How the NHS failed me and mine.
What it did, to the most important person
in my life and how it could happen to you unless
we do something about it!

Monday, 22 September 2014

Falling Back to Earth.

A Patients Experience.

It was a little like living a life where you were standing on the outside looking in. Certainly I was there; I was alive, but not quite. I was watching myself, going about my everyday life; my business, but I was not really participating.

But to begin at the beginning; I was diagnosed with glaucoma in 1986, after a routine optician's visit showed that I had raised IOP (interocular pressure). This in turn led to a Consultants surgery where tests were undertaken that confirmed the pressure was high and 'open angle glaucoma' was diagnosed on the basis of the pressure (about 24, if I recall). I was placed then on a regimen of beta blocker eye drops, timolol maleate (timoptol), to be used twice per day. Not given any specific warnings about problems that could occur, I took these religiously, as I was told that I could lose peripheral vision if the disease progressed and eventual blindness could result.

I knew little about the ailment, despite having an Applied Science Degree in Human Biology and Biochemistry, because that had been twenty two years before and I had not used much of that knowledge as my life had taken a different turn (use it or lose it), taking in construction materials testing and crash barrier design; now I was self-employed as a Consultant. The research I did do however, confirmed that raised IOP was a surrogate marker for glaucoma, but let's face it, there was little Internet coverage then and I didn't really have much access to research, except through books and back issues of the Lancet and the BMJ. So I took the advice and carried on with the protocol.

Nothing much happened for a few years, but I did notice that I was losing my hair but put this down to age. I was becoming increasingly depressed as well; feeling detached from life. Whilst I had not lost all emotion, I did notice that stressful events did not impinge upon me as they used to do; that I was losing the ability to be scared almost. I was distant with my wife, my family and it seemed better to work than do anything else, and I had lots of work. My sleep patterns became erratic; I stayed up late often and then had really vivid dreams and many nightmares when I eventually did sleep. I panicked often, especially when away from home and had irrational fears about mundane things. This culminated one night in 1997 when I had so much trouble breathing that I was taken to A and E. They seemed to think I had asthma and gave me a nebulizer, which I used for all of two days when I realised this was complete 'tosh', I also had cold hands and feet, and had to wear gloves more often to stop my finger turning blue.

Then one day in 1999, at my annual review at the Consultants, I was told that I had to lose the drops I was using straight away and was to be given a new regimen of a prostaglandin analogue called 'Xalatan'. This was 'the new kid on the block' and my previous eye drops had been shown to cause asthma like symptoms in patients (oh really). Happy in a way, that this was now a once a day regimen and at night only, I adopted it with sanguine. Within a matter of a few weeks I started to get severe panic attacks; I would become frightened to drive on motorways. I had morbid fears and in 2000 I had a breakdown and was diagnosed with moderate to severe depression.

Despite my scepticism, I had psychotherapy. It helped a bit and as I now had antipathy to any drugs that were available for my condition ( I had refused Paroxetine), there was little else available to me. At the end of 2006 I left my wife, who had severe problems of her own that were being made worse by me. I blamed myself for all of this and my depression deepened until in 2008 a further crisis occurred that rendered me almost incapable of doing anything. I would burst into tears; I was unable to read anything for more than few minutes (I had been an avid reader). I couldn't concentrate on anything and had this awful sense of doom hanging over me constantly. My business nearly collapsed and what little wealth I did have was hit hard by the recession. I was falling back to earth, and without any parachute.

Then I found a new therapist; someone who was a 'real person', who talked to me the way no-one had before. She taught me how to rationalise my fears; explained to me that which had happened was a result of  too much at the same time and that I had PTSD. It wasn't my fault anymore than it was anyone's. She was also fairly certain that some of the problems were related to rapid withdrawal from the beta blocker eye drops, which despite the contrary view of some Doctor's, and of course the makers, can trigger some of the symptoms I had, especially the cold hands and feet called Raynaud's Phenomenon or Disease.

As I began to take control of my life again I researched both the Raynaud's and the belief that I now had, that beta blocker eye drops had the capability to enter the bloodstream and act much the same as oral beta blockers prescribed for hypertension. I had been told that if used carefully and a finger is applied to the caruncula area of the eye (the bit near your nose) for about a minute, the drops should not be absorbed into the system. My research confounded this completely as experiminents had been done that indicated that the drops were absorbed as successfully as if if injected, and could invade the central nervous system with comparative ease.

There is no happy ending to this tale, except that I no longer take any eye drops, of any sort. It was determined quite recently that my IOP was now considered 'high-normal' and watchful waiting should be employed.This came about as I had sought help for an allergic reaction to Prostaglandin which brought on a dreadful skin condition called Erythasma (It took four months to diagnose).

I had had a somewhat less than successful operation for my right eye cataract in 2001 which caused some quite substantial 'posterior vitreous detachment', leaving me with a vertical band of blurring that 'flips' across my view as I move my eye. My left eye has also deteriorated quite rapidly recently, again with a cataract, that has caused Anisometropia (a huge difference in visual acuity between eyes). I am trying to make up my mind as to whether to have the cataract removed, to save my left eye vision or not.

This post is part of a series on patient experiences of drugs and treatments that I'm working on currently, along with many other things. I am particulary interested in drugs that pass through the blood brain barrier and exert an effect on mental health as well as their designated effect.  so I decided to comence with one of my own experiencies. The following is the result of my research and is highly subjective, retrospective and anecdotal, but there is enough evidence, I feel, to lend quite some credence to my observations.

It is apparent to me, that I experienced some effects of the medication that were subject to the 'law of unintended consequences'. It has been proven that infusing eye drops, irrespective of any measure taken to ameliorate their invasion of the central nervous system, is almost as good as injection. 

Lipopholic Beta Blockers are not something you need unless you are hypertensive and even then their side effects can be quite devastating.They also contribute to the formation of cataracts, especially in eye drop form.

Reynauds is also widely reported by most who take this type of beta blocker  and many other anithypertensive drugs. It rarely resolves, even after stopping the drug (it never has with me).

It is almost certain, that when withdrawn without any 'tapering off' period that there would be some 'rebound' effect. So I almost certainly would have had elevated BP for some time after withdrawal (which I did), as well as an elevation of adrenaline and noradrenaline. These govern the 'flight or fight' response and to go from suppression to normality would have exerted some powerful emotions.

What is certain however is that neither my GP or Consultant took my problems with any degree of seriousness, warned me of the side effects of use or withdrawal, nor made any report about what was happening to the MHRA (or the MCA as it was then). I had to find and to fund my own therapy because even today, mental health is poorly funded or unavailable, or is so far into the future of a patient as to be viewed as such.

This is what happens in 'real world' medicine and mostly goes unreported, or is dismissed as a symptom of the disease or problem under treatment. Emotional and Mental problems are highly subjective and can only be anecdotally reported (mostly) so there is a reluctance to take patients seriously. 

