Richard Smith recently proposed banning the word ‘prevention’ in healthcare:

A few years ago, my friend Pritt, one of life’s instinctive radicals and iconoclasts, talked to me about “the deficit model of health.” At first, I didn’t grasp his point, but slowly I came to understand. What is being prevented? Sickness, of course. Prevention leads to health, which is the “absence of sickness.” Health is defined as a deficit, the absence of sickness. And who determines if you are sick? Doctors. If we stick with “prevention” then doctors will determine who is sick and who is “healthy” because they are not sick.

Like most radical ideas, this one took me on a journey. My instinctive response was to agree: I smiled broadly as I read, ‘Dying is healthy; living forever would be unhealthy.’

Of course, ‘we need a bolder and broader definition of health—something to do with resilience, adaptability, coping, interdependence, and relationships with others, our community, the planet, and nature.’

But then, I paused. I work in health protection. Most of my job is about ‘preventing’ illness. If someone is a close contact of a patient with a particular disease, then they may need antibiotics to prevent them from becoming unwell themselves. If there’s a high likelihood that a foodstuff in someone’s fridge was manufactured in a way which has introduced contamination, that food might be better off binned to prevent food poisoning. If a cloud of chlorine gas is rolling towards a housing estate, then the people must be evacuated to prevent them from choking to death.

And then I saw the point. To see my job as ‘prevention’ is precisely the sort of simplification that I myself often rail against. My job isn’t really to prevent people from becoming unwell: they can take as many risks and be as unwell as they damn well please. My job is really to inform them of the risk they face, help them to decide whether they want to act in light of that new information, and to support them to act if they wish to do so.

This is significantly different because—as I frequently find myself emphatically explaining to others—it can be perfectly rational not to act in response to a risk. This is especially true given that most actions generate side effects, which each of us will value differently. We don’t—and shouldn’t and mustn’t—compel people to act based on our assessment of the risk to their physical health, because there might well be other things that they value more greatly.

Banning the word ‘prevention’, even from an area of medicine that might seem to be entirely focused on it, would be enormously helpful in reframing what we do.

In 2005, I was just starting to be released onto the wards in the third year of my medical degree. One of the dullest weeks focused on orthopaedic surgery. The operations were life-changing for the patients but struck me as a sterile version of Meccano. The techniques were ingenious, but their application to a conveyor belt of patients felt depressingly repetitious. Give me a knotty, intractable problem to tilt at (and fail to solve) any day.

The specialty wasn’t right for me, and I wasn’t right for the specialty: I have neither the ego nor the bravado to be an orthopaedic surgeon. I sincerely hope things have moved on in the past two decades, but the male orthopaedic surgeons’ changing rooms were Lynx-Africa, Page-3, clothing-on-the-floor hellholes ripped from straight from a sleazy gym. No thanks.

My over-riding memory of that week, though, is not the surgery: it’s a specific patient. She was in her late 80s, she lived alone, and she was fiercely independent. She had never married and was proud of the fact: woe betide anyone who prefixed her surname name with ‘missus’. She had fallen a couple of years previously and broken her hip. She was in hospital because, unfortunately, the nail which was holding her femur together had fractured following another fall.

I met her shortly after her admission, when I was allocated to her to practice my history-taking and examination skills. We fell into a long chat about her fascinating career, an area of work I knew (and know) nothing about.

One thing she was keen to tell me was how ‘miraculous’ the NHS was. She grew up in a poor household. She talked about her experience of TB in her youth, and of being isolated in a charitable sanatorium with no contact with her family for months on end. She talked movingly about one of her younger brothers becoming very unwell when she was a teenager, her parents being unable to afford to call a doctor and having instead to seek help from the church. Her brother died, having never seen a medic.

I remember going with the occupational therapy team to see this lady’s house: a standard part of their practice to see what home aids she might require, or what trip hazards might be lying around. The house was immaculate, not a thing out of place. I could scarcely believe that someone in their late 80s could keep a house so beautifully.

