Time to assume that health research is fraudulent until proved otherwise?

Health research is based on trust. Health professionals and journal editors reading the results of a clinical trial assume that the trial happened and that the results were honestly supported. But about 20% of the time, said Ben Mol, professor of obstetrics and gynaecology at Monash Health, they would be wrong. As I’ve been concerned about research fraud for 40 years, I wasn’t that surprised as many would be by this figure, but it led me to think that the time may have come to stop assuming that research actually happened and is honestly reported and assume that the research is fraudulent until there is some evidence to support it having happened and been honestly reported. The Cochrane Collaboration, which purveys “trusted information,” has now taken a step in that direction.

As he described in a webinar last week, Ian Roberts, professor of epidemiology at the London School of Hygiene & Tropical Medicine, began to have doubts about the honest reporting of trials after a colleague asked if he knew that his systematic review showing the mannitol halved death from head injury was based on trials that had never happened. He didn’t, but he set about investigating the trials and confirmed that they hadn’t ever happened. They all had a lead author who purported to come from an institution that didn’t exist and who killed himself a few years later. The trials were all published in prestigious neurosurgery journals and had multiple co-authors. None of the coauthors had contributed patients to the trials, and some didn’t know that they were co-authors until after the trials were published. When Roberts contacted one of the journals the editor responded that “I wouldn’t trust the data.” Why, Roberts, wondered did he publish the trial? None of the trials have been retracted.

Later Roberts, who headed one of the Cochrane groups, did a systematic review of colloids versus crystalloids only to discover again that many of the trials that were included in the review could not be trusted. He is now sceptical about all systematic reviews, particularly those that are mostly reviews of multiple small trials. He compared the original idea of systematic reviews as searching for diamonds, knowledge that was available if brought together in systematic reviews; now he thinks of systematic reviewing as searching through rubbish. He proposed that small, single-centre trials should be discarded not combined in systematic reviews.

Mol like Roberts has conducted systematic reviews only to realise that most of the trials included either were zombie trials that were fatally flawed or were untrustworthy. What, he asked, is the scale of the problem? Although retractions are increasing, only about 0.04% of biomedical studies have been retracted, suggesting the problem is small. But the anaesthetist John Carlisle analysed 526 trials submitted to Anaesthesia and found that 73 (14%) had false data, and 43 (8%) he categorised as zombie. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15263  When he was able to examine individual patient data in153 studies 67 (44%) had untrustworthy data and 40 (26%) were zombie trials. Many of the trials came from the same countries (Egypt, China, India, Iran, Japan, South Korea, and Turkey), and when John Ioannidis, a professor at Stanford University, examined individual patient data from trials submitted from those countries to Anaesthesia during a year he found that many were false: 100% (7/7) in Egypt; 75% (3/ 4) in Iran; 54% (7/13) in India; 46% (22/48) in China; 40% (2/5) in Turkey; 25% (5/20) in South Korea; and 18% (2/11) in Japan. https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15297  Most of the trials were zombies. Ioannidis concluded that there are hundreds of thousands of zombie trials published from those countries alone.

Others have found similar results, and Mol’s best guess is that about 20% of trials are false. Very few of these papers are retracted.

We have long known that peer review is ineffective at detecting fraud, especially if the reviewers start, as most have until now, by assuming that the research is honestly reported. I remember being part of a panel in the 90s investigating one of Britain’s most outrageous cases of fraud, when the statistical reviewer of the study told us that he had found multiple problems with the study and only hoped that it was better done than it was reported. We asked if had ever considered that the study might be fraudulent, and he told us that he hadn’t.

We have now reached a point where those doing systematic reviews must start by assuming that a study is fraudulent until they can have some evidence to the contrary. Some supporting evidence comes from the trial having been registered and having ethics committee approval. Andrew Grey, an associate professor of medicine at the University of Auckland, and others have developed a checklist with around 40 items that can be used as a screening tool for fraud. https://www.nature.com/articles/d41586-019-03959-6  The REAPPRAISED checklist (Research governance, Ethics, Authorship, Plagiarism, Research conduct, Analyses and methods, Image manipulation, Statistics, Errors, Data manipulation and reporting) covers issues like “ethical oversight and funding, research productivity and investigator workload, validity of randomisation, plausibility of results and duplicate data reporting.” The checklist has been used to detect studies that have subsequently been retracted but hasn’t been through the full evaluation that you would expect for clinical screening tool. (But I must congratulate the authors on a clever acronym: some say that dreaming up the acronym for a study is the most difficult part of the whole process.)

Roberts and others wrote about the problem of the many untrustworthy and zombie trials in the BMJ six years ago with the provocative title: “The knowledge system underpinning healthcare is not fit for purpose and must change.” https://www.bmj.com/content/350/bmj.h2463 They wanted the Cochrane Collaboration and anybody conducting systematic reviews to take very seriously the problem of fraud. It was perhaps coincidence, but a few weeks before the webinar the Cochrane Collaboration produced guidelines on reviewing studies where there has been a retraction, an expression of concern, or the reviewers are worried about the trustworthiness of the data. https://documentation.cochrane.org/display/EPPR/Policy+for+managing+potentially+problematic+studies%3A+implementation+guidance

Retractions are the easiest to deal with, but they are, as Mol said, only a tiny fraction of untrustworthy or zombie studies. An editorial in the Cochrane Library accompanying the new guidelines recognises that there is no agreement on what constitutes an untrustworthy study, screening tools are not reliable, and “Misclassification could also lead to reputational damage to authors, legal consequences, and ethical issues associated with participants having taken part in research, only for it to be discounted.” https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.ED000152/full The Collaboration is being cautious but does stand to lose credibility—and income—if the world ceases to trust Cochrane Reviews because they are thought to be based on untrustworthy trials.

