Spectator Health May 2015

JOH AN N HARI | SUZY LISH M A N | M A U RE E N LIP M A N | JU S TIN E HE X TA L L TH E OD ORE DALRYM PLE | ROG E R HE N D E RS O N | TO M CHIVE RS | E LLIE C A N N O N

9 MAY 2015

IS GARLIC MAGIC? Professor Edzard Ernst on the surprising benefits of his favourite food

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elcome to this, the fifth edition of Spectator Health. In this issue we have a powerful essay

by Johann Hari telling the story of how our drug laws fail addicts. As a doctor, I have worked for years with drug addicts and still feel torn about how effective criminalising drugs really is, but I can’t quite bring myself to advocate decriminalisation. Hari’s argument gave me a lot to think about and I hope it will do the same for you.

As the summer approaches, Dr Justine Hextall writes about how to protect the skin from sun damage, in particular from infrared rays, which seem to be as damaging as ultraviolet from sunlight. Laura Freeman questions dairy intolerance, while in our cover piece Edzard Ernst praises the health benefits of garlic. We also have Suzy Lishman, president of the Royal College of Pathologists, providing an expert’s guide to autopsies, and of course all our usual columnists, including Tom Chivers, Theodore Dalrymple, Christine Webber and David Delvin, Ian Marber and Maureen Lipman.

We will soon launch the health portal on the Spectator website, which as well as the content of Spectator Health magazine will include regular blogs and news updates.

We want this to become the go-to place for people to find information and sensible debate about health news and interesting advances in medicine. Do have a look: www.spectator.co.uk/health.

Max Pemberton Editor Max Pemberton Design and art direction Sasha Bunch Cover illustration Kyle T. Webster Advertising Sophie Longhurst Tel: 020 7961 0090 Email: slonghurst@pressholdings.com Supplied free with the 7 May 2015 e ­ dition of The Spectator www.spectator.co.uk/health The Spectator (1828) Ltd, 22 Old Queen Street, London SW1H 9HP, Tel: 020 7961 0200, Fax: 020 7961 0250

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No.05 2015

Contents Regulars

Features 24 - 26

27

6-7 Check up Health in the headlines

8-9 Garlic is good for you And vampires hate it Professor Edzard Ernst

27 Spa review Mandarin Oriental, Paris

10-12 Junk policy Criminalising drugs kills people Johann Hari

Opinion

13 Second opinion Theodore Dalrymple on meddling bureaucrats

21 Bad Medicine Tom Chivers on being told to drink too much water

29 What to eat Ian Marber on what ‘five a day’ means

38 - 40

28 Acne for adults More and more women get it Dr Ellie Cannon

30-32 Vision for the future An exciting new AMD treatment Sarah Rainey

14-16 That falling-down feeling How to regain your balance Julia Glass

34-35 Insight on autopsies What you need to know Dr Suzy Lishman

18-20 Our lung cancer shame Official policy is all over the place Dr Roger Henderson

36-37 Beating anxiety attacks Five ways that work Patrick Strudwick

38-40 Sunshine and wrinkles How to keep your skin young Dr Justine Hextall

22-23 Self-tracking fitness gadgets They’re getting smarter Victoria Lambert

41 Sex and relationships Christine Webber and Dr David Delvin on what makes women happy 24-26 Dairy scares The case for real milk Laura Freeman 42 Well worried Maureen Lipman on late-night trips to the loo

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Check up We take the pulse of the health stories hitting the headlines Diabetes, depression and dementia ● A surprise finding

published last month showed that people with type 2 diabetes who also had depression were significantly more likely to go on to develop Alzheimer’s disease and other types of dementia as they got older, compared with the general population.

The research was carried out by the University of Washington School of Medicine in Seattle, where doctors analysed data relating to almost 2.5 million patients. It’s not clear exactly why there is this link, although it is known that poor mental health can have knock-on effects on other aspects of people’s lives, such as sleep and nutrition, and this might account for the association. Regardless of the underlying mechanism, it does provide further reason for those with depression to seek treatment for their low mood. Of the study sample, 3.9 per cent (95,691) had type 2 diabetes as well as depression, with these individuals 117 per cent more likely to be diagnosed with some form of dementia by the end of the investigation.

The link was particularly strong for individuals younger than 65 years old.

For more on mental health, read Patrick Strudwick’s article on page 36.

Divorce could break your heart ● According to the Office

for National Statistics, nearly half of all marriages are now estimated to end in divorce.

Studies looking at the health implications of this shift in society have therefore become increasingly important.

A large-scale study just published has further added to the medical literature suggesting that being married is good for people, but getting divorced is associated with poorer health outcomes. The study published in the journal Circulation showed that divorce had a marked impact on heart health. They analysed 15,827 adults aged 45 to 65 between 1992 and 2010, during which one in three divorced at least once. It was found that women were worst affected, with 24 per cent of those who divorced once more likely to have had a heart attack during the study than women who remained married. This figure rose to 77 per cent for women who had multiple divorces.

Men with at least two divorces had a 30 per cent risk of having a heart attack.

Eat organic fruit and sow your seeds ● Organic produce has, for

many years, been championed as healthier than non-organic.

Get your (organic) oats

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Evidence supporting this, though, has been sorely lacking. However, new research has shown that men who consume fruit and vegetables that are high in pesticide residues are more likely to have lower sperm quality than those who eat fruit and vegetables with low pesticide residues. It was found that the participants who consumed more than 1.5 servings of the foods considered to be high in pesticide residue daily had a 49 per cent lower sperm count and 32 per cent fewer normal sperm than those who ate less than 0.5 servings of these fruits and vegetables each day. In addition, men who ate more low to moderate pesticide residue fruits and vegetables had a higher percentage of normal sperm than those who consumed less. As many of the pesticides are absorbed into the fruit or vegetables, simply washing the food doesn’t do

much good, meaning that the best option is to buy organic.

For more on what to eat, read Ian Marber on page 29.

Paracetamol may add to liver risks ● Paracetamol has long been

the GP’s go-to medication for aches and pains, including back pain and joint pain from osteoarthritis, but new research out last month has cast doubt on how effective paracetamol really is in relieving this pain.

Around 26 million people are affected by back pain every year, making it the leading cause of disability in the UK. The report was undertaken by researchers from the University of Sydney and published in the British Medical Journal. The team reviewed 13 clinical trials and discovered that the drug does not improve quality of 9 MAY 2015 | SPECTATOR HEALTH

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GETTY IMAGES

The hidden perils of dining out ● For many,

eating out is associated with a treat. According to a new study, however, meals out are more likely to lead to health problems such as high blood pressure.

