health – dr cedar

The busine$$ of health

We are coming up for elections in the UK and the National Health Service (NHS) is always on the political agenda. However, nobody has the real discussion. They get bogged down in waiting lists and costs and rationing. But none of us has really decided what the NHS is and what we want. We confuse medicine and health and we put them into a strange administrative stricture called ‘business’.

We have taken on a ‘business model’ for health and health provision. (We have taken on a business model for everything it seems and money is the root of all decisions rather than what it is that we want; our values and aspirations). This business model has probably come from the USA where health is a very big, private business with large vested interests that want to keep it that way.

In a naïve, at best, and daft, at worst, way we have fallen for this model while having an NHS which was set up with a completely different, and in many peoples’ mind better, aspirations. We are in danger of losing the NHS. I have nothing against business. I have a lot against turning everything into currency. You know the definition of a cynic: ‘a person that knows the cost of everything and the value of nothing’. I do not want health to become a mere cost, rather than a true value.

Let me explain what I think business is for those who spend years and lots of money doing business degrees and ending up as Business Administrators- which is not the same as being a business man or woman.

Business has one model really:

Buy cheap, sell dear.

In other words, business is about making a profit. It of course looks at getting customers in to spend their money and be loyal to your brand, but the real ethos is, buy cheap, sell dear.

Point number 1: For the NHS to take on this model is deeply and profoundly stupid. The NHS is not set up to make a profit. It is about curing people of an illness (the medical model). That is what it was set up to do: treat people.

The NHS is not free. All the people that work in it are paid. It is given money by the tax-payer to do that. It is a good use of taxes. Those people that are paid to work in the NHS then in turn pay their taxes.

There is a problem in that the NHS is generally used by people who do not pay taxes: children and older people, but the families of the children and the older people themselves have paid taxes into the system. In fact, there is a separate tax for Health and Welfare called National Insurance. The major problem with all British Governments is that they do not ring-fence that money and use it for the purpose it was set up for. It has become just another form of tax, when in fact it is meant to be a public insurance for health care.

Point number 2: The whole point of hospitals and doctors is to repair you and hope you don’t come back. The one thing the NHS doesn’t want is customers. It does not offer a loyalty card for frequent users! It should not offer a card for those that don’t use it to get some sort of discount. It is there for when we need it. If we were all healthy we would not be using the NHS and that is really the goal. So the NHS is only there for when we are not healthy and is not touting for business.

Businesses need people to buy their products so that they can make a profit. They spend money advertising their goods to attract people to buy their brand and then hope they like it so much they will come back and buy more of it, that they will feel it value for money, while the business also makes a profit. That is not the medical model.

Of course that is the medical model for which the NHS was set up. The health model needs each individual to take responsibility for their health. The NHS is a safety net for when things go wrong, rather than promoting its services, touting for clients.

Some businesses think they must diversify. This is usually a big mistake. Because you had a good idea and made it work does not mean you are the source of all knowledge and ideas. If your idea was a food product, it does not mean that you should go into fashion or home furniture. This is the big mistake of many an entrepreneur. We see it on programmes such as Dragon’s Den where successful entrepreneurs forget themselves. They had one good idea and maybe some luck. This does not make them the world’s expert on other ideas (or politics, education or health).

Point number 3: We need to decide what Health is and what Medicine is and what Social Care is and what Care is and then act on our findings and aspirations.

Our NHS is really for healing those who have become ill. It is good at acute care. It patches you up and then you are meant to be able to take care of yourself as a grown up individual. You are meant to be able to maintain your own health, that is called homeostasis and is the root of all our health, our ability to carry out our lives, our Activities of Daily Living (ADL) such as breathing, walking, feeding, excreting, communicating.

Some of us cannot do all these things and need constant help. That is care.

Some of us lead unhealthy lives and put ourselves at risk. We are repeat offenders/customers in the NHS. But that is our choice and entitlement.

We need to decide about the NHS at a fundamental level as we have some great things about it and some very poor things about it.