In defence of medicine (something I rarely do) it's unlikely that a similar scenario would be enacted today, as glaucoma has much more powerful diagnostic and testing tools. Photography is used extensively to view the optic nerve and the diagnosis is usually not solely dictated by elevated IOP. Even this marker has been set higher than it was in the 1980's and figures of 21-22 would not be viewed with the same alarm as they were then. The problem may be that those diagnosed some years ago can be left behind and remain in this hinterland, of being on a relatively dangerous medication, that has significant side effects for no useful purpose and very little note has been taken of the extensive research that shows eyedrops can be absorbed into the system much more readily than was thought. Topical should be viewed more as in vivo than many believe.

Whilst this information is anecdotal, in that it is retrospective and self reported, there is a foundation of both cause and effect here that leads me to the belief that at least some of the problems were caused by the use of these eyedrops. It is far too late to do very much about it other than to report it for others to take heed. 

If any readers have problems I would suggest they report to.... well anyone who will listen, but try

Tuesday, 7 January 2014

More Usually Means Less.

Oliver Wendell Holmes.
" I firmly believe that if the whole materia medica, as now used, could be sunk to the bottom of the sea, it would be better for mankind-and all the worse for the fishes."
(so said Oliver Wendell Holmes).

He excluded Opium and Alcohol, powerful medicines of the day (1860), as would I.

If the NHS and Pharma are to believed, we are all suffering, as a Nation, from a lack of Drugs, Interventions for Health and Implementation of Guidelines. General Practitioners, clamouring for our attention, wish us to adopt 'healthy lifestyles': stop smoking and drinking alcohol, eat 'five a day'; get our vaccinations; get our blood pressure down; our cholesterol (sic) down, but above all get tested, tested, tested, and then 'do what we we tell you, you morons!'

Once tested, they will wish us to accede to a 'polypharma' of drugs and dietary interventions to enable us to live longer and especially not perish from Heart disease or Cancer, but the third largest cause of our demise (in the World); Prescription Drugs, will be neatly sidestepped and never mentioned. Delusional as they are, Doctors, embedded in their hubris of 'caring' for their patients, fail at its first hurdle of 'do no harm'. We as patients, are likewise deluded  that we can stave off sickness and morbidity by slavishly (or not) following their advice in the vain hope of an extra few days, weeks or at best months of additional (but miserable) life.

The effectiveness of medical interventions to save our lives has always been over emphasised. Death often stalked our lives in the nineteenth and early twentieth centuries in the form of tuberculosis, diphtheria and cholera, but these were modified more by societal changes, long before we had the capability of curing them.When Koch isolated the Tuberculosis bacillus in 1882 mortality had already fallen by by some 50% in the preceding 50 years for this disease. Before widespread immunisation and the advent of successful treatments with antibacterials, the mortality rate had fallen from 70 per 1000 (1812) to 5 per 1000 (1944). Similarly most infectious diseases were in decline long before Medicine had the interventions available to modify or cure them. This in the main has to be attributed to better nutrition, clean water, effective sewage systems and resistance to disease; we have to thank Engineers for this, more than Doctors.

Improvements in general health can also be attributed to simple non medical measures; soap, scissors and disinfectants, wrought a miracle in the deaths of babies and their mothers.Contraception, even its crudest forms reduced unwanted pregnancies and the associated mortality's it fosters. It also has to be said, that the discovery of the sulfa drugs' and penicillins' changed the aetiology of infections, especially battlefield wounds. The miracle was that bacterial infections no longer took lives and those previously condemned, arose from their deathbeds to resume a useful life (or pick up a rifle again). The early vaccination of children also reduced childhood mortality significantly in the third quarter of the twentieth century, although the plethora of those initiated today has a more dubious legacy and sometimes a terrible one.

The rhetoric that modern medicine is highly effective is writ large by Doctors' and Politicians' but is far from the truth. Certainly the discoveries of the first half of the twentieth century have had significant impact upon the disease burden of mankind; well in rich populations at least. But little that has been initiated since, has had any real impact on that which kills us and worse; much of that which passes for modern medicine is actually doing a lot of the killing, or at best, modifying symptoms and that is Prescription Drugs.

In the field of Cancer little has been achieved in forty years, that reduces mortality in 90% of the common cancers (Lung, Breast, Colon). There has however been an explosion of Drugs and Treatment Protocols, most of which are highly toxic and of dubious efficacy. The cost of these has been counted in Billions per annum and at best are 'treatments' not cures. Treatments are good (cures are not); they give hope, however false, to both Patient and Doctor, that 'something' is being done, no matter how futile or expensive and they give 'Pharma' a licence to charge whatever they feel like for it. Avastin for instance, costs £25k (April 2013) to extend the life of a colon cancer patient, for about six more weeks. That will be six weeks of absolute misery, suffering from the side effects of the drug and the chemotherapy that goes with it. Yet patient advocacy groups, often funded by 'Pharma', clamour for it with ever increasing stridency which has caused the institution of special fund (UK Cancer Drugs Fund) to buy it and other stupidly expensive, highly dubious drugs.

We are now beset by a quite different group of sicknesses and diseases than those of our forefathers, unless you are very poor, living in a war zone, or an area of climactic disaster, when most of the old diseases arise or increase, just as in times past. These of course are the 'modern' epidemics of; Diabetes, Obesity, Heart Disease, Respiratory Diseases, and many Cancers. With these also go; Hypertension, High Cholesterol, Osteoporosis ADHD, PTSD, Depression and Bipolar Disorder, most of which having been largely 'invented' and  for which we usually have no symptoms, little likelihood of morbidity (unless we believe 'Pharma' and its whores) but a whole plethora of drugs with we which we can be treated, some just to achieve a slightly lower surrogate marker of something we didn't know we had! So now we have drugs that hark back to the beginnings of  'Pharmas' inexorable rise to fortune; 'snake oil' treatments, that promise much and deliver very little.

Greed and corruption have dominated Health care in the last forty or so years just as it did in the nineteenth century. Certainly Roche no longer sells us Heroine (diacetylmorphine) illegally, upon which it built its fortunes, in the gap between the two World Wars, but more subtle, nonetheless completely immoral 'scams' are perpetrated continually by 'Pharma'.

Take for instance citalopram (Cipramil), Lundbeck's SSRI from 1989. This drug is a stereoisomer, both of which are 'mirror' images of each other; one of which is the 'active' component. The drug was about to run out of patent in 2002, thus allowing generics to be made at much lower prices legitimately. So Lundbeck then patented the other isomer; escitalopram (Cipralex); and charged nineteen times as much for it even though it was the same drug! The worst aspect of this charade was that the stupid, gullible (or corrupt?) doctors then proceeded to boycott the 'old' version in favour of the new!

You may notice from the illustrations that these are the same in every way except 'handed' differently. This is often referred to as 'me again' or 'play it again' drugs and is often built in to the molecule to enable this scenario to be enacted close to patent expiry (this sometimes also occurs by accident).

We also have the 'me too' drugs that dominate the market once a new drug, or more likely a slightly different play on an old one, comes out. That is why we had a plethora of 'statins' once Merke patented Mevacor in 1987; nine by 2010 plus the combinations. But statins are but the tip of an iceberg of drugs specifically targeted at 'diseases of invention', primarily to sell a drug rather than inventing one to treat a 'real' disease.