According to the NHS, around 30 per cent of people in England have high blood pressure, but many don’t know it. High blood pressure

life or reduce disability. In fact, the group of Australian scientists warned that use of paracetamol increased a person’s risk of encountering liver problems. The National Institute for Health and Care Excellence (Nice), which establishes best NHS practice, currently recommends paracetamol for lower back pain and for osteoarthritis.

While experts recommend that patients consult their doctor before making any changes to their medicine regime, the NHS will now review its guidelines for this drug.

though, some satisfaction for those who are tired of biting their lip when confronted with spoilt brats. According to research conducted by Ohio State University in Columbus and the University of Amsterdam in the Netherlands and published last month, parents who overvalue their children are contributing towards the likelihood of them being narcissistic in later life.

It was found that children of parents who described them in the surveys as ‘more special than other children’

Spoilt brats are bad for society ● One of the scourges of

modern life is having to endure other people’s badly behaved children. Gone are the days when children were seen but not heard. At last,

Don’t call me a narcissist!

performed higher on tests of narcissism at follow-up. One of the researchers from the study explained: ‘People with high self-esteem think they’re as good as others, whereas narcissists think they’re better than others. Children believe it when their parents tell them that they are more special than others. That may not be good for them or for society.’

Take cat naps, it’s important ● At last, there is evidence

that people who take cat naps are not lazy but actually looking after their health. It is known that a lack of sleep can lead to reduced productivity levels, and studies have shown that people who don’t get enough sleep have a higher risk of developing health conditions such as obesity, depression, diabetes and high blood pressure. This prompted researchers to look into the relationship between taking

taste appealing compared to when people prepare the meals themselves.

People are also more likely to drink alcohol and eat pudding when eating out. All of these things are known to increase the risk of health problems and it is thought that when combined on a regular basis, they have a marked impact on health outcomes.

short naps and hormone levels.

The study showed that levels of norepinephrine, a hormone known to raise the body’s heart rate, blood pressure and blood sugar, more than doubled in subjects who had not slept properly the previous night. This was in contrast to subjects who had taken two 30-minute naps during the day after a night of poor sleep. In these subjects, there was no rise in norepinephrine levels.

This suggests that taking even a short nap during the day can counteract the negative health impact of a poor night. This is important for those who work night shifts as well as those who have difficulties sleeping.

A healthy option 7

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increases the risk of heart attacks and strokes. The study found an association between eating out and higher calorific intake compared to those who ate at home. They also tended to eat more fats and salt. It’s thought that restaurants and cafés are more likely to add fat or salt to their meals to make them

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A cure for what ails you?

Were the ancients right about garlic as a great healer? Professor Edzard Ernst investigates I’d better declare a conflict of interest straight away: I am rather taken by anything to do with garlic, have researched it for more than 30 years, and am particularly fond of it when it is served with spaghetti as aglio e olio. This article, however, is almost entirely focused on its medicinal usage.

The history of medicinal garlic is almost as long as that of medicine itself. Hippocrates, Galen, Pliny the Elder, and Dioscorides all mention garlic for therapeutic or prophylactic reasons. More recently, researchers have identified the plant’s pharmacologically active components and have studied their biological actions in some detail.

The most important of these components is alliin, which is quickly transformed into allicin when garlic is crushed or chopped. Like most of the other components (and there are many) allicin contains sulphur, which explains garlic’s famously pungent smell — and indeed that of people who eat a lot of the stuff.

The list of diseases that were once believed to be curable by garlic now seems remarkably diverse. Even so, garlic’s active compounds have a wide range of actions that are of interest to modern medicine

— from its antimicrobial properties to its effects on the cardiovascular system and on cell proliferation and division. As a result, research has concentrated mainly on three areas: 1. Garlic’s alleged effects against the common cold.

2. Its benefits for the cardiovascular system.

3. Its potential to reduce the cancer risk.

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COMMON COLD One study claims that garlic cuts the chances of a cold by half

1. COMMON COLD

Garlic supplements are frequently recommended for colds. The evidence, however, is flimsy. The only rigorous study suggested that regular garlic supplementation for 12 weeks does indeed reduce the chances of getting a cold by about half. But it also showed that, once you’re suffering from a cold, garlic supplements don’t shorten it. Nor is one trial usually enough to base therapeutic decisions on. So if you ask me, garlic supplements might reduce the risk of colds, but I’d want more evidence before being convinced.

2. CARDIOVASCULAR DISEASE

Garlic’s cardiovascular effects have been much better studied.

Numerous test-tube and

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animal experiments, as well as clinical and epidemiological investigations, have been published. Their findings are complex and by no means free of contradictions. My reading of this sizeable chunk of evidence is that regular garlic consumption or supplementation has multiple potentially positive effects. Each of them on its own is fairly small and seemingly insignificant; but their totality might well have

important consequences on cardiovascular health.

• Garlic has been shown to normalise elevated blood lipids.

• Some studies suggest garlic lowers high blood pressure.

• Other studies have demonstrated that garlic inhibits blood clotting and promotes the dissolution of clots that do form.

• Garlic might keep our arteries flexible in old age.

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GASTRIC CANCER Research suggests that regular garlic intake ‘significantly reduces’ the risk of intestinal cancers

3. CANCER

SIDE EFFECTS

Dozens of epidemiological studies have compared large populations of people who regularly consume considerable amounts of garlic with those who do not. The results have been somewhat contradictory, but it seems that garlic consumption does lower the risk of certain cancers, particularly those of the intestinal tract, e.g. gastric and colorectal cancers.

Sadly, epidemiological investigations are rarely conclusive about the value of a therapy, and large long-term clinical trials would be needed to be sure. To date, only four such studies have become available — and again their findings aren’t uniform. Nonetheless, the biggest study by far has suggested that regular garlic intake does significantly reduce the risk of gastric cancer.

The notion that everything natural must be entirely safe is as popular as it is misleading.

Most herbal remedies can cause side effects, and garlic is no exception.

No matter whether one consumes garlic as food or as a supplement dosed correctly for medicinal purposes, garlic will produce a smell that emanates not just from the mouth but also from the skin. Garlic fans might well put up with it, but it’s advisable to make sure your partner and close friends love garlic too; if not, you might find life a lonely experience.

Some of the more serious adverse effects of regular garlic intake include nausea, diarrhoea, vomiting, allergic reactions and anaemia — which can occur in predisposed people, particularly those on high doses. Moreover, garlic can interact with a range of prescribed drugs such as anticoagulants — it would be prudent to inform your doctor before you embark on a selfprescribed garlic regimen.

