A tale of whelks and two small girls

How people react to a whelk is a good test of character. The test is nothing to do with whether people are good or bad, but the reaction does reveal something deep about them. I saw this yesterday with two of my granddaughters.

A whelk, in case you don’t know, might be described as a sea snail. It’s a mollusc that lives in the sea, clinging to rocks and, it’s often perjoratively said, sewage pipes. Some people—with me foremost among them—find them delicious to eat. I like all sea food, but for me a whelk is more magnificent than an oyster, another mollusc that has much higher social status than the whelk. Oysters are eaten by the high-born, often with champagne. Whelks, in contrast, have traditionally been eaten by the working classes of South London. They must be one of the very cheapest sources of protein.

I was delighted when my son knocked at our door on Saturday morning and gave me about half a kilo of whelks. The whelks could not have been fresher, as they were still alive. I boiled them, and immediately ate about half of them. Whelks are at their best when they have cooled after being boiled. I winkle them out of their shelves with a special implement I was given for Christmas and gobble them down as they are, without any condiments. Delight runs through my whole body.

As they are boiled they give off a strong smell that my wife finds disgusting. Indeed, she finds the whole idea of eating whelks as disgusting. She is by no mean alone in her disgust. We whelk lovers are a small and diminishing band.

Having gorged on half of the whelks, I put the other half in the fridge and thought that I would show them to our granddaughters when they came on Sunday morning. I thought that they would be fascinated, and I was right.

I demonstrated winkling out the soft creature for inside the shell and showed them the muscular part that clings to rocks and the long tail that runs away to what might be described as whelk shit. I put the whelk in my mouth, chewed, and swallowed it—and then offered them one. The girls watched closely.

Betty, who is 3, very vocal, and loves to dress up, reacted with the almost-to-be-expected “Ugh, disgusting.” But Thirza, who is 18 months old, wanted one. Thirza is a girl who loves adventures. The minute she arrives at our house she starts climbing the stairs. When outside she runs off. In the garden she chases the ball. When she sees dogs she reaches out to them.

I wondered if Thirza wanted the shell or the soft creature inside. She wanted both. With one in each hand she went to show her mother and father. She wondered about eating the soft part but decided against. Instead, she returned to me and got me to eat it. She was impressed.

“More,” she said. More is word for her that has a thousand uses, one of which is to indicate that she wants something repeated. I gave her another whelk, both the shell and the soft creature. She circled the room with her prizes and then returned to me to eat the whelk. We did this a few times.

Thirza is a girl who loves to eat and is bold in what she eats just as she is bold in her life. My hope is that next time she’ll eat the whelk and join her grandfather in the shrinking band of whelk lovers. She may carry that tradition into the future and 70 years from now think of her long-dead grandfather as she pops a whelk into her mouth.

A megapolyphonic novel of vengeance

I first read The Count of Monte Cristo by Alexandre Dumas 30 years ago, and I’ve listed it as one of my top three books along with The Leopard and Love In the Time of Cholera. (It always slightly disturbed me that none of the three was by an English author.) Now that I have read another 1500 or so books I’ve given up on the idea of having three top books, but rereading the 1079 pages of The Count of Monte Cristo I see again why I ranked it so highly.

It’s a book of ceaseless action and development. There are no longeurs, no passages of philosophical reflections, but there are plenty of acute observations on life, death, suffering, suicide, mankind, women, vengeance, politics, and much else (I’ve collected some of the observations in quotes below.)

The novel is one of the great popular novels of all time, translated into dozens of languages, lionised, bowdlerised, cleansed, copied, and made repeatedly into plays, films, and television series. Victor Hugo said that Dumas “creates a thirst for reading.” That seems to me one of the finest things you might say about a writer, and it can be said about Dickens and Trollope but also about J K Rowling, Jeffrey Archer, Barbara Cartland, Agatha Christie, and all “popular” authors. Perhaps Hugo’s quote was not without a sting, although it could be said of Hugo himself.

The story of The Count of Monte Cristo is both simple and complex. The simple version is that an ordinary but noble man is imprisoned for a crime he didn’t commit because of the wickedness of four men. In prison he meets a priest who teaches him multiple languages and about the world (his greatest gift) and also tells him where he can find limitless treasure. The ordinary man is transformed into a superman and in the second part of the book (about 80% of the length) wreaks a slow and terrible revenge on the four men. But it’s also  a highly complex story with multiple characters, side stories, and twists and turns. It is a megapolyphonic novel with multiple voices and viewpoints.

Dumas seems to have been the Rubens of writing with people to find him plots and sketch out the story. Dumas would then write the novel adding verve and colour, and, as he was paid by the word, keeping it long and telling side stories along the way. In ten years he wrote 41 novels, 23 plays, seven historical works, and six travel books. In contrast, Flaubert spent a dozen years writing one novel, Madame Bovary. Dumas must have written at great speed, but for me it didn’t show.

The Count, who I naturally at the centre of this vast book, is wholly unbelievable, but it doesn’t matter. He is a Byronic super-hero, and because we have known his great suffering so intimately we enjoy the cleverness, deviousness, and completeness of his slowly extracted revenge. His four victims are all duplicitous villains, all of whom unbelievably have risen from provincial obscurity to become leaders in Parisian society. We are pleased to see them crushed.

The unbelievability f much of the story doesn’t matter (at least not to me). This is more legend, epic poem than realistic novel.

One bit of the story that I didn’t like was how the Count did not marry the woman he was about to marry when arrested. She was the one person to recognise him when he reappeared transformed after years in prison and exile, and she had always loved him despite having married somebody else, one of the four men who betrayed the simple man who became the count. Although the Count had transformed himself into a man “with a heart of bronze,” he loved her. But he could not forgive her for marrying somebody else. His perhaps reflects the times that put great store on honour: it was dishonourable of her to have abandoned the man she loved, even though everybody was sure he was dead. The Count made a mistake in not marrying her, although he did sail away literally with the extraordinarily beautiful and very young Albanian women who had been his slave and was to become his wife.

Edward Said would not, I think, have liked the novel because the East is depicted as a place of magic, mystery, and strange customs. Perhaps I’m wrong because Dumas does not disparage the East, rather he admires its magic and capabilities. But he doesn’t depict it as a real place but more a place of imagination. Dumas was inspired by The Thousand and One Nights, and The Count of Monte Cristo clearly takes a lead from that classic work.

At one place in the book a young lesbian woman has avoided being forced to marry a man she doesn’t want to marry says: “I have some wit and a certain relative sensitivity that allows me to extract what I find acceptable from the generality of existence and bring it into my own, like a monkey cracking a green nut to take out what is inside.” This seemed to me an excellent description of what Dumas had done in writing this magnificent novel.

Quotes from the Count of Monte Cristo by Alexandre Dumas

Introduction

During his most productive decade, from 1841 to 1850, he wrote forty-one novels, twenty-three plays, seven historical works and half a dozen travel books.

Dumas’ novel stands at a crucial point in the development of modern popular fiction, drawing into the genre elements from Romantic literature, popular theatre, history and actuality, and wrapping them up in a narrative carefully enough constructed and dramatic enough to hold the attention of a growing reading public with a great appetite for fiction.

