detailed account of the problems of old age here. These are just musings in the hope that some people will be find it interesting and maybe learn something. This isn’t the place for detailed discussion on how to keep healthy in old age, still less to say anything about the many diseases we can get. There are many books, websites and community groups which do that, and of course if you have medical problems or questions you should consult a doctor.

Next time I will write about such varied problems as swollen ankles, feeling the cold, weight gain and weight loss, before finally tacking the most difficult of all – memory problems, other mental problems, and the frailty of old age. If there is anything else you want covered, reply to this post.

 

 

 

 

 

 

 

 

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Old age doesn’t come by itself

Posted on October 23, 2016 by Elen Samuel

There is an old Welsh saying that patients used to tell me when they came to see me in the surgery complaining of aches and pains, or failing eyesight and many other things – “old age doesn’t come by itself”, meaning all these ailments that just seem to appear from nowhere when we get older. The saying rings true more and more for me as I approach the age when they used to consult me. It is true that the aging process is impossible to avoid – sooner or later the problems come, unbidden and unwanted. Some can be put off for a while by looking after ourselves and avoided things like smoking and putting on too much weight which we know will cause problems; others need a touch of the magic of modern medicine to put us right so that we can keep going for longer. Now I am at that age, my friends often ask me for advice, so I thought I would bring back this blog, which seems to have strayed away from its roots a bit recently, by talking about the common things us oldies will get. I can remember very well those older people who used to come to see me when I was in my prime, grumbling so much about things which I hadn’t been taught about and often seemed very trivial. I don’t think I really gave a very good service then, concentrating, as I had been taught to do, on “real” serious illness, but now perhaps with the perspective that comes with age I can remedy that. The one thing this blog will not do is to try to sell you anything, as happens whenever you go on to the web for advice.

We all want to live longer and longer, and some of us spend a lot of time reading news articles of new advances to prevent illness, but there doesn’t seem much on how to cope with these things – joint problems, deafness, wrinkles and insomnia for example without the inevitable disclaimer – “consult your doctor”. So I thought I would compile a list and give my thoughts on how to deal with them. The whole point is to help oneself, and although you probably know most of it, I hope there will be a few nuggets that will be of interest.

The first thing that most of us notice as we get older is that our skin ages – all those wrinkles that start appearing in our late forties and go on deepening year on year. When I was in practice the only thing that would get rid of them was a face lift; and a few of my wealthier patients did that – privately of course. I remember several women coming in, really desperate for something that would stop them looking so old, but if they had no money nothing could be done – just like now of course. Cosmetic treatment has never, rightly, been available on the NHS. There were creams available to cover up the wrinkles – they worked, as they do now, by irritating the skin slightly so that the skin reacts by producing fluid under the skin. This fills up the wrinkles and makes them look less obvious. Such creams are not very effective though. These days ladies start having botox treatment in their thirties, and many in their fifties have no discernable wrinkles at all. It all looks rather false, and I wonder how these women’s skin will hold up in their seventies after decades of botox, fillers and the like. But for now they are benefiting from looking younger, in the workplace, in their marriages and in their self confidence, Those of us older ladies who have never done this will look a bit sad. But life is not just about looking young – you have to be healthy and active to enjoy old age.

Skin deteriorates in other ways too. In fair skinned people sun damage is a real problem, making the skin of the arms for instance look mottled, and increasing the risk of tumours of various sorts, some benign, some very dangerous indeed. Sun creams are essential if you have fair skin, and these should be started in childhood. The sunscreens available in my childhood were really pretty useless, (even if we thought to use them) but now a lot of unpleasant sun damage can be prevented. But the tissues underneath the skin degenerate with age even without sun damage so that the skin is no longer supported and sags. This sometimes irritates the nerves under the skin causing itching, with no rash to be seen. This is the commonest reason for itchy skin without a rash. The answer to this is to use a lot of emulsifying ointment. No need for expensive “serums” – just simple E45 or similar. If there is a rash it is generally due to drying of the skin and this causes eczema – not an allergic problem but just due to degeneration. Emulsifying ointment is the answer again.

Then there are all the lumps and bumps that appear with old age – most benign, such as solar keratosis – warty like lumps which sometimes go on their own. Most of these do need to be checked out by a doctor.