Research fraud is often viewed as a problem of “bad apples,” but Barbara K Redman, who spoke at the webinar insists that it is not a problem of bad apples but bad barrels if not, she said, of rotten forests or orchards. In her book Research Misconduct Policy in Biomedicine: Beyond the Bad-Apple Approach she argues that research misconduct is a systems problem—the system provides incentives to publish fraudulent research and does not have adequate regulatory processes. Researchers progress by publishing research, and because the publication system is built on trust and peer review is not designed to detect fraud it is easy to publish fraudulent research.  The business model of journals and publishers depends on publishing, preferably lots of studies as cheaply as possible. They have little incentive to check for fraud and a positive disincentive to experience reputational damage—and possibly legal risk—from retracting studies. Funders, universities, and other research institutions similarly have incentives to fund and publish studies and disincentives to make a fuss about fraudulent research they may have funded or had undertaken in their institution—perhaps by one of their star researchers. Regulators often lack the legal standing and the resources to respond to what is clearly extensive fraud, recognising that proving a study to be fraudulent (as opposed to suspecting it of being fraudulent) is a skilled, complex, and time-consuming process. Another problem is that research is increasingly international with participants from many institutions in many countries: who then takes on the unenviable task of investigating fraud? Science really needs global governance.

Everybody gains from the publication game, concluded Roberts, apart from the patients who suffer from being given treatments based on fraudulent data.

Stephen Lock, my predecessor as editor of the BMJ, became worried about research fraud in the 80s, but people thought his concerns eccentric. Research authorities insisted that fraud was rare, didn’t matter because science was self-correcting, and that no patients had suffered because of scientific fraud. All those reasons for not taking research fraud seriously have proved to be false, and, 40 years on from Lock’s concerns we are realising that the problem is huge, the system encourages fraud, and we have no adequate way to respond. It may be time to move from assuming that research has been honestly conducted and reporting to assuming it to be untrustworthy until there is some evidence to the contrary.

Competing interest: RS was a cofounder of the Committee on Medical Ethics (COPE), for many years the chair of the Cochrane Library Oversight Committee, and a member of the board of the UK Research Integrity Office.

Is it a masterpiece?

“A masterpiece,” says the Sunday Times on the cover of The Tartar Steppe, a book written in 1938 by Dino Buzzati. But is it a masterpiece? The friend, a highly-accomplished novelist, who gave it to me seemed to think so, and J M Coetzee, Borges, and Yann Martel, all writers I admire, also greatly admire the book.

What is a masterpiece? For me it’s a book that has startling originality in content, style, or both and says something to me about the world, myself, or preferably both that I hadn’t thought before. It’s also a book that lingers in the mind and comes back to you. Perhaps as well masterpieces become well known if not widely read (Is Finnegan’s Wake a masterpiece?), but I’m comfortable with the idea that there are lost masterpieces, and if The Tartar Steppe is a masterpiece it does seem to be a lost one. I’d never heard of it. Had you?  A masterpiece doesn’t have to be enjoyable to read, and I didn’t much enjoy The Tartar Steppe. The novel is easy to read—and I read it in six days—but I didn’t approach it with enthusiasm, as I do most books.

I may not have found the book enjoyable to read because it’s a bleak book, as the title suggests. A young soldier, Giovanni Drogo, leaves the city to work as a soldier at a fort in the mountains. The foot looks North to the empty steppe from where many years before—perhaps even centuries before—that Tartars invaded. But nothing has happened for years. Despite nothing happening the soldiers patrol the walls of the fort night and day, and endless reports are written. Drogo wants to leave as soon as he arrives, but he’s there until he’s old and dying. The soldiers long for war, and it may even be that war arrives just as Drogo leaves to die back in the city. It’s the story of a pointless life spent in pointless busyness.

Yann Martell writes: “It is the story of one Giovanni Drogo—yet how many of us will be stricken to recognise something of ourselves in him?” Because I wasn’t completely caught up in the book and because it reads like an allegory I kept thinking “What is this book about?” and trying to find ideas that told me something about myself. I have certainly spent plenty of time in activities that proved pointless, and there is a sense in that most of us are forgotten quickly after our deaths and leave no legacy that most lives are pointless. I worked 25 years at the BMJ. Was that an activity comparable to guarding a fort night and day against an enemy that never came? I must confess that there were some similarities. I am perhaps just diverting myself with pointless activities until death arrives or the war starts. I haven’t decayed as fast as Drogo, and unlike him I have and have had many relationships that feel and have felt important to me. I’ve no doubt like him deluded myself and gone on with activities that I would have done better to abandon. I’m probably doing that today.

Tim Parks in an introduction quotes D H Lawrence: “A book lives as long as it is unfathomed. Once it is fathomed, once it is known and its meaning is fixed or established, it is dead.” For me this book remains unfathomed, and I like that.

The book is, I can recognise now, replete with unfulfilled hopes, and I’m interested in the negative side of hope—something that the world generally sees as wholly positive. https://richardswsmith.wordpress.com/2021/05/27/hope-is-hazardous/  Parks sees links between Buzzati and Giacomo Leopardi, Italy’s great poet who was “obsessed by the role of hope in human life, a hope he remorselessly exposed as the product of illusion, yet saw, and occasionally celebrated, as ever ready to flower again even in the most barren places, the most unexpected forms. This incorrigible inclination to hope…was both the curse and salvation of the race: it guaranteed that the defining experience of human life would be disappointment, and allowed us to press on regardless.”

Parks goes on: “Buzzati’s intuition is that with the collapse of the great collective illusions—religion, national destiny—and the consequently intensifying sense of absurdity…the individual mind can only react with ever more frenetic attempts to generate hope, the most preposterous hopes out of nothing, to enchant itself with whatever desert terrain is available.”