DOSAGE

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HEART ATTACKS Garlic reduces blood pressure and normalises blood lipids

synthetic drugs developed for specific purposes often have much stronger effects — statins, for instance, lower blood cholesterol levels more dramatically than garlic. Yet all of garlic’s effects working together do have the potential

to impact on our health. To be certain, we’d need very large, long-term studies — which so far don’t exist. They’d be prohibitively expensive and so might never be initiated.

My conclusions must therefore remain tentative.

Multiple effects have been described with garlic’s potential to lessen the risk of heart attacks, strokes and other cardiovascular diseases. But whether this is truly the case is still an open question.

AND FINALLY…

No discussion of garlic would be complete without mentioning its unbelievable power to protect us from blood-sucking vampires. I can confidently vouch for its effectiveness in this particular application: I have never seen or heard of anyone falling victim to a vampire while wearing a wreath of garlic around their neck.

Professor Edzard Ernst is emeritus professor of complementary medicine at Peninsula medical school, University of Exeter.

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Even those of us who like garlic have to admit that there’s a limit as to how much of it one can enjoy. About 4g of fresh garlic a day would be enough for achieving the pharmacological effects described above, but that might be a tall order for regular consumption.

People who don’t want to stomach such heroic amounts of the real thing might prefer to buy a garlic supplement — not that this would avoid the body odour, but it is easier to swallow. My advice is to purchase a highquality supplement that’s standardised to about 1.3% alliin content, and to take 300mg three times a day.

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Long-term effects of heroin

BRAIN

CIRCULATORY

HEART

RESPIRATORY

LIVER

• Addiction • Tolerance • Dependence

• Collapsed veins • Bacterial infections

• Infection of heart lining valves

• Pneumonia • Breathing illnesses

• Decreased function • Hepatitus A, B or C • Liver & kidney disease

Junk policy It’s the illegality of heroin which leads to the deaths among users, says Johann Hari

I

n 1982 a doctor called John Marks walked into a grey little GP surgery in the Wirral, in the drizzly north of England where they used to build ships but now they built nothing. It was his first day as a psychiatrist there, and he was about to discover that this surgery was doing something he regarded as mad. It was handing out heroin to addicts — free, on the NHS. Dr Marks was a big, bearded Welshman from the valleys, and his real interest was the mystery of schizophrenia and what causes it. But because he was the new boy, he was given a chore. His colleagues said to him, ‘You can have all the addicts, John — all the alcoholics and drug addicts.’

He was about to stumble across one of the last remaining loopholes in the global war on drugs. A century ago, in 1914, the United States banned heroin and cocaine, and it then gradually used its diplomatic might to impose this ban across the world. Doctors tried to resist here in Britain and across the world, because they believed that if addicts were forced to buy contaminated drugs from armed criminal gangs, their health would only get worse. Doctors wanted to prescribe drugs to chronic addicts.

This resistance only succeeded in one country — Britain. This little window of legal drug use continued quietly for decades.

So Dr Marks watched as, every Thursday, a slew of addicts came into the clinic and received their heroin prescriptions. They were, he recalls, ‘maybe a few dozen lads, the occasional girl, who came and got their tot of junk…

Railwaymen, bargemen, all walks of life really.’ He told them to stop using, and they argued back, telling him they needed it. ‘I found this a bit of a headache,’ he says, ‘and I had bigger fish to fry.’ He decided to shut the programme down.

But as he prepared to do this, there was a directive from Margaret Thatcher’s government.

Every part of Britain had to show it had an anti-drugs strategy, it said, and conduct a cost-benefit analysis to show what worked. So Marks commissioned the academic Dr Russell Newcombe to look into it. He assumed Newcombe would come back and say these patients were like heroin addicts everywhere, at least in the cliché — unemployed and unemployable, criminal, with high levels of HIV and a high death rate.

Except the research found something very different.

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Illustration by David Humphries

Newcombe found that none of the addicts had the HIV virus, even though Liverpool was a port city where you would expect it to be rife. Indeed, none of them had the usual problems found among addicts: overdoses, abscesses, disease. They mostly had regular jobs and led normal lives.

After receiving this report, Marks looked again at his patients.

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Short-term effects of heroin

BRAIN

MOUTH

SKIN

RESPIRATORY

• Euphoria • Alternately alert and drowsy state

• Inflammation of the gums • Dryness

• Warm flushing • Supression of pain

• Slowed breathing

Sydney was ‘an old Liverpool docker, happily married, lovely couple of kids’, Marks recalls.

‘He’d been chugging along on his heroin for a couple of decades.’

He seemed to be having a decent, healthy life. So, in fact, now Marks thought of it, did all the people prescribed heroin in his clinic.

He asked himself: but how could this be? Doesn’t heroin

inherently damage the body?

Doesn’t it naturally cause abscesses, diseases and death?

He discovered that all doctors agree that medically pure heroin, injected using clean needles, does not produce these problems. That’s why when people are routinely given heroin in hospitals — to treat the pain of a hip operation, for example — none of these

• Weakness • Muscle and bone pain (withdrawl)

problems occur. But under drug prohibition, the criminals who control our drug trade cut their drugs with whatever similarlooking powders they can find, so they can sell the heroin in more batches and make more cash. Allan Parry, who worked for the local health authority, saw that patients who didn’t have prescriptions were injecting smack with ‘brick dust in it, coffee, crushed bleach crystals, anything’.

He explained to journalists at the time: ‘Now you inject cement into your veins, and you don’t have to be a medical expert to work out that’s going to cause harm.’

Dr Marks could see the difference between the street addicts stumbling into the clinic for help for the first time, and the patients who had been on legal prescriptions for a while. The street addicts would often stagger in with abscesses that looked like hardboiled eggs rotting under their skin, and with open wounds on their hands and legs that looked, as Parry told me, ‘like a pizza of infection. It’s mushy, and the cheese you get on it is pus. And it just gets bigger and bigger.’

The addicts on prescriptions, by contrast, looked like the nurses or receptionists or Dr Marks himself.

As a group, you couldn’t tell.

Faced with this evidence, Marks was beginning to believe that many ‘of the harms of drugs are to do with the laws around them, not the drugs themselves’. In the clinic, as Russell Newcombe tells me, they started to call the infections and abscesses and amputations ‘drug war wounds’. So Dr Marks

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You inject cement into your veins, and that’s going to cause harm

MUSCULAR

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continued from page 11

began to wonder: if prescription is so effective, why don’t we do it more? He expanded his heroin prescription programme from a dozen people to more than 400.

The first people to notice an effect were the local police.