Bones are the next part of one’s anatomy to get old, all too soon . Back ache is common, and may be due to simple wear and tear. But osteoporosis is something that can quickly cause trouble in the over 70s, especially in those who are not very active. The fact is that bone strength is something that develops during our young adult years and depends upon enough weight-bearing exercise, walking, cycling or running while young, and for those who haven’t done any of this, their peak body mass is less than it would have been otherwise. Then, past the menopause for women and later for men, the process of losing bone strength starts to accelerate. Smoking makes it worse, as does lack of sunlight. There are effective treatments for osteoporosis, but it is far better to prevent it. Regular exercise and adequate sunlight are the best preventatives. Calcium and vitamin D are essential. Once bone mass deteriorates in the spine the vertebrae weaken and pressure of gravity reduces their height causing the familiar loss of height in older people. This is usually painless, but once a certain threshold is reached the vertebra collapse completely, and that is very painful indeed. Easy ways of prevention are to walk to the shops instead of taking the car, use every staircase as a “free gym”, get a dog, and walk or cycle at least once a week. In bones other than the spine, the result is easily fractured bones – the wrist and hip are the usual sites. Most people who have any sign of a problem will get a Dexa scan which will tell exactly how much at risk they are, and whether treatment is needed. But it is never too late to just take exercise, eat foods containing calcium (milk cheese and vegetables) and get sunshine when you can. If you can’t do these things then you can supplement with calcium and vitamin D, although the evidence on whether it is useful is mixed.

But other things that also come with old age can prevent people doing exercise. Feet for instance, have had an awful lot to put up with over the years, and corns, bunions, foot deformities, and collapsed arches are common. A good podiatrist can often prescribe orthoses (orthopaedic appliances) which re-align the feet so that walking is safer and more comfortable; and exercises which strengthen themuscles, and good foot wear is essential at all times. Foot problems should be treated and not used as an excuse not to walk as much as possible.

Joints have also taken a lot of wear over the years. Too much running and pounding hard pavements can cause excessive wear. It can be hereditary too. One of the main causes is excessive weight, which increases the risk of arthritis especially in the knees. So losing weight is definitely a good thing. Apart from that there is nothing that you can do to prevent arthritis, but I would of, course, support getting joint replacements when necessary. They can be life changing, and then you can continue to exercise and prevent osteoporosis!

Muscle weakness creeps up on you slowly, and is inexorable. However much you exercise and try to keep you muscles in trim, you will lose muscle mass year on year. It starts in your thirties it seems! It is called sarcopenia (“sarco” is Greek for muscle and “penia” means less of it). and this is the cause of difficulty in getting up from the floor and later from a sitting position. It is a real problem when people start getting frail, and can stop people living independently. A good physio can give you exercises which will slow the process though not stop it, although unfortunately it is not a priority for NHS physio services (it should be) so you may have to get it privately. Again excessive weight makes things worse. Diet is important – you need to make sure you increase the amount of protein in your food as you get older.

All these things, loss of bone, loss of muscle, wear and tear, deterioration of skin are inevitable. But as you can see an active lifestyle is essential – you have to use it or you will lose it!

Courtesy of my twin brother, I now share the following to illustrate the points above: –
How to start a fight –
“My wife was standing nude, looking in the bedroom mirror. She was not happy with what she saw and said to me, ‘I feel horrible; I look old, fat and ugly. I really need you to pay me a compliment.’
I replied, ‘Your eyesight’s damn near perfect.’
And then the fight started…”

My next blog is going to cover deafness, eyesight problems, swollen ankles and sleep problems. Then if I get that far, memory…….
Now what was I going to say??

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David Attenborough or Alice Roberts – who do you think is right?

Posted on September 18, 2016 by Elen Samuel

It has been quite a week for those of us interested in the evolution of human beings. On Thursday, David Attenborough gave a talk on BBC radio 4 entitled “The Waterside Ape” and brought us an update on this intriguing theory, first proposed by Prof Alister Hardy in the sixties, and developed and popularized by Elaine Morgan in the seventes and later, a theory which is usually known as “Aquatic Ape” theory of evolution. This suggests that at the time of the split between chimps and humans, early hominids went through a long period of time at the water’s edge, diving and swimming in water, where walking on two legs in shallow water made a very good transition to walking upright. They made a living there from the easy pickings of nutritious sea foods on the beaches and at the bottom of seas and rivers, before returning to the land. It seems that the theory is now known as the “Hardy-Morgan theory of the Waterside Ape” (amongst believers anyway) and Sir David Attenborough gave us a fascinating account of developments in the field in the last 12 years which he thinks support the theory.
Listen to it on http://www.bbc.co.uk/programmes/b07v0hhm ; I think some of the evidence he gives, such as evidence of seafood in sites where ancient hominids have been found, alteration in bones of the ear, which occurs in modern divers, being found in ancient early skeletons of hominids, and others, certainly make it at the very least a very credible theory which should not be dismissed out of hand.

Yet immediately comes back a riposte from physical anthropologists, the scientists who have always been the most scathing about this theory, in the form of Professor Alice Roberts, the well known presenter of programmes on archeology and bone science, who prefers the “Savannah hypothesis”. This is the more masculine theory of man’s origins where we began walking upright as a response to moving on to the savannah, those vast stretches of open grassland, where man is supposed to have adapted to being primarily big game hunters, with the womenfolk taking a more passive role.