Perhaps the true mark of a masterpiece—whether, novel, piece of music, panting, play, or poetry—is that you can go on mining it forever, always finding something new. Maybe by that definitionThe Tartar Steppe is a masterpiece, but it’s not one I will read again.

The role of digital health in keeping health systems financially, socially, and environmentally sustainable

I am the chair of Patients Know Best (PKB), https://patientsknowbest.com/ a company that brings together a patient’s records from hospital, general practice, mental health, and social care and puts them under the control of the patient. We have contracts to do this for many millions in the NHS. One of the benefits of digital health is that it can help keep the NHS and other health systems sustainable. I wrote this blog to accompany a short piece in the Guardian about what PKB is doing to support NHS sustainability. https://www.businessandindustry.co.uk/sustainable-healthcare/digital-move-leads-to-better-outcomes/?utm_source=PatientsKnowBest-distro&utm_medium=client

To survive and prosper long health systems must be financially, socially, and environmentally sustainable. All health systems face a challenge in being sustainable in that costs rise ahead of inflation; patients and citizens can lose confidence in systems that offer poor quality care, are hard to access, and feel unresponsive; and most health systems have rising emissions of greenhouse gases and generate huge amount of waste, including leaking pharmaceuticals into the environment. Digital health has an important contribution to make to financial, social, and environmental sustainability of health systems—and Patients Know Best, which I chair, is taking a lead.

I want to concentrate in this blog on the role of digital health and Patients Know Best in environmental sustainability but I also want to write a few words on financial and social sustainability—not least because the three forms of sustainability are intertwined, actions that benefit one often benefit the other two.

Economic sustainability

Expenditure on health care in Britain has risen from 25% of public expenditure to 40% in two to three decades—and it will have risen still higher with pandemic. The rise is partly caused by aging of the population, but the main driver is that health care can offer much more. Ironically the higher spend on health care (which is mostly sickness care) crowds out expenditure on education, housing, and the environment, which are more important for health than is health care. (There is a widespread almost irresistible tendency to conflate health and health care, but they are quite different: the best estimate is that health care accounts for about 10% of health, with the environment, lifestyle, and genes accounting for 90%.)

Most of the expenditure of the health system is on hospital care, with community care having a falling proportion. Despite the increase in expenditure on health care, most commentators insist the NHS is underfunded, and the backlog in care resulting from the pandemic has caused further strain.

There is increasing consensus that “more of the same” will not keep the NHS financially sustainable and that a different model is needed. The main change that is needed is to move from a model of the “NHS fixing people’s problems” to one of the “NHS supporting people to stay healthy and then cope with—or self-manage—problems when they do become sick.”

This change is necessary not just for financial sustainability but also because of the change in disease patterns: in the early days of the NHS people presented with infections and trauma, problems that could be “fixed” in short episodes; now people mostly have long-term conditions, often multiple conditions, that cannot be “fixed.” If patients have meningitis, then whether they live or die depends mainly on the clinical teams, but if patients have diabetes, chronic obstructive pulmonary disease, heart failure, arthritis, or depression then how well they do depends primarily on them and their families not on the doctors and nurses. This is not an ideological statement but simply a fact when patients may spend three hours a year with clinicians and the other 8757 living with and managing their conditions.

Making such a fundamental change is not easy for either health professionals or citizens and patients, but digital technology can help—and giving patients full access to and control of their health records, as Patients Know Best does, is a necessary but not sufficient step.

Social sustainability

When the NHS began patients and citizens were extremely grateful that access to care was free and that the anxiety of not being able to access or afford care had gone. But over 70 years people have come to expect much more than simply access. We live now in a consumer-driven world where a huge range of services are a “click away.” People, particularly younger people who have always known the NHS and don’t have the same “gratitude” for it, expect services as good as those available from the best retailers. The social sustainability of the NHS depends in part on being able to meet those expectations—and so must include better digital access to information and services.

Social sustainability also depends on the NHS being able to provide good access to high quality care and being responsive and humane. One way that the NHS would fail is if the middle classes were to desert because the service did not meet their expectations. This fear has receded with the pandemic and the mass vaccination programme but could return if the NHS fails to catch up with the huge backlog of work left after responding to the pandemic.

Environmental sustainability

The NHS did perhaps not worry much about environmental sustainability until recently. Like most of the rest of the world it took the environment for granted and didn’t think that its limits could be reached. Growing recognition of the gravity and urgency of climate change and ecological destruction has changed that. NHS England has become the first health system in the world to have a detailed plan for achieving net-zero by 2040 for all it controls and 2045 for all that it procures. https://www.england.nhs.uk/greenernhs/publication/delivering-a-net-zero-national-health-service/  The health and social care system accounts for about 5% of the UK’s greenhouse gas emissions, and if health care across the world were a country it would be the fifth largest emitter of greenhouse gas emissions.

Increasing digital healthcare is an important part of reducing the carbon footprint of the NHS, and carbon and cost are closely related. Even in a world without a substantial carbon tax (and such a tax will have to come soon) savings in carbon usually mean savings in cost.

Some of the savings in carbon are straightforward. Substituting electronic messages for paper letters means savings in paper, emissions from transport, and cost. Letting patients book appointments online is a small step along the road that banks followed many years ago of getting customers rather than staff to do much of the work. Allowing people to consult online can provide a better service and also save the 10% of the NHS carbon footprint that is accounted for by patient and staff travel: one in 20 journeys on Britain’s roads is associated with the NHS. Optimal online consulting depends on the consultations being incorporated into health records with both patients and clinicians having access to them, as Patients Know Best allows.