We keep blaming it for the poor health of the nation, but firstly, it was set up for acute care and secondly, the British are just culturally not very good at health. We are very good at medicine and clinical care. We do have public health and health promotion, but it is very badly done. We are good at epidemiology, the causes of a disease upon a people, a population. But we are not good at being healthy. We do try to promote health, but we tend to do it in patronising and infantilising ways, merely irritating those we are aiming our good intentions at. It is often carried out by people who do not really understand what they are saying, grasping at the latest poor research findings of a rather weak correlation, such as more people in the summer drown than in the winter and then ending up with some profoundly stupid proposal (should we ban summer or swimming?).

We train our doctors and increasingly our nurses in what is called the Medical Model. It is very successful at diagnosis, finding out what is wrong with somebody by inventing tests and investigations to see which part of us is not performing well, say our haemoglobin or our pulmonary circulation. By investigation we diagnose and then we treat, medically, with pharmacological drugs or by surgery. That’s it. It does not cure your life. It fixes the part that is wrong. The NHS was set up to do that. It should not be accused of being bad at other models as that was not its point.

In the UK we have not decided what health is and who should care about it and who should care about us so we do not know what it is and what we want and what we are willing to do as a nation.

In France they have. So perhaps we can look across the channel to them. The difference between France and Britain, according to the presenter Melvin Bragg is that ‘France is cultured and Britain is civilised’. I think he has made an important point there.

The French have a philosophy of health and of hospitals. They build them differently. They look at health differently. They have a different education to us. All school children study philosophy. They are not embarrassed about having discussions about meaning and context. We are.

The population of France cares about its food. We don’t. We will eat any old crap so long as it is cheap. They care about many of the basic things that we don’t care about. They have a culture of beauty. To have a care service run by people who don’t care about how things are is never going to work.

So while patching people up is done very well by the NHS, caring isn’t. We are civilised people in the UK, so we care about people, but we are not cultured so we are a bit careless about how we care, what care we offer. We don’t have a great culture of care. How can you be taught to care by someone that doesn’t care for themselves or others?

When I was young I had school cookery lessons by a woman who taught us to cook food that was really nutritionally poor and had no flavour to it. I got the impression she had never eaten sumptuous food or been exposed to a variety of cookery books and had her imagination stimulated. How could she teach us to eat well if she had not experienced what that was? She lacked food culture.

We need to learn how to improve the health of the nation. That is a philosophical debate about personhood, independence, community, tax, care, identity, homeostasis, ADLs, ethics and values. It includes funding. It does not include business. Health should not be a business. It should be an ethic. How we care about ourselves and each other. What we want and how to achieve those aspirations and values.

We were told, when we privatised everything, that we would have better services. All we have seen is larger profits for share-holders. A country that does not own its own infrastructure is not really a country. Why would you fight to defend Thames Water, Eon, Glaxo’s, Pfizer’s or Virgin Trains?

We were told that efficiency is the model for business (profit is, actually). Efficiency is a method of getting maximum profit. Speed to get to the end is the goal of many businesses. There is a cookery programme on TV where chefs compete to see who can make the fastest omelette. Really? Why would you want to eat the fastest omelette rather than the best? We have made many valuable commodities into puerile entertainment to generate money. But we must put our values and aspirations back on the agenda.

Point number 4: We must stop the internal market in the NHS competing for money on false objectives. How fast you can do something is not the root of medical practice or care. Time and motion studies should not be the ethos of the NHS. Competition among health care providers has not been shown to provide better care.

The NHS is fabulous at treating illness. It is not fabulous at caring. It is very poor at holistic care. It has the right ethos, but needs better training for caring. We do not have a culture of health and that is what we need in our population and in our NHS. But we must not throw out the NHS because it does not do what it was not set up to do. It was set up to cure. It does that very well. We may want to extend it to care and health, but we need a debate about who should be doing that and what it is we want. It may need a separate structure for health care or it may need a cultural shift, an educational change. We need to keep business out. Health should not be conflated with business, nor should the NHS.

