Wednesday, 17 September 2014

Cake and regurgitating babies: words, words, words

Think about the words you hear, and how they affect you. When someone says: “Would you like a slice of chocolate sponge cake?” does that somehow paint a different picture in your mind than “Would you like a segment of baked fat-flour mixture?”. Of course it does. It might even affect whether you accepted a piece or not.
Over the past three days, attending a splendid British Medical Journal conference on overdiagnosis in Oxford, it struck me again and again (and to be honest, it’s been a bee in my bonnet for a while now) how the words chosen by doctors, companies, charities, politicians and newspapers to describe our health affect our decisions. Hugely.
The most obvious example is sticking the word “disease” on the end of other words that represent, in themselves, a fairly harmless concept. The "D" word will get a normal person’s stress hormones flowing, induce fears for the future, and influence actions. Most likely, it makes us rush for tests and treatment.
Assistant Professor Scherer, from the University of Missouri, investigated this, and presented her results at the conference. Any parent knows that babies can vomit milk in a rather alarming way: it's often called reflux, colic, regurgitation. Recently, doctors have taken to classifying more extreme cases as gastroesophageal reflux disease (GERD). And interestingly the rise of this "new" condition coincided with a dramatic rise in the use of medications to treat GERD. Even though research indicates the medications bring no benefit whatsoever.
Laura Scherer investigated. She took 275 parents through a scenario, asking them to imagine that their child regurgitated and cried excessively. They were all told that medications didn’t help. But half the parents were told that the doctor in the scenario diagnosed the condition as gastroesophageal reflux disease, and half were not. 
The result? The parents told that the condition had a long name ending in “disease” showed considerably more interest in medicating the child, even though they knew the medicine was unlikely to work. And they were also less likely to believe that the child would get better without medication. In other words, use of the "D" word would lead to them over-treating their child with a useless medicine.
Doctors and policy makers struggle with why people make bad health decisions, or get over-anxious about their health. And often – very often – the answer is that simple. Words, words, words.

Thursday, 11 September 2014

Former Pharma: Tremol and the National Infirmary for Bad Legs

What’s the difference between a legitimate medicine and a quack cure? Until medicine regulations were introduced in the 1960s, it was virtually impossible to tell – especially when the product was being marketed by medics at a national hospital. Supposedly.
Step forward Tremol – a cure for “varicose ulcers, varicose eczema, sore legs, swollen legs, painful joints”, widely advertised in story magazines of the 1910s and 1920s. Its purveyors? The National Infirmary for Bad Legs in Manchester. Yes really. They apparently worked from Ward CA (occasionally ER) of the institution on Great Clowes Street in Broughton. “Every form of bad leg succumbs to this new treatment” said the advertisement. “You are cured to stay cured for all time.”
The form the “infirmary” actually took is uncertain – there are no records of any type of hospital on Great Clowes Street. But we do know that the British Medical Association investigated it as early as 1912, and found evidence of pressurised selling. It also found no sign of supervision by a “fully qualified medical man” as the infirmary claimed. “If there is a registered medical man connected with the place, he is certainly acting in a way that makes him liable to be arraigned before the General Medical Council.”
The BMA’s analysis of the “Tremol blood mixture” (one teaspoon to be taken morning and evening) revealed the following ingredients: calcium chloride, ferric chloride, hydrochloric acid, rhubarb infusion, peppermint, water. Nasty. Yet Tremol clearly had a market and continued to be sold until at least 1928. Bad legs make you desperate, you see. 

Tuesday, 9 September 2014

Deafened by a killer yukka (nearly)

Clogwog/Foter/Creative Commons
Last week I was nearly deafened by a yukka plant. It’s certainly up there, as odd injuries go. You may be interested to know that every year there are around 2,500 household plant-related injuries reported in the UK, though I haven’t been able to find out how many are caused by yukkas.
The overgrown houseplant toppled off the window ledge as I was trying to open a window, and it sent one of its sharp spear-like leave straight down my ear canal. The pain when it hit my eardrum was exquisite. My hearing started to go all buzzy.
The reaction of my doctor (and this is the reason I’m writing about this) improved my morale no end. As I told him what had happened, he actually grimaced (I think I was expecting laughter at my unluckiness). Then, taking up his otoscope, he looked in my ear. He delivered his assessment: “Ouch”, he said. I could have hugged him. 
What we expect from doctors is mild chastisement, or impatience, or bewilderment. What I got was a little bit of honest human empathy, and I didn’t feel such a fool any more. 
“You’ve got a huge blood blister on your ear drum,” he said. “But don’t worry, it should get better by itself. Even if the ear drum is punctured, it should heal over. Come back if it gets any worse.”
More plus marks for my doctor. “It will get better by itself.” That’s what I like to hear. Most things do. I remember another doctor at the surgery, whose first reaction to a mysterious and huge swelling on my daughter’s foot was to squeeze it to see if it popped. “First do no harm” indeed. I’ve never consulted him again.
I can hear fine how.  No buzzing. The yukka has been pushed into a safe corner. And my faith in medicine has been boosted no end by my doctor's well-judged squeamishness and inaction.

Friday, 6 June 2014

"I say Holmes, have you seen this rum story about meningiomas in today's Times?"