Inspector Michael Lofts studied 142 heroin and cocaine addicts in the area, and he found there was a 93 per cent drop in theft and burglary. ‘You could see them transform in front of your own eyes,’ Lofts told a newspaper, amazed. ‘They came in in outrageous condition, stealing daily to pay for illegal drugs; and became, most of them, very amiable, reasonable law-abiding people.’ He said elsewhere: ‘Since the clinics opened, the street heroin dealer has slowly but surely abandoned the streets of Warrington and Widnes.’

One day a young mother called Julia Scott came into Dr Marks’s surgery and explained she had been working as a prostitute to support her habit. He wrote her a prescription, and she stopped sex work that day.

And something nobody predicted took place. The number of heroin addicts in the area actually fell. Research published

by Dr Marks in the Proceedings of the Royal College of Physicians of Edinburgh compared Widnes, which had a heroin clinic, to the very similar Liverpool borough of Bootle, which didn’t — and found Widnes had 12 times fewer addicts.

But why would prescribing heroin to addicts mean that fewer people became addicts?

Dr Russell Newcombe, working out of John Marks’s clinic, told me what he believes is the explanation. Imagine you are a street heroin addict. You have to raise a large sum of money every day for your habit: £100 a day for heroin at that time in the Wirral.

How are you going to get it? You can rob. You can prostitute. But there is another way, and it’s a lot less unpleasant. You can buy your drugs, take what you need, and then cut the rest with talcum powder and sell it on to other

Heroes and heroin: famous users

COCO CHANEL

BILLIE HOLIDAY

MILES DAVIS

ERIC CLAPTON

JANIS JOPLIN

KEITH RICHARDS

ROBERT DOWNEY JR

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PHILIP SEYMOUR HOFFMAN

people. But to do that, you need to persuade somebody else to take the drugs too. You need to become a salesman, promoting the experience.

So heroin under prohibition becomes, in effect, a pyramidselling scheme. ‘Insurance companies would love to have salesmen like drug addicts’ — i.e. with that level of motivation — Dr Marks explains. Prescription kills the scheme. You don’t have to sell smack to get smack.

When Dr Marks’s experiment began to attract tabloid attention — and bring diplomatic pressure from the US government — the British government panicked and shut it down. The results came quickly. In all the time Dr Marks was prescribing, from 1982 to 1995, he never had a drug-related death among his patients. After the closure, of the 450 patients Marks prescribed to, 20 were dead within six months, and 41 were dead within two years. More lost limbs and caught potentially lethal diseases. Both Sydney, the Liverpool docker, and Julia, the young mother who had given up prostitution, died.

Dr Marks found he was blacklisted within his own country.

He ended up literally at the other side of the earth, in Gisborne, the farthest corner of New Zealand, the place from which he told me his side of the story by telephone.

One day, the Royal Astronomical Society asked him to play Galileo at an open day, and he had to playact being burnt at the stake. When I expressed frustration at his fate, he said to me, ‘Whatever gave you the idea folk in authority operate according to reason? Your trouble is you’re being rational.’

Today, Britain has more than 250,000 people using illegal opiates — and Dr Marks’s experiment, in the drizzle and hope of the Wirral, has been written out of history.

This is an extract from Chasing the Scream: The First and Last Days of the War on Drugs, Bloomsbury, £18.99. The full references and sources for everything in this article can be found in the book’s endnotes.

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Second opinion

The bureaucrats’ boom

‘Professionalising’ public-service management is effectively a means of legalising corruption, says Theodore Dalrymple

I

once had a medical secretary who, aged 65, was about to retire. She had been a secretary for about 45 years and was extremely competent. She knew how to spell and punctuate and never reduced my letters to gibberish; she was also well-read.

And she was very good with the patients.

Three weeks before she retired, she received the order from her ‘manager’ (she hadn’t needed one for more than nine-tenths of her career) that she attend a course on how to answer the telephone.

She pointed out that she was about to retire, but the manager could, or would, not see the absurdity of the idea, let alone how wounding and insulting it was to a woman who was, in her way, quite distinguished.

Of course I understood what was going on. The hospital had contracted a ‘consultant’, almost certainly personally known to a member of the bureaucracy, and possibly a former employee of a nearby hospital, to teach ‘telephone skills’. It needed as many staff to attend the course as possible to justify the expense.

That was a good few years ago, but it was a herald of things to come. It was a fine example of the professionalisation of management in the public service — in effect the legalisation of corruption — that was one of Mrs Thatcher’s great legacies, and of which Mr Blair, wittingly or not, took political advantage. The road was open to the creation of public-service millionaires and the diminishment of the distinction between the public and private sector, so that the two are now almost impossible to disentangle.

Any reader of Henry Marsh’s book Do No Harm will realise that my anecdote is not merely anecdotal: an anecdote that can be repeated in a thousand instances, by a thousand people in a thousand different circumstances, ceases to mean nothing but

itself. Rather, it reveals something essential about the world in which we live.

Henry Marsh is a neurosurgeon, and no one who reads his book would doubt that he is a man of the highest calibre, standing and probity. Yet he was obliged — obliged — to attend a course on empathy and communication given by a man who had risen from the ranks of the hospital kitchens to lecture senior neurosurgeons, among others, on how to speak to their patients. (I am all for rising through the ranks, but not where opportunities are systematically created for the economic benefit of ambitious mediocrities.) Mere brilliance is no defence against the highly

Mrs Thatcher opened the road to public-service motivated idiocy of bureaucrats posing as shopkeepers.

The absurdity to which Henry Marsh was humiliatingly subjected (and humiliation is an essential part of its purpose, for humiliation leads to docility) is the apotheosis, and not the deformation, of professional management in the public service. It arises from a crude and onedimensional theory of human motivation — in this case that the motivation of a manager in the public service can beneficially be made the same as that of one in a private business. (Even in large privately owned businesses, as James Burnham pointed out as long ago as 1941, the interests of the managers have long since ceased to be identical to those of shareholders, a fact of which Mrs Thatcher appeared to be oblivious, and which helped to bring about the banking crisis. She was predictably no match for the dimmest

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manager of Boghampton Social Services, once that manager was freed from the straitjacket of a salary structure and could pretend to be a businessman or woman, complete with strategic — never tactical — planning and business models, the development of which necessitated teambuilding weekends in country hotels and away days in pleasing locations.)

Before management became fully professionalised, managers in the public service — and while there is a public service there will have to be managers of it — were often inefficient and sometimes incompetent. But at least they had no vested interest, as they do now, in inefficiency and incompetence, in the insolubility of all problems and in the creation of new ones. They might not always have been the sharpest scalpel in the operating theatre, but generally they were well-intentioned, and had few reasons to be otherwise.