‘He creates a thirst for reading.’

The Count

The count himself is a poetic character, a creature of the imagination who draws on elements from myth as much as from everyday psychological observation.

Dantès was on the track that he wished to follow, proceeding towards the end that he wished to attain: his heart was turning to stone in his breast.

Only the count appeared impassive. More than that: a faint blush of red seemed to be appearing beneath the livid pallor of his cheeks. His nose was dilating like that of a wild beast at the smell of blood, and his lips, slightly parted, showed his white teeth, as small and sharp as a jackal’s.

Albert was used to the count’s ways and knew that, like Nero, he was in pursuit of the impossible.

Some kind of Byronic figure, branded by Fate’s dread seal: some Manfred, some Lara, some Werner … In short, one of those rejects of an old aristocratic family, cut off from the paternal inheritance, who made a fortune for themselves by the force of a daring and a genius that put them above the laws of society …’

A spectre returning from the Beyond.

‘Yes, Monsieur. I am one of those exceptional beings and I believe that, before today, no man has found himself in a position similar to my own. The kingdoms of kings are confined, either by mountains or rivers, or by a change in customs or by a difference of language; but my kingdom is as great as the world, because I am neither Italian, nor French, nor Hindu, nor American, nor a Spaniard; I am a cosmopolitan. cosmopolitan. No country can claim to be my birthplace. God alone knows in what region I shall die. I adopt every custom, I speak every tongue. You think I am French, is that not so? Because I speak French as fluently and as perfectly as you do. Well, now. Ali, my Nubian, thinks me an Arab. Bertuccio, my steward, takes me for a Roman. Haydée, my slave, believes I am Greek. In this way, you see, being of no country, asking for the protection of no government and acknowledging no man as my brother, I am not restrained or hampered by a single one of the scruples that tie the hands of the powerful or the obstacles that block the path of the weak. I have only two enemies: I shall not say two conquerors, because with persistence I can make them bow to my will: they are distance and time. The third and most awful is my condition as a mortal man. Only that can halt me on the path I have chosen before I have reached my appointed goal. Everything else is planned for. I have foreseen all those things that men call the vagaries of fate: ruin, change and chance. If some of them might injure me, none could defeat me. Unless I die, I shall always be what I am. This is why I am telling you things that you have never heard, even from the mouths of kings, because kings need you and other men fear you. Who does not say to himself, in a society as ridiculously arranged as our own: “Perhaps one day I shall come up against the crown prosecutor”?’

There may have been more handsome men, but there was surely none more significant, if we may be allowed to use the word. Everything about the count meant something and carried some weight; for the habit of positive thought had given to his features, to the expression on his face and to the least of his gestures an incomparable strength and suppleness.

The man of bronze.

‘Come, then, resurrected man; come, extravagant Croesus; come, sleepwalker; come, all-powerful visionary; come, invincible millionaire, and, for an instant, rediscover that dread prospect of a life of poverty and starvation.

A man who, like Satan, momentarily thought himself the equal of God and who, with all the humility of a Christian, came to realize that in God’s hands alone reside supreme power and infinite wisdom.

Vengeance

In return for a slow, deep, infinite, eternal pain, I should return as nearly as possible a pain equivalent to the one inflicted on me.

Hatred is blind and anger deaf: the one who pours himself a cup of vengeance is likely to drink a bitter draught.’

‘Oh, God,’ said Monte Cristo, ‘your vengeance may sometimes be slow in coming, but I think that then it is all the more complete.’

‘No,’ Mercédès said, interrupting him. ‘But I have seen the man I loved preparing to become the murderer of my son!’ She said these words with such overwhelming grief, in such a desperate voice, that when he heard it a sob rose in the count’s throat. The lion was tamed, the avenging angel overcome.

A face rejuvenated by the joy of revenge,

Women

The heart of a woman is such that, however arid it may become when the winds of prejudice and the demands of etiquette have blown across it, there always remains one corner that is radiant and fertile – the one that God has dedicated to maternal love.

Women have infallible instincts and can explain even miracles by an algebra of their own devising.

Politics

There is no such thing as murder in politics. You know as well as I do, my dear boy, that in politics there are no people, only ideas; no feelings, only interests. In politics, you don’t kill a man, you remove an obstacle, that’s all.

Suffering

To a happy man, a prayer is a monotonous composition, void of meaning, until the day when suffering deciphers the sublime language through which the poor victim addresses God.

Moral wounds have the peculiarity that they are invisible, but do not close: always painful, always ready to bleed when touched, they remain tender and open in the heart.

What, can it be that in a single hour the architect can become convinced that the work into which he has put all his hopes was, if not impossible, then sacrilegious?

There is neither happiness nor misfortune in this world, there is merely the comparison between one state and another, nothing more. Only someone who has suffered the deepest misfortune is capable of experiencing the heights of felicity.

Misfortune is needed to plumb certain mysterious depths in the understanding of men; pressure is needed to explode the charge.

Suicide

I have lost everything that could make me love life and now death smiles at me like a nursemaid to the child she will rock to sleep. Today I die at my own pleasure and go to sleep, tired and broken, as I used to fall asleep after one of those evenings of despair and fury when I had counted three thousand circuits of my room, that is to say thirty thousand paces, or almost ten leagues.’ As soon as this thought had taken root in the young man’s mind he became milder and more amenable. He was more ready to accept his hard bed and black bread, he ate less, no longer slept and found this remainder of a life more or less bearable, being sure that he could cast it off when he wanted to, like a discarded suit of clothes.

‘If anyone had said to your father, at the moment when he was lifting the barrel of the pistol to his head, and if anyone had said to me, at the moment when I was thrusting away from my bed the prison bread that I had not touched for three days, I say, if anyone had said to us at that climactic moment: Live! Because the day will come when you will be happy and bless life; then, wherever that voice had come from, we would have answered it with a smile of scepticism or with pained incredulity; and yet, how many times, when he embraced you, has your father not blessed life and how many times have I …’

Death

There is only one serious matter to be considered in life, and that is death. So! Isn’t it worth one’s curiosity to study the different ways that the soul may leave the body and how, according to the character, the temperament, or even the local customs of a country, individuals face up to that supreme journey from being to nothingness?

On the first step of the scaffold, death tears away the mask that one has worn all one’s life and the true face appears.

The dead have never done, in six thousand years, as much evil as the living do in a single day.

The doctor has a sacred mission on earth; to fulfil it he must go back to the well spring of life and descend into the mysterious darkness of death.

I know that the world is a drawing-room from which one must retire politely and honourably, that is to say, with a bow, after paying one’s gaming debts.’

Grief is like life and that there is always something unknown beyond it?

Death, according to the care we take to be on good or bad terms with it, is either a friend which will rock us as gently as a nursing mother or an enemy which will savagely tear apart body and soul. One day, when our world has lived another thousand years, when people have mastered all the destructive forces of nature and harnessed them to the general good of mankind, and when, as you just said, men have learnt the secrets of death, then death will be as sweet and voluptuous as sleep in a lover’s arms.’