The curious case of the mobile phone and the elusive tumour 

I’ve been trying to think of the right word to describe how we should read health stories in newspapers, magazines and online. Sceptically? No, that’s not right.
My thoughts are prompted partly by the fact that I’m judging several journalism awards at the moment, and partly by stories that have appeared in the Daily Mail and the Guardian on new evidence of a link between mobile phone use and brain tumours. This week Cancer Research UK published an excellent analysis of these stories.
The mobile phone stories reported that a new study had found that people who used their phones more than 15 hours each month had two to three times the risk of developing glioma and meningioma tumours. Cancer Research UK has, in turn, provided the context.
The headlines are misleading, it says. The quoted study was small and had several flaws. Many larger, more authoritative studies have indicated that there is no link. No study can be taken in isolation, and all have limitations. Quite right. As Cancer Research UK says: “When the media report small increases in already-small chances as meaning people who do a particular thing are ‘particularly likely’ to develop a disease it not only is a complete misrepresentation of what a study says or means. It also scares people.”
Yet I’ve been there. There are immense pressures on journalists to produce stories that sell or scare. PR people are also constantly selling us stories about health benefits or concerns, often seemingly quoting reputable research – which only on close analysis are revealed to be a distortion of the facts or part of a sophisticated marketing campaign (often from industry) designed to look independent and science-based.
Sometimes journalists peddle out the sell or scare stories. But sometimes – a lot of the time – journalist are very good at revealing the oversimplifications, exagerrations and even deceptions we are fed, not just by industry but by charities and scientists themselves. Don’t just think Thalidomide and MMR, think the current sugar controversy and the way the media has spotlighted clashes in the scientific about the benefits and drawbacks of statins.
So how should we respond, when we read about cancer and mobile phones, sugar addiction, statin side-effects or miracle-working?
With scepticism? No, scepticism is not the word. Not pragmatism either – which sounds as if we shouldn’t care. I wondered about intelligence, but not all of us can immediately access knowledge to help guide our judgement. If only we could all be Sherlock Holmes, capable of using a knowledge-packed, rapier-sharp mind to cut through concealments to recognise the truth for what it is.
The best I can come up with is that we should approach all these stories with curiosity – the very quality that produces the best in health journalism. We can all wonder, ask questions, and refer elsewhere to fill in gaps in our knowledge. In an information-rich world, doing a little bit of your own legwork isn’t that big a commitment on subjects that really matter. We’re all capable of saying: “Really?”; “According to whom?”; “Do other studies have the same finding?”; “What criminal mastermind might be behind this?”
We may not all be Sherlock Holmes, but most of us can be John Watson – diligent, alert to clues, hungry for the truth and prepared to ask someone else if we don’t know the answer.

Thursday, 6 March 2014

Age of the sugar-free caveman

High protein diets are as deadly as cigarettes. Sugar is addictive and the real cause of diabetes and the obesity epidemic. Diets high in saturated fat are not bad for you...
Boy, it’s been a week and a half of headlines when it comes to diet. Healthy eating? It’s all up in the air.
As far as I’m concerned, the uncertainty is a good thing. Health and diet isn’t about having lots of the things that are “good” for you and none of the things that are “bad” for you. It’s about balance. Not least because our knowledge about what is good and bad is constantly changing – remember it took 150 years of tobacco use before we finally worked out it was bad for you in 1950. 
But balance isn’t easy for us, because our environment is constantly discouraging us from moderation. The world of market forces depends on giving us more and more of what we want.
Yesterday I was talking to a representative of food and drinks companies, who asked me how the industry could get the trust of the public and journalists like me. (This, appropriately enough, was on the day that Sally Davies, England’s chief medical officer, suggested a sugar tax in the face of the food industry’s reluctance to reformulate sugary products.)
It struck me as a curious question. I tried to explain to her that trust is a strange quality to expect from a journalist, whose job it is not to trust anything. Even for the general public, “trust” is complex: just because you trust a company to provide a crisp that gives you the flavour you want, it doesn’t mean you trust it to provide something healthy. 
I suggested to her (perhaps a little too bluntly) that the words food, industry and health are incompatible. As long as food production is organised into large companies, the priority will be – has to be – making money. Making money out of food involves giving people what they want.
If foods that naturally appeal to us are offered to us at very affordable prices, then we are going to eat more and more of them. And the fact of human biology is that we are programmed to crave foodstuffs that, in our ancient history, gave us an important survival boost but were available only in small quantities. For ancient man, getting some sugar and fat into your system over the course of a long winter might be the difference between surviving and dying. Today, such is the surplus of sugar and fat we are confronted with that they are the threat to survival.
It’s all about supply and demand. For our health’s sake, what we need to do is artificially create a new caveman environment: free from the danger of famine, free from the danger of surplus. 
One way to do that would be to control how much of these products we could afford, for example by introducing a sugar tax, as proposed by Sally Davies. Not a bad idea, not perfect. Another way would be to ask the food and drink industry to genuine re-think everything they do: limit the supply of the foodstuffs we crave, make genuine efforts to reformulate products, stop trying to convince us that brands full of sugar, fat or salt are really “healthy”, embark on a national, collaborative endeavour to reshape our tastes.
Do I “trust” them to do that? No, I’m afraid I don’t, and that’s what I told the unfortunate woman on the telephone. They simply wouldn’t take the risk to profit. The food industry thrives on “more” and “less”, “high in...” and “low in..”, “good for...” “bad for” – those are the marketing messages that produce profit. Our bodies don’t thrive in that world. So, barring everyone becoming self-sufficient, it looks as if taxes and government interventions are the only way forward.

