How does our Neanderthal ancestry affect what diseases we get?

Posted on December 12, 2015 by Elen Samuel

I have always been interested in anthropology, and especially the study of hunter/gatherers, particularly the first modern humans who first made their appearance in Africa during the Pleistocene 200,000 years ago, and then migrated out of Africa about 70,000 years ago. It is such a pleasant thought to imagine them in their pristine environment, unadulterated by the havoc that people eventually created for other species with global warming, overpopulation and intense pressure on our environment. At that time, these early humans (Homo Sapiens Sapiens – us) lived in an unspoilt world with luxuriant growth of fruit and vegetables, and unending supply of small animals to eat. This is even without the huge animals such as mammoths and other large game which the male of the species was supposed to be so good at hunting. It seems that the hunter/gatherer existence was usually a very pleasant one. People had to work to get food for only 4 to 6 hours a day; the work was often cooperative and interesting, and they had the rest of the time to enjoy themselves. A far cry from most agrarian societies where most people lived lives of endless drudgery, working 10 or more hours a day, and being at the mercy of hunger when the crops failed because of drought or pestilence.
Early hunter/gatherers ate very healthily, and indeed the whole cult of “paleo” diets is based on what people were supposed to eat at this time (Paleolithic means stone age, which came a bit later, but essentially their way of life was very similar). These diets are based on the fact that high protein, moderate fat and low carbohydrate diets are less likely to make you fat because of the lack of refined sugar and grains, which were only available after people invented agriculture. (Although obesity was not unknown then – there are some art objects dating from this time which depict people who were undoubtedly very fat!)

The problem with agriculture was that the increasing amount of food produced by these societies allowed the population to increase vastly, but often limited their diets to those based on a few crops. Those early agrarians may not have been as healthy as their predecessors. While the increase in population led to the creation of elites who brought the modern world of technology science and art into existence, there was always a considerable cost to those at the bottom of society.

Were these early hunter/gatherers healthier in the sense of having fewer diseases? Many of the skeletons from that time show evidence of fractures and other injuries which in many cases would have been lethal. But it has always been presumed that people would not have suffered so many infectious diseases, because they did not live in such crowded societies, so bacteria and viruses did not get a chance to spread so much. But recently this has been put in question by some research on DNA, and particularly by comparing early modern human remains with Neanderthals. Neanderthals were not modern humans, but a closely related species which lived in Europe and other places outside Africa from about 200,000 years ago until about 40,000 years ago. They died out shortly after early modern people arrived on the scene, (the two species were co-existing from about 55,000 to 60,000 years ago) and it was always thought that they did not interbreed with Homo sapiens sapiens (us). But now the whole DNA sequence of Neanderthal remains has been identified, from many individuals, and it is clear that we share many genes with them, which must have come from interbreeding.

We don’t know why Neanderthals died out shortly after we came upon the scene. They were well adapted to the colder environment of Europe and had been successful for over 200,000 years. We now know that they had good language skills, had bigger brains than Homo Sapiens Sapiens, and had especially big occipital lobes that made them very good at visual discrimination. They were pale skinned, had blue eyes and often had red hair. They were very cold adapted, and could live easily in northern areas with little sunlight and in severe cold. It could have been that modern humans were more agile, more flexible and had a more complex culture than the Neanderthals, but the Neanderthals certainly had a complex culture as well. There is evidence that they may have made art and wore jewellery, and possibly they even buried their dead in graves in caves and rock shelters..
They were certainly not the brutish cave men of legend. So why did they die out? It may be that ‘we’ out-fought them, or competed more successfully for food and game.

But another theory is that it was infectious disease brought by the newcomers which did for the Neanderthals. Both species had genes relating to prevention of bacterial sepsis so pathogenic organisms must have been living in both, and may have been shared between them. But by the time the groups met, the viruses and bacteria will have been quite different. There must have been many diseases in Africa which developed after the group that became the Neanderthals left, and which were carried by people migrating out of Africa. For example, helicobacter, the bacteria responsible for stomach ulcers seems to have been one of them. This meant that when early modern humans brought helicobacter with them the Neanderthals would have had no resistance. There may well have been others with even more lethal effects. On its own, this is not proof of anything, and there is no direct evidence of infectious disease transmission between early humans and Neanderthals, but when you consider the record of Europeans in affecting people in other parts of the world (original Amerindians, Easter Islanders, Australians) with their diseases such as measles, tuberculosis, typhoid, and whooping cough (not to mention diabetes and alcohol from new diets), almost wiping them out, one can think that perhaps this was just first of many genocides by infection. There is evidence that Neanderthals did suffer from these diseases. Note that Africans on the whole have been more resistant to European diseases, at least in the sense that populations there did not decline when Europeans came, although this may have been because on the whole African diseases such as malaria were far more likely to kill Europeans than the other way around. It seems that many infections including tuberculosis, brucellosis, whooping cough and typhoid which were originally thought to have originated in pastoral animals actually originated in early modern humans in Africa, who then passed them to animals as they domesticated them, and they might have been passed to Neanderthals as well.

However this would not have been the only factor in the rapid disappearance of Neanderthals from the fossil record. Another was inbreeding. The parents of one Siberian Neanderthal studied was shown to be very closely related (e.g. double first cousins). We know that Neanderthals were almost certainly part of very small groups and genetic variants increasing susceptibility to infection would become more common in the population and the likelihood of infants being born with primary immune deficiencies increased.

But did it work the other way too? Did those early modern humans take over some of the best-adapted genes from Neanderthals? It seems clear that they did. It seems that there wasn’t enough time for pigment in skin to decrease by natural selection from the time early modern humans left Africa to prevent rickets. So our light skin, which enabled us to make essential vitamin D, may have come, at least partly, from the Neanderthals who had had another 200,000 years to develop this advantage. Neanderthal gene sequences coding skin and hair are found in the modern human genome and those instructions are as much as 70% Neanderthal, although we don’t yet know exactly what these sequences encode in skin. But it must have been important for modern humans to receive these genes as they survived so well.

This may have been true for immune system genes as well. In many of Neanderthals studied, their mitochondrial DNA, the type passed on unchanged through the ovum from mother to daughter, shows some gene patterns that are particularly important in immunity and infection control, and it seems that these were passed on to early humans. So the maternal (mitochondrial) genes inherited by many of us may have been instrumental in allowing early modern humans in Europe and South Asia to be more successful than they otherwise would have been.

Some of these gene patterns are also helpful in adaption to stress due to extreme cold, so improving survival. The main function of mitochondrial DNA in the body is to produce energy and some maternal DNA groups have a strong correlation with a type of climate, suggesting that it may provide a better resistance to extreme temperatures. If so, it would have been beneficial to Homo Sapiens to inherit Neanderthal maternal DNA, better adapted to the cold climatic conditions, especially since Homo Sapiens lived side-by-side with Neanderthal during the last ice age (70,000 to 10,000 years ago). Such DNA patterns would have progressively faded out of the population once the weather got warmer, except in northern Europe, Siberia or Central Asia, where it was still somewhat useful for survival.

Recent research has shown that everyone outside Africa has some Neanderthal genes.3 For Europeans and East Asians it is about 2%, in chunks of sequences that are exactly the same as Neanderthals amongst ordinary modern gene. But for East Asians (Chinese, Japanese, Melanesians) and also their descendants in the New World the percentage is higher – about 2.5%, and it seems that they must have come into contact and interbred with Neanderthals for a second time in the far East, thus getting a second chunk of Neanderthal DNA.

Many researchers have also pointed out that some Neanderthal genes are definitely deleterious to us. Humans outside Africa are more vulnerable to Type 2 Diabetes and cancer because they have a Neanderthal gene that are code for risk factors, although the increased risk is not great.

