Elen Samuel, doctor and writer

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

Posted on February 19, 2016 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Apes and Women

Posted on January 29, 2016 by Elen Samuel

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

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

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

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

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

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

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

Giving to Charity at Christmas

Posted on January 12, 2016 by Elen Samuel

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

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

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

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

Click to access syr.pdf

Posted in Health Delivery, Uncategorized | Tagged contraception, refugees, Syria | Leave a comment

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

Posted in Anthropology | Tagged cancer, diabetes, DNA, health, Neanderthal | Leave a comment

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/}

Posted in Uncategorized | Tagged British National Health Service, evidence based medicine | Leave a comment

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

Posted in Health Delivery, Health Policy, Uncategorized | 1 Comment

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

Posted in Uncategorized | Tagged health service, patient stories | Leave a comment

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

Posted in Health Delivery | Tagged Aspirin, assisted suicide, cancer, health, heart attack, statins, stroke | Leave a comment

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

Posted in Health Policy | Tagged cancer, David Cameron, end=of-life drugs, health service, hip operations, Offa’s Dyke, Wales, Wales and England | Leave a comment

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)

Posted in Uncategorized | Tagged immunization, MMR, Pertussis | 2 Comments

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