Tuesday, 11 February 2014

Forgotten gurus: Lionel Stebbing

“Be tall”; “Robust health”; “Manly strength”; “Double your stamina”. Through the 1920s and 30s, advertisements for the Stebbing System in comics and magazines tantalised boys and young men with the prospect of a rock-hard, muscle-bound and lofty manhood. Much the kind of vision dangled before men today in Men’s Health magazine. 
“Your height increased in 14 days or money back” promised Lionel Stebbing, who called himself a personal consultant in body building and health practitioner. “I positively guarantee to give you perfect health and double your stamina in 30 days or return your money in full.”
All you had to do was send Mr Stebbing five shillings, then simply adhere to the suggestions Mr Stebbing sent to you in the form of a typewritten “4-in-1 supercourse”.  The course was a mere matter of meeting his daily requirement over the course of two weeks: 27 exercises, two and a half hours outdoors, relaxing, smiling, never bearing a grudge, drinking a quart of milk, eating fruit, vegetables and dripping, taking patent vitamins, deep breathing exercises, muscle control movements, bathing in Stebbing bath revitaliser... and much much more.
Sound advice perhaps (apart from the dripping) – but could a young lad’s life possibly accommodate so much healthy activity in 14 days?  
But Mr Stebbing was no fool. A man of many talents, his other publications included: “The Secret of Beautiful Magnetic Eyes”, “Stronger Sight without Glasses”, “How to Develop a Perfect Voice”, “Music, it’s Occult Basis and Healing Value” and “The Correction of Stammering”.  
It was only when he neared the end of his career, in the 1960s, that he let the cat out of the bag about his own dubious expertise in all these matters, when he published two little business books candidly titled: “How I made a fortune with a home mail order business” and “How you can build a second income fortune at home without special skill or expertise”. 

Yes, all Mr Stebbing’s endeavours selling his skills were made without any skill – apart from entrepreneurial, creative and typewriting ones – from his small semi-detached house at 28, Dean Road in Willesden, London – a house you can still see to this day. Alas there is no blue plaque.

Sunday, 2 February 2014

A letter to Bill Bailey part 2: the scary bits

Dear Bill Bailey

Hyena Reality/Free Digital Photos
Here is my (probably not) much-awaited second letter to you. As you’ll remember, I’ve got worries about the messages that Prostate Cancer UK is putting out as part of their Men United campaign – a campaign that, with your involvement, is already having widespread coverage on television, in print media and online.

Prostate Cancer UK – and in particular its Chief Executive Owen Sharp –  has taken to saying as part of the campaign that “by 2030, prostate cancer will be the most common cancer”. Scary.

It’s certainly a useful message to spread if you’re an organisation that wants to raise awareness and lots of money – make prostate cancer have the same sort of public impact as breast cancer. 

Unfortunately, it’s also badly misleading to the public. Money shouldn’t be raised by throwing around convenient statistics to frighten people, when they are only a small part of a complex picture.

The figure much quoted by PCUK comes from a study in the British Journal of Cancer in 2011, which predicted that prostate cancer incidence among men would rise 2% between 2007 and 2030 (doesn’t sound quite so frightening does it?). 

It also stated that, although the estimated rise in cases of prostate is partly attributable to an ageing population, it is also the result of more and more men having PSA tests, uncovering disease that wouldn’t previously have ever been known about.

The authors give an explicit warning: “There is considerable uncertainty,” they say, “in predicting prostate cancer incidence, which is being driven not only by an inherent increase in risk of the disease, but also by the over-diagnosis (and over-treatment) as a consequence of testing with PSA.” 

In other words, increased awareness of prostate cancer causes more prostate cancer. Men Utd, ironically, will raise the incidence of prostate cancer.

I hope you understand that there is no way I want to belittle prostate cancer and its impact. My father died of it, I am at higher risk than most men. But Prostate Cancer UK and Movember (which have been increasingly closely aligned) want to make prostate cancer into a men’s version of breast cancer – same high profile, same kind of campaigns, same fundraising clout – without learning the lessons from breast cancer, without thinking how prostate cancer is different than breast cancer, and without thinking about the costs of getting things wrong. The cost, unfortunately, will be a very large number of men suffering unnecessarily. 

If PCUK really wants to help men it needs to be responsible. It needs to recognise that powerful fundraising messages aren’t the same as valuable public education messages. I hope you will discuss this with them.

Thank you for reading this. Now I will leave you alone to be wonderful, funny and inspiring again.