Mankind

‘Oh, what is man!’ d’Avrigny muttered. ‘The most egoistical of all animals, the most personal of all creatures, who cannot believe otherwise than that the earth revolves, the sun shines and death reaps for him alone – an ant, cursing God from the summit of a blade of grass!

I have some wit and a certain relative sensitivity that allows me to extract what I find acceptable from the generality of existence and bring it into my own, like a monkey cracking a green nut to take out what is inside.

Oh men! Men! Race of crocodiles,

You see everything from the vulgar and material point of view of society, beginning and ending with man, that is to say, the most restricted and narrow point of view that human intelligence can adopt.’

Every man has a passion gnawing away at the bottom of his heart, just as every fruit has its worm.

‘The wickedness of men runs very deep….since it is deeper than the kindness of God.

Observations

Uncertainty is the worst of torments.

Learning does not make one learned: there are those who have knowledge and those who have understanding. The first requires memory, the second philosophy.

Wealth – that first and greatest of forces that a human being can control.

Some poor devil destroyed by literature:

[There are] people whose wits are so used to paradoxes that they mistake the most undeniable truths for mere figments of the imagination

There are two medicines for all ills: time and silence.

‘Admire yourself and others will admire you’, a hundred times more useful in our days than the Greek one: ‘Know thyself’, which has now been replaced by the less demanding and more profitable art of knowing others.

I have in my heart three feelings with which one can never be bored: sadness, love and gratitude.’

What is a marvel? Something that we do not understand. What is truly desirable? A possession that we cannot have.

It is true that every one of our actions leaves some trace on our past, either dark or bright. So it is true that every step we take is more like a reptile’s progress across the sand, leaving a track behind it. And often, alas, the track is the mark of our tears!’

There are two ways of seeing: with the body and with the soul. The body’s sight can sometimes forget, but the soul remembers for ever.’

When one lives among madmen, one should train as a maniac.

Hearts which are fired to overcome obstacles go cold when these are removed

The greatest virtue of all in my opinion is to be able to admit when one is wrong.

‘Beware! A piece of advice is worse than a helping hand.’

Society receptions are a bed of flowers that attracts capricious butterflies, hungry bees and buzzing hornets.

One should not even try to offer the trite consolations that make the best of friends so unwelcome in the event of a great catastrophe.

For some constitutions work is the cure for all ills.

Until the day when God deigns to unveil the future to mankind, all human wisdom is contained in these two words: ‘wait’ and ‘hope’!

A great teacher

Moreover, my true treasure, my friend, is not the one that awaits me under the dark rocks of Monte Cristo, but your presence, presence, and the time that we spend together for five or six hours a day, in spite of our jailers; it is those rays of understanding that you have shone into my brain and the languages that you have implanted in my memory and which now grow there, putting out further branches of language in their turn. The many sciences that you have brought within my grasp by the depth of your own knowledge of them and the clarity of the basic principles which you have derived from them – this is my treasure, my friend, this is what you have given to make me rich and happy.

Believe me, and console yourself; this is worth more to me than tons of gold and trunkloads of diamonds, even if they were not uncertain, like those clouds which can be seen in the morning above the sea and which appear to be dry land, but which evaporate, disperse and fade away as one approaches them.

Having you close to me for as long as possible, hearing your eloquent voice as it enlightens my mind, re-tempering my soul, making my whole being capable of great and awe-inspiring deeds if ever I should be free, filling my mind and soul so thoroughly that the despair to which I was ready to give way when I met you can no longer find any place in them – this is my fortune. It is not a chimera. I truly owe it to you, and all the sovereigns on earth, were they all Cesare Borgias, could not succeed in taking it away from me.’

The treasure that a teacher gives you

Alexandre Dumas describes well in “The Count of Monte Cristo” the treasure that a great teacher can give you. I dedicate this quotation to the people who have taught me–and may I continue to learn.

Moreover, my true treasure, my friend, is not the one that awaits me under the dark rocks of Monte Cristo, but your presence, presence, and the time that we spend together for five or six hours a day, in spite of our jailers; it is those rays of understanding that you have shone into my brain and the languages that you have implanted in my memory and which now grow there, putting out further branches of language in their turn. The many sciences that you have brought within my grasp by the depth of your own knowledge of them and the clarity of the basic principles which you have derived from them – this is my treasure, my friend, this is what you have given to make me rich and happy.

Believe me, and console yourself; this is worth more to me than tons of gold and trunkloads of diamonds, even if they were not uncertain, like those clouds which can be seen in the morning above the sea and which appear to be dry land, but which evaporate, disperse and fade away as one approaches them.

Having you close to me for as long as possible, hearing your eloquent voice as it enlightens my mind, re-tempering my soul, making my whole being capable of great and awe-inspiring deeds if ever I should be free, filling my mind and soul so thoroughly that the despair to which I was ready to give way when I met you can no longer find any place in them – this is my fortune. It is not a chimera. I truly owe it to you, and all the sovereigns on earth, were they all Cesare Borgias, could not succeed in taking it away from me.’

Populism and the NHS: a toxic mix

Despite the worst economic position for 300 years, populism dictated that the Chancellor of the Exchequer would spend more money on the NHS and allow a pay increase for NHS staff while freezing the pay of other public sector workers. Populism also meant that nursing home staff, who were at greater risk from Covid-19 than most NHS staff because less well protected, are neglected (most are anyway in the private sector). Populism also means that overseas aid is to be cut. All this reminded me of my blog arguing populism is not good for the NHS https://blogs.bmj.com/bmj/2019/08/05/richard-smith-populism-and-the-nhs/, which is below. I’ve also argued that spending more on the NHS is bad for health—largely because health services account for only 10% of health, even adopting a narrow definition of health. https://blogs.bmj.com/bmj/2018/04/18/richard-smith-why-the-nhs-shouldnt-be-given-more-funds/

The NHS is by far the most beloved of British institutions. British Rail was a byword for inefficiency and squalor. Nobody loves British Telecom, British Gas, or British Airways, and the BBC is scorned by extremists on both sides. This makes the NHS, which featured in the opening of the London Olympics and belief in which has been compared to a religion, a natural target for populists. This, I suggest, has some upside but more downside.

The central image of the deeply divisive Brexit referendum was the bus featuring the words: “We send the EU £350 million each week. Let’s fund the NHS instead. Vote Leave. Let’s take Back Control.” These are clever words. There is one fact in the words—that Britain sends £350m each week to the EU—and that is true. The fact that Britain gets most of it back and enjoys many other advantages from the EU is omitted. The money could not thus be spent on the NHS, but the words on the bus do not directly say that it would be. The strong implication was that the EU—an organisation which few understand, is comprised mainly of “foreigners,” and nobody much loves—was an enemy to a much loved national treasure.

The slogan and the strategy of linking the European Union to the NHS were supposedly thought up by Dominic Cummings, the radical director of the Leave Campaign, who has been described as an “evil genius” and by a former prime minister as a “career psychopath.” He is now chief executive of the current prime minister’s staff and committed to achieving Brexit by 31 October by any means possible, including if necessary ignoring Parliament.