Another interesting point about the inheritance of Neanderthal genes is that so far no such genes have been identified through the fatherline (Y chromosome). All genes so far have been found in mitochondrial genes through the mother, and in the other chromosomes. It is supposed that this might be because the it was far more common in early societies for conquered women to be taken over and incorporated into the winning side, while conquered men were more likely to be killed before they can propagate their genes. But oddly, there is no Neanderthal influence in the X chromosome either, and none in the region which codes for testicular function. So another possibility is that male children with a Neanderthal father and a modern mother weren’t very fertile, so their progeny did not reproduce as successfully within the early modern human tribes, over very many years. Of course, the offspring of Neanderthal men who took early modern women to live in their groups would have died out with them, so we will never know whether that combination would work, except that it is said that some Neanderthal remains found in Spain just before they disappeared showed clear signs of anatomical admixture with early moderns. Perhaps though we will eventually find Neanderthal genes through the fatherline – we just haven’t tested enough people yet.

Finally and most interesting to me, Neanderthals did leave a lasting inheritance on us. It seems 2% of our genes are shared with Neanderthals, and these genes appear in almost all the human genome in discrete strands. But it also appears in the motherline – the mitochondrial DNA. I did my own DNA analysis recently, and I found that my motherline, W, originated in what is now Pakistan abut 45,000 years ago. It may be that sometime before that a Neanderthal woman had come into the tribe and passed on a specific gene 16223T, which is also found in almost all the Neanderthal women studied so far. That gene is in the W haplogroup today. People with the W haplogroup spent the last ice age in a refuge in Turkey, before passing through northern Scandinavia and then coming to Britain, presumably with the Vikings. (I was surprised at this because my mother line is Welsh back to my great grandmother, and the main Welsh motherline haplogroup H came not from the refuge in Turkey but from one in the Basque country, and repopulated Britain from the Atlantic). Anyway, I possess this Neanderthal gene, together with many other European and West Asian people living today. No Africans possess it, and it did not get to East Asia either. I don’t know, and neither does any one else if this gene conveyed any specific advantage on my motherline. But it survived all this time so I like to think it did.

The study of how modern humans took over from not only Neanderthals, but also other early groups – the Denosovians, Homo floriensis (the hobbit people) and other early humans who lived in Africa at that time, is fascinating in itself. But there is real practical value all this research as the science of immunity and DNA is really taking off. DNA evidence is even now being used to target how each of us will respond to different treatments especially for cancer, and this may well be the best direction of research in medical science in the future. So the more people get their own DNA analysed, the better we can understand the relationship between disease and immunity.

References
1. Charlotte J. Houldcroft1,2 and Simon J. Underdown, Neanderthal Genomics Suggests a Pleistocene Time Frame for the First Epidemiologic Transition March 31, 2015; doi: http://dx.doi.org/10.1101/017343;
2. Benjamin Vernot · Joshua M Akey Complex History of Admixture between Modern Humans and Neanderthals: The American Journal of Human Genetics 02/2015; 96(3).DOI:10.1016/j.ajhg.2015.01.006 ·
3, Origins of the Human Brain Holloway, RL (1995). Changeaux JP, Chavillon J, ed. Clarendon. pp. 42–54. ISBN 978-0-19-852307-9.
4.Slim Initiative in Genomic Medicine for the Americas (SIGMA) Type 2 Diabetes Consortium

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Money, money, money

Posted on November 2, 2015 by Elen Samuel

Following my previous blog on people wanting it all, I think we have to ask why the British public thinks it can have everything it wants. When I started out as a GP in 1970, people did not think like this at all. I remember an eighty year old lady who called me out at 3 am because she was short of breath. She was in heart failure, and as I treated her I asked whether it had happened before. “Oh yes”, she said, “several times. I thought each time that someone would find me dead in the morning. But that is what happens when you are old doesn’t it?” She said it calmly, not complaining in any way. Expectations were low, and there weren’t so many things that could be done. Now people don’t think they should ever die. Some new treatment will always come along to prolong life, and of course they should have it regardless of cost. The change in attitude has come about because of the success of the business model of medicine. Doctors, pharmaceutical companies, and private investors all make money out of new treatments and the media and politicians whip up the frenzy of more, more, more. It is this ethos, part and parcel of the marketization of healthcare coming ultimately from America, which has made the NHS unsustainable.

I occasionally like to read the Economist, a right wing publication which comes into the house through my dear husband, on health matters. As an incorrigible left leaning GP, brought up in Aneurin Bevan’s home town, it reminds me of what those in more exalted circles and now those in power in Westminster think about health and what to do about it in these challenging times.

The Economist’s columnist is knowledgeable and fair in his (or her) analysis, but always comes to the same conclusion. Given that the NHS needs vastly more money spent on it, and the general public so far, at least in England, has voted for the party which is very keen on balancing the books, it seems that the NHS is unlikely to get this money and therefore will become unsustainable. The solution therefore would be to go towards an insurance type of system as is common on the continent, with people paying their own insurance at a level they can afford, for the benefits they want. In the latest article1 he acknowledges that this is not the most efficient or effective way of providing universal coverage for health, but it accords with the conservative way of thinking about an individual’s choices and autonomy as opposed to the idea that the state tells you what you can have for free.

For me, this is not the way forward. We know the UK spends far less on health care compared to other similar countries, and experts tell us that there is a £30 billion gap between what is needed and what the NHS gets at the moment, because of population increase, people living longer, and poor lifestyle choices leading to obesity, degenerative diseases and lack of fitness. So, what to do?

One choice would be to pay the £30 billion, getting it from taxation, probably a hypothecated tax which can only be spent on healthcare. Would people vote for this? They might; people do value the NHS very highly. However it is likely that this would not be enough in the long term without other changes.

So, if we are to balance the books, what would be needed?

The article points to the changes promoted by Simon Stevens, the CEO of NHS England, and most commentators agree that these reforms are sensible and should make the NHS much more efficient. They focus on making the Health Service more productive; improving the quality of the product – for example, not just more hip replacements, but hip replacements with reduced recovery times, using hips that last longer and produce bigger improvements in patients’ self-assessed health status. They also centre on treating people in more local, low tech settings whenever possible to prevent them coming into hospital, and lifestyle measures which would try to prevent people getting ill in the first place.

To be honest though, there is nothing new in these proposals. These are measures which have been tried for years, and when I was a medical manager in a Welsh Health Board from 2006 to 2010 this is what we were all trying to do. We put an enormous amount of time and effort into it, but it never worked. Not because the ideas themselves were impractical, but because in order to implement the changes you had to invest in new efficient services first before being able to disinvest in the old expensive and inefficient ones. We thought money was short then, but it was goldrush time compared to the austerity we have now, but the necessary money was never forthcoming.

And as I wrote in my previous blog,2 the great British public expects every healthcare intervention to be available when they want it regardless of the cost.

One woman in her forties wanted a small red spot (haemiangoma) removed from the side of her nose, and asked me to refer her. Even at that time, in our locality, this sort of cosmetic benign lesion was not supposed to be referred, so I suggested she go privately. She got very angry, and insisted on me referring. So perhaps rather cowardly, I gave in, and referred to the plastic surgeon. He refused to do it on the NHS, whereupon the woman’s husband, who was a solicitor, started writing some very forceful letters saying it was her right to have it done on the NHS. After a bit of this, it was referred to the local Health Bard, whose policy it was not to do these operations, but after a while I heard that she had it done after all. It is hard to keep to the policy when people get so angry and threaten to go to the papers. Anything for a quiet life, and indeed to involve legal action is much more expensive than doing the treatment. This happened time and time gain, and I don’t suppose it is much different now. And this was something very clear cut – cosmetic surgery – so how it will go down when it is a heart operation (where the evidence is not at all clear cut as to whether it would work for many people) or something life threatening?

So, yes, we could go for an insurance based system, whereby you get what you pay for, the poorest getting only the basics and the wealthy getting what they want. It would be far more expensive for the individual , so that even poor people would have to pay something for the lowest level of care for themselves, and the middle income groups paying a lot. Even so the government would have to pay for those unemployed, elderly or very sick who could not pay anything.

