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31 things I learned in January 2020

1: Alan Bennett had open-heart surgery in Spring 2019 and the news completely passed me by.

2: A paucity of Papal patience provides problematic publicity for a Pontiff preaching peaceful pacifism to pious pilgrims.

3: Norovirus probably causes about two-thirds of care home outbreaks of gastrointestinal disease.

4: Fewer than 20% of schools in Texas teach children about safe sex. Texas is among the States with the highest teen pregnancy rate. Any connection is disputed by conservatives.

5: I’m reading Matt Haig’s Reasons to Stay Alive at the moment, and there’s a line advocating for greater ‘mood literacy’ which I found a rather lovely turn of phrase. It reminded me of this blog post advocating examination of one’s own response to the outside world to better understand one’s mood. Both taught me something about self-examination.

6: One of the room booking systems at work requires me to “invite” a given room to attend a meeting. I’ve now learned through bitter experience that rooms can decline invitations… which felt a little humiliating, even if it does open up a whole new seam of entertaining insults (e.g. “that meeting sounds so pointless that even the room declined the invitation”).

7: Populist ‘knee-jerk’ reactions in politics are commonly discussed and clearly dangerous. I’ve been reminded today by an article on the lack of legislation around in vitro fertilisation research in the USA that the opposite—a complete failure to react because issues are complex and divisive—can be just as dangerous.

8: Merely possessing a placebo analgesic, without even opening it, has been shown to reduce pain intensity.

9: The average age of a BBC One viewer is 61. If one considers that a problem, as the BBC seemigly does, then I suppose one might conclude that removing children’s programmes from the channel was not the right approach.

10: The Royal Botanic Garden Edinburgh is only a short walk from the city centre and is a great place for a winter stroll. The uphill walk back to the city centre is a touch more tiring.

11: Over the past decade, the proportion of the UK’s electricity generated from wind and solar power has increased from 2.4% to 20.5%. The proportion from coal has fallen from 31% to 2.9%. (As reported in Positive News, though the specific article isn’t online.)

12: Aspiring comedians often go on ‘introduction to stand up’ courses. I’d never thought about these sorts of courses existing, but of course they do.

13: More than half of Luxembourgers speak four languages. The best-selling newspapers in Luxembourg have articles in two languages. This makes me feel inadequate.

14: In the 1990s, John Major mooted renaming Heathrow airport after Churchill, while Lindsay Hoyle and William Hague fancied naming it after Diana.

15: I have long known the North East is an outlier for antibiotic prescribing in primary care, but hadn’t fully realised until a meeting today that the North East isn’t an outlier for antibiotic prescribing in secondary care.

16: I was surprised to read that a survey suggested that only one in three people on the UK knows the standard VAT rate is 20%, and one in ten knows the basic rate of national insurance is 12%. But then, on reflection, my own surprise surprised me, because I don’t really know how or why I know those figures myself. I’m sure there are plenty of similar figures on which I’d have no idea myself!

17: Since last September, Monday to Friday, the City of London Magistrates’ Court has been filled by Extinction Rebellion defendants from around the country.

18: The developers of Morecambe’s Central Retail Park have “put an extraordinary amount of effort into stylising the car park” including quirky themed artworks, sculpted steel waves and effigies of seabirds diving for fish.

19: In the US, a broadly similar amount is spent on treatment for back pain ($88bn) and treatment for cancer ($115bn).

20: Office for National Statistics Travel to Work Areas are an interesting way of dividing up the country.

21: Civil servants in China cannot ordinarily be dismissed. One wonders what Dominic Cummings makes of that.

22: Over 70% of 12- to 14-year-olds in China are short-sighted. The Communist Party has set targets for reducing that, leading to some slightly strange practices in schools, including compulsory twice-daily eye massages and dressings-down for those whose sight worsens over time.

23: It’s not a public health emergency of international concern.

24: Blinded trials are not always best. I remember having to write an essay or answer an exam question on this topic at some point in the past, but haven’t really thought critically about it in years.

25: The attendance fee for the 2020 World Economic Forum in Davos is 27,000CHF (£21,400). I will never complain about medical conference registration fees again!

26: Luxury branded homes—as in, “I live in a Bulgari residence” or “I’m in the Porsche apartments”—are now a thing. Is it possible that this is a global conspiracy to see how far the definition of “gauche” can be pushed?

27: “We fill our days with doing laundry, replacing our brake pads at the auto shop, or making a teeth-cleaning appointment with the dentist, in the expectation that everything will be fine. But it won’t. There will be a day that kills you or someone you love.”

28: “To err is manatee. A manatee might mistake a swimmer’s long hair for shoal grass and start munching away, oblivious to the attached figure. To err is baby elephant, tripping over her trunk. To err is egg-eater and moonrat and turnstone and spaghetti eel, and whales, who eat sweatpants.

29: Pulmonary tuberculosis can be detected in babies by doing PCR tests on faecal specimens. Sensitivity of the test varies according to the exact methods used, and this is an active area of research.

30: It’s a public health emergency of international concern.

31: The TV series Love Island has an unexpectedly innovative business model which involves selling items seen on the show via the app which viewers download to vote for contestants.

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Acupuncture stings

In most of medicine, and in Health Protection in particular, one occasionally comes across people who have made questionable decisions which have had severe consequences. When people decline routine vaccinations or fail to use a condom for specious reasons, it can be both depressing and frustrating to be picking up the pieces.

It’s easy to rationalise that health is not at the top of everyone’s personal agenda and that sources of misinformation are common and commonly believed. At these times, it feels like the most productive outcome is to channel the frustration into improving the information on offer and trying to reach the people who have missed it.