She wrote in the “i” newspaper two days later:

“It is a great shame the BBC recently indulged this implausible theory as it distracts from the emerging story of human evolution that is both more complex and more interesting. Because at the end of the day science is about evidence, not wishful thinking,”

https://www.theguardian.com/science/2016/sep/16/david-attenboroughs-aquatic-ape-series-based-on-wishful-thinking

Now this is an unduly harsh attack on a theory that has persisted for over 50 years, in which, as is her right, tries to refute the evidence presented by Sir David, (although her brief article is inevitably again short on actual evidence to the contrary), but also chides the BBC for even allowing Sir David, who does know a thing or two about animals, to air his views. He may not be as profoundly a scientist as Alice Roberts in her more specific way, but perhaps he is more of a synthesist. She should be ready to allow that the more discussion on this fascinating dichotomy of views the better for the advancement of scientific knowledge.

Are there any underlying issues here?
I have written several blogs on the topic (see previous articles in my blog), which will give you a background to the difficulties faced all along by the supporters of the Hardy-Morgan theory. At the core of the argument, I believe, is the status of the study of bones in the archeological record as the be all and end all of the scientific endeavour to find the origin of modern human beings. For most of time, bones were all we had, and it is obvious that ancient bones are indeed absolutely crucial to piecing together the history of what actually happened. But inevitably, the evidence from bones omits all the really interesting things happening to the developing hominid body. It will tell you about the stages in the changes in the spine, pelvis, and legs as a result of learning to walk upright, the increase in size of the skull, and the changes in the angle of the skull on the vertebral column, and even about the whereabouts of the hyoid bone – crucial to the ability to speak. But it cannot ever tell you about why and when we lost our hair, why we have a layer of fat bonded with the skin, about our social arrangements, why we sweat as we do, and a myriad of other changes as we developed away from the proto-chimp model. These questions lie outside what bones can tell us, and need the attention of other scientists with a wider outlook; after all it is no coincidence that Prof Hardy the originator of this idea was a marine biologist, not an archeologist. We need thinkers outside the box to come up with further evidence, and these may be other biological scientists, scientists outside biology altogether, and of course non-scientists like Sir David Attenborough and Elaine Morgan. It must be remembered that many advances in the life sciences came from people whose first training was in other areas, and this includes Darwin himself who graduated in theology, and whose initial scientific education was in geology.
Professor Roberts is a professor of Public Engagement in Science at University of Birmingham, and her background is as a medical doctor and anatomist who has specialized in paleopathology. She is of course correct about the huge increase in discoveries of new evidence in Africa of intermediate forms of hominids from different ages, with varying degrees of adaptation to walking erect, the gradual loss of arboreal features such as the opposable big toe, and so on. I readily admit to not knowing much about these new developments, but I agree that some of them seem not really to fit the Waterside Ape theory very well, unless the events of the waterside theory are pushed forward much further forward in time than the original hypothesis of 6-7 mya. But the problem for the archeologists is that they can never be sure of which of these ancient skeletons were actually those of our direct ancestors. There seem to have a great many species of early hominid in Africa at that time, and many of these must have died out, leaving only one to be our immediate forbear. So there are problems with just focusing on the bones. We do in fact need other evidence to add to the story of bones, and I think eventually it is likely to come from DNA. Alice Roberts does not talk much about DNA in any of her books, and like many scientists in the field of paleontology, she would restrict the discussion to bones.
She says herself that the theory of the waterside ape is beguiling; why is that? I think it is fascinating because it chimes with another view of ourselves – not the aggressive savannah ape hunting with tools, but the gentler ape on the seashore, feeding her young in peace on the nutritious seafood which is ideally placed to promote brain growth, intelligence and speech.
Well done the BBC for airing David Attenborough’s talk. I hope that the bone specialists don’t achieve their aim of shutting down discourse on this very important topic. We would all be the poorer if they do. There have been similar responses over climate science and finger print research, and suppression of this sort is the negation of a major principle in science; no-one should have the last word.

Posted in Anthropology, aquatic Ape Hypothesis, Elaine Morgan, Medicine, science | Tagged , , , , | 1 Comment

Children taught adults the beginning of language, not the other way around

Posted on February 19, 2016 by Elen Samuel

I am never sure why scientists of all disciplines, anthropologists especially, say that the most distinctive thing about humans compared with all other primates is the fact that we walk upright. All right, it frees our hands to do all sorts of useful things such as making tools, carrying things, writing and using computers, but was that an absolutely necessary prerequisite for big clever brains? You can imagine small brained, but erect, ape-like creatures going about their business quite satisfactorily almost as before, eating vegetarian food which their erect posture made it easier to collect, store and eat because their hands are getting better at shaping a few more tools. But nothing world-changing had to happen as a result. That bipedalism seemed so important is only because scientists have been entirely dependent on fossils, and particularly bones, to find out anything about our early ancestors, and why hominids split off from chimpanzees about 6 million years ago. So it seemed obvious that if we found out when primates began to be bipedal that would immediately tell us we were on the right path. Having found Ardipithicus remains that dated between 3 and 4 million years ago, which showed clear evidence of the beginnings of walking on two legs most of the time, the problem seemed to have been solved. But why would this different way of walking on its own inevitably set them on a path to becoming human? It does not even begin to account for the huge explosion of brain size, and its inherent complexity, from 380-610 cc in Australopithecus to 650-900 cc in Homo erectus, about 1.6 million years ago.

