I don’t often link to journal papers, but this one by Sabrina Jin et al in The Lancet Infectious Diseases really tickled my fancy. It introduces the concept of ‘infodemics’—’an inundation of information accompanying an epidemic or acute health event’—and makes the case that these have always existed. It’s a neat corrective to the societal panic about the spread of health misinformation on social medical, suggesting that not much has really changed.

There were two bits that I especially enjoyed.

The first was the painting at the top of this post—and 1802 etching by James Gillray of small cows erupting from the sites of the cowpox vaccination, lampooning a common reason for vaccine hesitancy. Concern about vaccines is far from new!

The second was the challenge back to the medical profession about our own indulgence in disproven myth, using perhaps the best imaginable public health example (ahem):

Although medical institutions often praise John Snow, some aspects of Snow’s work have been altered as part of public health mythology. According to popular renditions of his biography, Snow created a dot distribution map that connected patterns of cholera mortality with the Broad Street water pump used during the 1854 cholera epidemic in London, UK. These observations allegedly led to the removal of the pump and halted the outbreak in the surrounding community. However, close examination revealed that the cholera outbreak had already peaked before Snow’s discovery, indicating that the reduction in mortality was not directly associated with removal of the pump. Despite this inaccuracy, Snow’s work—including its mythicised features—continues to be celebrated as an integral part of medical history. This continued celebration of historical falsehoods indicates the enduring existence of mythology and inaccuracies, even among medical and public health professionals.

Splendid work.

60 years ago, the ‘bullet train’ first ran on Japan’s newly built East Coast Tōkaidō Shinkansen line. In celebration, a nose cone from one of the first trains has just gone on display at Japan House in London. I’m not sure I’ll go and see it, but news of the exhibition did make me ponder.

When the Tōkaidō Shinkansen line opened in 1964, trains ran at a maximum of 130mph—faster than Britain’s East Coat Mainline, but not by all that much. Our (diesel-powered) trains ran at 100mph on sections of the line.

By the time the first generation of bullet trains retired in 1999, the line was running at a top speed of 168mph, and the now-electrified East Coast Mainline had bumped up to 125mph.

Thanks to a commitment to continuous improvements, today the Tōkaidō Shinkansen line runs at 177mph. Yet, the East Coast Mainline’s top speed hasn’t increased in the last 48 years. A line whose speed was once competitive has since stagnated.

But the UK certainly beat Japan on one big improvement: smoking was banned on East Coast Mainline trains in 2005, but astonishingly persisted—albeit in designated on-board smoking rooms—until March this year on the Tōkaidō Shinkansen line.

In a subway in Lisbon, there’s a 2024 cork artwork by Sagmeister & Walsh that spells out a sentence, repeated on a nearby plaque for much easier reading:

If a newspaper would only come out every fifty years, it would report how life expectancy rose by twenty years.

I scoffed to Wendy that this couldn’t possibly be true. In the UK, life expectancy has increased by about a decade since the 1970s and is now in decline. Surely Portugal couldn’t be so different?

With her usual sagacious wisdom, Wendy suggested that it was probably not meant to be taken literally. We were probably supposed to contemplate the negativity bias in the news and note how poorly it reflects the long-term improvements that I talk about regularly in a professional context.

But I couldn’t let it drop, so I did the research. Astonishingly, the artwork is reasonably accurate.

In the fifty-year period between 1970—when, of course, Portugal had yet to return to democracy—and 2020, life expectancy grew from 63 years for men and 71 years for women to 78 years and 83 years, respectively. It’s not quite a twenty-year increase, but it’s in the ballpark.

In 1920, the average life expectancy in Portugal was about 40 years, so the increase from there to the 1970s exceeded the artwork’s claim.

In 1870, the average life expectancy was around 29 years. The fifty-year span to 1920, therefore, delivers less than a twenty-year increase, but again, it’s in the right ballpark—and proportionately, it is astonishing. An extension of the average lifespan by a third in fifty years.

Exactly as the artwork (and Wendy) tried to tell me, it’s easy to underestimate gradual changes.

There’s a form I have to fill in at work every quarter, in which I’m invited to answer the question ‘How are you?’ with an integer. The instructions say that I ought to ‘rate how things are feeling 1-10’.

Anyone who knows me well enough will be unsurprised that I have a cut-and-paste paragraph that I shove in the box intended for an integer. It explains that I am declining to answer in the requested format because I cannot summarise how I feel in that form, and that I find the question inappropriate and mildly offensive.