Her surgery turned out to be more complicated than was initially expected. The broken nail proved difficult to remove—by virtue of being broken, it couldn’t just be cleanly pulled out of the hole it had been driven into. Once it had been quite traumatically extracted, the patient required a plate to be screwed in to hold her femur together, with something like a dozen screws. It wasn’t a light undertaking, and this lady ended up spending quite some time in intensive care.

By rights, my story should end there: I moved onto other training weeks. But I kept popping back to see this lady. Every time I saw her, without fail, she talked about the ‘miracle’ of the NHS. She talked about how, when it was first introduced in her twenties, people were terrified to call a doctor as they couldn’t believe there would be no bill. It took a long time and countless leaflets and word-of-mouth until people really trusted that they could use the service. She talked more eloquently than I ever could about how it transformed the life chances of those around her: how gradually, over time, illness came to lose its life-changing significance, and became more of an irritation than a life event. She lamented the loss of her brother.

She talked, too, about her concern for the future of the NHS. She thought that those who hadn’t lived without it didn’t appreciate it. For some reason or other, NHS waiting lists were in the news at the time. She saved a newspaper clipping for me, and when I went to visit, remonstrated with me: why did these people not realise how lucky they were to be on a waiting list for free care? Would they complain if they were on a waiting list to win the lottery? People won’t realise what they’ve got until it’s taken away again.

Over the course of about six weeks, her tenacity and drive—plus support from nurses, physiotherapists, occupational therapists, and pain management specialists—resulted in a truly astounding recovery. My last memory of her is of her being wheeled off the ward—backwards, for some reason—with a massive grin on her face, arms waving in the air, thanking everyone she passed (even the other patients). Remarkably, she was going back to her own home, to continue living independently.

Clare Gerada, the president of the Royal College of GPs, once wrote:

One cannot see patients, day in day out for years, without being profoundly affected by this experience and the struggles we witness. Even now, as I write this chapter, I see the faces of my patients and hear their words, some long deceased. I see their ghosts as I walk my dog, shop in the supermarket or walk past their old homes. Many of my patients still live in my mind.

I agree, and today—the 75th anniversary of that day in 1948 that this patient remembered so well—this patient is making her unique presence very well known to me.

Of course, her reflections aren’t really about the NHS as it is currently structured: her point is about the value of care which is free at the point of use, funded through general taxation. Politicians like to politic about the specifics: organisational structures, social insurance models, completely free care¹ versus co-pay models, the level of involvement of the private sector. At it’s founding, NHS hospitals were made into a single organisation. These days, there are countless separate organisations, many operating in competition with one another, mostly on the basis of finance rather than quality of patient care.

But sometimes, and particularly on an anniversary like this, it’s worth taking a step back and realising what we’ve got: the NHS is a miracle. We shouldn’t forget that it wasn’t always like this, and won’t necessarily be like this forever.

The NHS is under extreme pressure at the moment: it feels like it’s falling apart in front of our eyes. But at least we still have an NHS which strives to deliver its founding principles. Sadly, these days, political rhetoric around the NHS has become entirely about patching it up, about making it live within its means—as though those means are not entirely determined by us.

How wonderful would it be if we used the 75th anniversary to invent the same thing for social care? To have the vision to say “the whole of society will take the risk” instead of the individual? To proceed with visionary boldness to meet the need, not balance-sheet-driven timidity. To prioritise compassion over efficiency.

My birthday wish for the NHS is that, perhaps, we’ll have moved in that direction before it reaches its century.

1. We don’t have completely free care in England: there are prescription charges, dental charges, optical charges, and so on and so forth.
   

The image at the top of this post was generated by Midjourney.

Reflections are sparked by the strangest things.

I was on my way to deliver a teaching session scheduled for a room off a service corridor in the basement of a hospital. The corridor was familiar. I was transported back to working as a foundation doctor, when building work meant traversing this endless corridor in the dead of night to get between hospital wings.