I think a lot more than walking on two legs was needed to change the path of evolution. The attribute that really made us human is much more likely to be the use of language. Language fits the bill exactly for the trail of evolution which led to modern humans and their very large complex brains. Language doesn’t fossilize, so you can’t tell from skulls at what point language began. But it did, so it is necessary to look at what else was going on 4 to 5 million years ago. Firstly, it seems that the brain of Ardi was slightly smaller than that of modern chimpanzees, although it might have been larger than the brain of the ape of the time that was destined to become a chimp. Whatever had started it off on a path to big brains may have only just got going then, even though Ardi was well on the way to becoming bipedal. So something else must have been happening at that time, and I think that has to be the acquisition of language.

If you look at how the development of the human brain started, it seems that several things needed to be in place. Firstly, the brain had to get enough of the right sort of food in order to grow so large. Secondly there had to be some sort of selection for bigger brains. Thirdly language structure needed to be hard wired into the brain.

So how did the ancestor of homo, if it were Ardi, get so much food? Vegetarianism is not the most calorific of diets and so their diet needed to change, to use either meat or seafood.   Was Ardi a good enough hunter to be able to kill large animals? He still wasn’t that good at running, certainly not to out-run large animals and then kill them. What about seafood? That is well known to be nutritious, calorific and contain exactly the right fats to nourish the brain- an equal ratio of omega 3 and omega 6 fats. Many skeletons of ancient hominids have been found on the coasts, and middens of seashells and other evidence of seafood have been found round them. They would certainly need a lot of such food, and females could collect them as well as any male, so there would have been no need for complex hunting patterns.

It is a fact that the brains of hominids doubled in size over those 3 million years, so their babies’ skulls needed to grow too. But there was a problem. The demands of bipedalism resulted in the female pelvis outlet being smaller, not larger – so walking on two legs was never the most important development for humanity; if anything it was a disadvantage.

If the skull grew too large this would result in obstructed labour with the deaths of baby and mother – hardly a recipe for success of the species. So something had to happen; there was selection for those babies that got delivered earlier, and so babies were born more premature. Not so premature that their other systems such as breathing in air were compromised, but earlier so that they could easily pass through the birth canal. Note that this is never a problem in modern day chimps or any other ape – there is no tight fit and birth is very easy for them. But obstructed labour can happen in humans even nowadays with disastrous consequences if modern obstetrics isn’t there to redeem the situation.

But why was there selection for big brains anyway? Brains are expensive to maintain, and no species would invest so much in them if there weren’t a reason. Genetics tells us that there may have been sexual selection to do with Y-chromosomes and X chromosomes each trying to outdo the other. It is very complicated; I won’t go into it now, though it did appear to me that something of this sort might explain the tremendous antagonism between the sexes that permeates some cultures even today.   But while the theory may explain the genetic mechanism, I am not sure this really explains why brains grew so big.

What were babies doing with these larger brains in those first years that was so essential? They certainly weren’t doing much with their bodies – all right, they were learning to sit up, control their arms and legs and hands, and walk, but other primates do all that in a much shorter time. The thing that would enable the species to be more successful was much more interesting than that –they were learning to speak. Now, by the time children are two they have now laid the foundation for a complete language with grammar, syntax vocabulary and all the speech sounds that go with it. But it can’t have happened all at once. It must have taken a considerable time to do.

Many scientists think that proper grammatical language started much later. Some even think that Neanderthals had only very rudimentary speech. But from a linguistic point of view this seems very unlikely. Stephen Pinker argues for a language instinct starting quite early in prehistory, and certainly more than 2 million years ago. His point is that language isn’t taught in the same way as, say, reading is. It seems to be absolutely instinctive, that babies pick language up extraordinarily easily and rapidly. It predates almost all other skills other than gross motor ones like walking and running, and continues at an exponential pace throughout our childhood. So how did it come about?