There are literally thousands of instances like this, and together with the invention of diseases we have the 'missing data', the submission of thousands of non-searchable computer files for drug approval, literally meters long folder sets, for drug trials, hiding data in 'offshore' data caches, on the pretext of security. The use of 'seeding trials', recruiting of Key Opinion Leaders (KOLS) who are Doctors, paid consultancy fee's to 'push' the latest drugs at conferences and seminars purported to be 'teaching' other Doctors of the latest advances in Medicine. These are but thinly veiled promotional exercises funded by 'Pharma' to persuade Doctors to write their scrips for the product being discussed.

To these deceptions, in Primary Care we have to add the needs of the Quality Outcomes Framework protocols, the vaccination programmes for infants, minors, the elderly, pregnant women(?) and of course the full gamut of tests and management of pregnancy (sic), health checks for the elderly and those whose chronic aliments are being 'managed' in Primary Care, such as COPD, Asthma, Hypertension, High Cholesterol, Diabetes, Schizophrenia, Bipolar Disorder (another invention), Depression; the list is endless! Is it any wonder that A and E is under pressure when the chances of obtaining an appointment with a Doctor is slim to none (and slim has just left the surgery). If like me and many others, you are given a time in the far distant future, to see a Doctor, and your problem begins to get really serious, what alternatives are you left with? Answers on a post card please to one Jeremy Hunt MP.

What is the point of a system of a 'free at the point of treatment' health care system, if all of the Doctors involved are so busy earning points on the QOF (and points mean prizes), to bolster their salary, and pander to the Politicians and the 'worried well', instead of actually treating sick people? This is especially the case if diagnostic procedures undertaken in the name of better health and longer life, even when high levels of treatment are then undertaken, have no impact whatsoever on life expectancy, which is the case in virtually all of theses protocols. (His cholesterol was fine but the patient died). Health care and the NHS needs a new beginning

The NHS commenced its life as a fine and wonderful concept. It was meant to provide a milieu of  Health unavailable before to the bulk of the populace with the aim of raising standards to a position whereby the costs would reduce to reflect this 'Healthier' paradigm of the people. Well, that was the stated aim of Beveridge anyway. It did not come to pass. Instead we had ever increasing demands for Drugs, Treatments, Vaccines, and Screening of one sort or another. Between them, Pharma, Doctors and Politicians colluded to produce and strengthen industrial levels of growth in Health Care, at the expense of patient care and personal ownership of 'self'.In doing so they have robbed society of its ability to distinguish between benefit and harm.

The cost of the NHS has grown from around 3% of GDP to more than 10%, without any real reduction in Mortality or Morbidity. As some diseases have waned, others have taken their place so the morbidity that was viewed as being responsive to treatment in 1948, has defied efforts to be modified by Health care. Iatrogenesis has become one of the leading causes of death and harm, so surely we have to come to the conclusion, that in providing more, we have been delivered of much less. We cannot afford in both monetary and moral terms to continue in an endeavour that robs us of control over own health; we need to redact that part of pact we have had with NHS and Doctors that we would listen to their advice and submit to their ministrations without question. Collectively they have colluded with Politicians and the Food and Drug conglomerates at our expense, to construct an Empire of Deception, Fraud and almost limitless power.

We have to learn to accept as persons, the limits of what can be achieved in Health Care and shun the concept we have been sold, that everything can be 'treated', because we need to foster control of our own lives and health. The concept of screening has delivered much more harm than good, despite vast expenditure and the construction of a flawed view that it saves lives; it does more to end them.

We can devise a new pact with Doctors, based upon an understanding that they are no longer gifted with omnipotence nor are they the gatekeepers of Health, or the arbiters of our access to treatments or benefits we may actually need, (rather than what they think we need or would like bestow). They need to become truly the Patients Advocate rather than the mouthpiece of Politicians and Control Freaks. We need to be given the stature of ownership of ourselves and how we wish to live and thrive without the constant drip feed of censure from Medicine founded in obfuscation, corruption and privilege. We need to return Science to the 'real' Scientists rather than those who manipulate research to their own specious ends.

Thursday, 11 April 2013

Nobody Died!

"Call the Police", the fat controller said, "my voice mail has been accessed and private information has been leaked to the press". The Police were called and an investigation began. But nobody died.

"Call the Police", the BBC journalist cried, "that beardy DJ pinched my bum, thirty years ago". The Police were called and an investigation began. But nobody died.

"Call the Police" the has been film star said, "my reputation has been slandered on Twitter". The Police were duly called and an investigation began. But nobody died.

"Call the Police", the fan said, "that long dead blond DJ, touched me up in his dressing room, twenty years ago, when I sat on his knee, I want redress (from the BBC)". The Governor and the Police were called and an investigation began. But nobody died.

Heads rolled, a Newspaper closed; journalists were arrested;some were jailed; vast sums were paid in damages to rich (and a few poor) people but nobody died. Celebrities, famous Journalists, Politicians and pundits gave evidence to learned people shorn of their wigs. Even Policemen and women were deprived of their power and warrants. But nobody died.

 Many millions of the peoples money, was spent in tedious and long winded Commissions that helped to fund the retirement of M'lud's. But nobody died.

135 Journalists lost their jobs; 113 people were arrested; 4 officials were jailed. But nobody died.

Meanwhile, back in the real world, in Stafford, up to 1200 hundred people died. In the City, Bankers continued to get their bonus, despite the 'bailout' from the real people in the country. The Francis report was published and nobody got fired. Nobody got redress. Nobody was arrested. Nobody was convicted. What does this say about Society, Journalism, Doctors, Nurses, and Politics, ?

We will never know how many died. Discuss.

Thursday, 27 September 2012

Something Happened!

"I'm feeling strange, she said". I glanced across from the road in front. She looked agitated, and her voice became slurred, as if slightly drunk. I froze for a second and then asked her to smile for me whilst stopping the car. I put on the hazard lights and looked at her carefully."Lift your arms and close your eyes", I said. She did it. I got out of the car and went around to her door and opened it. She then said in a normal voice, " my arm's a bit numb and my leg too". I asked her to smile again, stick her tongue out and raise and lower her arms. She complied immediately. I got her out of the car and helped her stand. "Walk", I said, and slowly she walked at my side and we turned and went back to the car. "It's on the other side now and my cheek's tingling". "It's changed sides!" I said. She concurred; it had.

I was gripped by fear. The signs although small and transient were nonetheless bad. I did not want to admit it, but the woman I loved was possibly having a stroke! I needed to act and fast, just in case it progressed. I got her into the car went to the driver's side, got in and turned around, heading, not without some trepidation to that hospital, the scene of our past trials at the hand of the NHS. My car screamed it's way through the Friday afternoon traffic, headlights on to try to clear a path. It was 4.30 pm and busy. It was also August. The new intake of FY1's would be there to greet me no doubt, anxious to contradict the view that they were presiding over a another 'killing season' as August is aptly named in A&E, and that's just by the doctors.