The sensation was so reminiscent that my hand automatically wandered to my back pocket to make sure I still had my ‘list,’ the indispensable scrap of paper serving as an aide memoire, with tasks and patients scribbled all over it. For a junior doctor, losing your list is akin to losing your mind, but I haven’t carried one in over a decade.

As I walked that corridor years ago, I would often be strategising about how I could fit an almost endless list of tasks into a narrow window of time. Most of my anxiety was related to doing things. These days—and I think this is common to most doctors as they become more senior, not just those in health protection—most of my anxiety is related to not doing things.

When presented with a situation, ‘doing something’ is almost always the easiest option for experienced doctors, not least because the burden of actually doing the work typically falls elsewhere: taking a specimen, giving an antibiotic, calling a meeting, putting up a sign.

But ‘doing something’ is very frequently the wrong option, partly because resources are limited, but more importantly because not everything benefits from an intervention. Specimens won’t always change management and can cause anxiety while awaiting results. Antibiotics don’t work for everything, have unpleasant side effects, and are a limited natural resource. Meetings don’t always achieve anything and sometimes just kick the can down the road, at a huge time cost. The world already has too many signs, and signs rarely solve problems.

‘Doing nothing’ is often right. Time is a diagnostic and prognostic tool. Waiting to see if a risk is realised is sometimes more rational than responding to an uncertainty.

But ‘not doing things’ is hard. As the adage goes, the coroner doesn’t criticise the doctor who gave the antibiotic that didn’t work, but finds fault with the doctor who didn’t give the antibiotic that might have helped.

‘Not doing things’ is exhausting. Going against someone’s expectations and saying ‘no’ can be emotionally taxing as well as time-consuming. It frequently takes longer to explain and justify and document why you aren’t doing something than it would to just do it. It typically sets up a confrontation that needs to be de-escalated before it begins.

‘Not doing things’ is also necessary, particularly when it might save time. My time is limited and the demands on it are—at least as far as I can tell—unlimited. Working out where my time is best spent is not easy. Saying ‘no’ to things that I’d usually enjoy is dispiriting, but often necessary.

More challenging still is when someone else decides that ‘something must be done’ and requests my participation—even when my judgement is that the better option is to ‘do nothing.’ Do I participate to try to limit the madness? Do I opt out and leave them to it, even if this might precipitate bigger risks down the line?

I still worry about how to do numerous things in a short period of time, but the anxiety of commission is far outweighed by the anxiety of omission these days.

The picture at the top of this post is an AI-generated image for the prompt ‘a world of clocks’ created by OpenAI’s DALL-E 2.

At this time of year, along with the majority of medics, my thoughts are turning a lot to the process of reflecting on clinical practice. This is something that I think most of us do most of the time, but written reflections form a mandatory part of continuing professional development for most medics. Many of us fail to keep on top of them, and end up with a glut to write towards the end of the financial year.

I’m also currently reading Haruki Murakami’s Novelist as a Vocation. I’ll tell you more about that when I’ve finished it, but I wanted to feature this passage (actually, two concatenated passages) where Murakami is giving advice to aspiring novelists on reflecting on their everyday experiences. It’s as good a description as I’ve read anywhere of the process of reflection, and so really resonated with me.

Make a habit of looking at things and events in more detail. Observe what is going on around you and the people you encounter as closely and as deeply as you can. Reflect on what you see. Remember, though, that to reflect is not to rush to determine the rights and wrongs or merits and demerits of what and whom you are observing. Try to consciously refrain from value judgements—conclusions can come later.

I strive to maintain as complete an image as possible of the scene I have observed, the person I have met, the experience I have undergone, regarding it as a singular ‘sample,’ a kind of test case, as it were. I can go back and look at it again later, when my feelings have settled down and there is less urgency, this time inspecting it from a variety of angles. Finally, if and when it seems called for, I can draw my own conclusions.

