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

Posted on January 16, 2018 by Elen Samuel

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

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

Posted in Health Delivery, Health Policy, Medicine, old age, Sir David Attenborough | Tagged , , , | Leave a comment

Virtual Beds anyone?

Posted on January 16, 2018 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

Posted in Europe, Health Delivery, Health Management, Health Policy, hospital beds, Medicine, old age | Tagged , , | Leave a comment

Breast surgeon guilty of doing unnecessary operations.

Posted on May 10, 2017 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Breast surgeon convicted of carrying out unnecessary-srgery

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

Posted in Health Delivery, Health Management, Health Policy, Medicine, Private health care, science | Tagged , | Leave a comment

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

enes?

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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