A brilliant television play Brexit: The Uncivil War illustrated well the cleverness of Cummings, so much so that Remainers objected that it made him a hero. A key scene showed him unhappy with the slogan “Take control” and coming up with the words “Take back control.” The insertion of the word “back” changes everything, moving the slogan from something that feels aggressive to a slogan that sounds reasonable and resonates with those who think we have lost control and those who hanker after a golden, simpler past when Britain ruled the world and doctors, not bureaucrats, ran the NHS.

Like a wolf into the fold Cummings, an instinctive if elitist populist, has again put the NHS at the centre of the battle over Brexit. Boris Johnson, the new prime minister, is making promises about the NHS, and in particular has committed £850 million to various capital projects within the NHS. This money, which is mostly not new, is tiny compared with what is needed. As I reported a few weeks ago: “The capital budget for the NHS has fallen by 7% from £5.8 billion in 2010/11 to £5.3 billion in 2017/18 with money being transferred from the capital to the revenue budget. Capital spending in trusts has fallen by 21% over the same period—from £3.9 billion to £3.1 billion. The maintenance backlog has increased from £4.4 billion in 2013/14 to £6 billion in 2017/18. To bring capital spending up to the OECD average would require another £3.5 billion in 2019/20. Around 40% of NHS buildings…are more than 30 years old, and 18% date back to before the NHS was founded in 1948.”

Populism dictates how the money must be spent. Firstly, it must be scattered around the country, which means funding lots of the smallest capital projects rather than a few big ones. Secondly, it must be spent on something tangible, something that people can easily understand and the prime minister can visit. Thirdly, you must give the impression that the money will mean not just mending ancient, collapsing infrastructure but will bring “world class care” to Britons and will help with the recruitment crisis.

In other words, the money is primarily intended, as with the Brexit bus, not to improve the health of the British people or their services but to increase the popularity of the new government, making it more likely that it will be able to push through Brexit and be re-elected. If you really wanted to improve the health of the people and their services you would spend the money very differently, probably not on the NHS at all and certainly on social services ahead of NHS buildings.

Another clever part of the strategy is that those within the NHS cannot do anything but thank government for the money and worse go along with the fiction that it will make an important difference. Thus you have the medical director of NHS England on the radio talking up the value of the investment, repeating, as he was undoubtedly told to do, how he had worked on the frontline of the NHS for 30 years. This was no untrustworthy politician talking but a real doctor, not a bureaucrat.

Health systems everywhere, however funded and structured, are politically important, but the NHS, which we are busy “loving to death,” is a prime target for populist politicians—and pandering to populism is perilous.

The issues raised by the Nuremberg trials are as relevant to medicine in 1996 (and 2020) as in 1946

Today is the 75th anniversary of the beginning of the Nuremberg trials of Nazi war criminals. The BMJ on the 50th anniversary published a special issue on the trials arguing that “the issues thrown up by the trials–informed consent for experimentation, the involvement of doctors with the state, patient autonomy, genocide, and the behaviour of doctors when associated with abuses of human rights–are as relevant today as the day the trials began.

Here is the piece I wrote to introduce the special issue:

The Nuremberg trials of doctors who had committed war crimes during the second world war began 50 years ago this week. The BMJ has devoted many pages in this issue to exploring the Nuremberg trials, what went before, and their aftermath for two main reasons. Firstly, we must never forget. On the wall of the highly moving United States Holocaust Museum is a quote from Deuteronomy: “Only guard yourself and your soul carefully, lest you forget the things your eyes saw.” Secondly, the issues thrown up by the trials–informed consent for experimentation, the involvement of doctors with the state, patient autonomy, genocide, and the behaviour of doctors when associated with abuses of human rights–are as relevant today as the day the trials began. Indeed, there is a sense, particularly in Germany, that we are at the very beginning of thinking through the issues thrown up by what doctors did in the second world war. We needed 50 years to be able to begin to think clearly about something so horrible.

Informed consent to experimentation is the issue most closely associated with the Nuremberg trials. The Nuremberg code produced in 1947 (p 1448) made informed consent an absolute requirement. But, as Jennifer Leaning explains in an editorial (p 1413), that code was about non-therapeutic research and did not consider the possibility of research in patients not competent to give consent. Thus in 1964 the World Medical Association produced the less restrictive Declaration of Helsinki (p 1448). Jochen Vollmann and Rolf Winau describe how guidelines on informed consent had actually appeared at the end of the 19th century (p 1445), while Jennifer Leaning (p 1413) and a book review (p 1494) remind us how experimentation without consent has continued since Nuremberg. Paul Weindling notes that the BMJ had a correspondent covering the Nuremberg trials who had views that were more sympathetic to the Nazi doctors than is now fashionable (p 1467). Twice in the past fortnight we at the BMJ have debated whether to publish trials that did not include fully informed consent, and the Food and Drug Administration in the United States has just produced guidelines saying that research on patients needing immediate intensive care can be conducted without consent (16 November, p 1223). The debate on informed consent is still very much alive, not least in the case of a British woman being denied the right to have her dead husband’s sperm inseminated into her because he never gave written consent (p 1477). News stories also describe how the United States government last week had to pay compensation for radiation experiments conducted without consent (p 1421) and new research showing that patients often don’t read consent forms but simply trust their doctors (p 1421)

Several of the articles in this Nuremberg issue revolve around doctors’ involvement with the state. Robert Proctor describes how the Nazis developed the world’s first and strongest antismoking campaigns (p 1450). Hartmut Hanauske-Abel argues that, far from German doctors being corrupted by Hitler’s regime, they were ahead of the regime in advocating policies on eugenics (p 1453). And William Seidelman says that doctors have not fully considered “the inherent conflict between caring for the individual as opposed to the health of the population” (p 1463). Doctors today are very involved in debates about public health and the rationing of health care, and they would do well to consider the relation of what they are doing to what German doctors were doing under National Socialism.

The killing by doctors of “less worthy” people was one of the main crimes addressed by the Nuremberg trials, and physician assisted suicide is perhaps the hottest issue in medical ethics today (p 1495). The public in many countries – including, for instance, both the Netherlands (p 1423) and Britain (p 1423) – is beginning to look favourably on the idea of physician assisted suicide, and it has recently been legalised in Australia’s Northern Territory. Most doctors’ organisations continue to be strongly against physician assisted suicide – partly because of memories of how the ethical code of medicine was debased during the second world war. But another issue thrown up by Nuremberg – that of the importance of patient autonomy – can conflict with the fundamental principle of “first, do no harm.” If patients clearly of sound mind want their doctors to hasten their ends, might the concepts of patient autonomy and serving the patients override the deep professional instinct against euthanasia?

Horrifyingly, genocide is an issue that is as current in 1996 as it was in 1946. Donald Acheson, who grew up in Northern Ireland and who led the World Health Organisation’s relief efforts in Bosnia, describes what he thinks are the three stages of genocide (p 1415). (His editorial includes a speech made by Hitler in 1939 in which he made very clear how he planned genocide.) In the first stage of genocide there is systematic discrimination against a particular ethnic group. This stage is seen in most countries. In the second stage there is violence against the group. Again this is common. The third stage, argues Acheson, entails the state becoming involved – openly or in secret. We have seen the terrible consequences of this in Bosnia and Rwanda. Children suffer horribly in these conflicts, and David Southall and Manuel Carballo argue that the world needs to find mechanisms to protect children in these circumstances (p 1493).