Simon

Tuesday, 28 January 2014

A letter to Bill Bailey

Dear Mr Bailey
I’m a fan, but hopefully not in a spooky way. My children have been brought up on Part Troll, Dandelion MInd, your Remarkable Guide to the Orchestra and even your peculiar Birdwatching Bonanza. I’m delighted that, as frontman for Prostate Cancer UK’s Men United campaign, you’re lending your support to fighting prostate cancer. It’s a really worthwhile cause, and better treatments, support and screening tests are desperately needed. 
But I’d like you to think about about a couple of things that Prostate Cancer UK is encouraging you to say. Because the fact is that your advice may hurt more men than it helps.
You’ve been advising men to talk to their doctors about the prospect of prostate cancer – even if they have no risk factors, family history or symptoms. This week’s PCUK campaign was launched with the message that men should “man up” and start the conversation.
With what object? 
You will know that there is currently no effective screening test for prostate cancer – only a very inaccurate one (the PSA test) which leads to unnecessary and harmful biopsies, and unnecessary and harmful prostate surgery. So what happens after men have manned up for the conversation with their GP?
Let’s imagine that the Men United campaign is a huge success: so successful, in fact, that all men over the age of 50 go to their GPs and start talking about their prostate cancer. And let’s say that, as a result of that conversation, all their ultra-keen doctors decide to play things safe and give their patients PSA tests and biopsies to check for prostate cancer. 
What will be the result (apart from a lot of pain and urinating problems caused by the biopsies)? The result will be that third of the men will be found to have prostate cancer. Yes, that is correct. Autopsy studies consistently show that prostate cancer is regularly found in men who die of other causes, who never even knew they had cancer until their dying day. You can see one recent piece of such research here
So one in three men over the age of 50 have prostate cancer. But prostate cancer accounts for just one in 20 deaths. Put the two together, and the campaign to get all men to start addressing prostate cancer doesn’t add up.
If a million of men go to the doctor as the result of your campaign, a few may have their lives saved by early investigation. But the lives of many thousands will be wrecked with impotence, incontinence, pain and anxiety as a result of unnecessary testing and treatments.
That isn’t a good solution.
What we need are better screening techniques, better ways of differentiating the tiger cancers from the pussycats. I know that your profile-raising work will help raise money to do just that, and that’s very good news. But please don’t make out, as Movember and Prostate Cancer UK are fond of doing, that the answer to prostate cancer is to get men to talk to their doctors about getting tested. It creates as many problems as it solves. Maybe one day, when the tools are there to do something useful, but not now.
My second point will have to wait for another day. Thank you for listening.
Simon

Tuesday, 7 January 2014

Episode 8: the blood begins to flow

The story so far... in the midst of following an international trail of subterfuge, agent John Drake has found himself pursued by doctors and dragged down by unexpected suspicions of lurking disease. Now he has awoken in a strange hospital, with no idea how he got there...
Sinner Photography/Foter.com/CC-BY-NC
“There, I think that’s enough blood,” Nurse Cooper held up the full syringe to the light.
“I want to leave please.” Drake struggled to raise himself from the bed. His legs still failed to respond.
“You are free to leave at any time,” said Nurse Cooper with a smile as she decanted the crimson fluid into specimen containers. 
“Well, give me a hand then.”
“I’m sorry, I can’t do that. It would mean I was abetting you – defying the wishes of the doctors. I can’t go against the wishes of the doctors. We’d all like you to stay.”
“Why?”
“We’d like you to be well.” Nurse Cooper smiled her bland smile again. 
Drake flumped back onto the pillows. He was powerless, and he lay there inwardly fuming. He heard the sharp tap of footsteps echoing down the white corridor, and then a dark and familiar figure appeared at the nurse’s side.
“Dr Sixsmith! Finally someone who can inject some sanity. Please will you get me out of here.” 
Drake’s GP patted him on the arm. “Sorry to see you here old chap,” said Dr Sixsmith. “But the thing is, it’s the best place for you. We need to get to the bottom of why you collapsed yesterday. It’s also an opportunity to follow up on those abnormal readings we were getting for your prostate, cholesterol, blood sugar, blood pressure...”
“Abnormal? What do you mean abnormal? You told me they were nothing to worry about.”
“Yes, but they were still outside the normal range. They might indicate arterial problems for example. Now be a good fellow, sit tight and we’ll soon have you as right as rain. Be seeing you.”
He turned to go, and as he did so took Nurse Cooper aside. “Nurse, would you mind trotting along to the Director. Tell him that Bed Number 6 is settling in fine, but we may need to make to accommodate him for a few days. We want to make sure he’s well. Would you mind passing on those words?”
Nurse Cooper nodded eagerly.

Saturday, 21 December 2013

Why aren't apples more tempting? Adam speaks

It’s so simple if you look at the research. An Oxford University study, published in the British Medical Journal, has concluded that eating an apple a day could save as many lives in the over 50s as a daily statin.
Regular readers of Danger Man’s Doctor will already be aware of our interest in brocolli, and apple is as noble a variety of vegetation. Readers will also be aware of our curiosity that, while everyone bemoans the nation’s stubborn refusal to eat more of said brassicas and fruits, no one stops to ask why we won’t do as we’re told. 
The Oxford University study is a case in point. “We could all benefit from simply eating more fruit,” says study author Dr Adam Brook wistfully, in the face of evidence that one in ten of us can’t even manage one portion of fruit and veg a day.
If people did ask why we aren’t listening, they might find some answers quite quickly. Strong clues came in two news stories published in the past fortnight.
First, a study in the Journal of Consumer Research found that we remember the least when we feel most threatened. If information makes us worried, our brain’s first response is to blank it. 
The researchers used the example of breast cancer awareness campaigns: an advertisement dwelling on women’s vulnerability to the disease is likely to make them feel threatened, and the prevention message is more likely to be forgotten.
As we’ve said before on this blog, scaring people about health doesn’t work. We freeze like rabbits in the glaring headlights of our impending mortality, and can only move on by forgetting we ever heard the message.
The second enlightening news story was that drug giant GlaxoSmithKline has announced it will stop paying doctors to promote its drugs at medical conferences. Amazing that it ever happened at all isn’t it? 
What this tells us is that getting an accurate picture of what’s good for us – not a simple prospect in itself – is made much more difficult by commerce weighting the answers we get. Industry funds research about industry’s products – which is why there’s a wealth of evidence showing the benefits of statins, but hardly any research showing the benefits of apples. Why would drug companies fund research into apples? Why would multinational food companies for that matter? Until someone comes up with a body of research about apples that compares with the vast amount invested in for statins, doctors are not going to be prescribing fruit.
It’s not really our fault that we don’t behave sensibly when it comes to our health. It’s the result of health information campaigns being based on how we’d like humans to be, rather than how we actually are. And it’s the result of industry simply having too much clout in determining what doctors tell us and what foods are allowed to seduce us.  