Nobody has ever questioned my response.

I was reminded of that when I read this article by Elisabeth Rosenthal in The Atlantic. As a doctor, Rosenthal admits that she has asked many patients to rate their pain on a scale of zero to ten, but reflects on how useless this question is when asked to rate her own pain:

Pain is a squirrelly thing. It’s sometimes burning, sometimes drilling, sometimes a deep-in-the-muscles clenching ache. Mine can depend on my mood or how much attention I afford it, and can recede, nearly entirely, if I’m engrossed in a film or a task. Pain can also be disabling enough to cancel vacations, or so overwhelming that it leads people to opioid addiction. Even 10+ pain can be bearable when it’s endured for good reason, like giving birth to a child. But what’s the purpose of the pains I have now, the lingering effects of a head injury?

The article dives into the history and future of this kind of pain scale and was a great read: it’s well worth a few minutes of your time.

The image at the top of this post was generated by DALL·E 3.

In The Times last week, Matt Chorley wrote about a focus group’s reaction to the Government’s oft-repeated plea:

In the meantime, Sunak presses on, vowing to listen to voters while refusing to change. “Stick with the plan that’s working.” On our most recent Times Radio focus group of swing voters, we asked about that slogan. “Which plan’s that?” scoffed one. “And what’s working?” said another, before they all descended into guffaws.

This was still ratting around my mind when I saw this laminated sign above a hospital bed—not in deepest mid-winter, but on a glorious spring afternoon:

This isn’t a one-off: it has become the norm in many NHS hospitals these days. It’s this graph of the relative collapse capital spending in the NHS made photographic:

‘Which plan? What’s working?’ might be the most apposite piece of political commentary in years.

Last weekend, I read a brilliant article in the FT Weekend about a call centre which receives emergency calls from people trapped in lifts—the people who answer when you press the ‘alarm’ button.

It was written by Aidan Tulloch, who I’ve never come across before, but who is clearly a remarkably talented writer of lyrical and absorbing journalism. It’s a truly absorbing piece that’s worth reading for the quality of the writing alone.

I haven’t been able to get the article out of my head since I read it, and during a conversation with a colleague about something entirely different, I suddenly realised why.

In England, as in most countries around the world, doctors must notify health authorities if they suspect someone of one of the diseases set out in legislation. This allows other doctors—like me—to take action to protect the wider population from whatever threat that disease might pose.

From a process mapping perspective, this is straightforward: one doctor has information that another doctor needs. There are myriad routes to streamline or automate the communication of that message. A lot of the time, that would be enormously beneficial.

But my colleague and I were reflecting on how much more there is, sometimes, to those conversations than a simple passing over of information. There can be relationship building (‘how are you these days?’); education and clarification (‘that really doesn’t sound typical of disease X, are you sure that’s a likely diagnosis?’); reinforcement of the value of the notification (‘what do you do with these anyway?’); sharing of situational awareness (‘we’ve seen a lot of these lately’).

It might be massively more efficient for Stannah—the lift company in the FT Weekend article—to make buttons in lifts that just send an automated notification of a fault. But they’ve clearly understood that there’s much more to the interaction than that core notification.

The surrounding chat can be as important, and sometimes more important, than the actual message to be imparted.

The image at the top of this post was generated by DALL·E 3.

Crocuses are a lovely reminder that spring is on the way. Both globally and across the UK, purple crocuses are planted to remind us of humanity’s pledge to eradicate polio.

In the years when my parents were born, there were as many as 8,000 cases of polio each year acquired in the UK, leaving many families bereaved and tens of thousands of children with lifelong disabilities. An effective vaccine was developed in the late 1950s, and as a result of the success of its rollout in the UK, there has been not a single UK-acquired case of polio in my lifetime. It’s easy to forget the astonishing and unprecedented progress we made in public health in the twentieth century.

We haven’t eradicated polio worldwide quite yet, though we’re getting close, with only tens of cases reported each year. Two of the three strains of polio have been consigned to the history books. The purple crocuses should remind us that we still need to finish the job.

I had to attend some leadership training this week, which is a cross we must all bear from time to time.

The trainer declared that IQ, as in ’intelligence quotient’, was one of only four jointly conceived attributes which make up a rounded person. The others, for what it’s worth, were cited as the ‘emotional’, ‘physical’ and ‘spiritual’ quotients.

The trainer explained that the word ‘quotient’ shared a root with ‘quadrant’ and was chosen because there were four domains.