A final issue at Nuremberg was the behaviour of doctors involved in wars and abuses of human rights. Paula Brentlinger describes her recent experiences in El Salvador and tries to draw out lessons for other doctors who find themselves caught up in wars (p 1470), while Hazim Naif Barnouti paints a bleak picture of what war and sanctions have done to the health services in Iraq (p 1474). The world is as restless in 1996 as it was at the end of 1946.

And is more restless still in 2020.

Quotes from The Affluent Society by John Kenneth Galbraith

I’ve written a blog on this remarkable book, https://richardswsmith.wordpress.com/2020/11/16/how-to-stop-affluence-destroying-us-and-use-it-creatively/ but below are the many quotes I took from the book–most of them splendid. It was a labour of love to do this as the book is not available in electronic form and I had to copy out each quote. It took me hours.

The Affluent Society

Wealth is the relentless enemy of understanding

Nearly all, through all history, have been very poor

Few people at the beginning of the 19th century needed an adman to tell them what they wanted

We face here the greatest vested interests, those of the mind

The shortcomings of economics are not original error but uncorrected obsolescence

Negative thoughts cannot but strike an uncouth note in a world of positive thinking

The simple exigencies of poverty preclude the luxury of misunderstanding

“We are ruled by ideas and very little else,” John Maynard Keynes

The American Mood

The evolving economic society is destroying not only itself but all civilization as well. Such was the view of Thorstein Veblen (1857-1929), one of America’s greatest economists

“The law of the survival of the fittest was not made by man. We can only by interfering with it produce the survival of the unfittest.” William Graham Sumner, 1885. To this day a man who refuses a beggar and righteously observes, “I’m told it’s the worst thing you can do,” is still finding useful the inspired formula of Sumner.

The Marxian Pall

The inevitable impoverishment of the masses, the progressive enrichment of those who own the natural means of production, the inevitable conflict between wages and profits and the priority of the latter for progress. The conclusion of David Ricardo according to JKG.

The effect of the advance of the arts and the accumulation of capital on the average man, according to Marx: they “mutilate the labourer into a fragment of a man, degrade him to the level of appendage of a machine, destroy every remnant of charm in his work and turn it into hated toil…drag his wife and child beneath the Juggernaut… [bring] misery, agony of toil, slavery, ignorance, mental degradation….”

To him, as to any believer in a faith, the opponent is not merely in error but in sin.

Inequality

It is the increase in output in recent years, not the redistribution of income, which has brought the great material increase in the well-being of the average person.

The Paramount Position of Production

“Any device or regulation which interferes, or can be conceived as interfering, with [the] supply of more and better things is resisted with unreasoning horror, as the religion resist blasphemy, or the warlike pacifism.”

The unnatural triumph over nature.

Our preoccupation with production is, in fact, the culminating consequence of powerful historical and psychological forces—forces which only by an act of will we can hope to escape.

The Imperatives of Consumer Demand

Economic theory has managed to transfer the sense of urgency in meeting consumer need that once was left in a world where more production meant more food for the hungry, more clothing for the cold and more houses for the homeless to a world where increased output satisfies the craving for more elegant automobiles, more exotic food, more erotic clothing, more elaborate entertainment—indeed, for the entire modern range of sensuous, edifying and lethal desires.

The value system of economists:

  1. The urgency of wants does not diminish appreciably as more of them are satisfied.
  2. Wants originate in the personality of the consumer

As Adam Smith observed: “Nothing is more useful than water; but it will purchase scarce anything; scarce anything can be had in exchange for it. A diamond, on the contrary, has scarce any value in use; but a very great quantity of other goods may frequently be had in exchange for it.”

The Dependence Effect

Production only fills a void that it has created.

“Ours is a society in which one of the principal social goals is a higher standard of living…[This] has great significance for the theory of consumption…the desire to get superior goods takes on a life of its own. It provides a drive to higher expenditure which may be even stronger than that arising out of the needs which are supposed to be satisfied by that expenditure.” James Diesenberry

As a society becomes increasingly affluent, wants are increasingly created by the process by which they are satisfied.

In technical terms, it can no longer be assumed that welfare is greater at an all-round higher level of production than at a lower one. It may be the same.

It is far, far better and much safer to have a firm anchor in nonsense than to put out on the troubled seas of thought.

The Vested Interest in Output

A businessman who reads Business Week is lost to fame. One who reads Proust is marked for greatness.

No one should doubt the convenience of a simple arithmetical measure of success in a world in which so many things are subjective.

The Bill Collector Cometh

That full employment is more desirable than increased production combined with unemployment would be clear alike to the most sophisticated and the most primitive politician.

One danger in the way wants are created lies in the related process of debt creation.

Nothing in our economic policy is so deeply ingrained, and so little reckoned with by economists, as out tendency to wait and see if things do not improve by themselves.

Inflation

There is a well-known and statistically quite demonstrable tendency of people who have an increase in pay to celebrate with red meat.

The Monetary Illusion

Monetary policy became a form of economic escapism. Without it, realities would indeed be hard. Unhappily, faith or urgent need is not an assurance of practical performance.

It has long been clear that economic management, especially in the UK, would be greatly facilitated if resort could occasionally be had to witchcraft.

Monetary policy is a blunt, unreliable, discriminatory, and somewhat dangerous instrument of economic control. It survives in esteem party because so few understand it. No other course of action in economics has ever rivaled monetary policy in its capacity to survive failure.

The Theory of Social Balance

The line that divides our area of wealth from our area of poverty is roughly that which divides privately produced and marketed goods and services from publicly rendered services.

In recent years, the papers of any major city tell daily of the shortages and shortcomings in the elementary municipal and metropolitan services. The schools are old and overcrowded. The police force is inadequate. The parks and playgrounds are insufficient. Streets and empty lots are filthy, and the sanitation staff is underequipped and is in need of men. Access to the city by those who work there is uncertain and painful and becoming more so. Internal transportation is overcrowded, unhealthful, and dirty. So is the air. Parking on the streets should be prohibited, but there is no space elsewhere. These deficiencies are not in new and novel services but old established ones. Cities have long swept their streets, helped their people move around, educated them, kept order, and provided horse rails for equipages which sought to pause. That their residents should have a nontoxic supply of air suggests no revolutionary dalliance with socialism.

Private opulence and public squalor.

It is scarcely sensible that e should satisfy our wants in private goods with reckless abundance, while in the case of public goods, one the evidence of the eye, we practice extreme self-denial.

Advertising operates exclusively, and emulation mainly, on behalf of privately produced goods and services.

To suggest that we canvass our public wants to see where happiness can be improved by more and better services has a sharply radical tone. Even public services that prevent disorder must be defended. By contrast, the man who devises a nostrum for a nonexistent need and then successfully promotes both remains one of nature’s noblemen.