Wednesday, 4 December 2013

Bad gen on the antigen

I’m a loyal follower of The Times: I worked for it for 14 years. I’m also a great supporter of prostate cancer support and research: my father died of the condition.
So you’d have thought I’d be rejoicing about the fact that this year The Times Christmas Appeal is supporting Prostate Cancer UK. But I’m not. Why?
Because it seems the charity is using this wonderful opportunity to raise money for research, to promote messages about prostate cancer which are unhelpful and possibly damaging.
This week the journal Biomarkers in Medicine pointed to the shortcomings of the PSA (prostate specific antigen) test in diagnosing prostate cancer or indicating its aggression. It highlighted the need to find new biomarkers that would provide doctors with a genuinely useful test – one that wouldn’t throw up vast numbers of false positives, and expose men to tests and treatments that could leave them unnecessarily impotent, incontinent or in pain. Such a test currently does not exist.
The prostate specific antigen. Pic: EAS 
Yet here in the same week is Owen Sharp, Chief Executive of Prostate Cancer UK, quoted in an article in The Times to launch the appeal:
“Low awareness of the PSA test means that lives may be lost every single day because men don’t know what is already available to them,” he said.
“We know that GPs are turning men away and talking them out of it. It’s not the majority but it’s about one in eight. Some of them don’t believe in the PSA test. We have calls from men about this all the time and I spoke to a man last week who had a stand-up row with his GP to get the test. We need to be very clear that having had the conversation, it is men’s choice and they shouldn’t be turning men away.”
A more responsible approach might be to support GPs who are not rushing men into having a potentially damaging test; to make clear that the PSA test is the bluntest of instruments; to stress that this is exactly why all of us need to support the quest for a new test.
Thankfully, Rosemary Bennett, the Times journalist who wrote the piece, had the sense to put Sharp’s words into context with comment from GPs about the dangers of PSA testing.
And they say it’s journalists who over-simplify... 

Friday, 29 November 2013

Men's health in proportion 2: the God Doctor

You will remember that in a recent post I looked at a crowd of 100,000 men in one of the world’s largest football stadiums, and asked what they’d all eventually die of. The surprising answer was that around a fifth of them would die from heart disease and stroke, less than a 20th of them would die from prostate cancer, and around 40% of them would die from dozens and dozens of less common conditions that we rarely think about when it comes to men’s health.
Photo credit: Dieter Drescher / Foter.com / CC BY-NC-ND
Let’s take another look at this crowd, this time from the perspective of a psychic doctor who has the power to see one year into the future. Let’s call him the God Doctor (some believe he exists). When he looks down on the football crowd at a game being played in May, he can see who is going to be diagnosed with a new condition before the following May.
What he’ll find is this. Out of the crowd of 100,000 men:
  • 500 (that's one in 200) will be told they have heart disease
  • 250 will have a heart attack
  • 180 will have a stroke
  • 105 will be told they have prostate cancer 
  • 58 will be told they have lung cancer
  • 58 will be told they have bowel cancer
(The figures aren’t exact, because sadly disease incidence figures aren’t easily comparable, but it provides a rough idea).


You may look at such statistics, as I do, and draw some simple conclusions. You may say...
“Getting to grips with how I can avoid disease/keep alive, isn’t simple.”
“If I’m going to live by the law of averages on what’s going to kill me, then I’m going to concentrate on reducing my risk of stroke and heart disease. If I exercise properly, eat a varied diet and stop smoking, I’ll definitely be reducing my risk of conditions that definitely kill a lot of men – heart disease and stroke.”
“If I do that, it’s very likely that I’ll reduce my risk of all those other conditions, like many cancers, where smoking, diet and exercise may play a part.” All good thinking so far. Entirely sensible.
But then you might think some more about these statistics and the statistics about mortality in the previous post and start to get confused. With prostate cancer, for example, it looks as if there’s a reasonable chance of me getting it, but much less of a chance of me dying from it. And you might start to wonder whether statistics can be used from many perspectives, according to what message you want to give the public.
Most of all, your confusion might result in one big question. What about me? It’s all very well having these averages for populations, but what if you’re my age, with my parents, in my country, with my background? What if some diseases actually hold more fears for you: should that be ignored?
Good point. I’d like to talk about that some more, because in this age of “personalised medicine”, we’re absolutely rubbish at personalising information to make it useful. More in another post.