I made remarkable time, all the time hoping I would wake up and this would be just a bad dream. It wasn't of course, it was real life. I parked illegally by the Ambulance bay and helped J', who was not very ill just very scared, into Reception. Taking grasp of the situation, I shouted that my wife was probably having a stroke and to help me. That worked. They got her onto a trolley straight away and pushed it into the Department and then left us! And so the waiting began.

I stood at the side of the trolley, holding her hand and trying to assure her that she would be fine. She still had some 'tingling' sensation in her right cheek and was extremely frightened, but little was happening and the floor was filling with patients on trolleys. It was more than an hour before we were taken to a cubicle and a nurse (well a nursing assistant) said she needed some 'bloods'. As she said J' may need some IV medication she would insert a cannula. I was about to protest but J' stopped me. I do not believe in invasive procedures 'just in case' and there was no way she was going to be infused with anything without considerable evidence of need, but I held my tongue. She was also completely useless at the task, took many tries and caused considerable bruising in the antecubital fossa.

A Doctor eventually showed up after some two hours and conducted tests; the usual smile, open/close your eyes, lift your arms etc. He also tried the resistance tests (pushing/pulling against his hands). He then departed and shortly after the ECG/EEG trolley was wheeled in and a nurse applied the twelve leads and conducted the test. I don't have too much knowledge of this procedure, but sufficient to see there was no atrial fibrillation, which was a relief. She went away again saying that a doctor would come and interpret the test results, but before this could occur they came to take J' for a head CT scan. I went with her; they sure as hell were not going to separate us this time! She was not in there long and when I asked the nurse she had no idea of the dose rate of radiation she had received. But, I knew it to be 2 mSv or about 20 chest X-rays and because it's the brain we're scanning that's a lot. Again we were told that a Doctor would be along to give us the results.

Well, we waited and waited. They had left the charts and I checked for obvious problems. Her BP and pulse were very high and blood sugar too at 8.5 mmol/L, although the stress of it all and the natural protective measures of the human body would have been responsible for this I was certain, although even so 190/95 seemed high for someone who regularly records 120/70. Then, over three hours into the event we saw a Registrar who basically said that nothing on the test showed any abnormalities and he went through the routine tests again. I said I thought it was time to go as J' was becoming agitated and the situation was becoming more harmful than productive. As the 'event' had crossed the mid line (changed sides) I was pretty certain it was not a stroke or TIA (trans ischemic attack) and voiced this opinion. He agreed, although was somewhat guarded but did think J' would be discharged quite soon, to my care.

As it was August I suspected he had just been 'made up' to this position and was not really confident in his decisions and he went away saying he would return soon. He didn't. Yet another nurse arrived to say J' was being taken to the Stroke Unit on the other side of town! And of course she had to go by Ambulance, not with me, unless I abandoned my car. I reminded her to remove the cannula which she did reluctantly and I said I would follow the Ambulance. I talked with driver while he waited for his partner to collect the paperwork. He told me to follow him out and he would ensure we did not get separated, which he truly did, slowing down if I got caught at traffic lights. It was nonetheless a nightmare, with me anxious and extremely stressed at the separation from J' as I did not trust the NHS or any Doctor I had seen thus far. I was also bemused as to what had occurred and hated once more the prospect of being caught up in the 'machine' that passes for Medicine today.

We arrived twenty minutes later and J' walked in accompanied by me and the driver. After a couple of minutes I was then allowed to be with her on the ward. They had given her a bed! BP and Pulse were taken together with blood glucose and oxygen levels. If anything BP had increased, to 201/95 and I was a beginning to feel the place we were in was more to blame for this than anything else. I wanted us to leave, but I also wanted to be sure that in so doing I was not putting J' in jeopardy.

 After an hour or so a nurse appeared who seemed to be in charge. She had decided to do a 'swallowing test' which apparently gives some indication of Stroke/TIA if the patient cannot swallow sips of water from a spoon. As the nurse was holding the spoon J' gagged a bit, which I found unsurprising and as she had already taken sips of water from a cup earlier, (which apparently she should not have done) I thought it was useless as a test. She also apologised for the delay in seeing anyone (but her) due to an emergency. Ah well, I thought that's triage for you.

By this time it was well after 10 pm and we were some five and a half hours into the event. And here's me thinking the first three hours were critical in stroke diagnosis! We sat there for another hour, with a sense of dread coming over both of us. J' was all for going anyway by 11.30 and said she felt fine in every way and just wanted to escape the clutches of the NHS which by this time we felt were just trying to cover their collective arse's. Just as we were about to do precisely that, a Doctor arrived.

He was quite affable and at least not patronising, recognising that we were not average punters and at least gave us some respect. He went through all the procedure again and also allowed J' to sip and then gulp water from a cup, which she did without problems. He said he thought an MRI would be useful together with an ultra sound of the neck to check for plaque in the arteries. He also said it would not be possible for this to occur now as the facility was not on line. Whether this was because it was the weekend or for some other reason he did not allude to, but after conducting a 'stress test' comprising J' blowing a stiff sheet of paper until it bent, for a whole minute, he decided he would discharge her to my care. Not before however, she was coerced into taking 300 Mg's of soluble aspirin and a promise that she would continue with this regimen until an appointment could be made for the tests by 'phoning them on Monday of the following week.

I discussed with him the likely cause of the event and that it did not seem to fit into the pattern of a stroke or TIA and he at least admitted that he was baffled. But he said until he had seen more test results he would not pass judgement and for safety's sake we should keep up the aspirin protocol and be prepared for other interventions such as Clopidgrel. Not on your life mate, I thought, aspirin, enteric coated at 75 Mg's maybe, but not that awful stuff! But at least we were able to escape, clutching a sheet of paper with advice about TIA's we exited the building as fast as possible, in case they changed their mind! It was gone midnight and we had been in their care for more than seven hours and still no real diagnosis!

We reached the car and I opened the door. I held J' in my arms before she could take her seat, grateful that she was still with me. It was a long moment before I let her go; I never really wanted to let her go ever again but I did and we traversed our way to the entrance and sped off back to the 'hovel' both emotional but relieved to have escaped, relatively unscathed from the NHS and the events of the day.

At home we were both agitated and bemused. We had no idea of what had occurred or its reason. I know Diabetics are more prone to any sort of stroke than the normoglycemic community but all other factors were not present. She maintains good control of her diabetes's with HbA1c of the low 6%. She has excellent low BP to the tune of 120-130/70-80. She does not smoke, takes regular exercise and her clotting factor was low normal. If we ignore the 'drivel' about cholesterol (her non-fasting total is 6.5mmol/l total lipoprotien) but most scientists know that in a women this is viewed as 'protective' rather than indicative of any danger. So what may have caused this? Obviously the Neurologist did not know because he said as much. It would be rare, even if there was some plaque formation that it would cause a bilateral blockage almost simultaneously, but that would have to be determined for certain by MRA/MRI. So we would have to wait for this determination before reaching any conclusion. And of course that would not be until Monday.