I don’t think such an insurance system is necessary or advisable. I agree with Simon Stevens that we should concentrate on public health initiatives to improve activity and prevent obesity. We should also improve contraception and drive forward an expectation that two children per couple is plenty, with no exceptions for religions where fecundity is prized, – the world, let alone the NHS, cannot take the increase in population that is happening now. Keep the NHS as it is, but provide only well-tested, cost effective treatments we know work well. Concentrate on providing these efficiently and safely, in the public sector, making sure that the private market does not come anywhere near them, and drawing on best practice from over the world to make sure the methods are tried and tested. Innovation should come slowly and carefully, with continuous audit to make sure it is safe and value for money. Organizations like NICE would be tasked with preventing many more expensive treatments being done than at present. So no, you won’t get your knee replacement until you have lost weight, reduced smoking and become more active, and you won’t be offered expensive and maybe harmful new painkillers at all. You won’t get a caesarian section unless it is essential, and you won’t get that expensive cancer drug at eye-watering prices. What you will get is effective, tried and tested treatment in centres as near to you as possible, keeping hi-tech hospitals for those that really need them. All this would still be provided free, and yes, you may well have to wait for some treatments. But in my world diagnostic tests and diagnosis should be prioritised so that everybody starts treatment sooner, preventing the waste that goes with late diagnosis. Cutting out treatments of dubious merit (apparently the NHS still spends millions on homeopathic treatment) would save a lot of money which could then be invested into improved diagnostics and effective local treatments.

This would be called rationing, but rationing on rational grounds. It seems self-evident but is unlikely to happen. The biggest obstacles are the press and media which know that health stories sell newspapers, and the best stories are when things go wrong. It seems to me very unfair that they should always blame politicians (usually those on the left) and the management of the service, just because we have a very respected and cost effective service. In other countries this just does not happen – when things go wrong the hospital or the doctor may be blamed, but it will just be a local story. They can’t blame the service as a whole because it is so fragmented and each patient has signed up for different things.

Not even I think that you can take consumerism out of the equation altogether. It is a basic human trait to want things regardless of need, and people could still insure themselves (as they do now) to get these extras, to buy time or get a more personal service. The private sector will undoubtedly persuade many to have these non-essential treatments, which indeed may well help some people. and many people will get top up insurance. Possibly the new experimental treatments would be tried ut in the private sector, which may well get bigger and more important. But the basic NHS would remain, albeit with more caveats and restrictions than before, giving world class treatment to those that need it, and we would be able to afford it.

1http://www.economist.com/news/britain/21676793-jeremy-hunts-battle-junior-doctors-exposes-awkward-truth-britons-do-not-love?frsc=dg|a

2 https://scepticalgp.wordpress.com/2014/12/24/we-want-it-all-dont-we/

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We want it all, don’t we?

Posted on December 24, 2014 by Elen Samuel

I haven’t written a blog for a while. My excuses range from being too busy, to feeling that I haven’t got much to say any more. The message that I and people like me have been putting out, about the need for healthcare to be effective and not to harm people, seemed to have been generally accepted.
It seems so obvious to me that healthcare should only be available if it is effective and can be proved to improve outcomes, and that only the interventions that are value for money should be provided by a universal health service.
But do most people wanting treatment really think like this? Well, it seems they don’t.
I was jolted out of my complacency yesterday when I read a blog by John Appleby, from the think-tank The Kings Fund, which looked at a survey done in 2012, the British Social Attitudes survey.1 It had asked the public a simple question, what treatments should be available on the NHS in times of austerity?
The questions were as follows:
1. The NHS should provide all treatments regardless of cost or whether they provide proven health benefits
2. Or should it provide only those services that provide proven benefits, regardless of cost
3. Or only those that provide proven health benefits and good value for money.
To me, the answer should undoubtedly be number 3. Why should anybody, whether they are paying for their treatment or not, ever want treatment which does not work? And in a cash limited service, which is free at the point of need, should not the money you have be spent on the most cost effective treatments?
Yet 31% of respondents answered yes to question 1 – they thought that they should have all treatments whether effective or not and regardless of costs. This is almost unbelievable. 3 out of 10 people would like our NHS, funded out of taxation, in other words, by all of us, to provide treatments that either have been proved to be ineffective, or harmful, and also to spend an unlimited amount on them. How do these people think this can be afforded? And what do they really understand about outcomes of operations and treatments? Do they think that they should have the right to any treatment that some one somewhere, whether qualified or not, has decided to offer to the general public? Going further – do they think that they should have whatever they want, for free, AND if it doesn’t work they should then be able to sue for compensation?
I can understand the public’s lack of trust in evidence provided by medical researchers. In general the principles of scientific evidence have not been taught in schools or anywhere, and people are much more likely to believe in something if someone has told them that they have benefited from it themselves, or it has been advertised cleverly. I know that treatments such as homeopathy, vitamin cures, and other complementary therapies, are incredibly popular despite there being no evidence to support them. But people do pay for them, and sometimes the fact that they do so sometimes makes them seem more effective. But for these treatments to be free would mean that other treatments which do work would not be available, or not in sufficient amounts for those that need them.
In fact, only 28% of respondents came up with the answer I think is correct – no 3, only those treatments that provide proven health benefits and good value for money should be provided. And the largest number, 42%, 4 out of 10, picked number 2 – while treatments should have proven benefits, cost should not be considered as part of a decision about what treatments the NHS should provide.
I think this explains why politicians are so scared of saying anything about what should not be available on the NHS. They cannot rely on the general public thinking logically at all. If any party proposes to cut out treatments, either because they are ineffective or too expensive, they will immediately risk 30% of the vote.
Recently I was asked by someone from the Department of Health to give ideas on how to reduce referrals from general practice to hospital, because I had written a paper on it.2
I made a few suggestions of things that had worked in my experience, things like providing services for the less complicated treatments out of hospital, such as extended role physiotherapists doing joint injections, nurses doing complex investigations such as endoscopy, bunions operated on in podiatry clinics) so that patient still get the treatment but nearer to home and less expensively). And I also suggested that the NHS should make sure that treatments definitely proved to be ineffective should be stopped – like arthroscopy for arthritis of the knee, coronary artery bypass graft surgery for those suffering from chronic angina which is not getting worse (it is no more effective than taking tablets), and most tonsillectomies. But the lady on the other end of the phone cut me short –she wasn’t interested in stopping people getting anything. She wanted me to say something that would magically stop these pesky GPs referring patients to hospital at all. I tried to say it doesn’t work like that – if a patient has a problem as a GP you have to try to do something about it. If there is effective treatment you have to refer. That is your job, but if no treatment is needed you have to say so. And you need to be backed up by health service managers and politicians when you say it.

But this is too politically dangerous. So we are going to have to go on expecting the NHS to provide everything, and so in a cash limited environment what will happen is that people for whom there is effective treatment and who really need it, are not going to be able to get it. We are not very good at planning for the future, whether planning to keep healthcare costs affordable, or using contraception to stop the world running out of resources, it seems.
So what can be done about it?
I think people need to be confronted with the logic of the situation, and politicians need to understand that they have to give meaningful choices to the electorate. After all, people now accept that we have to some austerity – we cannot just spend our way out of our financial difficulties. So why should health be any different? How to do we convince the general public that they can only have cost-effective treatments on the NHS, or it will collapse?
What do you think?

References

http://www.kingsfund.org.uk/blog/2014/12/public-view-which-treatments-should-be-available-nhs
Evans E, Aiking H, Edwards A. Reducing variation in general practitioner referral rates through clinical engagement. Quality in Primary Care; 2011;19(4):263–72

 

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New updated edition of “A Sceptical GP”

Posted on August 23, 2014 by Elen Samuel

Statins – The Well are Worried yet again
If you are interested in this post on preventing heart problems and cancer, perhaps you would enjoy my book, “A Sceptical GP” which is full of similar stories. I have recently (August 2014) published an updated version on Kindle, and it is available for only £2.43 despite being over 400 pages. Here is a review written by a health journalist, so that you can see what it is about.