But, as the NHS net-zero plan makes clear, changing buildings, using renewable energy, and introducing electronic vehicles will not be nearly enough to get the NHS to net-zero. Everything, including clinical practice and pathways, has to change. This reality is only just beginning to sink in with many health professionals.

The real power of digital comes from empowering or activating patients, and to be much more active in their own health and care patients must have access to their own records and results and high-quality information. They must also have the chance to share data they collect themselves with health professionals. Care becomes a partnership that recognises that patients know best what matters to them.

An example of change is recognising that the widespread routine six-month follow-up of patients with long-term conditions is inefficient. The pattern of most long-term conditions is that patients are stable for much of the time but then have flare-ups when they need professional care. If patients are given access and control of their records and test result and “put in charge” then they can keep themselves stable, feedback to clinicians that they are well and don’t need to be seen, and then request to be seen as a flare-up begins. A study of using a pathway along these lines with patients with inflammatory bowel disease showed that visits to outpatients and the emergency department and admissions fell and that patients with flare-ups were seen within a week rather than usual six weeks. https://www.rcpjournals.org/content/futurehosp/6/Suppl_1/85

Redesigning pathways in this way can reduce cost and carbon consumption. The changes that occurred at the beginning of the Covid-19 pandemic illustrated how quickly and extensively clinical pathways can change when it’s essential, and pathways have to change to keep health care financially, socially, and environmentally sustainable. The need may not feel as urgent as with the start of the pandemic, but the need is just as urgent. We are running out of time to keep the global increase in temperature at less than 1.5C above pre-industrial levels, and increases above 1.5C open up the possibility of a rapid descent into chaos.

Digital health, including all patients having access to and controlling their records through Patients Know Best, is an essential component for sustainability, but ultimately patients and health professionals working together have to innovate using the technology.

Why would a world-class writer publish novels anonymously?

Reading Anthony Trollope’s novels is one of the joys of my life, and I was delighted to find that there are novels that he published anonymously that I knew nothing about. I have now read one of them, Linda Tressel, and I was disappointed. It didn’t seem up the standard of the novels he published over his own name. But the book does have some merits.

The first question is why he published the novel anonymously. I have been able to find remarkably little about Linda Tressel online; it doesn’t even have a Wikipedia entry. I’ve found one blog that offers an explanation: “Trollope conceived the idea of experimenting with anonymous publication, in order to find out whether the multitude bought his books for their literary excellence or merely for the “brand name” on the cover.” https://stromata.tripod.com/id78.htm  I was sceptical that was the only reason, but I managed to find a biography of Trollope that offers the same explanation: “At the height  of his reputation and earning power, he had qualms. How much of all those rewards depended on his name alone? No other writer known to man has had this particular attack of conscience.” Is that, I wonder, true? The answer he got cannot have been comforting. The books did not sell. I haven’t read the others (Nina Balatka and The Golden Lion of Grandpere), but Linda Tressel may not have sold as well as his signed novels simply because it isn’t as good.

I wonder if there might be another reason why Trollope published Linda Tressel anonymously. The book is a forceful attack on fanatical religion, of which there was plenty in 19th century Britain, and deplored the subjugation of women. It’s also sceptical about marriage. Plus, at the end of the novel Roman Catholicism makes a brief appearance and is described positively. If Trollope had been on Twitter when the book was published, he might have been attacked strongly on some of these themes.

The novel, which does, as Joanna Trollope has commented read like a fairy tale, tells the story of the attempt by her fanatical aunt to marry Linda Tressel to an ugly and horrible man much older then her who is more interested in Linda’s house than her. Linda is disgusted by the man. The story does not end happily, as Trollope tells us it won’t at the beginning.

Again and again in the book (too many times) Trollope refers to the belief of the aunt (and perhaps many Victorians) that women should be “crushed.”

“It may be necessary that a man should be stiff-necked, self-willed, eager on the world, perhaps even covetous and given to worldly lusts. But for a woman, it behoves her to crush herself, so that she may be at all points submissive, self-denying, and much-suffering. She should be used to thorns in the flesh, and to thorns in the spirit too. Whatever may be the thing she wants, that thing she should not have. And if it be so that, in her feminine weakness, she be not able to deny herself, there should be those around her to do the denial for her. Let her crush herself as it becomes a poor female to do, or let there be some other female to crush her if she lack the strength, the purity, and the religious fervour which such self-crushing requires.”

Perhaps there are many men—and women—in the world today who still believe this.

One feature of the book that fascinated me was the omnipresence of Satan and the prospect of Hell. Fear of Satan and Hell was a major factor in the behaviour of the aunt and to a lesser extent that of Linda. Surveys suggest that many people today believe in Hell, and I found myself wondering how much behaviour today is driven by a fear of spending eternity in Hell. That will be the subject for another blog.

My conclusion is that Trollope’s anonymous novels are to be avoided.

Three old geezers go bicycling: Day 3—against the clock to the Cotswolds

Maybe I’m too old for Google maps. I never know which way up they are, and they are cluttered with restaurants and shops that are irrelevant to my purpose. My father was too old—or perhaps too poorly educated—for any map. He distrusted maps but trusted his instincts. He got where he needed to go. Similarly—unlike yesterday when I took us up the wrong hill—I managed to steer us through the labyrinth of Roman Bath onto the right road to the cycleway to Bristol. Again, I saw parts of Bath I’d never seen before, making me think of Will Self who walked in straight lines in every direction from his London home. You soon discover wonders.

Omnia mirari etiam tristissima. “Wonder at everything, even the most everyday” said the great biologist Carl Linnaeus. I’m tempted to modify it to “Wonder at everything, especially the everyday.”