I really liked this description, but it was Murakami’s next paragraph that completely stopped me in my tracks:

Nevertheless, based on my own experience, I have found that the occasions when conclusions must be drawn are far less numerous than we tend to assume. Indeed, the times when judgements are truly necessary—whether in the short or the long run—are few and far between. That’s the way I feel, anyway. This means that when I read the paper or watch the news on TV, I have a hard time swallowing the reporters’ rush to give opinions on anything and everything. ‘Come on, guys,’ I feel like saying, ‘what’s the big hurry?’

When Wendy and I are watching the news on TV, we frequently comment “It’s not though, is it?’ in response to opinions given by reporters who get caught up in their story’s importance. It irritates us when reporters give commentaries that a moment’s thought would dismiss: ‘this is the most serious crime of the decade,’ ‘this is the biggest political crisis since the second world war,’ ‘this is a make-or-break moment for the political party,’ and that kind of thing.

I’d never before made the connection between thinking reflectively and avoiding a rush to judgement. Now that it has been pointed out, it’s obvious—but reading the above passage was a definite ‘aha’ moment for me, a moment that allowed to see a connection between disparate ideas for the first time.

The picture at the top of this post is an AI-generated image for the prompt ‘a photo of a doctor looking pensive in a mirror’ created by OpenAI’s DALL-E 2. The mirror is a pun on the word ‘reflection,’ just in case that’s not immediately obvious. There’s nothing funnier than a joke that has to be explained.

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.

I’m currently reading My Brilliant Friend, which is the first of Elena Ferrante’s Neapolitan novels. I’m not particularly enjoying it… but it does remind me of the lovely couple of weeks Wendy and I spent in Naples back in 2014. While Naples is not a universally loved tourist destination, Wendy and I had a wonderful time, and it ranks among our favourite holidays together.

There is frequent mention in My Brilliant Friend of Ischia, the distinctive volcanic island on the edge of the Bay of Naples, famous for its thermal spas. Wendy and I didn’t go there.

The source of the name ‘Ischia’ is much disputed. But seeing it written down so many times (and with so little distraction from meaningful plot) I started to wonder about two medical words which bear a striking resemblance: ischaemia, where a part of the body receives an inadequate blood supply, and ischium, which is part of the pelvic bone and the hip joint.

I didn’t imagine that either of these were connected to Ischia, which is just as well, as they are not. But I did think that there much surely be an etymological connection between ischaemia and ischium – but couldn’t for the life of me work out what might connect the two. I even asked Wendy, and she also couldn’t think of a plausible connection, and she’s far cleverer about this sort of thing than me.

Neither the Collins, Penguin nor the Oxford Compact dictionaries on my shelf offered any etymological notes, but nevertheless increased my sense of intrigue by listing no other words which start with an isch- prefix. So surely they must be related!

And so to the OED online – this confirms that both words are derived from Greek, and that the isch- prefix comes from the Greek ‘to hold’. In the case of ischaemia, to ‘hold blood’, and in the case of ischium, to ‘hold’ the hip.

The OED also lists a few other lovely medical isch- words that have long since fallen out of use: ischuria, for urinary retention, is my favourite of these. Health protection rarely calls for reference to urinary retention, but “I’m sure it’s ischuria” could become a favourite refrain should I ever return to hospital medicine!

Ten years ago today (eleven by the time this is published), I learned that I had passed my medical school finals and became a doctor. It doesn’t feel like it was a decade ago.

At work, I recently happened to have a meeting with someone I worked with as an F1 doctor but haven’t seen since. It felt like we worked together a month ago rather than a decade. I still occasionally say “hi” in the street to the porter who used to comment on my “Bird’s Custard” colour tie as an F1. And yes, somehow my F1 year was long enough ago that ties weren’t yet banned in hospitals.

I think the Simon of ten years ago would be amazed to find that I’m now working in public health. I didn’t enjoy the occasional public health bits at medical school, and I wasn’t even really aware that it was it’s own specialty until I came to pick a career path. Public health always struck me as worthy, dull, and far removed from anything that actually had any measurable impact on patients.