The Investment Balance

The high return to scientific and technical training does not cause the funds to move from material capital to such investment. There is no likely flow from the building of refineries to the education of the scientists.

Houses; automobiles; the uncomplicated forms of alcohol, food and sexual enjoyment; sports; and movies require little prior preparation of the subject for the highest entertainment. A mass appeal is thus successful, and hence it is on these things that we find concentrated the main weight of modern want creation. By contrast, more esoteric desires—music and fine arts, literary and scientific interests, and to some extent even travel—can normally be synthesized, if at all, only on the basis of a good deal of prior education.

Education…by widening tastes and also including more independent and critical attitudes, it undermines the want-creating power which is indispensable to the modern economy.

The Transition

The main task of this essay…has been with the thralldom of a myth—the myth that the production of goods, by its overpowering importance and its ineluctable difficulty, is the central problem of our lives.

Emancipation of the mind is a no less worthy enterprise than emancipation of the body.

Men must see a purpose in their efforts. This purpose can be nonsensical and, as we have seen, if its elaborately nonsensical, that is all to the good. Men can labour to make sense out of single steps toward the goal without ever pausing to reflect that the goal itself is ludicrous.

One could indeed argue that human happiness would be as effectively advanced by inefficiency in want creation as by efficiency in production.

It is so much simpler [to value production] than to substitute the other tests—compassion, individual happiness and well-being, the minimization of community or other social tensions.

The Divorce of Production from Security

The income men derive from producing things of slight consequence is of great consequence for them

The first needed action is to bring the level of unemployment compensation much closer to the average weekly wage and to extend greatly the period of eligibility.

The next step is to produce alternative sources of income, unrelated to production, to those whom the modern economy employs only with exceptional difficulty or unwisdom.

The Redress of Balance

The line between public and private activity, as we view it at any given moment, is the product of many forces: tradition, ideological preference, social urgency and political convenience all play some part. But to a far greater degree than is commonly supposed, functions accrue to the state because, as a purely technical matter, there is no alternative to public management.

The community is affluent in privately produced goods. It is poor in public services. The obvious solution is to tax the former to provide the latter—by making private goods more expensive, public goods are made more abundant.

The Position of Poverty

[To keep poverty from being self-perpetuating] requires that investment in children from families presently afflicted be as little as below normal as possible. If the children of poor families have first-rate schools and school attendance is properly enforced; if the children, though badly fed at home, are well nourished at school; if the community has sound health services, and the physical well-being of children is vigilantly watches; if there is opportunity for advanced education for those who qualify regardless of means; and if, especially in the case of urban communities, housing is ample and housing standards are enforced, the streets are clean, the laws are kept and recreation is adequate—then there is a chance that the children of the very poor will come to maturity without inhibiting disadvantage.

 The survival of it [poverty] is remarkable. We ignore it because we share with all societies at all times the capacity for not seeing what we do not wish to see.

Labour, Leisure, and the New Class

The case for more leisure is not stronger on purely prima facie grounds than the case for making labour-time itself more agreeable.

Another of the obvious possibilities with increasing affluence is for fewer people to work

The greatest prospect that we face—indeed, what must now be counted one of the central economic goals of our society—is to eliminate toil as a required economic institution.

Onee of the oldest and most effective obfuscations in the field of social science…is the effort to assert that all work—physical, mental, artistic, or managerial—is essentially the same.

Membership of the new class has important rewards. Exemption from manual toil; escape from boredom and confining and severe routine; the chance to spend one’s life in clean and physically comfortable surroundings; and some opportunity to for applying thoughts to the day’s work are regarded as unimportant only by those who take them completely for granted.

On Security and Survival

The pursuit of happiness is admirable as a social goal. But the notion of happiness lacks philosophical exactitude; there is agreement on neither its substance nor its source. We know that it is “a profound instinctive union with the stream of life” [Bertrand Russell] but we do not know wat is united.

To furnish a barren room is one thing. To continue to crowd in furniture until the foundation buckles is quite another. To have failed to solve the problem of producing gods would have been to continue man in his oldest and most grievous misfortune. But to fail to see that we have solved it, and to fail to proceed thence to the next tasks, would be fully as tragic.

Afterword

Two major effects of affluence  I want to emphaise.

  1. The danger that with affluence we will settle into comfortable disregard for those excluded from its benefits.
  2. The resources for the production of weapons of ever increasing danger, ever greater capacity for devastation.

Let us protect our affluence from those who, in the name of defending it, would leave the planet only with its ashes.

How to stop affluence destroying us and use it creatively

The starting point for John Kenneth Galbraith’s book The Affluent Society book is that for most of recorded history most people have been poor, meaning that they struggled to feed, clothe, and house those themselves and their families. (It may not have been that way before the start of farming—“the fall of man”—but Galbraith doesn’t discuss that.) He is concerned primarily with the failure of economics to adjust to the fact that societies like the US and the UK are now affluent, and he argues that that failure has profound—indeed, probably catastrophic—consequences for us all.

Galbraith’s book was named one of the New York Public Library’s “Books of the Twentieth Century,” and although published in 1958 (and tweaked in 1999), it has just as much relevance now as then. The power of the book lies not only in its argument but also in its style: Galbraith, a lover of Trollope, writes in a style like that of the 19th century novelist with a gift for witty phrases and one-liners. Four examples: “Wealth is the relentless enemy of understanding”; “Few people at the beginning of the 19th century needed an adman to tell them what they wanted”; “We face here the greatest vested interests, those of the mind”; and “Negative thoughts cannot but strike an uncouth note in a world of positive thinking.”

The two great problems of everybody being poor are security and inequality. Poor people are constantly insecure: crop failure, unemployment, or death of a breadwinner can destroy a family. Although most people were until recently poor, some were fabulously rich, giving Gini coefficients a whisker away from one. The distribution of the world’s wealth still has the shape of a champagne glass with the top quintile of the population representing the bowl and most of the wealth and the bottom four quintiles the stem, being equally poor.

The industrial revolution and particularly production made inroads on insecurity and inequality. People earned money working at making things, although often in terrible conditions (as today in Bangladesh’s garment factories). Food, clothing, and housing became more affordable. Insecurity and inequality were eroded but have never disappeared even in wealthy countries. Growing the Gross Domestic Product (GDP)became the aim of societies and remains so. “No one should doubt,” observes Galbraith, “the convenience of a simple arithmetical measure of success in a world in which so many things are subjective.”

Unfortunately, argues Galbraith, increased production and growth of the GDP has become the obsession of economists and governments long after those in affluent societies have enough “stuff.” Because we have essentially all we need we have to be made to want things we don’t need—the job of the advertising industry. As Galbraith puts it: “Economic theory has managed to transfer the sense of urgency in meeting consumer need that once was left in a world where more production meant more food for the hungry, more clothing for the cold and more houses for the homeless to a world where increased output satisfies the craving for more elegant automobiles, more exotic food, more erotic clothing, more elaborate entertainment—indeed, for the entire modern range of sensuous, edifying and lethal desires.”