We spent a somewhat agitated weekend, with me watching her like a hawk, not letting her drive and giving her a daily dose of enteric coated 75 mg aspirin, just in case there was any possible problem, to be reviewed in the light of further tests. Aspirin is not a drug I like and cannot take myself due to a past ulcer, but J' has a very strong stomach and never even gets heartburn, ever, so I was confident that a few days intake would likely do little harm. Long term use was not something I wanted to contemplate (yet). I did increase the dose of Omega 3 capsules to 2.10 gms (in 3.30gms of capsules) as this is a fairly benign anticoagulant,( from its previous 1.40 gms), although I knew it's effect would take some time to be realised. I also took her BP and pulse regularly and as sure as predicted, it returned to usual levels within 24 hours of the event, in fact by Saturday night it was 118/71 and the pulse was 76!

Monday came and I 'phoned up about the appointment the Neurologist said would be made first thing. They hadn't even heard of us! They promised to call back. They didn't. At 12 noon I rang back once more and was told that it was now too late for that day but 11.30 Tuesday was the time they had arranged. So that was another day wasted, and so much for the urgency of the tests the Doctor had said were essential, and had to be undertaken that day!

After another fitful night, whilst we were preparing for the day, we then had a call from the Hospital. They had a spot available as soon as possible, could we come in straight away? Obviously we agreed, fools that we were. We got there and after another bout of form filling were ushered in to see the duty Neurologist Dr. W. Without an doubt whatsoever he was dick! Uninterested, remote, rarely looking at the patient, he said very little, asking a few questions and making a very short examination. Just the pulse, wrist and carotid and the usual tests for stroke. He conveyed no view when I asked him about the symptoms crossing the mid line just stared at his screen. He did say J' should have an immediate MRI of the brain together with an MRA with contrast dye, of the neck, no doubt to check for any plaque in the Carotid.

He then told his female assistant ( a trainee) to arrange this and we were dismissed. We sat outside awaiting the news and the young woman came and told us she could not arrange it until 1 pm, which was some two hours away! Not enough time to go home and then struggle back across town and find a space again in the immensely expensive car park, which was half a mile from the unit. She then said she would need to install a cannula for the dye infusion, so we would need to come back to the unit for this before we went to the imaging unit for the MRI/MRA.Why they had not already arranged a test  when it was obvious that it was a need, and the entire reason for our visit, escapes me, but obviously our time was of no matter and theirs at a premium, despite the fact that they would be hard pressed to arrange an orgy in a brothel.

So we went into the Hospital and tried to obtain some food and drink. Well there was coffee, of a sort. The food was all 'junk food', all very high in carbohydrates and totally unsuitable for a diabetic, and frankly it was all highly processed rubbish. We took a further walk through the grounds back to the unit and the trainee then came to insert the cannula for the dye infusion. She seemed different now the boss wasn't around and told me she had researched the dye side effects whilst we were away and attempted to assure us both that it was relatively benign. I discussed her training whilst she was at work on the antecubital fossa. She had just completed FY2 and was now a GP trainee and knew a number of my friends in research and emergency medicine. She was also excellent at inserting cannula's, with confidence, gentleness and expertise that produced no pain or bruising. So we trotted off to the MRI facility half a mile away.

I was stunned when I saw it. It was a brand new building, in the grounds and provided on a 'contract' basis by a private provider; more cash for the private sector! Anyway, after a minor altercation with the 'prick', who drives the machine, J' went away to return fifteen minutes later, sans cannula and in no distress from the dye infusion which said she hadn't felt. We had been told we would get a 'phone call later with the results after they had been evaluated by Dr. W. In fact his secretary rang about 5 pm to tell us that everything was normal and that nothing at all had been found! I'm sure the sod's always get their underlings to provide this sort of information just so you can't ask questions, because we both had many, but for lack of anything else we could do, we would have to wait for the letter they would send.

We had a long wait. After four weeks I rang the unit and spoke to said secretary who informed me that we were not getting a letter but one had been dispatched to the GP some weeks ago. Upon further probing I found they had sent this to our GP of five years before and not to the current one, despite the fact I had filled forms in with the correct information; twice! She did say she would ask permission of Dr. W  for us to receive a copy. I was almost choking with anger by then. "You mean that we are not allowed to see what has been determined about my partners event, but you, our GP and anyone with the access password can?". I said I felt it both insulting and patronising that such should be the case and I would complain in the strongest terms if this was not rectified. She promised to do what she could and I left it there. I explained it to J' who responded with a few expletives,somewhat worse than any in this post.

We did get that copy after another week, and it simply said that J' was healthy without any evidence at all of any abnormalities and, curiously, 'the rest of her history is non contributory'. What! The trauma surgery your colleagues botched, the diabetes they missed, the keto-acidosis, the fact she cannot take vigorous exercise, because the hemiarthroplasty starts to hurt after half a mile, and the chances of revision surgery succeeding or her surviving it, recede with every passing year!

It's also interesting that at no time was J' asked to give any informed consent, written or verbal, for any of the investigations, nor was anything ever explained in any detail until I pressed those involved to do so, and was able to demonstrate knowledge and qualification. Even then, they spoke over J' to me, or directly at me. Bunch of patronising misogynist prats. I really shudder when I think what may have occurred had I not been there to fight her corner. And what is my take on the event? I do not really know, although I suspect it may be microscopic particles of debris (plastic/bone/metal) from the hip implant momentarily lodging in the brain. We are at the stage when the joint will be producing quite lot. Active people can wear them out in five years. J's active and that's next June.

This, dear patient reader is the reason why my blogging has been somewhat curtailed of late. These events have had a profound effect on us both, highlighting the fact that our grasp on life is at best tenuous. But that can be said of us all. But, wherever possible we should all keep away from hospitals; they're full of sick people and not all of them are patients.

Monday, 23 July 2012

Obama's Gift To Pharma.
Once the 'individual mandate' takes effect in the US 'Pharma' will have more patients to sell it's dubious health care products to. About 23 million more to be precise, and whilst I applaud the concept of Heath care for all, do wonder what they will be letting themselves in for.

With Worldwide drug sales having already topped the 1 trillion dollar mark it seems a strange commentary on the success of the sector, that it is also the largest recipient of fines and censure for it's outrageous behaviour to it's customers, the patients, by the manipulation of data, bribery and corruption, and  'off-label' promotion of its products. Some of these would be termed 'technical breaches' and whilst some practitioners in medicine, will use drugs that are not 'approved' for the treatment of a particular disease or condition, it is illegal for the makers to actually promote the use in such a manner. Drugs are licenced for particular conditions and if used for others they need further approval for any secondary use before they can be included in a 'guideline' for treatment. I don't particularly support these licensing arrangements excepting that I approve of any measure that attempts to keep this self serving and immensely greedy sector in check.

Looking then to the many appalling incidents that have brought 'Pharma' to ordure, the recent record fine of $3billion to GlaxoSmithKline was the landmark to judge others by, although no-ones in jail, least of all CEO Andrew Witty. His reward was a knighthood from one of the 'Dave's' that govern the UK (rather badly). Witty of course absolves himself by denying any participation and that it all happened in the past, when in fact much of the time line disproves this.