It was only after a serendipitous run of F1 hospital rotations that I started to see the point. My first job was in upper gastrointestinal surgery, a subspecialty involving seriously brutal surgical interventions to treat cancers with very poor prognoses. My second job was in stroke medicine. My third was in gastrointestinal medicine, a speciality in which a large proportion of the patients had end-stage liver disease as a result of alcoholism.

I think it’s impossible to go through that sequence and not feel slightly despairing: hospital medicine comes too late for most of these patients. Their lives very often cannot be pieced back together: as one particularly insensitive consultant used to regularly say, for those patients “the party’s over”.

The most effective treatment for these patients would be to rewind time and tackle their problems before they were ill. This initially pushed me towards General Practice, until I realised (late) that this was the point of Public Health. My realisation of this came so late that I didn’t really know what public health doctors did all day, but stuck in an application to the specialty anyway… as well as general practice.

After long essay-style application forms, written exams and half-day intensive interviews known as “selection centres”, it somehow came to pass that I was offered places on both the GP and public health training schemes. I had 48 hours to decide between a familiar career path and one which sounded fascinating but that I barely understood. In truth, I hedged: I went with public health because general practice always under-recruits, and I was pretty confident that a re-application to GP would be successful in 12 month’s time if public health turned out to be awful.

I was also put off by the obsession with portfolios in General Practice. My experience of clinical portfolios was that doctors were judged too much on their ability to write and present evidence rather than on their practice of medicine. I was, even if I say so myself, great at presenting portfolios of glowing assessments as a Foundation Doctor, but this felt a bit flat. It seemed to me that people in public health were known by results and reputation, and I liked that idea. I’m not so sure that was an accurate assessment of either speciality, but it certainly played a part in my decision-making at the time.

Leaping into public health felt brave at the time, even if it seems like hedging in retrospect: no end of people were telling me that I’d be “wasted” in public health and that my skills with patients meant that I’d be a fantastic GP. Some of this was subfusc whispers in my ear, some was formal written feedback, some was mildly paternalistic advice. Only a minority were enthusiastic. Luckily, once I set my mind on something, I’m pretty strong-willed.

Public health wasn’t awful. I mean, it had its moments: within weeks of me accepting a place, the coalition Government announced an intention to move public health outside of the NHS. This may have been the right decision, but it was terrifying for me as an NHS doctor to know that my NHS career path had been cut off just as it was beginning.

As I progressed through my training, I came to really enjoy health protection, the part of public health which deals with outbreaks and other biological, chemical and radiological threats to the population. I liked the combination of clinical-style short-term pressure, thoughtful balancing of risks, and the close association with clinical colleagues (and occasionally patients). I wrangled the system to spend almost half of my training in health protection placements, and since 2016 I’ve been a consultant in health protection. It is—by far—the most enjoyable and rewarding job I’ve ever done, in which I’m surrounded by a brilliant team who never give anything less than their best.

So, in career terms, I could not be further from where I thought I’d be ten years ago. But I also couldn’t be happier with the choices I’ve made. I don’t really know that there’s a lesson in that.

Someone once told me that the most important thing in career planning is to do what you enjoy and collect certificates along the way. Delayed gratification is rarely worth it in career terms: the gratification might never come. But its hard to ever regret doing something you enjoy, and collecting certificates provides tools to make a “leap” to something else when the first thing stops being fun.

I don’t know whether that’s good advice or not, but it roughly correlates with my experience over the last ten years. Let’s hope that I’m still enjoying things as much ten years hence – whatever I’m doing then!

The picture at the top is obviously my own. It was from my graduation which was, of course, a little later than the day I found out I’d passed.

In this morning’s Monocle Minute, there was a fascinating bit about a public health measure in Pakistan which had completely passed me by:

Pakistan’s Punjab province has taken an intriguing step to discourage its citizens from chugging too many cans, demanding that brands such as Red Bull and Monster remove the word “energy” from their packaging and replace it with “stimulant”. The move comes from the scientific advisory panel of the Punjab Food Authority (PFA), who ruled that the word was misleading. The PFA decided that the drinks do not provide people with nutritional energy per se, rather that the caffeine, taurine and guarana merely stimulate drinkers.