The solution is clear. So long as we have a public service — and I leave aside the contentious question of how far health care and other services should be publicly or privately funded — what we need is amateur, not professional, management.

The highest echelons of any public institution must be composed of volunteers.

At most they should be rewarded by the refund of their bus fares to and from meetings, and perhaps a CBE or two; under no circumstances should they be rewarded financially. Furthermore, the professionals under their direction should live in fear of them, for example of dismissal in the event of incompetence. No more away days, no more team-building, no more strategic planning, no more business models. Let bureaucrats be bureaucrats — in proper circumstances, a perfectly honourable if not high calling — not ersatz businessmen.

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Get your balance back That falling-down feeling is scary. But help is available. Seek advice, says Julia Glass

I

don’t remember with any clarity the first time I fell, just a sudden awareness that rather than being perpendicular to the floor, I was lying on it.

How strange, I thought to myself.

I picked myself up and dusted myself off, prodding joints as I did to see if anything was broken. It all appeared to be in order and nothing hurt. I put it down to it being early morning and the fact I was probably still half asleep.

The second time it happened I realised something wasn’t right and although I was keen to brush it off as a coincidence, by the third time I began to worry.

Eventually I was referred to a neurologist, who dutifully did a scan, which showed I’d had very small strokes. I’d been lucky and they had affected parts of the brain that I could do without, although I noticed that my balance was not always good. The neurologist explained that this was probably down to a combination of damage to the parts of my brain involved in fine motor control as well as a bit of a knock to my confidence from the previous falls, which had left me questioning how steady on my feet I was. There was no doubt that balance — something I’d entirely taken for granted my entire life — suddenly seemed

remarkably precious. It felt as though, at the age of 68, I had been catapulted back to the vertical uncertainty of a toddler.

And then, in a cruel twist of fate, I developed labyrinthitis. This is an infection of the inner ear which affects the delicate organs involved in balance. It was very unpredictable.

My ability to balance seemed now to be, well, hanging in the balance. One minute the room would be upright and static, the next, without warning, it seemed to swirl and spin, just like I’d stepped on a merry-go-round.

This did soon pass, but by then, my confidence had taken a real knock. A cataract meant that I started using a stick temporarily and, once the cataract was operated on, I found I didn’t want to give up the stick. I found myself walking more tentatively.

All this was compounded by arthritis in the knee. Apparently this is common; people with poor balance often have multiple minor problems which on their own do not cause much impairment but which, when combined, mean that the complex set of information required to maintain balance doesn’t always get processed in the right way.

I soon learnt that the balancing process was far more complicated

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Suddenly the room seemed to swirl and spin

than I had appreciated. The inner ear comprises bony chambers known as the labyrinth. This is divided into three parts. The first, the cochlea, is involved in hearing. It’s the other two that contain the organs of balance.

These are known as the vestibular apparatus.

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The first of these concerns itself with the position of the head. It contains two fluid-filled sacs called the utricle and the saccule. Within these sacs are sensory hairs known as maculae.

When the head is tilted, gravity causes the hairs to move and this creates electrical impulses which

travel via the vestibular nerve to the brain.

The second is concerned with the rotation of the head. It is made up of three fluid-filled loops that sit at right angles to each other, known as the semicircular canals. They are also lined with tiny hairs. When the head moves,

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Heads up: even among older people the brain can form new pathways

the fluid in the canals also moves, and this is detected by the tiny hairs which also send electrical impulses to the brain. Here all this information is processed and the impulses from the different hairs in different planes allow the brain to work out the exact position of the head in space.

In addition to the vestibular apparatus, the brain assessed balance by obtaining information from other body parts such as your eyes and specialised nerve sensors known as proprioreceptors which detect how much tension your muscles are under. With such a complicated system relying on so many sources of input, it’s easy to see how things can be disrupted.

So, what to do? I did aquaaerobics at a local sports centre and found that this helped.

Overall, though, I was pessimistic.

However, my neurologist explained that, even at my quite advanced age, the brain can change. This ‘plasticity’ means that the brain, even if damaged, can form new pathways. This gave me a sense of hope that I’d not experienced for some time. He suggested I start practising how to balance, relearning to stand and walk. He seemed to think that if I could feel more confident on my feet, then this would help my balance.

Physiotherapy has been shown to help in people with poor balance, but it’s very limited on the NHS. As I was not acutely unwell, there was nothing available for me. I would only qualify for input if I had a fall and damaged a joint. It seemed counterintuitive — surely prevention was better and, in the long term, cheaper for the NHS? The real breakthrough came when I heard about a new programme to improve people’s balance and mobility at Clinique La Prairie, a private medical clinic in Switzerland. It’s located about an hour’s drive from Geneva, next to a lake and with the Alps in the near distance. I had been once before to recover from an illness, and had been bowled over by the

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facility. The clinic was founded in the 1930s and its guests have included Winston Churchill and Marlene Dietrich. I was interested in their programme called ‘Better Mobility’. This programme is a six-night, full-board package that offers intensive medical, physio and fitness input. In one week, they promised me, they’d improve my balance.

An evaluation with a rheumatologist and physiotherapist at the beginning and end of the programme means they are able to see what the problems are and tailor the package accordingly, and also show you how you’ve improved and areas that still need work.

My initial tests provided stark evidence for what I had suspected all along — my balance and mobility were severely impaired.

Stability tests which detected small movements in my muscles and thus how stable I was when standing or walking showed that, to my horror, I was barely able to stand upright — my muscles were having to work overtime continually to correct my balance.

While I hadn’t even been aware of the tiny adjustments I was having to make to keep myself upright, it went some way to explaining why I felt so much more confident with a stick and why I struggled to recover my balance from even the smallest trip. When I closed my eyes, the readings showed that things were even worse, and I wondered how I’d ever managed with my cataracts.

Over the next few days I was put through my paces, undergoing rigorous testing and exercise regimes to strengthen my muscles and help me gain confidence.

A timetable was devised, based upon my own specific needs. Each day I went to the impressive gym and was guided by my own fitness trainer, who was firm and gave me challenging tasks, but was infinitely patient and encouraging, never giving me an easy time, but also pushing me to achieve more than I would have deemed possible. I received physiotherapy

Spa partner: Clinique La Prairie in Switzerland is a nice place to find your feet

from Malcolm each morning, which again required maximum effort from me, but I was never uncomfortable, just aware of the benefits. This is not for the fainthearted. It’s hard work. But I live on my own and before coming my poor mobility had meant I had lost the motivation to go out sometimes, and I didn’t want to return to that.

The approach is holistic, so food requirements and any dietary restrictions are also fully considered and advice is given.