Consider the well-known fact that adults are not able to learn new languages anything like as easily as children. If you put a group of people permanently in an environment where there is no common language, these people will eventually learn to communicate; but this will be in a very simple way with very little grammar. Such languages are called pidgins and are used all over the world when they are needed. If these people then have children and they talk to them in pidgin, or they learn pidgin from other children, then these children will superimpose grammar on to the pidgin, making it much more versatile and able to express things much more clearly. The next generation of pidgin speakers then speaks a creole, a proper language, on a par with any other language on earth. This is one of the reasons that Stephen Pinker thinks that language is an instinct, not a learned behavior. All children will learn to speak properly and grammatically unless particular areas of their brain are damaged in some way – even children who are way behind their peers developmentally. For those interested in grammar, the basic bit that seems to be hard wired is the ability to hold in the mind a dependent or “relative” clause and to be able to incorporate it into a sentence which conveys the meaning. Just think of a child discovering a way to say, “I don’t want the food that we had in the cave yesterday, I want the food from this tree today!” Then adults could also say “The herd of animals we saw by the river a week ago is now near by”. Such a group with this ability would immediately have an advantage over other groups who could only say that the herd week ago is now nearby. This basic bit of grammar goes far beyond just naming things or actions, and would be the forerunner of language as we know it. Now once this bit of crucial brain organisation was achieved, real communication could develop. As the children of the hominids developed this ability (and the adults certainly couldn’t do it) then that gave the now grown adults the ability to cooperate in many, many ways and be more successful in feeding themselves and reproducing. This would then give a huge impetus for the continued growth of the brain.

Between conception and age three, a child’s brain undergoes an impressive amount of change. At birth, it already has about all of the neurons it will ever have. It doubles in size in the first year, and by age three it has reached 80 percent of its adult volume.

Even more importantly, synapses are formed at a faster rate during these years than at any other time. In fact, the brain creates many more of them than it needs: at age two or three, the brain has up to twice as many synapses as it will have in adulthood. Once language has been wired in, the more connections that can be made within the brain, the more opportunity for complex group activities would result. This process would have developed gradually generation by generation, and this would really be the driving force behind the increased size of the brain, regardless of what the X and Y-chromosomes were fighting about.

But we are still missing a bit of the story. It is well known that it is impossible to teach chimpanzees to speak. Years of work have all proved negative. It isn’t that chimps don’t understand how to communicate – they have rich signing gestures and behaviours that make it completely clear to others what they are getting at. They can also make many of the sounds essential to speech – most consonants and a few vowels, certainly enough to make understandable words. But what they can’t do is control their breathing in order to make sounds voluntarily. This may be anatomical, and associated with the descent of the larynx so that air can go through the larynx under the brains control to start the production of sounds. It certainly isn’t an instinct that chimps have, or any idea how to do it. The only explanation of this that makes sense to me is that which Elaine Morgan explains in her book “The scars of evolution”. While the ancestors of Ardi or similar small hominids were spending a lot of time at the seashore, getting all those wonderful fats in the right proportion for the brain, they learned to dive. Diving means getting the ability to hold your breath voluntarily while you are under water and let it out when you surface. Again, that is something with immediate benefits for the individual and group – more fish, more food. This was the fundamental difference that made it possible for the species to start on a path that developed a spoken language gradually as hominids spread into different habitats.

So it was the children who invented the language, little by little, noun by noun, sentence by sentence. And when they became adults the group benefitted from this and survived and prospered. But most likely they continued to prosper near the sea which provided their ideal diets, Only when a species developed which could not only speak but also run, could Man the Hunter finally put in an appearance. To hunt on the savannah he would certainly need to cooperate with his group in order to develop a strategy that could bring sufficient good protein to the whole group to ensure the expensive brains got enough nurture.

We shouldn’t think of everything human being the result of what adults do; the foetus, new-born and infant have their own natural selection going on, which chooses the bits of evolution that improve their chances of their survival even at the expense of the adult. And it is in those early years, by those babies, not their parents, that grammar and full language was developed for the human race.

So linguists believe there is a language instinct operating in small children, which underpins the structures of all languages in the world. There are enough similarities in basic grammar in all languages to be sure of this. We don’t know whether this happened just once or several times, with newer and better structures being selected for. And we know that, sadly, this hard wired ability to learn languages disappears in childhood. Up to the age of seven children will learn languages very easily, but it becomes progressively more difficult to learn a new language until after about 13 or 14 years it becomes impossible to learn new sounds and accents, and grammar becomes a chore to be learnt, not an instinct at all.

I am intrigued as to what will happen to the mental processes of the next generations. Children in developed countries now use I-pads at 2, and learn pattern recognition and reasoning well before they used to. The adults they become will have a head start over adults now in many areas of brain function. In the developing world children’s IQ results are showing an increase too, as more get an education, so that they may well start catch up with their peers in developed countries, whose IQ rise is beginning to plateau or even fall. Early years of childhood have always been even more important than we realize, and investment here is paid off many times in the future.