Cancer and Blame

Most of us probably want to believe that we get what we deserve! However, we were not really put on this earth to make these judgements. We cannot tell how other people really live, what they face each day, and what they deserve let alone blame them for all that happens to them.

A lot of money has been spent on bad science, pseudo science and bad public health. Most epidemiology looks backwards, what has happened, and from that tries to predict what will happen. But we don’t have a crystal ball and no event reoccurs in human populations exactly the same way twice. Yes, we can learn from history, but we cannot copy it or predict how things will turn out in the future. Hence economic prophecies based on pseudo scientific principles. What a lot of twaddle we hear from economists.

Public health initiatives are often based on very poor ideas. You read those ridiculous articles such as eating salt increases your chance of heart attack. The chance they are talking about is usually very small and the amount of salt that had to be consumed to increase this small chance was very, very large. But then a public health official will spend a lot of your money on an anti-salt campaign.

You cannot live without salt. All of your reactions in your body (your metabolism) occur in a salty liquid, a plasma-type substance, which exists both within the cell and between the cells of your body. You are about 80% water and a lot of salt. You are salty. Your kidneys filter water and salt keeping them in balance to meet your body’s needs. In fact where water goes so does salt. One cannot travel without the other. It is to do with osmotic pressure, keeping your cells at the correct salt-water balance. Too much water (i.e. too little salt) and your cells would swell up and burst. Too little water (i.e. too much salt) and your cells will shrivel and die. It is in balance. There can be too much or too little of everything. Life needs a balance. So campaigns that reduce salt too much also do you harm. If you live in a hot country where you sweat to cool yourself down (too much heat in your body kills you) then you are losing water AND salt. You need to replace BOTH.

A lot of bad science and pseudo science has been done on cancer. Why? Because it gets funding is the simple answer. Unfortunately, if you put in a proposal about cancer (or include education as an outcome!) you tend to stand a better chance of funding. While basic research, the science of cancer cells for example, is needed, a whole load of others get funding on the back of this. So we get the poor results and the silly links between things that aren’t linked at all.

I can invent some silly links myself such as ‘watching tv after 6pm gives you cancer’ or ‘reading gossip magazines gives you cancer’. I can prove these while sitting in my armchair. I would bet that nearly everybody that has died of cancer has watched TV after 6pm. There may be a few exceptions, but they would be brushed aside as exceptions. As to the gossip magazine, if you haven’t read one, you still probably read some gossip in a newspaper or heard it on the radio or TV or from a neighbour so I could still justify my arbitary claim somehow. This is because correlation does not prove causation.

Correlation is when two things occur together. The best example I was given to explain this was by a psychologist colleague. This is it:

In summer more people eat ice cream than in winter

In summer more people drown than in winter

Therefore (stupid correlation bit) eating ice cream causes you to drown.

No it doesn’t. More people eat ice cream in summer because they are hot and it may cool them down. More people swim in summer also to cool them down rather than go swimming when it is freezing outside. You could say that cooling down causes you to drown, but you don’t tend to drown from eating ice cream or sweating, which also cools you down. To drown you need to be trying to swim. In water or another liquid. If more people swim in summer than in winter than there are increased numbers of people at risk of not being able to swim in the water they are in and therefore drowning. We could probably argue that fewer people are watching TV in the summer as they are out doors swimming so watching TV prevents you from drowning. I guess it does as most of us don’t watch it while swimming (or even bathing in our bathrooms, although I have stayed in an hotel with a TV in the bathroom). Still, I would not say that watching TV prevents people from drowning. Now I hope you see that two things may occur together, ice cream eating and swimming, but they don’t necessarily cause the effect, drowning. Swimming doesn’t cause drowning either, if you think about it. It is the inability to swim at that moment in time that may cause you to drown. That may be due to a number of reasons: your general inability to swim, sudden changes in conditions, freak accidents.

Most of the bad pseudo science you hear is this sort of statistical analysis of populations done by people that say they are doing science, but they aren’t.