Monday, 25 November 2013


Mental disintegration: the unacceptable face of cricket

Well done then, Australian cricketer David Warner. There you are sporting your Movember moustache, supposedly declaring your allegiance to the cause of men’s health, supporting men who are struggling with physical and mental health problems.
And then, after the Aussies paste England in the first Ashes test match, you gleefully declare that the performance of England cricketer Jonathan Trott was “poor and weak” and that he had “scared eyes”. You promise him there will be more “sledging” (the cricketing art of heaping abuse on batsmen with the aim of causing “mental disintegration” – a term coined by one Australian captain ). 
“Disrespectful” is how the cricketing community has condemned Warner’s words. For those who care about mental health, the condemnation should be stronger – particularly after the news that Jonathan Trott has now had to withdraw from the Ashes tour “because of a long-standing stress-related condition”.
In some machismo circles, it is seen as a necessary part of being a competitive male that you should put those down who can be labelled weak or mentally frail.  In school, such behaviour is called bullying.
Can it have any long-term effect? You bet. More and more studies are showing that bullying leads to mental health problems. A study published in one of the most respected psychiatric journals this year found that victims of bullying were nearly five times as likely to have anxiety and panic attacks than those who weren’t bullied.
It’s pretty clear that David Warner’s comments didn’t cause Trott’s stress-related problems, but they didn’t help. Anyone who really wanted to help the cause of men’s health wouldn’t be attempting to cause mental disintegration. Perhaps David Warner needs to be told that nearly 10% of premature male deaths are the result of suicide, self-harm and accidents. 
Hairs come easy. Actions don’t. 

Friday, 22 November 2013


Men's health in proportion: the football ground

Welcome to the Nou Camp stadium. It’s the Champions League final 2015 between Manchester United and Chelsea. The ground is massive – it has a 100,000 capacity. Today it’s full at the seams with a crowd is entirely made up of British men and boys – of all ages from five to 90. The women have something better to do.
Let’s look at this crowd of men, with the eye of an all-seeing God who can look into the future. And let’s bear in mind that this is an unusual crowd, because as it represents a cross-section of the entire British male population – one in six is over the age of 65. Quite a few will be there in wheelchairs.

The God view of the crowd 

Out of that enormous crowd of 100,000 men, 847 will die in the coming year. Nearly half of them over the age of 80.  
What will they die of? I’ve scrawled over the nice picture of the Nou Camp to give you a general idea (below) but here are the figures (based on data from National Statistics).

136 of them will die of heart disease (16.1% of the deaths)
61 of them will die of lung cancer (7.2%) 
52 of them will die of a stroke (6.1%)
49 will die of respiratory disease (5.8%) 
43 will die of dementia (5.1%) 
39 will die of influenza and pneumonia (4.7%)
40 will die of accidents, suicide and self harm (4.7%)
34 will die of prostate cancer (4.1%) 
27 will die of bowel cancer (3.2%) 

Picture: Oh-Barcelona.com/Foter.com/CC BY

You’ll be wondering what all the others died of. Other types of cancers, liver disease, and dozens of other conditions that affect a smaller number of men across all age ranges.
What does this show? Well, it shows first of all that people die, even if they’ve just been to the football. You’re not “unlucky”, you’re just human. You’re part of the football crowd.
What else does it show? It shows that an awful lot of men die of heart disease, and not that many from “male specific” conditions like prostate cancer.
It’s one way of getting our health, and the things we should worry about, in proportion. There are others... coming soon.

Tuesday, 19 November 2013

Getting health in proportion: the No I'm Not Lost Effect


So you’re a practical, generally responsible chap – most of us are. You’re concerned about your health, in a vague sort of way. Most of us are. You don’t want to die, you don’t want to burden to your family, you don’t want to be useless. Most of us don’t.
But you also find the whole health thing a bit of a pain. You’re fed up with everyone telling you to start doing this, and stop doing that. You frankly don’t want to spend your life at the doctor’s surgery: it seems dull, dependent, confusing and might confront you with something that makes your life more complicated than it already is. 
This is what I call the No I’m Not Lost Effect. It’s a cliché, but still perfectly true, that most men would rather have their toenails pulled out with molegrips than stop the car and ask someone for directions if they’re lost. The invention of satnav may have saved men a haranging from women passengers only too willing to acknowledge failure to passers by, but the problem persists in health. 
"For God's sake Amanda, don't ask that man
for directions!"
Men want to find their own way when it comes to keeping healthy. We’d rather do our own own groundwork, find ways of doing things that fit our own lives, decide our own routes and not have to stick what some so-called “expert” says is the proper way.
There’s another cliché about men which is relevant: that we can’t multitask. We like to focus on one thing at a time. The truth is that it is impossible for the average male to absorb, assimilate and implement all the health information fired at us by doctors, health education campaigns, or the media. There’s just too much – or even if there isn’t too much, it seems too much. We don’t want our brains cluttered with stuff which may or may not be relevant to us. 
Clearly, ignoring the opinions of others and concentrating on one thing at a time has its hazards. But I don’t think it’s stupid. I’d say it has its advantages.
What if we built on men's need to control and focus?  Men need to be helped to work out for ourselves what we’re most likely to die of – doctors could do more to help us do that. Because frankly we’re currently being told to worry about too many things that will never, ever effect us.
Each of us will die of something nasty: a single condition. Before that happens, it is possible we will be affected by anything between none (if we’re very lucky) and 20 (if we’re very unlucky) potentially serious conditions. Some of the conditions we get will be completely unpredictable – against the odds and possibly obscure – so there’s little point in trying to predict them. 
But some, and particularly the ones we are likely to die of, are much more predictable.  This is either because of our family history, or because simple statistics reveal how common they are in men.
As a society, we’re very bad at helping men get things into proportion in this way. I’ll be trying to help in posts that follow.