My bullshit antennae were firing so intensely at this point that they may have been visible if it wasn’t quite so long since I last cut my hair. Yet, at least the trainer’s misplaced confidence made me spend a few minutes reading around the topic from sources more reliable than the course’s tie-in leadership paperback.

The Oxford English Dictionary says that ‘quotient’ is a direct borrowing from the Latin ‘quotiens’ meaning ‘how many times’ or ‘how often’. In the ‘intelligence quotient’ sense, it’s referring to the quantity of intelligence. There’s no historical or modern sense in which it connects to a sense of there being four parts.

The prefix ‘quadr-’, as I should have remembered from school, comes from the Latin numeral ‘quattuor’.

But what about IQ? I should have remembered this, as I recall presenting on it during a special study module I took in learning disabilities a couple of decades ago. It was created in the early 1900s by the German psychologist William Stern as a standardised figure for monitoring child development: simply divide their ‘mental age’ by their ’chronological age’ and multiply by 100.

EQ is rooted in more modern psychology, while PQ and SQ seem to be modern inventions by leadership gurus, keen to repackage and upsell ancient philosophy.

I may have been cynical about the course, but it clearly has made me learn something.

In my job, one of the trickiest things to consider in outbreak management is the secondary effects of any restrictions. They are often difficult to predict, let alone quantify, yet they can drastically alter the balance of risks.

Imagine, for example, a batch of ready meals which are suspected of being contaminated with a bacterial pathogen yet are destined to be heated and served to hospital patients. I think everyone’s first instinct would be to withdraw the meals to reduce the risk of giving patients food poisoning.

But this decision would not be as straightforward as it first appears. The risk of illness from the meals might well be mitigated—but not necessarily eliminated—by the need to heat them, which will usually kill the bacteria. If the patients are not to have the hot meals, then they will have to be served something else. If that ‘something else’ is, for example, pre-packed sandwiches, then the risk of illness for vulnerable patients from pathogens such as listeria, which are reasonably common in pre-packed sandwiches, might be higher than the risk associated with the hot meals.

In this scenario, the fact that patients must be fed and that there will, therefore, be a secondary effect is obvious and predictable. Sometimes, secondary effects are entirely unpredictable, and you can do no more than take an informed, professional guess. And then, crucially, keep an eye on the impact of interventions so they can be tweaked if necessary.

The same is true in clinical medicine: adding one extra tablet to a patient’s regimen might reduce their risk of developing a particular illness. But it might also increase their side effects, interact with another medication, or be the extra tablet that tips them over the edge into non-compliance with the whole regimen. Well-intentioned decisions can have unexpected secondary consequences.

Kelsey Piper of Vox gave a great example of the importance of considering secondary effects last week. She describes the fact that the US Federal Aviation Authority has done extensive research which has found that it is considerably safer for very young children to fly in their own secured seat, rather than travelling in someone’s lap. They give clear public advice on this, yet—despite all the evidence—choose not to mandate it.

Their rationale is that requiring the purchase of a seat for very young children would make flying unaffordable for many families, and a proportion of those families would choose to drive to their destination instead. Driving is considerably more dangerous than flying, to the point where the FAA calculates that for every life saved by a ‘separate seat’ mandate, sixty lives would be lost on the road.

Sometimes, we can all get drawn into looking only at our piece of any given puzzle, but it’s essential to keep a broad view: you never know when a secondary effect might undermine your action.

The image at the top of this post was generated by DALL·E 3.

Last week, The Times’s leading article asked:

Why should doctors, trained at great expense by the state, not be obliged to serve a minimum number of years in the NHS?

Politicians occasionally suggest that doctors who have been trained in the UK—and who have accumulated an average of £71,000 in debt in the process—should have a period of indentured service to the NHS or else pay a still higher contribution to the cost of their training to be freed from this requirement.

I always wonder why the equivalent suggestion isn’t made regarding politicians themselves. Elections are costly, and when MPs resign mid-term, before the end of the period of service for which they were elected, there is a cost to the public purse of running an election to replace them. Why not require MPs to serve their term or repay the by-election costs if they don’t?

The answer is obvious: it’s in no one’s interest to have a de-motivated, disruptive, non-attending Nadine Dorries of an MP, trapped in a job they want to leave because of a perceived ‘fine’ if they quit—a ‘fine’ that they may not be able to afford. And it strikes me that the same applies to doctors.

The image at the top of this post was generated by DALL·E 3.