Review of “A Sceptical GP” by Elen Samuel
Carolyn Faulder

“Here is a book that everyone who is interested in the NHS, especially in this time of turmoil, and who cares about its survival as a truly free and open service available to all who need it, will want to read.
Written from the personal perspective of a GP who has spent her entire career in a rural practice in Wales, it covers all the issues that confront busy doctors in their day –to-day working lives. To name but a few: diagnosis; serious and not-so-serious illnesses; decisions about treatment; developing trust and a good patient-doctor relationship; clinical evidence for what works and what does not; the interface between primary care and hospital specialities; advising patients on their self-care as well as the care of dependents (children and/or elderly relatives); helping patients (and their families) to access other services; mental health issues; liaising with medical colleagues and other professionals; the role of public health.
It’s all here, and much, much more. The author is not afraid to tackle the knotty problems, ethical as well as practical, that arise inevitably from the responsibility of running an organisation as vast as the British National Health Service. Pressures from Government to save money, cut services; the interests of big business; the role of the pharmaceutical companies; the in-fighting between different medical specialities; the power struggles; who decides on priorities; Dr Elen Samuel (not her real name) offers some fascinating insights and wise views on these and other aspects of life within the NHS, based on her long experience as a medical practitioner.
Informative and up to date, covering some of the background to the recent changes in the NHS, this book is essential reading for anyone who wants to know just why we should value our NHS and be so vigilant on behalf of both it and ourselves. Never fear! The book is long but it is an easy read, enlivened by many patient stories and anecdotes from the author’s casebook.”
There are also still a few copies available of the print edition published in 2013 by Rheafield Publishing, through bookshops and on Amazon, price £11.99

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Statins – the Well are Worried yet again

Posted on August 23, 2014 by Elen Samuel

Are you over 60? Or younger but worried about your health? Then chances are you will be taking statins and/or aspirin. One in three people over 40 take statins, (up to seven million people in England), costing the NHS at least £450 million a year, and now NICE, the body that recommends what treatments are effective, is saying that that even more people should take them. 1
We all know the benefits, don’t we? – they reduce bad cholesterol and prevent heart attacks and strokes. So almost all of us over 40 should now “consider” taking them, say the experts (that means discuss it with your GP, of course – never mind the extra workload on a very hard pressed part of the NHS).
For those of us older people, like me, who do not want to take medication which may have side effects, all this media attention is making us feel that we really are missing a trick. Are we going to meet a premature death from a heart attack if we carry on putting our heads in the sand? So here are just a few little stories that put my mind at rest, at any rate. Recently a 61-year-old doctor, a leading public health specialist, wrote a letter to the BMJ 2 about this dilemma. He said that he knows that he is at least at moderate risk of heart attacks as he is of South Indian parentage and has a tendency towards diabetes, so he has researched all the recent papers thoroughly. He has come to the conclusion that he will not take statins – he does not think the benefits outweigh the harms. He says they don’t actually reduce the death rate from heart disease, and we need to treat around 67 people at this lower level of risk to prevent one person actually getting a non-fatal heart event. And the others get only the side effects, and the worry of taking tablets and worrying if they forget them. If he has made that decision, I feel a lot better about not taking them.
Then, what about the side effects? When I was in general practice, people certainly did complain of side effects, and some of the happiest patients I had were those in which I had stopped their statins! When you are treating at least 66 people who won’t benefit anyway from a drug, any side effect is reducing their quality of life. Statins have been linked to diabetes (in one out of a hundred patients) and dementia, though not conclusively, and they certainly did cause muscle pains, although I remember one patients whose muscle pains were put down to statins for months before the correct diagnosis – a form of rheumatism – was made, so it can confound the issue as well.
And there is the problem of medicalising people and illnesses. The psychological impact of going from some one who considers themselves healthy to someone who is ‘on medication’ can be large, the daily reminder of your own mortality when you take your morning pill. What of its effect on life insurance, and travel insurance? Also it now strays into philosophical realms. What do you want to die of? You do in fact have to die of something. Although heart disease in a young person is a tragedy, in a person in their nineties it is a ‘natural’ way to go, like pneumonia. Though not painless, it can be quick. Would you prefer cancer? Or a neurological condition such as Parkinson’s? What about dementia? Think carefully before you try to exclude a heart attack from the long list of things you can die of.
Lifestyle is far more important than tablets. Avoid tobacco and other pollutants and eat healthily. Of course you need to have chosen your parents wisely. I’ll tell you what I am going to do, for what it is worth. I am going to live as healthily as possible, eating plenty of fruit and veg, getting plenty of exercise and not too much alcohol. Then, if I do get a coronary event, I will start statins. Statistically if I am the one in 67 who does get a heart attack because I didn’t take a statin, it won’t kill me. After my “cardiac event” I will then take a statin knowing that the evidence proves conclusively that I do have a problem which statins will fix and by then I will be taking a whole lot of tablets anyway so one more won’t make any difference!

The other big story this year is aspirin. Millions of people take them, correctly, for angina and to prevent further heart attacks, and the dose is low so that only a few get serious side effects. Now, another academic paper 3 has shown that aspirin can help to prevent cancer too. Is this real? Should you take an aspirin a day even of you have no risk factors for cancer? I saw a lovely slide 4 illustrating this paper; of 100 patients taking aspirin, fewer than 2 will not get a cancer they would otherwise have got. So again 98 patients have to take a drug which is very well known to have side effects – indigestion and bleeding (very occasionally fatal) – when they won’t benefit. The study noted that everybody has to take aspirin for at least three years before any benefit is seen. And which cancers? They are mostly digestive tract cancers, and possibly lung, breast and prostate cancers. But your risk of lung cancer is small if you are a non-smoker, and being overweight increases the risk of breast cancer. Aspirin has no effect on other cancers – skin cancer, pancreatic, or brain cancers. Since this recent paper has come out, the number of people rushing to buy aspirin has increased by 10%. But such people think that aspirin will help to prevent all cancers and don’t understand the risks.
As for taking aspirin to prevent stroke, which is a very well established treatment for those at risk, only 1 in a hundred of those with no risk factors will benefit. Eating fresh fruit will help to prevent stroke5. Over the age of 70, the risk of a fatal bleed due to aspirin is so large that you shouldn’t take it anyway.
But newspapers have to run stories and people want to read them, and people get confused. They think – better safe than sorry. The only winners here are the pharmaceutical companies. Let’s get back to basics and live healthily and forget about all these health scares.

1. https://www.nice.org.uk/News/Article/wider-use-of-statins-could-cut-deaths-from-heart-disease
2. Raj S Bhopal BMJ 2014;349:g4980
3. .http://annonc.oxfordjournals.org/content/early/2014/07/30/annonc.mdu225.full Cuzic et al Estimates of benefits and harms of prophylactic use of aspirin in the general population Annals of Oncology10.1093/annonc/mdu225
4. http://annonc.oxfordjournals.org/content/early/2014/07/30/annonc.mdu225/F1.expansion.html
5. Fresh fruit meta-analysis American Health Association Dr Yan Qu

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Offa’s dyke and the Line of Death

Posted on June 2, 2014 by Elen Samuel

Did you know that Offa’s Dyke is the “Line of Death”? In case you missed this bit of blatant party political rubbish from our Prime Minister, he said it in a speech in North Wales to local Conservative party members(1) recently. According to him, once you cross Offa’s Dyke (the ancient boundary between Wales and England for you foreigners) you go into a land where people are dying because of lack of good NHS care. The reason he wants to say that? Because health services in Wales are run by the party in opposition to him – the Labour Party, so he is saying that only the Conservatives can run a health service, as things are so much better in England. He goes on to say that waiting times for hip operations is much longer in Wales.