Some 50 years ago I walked the Cotswold Way from Chopping Camden to Bath. I walked it with Douglas, who now has Parkinson’s Disease. It was December, and there was snow on the ground. We stayed in youth hostels that we couldn’t get in until 5pm—and so we sheltered in phone boxes after it was dark at 4pm. We passed through Stroud, our destination today—but annoyingly there is no cycle route that follows the direct route along the crest of the Cotswolds. That’s why we must go by Bristol.

The cycleway to Bristol is busy. Britain has become a cycling country—but more for leisure that practicality. When I cycled to work in 1979 there were few of us on bikes. Cycling was for the poor and eccentrics—like Quintin Hogg. Now the country is full of MAMILs (middle-aged men in lycra) on titanium bikes costing thousands of pounds roaring down every country lane.

Again, we are up against a deadline. Robin and I must catch the 16.28 from Stroud or buy a new ticket and possibly not be able to get our bikes on the train, and young David is booked from a different station at a different time. Despite our deadline we stop at a café based in an old station on the edge of Bristol. Our conversation revolves around whether health could be made as central to life and political discourse as economics. I describe the long-held fantasy of a health equivalent of the Economist—built on the idea that health is part of everything as is economics. But it remains a fantasy because health is a slippery concept (and for too many people a negative concept—“if I’ve not got a disease I’m healthy, if I have I’m sick.”) In contrast, economics is addressing the fundamental questions of “How do we share out what we have?” and “What will we use our resources for?” Robin is more optimistic about the possibility of health becoming as central as—or even replacing—economics.

We cycle on, skirting our way round Bristol. Bristol like Birmingham is a place where motorways meet. We cycle beside, over, and under them. Besides the motorways are grassy banks filled with poppies and wild flowers? Might there ever be a world—perhaps post-apocalyptic—where there are still bicycles and wild flowers but no cars?

Eventually we must resort to road—a B road, which means that cars pass us regularly. There are hills, but they are initially neither long nor steep—but we can see the scarp of the Cotswolds coming closer. We must climb a short but steep hill into Wootton-under-Edge. I get off and walk, but young David carries on—almost at walking pace. Cars build up behind him, a cause for him of celebration not embarrassment.

Young David negotiates us skilfully into the garden of a café through the back alley. Two of us eat Buddha Bowls, which are filled with fashionable foods (humus, avocado, spinach, chickpeas), and two us drink cider.

Then we must part—with the hugs that are now unfamiliar and almost rebellious. Young David heads north-east, and Robin and I north-west. We have to climb a hill that is both long and steep. I alternate walking and cycling. Once on the top we can see long distances both west and east. At one point I can see the wide Severn. We are headed towards Nailsworth, then to follow the cycle path to Stroud.

We go wrong and must turn right down a narrow, single-track road. We pass through a village just as parents are collecting their children from school, many (most?) of them in cars. Some of them follow us, but they can’t pass us. When we finally reach a roundabout the car immediately behind me screeches off to the left, the driver expressing his or her irritation at having followed us for so long. The centre of Nailsworth is filled with cars. Does it have to be this way?

We find the cyclepath through woods, very pleasant. Again, we miss a turning, but still we make it to the station with 15 minutes spare. Because we get in the wrong door we are in a first-class carriage but are allowed by the guard to stay. My sore bum enjoys the soft seats. As we leave Stroud, a town of hippies, I think of my friend Louis, a Scot who died in Stroud. He spent years writing the first sentence of his great novel but never wrote the second sentence.

At Paddington I say goodbye to Robin and cycle through the hot evening to Clapham. “I’ve never seen you looking so exhausted,” says Chicken laughing. “It’s good, healthy exhaustion,” I reply as I go to bed at 9.30.

Three old geezers go bicycling: Day two—to Mells (with intimations of the Great War) and back

It feels as if we could be in Provence as we breakfast in the walled garden on melon, muesli, and Oxford marmalade on excellent toast. I have suggested that we go to Mells, a village that has a special place in my memory: it’s a place not of now but of a hundred years ago. When I look to see what Wikipedia say about it I find that not only is it the home of the Horners and Asquiths, which I knew, but also the home now of Annunciata Rees-Mogg and has been voted “one of the top 20 prettiest villages in Britain.” (I’m hugely suspicious of these lists of top restaurants, business schools, pretty villages etc—there are enough of the lists for every restaurant, business school, pretty village, and etc to make it on to one of them.)

My selection of Mells turns out to be highly fortuitous as we can cycle there with spending only a few miles on roads and almost none on busy roads—we will be mostly on cycle ways built on old railways. We set off through Bath, and I take us up the wrong hill. Eventually we winkle our way through to the cycleway built on what was once a railway that brought coal to Bath, Bristol, and beyond from the Somerset coalfields. As we winkle, I see parts of Bath I’ve never seen before and realise that the city is even greener and more beautiful than I’d ever realised.

We walk our bikes up to the cycleway, and a woman points us in the right direction—”through the long tunnel rather than the short one.” After a short distance we enter the long tunnel, which is over a mile long. It is cold. The tunnel is lit with LED lights on either side at about 10m intervals, but it feels very dark when you first enter—before your eyes adjust. I was at the front and had not thought to switch on my light. For a while I worried that I might crash into the side of the tunnel, but that anxiety soon passed. My next anxiety was crashing into people walking or running through the tunnel or people cycling the opposite way, some of whom, like me, didn’t have lights. All these anxieties passed, and I found it different and exciting to be cycling through the tunnel.

In the middle of the tunnel is an artwork “called Passage, from United Visual Artists and Mira Calix…The installation consists of interactive orbs which are situated in side arches and take their inspiration from the light reflectors used by the old trains, nodding to the tunnel’s industrial past. The glowing discs are fitted with motion sensors and dotted throughout the tunnel and also feature viola and cello scores composed by Calix. These soundscapes change depending on the speed and distance of people approaching.” https://www.vice.com/en/article/ez5gqp/augmenting-a-disused-railway-tunnel-with-sound-and-light We were going too fast to be able to pay much attention, but I imagined the sounds to be the voices of the long-dead workers who dug this tunnel, some of whom must have died doing the work.