I think there is much to be done around the regulation of food packaging, as it often seems pretty misleading. But most of what I’d thought about previously was around claims about the “healthiness” of foods and claims about calorific content. In fact, I’ve had previous publications ranting about both the food industry and the public health response on the latter point, but don’t have any clear answers of my own to offer. I’d never really thought about the connotations of “energy” drinks as a name, so I think the story above is a really interesting development and I’ll be intrigued to see whether it spreads more widely.

Sometimes, even those of us in public health miss public health developments in our own country. I only recently because aware of the fact that liquid laundry detergent capsules are now packaged in opaque containers not because of changing consumer preferences but because of very sensible European legislation, designed to reduce their attractiveness to children.

That’s a public health legislative win by anyone’s yardstick… and while most had realised the packaging had changed, no-one in my office was even aware that the legislation existed. It’s amazing how much public health measures can pass by even those of us working in the field – we perhaps don’t do enough to celebrate public health achievements that aren’t badged like that.

A year or so ago, my friend James O’Malley wrote a great article revealing that Fuller’s pubs had gone sugar-free on soft drinks – years before the Soft Drink Levy came into force. This was a voluntary public health measure by a private business. Wouldn’t it have been great if, say, Public Health England or the Faculty of Public Health had seized on this as an example of responsible action and praised the chain – rather than simply ignoring it? Just a thought.

The photo at the top is a cropped version of this photo posted to Flickr by Mike Mozart. I’ve edited and re-used it above under its Creative Commons licence.

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.

A couple of news stories I’ve read lately have made me think about our approach to regulation of advertising.

First, there was this story by Travis M Andrews in The Washington Post about the portrayal of smoking in shows made for streaming services:

Among the vices often embraced by streaming services and avoided by broadcast television is tobacco in all in its forms … A study compared seven popular Netflix shows to seven popular broadcast shows. In this sample, it found Netflix’s shows featured characters smoking almost three times as often as those produced by broadcast networks like NBC, ABC and CBS.

Now, we could spend all day poking holes in this ‘study’, but the thought is still going to fester: it does seem like there might be more smoking in these shows than in those on broadcast TV.

Second, there was this BBC Trending story by Branwen Jeffreys and Edward Main about YouTube stars being paid to encourage kids to cheat on school assignments:

YouTube stars are being paid to sell academic cheating, a BBC investigation has found. The BBC Trending investigation uncovered more than 1,400 videos with a total of more than 700 million views containing EduBirdie adverts selling cheating to students and school pupils. In some of the videos YouTubers say if you cannot be bothered to do the work, EduBirdie has a “super smart nerd” who will do it for you.

This isn’t so obviously related to health but does highlight an issue with inappropriate advertising within online streams which are typically seen by children and young people.

Both of these stories made me reflect on the work that has gone into restricting advertising of harmful products such as cigarettes and energy dense foods, and how the fruit of that work might be lost if legislation doesn’t keep up with changing media consumption habits.

For example, there are no regulations around the portrayal of smokers on streaming shows, whereas broadcast shows must comply with Ofcom’s rules, including Rule 1.10:

Smoking must generally be avoided … unless there is editorial justification.

There seems to be non-stop debate in the media press about whether TV ads or online ads are more ‘impactful’, with the conclusion usually predictable according to who has funded or published the work. But it does seem increasingly clear that many people (including me) are now watching more streamed content than broadcast content, and that this is more common among younger people.

It’s hard not to worry that the slow pace of legislative change might cause us to unintentionally slide back to an era of lesser regulation of what is actually seen despite strong evidence of harm. We really mustn’t let that happen.

The photo at the top was posted on Unsplash by Tina Rataj-Berard and is used here under the Unsplash licence.