The impression you get from the London crowd, certainly in politics, is that nothing good comes out of Wales, ever. That is certainly the message I hear from friends in England, and in Scotland come to that. So let’s go into what David Cameron said a bit further. On the Offa’s Dyke story, was he talking about life expectancy? No, because Wales despite being poorer, life expectancy is hardly less than England, and has been catching up in the last four years. No, he was actually talking about end-of-life medicines. These are the new cancer drugs on which many Pharma companies are expending a lot of their energies. Remember Herceptin for breast cancer? This was one of the first big issues to hit the headlines, as patients (worked up through the media mainly by the drug manufacturer) clamoured for this very expensive treatment and objected to the time it was taking to become available. In the end the drug company and the media won and it was fast tracked, at enormous expense, but the ultimate result was that it really didn’t live up to expectations and helped very few people(2).
The new cancer drugs that are coming on stream now are mostly ones which provide only a very limited extension of life. And because there are far fewer people who need this sort of treatment than people who need treatment for blood pressure for instance, they have to be priced very highly. So how much would you pay in a free market, say, for 4 months extra, not high quality life? Already you will have many symptoms from your disease, you may be weak and in pain, and the new life prolonging treatment may actually make you feel worse. On the other hand, life is irreplaceable and the thought of death, final death, inconceivable. Saving lives is very emotive. There are patients’ pressure groups, often funded by the drug companies, and such hard choices make for very good newspaper copy. So, would £10,000 pounds for 3 months be about right? If you, the patient, had the money yourself, and had no-one you wanted to leave it to – why not? For the guardian of the public purse, NICE, the usual cost limit is £30,000 per quality year. But for these really difficult end of life cases, public pressure (from the patients and doctors’ lobbies via the media) has resulted in an increase to £40,000 per year, despite the lack of quality of life. But in a cash strapped health service, the payers, CCG’s in England, can’t actually afford this.

So, for political reasons, England has found the money from elsewhere and has established the Cancer Drugs Fund, which can pay this excessive amount for selected patients to access the them. Wales hasn’t played this game. NICE says it isn’t cost effective, and Wales certainly doesn’t have the money. People in Wales are poorer on average, and there are many other more pressing needs, so there is no such cop out available here. This is what David Cameron is referring to. It is a cheap, inaccurate and unfair political point, and actually hasn’t helped his Conservative candidates in Wales at all. It just put peoples’ backs up.

For every patients who wants to hang on to life as long as possible, at whatever level of suffering, there are also many who don’t ask for these drugs, and accept that their time has come. A close friend of mine, dying of oesophageal cancer, told me that she had refused offers of further therapy, after surgery, radiotherapy and chemotherapy had failed. She chose the time of her dying, with dignity and acceptance of death, and died peacefully after relatively little suffering, with her family around her.

Doctors don’t usually choose these end-of-life treatments for themselves. A recent study from California (3) showed that “Most physicians (88.3%) would choose a do-not-resuscitate or “no code” status for themselves when they are terminally ill, yet they tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis.” It goes on “A big disparity exists between what Americans say they want at the end of life and the care they actually receive. More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden.”

It is no different in the UK. So why should this happen?
The author says the problem is that doctors are trained to be active and do things. “We don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”
I quite agree. The trouble is that it is politics that gets in the way. One story in the media and patients get really angry that they are not getting their “fair share”.

David Cameron also talked about waiting lists for hip surgery, which are longer in Wales than in England. In my view waiting lists are not too long – many doctors think they are too short. People are now having hip and knee surgery when they have only minimal symptoms. All such operations have a risk attached, a surgical risk, and an anaesthetic risk, and the prostheses only last 10 years or so. Each successive “revision”, where a new prosthesis is put in, will cause new problems. I remember a lady, very wealthy, who started having hip operations in her early 60’s (privately, as she would have had wait years on the NHS) but by her early 80’s was in a wheelchair because of complications after the fourth “revision”. I think she would have done better if she had waited longer before having the first operations. I certainly don’t want to get back to the times in the early noughties when you could wait 4 years, but a wait of 6 months is not unreasonable.

Public expectations are very high; we are not supposed to die, we aren’t supposed to have any disability, or it is the fault of the health service. And that is why politicians score these cheap points.

In fact, the same day that the Prime Minister made these comments, a report came out from the Nuffield foundation comparing the four health systems(4), 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. More recently a survey(5) has been published showing that people in Wales are in fact very satisfied with their health service – more satisfied than people in England. All countries are having problems in funding health services in times of austerity, and all have their scandals. Everyone has to make sure that every penny is spent according to the evidence of what works and does not work, and our politicians should be taking this on board, rather than scoring cheap points at each other.

1. http://www.telegraph.co.uk/health/nhs/10760842/Offas-Dyke-is-line-between-life-and-death-says-David-Cameron.html
2. Two breast cancer drugs not cost effective, says final NICE guidance. NICE, 2012. http://www.nice.org.uk/newsroom/pressreleases/TwoBreastCancerDrugsNotCostEffective.jsp
3.htmlhttp://www.sciencecodex.com/most_physicians_would_forgo_aggressive_treatment_for_themselves_at_the_end_of_life-134539
4. http://www.nuffieldtrust.org.uk/our-work/projects/funding-and-performance-health-care-systems-four-countries-uk
5. http://www.bbc.co.uk/news/uk-wales-27616963

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Should you immunise your child?

Posted on April 16, 2014 by Elen Samuel

This blog is in response to a post about childhood immunizations. I did not write about it in my book, as the subject has been extensively written about elsewhere. However it is indeed a very important subject, and I am very pleased to write about it now.

Shortly after I started in general practice in the early 70’s, there was a big scare about the pertussis (whooping cough) part of the childhood immunization programme. I can’t even remember the details now, but there had been many reports of side effects, mostly minor ones but also some serious neurological ones, after the addition of pertussis to the vaccine. Up to that time immunization against polio and tetanus had been very well accepted. All of us at the time knew of children crippled by polio – there was one girl in my class at school confined to a wheelchair – and the very idea that polio vaccination was not a good thing was unthinkable. But the pertussis element did appear to have  side effects, and soon there was a big public campaign against it. So then when I had my two children in the following years I considered long and hard whether to give them the vaccine. I read some of the literature, but this was before “evidence based medicine” had become established, and it was very difficult to find out what the true effect of the pertussis jab was. I felt, like Sue perhaps, that I wouldn’t want to be responsible for harming my children – somehow, failure to prevent wasn’t as culpable as harming them. So I didn’t give them the pertussis jab.

The following year, as parents, sometimes influenced by doctors like me, were deciding against giving  the pertussis jab to their children, the percentage of those being immunized plummeted to way below the herd immunity needed to prevent the disease. So there was an epidemic of pertussis nation-wide, and along with many other children, my two got it. It was indeed a horrible disease, a dreadful cough which made them terribly sick, and it went on for months. Babies died from it. Fortunately my children recovered completely, but not all did. A little later, a lady registered with our practice who had had pertussis in infancy (long before the vaccine was developed). Her lungs had been severely damaged, and now, in her early thirties and pregnant with her second child, she was in a bad way. She was very carefully looked after by the lung specialists in pregnancy and delivered her little girl, though not without a lot of medical input to keep her oxygen levels up. Afterwards she continued to deteriorate, though slowly, but the end came when her daughter was eleven, and she died in one of her serious lung infections. Her husband continued bringing up the child very competently, but I thought what a tragedy, and I felt very guilty about not recommending the jab to children earlier.

In the 1980’s an improved pertussis immunization was developed. It was thought that a pertussis endotoxin in the original formulation had been responsible for the side effects, and the new acellular vaccine included only a few selected pertussis antigens. Indeed this one did not have nearly so many side effects. The wheel turned, and immunization levels soared with incentives for family doctors to ensure high rates, and pertussis again disappeared. The pertussis jab became very well accepted and no one objected to their children having it. Later, the measles vaccine was introduced and this too was well accepted. But when combined with mumps and rubella, the story repeated itself and there were scare stories in the media about MMR causing neurological or developmental delay.