The day was rounded off with a massage — again it was specific to my requirements. The medical assessment had revealed that I have a sluggish lymphatic system, so I had a lymphatic drainage massage. By the end of the week,

Organs of balance Semicircular canals

Vestibular apparatus

Cochlea

Ultricle Saccule

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my ankles had emerged! My legs felt lighter and more comfortable.

Then I had the final medical examination with both the physiotherapist and the doctor.

Every joint had improved in terms of how much I could turn it. I was delighted to touch my toes, and my neck had become positively owl-like.

My knee, often stiff following my operation, showed a vast improvement and I appeared to have grown two centimetres.

In fact I had simply improved my posture so that at last I was standing correctly, instead of slouching. The graphs showed the improvement I had made, and when I looked at them and realised how much I had progressed in such a short space of time I could not believe it.

The staff were so pleased, and nothing can describe how jubilant I felt. To feel so good, and to have achieved this while breathing the pure mountain air in glorious surroundings and with smiling people at every turn. Wonderful!

More than anything, though, it showed me that the brain is an amazing organ and that along with the body, even in older age, it can still change and adapt. To remind me of this, every morning I touch my toes, just because I now can.

For more information on the Better Mobility programme visit www.laprairie.ch or telephone +41 21 989 34 07 or email reservation@laprairie.ch 9 MAY 2015 | SPECTATOR HEALTH

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ADVERT - Otex_04-May-2015_Spectator Supplements 210x260 17

30/04/2015 11:41

Our lung cancer shame

Official policy on this deadly disease looks illogical, inconsistent and subject to political whim, says Dr Roger Henderson

G

eneral elections come and go — and pub bores bray about it not mattering who you vote for because the government still gets in — but illness does not have a calendar, and in general practitioners’ offices medicine rolls on regardless. Giving bad news to patients can sometimes be rather like waiting for a bus: you don’t see any serious cases for a while and then three come along at once.

I’ve been feeling a bit like that this week, having had to give the worst kind of news to several patients including two cases of lung cancer — the most common form of cancer in the UK and one that kills about 40,000 people in the UK every year, killing more men than bowel and prostate cancer combined. It remains the most common cause of death from cancer in both men and women, although it affects slightly more men than women.

Somewhat depressingly, only

Typical symptoms of lung cancer • A chronic cough • Breathlessness • Weight loss • Excessive fatigue • Persistent pain in or discomfort in the chest • Coughing up blood – one of the most characteristic symptoms of all

some 6 per cent of patients with lung cancer can expect to be alive five years after diagnosis. The reasons for this grim statistic are varied but key ones include late presentation at diagnosis, social deprivation, a lack of advocacy and research, old-fashioned

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cancer stigma and variable access to staff, diagnostics and treatment.

As most people are aware, smoking remains the primary cause of lung cancer, and although non-smokers can get lung cancer, the risk is about ten times greater for smokers and 9 MAY 2015 | SPECTATOR HEALTH

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GETTY IMAGES

this increases with the number of cigarettes smoked. Smoking more than 20 cigarettes a day increases the risk of developing lung cancer by some 30 to 40 times compared with non-smokers although the risk of lung cancer in an ex-smoker falls to the same level

as a non-smoker about 15 years after stopping.

Unfortunately, a great many of the cases of lung cancer I see present too late for curative treatment and in more than half of them the disease has already spread to other parts of the body

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Are your tests up to date?

New techniques such as endobronchial ultrasound are twice as readily available in France

at the time of diagnosis. Early diagnosis is more difficult than you may think because many of the common symptoms of lung cancer (see box, p18) are similar to conditions such as chronic bronchitis and emphysema. The first investigation I always use is a chest X-ray — but if a lung tumour is present, it needs to be at least a centimetre in diameter to be detectable.

By the time a tumour has reached this size, the original cell which became cancerous has divided (or doubled) 36 times.

As death usually results after 40 such cell divisions, it can be seen that lung cancer is a disease that is usually detected late in its natural course. Simple blood tests are also carried out and there is usually a bronchoscopy — a direct inspection of the inside of the lungs with a thin fibre-optic instrument. Depending on where the cancer is, a sample of the tumour may be obtained and a sample of spit will be examined for cancer cells. If the cancer has spread, then a CT scan can provide more information about how severe this is.

Only one in five patients are suitable for surgery — another grim statistic — and many cases are therefore treated with chemotherapy, given either by an oncologist or by a physician in chest diseases with special experience in chemotherapy.

Chemotherapy is effective in that it both prolongs and improves the quality of survival in many lung cancer patients but it is a powerful treatment and so has side effects, particularly

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Lung cancer stats

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nausea, vomiting and hair loss.

Radiotherapy (X-ray treatment) can also be used in certain lung tumours, either with localised cancers that are inoperable, or for relieving symptoms such as blood in the sputum and severe bone pain.

So far, so depressing, and politicians of all hues queue up to promise various panaceas.

However, this is where the harsh realpolitik of the NHS begins to show its face and it all starts with clever science in a laboratory.

Scientists have found that lung cancer cells have molecules on their surface that can in turn stimulate more cancer growth.

This is similar to the situation we have in breast cancer, and just as with that type of tumour, drugs have now been developed to block these lung cancer receptors and so limit its growth and spread.

This depends on knowing the genetic profile of the tumour from a biopsy — an unpleasant experience for the patient but one which has now been made easier and simpler by a new technique called endobronchial ultrasound.

Here, a special probe takes tissue samples from the lungs.

This is employed in around 100 specialist units in Britain but regional variations exist and not all patients have easy access to this test, or any access at all. Indeed, physicians have no standardised pathway: the three main challenges to conducting tests locally are reported as no biopsy samples being available, no clear testing pathway, and a lack of funding for ordering tests.

In plain language, the NHS has no infrastructure in place to enable the cost-effective and quick processing of these samples.

It is shameful that rates of such molecular tests for lung cancers are less than one third in the UK.

43,500

9 in 10

Around 43,500 people were diagnosed with lung cancer in the UK in 2011

Almost 9 in 10 lung cancer cases occur in people aged 60 and over.

4 to 10

48%

For every four to ten cases in women there are around 12 in men

Since the late 1970s incidence rates in men have decreased by 48%

86%

9 in 10

Smoking is linked to an estimated 86% of lung cancer cases in the UK.

Almost 9 in 10 lung cancer cases occur in people aged 60 and over.

7th

410,000

Six countries in Europe have a higher incidence rate among women than

In Europe, over 400,000 cases of lung cancer were diagnosed in 2012

1.83m

5%

Worldwide, 1.83 million new cases of lung cancer were diagnosed in 2012

Overall, 5% of people diagnosed with lung cancer survive the disease

89%

9%

An estimated 89% of lung cancers in the UK are linked to lifestyle factors

Insufficient fruit and veg intake is linked to 9% of lung cancer cases in the UK

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In France, over two thirds of all lung cancer tumours are tested in this way.