Well you must have heard a lot about cancer if you are over 20 years old. The most obvious one is ‘smoking causes cancer, particularly lung cancer’. I have a colleague who has never smoked or lived with smokers or lived in smoking areas and died of lung cancer. That would be impossible if smoking causes lung cancer. It increases your risk of getting lung cancer. The problem is that we are very bad at thinking about risk. Risk is to do with probability and we humans are not good at that, hence so many of us gamble. I hear people say that they make a living out of gambling. The only people that really make a living at gambling are the bookies and betting shops, the people behind the counter, not the people in front of it. We all have a flutter. But the flutter has been calculated so that we generally lose. The bookies are better at probability than we are.

Richard Doyle is the epidemiologist that came up with the link between smoking and cancer. He was good at his job. What he also said, that people have chosen to ignore is that if you give up smoking by the age of 30 you will, within about 10 years, have lungs as if you have never smoked. All those campaigns wasting money on getting teenagers to quit. It is the older (parents) that need to quit, the 30+ year olds. All that wasted money because they did not read the rest of the article!

How many of you have been asked by the doctor if you have ever smoked and if you were to say yes, 25 years ago, they would write you down as a smoker and blame all your problems on that. My father gave up smoking 40 years before he died. Still, any pulmonary (lung) condition he had they tried to blame on his having smoked. I would think that being a ‘Bevan Boy’ (sent down the coal mines) in World War 2 at a young age would have been more detrimental to his pulmonary health. Living 40 years after smoking and not having lung cancer may have been a bit of a give away in diagnostic terms; but why go with intelligence when you can go with poor science? There is a lot of stupid on the planet and wow, am I fed up of hearing it.

Coal tar has a detrimental effect on genes. It has carcinogenic chemicals, ones that can alter genetic material, ie cause mutations. That is what a mutation is. A change in one letter in your genetic code. You have three billion letters so finding a change in one of them is a tad difficult. Coupled to that you have 10 trillion cells. Each cell has that 3 billion letter dictionary. So you are looking for one letter change amongst 3 billion x 10 trillion. That is a one in a 30 billion, trillion letter. Now do you see the problem?

When daft pseudo-gerontologists (I have one in mind) come up with ways to live longer, which basically boil down to the need to diagnose people earlier with any disease potential (and we all have that) so they can live longer they aren’t really gerontologists. They aren’t biologists. They are popularists. They are talking for the sake of hearing their own voices. Where do you look? Which one of the 10 trillion cells? Which one of the 3 billion letters in one of those cells? Do you think people haven’t been trying to diagnose cancer before it kills you? Not just treat it, but spot it as early as possible?

We have always known that diagnosing cancer is problematic. By the time we can see it there needs to be about a gram of cells. A gram is a very small amount. A teaspoon of sugar (which may ‘help the medicine go down’!) has about 5 grams on it. A gram of cells contains about a billion cells. That’s a lot of cells. Cancerous cells.

The problem with bad science is the lack of understanding of the biology of us.

Cancer has two things going on; one is genetic, the other is cell growth. The genetic bit is that there needs to be a mutation and they occur randomly. A mutation can hit a gene that has no effect on cancerous growth. But it can hit a gene that does. However, one gene in one cell won’t kill you. What you need is for the cell to grow and grow.

Most cells only grow, make new cells, to replace old cells that have worn out and died. Most of your bodily activities are carried out by ‘terminally differentiated cells’ functional end cells which do not grow and make new cells. For instance oxygen is carried in your blood by red blood cells (erythrocytes). They are terminally differentiated. They have completed their growth and development and have become restricted in what they can do (differentiated). They can only be red blood cells. When they get worn out they get replaced by cells further back in development, growing cells that are quite undeveloped. They form pools of new cells that then go on to differentiate (become different) and highly specialised, such as red blood cells that only really carry out one function, carry oxygen in the blood. It is a bit like any manufacturing process. You take a sheet of metal, It could be made into anything. If is made into the front driver side of a car door. It does not then become a car roof.