When we emerged from the tunnel we were bathed in warmth and sunlight. Bath had disappeared completely, and we carried on along the cyclepath, high up and crossing a viaduct. After about 30 minutes we reached a horse-riding centre with a café where the path ended and we had to join the road. I made us coffee and tea in what I took to be a serve-yourself café and was embarrassed when I went to wash up to discover that it was the staff room. The horsey staff didn’t seem to mind.

We cycled a few miles along road before rejoining the cyclepath, which took us into Radstock. We came this way on our last cycle and found it even more of a joy then than now to join the carless and relatively flat cyclepath that took us to Frome. This time we left shortly before Frome and descended by road into Mells. We made straight for the church but found it locked. Young David texted the church warden to see if we might let us in, writing that we had travelled a long way to see the equestrian statue of Edward Horner, who died at the Battle of Cambria in 1917. It was the statue, which almost better than anything catches for me the futility, sadness, but also (misplaced) nobility of the First World War. (A pot of Arum lilies from Mells also sticks in my mind, but I didn’t expect them still to be there.)

Not only was the church closed but also the pub and the café in the walled garden (Mondays and Tuesdays are not the best days to visit Mells), but we could get sandwiches and a drink in the community shop and café. We ate them by the river, and then went for a walk along the river, a walk I remembered well. (My memory, however, was wrong: the walk must have been in another village.) While all this was going on young David got a text saying that we could visit the church and giving us the numbers of the lock on the front door and the box enclosing the key.

Robin knew nothing of the texts, and young David claimed that he would be able to crack the locks. With the acting skills he leant at Cambridge he showed Robin how it was done. Robin was mightily impressed. I said nothing. With his church-breaking skills, David got us into the church. I would have been horribly anxious about breaking into the church, a criminal offence, but Robin, who believes in breaking rules for good causes (see the account of his arrest in the Lancet https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)33058-2/fulltext ), was unphased. When I explained how young David had done it, thinking I might relieve Robin’s anxiety, Robin was disappointed.

Inside the church I made for the statue and realized that it was bigger than I remembered. But it is less than quarter lifesize, and it is unusual to have an equestrian statue inside a church. I found it as moving as ever. I hadn’t grasped before that the statue was by Alfred Munnings, the intensely conservative president of the Royal Academy, and the plinth by Lutyens, although you can see at once the similarities with his Cenotaph in Whitehall. Nor did I remember the wreath by Lutyens with lettering by Eric Gill (who designed the descending J of BMJ), the plaque by Edward Burne-Jones, or the stained glass window of St Francis by William Nicholson.

The church has such riches because Mells is the home of the Horners (including Little Jack, who “sat in the corner”) and the Asquiths. Siegfried Sassoon is buried in the churchyard, and we found his grave. But we missed the grave of Helen Violet Bonham Carter known before her marriage as Violet Asquith. She was the daughter of Asquith, the prime minister, an MP, diarist, and closest female friend of Winston Churchill.

We returned by the route we had come by, stopping for tea and ice-cream in a café attached to a house that is “off the grid,” connected neither to a water supply nor sewage system, although it does have electricity. The man who runs it once worked for the Ministry of Defence and loved to talk, the main reason, I speculated, for running a café. He told us how his alpacas keep away foxes because they destroy them with hooves that are sharp with “toes” that are like sets of razor blades.

Back in Thomas Street I had time for a bath and a read before we walked to the Ivy in Milsom Street, the classiest street in Bath. The food was better than last night, and we discussed the difference between “needs” and “wants”: are they distinct or do what start off as wants become needs as we get wealthier? The man who owns the house where we are staying has written a book where he tries to calculate if the needs of everybody in the world could be the met. The answer seems to be no.

We walked back through the quiet streets past the Abbey, weir, and Poultney Bridge. Bath was very beautiful in the last light of a hot summer’s day.

Three old geezers go bicycling: Day one—along the canal from Bedwyn to Bath

The first challenge for Robin and me was hanging our bikes at Paddington in the tiny space reserved for them on the swanky First Great Western trains. You must hook the front wheel over a hook nearly seven feet high, pull down a barrier, and then do the same with the second bike. There is almost no space between the bikes. Putting up the the first bike is difficult—and surely impossible for many—and the second bike even more difficult. The bikes then dangle there looking dead (which of course they are) and vulnerable. As a cyclist you are left with the impression that the owners of the trains had no enthusiasm for being friendly to cycling and were probably forced provide spaces for bikes—just like developers of fancy buildings who must reluctantly incorporate “affordable housing” as part of gaining planning permission.

At Reading we had to scrambled to get our bikes off the train before they were transported to Plymouth. Getting them down is easier than getting them up—but not by much. Putting the bikes on the smaller second train was much easier. Perhaps train owners think that cyclists shouldn’t aspire to long journeys.

As we travelled Robin became worried that if we started along the canal towpath at Hungerford as we intended we would not make our booking for dinner at 7.45 in Bath. We decided to go onto Bedwyn, the end of the line and perhaps five miles closer to Bath. The train guard let us go for free.

It was hot when we arrived in Bedwyn, perhaps 27C. It’s a somnolent station, right beside the canal. In moments we were ready to go, rattling along the rough canal towpath, which was baked hard with its ridges, roots, hollows, twists, and turns. If I was milk, I would have been turned to cheese by the time we reached Bath. The path was often narrow and close to the canal. When we started I thought it likely that I might plunge into the canal at some point; I‘d be fine, I assumed, but would I be able to get my bike out? And what about my phone, Kindle, and wallet? All disposable, I decided.