Read more on my blog

Apes and Women

 

References

Elaine Morgan: The Descent of the Child
Genome: Matt Ridley
Rice WR Holland B: The enemies within, ICE and the intraspecific Red Queen Behav Ecol Sociobiol 41 1-10 https://www.researchgate.net/publication/227329481_
The Language Instinct: Stephen Pinker
Elaine Morgan: Scars of evolution
Richard Lynn, John Harvey: The decline of the world’s IQ http://www.iapsych.com/iqmr/fe/LinkedDocuments/lynn2008.pdf

Posted in Anthropology, aquatic Ape Hypothesis, Elaine Morgan, Food, healthy food, language, linguistics, Medicine, Physiology | Tagged , , , | 1 Comment

Apes and Women

Posted on January 29, 2016 by Elen Samuel

I have long been interested in human evolution, and especially in the very early split between ancestors of chimps and humans. I like to think of bands of very early hominids in that pristine environment six million years ago (6 mya), especially the females and their babies. What caused the two lines, one arboreal and the other bipedal, to split off? Why have humans lost their hair, are fatter than chimps, and are able to talk?
These are questions that have long lain beyond the reach of archaeology and palaeontology – and it appears, modern doctors.
“Humans evolved as long distance persistence runners on the arid Savannah of south and East Africa. We acquired our ability to regulate our body temperature during prolonged exercise in dry heat despite quite large reductions in total body water – no other mammal has the equivalent capacity.”
This was the beginning of a recent article in the BMJ by Timothy Noakes, Discovery Health Chair of Exercise and Sports medicine, Cape Town. It was an excellent account of how humans are able to regulate their water balance relying on thirst alone, and how unnecessary it is for us all to be exhorted to drink more and more fluids.
However, the beginning dismayed me. Yet again the “savannah” hypothesis is being trotted out to account for why and how we diverged so much from the primate line which had occupied the arboreal niche for so long. The main problem (out of very many) with this “theory” is that the savannah did not exist in Africa at the time hominids were beginning to go about on two legs. The savannah, with its endless grassy plains, did not come into existence until 2 mya, long after skeletons of early hominids had shown clear evidence of bipedalism. There is no evidence at all that the savannah played any part in the crucial changes – bipedalism, subcutaneous fat, hairlessness, our loss of smell, our ability to sweat or our ability to talk, let alone our big brain, that distinguish us from the chimpanzees, as these were already there before the savannah appeared.
The trend to bipedalism started much earlier. The ancestors of chimps and humans started to diverge between 6 and 7 million years ago and the skeletons of Ardi, dated at 4 mya and Lucy at 3 mya, showed that bipedalism was well under way by then. Ardi is very much in transition with features both of tree dwelling and bipedalism while Lucy is definitely bipedal though not terribly good at it – her knees would not lock and her feet would not allow for any sort of running. The savannah did not appear until 2.5 million years ago and indeed by then the process had gone on for long enough for some hominids to be able to do long distance running. So whatever started bipedalism off it was not the prospect that some time in the future man would need to be a long distance runner on the savannah. It was just that by that time bipedalism had advanced to such an extent that early hominids could expand their habitat into it.
Most of the other characteristics peculiar to humans had also probably come into being in the intervening four or five million years, well before the savannah made its appearance.
So why do doctors and scientists like Timothy Noakes, and most notably palaeontologists, still seem to think this is the only explanation? I think this is because of a tendency amongst scientists to ignore any suggestions that do not come from their own kind – especially if that someone is a woman.
There is another good theory which explains all of these developments simply and elegantly – the Aquatic Ape theory, first suggested by Sir Alister Hardy and promulgated in the 90’s by a series of very popular books by Elaine Morgan, who originally was a writer for television.
To me, and I would have thought to anyone (such as a doctor) who is interested in our physiology as well as our skeleton, this is an enormously attractive theory. According to it, our ancestors, tree dwelling African primates, suddenly found their terrain covered with water. This could well have happened in the north east of Africa at about that time (6 million years ago) due to movements of tectonic plates. Many will have drowned and some moved away back to the trees, but some were trapped at the water’s edge. This they found to their liking. Their diet was excellent with abundant marine and coastal life, easily caught by primates with hands used to grasping. It was rich in protein and omega 3 fats – good for brain development. However this wasn’t a quick trip to the seaside – it lasted about 3 million years, long enough for considerable adaptations to have been made to the anatomy and physiology of these early hominids.
Firstly, hairiness would have been very unhelpful. Wet hair does not insulate. At first there may have been changes in sebaceous glands which secreted sebum, the only purpose of which is to waterproof hair (such as with seals and otters). This is now seen in foetal development with the lanugo and sebaceous glands growing in parallel in the latter half of pregnancy. But the lanugo is shed just before birth and, after producing the vernix, (which protects the skin from amniotic fluid), the sebaceous glands disappear except for on the face, back and pubic areas. And in the meantime the foetus is putting on fat as fast as it can, not, as in most mammals, around the gut, but just under the skin, in fact bonded to the skin in a way not seen in any other mammals except those which have gone back to the sea such as elephants and sea cows. The hair, even protected by sebaceous gland secretions, became functionless and was lost. It was a good choice – subcutaneous fat is an excellent insulator in water. It also increases buoyancy and of course protects against famine.