Thursday, 14 November 2013

Men and women: one size doesn't fit all

So which is the sneezier gender? New research from the American College of Allergy, Asthma and Immunology shows that women are more at risk from allergies, asthma and other diseases that affect the body’s immune system.
The researcher, Renata Engler, has also found that the pattern of which gender is most susceptible to allergies changes over time – in childhood, it’s boys who suffer more.
Why is such research important? Because it joins a growing body of evidence that men and women have radical differences when it comes to physiology and health. For example,  it’s only in the past decade that doctors have begun to realise that heart attacks manifest themselves very differently in women than men. Women are less likely to get classic chest pain, and more likely to have indigestion-like symptoms.
It's increasingly clear that lumping everyone together in terms of typical symptoms, likely diagnoses, optimal treatments is not only unhelpful, but also potentially dangerous. In this supposed age of personalised medicine, one size won’t fit all. Which is particularly obvious (if you stop to think about it) when it comes to big hulking men and less than big and hulking women. 


Tuesday, 12 November 2013


Episode 7: Admission

The world gradually congealed into view. Drake was looking at a fluorescent light on a polystyrene tiled ceiling. Around him were curtains and above him stood a man with a benign smile on his face, wearing white.
“Where am I?” asked Drake.
“In the Hospital” said the man.
Drake was confused. “What do you want with me?”
“Well, we don’t want anything, apart from to make you well.”
Drake was trying to work out how he could be in a hospital, when he was clearly in a reeling ship. The room was swaying and he felt sick. Altogether he felt extremely strange, disconnected, and he didn’t like the look of the man in white now bending over and looking into his eyes. 
“Whose side are you on?” Drake demanded, but his words seemed slow and delayed. He tried to focus: the face had something of Kolotov about it.
The man looked puzzled, and then impatient.
“Look, you’re here because you had a nasty turn. We want to make sure you’re alright so we’re running a few checks. Now just relax, and we’ll soon have you as right as rain.”
You must be joking, thought Drake, and leapt out of the bed. Except he didn’t. He couldn’t. His legs didn’t move at all. He tried to heave himself over the bed rail with his arms, but the man in white stood in his way.
“I’m afraid you don’t have use of your legs at the moment,” said the man in white. “We’re not quite sure what’s happened yet, but it’s possible you’ve had some kind of small stroke, so we’re running some tests.”
Drake tried to think back. What was the last thing he remembered? He’d gone to see Dr Sixsmith, stormed out of the surgery, driven home... That’s right. Mrs Drake was out – she’d left a note to say she was meeting a friend in town. He’d gone to start packing for his trip to Zagreb and then... that was where his memory ended. He must have lost consciousness then.
“I’m going to leave you in the capable hands of nurse Cooper now,” said the man in white. He drew back the curtain and called to the other side of the room. “Nurse Cooper, will you attend to Bed Number 6”?


Thursday, 7 November 2013


Movember: a response from the Head HonchMo

Last week I talked to Movember’s Head Honcho Paul Villanti. He’d seen my earlier blog posts, raising questions about Movember’s aims and transparency. 
What he said clarified some of the muddy waters surrounding Movember, although some areas remain opaque. He acknowledged that there had been mistakes, and that the organisation had not always been clear in communicating what it aimed to achieve. 
In particular, he made clear that:
  • Movember never set out to transform men’s health in its broadest sense
  • Movember will finally be considering moving into UK mental health projects next year
  • Movember has some regrets about some of the men’s health advice it has put out in the past.


About Paul Villanti

Paul Villanti has a say in every aspect of Movember, overseeing its investments in health initiatives globally. He is not one of the charity’s original founders, but joined from a business background four years after Movember was established in 2003. Today he is Executive Director of Programmes, and a member of the Board, the Global Scientific Committee and the Global Leadership Team. He is also Director of Movember Europe, a Director on the Boards of the Prostate Cancer Foundation (USA) and Prostate Cancer Canada and is an Associate Director of Prostate Cancer UK.
That’s a lot of responsibility. 

The prostate question

I asked Paul Villanti about Movember’s focus on prostate cancer, even though the disease accounts for only 3% of premature male death in the UK. In some countries with lower male life expectancy the disease hardly features as a problem at all. “Changing the face of men’s health” surely involves tackling more than that?
He said that from the start Movember had been “results-focused”. 
“In deciding the areas to invest in, we’ve challenged ourselves to make a significant impact on men’s lives,” he said. “Strategically the decision was made a long time ago that we wanted to focus on areas where we could make a significant impact on men’s lives rather than having a Santa Claus strategy where you sprinkle a bit of money everywhere but actually not make much of a difference.” 
In the long-term, he said, Movember was all about building strong partnerships with specific organisations across many sectors, he said, and if funds allowed it wanted to expand beyond core areas: prostate cancer, testicular cancer and mental health. 
“I don’t think there’s any organisation in the world capable of solving all the problems in men’s health,” he said. “I fully accept that we aren’t tackling every men’s health issue, and I think it’s really important to be transparent about what we do raise funds for.”  
The initial decision to focus on prostate cancer was driven by the fact that investment in this field had been historically very low. There are complex and pressing issues to be resolved, such as the need for effective screening and overtreatment. “It is expected to be the most common cancer by 2030. It is a significant challenge facing men and under-invested in in every country,” said Villanti. 