But I adjusted, as we do. After a few miles of the 50 I came to think that I probably wouldn’t be plunged into the canal, although going under bridges on the narrow towpath unnerved me initially. Robin did fall of twice, but luckily he fell landwards not canalwards. After some 10 miles, which included lugging our bikes over the top of a place where the canal went through a tunnel, we met David, who had cycled from the other direction. He was lounging under a tree, wearing a floppy hat, nibbling a long blade of grass, and singing sea shanties. Even if that memory is not strictly accurate it’s my memory.

So continued a day of hurtling along the canal towpath. The dinner date required us to keep up the pace. Robin led, David was in the middle, and I was last—sometimes getting a fair way behind as my bum (note to self: remember to buy cycling shorts) alternated between stinging and being numb, I lost feeling in the ends of my fingers, and the backs of my hands became sunburnt. Robin, who is now 79, once cycled from Nairobi to Cape Town and has remarkable stamina and a very good bike. Young David and me, Mummy Bear, struggled to keep up.

The canal and its surroundings are beautiful. Once—two centuries ago—this was a major highway, but now it’s slow and peaceful, mostly avoiding towns and villages and creeping between the Marlborough Downs and Salisbury Plain. The sides of the canal are luxuriant and filled with wildflowers. Then the people of the canal are special: many seem to be hippies, drinking beer, cooking chicken over an open fire, stripped to the waist, and playing Led Zeppelin; others are old, draping their wrinkled, bikinied bodies on the top of their boats to capture the sun; and some are tourists not quite sure how to steer their boats.

Most of the boats are not moving, and perhaps some have not moved in decades. They are topped with flowers, illegal drugs, bicycles, and inflatable women.

A highlight of the cycle is riding down the series of 12 locks near Devizes. It seems odd that from the top of the locks you can look out across a panorama and that you can freewheel for about a mile.

We hardly stop—no time to stand and stare—and accelerate as we pass through Bradford-on-Avon, which is said—wrongly I think—to outBath Bath, as the path gets wider and gentler and the possibility of missing dinner comes closer. But we make it to Bath at about 7—after six hours mostly on our bikes—and arrive at the three-story house in Thomas Street in time for the quickest of ablutions. Thomas Street brings back memories for me—mainly of when my parents lived just above it and we would visit regularly with our children but also of Caroline, a delightful and vivacious woman who lived in the street with four small daughters who died in her late 20s.

There is time for us to walk to the Marlborough Arms, and every step brings back memories—Hedgehog Park, the Farmhouse (now an acupuncture and osteopathy centre), the back of Royal Crescent, and the pitch-and-putt course, where I’d play with the boys. The garden of the pub is pleasant and the service excellent but the food indifferent. I don’t remember exactly when what was said when over the three days, but there was a constant stream of wisdom or something that smelt like it.

The central theme is environmental destruction and the climate crisis, but we come at it in different ways. We are a sort of cycling seminar. One recurrent topic is meat-eating—Robin and I eat meat, whereas David doesn’t, although he is not vegan, leaving him on somewhat shaky ground. We are all appalled that the animal mass on the planet is 10% humans, 86% animals we eat and pets, and 4% wild animals (or roughly that). It wasn’t so long ago it was 100% wild animals. Robin and I insist that animals are part of natural ecosystems (justifying us eating a small amount of high-quality meat from much loved—but still butchered—animals), but David reels off the figures and we can but agree that the ratios are all wrong. I think of J M Coetzee comparing the killing of animals to the Holocaust with us today ignoring the slaughter just as people did then.

We walk back through Royal Crescent and Royal Circus, and once I’m in my bed I’m asleep not in my usual 90 seconds but 30 seconds. I’m still not hydrated despite my pint of ginger-beer shandy and plenty of water.

Different deaths: “I wanted to express how very simple death and burial are, just as easy as the falling of an autumn leaf”—but not always

“I have left out some details—I wanted to express by those ruins that the peasants have been paid to rest for centuries among the very fields in which they toiled when they were alive. I wanted to express how very simple death and burial are, just as easy as the falling of an autumn leaf—nothing but a bit of earth turned over, a small wooden cross. Where the grass of the churchyard ends, over the little wall, the fields around it form a last line against the horizon—like the horizon of a sea. And now the ruins tell me how faith and religion moulder away, no matter how firmly grounded they are—but that the lives and deaths of the peasants are always the same. Steadily sprouting and withering like the grass and the little flowers that grow in the churchyard there.” Vincent Van Gogh, 1885

“At 3.30 in the morning, I am woken by a doctor on the phone. He says my mother [who is 82, frail, and has made clear in an advanced directive that she doesn’t want invasive treatment at the end of life] has developed sepsis and a galloping infection in the ulcer. They are going to operate and she may well die. I am confused, I say that she has advance medical decisions against interventions of this sort. Oh well, says the doctor, we’re working with her, and she’s happy with this. She’s very bright, very alert. And he puts the phone down. I imagine my mother, docile and smiling as she always is in fear. I remember how she agreed to go to the operation that wasn’t hers, was rolled along the corridor, bright and smiling for the doctor. I imagine her infected leg. I imagine her waking up to find it gone…. And now she has been put on a ventilator, for her operation, and when I call the ICU they say she is stuck on it, she can’t breathe on her own. They don’t know if she will ever come off it, but if she does, they say, she will live a very limited life in a nursing home….[My brother] sneaked himself and my father on to what he thought was the palliative ward only to find my mother breathing with just an oxygen mask, conscious, but off her head.” [She died a few days later in hospital.] Kate Clancy, Guardian, 2021 https://www.theguardian.com/news/2021/apr/06/letting-go-my-battle-to-help-my-parents-die-a-good-death

Old men can shrivel to nothing more than a compilation of stories

The first day I arrived to work at the BMJ in 1979 I wore a suit. I hardly ever wore one thereafter, but the suit showed my nervousness. As I attended meetings, cocktail parties, and dinners I was deeply grateful to any older person who gave me time, rescued me from being stranded and awkward. One of these people I had subsequently to fire, a greater embarrassment to me than him, but one of those kind souls that I remember clearly was Dr John Havard, and unintentionally he taught me something about aging that is now affecting me.