The early, underdeveloped cells that provide later cells are the Stem Cells.

If you have a mutation in a cell that is about to become a red blood cell (a reticulocyte) it may not have much effect. Some red blood cells may lack a certain protein (genes code for proteins). If the mutation is in a gene for the protein that carries oxygen (haemoglobin) then there is a problem, the red cell is inefficient. If it is in a gene for cell growth it has no effect as red cells don’t grow. To get a cancer in blood cell you need to affect the cells that grow, the stem cells. There are not many of them and they are hard to find. Why would you look for them unless you already knew there was a blood cancer?

So predicting cancer and finding cancer is very difficult. If it was easy those pseudo-scientists could do it too.

Cristian Tomasetti and cancer geneticist Bert Vogelstein of Johns Hopkins School of Medicine have just released results showing that it is bad luck getting cancer, a matter of random chance. Which gene and which cell is not predictable.

Some cancers are more common than others. Cancers occur more often in tissues that are replaced often such as the linings of tubes (stomach tubes, gut tubes, urinary tubes) and the linings of us, our skin. These are from epithelial tissues and the cancers they give rise to are called carcinomas.

Cells involved in support and transport are also replaced due to wear and tear. Each time a cell is replaced it may cause a mutation to be made in its genetic material ( a misreading of the code). Tissue such as blood, bone, cartilage and dermal tissue is replaced often. This sort of tissue, connective tissue can therefore become cancerous causing cancers called sarcomas.

Cells that seldom grow and divide, muscle and nerves, seldom pass on mistakes so muscle and neural cancers are very rare. The neural tissue that supports nerve cells, glial tissue, does grow and that can become cancerous. Any tissue that grows is thus vulnerable. Tissue that doesn’t grow is less vulnerable. That’s it. Most of the other populist stuff about cancer is not worth the funding or the TV time. Hopefully this latest finding, which is what we all knew anyway, will stop some of the dreadful nonsense and false hope. Even more importantly, it may stop the blame.

Flu- Back in the food chain

We say we, humans, are at the top of the food chain.

We aren’t.

We are in the food chain.

We eat food to provide energy for all our activities, but there are billions of organisms that eat us. We worry about big organisms like sharks, but our real dangers come from some that are minute, micro-organisms, organisms that are so small you need a microscope to see them.

Some micro-organisms are useful, the ‘friendly’ bacteria, commensal, meaning they share the table. They use our waste products in our large colon. The large colon or bowel contains the food that we cannot digest and absorb into our bodies, such as fibre or roughage, usually cellulose. We don’t have the enzymes to digest these food types. If we cannot digest it this undigested food moves into our large colon. This undigested food, waste, provides food for micro-organisms in our guts. In return, their waste that they excrete into our guts is stuff we need such as Vitamin K. As they say ‘one man’s meat is another man’s poison’.

Unfortunately, a few of these microbes are not friendly. These other microbes are ‘pathogenic’, causing us disease either by their growth or by their waste.

I have just succumbed to a tiny virus. I feel like I have gone a few rounds with a heavy weight boxer, Mohammed Ali or somebody of that calibre in their day. But no. Merely a virus a few microns across (a micron, or micrometre, is a millionth of a metre). I am providing lunch for said virus, They are providing waste products that are making me feel wiped out.

This process of infection is causing temperature changes that may only be a rise of a degree or so, but can make you feel so bad. Going from say 36.8 Celsius to 37.8 is pretty bad. Half a degree above that, 38.4 is the start of that awful feeling, fever. You become very visceral, aware or all your muscles and bones.

That the human body can fight back (the process is called homeostasis) and return you to normal is amazing.

I don’t want to become one of those people that obsess about their health, but perhaps we can become a little too blasé. The body we have is the only body we have.

I hope none of you succumb to the micro-organisms that seek you out for their lunch, able to bring down people and nations.

But it is worth remembering that so far, more of us have died from pathogenic micro-organisms than all the wars put together.

We are definitely not at the top of the food chain.

They are.