A friend once told me to think of ‘health’, a topic which most of my life is dedicated to, in terms of ‘transport’, a topic with which I’m intimately engaged as a ‘user’ but in which I’m completely non-expert:

I might get frustrated that people don’t take obvious preventative health measures, but when was the last time I checked my tyre pressure, an obvious ‘preventative measure’ in the ‘transport’ world? (I’ve done it once in the nine years I’ve owned my car.)

I might get annoyed that people don’t have any idea of the true cost of their healthcare, but what’s the true cost of the public transport I take to work each day? (I’ve no idea.)

I might think that’s it’s patently obvious that homeopathic remedies contain no active ingredients and are a total waste of money, but what’s the evidence of benefit for the ‘premium’ grades of petrol? (I often buy them, even though there’s probably no benefit.)

And then, just occasionally, I come across something that seems so appalling unappealing that I’m baffled that anyone, medical knowledge or not, could possibly want to engage with it, let alone risk harm by doing so:

One type of apitherapy is live bee acupuncture, which involves applying the stinging bee directly to the relevant sites according to the specific disease.

Live bee acupuncture. Wowzers trousers. This paper by Vazquez-Revuelta and Madrigal-Burgaleta in the Journal of Investigational Allergology and Clinical Immunology, from which the above quote is taken, reports a terribly sad case of a 55-year-old woman who died from live bee acupuncture.

The paper reports that she’d been attending four-weekly for two years for the procedure, with the aim of treating

muscular contractures and stress.

As one might expect,

the risks of undergoing apitherapy may exceed the presumed benefits, leading us to conclude that this practice is both unsafe and unadvisable.

There is little about this paper which isn’t at least mildly astonishing. But then I wonder… I don’t know what the transport equivalent of intentional bee stings might be, but perhaps I engage in that too.

The alarmingly cute picture of a bee at the top of this post was posted on Flickr by Ozzy Delaney. I’m reusing it here under its Creative Commons licence.

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Knowledge and understanding

I recently finished reading Don Bartlett’s translation of A Death in the Family, which is the first volume of Karl Ove Knausgård’s radically honest autobiography. It took me a long time to get through this book (around three months) because I found it so intense that I had to read sections at a time, interspersed with other books. Nonetheless, I thought it was a masterpiece.

Roughly halfway through, Knausgård writes:

There is no one who does not understand their own world. Someone who understands very little, a child, for example, simply moves in a more restricted world than someone who understands a lot. However, an insight into the limits of understanding has always been part of understanding a lot: the recognition that the world outside, all those things we don’t understand, not only exists but is also always greater than the world inside.

This caused me to reflect for quite a long time and stimulated a couple of thoughts to jot down here.

The description of people understanding their own world and being restricted to the world they understand is fascinating. I think there are lessons in that formulation for public health. People frequently make choices which are, by any objective measure, bad for them: smoking, refusing vaccinations, drinking a G&T while blogging. But taking action which is objectively harmful isn’t necessarily irrational, and we often forget that.

If someone’s understanding of their world is that vaccinations cause harm to children, then refusing vaccination is a rational choice in line with their understanding. Their understanding is wrong, but they are acting rationally within the limited world in which they move. If we are to effectively influence the behaviour, then we need to inhabit the world to understand the rationality of the choices people are making. Unpicking the reasons for the incorrect understanding and setting about correcting it is likely to lead to greater success than lecturing people.

At work, there is a sign in the lift which reads “Could you have taken the stairs?”. The answer for me is invariably “no”—I only take the lift when I’m unable to take the stairs—and every time I see the poster I get mildly annoyed at its accusatory tone. It also seems unlikely that it changes anybody’s behaviour, given that it is only seen after someone has decided not to take the stairs. It’s a poster that doesn’t have any effect on anyone’s understanding, nor does it expand anyone’s worldview.

I realise this is a fairly incoherent ramble (see also the reference to drinking and blogging), but I suppose my point is that public health interventions should try to be less preachy and more practical.

In professional life, it isn’t uncommon to hear people imploring other people to ask questions if they don’t understand something. “There are no stupid questions” and “If you’re thinking it, someone else is thinking it too” are commonly heard refrains. And yet, professionals often remain frightened to ask questions which they think might reveal a degree of ignorance.

A few years ago, after a particularly tense meeting which had featured the world “I really don’t understand what you’re talking about”, a former supervisor gave me a one-to-one aside of valuable advice which they said it had taken many years to learn: “If someone is coming to talk to me and is so poor at pitching what they say that I can’t follow it, it is my professional responsibility to politely challenge that by asking them to explain themselves. It solidifies my reputation as someone who is engaged, intelligent and listens to what people say.”

This made me pay much more attention to my own and others’ reactions to people asking questions. The first thing I noticed was the frequency with which, when challenged, people often weren’t able to explain their waffle. This is useful because it helps people to make a value judgement about the rest of what someone is trying to tell them. The second thing I noticed was that when people could explain, they were usually happy to do so, and altered the rest of their ‘pitch’ to a more appropriate level. The third thing I noticed was that my respect for the person who asked the question generally increased.

This completely changed my perspective, and I now regularly ask questions which I’d previously have thought might make me look stupid. This took an effort at first, of course, but now comes naturally. Sometimes the questions I ask are bloody stupid and I should know better—but rarely, and when it does happen, it at least gives people a laugh. I don’t know if it’s bolstered my reputation, but it has certainly meant that there are lots of things I now understand that would have otherwise passed me by.

“An insight into the limits of understanding has always been part of understanding a lot”.

I took the photo at the top of this post at Charles de Gaulle airport. It is a chandelier, which has absolutely no relevance to the content of the post. I just thought it was quite pretty.

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