Moving right along then we come to Pfizer who scored the (then) highest settlement in history, of £2.3 billion for 'off label' marketing of Bextra, a Cox-2 inhibitor (as was Vioxx) which caused severe heart problems for those who took it ease the pain of arthritis. In fact the mechanism of Cox-2 inhibition is fraught with problems for the heart and is yet another 'blind alley' entered by 'Pharma' in the pursuit of profit. The rule of unintended consequences is one that is often ignored: stop one element of humans' biochemical machinery and you are likely to bring about a disaster in another.

Geodon an antiphyschotic, was also used off label for the treatment of bi-polar disorder in children! I will have to repeat that; bi-polar disorder in children! Apparently, manic depression, a very rare but quite awful disorder of adulthood symbolised by mood swings of euphoria to abject misery has now 'morphed' disorder. And now 'little tommy' who keeps having a tantrum when he doesn't get his own way and sulks, then five minutes later is running and screaming in the garden (yard) with his friends, is suffering from bi-polar disorder. My diagnosis would be that he is just being the pain in the arse (ass) that many children are, and if you stop filling him full of glucose laden food and drink he wouldn't be so hyperactive! But get real, he does not need any heavy duty antiphyscotic, nor except in extreme cases does any child or indeed anyone, he just needs his parents to start acting like...err, parents!

Zyvox was also promoted as a much more effective antibiotic than was the forty year old generic vancomycin, when in fact it wasn't; Pfizer had promoted it on the back of highly flawed (fudged?) evidence, simply to get paid for a much more expensive product. And of course Lyrica tanked when it failed to have any more effect than the placebo for the extension of use Pfizer had tried for.

Johnson and Johnson ("a family company") failed to live up to it's friendly (sic) image by the marketing of Risperdal, an antiphsychotic drug for other purposes. Natrecor, a heart drug alleged to improve patients breathing who were in heart failure, was actually less effective than placebo's, but it took ten years (of profit) before J&J were caught out. I could go on about J&J's sin's but this post would get too long. You can read all about the top eleven settlements at Fierce Pharma ,if you have the time. And I haven't even touched upon their medical device's such as metal-on-metal hip joints.

'The elephant in the room' (your doctors surgery), is the triumph of form over substance. Drugs are now prescribed on the basis of what is new and in patent, not that which is most efficacious, because certainly if you examine most that are (in patent) with any degree of scientific scrutiny, it will be seen that many are little different from the drug you may have been given twenty or even forty years ago. The irony being that the older drugs are cheap, or didn't have a patent ever, or they were only patented in the country of origin and thus made in other countries, very cheaply. The most obvious of these is penicillin which Ernst Chain wanted to patent (the production method that is) but his colleagues prevented it because of the importance it represented to health care. Similarly Lilly famously tried to patent the production of insulin but Banting's team sold it to The University Of Toronto for 50 cents.

These then, were examples of the moral integrity displayed by those in medical research, in our recent past, when the landscape of drugs was changed forever by the inventions of chemists and biochemists, immediately prior to and after the 2nd World War. We had sulfonamides, penicillin's, Salks' vaccine for polio (which he refused to patent), along with many extracts of the dyes perfected to bring colour to clothing, that spawned much of today's drugs including diuretics, antihypertensives and some of the oral hypoglycemics. Each was produced relatively cheaply, well by today's prices anyway, but even then there was rancour about the margins made. With the newer 'blockbuster' (over $1 billion sales) the margins are often in the order of 1000 to 2500%!

What needs to be understood today, is that the capabilities of molecular manipulation have expanded enormously and small adjustments to a drugs structure can often yield a new one without perhaps, changing it's design use. A better mousetrap; well this has often been the reason proffered but more likely is the excuse to charge more and market the resultant drug as a 'breakthrough' and by gist of clever and often ruthless selling techniques. Some of these are the reason for the huge fines and ordure heaped upon the industry illustrated in this post. But the rewards are so huge that a $billion or few is 'chicken feed', in the face of the profits to be made, fines then are reduced to a simple 'operating cost'.

Thus we have SSRI's derived from the older Antihistamines such as Diphenhydramine and Chlorpheniramine, when frankly these older drugs are often more effective (although sedating) than are Selective Serotonin Re-uptake Inhibitors, but they are off patent and cheap so you would be hard pressed to charge a fortune for them as you could for Prozac (at the time) or indeed any drug that is targeted at a 'niche' disease or one that cannot be the subject of a 'patent'.

 What 'Pharma' does and does very effectively, is to manipulate the market by the invention of a disease(s) that doesn't have any effect on anyone's real life but predicts the progress if unchecked, of a downward spiral of ill health and early death because of the presence of 'surrogate' markers of this disease, the most famous of which is 'high cholesterol'. The 'invention' of this so called disease, has probably been the most lucrative market for 'Pharma' and heralded the rise of the sector to the same levels as those of energy and banking. Quite beautifully, it depends entirely on the interpretation of a complicated set of figures that mark the various levels of lipoprotiens in the blood of humans. Persuading the somewhat gullible or even complicit members of the Politburo of Health in a given country that a particular set of numbers is healthy and another isn't, is the basis of the disease's progression. Moving these figures ever downwards also opens up the possibility of more and more members of a cohort that then become included in the 'at risk' population.

So now instead of being in the business of making drugs that can really save lives, 'Pharma' now is back to it's beginnings, selling 'snake oil' to punters out of the back of a covered waggon. And worst of all they don't have to convince the bulk of the populace (although in the US they can advertise directly) they just have to convince, coerce, bribe or even force (by the use of guidelines) the Doctor to write the scrip. Enrolling the Doctor onto the payroll metaphorically or even literally on many occasions, makes it both more complicated and simple at the same time. You have less people to convince to carry your message to the customer, but you also have to overcome the (once) innate scepticism of a relatively highly educated, sort of 'semi-scientist'. So in the UK at least, you start feeding money into research and medical education and promote the use of guidelines such that the younger cohort of students never even hear of the 'older' treatments and drugs, until even the generic makers stop producing them. Eventually you will have an entirely new generation of compliant GP's and Medical Practitioners carrying the message that you can provide a drug for every condition, ailment and disease and the plan will be complete. And of course your future profits assured.

We are staring into the abyss of a dystopian world where politicians, aided and abetted by the distortion of Capitalism that now passes for 'free enterprise' (but isn't) follows the trends set by the Industry that our taxes are funding. Patents are the antithesis of enterprise as are the monopolies they spawn. Prescriptions are the opposite of the 'buyer beware' culture that we utilise very day to prevent ourselves from falling prey to the many that would steal our wealth. If we had to work out our own destiny instead of being reliant on this distorted sales paradigm of industrial medicine it might make us more aware of the dangers we readily perceive when purchasing a used car. Ending 'prescription only' medicine may seem like a step too far but if we are really going to embrace 'free enterpise' then perhaps it should be taken to its literal conclusion. Let's then move to real market economy instead of the 'faux' one we have today.

If Circle can really live in the real world instead of the 'rigged' private enterprise market that sees them losing money except at Queen's Hospital in Nottingham, because they are crap at running other locations, where they haven't got a contract that ensures them all the easy jobs, then let it be so. Inject some real competition into the system and then we'll see just how good these providers like Serco, Crapita, Carrilion, and Virgin really are. Instead of handing them contracts on a plate backed by taxpayer gold if it all goes t*t's up. Give Capital free reign and let them see if they can survive without being bankrolled by the State. Maybe then all these recipients of our largess might actually earn their keep, or not?