To understand what happened, it is necessary to look at normal development in an infant. At birth babies are in effect quadriplegic – they have no control whatsoever over their arms and legs. Gradually over the first six months they gradually acquire the ability to control their arms and hands, body posture to sit up and later, to walk. Human babies are very unusual in this delayed maturation, and it is explained by the fact that babies had to be born earlier in order for their heads to grow outside the womb – if they continued to develop such big brains before birth their heads would be too big to pass through the birth canal and both mother and baby would die. So babies were “expelled” from the womb earlier and earlier as the trend towards bigger brains set in, but this meant that they were developmentally much less mature, and had to develop control over their bodies after birth. If you wish to read more about this, read Elaine Morgan’s book 1. For our purposes however the point is that the neurological system develops mostly outside the womb, and we can see it – and enjoy it. But if a child is severely brain damaged at birth it is not always obvious until weeks or months afterwards when the expected brain-muscular coordination just doesn’t happen. The realization that something might be wrong often comes at about the time babies are given their jabs. “My child was normal until he had the jab but straight afterwards we could see he wasn’t developing normally” said one parent – very understandably. But this is not necessarily cause and effect – it may be an association of events that happen at the same time, so a failure of development of the neurological system happens at the same time as an immunization is given. For instance, the pertussis jab is given in the first few months and this is the time that serious development delays and brain damage are first noticed. However, despite a full investigation, and a court case, no definite association between developmental delay and the pertussis vaccine was ever found. And there never was a scare in the USA, where pertussis became very rare from the start of immunization.

The MMR is given in the second year of life. And this is when a further neurological development takes place – the development of social understanding and language. Failure of development here leads sometimes to autism, and in milder cases Asperger’s syndrome. So again there is a co-incidence of timing, and many a parent noticing the sudden lack of progress in speech and socializing will blame it on the recent vaccination. A pressure group “Jab” was formed by parents who just could not understand how their beautiful baby who had been developing so well, suddenly stopped developing language and social understanding. It was possible that some babies had indeed been affected by the vaccine and it is understandable that parents turned to an organization which might not only “explain” what had had happened but also possibly provide some funding to help them cope. Inevitably lawyers will be brought in and the search for evidence will now be very important

Enter Andrew Wakefield, who in  1998 wrote a famous paper2 for the Lancet about the MMR vaccination. He was a young medical researcher, but not a paediatrician. He was a former trainee gastrointestinal surgeon with a non-clinical medical school contract, and was already interested in a possible association between MMR, bowel problems and autism. As a result he was approached by a firm of solicitors to look for evidence for a lawsuit against the vaccine manufacturers, and was put on a payroll for £150 an hour to further his research. This was two years before his paper was published, and eventually he received £435 643 plus expenses, from them. But this fact was not disclosed to the Lancet, as it should have been. In it, Wakefield put forward a hypothesis that MMR caused a bowel-brain syndrome which resulted in children getting a special form of autism called regressive autism, together with an inflammatory bowel disease – a new syndrome or disease, which he had been the first to identify. He found a series of 12 children who were supposed to have suffered from this new syndrome and wrote the paper about them. The paper was well supported by a team at the Royal Free hospital, and seemed genuine – and the Lancet, an extremely influential medical journal, published it.

The paper fuelled a storm of controversy and concern amongst the public, understandably so. Many parents felt this was the evidence they had been waiting for. Andrew Wakefield became famous straightaway, and the mainstream press took up the story. It was said, on not much evidence, that “single-shot” measles vaccination was free of these complications, and so began the drive for many people paying large sums of money in order to get the vaccinations done separately, as the clinicians in the NHS refused to believe that the MMR vaccination did indeed cause these problems. The result was a bit of a stand off with arguments back and fore, but inevitably vaccination rates again plummeted. In South Wales one local paper took up the cudgels against the MMR vaccine and ran story after story on possible links, and the fall off of MMR immunization rates in that area was much worse then elsewhere. The result was predictable, and in 2013 there was a very severe epidemic of measles in which many children were very ill indeed. Sadly, one young man, a student living on his own, did not call a doctor when he felt ill, and died. The post mortem confirmed measles as the cause of death.

The arguments continued and as in the pertussis case earlier many parents were still worried and asking for the single vaccine. But an investigative journalist called Brian Deer, supported and funded by the Cochrane Collaboration, which is a very important body which looks into evidence of what works and what does not work, and the medical journal the BMJ, looked into the paper in detail3. He identified which patients were in the study, and interviewed the parents of every child. As a result he found evidence that the information in the study was seriously flawed and that there had been deliberate fraud on the part of the authors. First of all only one child clearly had regressive autism, and three of nine children reported with regressive autism did not have autism diagnosed at all in the NHS records. Secondly, despite the paper claiming that all 12 children were “previously normal,” five had pre-existing developmental concerns documented in their notes. Thirdly, some children were reported to have experienced first behavioural symptoms within days of MMR, but the records which Brian Deer saw documented these as starting some months after vaccination. Fourthly, in nine cases, unremarkable colonic histopathology results—noting no or minimal fluctuations in inflammatory cell populations—were changed after a medical school “research review” to “non-specific colitis” indicating an inflammation of the colon.” There were other discrepancies too.

But a very big concern was that patients were not recruited because of their clinical symptoms, but were recruited through anti-MMR campaigners, and the study was commissioned and funded for planned litigation i.e. it wasn’t a normal scientific study at all.

Subsequently Andrew Wakefield appeared before the GMC at a mammoth hearing, which ran for 217 days between July 2007 and May 2010. It found that none of his cases was free of misreporting or alteration, and what was in the NHS records could not be reconciled with what was published, to such devastating effect, in the journal.

The Lancet retracted the paper, and Andrew Wakefield was struck off for fraud. He still maintains his innocence and works as a private consultant in the USA, still saying that single dose measles vaccine is best. Meanwhile in the USA, 11 children in one state alone have died of measles.

So I learned my lesson a long time ago, and I totally support the current child immunization schedule, which is as safe as it possibly could be, and saves many lives and even more distressing illnesses and complications. In my view, every child should be immunized.

References
1. Elaine Morgan The Descent of the Child: Human Evolution from a New Perspective by Elaine Morgan (6 Oct 1994)
2.Griffith AH. Vaccine. 1989 Jun;7(3):199-210.
3.Wakefield AJ, Murch SH, Anthony A, Linnell, Casson DM, Malik M, et al. Ileal lymphoid nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children [retracted]. Lancet1998;351:637-41.
4. How the case against the MMR vaccine was fixed BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c5347 (Published 6 January 2011)

 

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Dog Blog

Posted on March 22, 2014 by Elen Samuel

I am always amused by the number of my friends on Facebook who post about dogs. Sometimes, on a given day, half the posts are canine related. I don’t often read them as I dislike dogs (I must be one of a tiny minority in the population, and you will have to wait till the end of this post for the reason for this). But it makes me wonder what this obsession with dogs is all about. What is the nature of the bond between my friends (otherwise rational and sensible individuals), and their canine companions that they want to share their doings so often? It must be pretty important to the readers as well, as these posts always attract many comments.

We certainly know that keeping pets, and particularly dogs, is good for your health. A study done in 1991 looking at whether people’s self reported health improved over 10 months after acquiring a dog, as measured by the General Health Questionnaire, found that it did. Headaches, hay fever, nerves, palpitations, indigestion and constipation, all reduced markedly in this group. The study also looked at people who had acquired a cat, and found that though their self reported health also improved, it was not as great and did not last nearly as long. The researchers marked up the beneficial effects of having to walk the dogs as a major contributor to the positive health effects for dog owners over cat owners. But the main benefit was thought to be the improvement in psychological health of having a companion to share their social life and experiences.

Some people say that their dogs are incredibly intelligent, and that they really understand their owners’ commands and needs. But we don’t now think that is the reason why humans and dogs get on so well. Many birds, especially parrots, and of course chimpanzees, have much better problem solving abilities than dogs. But domestic dogs are unusually skilled at reading human social and communicative behavior – even more so than chimpanzees. If you hide a piece of food or an attractive object in one of several opaque containers, and then look at or point to that location in an attempt to help the subject find the hidden object, a dog will usually do this task very easily, and it is instinctive – they do it from early puppyhood. Human infants find this task trivially easy from around 14 months of age, but chimpanzees find this very hard; they seem to have difficulty with understanding the human’s gaze. Dogs, like human infants but unlike chimpanzees, only use the human head and eye direction cue to locate hidden food if the person is gazing directly at one of two possible hiding locations; they ignore a human’s gaze if the person stares into space above the correct hiding location. So dogs really do know how humans communicate and use similar methods..