The consequence of this overconsumption that concerns us most now is destruction of the planet, and in the penultimate sentence of his 1999 afterword Galbraith writes: “Let us protect our affluence from those who, in the name of defending it, would leave the planet only with its ashes.” But Galbraith does not write about externalities and how producers do not have to pay for poisoning our air, water, and soil. What he dreads most from our affluence and obsession with production is or capacity to disregard those who are not affluent (think of those drowning in the Mediterranean and Channel) and the possibility of nuclear war. (His concern makes me think of how manufacturer of arms is of central importance to the economy of many developed countries, including Britain.) Beset with new worries of the pandemic, climate change, and being taken over by our machines, dread of nuclear war has slipped down the list of worries—but may well be where the climate crisis will lead us.

Galbraith’s book is best known now for his phrase of “private opulence and public squalor.” Roads are full of potholes, the police are understrength, social services are threadbare, school buildings are leaking, and most of the country can hardly be reached by public transport. “It is scarcely sensible,” writes Galbraith, “that we should satisfy our wants in private goods with reckless abundance, while in the case of public goods, on the evidence of the eye, we practice extreme self-denial….Even public services that prevent disorder must be defended. By contrast, the man who devises a nostrum for a nonexistent need and then successfully promotes both remains one of nature’s noblemen.”

The book does describe responses to the problem, beginning with finding another aim from growing GDP, including “compassion, individual happiness and well-being, [and] the minimisation of community or other social tensions.” Galbraith advocates more investment in and expenditure on public goods and services, including “bringing the level of unemployment compensation much closer to the average weekly wage and to extend greatly the period of eligibility.”

Observing that “The survival of it [poverty] is remarkable” and that “We ignore it because we share with all societies at all times the capacity for not seeing what we do not wish to see,” Galbraith advocates a major attack on poverty. It’s clear that he was thinking mostly about the US as he wrote his book, but his formula should work worldwide: To keep poverty from being self-perpetuating “requires that investment in children from families presently afflicted be as little as below normal as possible. If the children of poor families have first-rate schools and school attendance is properly enforced; if the children, though badly fed at home, are well nourished at school; if the community has sound health services, and the physical well-being of children is vigilantly watched; if there is opportunity for advanced education for those who qualify regardless of means; and if, especially in the case of urban communities, housing is ample and housing standards are enforced, the streets are clean, the laws are kept and recreation is adequate—then there is a chance that the children of the very poor will come to maturity without inhibiting disadvantage.”

This is a good place to end my blog on Galbraith’s book because this last quote—a single sentence of 106 words—illustrates his use of the classic devices of rhetoric, in this case the periodic sentence. The great example in English is Rudyard’s Kipling’s poem If, where tension builds as the sentence never seems to end. Galbraith was a great economist, a great writer, and a great human being.

A new important study supports wider use of the polypill

By coincidence this morning my new polypills arrived together with the results of a major study confirming that use of the polypill containing a statin and four antihypertensives in people without established disease can cut cardiovascular events by at least a third—and closer to half if people take the pill regularly. https://www.nejm.org/doi/full/10.1056/NEJMoa2028220

The two arrive more than 17 years after the BMJ published a paper arguing that if everybody started taking the polypill at age 55 then heart attacks and strokes, still the world’s major killer, could be cut by 80%. https://www.bmj.com/content/326/7404/1419 I was the editor then and wrote a somewhat flippant “Editor’s choice” suggesting that this might be the most important issue of the BMJ for 50 years. https://www.bmj.com/content/326/7404/0.7  The suggestion was greeted with scorn but is remembered, probably because of its extravagance, but could still be true.

The new study published in the New England Journal of Medicine is a randomised trial of a polypill (a statin plus three antihypertensives) plus or minus aspirin in 5713 people with a mean age of 64 without established cardiovascular disease but some risk factors.https://www.nejm.org/doi/full/10.1056/NEJMoa2028220  In other words, these are like most people of that age in the world. Taking the polypill reduced cardiovascular events in the next 4.6 years by a fifth and by a third if the people took aspirin as well. The trial was conducted in nine countries (Bangladesh, Canada, Colombia, India, Indonesia, Malaysia, Philippines, Tanzania, Tunisia) with half of the patients coming from India, and problems of supplying the drug complicated by the pandemic meant that about a third of the patients were not taking the drugs all the time. The researchers calculated that those who took the polypill and aspirin all the time had a 40% reduction in cardiovascular events.

The trial started with 7534 patients, but 1821 were excluded after a run-in phase because of side effects attributed to the polypill and aspirin (715), not taking the pills regularly (560), or decline to be randomised (458). People were thus selected for not suffering from side effects and taking the pills regularly. Nevertheless, more patients taking the polypill (2.7%) or the polypill plus aspirin (3.1%) experienced hypotension or dizziness than in the placebo groups (1.1%, 1.5%).

These results join those of a pragmatic cluster-randomised trial reported in the Lancet of using a polypill (a statin, aspirin, and two antihypertensives) in 6838 people in Iran, some with and some without cardiovascular disease. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31791-X/fulltext  That trial found a reduction of cardiovascular events of just over a third in those taking the polypill and of more than a half in those who took the polypill regularly.

The trials have comparable results, but they fall short of the 80% reduction predicted in the BMJ 17 years ago. One reason is obviously adherence, but the trial reported today found that participants did not have the effect that the researchers expected from their pilot studies in reductions of blood pressure, heart rate, and blood lipids. Even in the pilot studies the researchers did not find the reductions the BMJ paper predicted—but the authors of the BMJ paper did find exactly the reductions they expected in a double-blind, cross-over trial in which I participated. https://pubmed.ncbi.nlm.nih.gov/22815989/ The polypills have all used slightly different combinations of drugs, which may provide some of the explanation for the different results.

We seem now to have good evidence that the polypill can reduce cardiovascular events and deaths by at least a third and probably by half in those who take the polypill regularly. It also remains possible that even better results could be achieved with the optimal components of the polypill. But as 18 million people a year die from cardiovascular events (80% of the deaths in low and middle income countries) and millions more are disabled by the events, widespread use of the polypill would have a major impact.

Had the trial reported today been of a new and expensive drug manufactured by a major drug company then the results would have been beamed around the world and covered on the front page of newspapers and in all major news bulletins. In fact it’s raised hardly a squeak and merits no mention on the BBC. (I find it impossible not to contrast the coverage of this detailed 13-page report in a major journal with that of an unpublished trial of a new vaccine for Covid-19).

Not only does the polypill, which could probably be made available for a dollar a month, not have the support of a major drug company but it also threatens lucrative markets the companies already have. It also disturbs cardiologists who feel despite the evidence that tailored treatments that are regularly monitored must be better. Public health people don’t like the polypill because they feel that healthy lifestyles must be better—even when for many systemic reasons most people can’t achieve them. Plus randomised controlled trial evidence has been lacking for the benefits in those without established disease, providing an excuse to those who don’t like the idea of mass medication for whatever reason. That excuse is disappearing—may, indeed, have disappeared.