So these small primates in shallow water and on the beach in temperatures which were very high at that time, could easily control their body temperature and could stay in this environment, eating food on the seashore and diving and fishing.
Now enter bipedalism, which came partly because of streamlining of the body shape for swimming and diving (would a gorilla have made an Olympic diver?) and partly because the hominids would have spend a lot of time walking on two legs in shallow water – allowing them to carry things, particularly babies. Once the hair had gone, babies could not hang on as can chimp babies, and have to be carried, and if babies don’t survive the species dies. These two developments – hair loss and bipedalism – must have happened gradually in order for babies to be reared. Note that hair remains on the head, which would have been out of the water so the older baby and small child could always hang on to that. As these early hominids spent more time erect they would have become better at walking bipedally, but it must have been a very long process – Lucy was not an efficient walker, but at least would not have had the dangers of practising unaccustomed walking on the savannah, where she and her offspring would have been easy prey.
It also explains speech – chimps can only make involuntary sounds, and teaching them to speak has been found absolutely impossible. But we can because we learned to control our breathing while diving (due to our descended larynx), and even primitive speech would have been an excellent way of communication. Speech, I think, started very early, much earlier than most scientists assume, and would have taken a long, long time to be really useful, as it would need a much bigger brain to develop proper language.
We don’t have a very good sense of smell either do we? Of course smell isn’t much use in the water and whales and dolphins have also poor sense of smell. Really, for land mammals as we are now, this was a terrible loss. Smell is incredibly important to all other mammals.

As the pelvis adapted itself to bipedalism, it became less easy to give birth to big babies. But babies were growing bigger, and especially their heads. The foetal brains were getting bigger due to this excellent food source of fish and marine animals, rich in omega 3 fatty acids. So what happened was that mothers gave birth earlier and earlier to less mature, or even premature babies. Those whose babies were born with heads too big would have suffered obstetric disasters and would not survive. Human babies therefore became the most helpless at birth of any other mammals. Once born however, the babies’ brains could grow rapidly, and the rest is history – high intelligence, language and social skills. These changes must have been completed after Lucy’s time, as her skull is not much bigger than any other primates.

And back to the article mentioned above, indeed we use sweat cooling to regulate our temperature in hot environments. Thirst is a very powerful drive – humans deprived of water will think of nothing else but the need to drink – but it is not the same with salt, which is also crucial to life. So infants in developing hot countries used to die of dehydration and salt depletion, and this was only prevented by the magic formula of a teaspoon of salt and a teaspoon of sugar in clean water, which was pioneered in the sixties. It has saved so many babies’ lives. The fact is, we don’t go seeking for salt (although we really like it when it is there). But we would not have needed to in an aquatic environment, because salt is very plentiful in food, whereas fresh water would be scarce and only available on coastal inlets.

Later the sea dried up but by then, these hominids were ideally placed to take advantage of many new environments, including the savannah. But the favourite one seems to have been a beach combing one, as several million years later the first humans out of Africa beach combed their way around the world, as proved by DNA evidence.

All these ideas and many more were researched and thought out by Elaine Morgan in her very readable series of books. The theory has never been proved, but hasn’t been disproved either, and it is at least as worthy of consideration as some of wild speculations of modern scientists. Some evidence may lie under the sea but soft tissues do not fossilize so it is very unlikely that paleontologists are ever going to be able to answer these questions. But the scientific world has not even considered this theory academically – it has been totally ignored. There are no papers in the literature that discuss it seriously, and certainly nothing that even remotely challenges it.
Probably the reason is that Elaine Morgan was not a scientist, and academics are not inclined to discuss a theory not by one of their own, despite the fact that all the books are completely referenced with scientific papers and books. They appear to have decided the best strategy is to say nothing at all about it, which seems extremely childish, although hardly unknown in science. Many theories such as the tectonic plate theory were ignored or ridiculed for decades before acceptance came.
At least they should produce more compelling reasons, for instance about why we lost our hair than the one most commonly quoted – to get rid of our parasites! (Babies and bathwater come to mind!)
To me, this very attractive theory which chimes in so well with what we know about ourselves, should be the mainstream theory that the general public hears about, rather than the male dominated savannah hypothesis (Man the Hunter bringing back the food to the women and children huddling somewhere out in the grassland). Why do we love water, showers, baths, and rivers to clean ourselves with? Other primates don’t. Why was most human expansion originally round the coasts? Why do we all love to be beside the seaside when the weather is hot?
Elaine Morgan died in 2013, age 92, without any discussion of this very interesting theory in the scientific world. I think it is high time that this was remedied. Perhaps DNA evidence is the way forward if only scientists could find a way to look this far back. But in the meantime we could at least discuss it!