Apparently dogs evolved from wolves many times over the centuries, and the first thing that had to happen was that the wolf/dog had to learn to overcome its natural fear and aggression on encountering humans. This must have been selected for because those individuals who did so were able to get food remnants from around human habitation. Once this had happened there would be biochemical changes in systems mediating fear and aggression, such as hormonal and limbic changes, so that dogs can develop emotional reactivity and human-like social skills. Thus human and dogs subsequently co-evolved to enable them to understand each other in ways that other more intelligent animals such as chimpanzees could not. It has been suggested2 that a similar situation had to evolve in hominids before they could co-operate with each sufficiently to develop human social skills and communication including speech.

Cats of course don’t do any of this, and I don’t see many cat posts on Facebook (though there are some). I quite like cats, as they are very undemanding. But I have been put off dogs for life, after years and years of visiting patient’s homes and having to negotiate dogs which insisted on protecting their human (my patient) from me! They are usually harmless of course, although it is difficult to examine a patient properly with a dog barking and jumping up trying to stop you doing it. But sometimes they are not so harmless. One of our nurses had to visit an eighty-year-old lady who was very immobile and had many medical problems, twice a week. Unfortunately the lady lived with her husband and a Rottweiler. The husband was supposed to exercise him, but was equally elderly and probably didn’t. The dog was bundled into a back room whenever the nurse came and for some time there were no problems. Then one day the lady forgot to shut the back room door and the dog got out, immediately sinking his teeth into the nurse’s leg. There was quite a bad bite that needed treatment in hospital and the nurse was off work for three weeks. Then of course the question was – is the nurse required to visit? The couple refused to get rid of the dog, and the replacement nurse refused to go. Her employers, the Health Authority first insisted that the new nurse had to go if the patient needed a visit, but she still refused, and there was a long bad tempered argument about this. In the meantime the lady still needed treatment (she had leg ulcers) and eventually she went in by taxi to have it done in the surgery. We couldn’t understand why she wouldn’t get rid of the dog – having a Rottweiler cooped up in a small house with no exercise seemed like cruelty to the dog. So we called the RSPCA but they said the dog was healthy and took the side of the elderly couple. But the nurse still refused and the first nurse then I think threatened to sue the Health Authority under Health and Safety legislation, and so there was stalemate. It ended some months later when the couple decided to get rid of the dog and visits resumed. I am personally of the opinion that any person visiting a home for professional purposes should be entitled to be safe and I think this has now been accepted – in the case of postmen at least!

I have known patients go into a deep depression on the death of their pet, and we used to try to remember the name of the pet in order to talk about it in the surgery, just as we would with a family bereavement. And people will spend the earth on veterinary treatment for their pets that they certainly wouldn’t spend on themselves. Yes, I think the dog/human relationship is a very fundamental one, and isn’t going to stop anytime soon. But I still don’t think I am going to read these numerous posts on Facebook about them!

References
1. Serpell, J. A. (1991). Beneficial aspects of pet ownership on some aspects of human health and behaviour. Journal of the Royal Society of Medicine, 84, 717–720.
2. Brian Hare and Michael Tomasello Review Human-like social skills in dogs? TRENDS in Cognitive Sciences Vol.9 No.9 September 2005

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Should Doctors Decide?

Posted on February 24, 2014 by Elen Samuel

Motor neuron disease is not uncommon, and every GP will look after some patients with it during their working life. I remember one man who was diagnosed in his early fifties. He was a teacher with teenage children, and the whole family was very badly affected. The disease progressed very quickly and he soon had to give up work, so there were financial problems, and the local community helped to raise money for him and his family. I visited him many times at home once he could no longer get out, and he was very stoical, but I don’t remember discussing end-of-life issues with him, apart from reassuring him that he would get all the care he needed. Perhaps I should have, although at the time assisted dying was not in the picture – this was before the option of going to Switzerland.  He died quite suddenly at home; I had visited him with a chest infection the day before and given antibiotics, and he hadn’t seemed all that ill, but he died peacefully in the night. I wondered at the time whether I should have sent him into hospital the day before, but hadn’t considered it seriously – he seemed to be doing OK and it was early in the illness. The family thought it was the best outcome, and he didn’t suffer.

Nowadays treatment would be much more pro-active than that, and he would probably have gone into hospital and had assisted ventilation, and his life would have been prolonged, possibly quite considerably, sometimes beyond the point at which he had any sort of quality of life. So everything gets a lot more complicated, for patients and doctors.

Assisted dying is a big issue at the moment. At the moment it is not illegal to try to commit suicide, but it is illegal for anyone, doctor or other person, to assist a person to take his own life. But patients suffering from illnesses such as motor neuron disease are usually physically unable to do this on their own, and some have asked that the law be changed to allow someone, a doctor or other designated person, to help them die.

This would put doctors in a very difficult position. Doctors are committed to saving life, not ending it, and the profession is deeply split between whether to support any attempt to change the law. At present Lord Charles Falconer’s Assisted Dying Bill, 1 a private members’ bill tabled last May, is going through parliament. In general, doctors who work as specialists in palliative care are vehemently opposed to any change in the law, as they strive to improve the care of people in their last days as much as possible. Many others are also very much against it, often because they worry patients will be coerced into agreeing, when they wouldn’t have wanted it otherwise. But other GPs are in favour in principle, although worried about the legal consequences of actually doing so, and want certainty in the legal process above all else. That is certainly my view.

Survey after survey of the general public however shows a large majority, even of religious people and disabled people, to be in favour of a change in the law to allow assisted dying for certain groups of people.2 They think people should have a right to choose when to die under some circumstances. It is true that the law at present is in complete confusion. Courts have been reluctant to punish people when they have acted in good faith to help their loved ones achieve their aim. One might say the present situation discriminates against those who are most likely to want to end their lives, because of their physical difficulties.

This week the Royal College of General Practitioners  (RCGP) recommended continuing its opposition to a change in the law,3 following its own consultation. 77% of the 1,700 RCGP members responding said the college should maintain its opposition. But how much weight should be put on the opinion of doctors’ leaders? The British Medical Association, representing its members who are doctors in every speciality, including GPs, continues to vote in its annual meeting to oppose a change in the law.4 But last year a poll in a medical newspaper5 showed that 38% of 689 GP respondents said they favoured the college adopting a neutral stance on assisted dying, while 31% said the college should go even further and support a change in the law to allow doctors to help the terminally ill patients to die in the UK.

Neither the RCGP nor the newspaper poll was at all representative. The medical newspaper response rate, where the questions were wide ranging and included many other issues, was 1.4% and the RCGP one was 3.5% and was deliberately not widely publicised. Probably both included many of those who had very strong views on the subject.

So should doctors’ associations have influence here? Doctors have a vested interest – some will be involved in a professional role, others worry about the religious and ethical problems that might affect professional practice. This is right and proper. But their experiences are and viewpoints are complicated by their responsibilities and so may be different from those of non-doctors. Our parliamentary process should rightly include medical views on the matter, but no-one knows whether doctors’ leaders organisations actually represent the views of their members. RCGP members during the consultation said they wanted the College to take a “leadership role”, and to influence other institutions, such as the House of Lords, which is still an unelected chamber of the “great and the good”.  But Dr Clare Gerada, until recently the Chair of the RCGP, in a personal view, believes that doctors’ leaders should stand aside from the debate.

“The decriminalisation of assisted dying should be a matter for society as a whole to decide, using established parliamentary processes. No particular group within it should have a disproportionate influence on this decision; in particular medical bodies should not impose the beliefs of some of their members on to patients and carers and oppose (or indeed support) a law on assisted dying.”   She goes on “The role of the medical profession is to advise on such things as assessing prognosis and setting guidelines for the best possible end-of-life care, and to ensure that the views of patients themselves gets priority. They should be concerned with areas of regulation, monitoring, and implementation, not with whether the law gets passed or not”6

From my personal experience I know that what patients want can change. I had a patient once who had made a “living will” (advance directive) specifying a wish not to continue living with particular disabilities, but when that actually happened, he changed his mind and accepted treatment. The will to live is indeed very strong in all of us. I am sure that in many cases of terminal illness a knowledge that people can end their lives at a time of their choosing in fact will mean that they do not feel they have to do so prematurely, and is a great comfort. Each case has to be considered very carefully whatever the law says.