If a biopsy is obtained, the sample can then be subjected to molecular diagnostic testing in order to match the tumour to a specific drug — known as ‘personalised medicine’ treatment. Such drugs are available that are both innovative and effective, and if I had lung cancer, I would be standing outside the Houses of Parliament demanding my right to them with my last breath. Ultimately we come down to the two things that any argument involving the NHS is always about — money and joined-up thinking.

In 2010 the government started a Cancer Drugs Fund, ostensibly to give people access to cancer medications that had not yet been approved by the National Institute for Health and Care Excellence (Nice). At ground level for my patients this has always seemed like smoke and mirrors and so it should have come as no surprise when last autumn it was announced that up to half the cancer drugs it was making available were being removed from the list because they were viewed as too expensive. This gives patients the impression that the whole scheme is illogical, subject to political whim and more like a vanity project than a serious attempt to improve the lot of cancer patients.

The money spent on the fund since 2010 would have been better served by ensuring that all laboratories across the country had co-ordinated facilities for molecular testing, so allowing for earlier treatment and improved survival rates in lung cancer. Until this happens, any new government will continue to fiddle while the lungs of the country burn.

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Bad medicine

The great water myth We’re all supposed to be knocking back eight glasses a day, right? Wrong, says Tom Chivers

I

n September 2013, the First Lady of the United States, Michelle Obama, lent her name to a major health campaign. That campaign was a drive to make Americans drink more water. ‘I’ve come to realise that, if we were going to take just one step to make ourselves and our families healthier, probably the single best thing we could do is to simply drink more water,’ she said.

There is a longstanding belief that many of us are ‘chronically dehydrated’. We don’t drink enough water, and the resulting dehydration, of which we are largely unaware, causes a variety of ills, including cognitive difficulties and poor memory.

Several news agencies, including CBS, reported in 2013 that up to 75 per cent of Americans suffered from this problem.

The answer is, apparently, that we should all drink more water. Mrs Obama suggests that we (well, Americans, but I’m sure she’d say Brits too) drink one more glass of water a day; CBS and others say, much more specifically, that ‘experts’ tell us to drink eight glasses of water a day. This claim has been doing the rounds for ages; it has almost achieved the status of received wisdom. Drinking eight glasses of water a day is good for you.

But where did that come from? It’s surprisingly hard to find out. Certainly, the claim that three-quarters of Americans are under-watered seems to be false. The admirable mythbusting website Snopes has looked into it, and the only place they can find it is in a 1992 book called Your Body’s Many Cries for Water, by Fereydoon Batmanghelidj. He says that people ‘need to learn they’re not sick, only thirsty’, and that drinking more water would cure or prevent ‘arthritis, angina, migraines, hypertension and asthma’. It appears to be based on no empirical research.

The ‘eight glasses’ (if you’re wondering,

each glass is supposed to be eight fluid ounces, or a bit less than half a pint, so the advice is sometimes known as ‘8 x 8’) claim is hard to source as well. There’s a review of the literature in the American Journal of Physiology from 2002 which says ‘No scientific studies were found in support of 8 x 8.’ The final line of its abstract admits that it’s impossible to prove a negative, and so rather plaintively ‘invites communications from readers who are aware of pertinent publications’. Dr Heinz Valtin, the author of the study, later said in an interview that ‘I searched for ten months with the help of a professional librarian. There wasn’t a single paper that gave any scientific support to this recommendation.’ It seems pretty clear there’s a shortage of evidence.

Your body is good at knowing how much water you need Dr Valtin’s best guess for where the ‘eight glasses’ myth comes from is a 1940s recommendation by the Food and Nutrition Board of the Institute of Medicine, which in a roundabout way suggested that adults ought to take in about two litres of water a day. But, Dr Valtin points out, the very next sentence in the advice is ‘and much of this can be gained from the solid food that we eat’. White bread is about 30 per cent water. Fruits and vegetables are much more.

We’re taking in water all the time. And, of course, we drink tea and coffee and juice and soft drinks, all of which are 90-plus per cent water, and do a perfectly good job of keeping us hydrated.

That last sentence may surprise you if you’ve read that caffeinated drinks dehydrate you. Caffeine is a diuretic, but only, according to Dr Valtin, in large doses.

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A 2003 review of the literature in the Journal of Human Nutrition and Dietetics found that ‘Doses of caffeine equivalent to the amount normally found in standard servings of tea, coffee and carbonated soft drinks appear to have no diuretic action.’

Even mildly alcoholic drinks, such as beer, can hydrate you if drunk in moderation.

So how do you know whether you’re getting enough water? Well, the simplest way to tell is if you feel thirsty. ‘The vast majority of healthy people adequately meet their daily hydration needs by letting thirst be their guide,’ says the US Food and Nutrition Board. If that’s not certain enough for you, check your urine colour.

Pale yellow is hydrated, darker yellow might indicate dehydration. There are Dulux-style charts available online if you want more detail.

Let’s drop the eight glasses of water thing, then. It’s a misunderstood solution to a made-up problem. Instead, let’s get back to Mrs Obama’s claim in the first paragraph.

Would we all really be better if we drank an extra glass of water a day? Probably not, unless you’re feeling thirsty all the time, in which case you ought to have worked it out on your own. Perhaps she means we ought to replace a glass of Coke with a glass of water, and that would be a good thing if you’re struggling with your weight and want to get your calorie intake down. But simply drinking a glass of water on top of your daily routine will do no good at all — and if you end up buying bottled water, you’re just adding to an environmental problem and costing yourself money. The most important message to take away here is that your body is actually quite good at knowing how much water it needs, which shouldn’t be a surprise. None of your ancestors died of dehydration before they managed to have children. Evolution is a marvellous thing.

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1

2

3

4

Swimming

Sun

Flexibility Flexibility

Heart

Misfit Shine £64.99 www.mobiles.co.uk

Netatmo June £119 netatmo.com

Zepp Multi-sport sensor £129.99 Argos and Currys

Mio Fuse £130 mioglobal.com

Swimmers will appreciate the Misfit Shine. It’s a basic tracker band — although it can be worn as a necklace or clip — that measures energy output and hours of sleep. But where it comes into its own is that it’s waterproof to a safe depth of 50 metres, so it can be used for scuba dives as well as triathlons.