Posted in Anthropology, aquatic Ape Hypothesis, Elaine Morgan, healthy food, Medicine, Physiology | 2 Comments

Giving to Charity at Christmas

Posted on January 12, 2016 by Elen Samuel

Giving to charity is something you have to think about at Christmas time. The huge number of charity leaflets coming through the post and by email, the focus on charities by newspapers and magazines and the ongoing bad news from Syria to floods in Britain – how can you not think of doing something to help those less fortunate than yourselves? Although I am not in the same league as the poor lady in her eighties who received hundreds of requests, (because I can be ruthless in ignoring charities I think are a waste of money), nevertheless I do receive an awful lot of stuff through the post, from suffering donkeys to save the whale.
Now that Christmas is behind us, I can reflect yet again on what my priorities are and to what organisations I have actually given.
To some extent they match. I am keen on supporting organisations countering environmental problems, women’s rights and education, certain medical charities, and these all feature in my list. I have supported Rainforest Savers, a small organization which is trying out a method of preventing slash and burn in Cameroon and other places, I support my old college in improving access to girls from poor backgrounds, and I have supported the Red Cross, MSF and Doctors of the World in their work with refugees. I also support Sightsavers, which tackles avoidable blindness all over the world; Action Aid, for their work in Kenya, and several one off donations to DEC and similar umbrella organisations. And Wikipedia, which is a huge resource for everyone needing a quick answer to everything!

But at the end of it all, what difference does it make? A tiny bit here and there perhaps, but considering the problems affecting the world, so little. Even the big philanthropists like Bill Gates can’t solve very much.

And the one cause I would really like to support, I find great difficulty in doing. My priority for funds would be to support people doing work in providing family planning for women in refugee camps all over the world, but particularly for those displaced by the Syrian civil war. Their needs are so great, for food, shelter, medical care and education for their children that family planning is barely considered. There is good evidence that major catastrophes and wars which kill and injure millions, don’t make a dent in the population. In the aftermath of the Haitian earthquake for instance, the population numbers soon rose again very quickly, because of lack of contraception or unwillingness to use it, even as poverty was getting worse. But trying to give money for family planning is fraught with difficulties. Telling people in refugee camps that they there are too many of them and they should reduce the size of their families seems callous in the extreme. And especially in the Middle East where large families are seen as a gift from God, contraception is often looked on with great hostility especially from the men. There are myths, that contraception causes sterility, that it causes disease, and of course men are often against it because they want as many children as possible.
“My husband says it is religiously forbidden, and that what God gives is good,” is a common refrain.
It is clear from working in the field that most women in refugee camps do want at the very least to space their families, as they are terrified of getting pregnant again in those conditions. Yet contraception is just not available. Contraception was free in pre-civil war Syria and 58% of women used it. But now for those in refugee camps in Lebanon it is expensive and hard to get. The result is that more than 250,000 women in Syria and refugee settings became pregnant during 2014. The burdens on the health services in Lebanon especially are huge, with 15% of deliveries needing medical care, and only part of this cost being covered by aid agencies. Refugees see their savings running out and many cannot afford such extra costs, so women suffer, and some die, because of pregnancy and obstetric complications.
Because there are so many needs in refugee camps “extras” like family planning get put to the bottom of the list, even though family planning provision would pay for itself very quickly, especially in reducing medical costs. Some charities like MSF and Merlin (now Save the Children) have tried, very, very cautiously to provide contraception to women who want to space their families. But conflict-affected settings receive 50% less funding for reproductive health than stable settings, so that women, who in pre -war Syria used to use contraception readily, now cannot.
But I cannot find any charity which will prioritise family planning in these areas, and when I give to MSF or Merlin I cannot state that this is what I want. While I am touched by stores of children suffering, like everyone else, I cannot but think that parents who cannot provide for more children should be helped not to have more.
Last year I gave to the Marie Stopes Foundation. They did not ask for it, I did not receive an acknowledgement and I have no idea whether it went to the rich world or to refugees. They certainly did not ask me to donate again.
Does anyone have an idea where I should send my money now?

References
http://www.prb.org/Publications/Articles/2010/haiti.aspx
http://www.theguardian.com/global-development/poverty-matters/2013/jul/25/refugees-family-planning-health-syria
Managing Complications in Pregnancy and Childbirth WHO report/RHR/00.7
WHO statistics Syrian Arab republic

Click to access syr.pdf

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