The expertise question

So what research and professional expertise informs Movember’s decision-making and health advice? The Movember Board, which decides strategy, is dominated by Australian businessmen and Movember’s founders, and has only one representative with any health expertise (in prostate cancer). Its Global Scientific Committee is almost exclusively prostate cancer experts.
Villanti explained that in each country, programmes are decided on and overseen by panels of national experts in particular fields (for example mental health). These groups, he said, do not feature on the Movember website but are working behind the scenes. I asked him what expertise informs Movember’s decisions on a higher strategic level to help change men’s health. Villanti assured me that there are a large number of experts that guide strategic direction, and then moved the subject back to the specifics of programme development again. 

The mental health question

In this blog I’ve pointed to my concern that Movember UK donated no money to mental health projects in the UK in 2011 and 2012, even though its website claims it raises “vital funds and awareness for prostate cancer and testicular cancer and mental health”. 
Paul Villanti reassured me that in March 2014, the Movember Board will be looking at ways to “expand investment” in the UK beyond prostate and testicular cancer. 
“We had always planned to review our options at this stage,” he said. It will be engaging independent experts in men’s health to inform this process, and will seek advice from mental health groups. “We expect the advice we get to inform the process,” he said. 

The health awareness question

I explained to Paul Villanti my reservations about Movember’s much-vaunted “awareness and education” work in the UK, which seems to consist entirely of hoping men will talk more about their health as a result of growing moustaches. There’s little evidence that talking about health, or going to the doctor for check-ups, will result in men living longer, I pointed out.
He acknowledged that there is much we don’t know about men’s health behaviour. However, it is clear that men have lower levels of health literacy than women, and this results in poor health outcomes, he said. “Step one obviously is to increase their levels of education and awareness, and the Movember campaign is respected across prostate cancer and mental health because it uses the unorthodox concept of using fun to increase men’s awareness of the risks they face, try and educate them and encourage them to take action when they’re sick.”

The screening advice question

Over the past two years, doctors in the UK and elsewhere have criticised Movember’s health education advice. Until late last year, its website advised men over the age of 50 to get a PSA test – even though the test is very contentious because of the dangers of over-diagnosis and incorrect diagnosis. 
Until last month, its website advice on colon screening and aortic aneurysm was at odds with NHS recommendations. The website still said that prostate screening at age 40 was “reasonable” and its information on mental health problems suggested they went no wider than depression. 
Villanti told me that Movember hadn’t recommended the PSA test since 2011 – it had instead encouraged conversations about screening with GPs. But he acknowledged that its attempts to take a global position on men’s health last year – including a recommendation on its website last year that men should have an annual health check and specific checks at different stages of their lives – had not succeeded.
“With the benefit of hindsight, there were a number of weaknesses with that approach which we have taken on board,” he said. Much of the advice Movember put on its website had been based on information from the Australian College of General Practitioners and other Australian health bodies. “What we realised was that there are major disparities in what professional health bodies say from country to country. To us, that seemed incredible: it’s supposed to be based on the best evidence out there. We can’t understand why one country recommends one thing, and another recommends another approach.” 
He emphasised that the organisation did have serious concerns about over-diagnosis and over-treatment, and the problem was being investigated in various Movember programmes. I told Villanti that his concern about over-treatment was not reflected in the messages that Movember pushes out.
“One of my big frustrations is that we don’t know at a population level how bad some of these issues are, and how different treatment modalities relate to poor outcomes, so we are investing in a national cancer registry in Australia. We see that as a powerful vehicle for improving the quality of treatment, and we’re hoping to do something similar in the UK.”

With Movember now in full flow, and millions already donated by members of the public, it’s surely right that those who oversee it are kept on their toes – something that, up until now, hasn’t been done in the media. We all love the story of how Movember grew from small beginnings, but it isn’t the only story. 
It’s good that Paul Villanti is prepared to respond to comment and concerns, and I hope that there are messages the organisation will take on board, because it has too good an opportunity to waste.
Movember needs to be more open about its strategy – even if that makes it appear more limited in its scope than it would like.
Movember needs to draw in a wider range of evidence and expertise when setting strategies and goals, and providing health advice.
Movember needs to be global in outlook, as well as activity – not taking Australia as a template for what the rest of the world needs.
Most of all, Movember needs to step up its game. It started as a group of Aussie blokes in a pub with an idea to change the world and the skills to bring it off, but with very little understanding of health or its global dimensions. Mistakes are bound to happen as long as Movember’s tight-knit structures and decision-making continue to reflect that historic and naive starting point.


video

Monday, 4 November 2013

Forgotten gurus: George R Sims

In this, the first week of Movember, let’s celebrate a true guru of male hair growth: George R Sims, journalist, dramatist, novelist, social reformer, gambler, sportsman, bulldog breeder and inventor of Tatcho hair restorer. 
Sims made a fortune from his diverse activities, and became a Victorian celebrity. By 1898 he earned £150,000 a year. Late in his career, he invented a hair tonic to prevent “inevitable” loss of hair, and the money continued to flow in. The bad news is that it didn’t do anything to improve his own receding hairline, and he lost virtually all the money he made through gambling.
In 1902, the British Medical Journal published an analysis of the content of Tatcho. It turned out to be mainly borax, glycerine, formaldehyde, alcohol, colouring and perfume: more cleaning product than growth-promoter. 
But as this 1909 advertisement shows, that didn’t stop Tatcho continuing to be a cultural phenomenon: “It will bring back the hair of your youth, make a new being of you, and give you a new grip upon life,” said the eternally reassuring advertisements. In an age when hair equalled vigour, men wanted to believe. And who knows, many may indeed have felt more confident in themselves having this slimy, semi-caustic blackening on their heads.