As for 'Pharma', well take their patent rights away, let competition rip and then see if they can 'cut it' in the real world. And if they cause harm let the architects of that harm be prosecuted for that harm and spend some jail time. Maybe 320 lb Marvin in cell block H with his tattoo's and general penchant for recreational sodomy might discourage them from repeating the offence.

Tuesday, 19 June 2012

Turning Gold into Lead.

The 'gold standard' of scientific study for many years has been the Randomised Control Trial (RCT), preferably 'double blinded', which means that none of the participants, doctors or the cohort, have any idea of whether they are receiving the drug or the placebo. Austin Bradford Hill is credited often with it's invention, but it had already been used in crop trials as well as psychology, before his ground breaking research into tuberculosis and the association of lung cancer with smoking. However, it has always been that which is held up as being the proof positive that a drug, protocol or intervention is better than the placebo and is safe.

I have often, in my posts pointed this out and, frequently been highly critical of trials that do not utilise this and resort to epidemiological or observational evidence as 'proof' of hypothesis, often calling them 'wibble'.  I have not changed this view, but I have distinct reservations about  most trials, if they emanate from 'Big Pharma' to support the approval of some new drug, device or protocol. I say that because 'pharma' has corrupted the very heartland of science, and caused the prescribers of their highly flawed products to become complicit in this calumny of the foundation of  'evidence based medicine'. In fact those words themselves have been used to conceal tracts of evidence that points without doubt to the fact that much of their output is considerably more toxic than they would have us believe, and is no more useful to patients than a placebo for many, if not most.

The main problem lies with the incredible rise and rise of Pharma companies since the 1970's when the constant seeking of 'blockbuster' drugs came about. In 2011 the total sales of the top 6 Pharma Co's amounted to $253.30 billion dollars, which is truly astounding. Aided and abetted by the captive audience of the prescribing team of their sales departments, Doctors. It is so lucrative, so incredibly valuable that virtually nothing will stand in the way of a 'pharma' co, in the pursuit of another Statin, Anti-hypertensive, Hypoglycemic, or better still Anti-Psychopathic or Anti-depressant (although these are usually interchangeable).

So much money is involved that they cannot be allowed to fail in the endeavour of bringing a new drug to market, even if the evidence that it has any efficacy is minimal or that it presents danger to the patient cohort for whom it's targeted. Ways and means will be found to ensure that data is concealed, patients re-allocated, P scores made to look more significant (by adding up lots of insignificant ones), removing completely any sub trial (or even a whole trial) that did not reach significant levels of proof. Generally 'fudging' the exercise to ensure you can convince the FDA, EMA, MHRA and NICE, that the drug you are offering is better than a placebo and does not present a danger; well not a lot of danger, to patients.Or better still a drug that does not present a danger to people that are not (yet) patients because 'disease mongering' is one of the classic methods of creating a lifestyle drug such as 'statins' that will ensure you have a ready pool of frightened and gullible people to the sell idea to, that they may have a chronic ailment that could kill them at some distant point in the future, if they don't take your benign (but essential) medication that will make them live potentially forever!

All you have to do to achieve 'mass medicalisation' of the populace, is to instill in their Doctors the belief that if you construct guidelines for 'surrogate markers' for possible ailments, they will become your surrogate indoctrinator, thus allowing you to market a a drug that circumvents the need for lifestyle adjustments that are frankly tiresome and often ineffective (usually because they are wrong). You then set about the task of hoodwinking the somewhat servile and often ignorant doctor cohort (biochemistry is not their speciality) by getting your drug approved by the authorities who are always ready to disport their desire to interfere in the lives of the proletariat, if they can prove by so doing they are actually saving people from themselves and thus reducing future costs of medical care for the State (in the case of the NHS). You do this by a process of 'ghost writing' studies, financing conferences with itineraries that suggest you wish to address an important societal problem that we never knew we had, for cohorts that are minuscule but could be potentially huge if you can manage to massage the data for such as being potentially an epidemic. You outsource the trial to one of the newer specialists, preferably in a poor country, populate the conference circuit with eminent lecturers, who have generous honorariums, shares, and even patents for some 'isomer' of a current drug you can make into yet another 'blockbuster'.

In recent years these 'areas' in need of special attention, have been cholesterol, osteoporosis, hypertension, pre-diabetes and diabetes, obesity, cervical cancer, manic depression (now bi-polar disorder), depression etc. which occasionally would have prompted an intervention in extreme cases by a doctor and drugs. These drugs would have been time tested, well known and for which (probably) there would have been no trials as such, but doctors would have been using them for most of their lives and they had the evidence of the patient in front of them, as being 'better', even cured due to your intervention. A lot of the time you simply employed 'watchful waiting' and a lot of the problems resolved, especially if you gave them a sympathetic ear and eliminated some of their worst fears. No more. You have a QOF protocol to serve and the politicians have 'sweetened' the pill for you to swallow by paying you for the dubious pleasure of carrying out their orders.

Now you are diminished to the level of a simple 'cog' in a wheel that is crushing the life out of you and your patients. You are the gatekeeper for treatment with your scrip pad as your sword of righteousness, and your test procedures as your shield of light. You are part of an industry that only needs to sell to you because of your (now) elevated status of the 'pill pusher' you can treat a patient by 'rote' safe in the knowledge that you are following 'guidlines'. You can ignore and dismiss the few that come back and complain about side effects as deluded, mistaken or, best of all, that their problem is symptomatic of the problem they have. Most won't bother because they cannot conceive that you, their Doctor, would do anything harmful. You hand out the latest 'blockbuster' from Pharma because it's the new kid on the block, despite the fact it costs 1000x the price of the old one and if you examined it's structure you would be hard pressed to know the difference because essentially it is the same; they've simply moved the 'hand' (example below,a generic amino acid).

Why is this possible? Because that's all that is needed to take out a patent. And by directing most of the efforts of marketing at Doctors (in the UK) by whatever means, you have a small target audience who hold in the their hands the opportunity to affect thousands. In fact Pharma spends considerably more on this element of their business than any research. They constantly collude with many in Healthcare to move the 'goalposts' of the levels at which people are viewed as 'sick', in the so called 'surrogate markers' of disease. Thus, we can look forward to the level of Low Density Lipoprotein as only being healthy if it's zero, and blood pressure targets of 100/60.

This madness is our future, if the power of Pharma is not curtailed and Doctors not allowed to resume their role of healer, rather than an administrator in the industrial machinery of Medicine. Is it not obvious from the disasters presided over by the Authorities in recent years that these 'blockbuster' drugs can be lethal. Avandia was on the market for eight years before it was withdrawn, but not before GSK had made $billions from it and the bodies had stacked up sufficient for someone to take notice. Plenty of money then to foot the bill for the fines and legal costs involved in settling with aggrieved patients and their families. Actis, Vioxx the list is in fact endless, of drugs that were so called 'blockbusters but proved in the longer term to be toxic.