Havard was the secretary of the BMA, the highest official in the catacomb of the BMA, when I was a lowly assistant editor. Patrician through and through (or so it seemed to me), he had trained in law as well as medicine, sprinted at near-Olympic standard, written an influential book on undetected murders, revitalised the BMA, played a prominent part in Britain requiring seat-belts to be worn in cars, and campaigned against boxing. The elected doctors at the BMA, I came to realise, resented his power, intelligence, and patrician manner, and when he retired they replaced him a dolt.

Like all of us, he had his failings, which are hinted at in the short sentence in his BMJ obituary: “He also had a son with Diana Northcott.” https://www.bmj.com/content/340/bmj.c3218 Readers are not told who she was, but we know she was not one of his two wives. The wicked but probably true story about him at the BMJ was that he married his mistress to be able to introduce her as his wife to the Prince of Wales in the year that the Price was the president of the BMA.

The BMJ obituary also notes that “he had few friends but many admirers.” Perhaps that’s why he was so generous in talking to me. The way that he talked to me is how, I fear, I now talk to many people. I would say something and rather like a shilling into a juke box (look it up if you don’t know what that is) some word would provoke not a song a story from his past. He had no other conversation. These were rehearsed monologues not a dialogue. They were good stories, but after a while I realised that I’d heard them all before. I was too lowly, timid, and polite to say so and would listen to the stories again and again. As my stature rose and he aged, I tried to avoid him—despite my gratitude for his kindness.

The same, I fear, is now happening to me. My head is filled with stories, some of them true, all of them distorted. In conversation—particularly, I worry, with young people—the person says something that triggers a story, just as happened with Havard, and off I go. Sometimes, I inquire, “Have I told you this before?” but I am, I suspect, telling the same people the same stories again and again.

Is this how we fade away? Slowly but surely, just as a cancer advances, we are invaded by our stories. The present becomes uninteresting or just too painful. The stories become more mythic than real, and perhaps, as we dement, they become locked in our heads. We shrivel away until we are nothing more than a compilation of stories.

Am I a pisseur de copie?

I’ve greatly enjoyed Muriel Spark’s satire on the publishing world, A Far Cry From Kensington, but I’m left haunted by the idea that I might be a pisseur de copie.

The book is spare, waspish, fast-paced, funny, and a joy to read, especially after a volume of Proust. Spark like Proust is observing the strange but endlessly fascinating ways of humans—but in a very different style.

Mrs Hawkins, the narrator, works briefly for three publishers: one is on his way to jail for fraud; another is an upper-class idiot; and the third are a gay American couple prone to dramatic fights. Spark has some sympathy for all of them.

Very lightly Spark offers advice on writing scattered throughout the book. I’ve already posted her advice on how to write a novel, https://richardswsmith.wordpress.com/2021/05/31/muriel-sparks-concise-and-excellent-advice-on-how-to-write-a-novel/ but here are other nuggets.

“That Loy [Spark?] style of ferreting out facts and juxtaposing them with inventions.”

“A novelist doesn’t really have to undergo every experience, a glimpse is enough.’”

“‘When you are editing copy, Mrs Hawkins, what sort of things do you look for?’ said Howard Send. ‘Exclamation marks and italics used for emphasis,’ I said. ‘And I take them out.’”

But what Spark hates most is a pisseur de copie, and the villain in the book is one. She writes: “I forget which of the French symbolist writers of the late nineteenth century denounced a hack writer as a urinator of journalistic copy in the phrase ‘pisseur de copie’, but the description remained in my mind, and I attached it to a great many of the writers who hung around or wanted to meet Martin York [the fraudulent publisher].” She forgets which French symbolist writer came up with the term because she’s invented it herself.

Once you know the phrase pisseur de copie you read them everywhere. Most of those obliged to make a living by spewing (pissing?) out columns every few days might be called pisseurs de copie. But am I one? I fear I am. I’m not financially obliged to write something every day, but some beast inside me encourages me to do so—and I enjoy it. It’s my hobby. I don’t suffer as I think a non-pisseur, a proper writer, must. My only excuse is that my pissing is not printed and sent to hundreds of thousands of people; rather it’s projected onto a screen where people can ignore it—and 99.99999999% of the world does. Good for them.

Other quotes I took from the book:

They [the Poles] greatly enriched London with their new and alien life. Like other groups of war refugees, they brought their courage with them; it was no mean offering.

People love coincidence, destiny, a lucky chance.

‘They’, which meant they, the Government, they, the Americans, they, the Irish, and many other theys; which left a very small world of ‘us.’

The sadness of these last gatherings of personal effects, the siftings and sortings and parcelling-up, is more inexpressible than the funeral, where at least there is a fixed rite, there are words, the coffin has a shape and the grave a certain depth, and even the sorrow of the mourners has some silent eloquence if only conveyed and formally interpreted by their standing still. But the grief which is latent in relics like Wanda’s pair of worn shoes has no equivalent at all.

I had always associated people of crusader-like left-wing leanings with grim faces and glum rectitude, with plans and statistics, and coming home from night schools at the London School of Economics, in the rain, sucking acid drops.

It is a good thing to go to Paris for a few days if you have had a lot of trouble, and that is my advice to everyone except Parisians.