WHO has three times considered the polypill for the essential drugs list and turned it down every time. Although the list does include polypills for HIV infection and other infections, a pill with four or five components makes WHO nervous. Then there is the problem of exactly what they are approving—a concept, a strategy, or a particular combination of pills? I hope that this new evidence will mean the polypill does make it onto the essential drug list.

Meanwhile, I’ve been taking the polypill (or a version thereof) for more than a dozen years. I haven’t had a cardiovascular event—but I might not have done anyway. I did think that I had a cough caused by the polypill at the beginning, but I was challenged to stop and restart the pill to establish whether the cough was actually caused by the polypill. I discovered it wasn’t. I’ve not had any other side effects. I haven’t seen the cardiologist who started me on the polypill since the very beginning: I receive the pill (or pills) through the post every three months after completing a questionnaire reporting that I haven’t had any side-effects. I pay about £25 a month for the pills. Like many men, I wouldn’t take them if I had to go the doctor every three months to be tested.

Originally I did have just one polypill to take, but the company who made them stopped. Another company manufactured another polypill, but eventually it stopped as well. For years I’ve had to take three or four pills a night, which is why I’m excited to again to be back to one with today’s delivery.

I don’t regret my flippant piece of 17 years ago, and I think that we will move to a place where everybody is offered the polypill at 55. The irony is that many people in their 60s and 70s end up taking most of the components of the polypill (separately and expensively) after they have had cardiovascular events.

And perhaps the most exciting thing about the polypill is that the concept–of combining cheap, off-patent drugs with different modes of action—can be effective in many other conditions, including diabetes, depression, asthma, chronic respiratory disease. Making cheap pills available to everybody is a better route for global health (but not business) than developing new, highly expensive drugs that only a few people can afford.

Competing interest. As the blog makes clear, RS has long been an enthusiast for the polypill and his been taking it himself for more than a dozen years. He has also worked with authors of the new study and was director of the UnitedHealth part of the UnitedHealth/NHLBI Centres of Excellence programme that was one of the funders of the centre at St John’s Medical College, Bangalore, India, which is one of the leaders of the new study.

How would a prominent oncologist manage his own stage 4 pancreatic cancer: A postscript to my blog on whether cancer is still the best way to die?

After posting my piece asking whether the developments in precision oncology and immunotherapy had changed my thinking about death, https://richardswsmith.wordpress.com/2020/09/12/is-cancer-still-the-best-way-to-die/  Curious George asked a prominent oncologist how he would hypothetically manage his own stage 4 pancreatic cancer https://cancercommons.org/latest-insights/how-an-expert-would-manage-his-own-stage-4-pancreatic-cancer/.

I was interested to read his answer: some part of me imagined, even hoped, that he would answer that he would consult with a palliative care team and set about enjoying his last few months of life and planning his exit from the world. My hopes were dashed.

He would consult with a palliative care physician, but he would also consult with a medical oncologist and a geneticist. In addition, he would have “experienced and dedicated nurses, advanced practice providers…clinic staff to provide extra support…. a skilled multi-disciplinary team…[and] access to other experts, including radiologists, pathologists, surgeons, radiation oncologists, and gastroenterologists. All of these physicians would be key to my health and symptom management.”

I’m no expert on pancreatic cancer, so it’s not for me to say this is wrong. But I wonder if the expert ever considered the cost, the sustainability, or the carbon footprint of this treatment? Did he reflect on how most people in the world with terminal cancer do not have access to opioid drugs and even the most basic palliative care? His account reminded me yet again of the joke of the health economist Uve Reinhardt that eventually everybody in the US would either be in hospital or working on one.

Perhaps one of the most profound problems of modern medicine is that the best is the enemy of the good.

Doctors: beware the curse of optimism

Breakthroughs announced in the media are rarely breakthroughs. Disasters rarely prove as disastrous as when first splashed in the media. I kept both these Kiplingesque thoughts in mind when nearly 40 years ago I did my six years as a television doctor. I thought of them again as I heard John Bell, Regius Professor of Medicine in Oxford, say on the radio that the press-released results of the covid-19 vaccine trial should mean that we would be back to normal by the Spring.

I learnt in my six years that I could do more harm by being optimistic rather than pessimistic about a new treatment. I was, for example, sceptical about treating multiple sclerosis with hyperbaric oxygen, which at the time was a comparatively new idea. Even in those days before social media, I was abused for my doubts, particularly by a friend’s mother who was outraged. Forty years on the treatment is not endorsed by either the National Institute for Health and Care Excellence (NICE) or the Food and Drug Administration (FDA), although lots of people still use it. https://theconversation.com/multiple-sclerosis-survivors-swear-by-hyperbaric-oxygen-but-does-it-work-64405

My scepticism was appropriate, and, although it might have annoyed some people, it didn’t do any harm. In contrast, I was somehow seduced by an electrical treatment for Bell’s palsy. I spoke positively about it, and many people, including a prominent comedian, contacted me and tried the treatment. It wasn’t any good, and I felt badly that I had created false hope.

As a television doctor, you don’t usually have the patient in front of you as real doctors do, and it’s not hard to be sceptical. But if you can feel the desperation of patients for something that will “cure” them, then it’s harder to be sceptical, which why many people are given treatments that may ultimately increase rather than decrease their suffering, particularly at the end of life.

Bell, who comes across well on the radio and has been heard repeatedly during the pandemic, must have felt the desperation in the country for “normality” and even in the voice of the interviewer, who had abandoned the scepticism we expect of journalists. Even investors, who are supposed to be cruelly rational, had cast aside any rationality and precipitated 40% jumps in the share prices of companies hit the hardest by the pandemic. Bell spelt out the many steps that need to be taken to have the vaccine licensed and rolled out, but when asked by the interviewer if we would be back to normal by the Spring he said yes.

It seems highly unlikely to me–and probably to Bell—that we will back to normal by the Spring. Indeed, we will probably never be back to life exactly as it was before the pandemic, which I suspect is what people mean by “normal.”

Producing the vaccine and testing its so quickly is a considerable scientific achievement, but it’s unsatisfactory that the results are announced in a press release. The manufacturer’s, Pfizer, seem to have broken their own protocol by looking at the results now. We don’t have the full data and must remain sceptical until we do. Even when we have the data we won’t know whether the vaccine prevents infection as opposed to symptoms. We won’t know how long immunity will last. How many people in the study were elderly or had comorbidity? Is the vaccine equally effective in them? Will it prevent hospital admission and death, the outcomes that interest us most? We’ll need a much larger trial to answer those questions; and we need a bigger trial to be confident about safety: vaccines for covid-19 will be given to billions, meaning a one in 200 000 serious side effect could kill thousands.

Then there are all the logistical problems of rolling out the vaccine to millions of people in Britain and billions worldwide. As one commentator said, vaccination not vaccines save lives, and the anti-vaxxers, assisted perhaps by Russia and China, will be getting to work.

Despite my scepticism, I like many others hope that Bell is right. I can then do my planned walk along Offa’s Dyke. But I think the population is better served by the scepticism of the mournful Chris Whitty, the Chief Medical Officer for England, than any understandable enthusiasm to tell people what they would like to hear.