But the recent decision of the RCGP to maintain its opposition to assisted dying should have no special weight when our lawmakers consider this issue. Nor should it influence people when they decide what they might want if they were in that position, nor whether or not to support a change in the law. Paternalistic decisions by doctors have no place in the modern world – a doctor’s duty is first and foremost to treat, help and advise a patient to the best of her ability in accordance with the patient’s wishes.

  1. http://services.parliament.uk/bills/2013-14/assisteddying.html
  2. http://www.dignityindying.org.uk/assisted-dying/public-opinion/
  3. RCGP http://www.rcgp.org.uk/policy/rcgp-policy-areas/assisted-dying.aspx
  4. http://bma.org.uk/practical-support-at-work/ethics/bma-policy-assisted-dying
  5. http://www.pulsetoday.co.uk/clinical/therapy-areas/elderly-care/more-than-two-thirds-of-gps-think-rcgp-should-change-stance-on-assisted-dying/20005114.article#.Uwntvf2s1g0
  6. http://www.livinganddyingwell.org.uk/sites/default/files/LDW%20-%20Medicine%20-%20BJGP%20-%20Gerada%20-%20Neutrality.pdf
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The Elephant in the Flood

Posted on February 13, 2014 by Elen Samuel

As we all look at our TV screens at the devastation caused by the recent flooding of the Somerset levels, the Thames and the Severn, our thoughts turn to climate change. Storms, unstable weather, floods were all predicted years ago by scientists noting the increased levels of carbon dioxide in the atmosphere, and most people can see the connection. Global climate change is also influenced by other factors such as sunspots1 and normal cyclical changes in weather systems, but few can now deny the contribution that our species makes.  So, looking for answers to the floods, we turn first to spending money for relief, making sure insurance systems pay up, then to better management of our rivers, more planting of trees at the river sources, possibly dredging (though this is disputed2), managed retreat of our coastal regions, and even looking at whether we really should continue building on flood plains.

But I see no mention at all of the basic problem. England, taken on its own, is already the most over-crowded country in Europe; the UK is 73% ecologically overshot (data from the Blue Planet Award-winning Global Footprint Network), and it is England that is suffering from the floods. Yes, Wales and Scotland have been affected, but not nearly to the same extent. (Anyway, they are used to rain aren’t they?) England, and especially the South of England, is suffering from severe problems of sustainability. The pressure on housing, especially in the Thames valley, is immense and flood plains are easy targets. In dry summers, people love to be by the river, and the risk of floods is forgotten.

It is hard-wired into our brains to want children. They bring meaning to our lives, joy, and even now, prestige. Some of my friends, now grandparents, take great pride in their tribe of offspring – some have ten, fourteen grandchildren. They are wealthy people, why shouldn’t they? But there has been an 18% increase in the birth rate in the UK in a decade, according to figures from the national census3. This is partly due to the higher birth rate of recent immigrants, but the indigenous population is having most of the babies. Britain’s population rose by more than 400,000 in 2012- the largest increase of any European Union member state – putting the present total at 63.7 million.

Project these figures forward, and we find that each additional person requires us to spend £165k on housing, infrastructure, equipment and training, to extend to them the services and living standard of current UK residents4. This cost is borne by existing residents, through a higher cost of living. At the current population growth rate, this corresponds to over £1k per person each year. We will need to spend vast amounts on new power stations as well as building many more wind turbines, and it is likely that we will miss the green and renewable targets, weak as they are, in the pressure to just stay still.

How will we feed ourselves? We can’t at the moment, of course. It seems we couldn’t even during the First World War! At current consumption levels, the maximum sustainable UK population would be 15million.4 The extra food we have to buy from abroad. If the population rises to 75 million we have to import much more, and on a global scale it is far from clear that the food will be there to import. Certainly our present high standard of living, eating so much meat, is not sustainable and we are likely to see world food shortage by 2040.5

Economists always tell us that we need more and more growth – that is the only way to pay our debts, and to have prosperity in the future. So how many new jobs would the UK have to create to keep unemployment at mid-2000 rates under different population projections to 2050? If there are 88 million of us, there would have to be an annual job creation rate of 0.60%; in a lower projection, 79 million, of 0.45%; and the lowest projection, 68 million, of 0.25%. A stable population is the best economically sustainable strategy to achieve long-term economic prosperity (real income per person). 
Conversely we are also told that we need more young people to care for the increasing elderly population – we need enough tax-paying young adults to pay their pensions!  This is certainly true, as at population sizes below 50 million we would struggle with rising pension and health-care costs. Inevitably the older generation will have to keep economically active for much longer, and more women will have to work. So a stable population would bring great advantages.

In the final analysis, we may never achieve a steady state of economic activity. It seems that as the world burns fossil fuels, we get economic growth, and if we try to limit it we will get a downturn in which everyone will suffer. And if we continue to grow our economies so that people in the developing world can increase their standards of living, we will, unless we are very careful, use up the earth’s resources and destroy it. The only way out would be to continue to innovate (nuclear fusion for energy? better food production?) to prevent this catastrophe.

In the meantime, I don’t think there is any doubt that the UK needs to limit its growth. 80% of people want a smaller UK population. Immigration is becoming a huge issue, and has been too unbalanced in the past, with very young, uneducated people coming to the UK, and some may have many more children than they can support on their own. Educated and hard-working people are very welcome and contribute a lot to our society.  But family planning issues are paramount, so that each family, whether rich or poor, should have a maximum of two children.

As a doctor, I think family planning and health education need to be improved, particularly to lower the teenage pregnancy rate. Teenage pregnancy in Britain has declined substantially over the past decade, as a direct result of the work of the teenage pregnancy unit, (now closed down), and this was a great success story. However it remains the highest in Western Europe. Personally I think this may reflect several things, such as poor quality sex education in schools7 , and a youth culture where alcohol is cheap and drugs are readily available.  There is very little evidence that teenagers get pregnant in order to get benefits such as housing benefit; the usual reasons in my experience is lack of clear aims and of control over their lives.  The present changes to withdraw housing benefit to the under 25’s is unlikely to reduce the teenage pregnancy rate much, but as many of the younger generation already find it tough to get jobs and housing, it will certainly concentrate people’s minds on the affordability of more children. Another thing that should really should be prioritised is adoption – only 60 babies were adopted in 2010/118 , a record low.

Quite apart from any efforts to stop global population increase and to try to reduce the effects of global warming and climate change, we ought to look to our own interests.

A recent report from Population Matters, a charity which aims to raise awareness of the cost to humanity of population growth, concludes that the Government should:

  1. Create a national consensus that a stable or smaller population is an urgent national interest;
  2. Add Population to the duties of an inter-departmental Minister, with a small coordinating staff;
  3. Review tax and benefit policies, removing perverse incentives for large (>two children) families;
  4. Set a long-term UK policy aim of balanced migration;
  5. Promote population stabilisation policies, by voluntary means, internationally.

What do you think?

References

  1. http://www.scientificamerican.com/article/sun-spots-and-climate-change/
  2. George Monbiot, The Guardian, Thursday 30 January 2014 14.30 GMT
  3. http://www.populationmatters.org/2014/newswatch/british-birth-rate-leaps-18-decade/
  4. Population Matters O’Sullivan Jane Univ Brisbane, http://www.populationmatters.org
  5. Aiking H Trends in Food Science & Technology xx (2010) 1e9
  6. http://ourfiniteworld.com/2011/02/21/there-is-no-steady-state-economy-except-at-a-very-basic-level/
  7. http://www.ncb.org.uk/media/333301/young_peoples_survey_on_sex___relationships_education.pdf
  8. http://www.theguardian.com/news/datablog/2011/sep/29/adoption-statistics-england
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