Over my next few posts I will present the case for the prosecution. But there will not be any such case in any UK court. 'Pharma' is part of all of our lives. It pervades every aspect of Healthcare and has reached a position of such power, that politicians treat extensively with them for their manufacturing plants to be sited in their countries including our own dear leader, the 'posh' twait David Cameron, who was so in love with GSK that he endowed the CEO David Witty, with a Knighthood in January, (along with some of my money) to encourage him to expand operations in the UK.

So wake up and smell the coffee! Costs will escalate no matter what fiscal austerity is applied to the NHS, because 'Pharma' needs our money, they don't care whether it comes from 'Obamacare' the NHS, Medicare, or the bloated Insurance sector so long as it is there. That is why most of the 'gold' of medical science has become lead.

Apologies for my absence from the blog over recent weeks. Rumours of my demise were exaggerated and I hope to post with renewed vigour and the rapier like wit I am renowned for (sic).  I have been ill but not terminally so, I hope!  And, the harsh reality of the current financial climate has also meant I have had to 'run' a little faster than is my want, to survive. I keep telling myself that the original objective was to traverse the swamp, but when you're up to your arse (ass) in alligators you do tend to react, rather than follow the 'plan'.

Thursday, 10 May 2012

An 'Ambiguity of Evidence'.

So says Dr. Edward Stefanek with regards to Cancer Screening in an article in Medscape Today. He cites the 'summoning' of women for mammography, contrasting with the 'informed choice' paradigm that exists for men with possible prostrate cancer. He suggests too that this is paternalistic, I would say more likely misogynistic as well, because men are viewed as being participants in some sort of  'club' by simple virtue of their sex, when it comes to honesty in health care. In fact the first rule of misogyny (just like 'fight club') is that we don't talk about misogyny.

Well, I for one don't want to belong to any such club, fraternity or organisation. I do not want to labelled as a feminist either, because I do not wish to 'steal' the term from women. I want to be known as an equal, and one who is just as vulnerable, fallible and more importantly human as is any woman. I am not strident (except in this view) aggressive or demanding of any submission (from women) and feel some men are 'spoiling' it for the rest of us, and the greatest of these are the those who lurk in Medicine, and within that cohort those who continually ram home the message that 'screening saves lives'. Well, patently it does not. It may facilitate an intervention that may do so, but screening per se cannot save any life.

Screening for all cancers is constantly on the rise, despite the fact of the paucity of evidence that exists to support it's continued promotion by the NHS. Medscape also featured Carole Schroeder  who has an interesting blog that provides good information for men about prostrate cancer, but the main thread is that for far too long, women in general (and occasionally men) have been subjected to a constant tirade that they are taking "unacceptable" risks with their health unless they submit to screening. Mammography leads the way despite the fact that recent studies have clearly shown that it is not effective for most and can be catastrophic for some as I detailed in a previous post. There is now a groundswell of opinion rising to ensure that all those who participate are fully informed of the risks, benefits and harms of the process, instead of the current paradigm of inflating the the risks of breast cancer and concealing the harms of mammography. The the BMJ highlighted this last July and I wrote about the innate misogyny displayed in many of the testing regimes, aimed at women, only recently.

A recent development however, is the call for younger women to be 'screened' for cervical cancer, which to be frank is bordering on the dangerous, but when a young Nottingham woman was diagnosed with cervical cancer the pressure was applied both at local and National level for this cohort to be screened. This is despite the fact that only ten deaths from this form of cancer in 20-24 year olds was recorded in the whole of England and Wales in 1988-1989 and it has subsequently 'fallen of a cliff in mortality terms down to 3.7 deaths per 100,000 by the turn of the century (overall mortality). So despite the fact that Natalie Carney did actually have cancer, which is appalling, should we then create a whole new subset of tested women because of one isolated case? Women in this age group often have abnormal cells but it is well known that virtually all of these regress spontaneously without intervention, which is largely why young women are not screened. In fact most screened abnormalities are either benign or regress generally but 'over-diagnosis', just as in mammography, dominates cervical screening. But there is a bigger issue, as always and that is Coercion.

Persuasive tactics predominate all cancer screening testing. The NHS and it's GP's in particular values it out of any proportion to the benefits, but it is a political imperative, maybe to show that they care (sic). 'List and chase' was the tactic employed in the 90's along with 'hit that target', all to encourage GP's to recruit women to the Cytology Screening Programme so they could get their target payments. Yes, they get paid substantial sums for achieving an 80% uptake of testing in the 25 to 64 yr old practise cohort. In fact until payments were commenced uptake was quite low, but once the money was there that all changed. One GP is alleged to have said, "We are afraid of missing our targets, not missing a cancer" (Journal of Medical Ethics 1998;24:151-157). I think that sums up the position quite nicely.

There is little in the way of information provided to women targeted, just exhortations that 'you put your life at risk, by not complying', or ' REMEMBER - regular smears saves lives' and other such coercive statements that are simply not borne out by the evidence. A balanced view is never given and feminine autonomy is usurped by this type of inflammatory rubbish because experts cannot predict the incidence of abnormal smears nor those that will definitely progress to invasive cancers. Quite large numbers of those tested are then subjected interminable waits to find out if there cancer is real and many go on to be treated with surgery or radiation for no useful purpose other than 'being sure'. Those who try to shun the tests are often singled out for bombardment with 'phone calls, text messages and mail shots that are akin to blackmail, foretelling all sorts of dire consequences if they continue to abdicate their responsibility to their partners and families.

Current leaflets explaining the test and likelihood of cervical cancer outrageously inflate the benefits saying that screening is responsible for the drop in the rate of mortality, when it was falling before the testing system got underway and there is no evidence whatsoever that the fall in incidence or mortality was due to screening. Almost 30% of actual cancers occurred in women who had adhered totally to screening guidelines. There were 6231 women diagnosed with cervical cancer between 2007 and 2010, in a population in England of 14.6 million. 44% of those cancers were classed as 'micro-invasive' and were conservatively treated by cone biopsy or loop excision (and of course may not have been true cancers). So that is approximately an incidence of 14.4 per 100,000. Or approximately 8 per 100,000 for those with Stage 1B+ Cancer or worst. At 1 in 3000, you are considerably more likely to to be hit by a meteorite ( I know I didn't believe it, but I did check) so let's get this into some sort of perspective. Of course as you get older the incidence and mortality increases, as will be seen from the graph. That of course is in accord with the aetiology of this cancer which can take many long years to develop. But it still remains quite rare. So does it warrant all the attention, cost and stress to women?
Numbers of deaths and age-specific mortality rates for cervical cancer in the UK
More important however, is the treatment of women as a whole as incapable of making an informed decision about their lives and the ethically unacceptable tactics employed to persuade them to bow to the dubious manipulation of the State. We all are (or should be) autonomous adults and it's completely unethical to attempt to infiltrate any of us with dubious medical opinions, statistics or advice instead of treating us a agents of our own destiny. It is generally women rather than men that are treated in this way and it is generally men who do it. I am ashamed of my gender, especially those called 'Doctor'.

Perhaps the words of Professor Michael Baum, one of my medical hero's may be the best ones to end with. They are here.