The Netatmo June — a little faceted doodah, pictured above, on a leather or silicone bracelet — tracks the intensity of UV rays in real time and tots up your skin’s sun exposure throughout the day. It’s synced to an app, and the user can get advice depending on skin type, including suggested maximum daily exposure. It will even recommend when to apply sun cream, though you’ll still need to find a human to do your back.

Golfers and racket sports fans will appreciate the Zepp multi-sport sensor, which analyses a user’s swing when playing golf and tennis via a small, fluorescent yellow cube-shaped device and an accompanying app. The cube gathers information and sends it to the app to be turned into practical advice.

The Mio Fuse is a heart-rate monitor and activity tracker that can be worn on the wrist, with no need for a chest strap. It measures blood flow plus temperature to analyse movements and provide an accurate reading. It also measures daily activity and can adjust to high-energy walks, workouts or runs. It’s water-resistant to 30 metres, so you can run through the rain without worrying.

Know yourself better Self-tracking gadgets are getting slicker, tougher and more capable.

Victoria Lambert takes a look at the future of self-monitoring and, above, rounds up seven of the most promising devices on the market 22

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New gadgets — so-called wearables — are mapping our every waking move, helping us to track everything from calories to steps, heartbeats to hours in the sun. According to the Institute of Electrical and Electronics Engineers (IEEE), 90 million wearables were sold worldwide last year, including fitness trackers and smartwatches, and the 9 MAY 2015 | SPECTATOR HEALTH

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number is expected to reach 200 million this year. Figures released by the Wearable Technology Show estimate the market to be worth $173 billion worldwide. ‘Wearables will become more ubiquitous than computers in the near future,’ says IEEE senior member Dr Kevin Curran.

You’ve probably seen or even tried multi-function

5

6

7

Style Style

Sleep Sleep

Office Office

Withings Activité £320 www.withings.com

iWinks Aurora Dreamband £133 iwinks.org

Apple Watch £299 www.apple.com

A sense of style is not something you can easily track, but for anyone who wants to avoid tacky plastic, look no further than Withings Activité — a Swiss-made tracker that combines old-school flair with all the usual body tracking, a battery that lasts for eight months, and French calf-leather straps.

It’s what Bond would wear if he worried about how many steps he took.

The Aurora Dreamband offers the tantalising prospect of helping you become aware that you’re dreaming — a state known as lucid dreaming. It’s a padded headband stuffed with sensors, and the inventors hope that by monitoring brainwaves and eye movements, they can analyse when you’re dreaming and then, via a subtle alert, help you become conscious of the dream without waking up.

This crowdfunded device is still in development, with the first units due to ship next month.

For some of us, just standing up during a day at the office is a triumph. Sound familiar?

Then invest in the Apple Watch, which among many other features contains an accelerometer to measure your total body movement and steps, to calculate the calories you burn during the activities you do throughout the day. It measures all kinds of physical movement, from simply standing up to running to catch the bus or playing with your children.

90 million wearables were sold last year.

This year, it’s expected to be 200 million

single-function devices such as activity-specific clothing, like Hexoskin which monitors workouts, or indeed wearable medical devices such as Vital Connect, which is a patch that tracks your vital signs and lets doctors access the data,’ says Dr Curran. (Pet monitoring is a growing trend, too.)

We’ve gathered seven of the best wearable options above.

wearables — wristbands and similar devices such as the FitBit Flex, JawBone, Nike Fuelband, Garmin Vivofit and Samsung Gear Fit: wristbands that monitor movement, heart rate and skin temperature to track your activity and sleep.

But wearables don’t — and increasingly won’t — stop there.

‘The latest trend is towards

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Scary dairy and silly moos Ignore faddish campaigners, says Laura Freeman. There’s nothing wrong with a glass of milk

O

n the shelves of Whole Foods, a vast and vastly expensive American supermarket in west London, you will find 14 different types of cow-free milk. There are cartons of soya, almond, macadamia, rice, coconut, cashew, spelt, oat, flax, barley, quinoa, hazelnut, buffalo and goat’s milks.

Other than the final two, none of these is strictly speaking ‘milk’.

The rest are made by soaking a nut, seed or grain in filtered water and then straining the liquid to make a drink of greater or lesser palatability. Anyone used to fullfat Jersey cow’s milk would find the quinoa stuff thin indeed.

But the market for nondairy milks is booming. In 2011, 36 million litres of milk alternatives were sold in the UK, according to retail analysts Mintel. In 2013, it was 92 million litres — a 155 per cent increase.

One in five UK households now buys some sort of non-dairy milk for health or lifestyle reasons.

Marks & Spencer last year launched coconut, rice and oat milks, having introduced soya milk in 2010. They now sell around 70,000 litres of these milk alternatives each week.

Starbucks introduced soya milk to its cafés in 1997, but has

One in five UK households buys some sort of non-dairy substitute

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been slow to expand its offering.

A Facebook petition group demands, ‘Ask Starbucks for more non-dairy milk alternatives.’

In Britain we now spend £150.6 million a year on these products, but are we right to avoid cow’s milk? Are we really suffering from a mass intolerance to the white stuff or is the nation labouring under a collective dairy delusion?

There is widespread concern that modern man struggles to digest lactose — the sugar present in cow’s milk — and that drinking milk causes digestive discomfort.

In 2007 a study from University College London was published in the journal Proceedings of the National Academy of Sciences. It argued that analysis of human remains revealed that no European adults could digest milk during the Neolithic period — roughly 10,200 to 4,500 bc.

The paper’s authors explained that early man went on to develop a gene, producing the digestive enzyme lactase, which allowed the body to break down the lactose sugars in milk. This, they argued, showed evolution in action.

It is estimated that 90 per cent of modern northern Europeans have this gene. The other 10 per 9 MAY 2015 | SPECTATOR HEALTH

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Green green grass… drinking milk gave early Europeans ‘a big survival advantage’

cent, however, may experience uncomfortable symptoms after drinking milk, such as bloating, abdominal pains or an upset stomach. They may find that milk exacerbates Irritable Bowel Syndrome (IBS).

In parts of the world where milk has not been widely drunk, such as China, south-east Asia and some parts of Latin America, lactose intolerance is far more prevalent.

Mark Thomas, Professor of Evolutionary Genetics at UCL, explained, ‘The ability to drink milk is the most advantageous trait that’s evolved in Europeans in the recent past… [it] gave some early Europeans a big survival advantage.’

Cow’s milk — nutritious and, unlike natural water sources, uncontaminated with parasites — may have allowed generations of Europeans to thrive, but it has in recent years acquired a bad press.

Dieticians, nutritionists, beauty journalists and celebrity chefs line up to tell us we would do better not to drink our daily pinta.

Calgary Avansino, a former beauty editor at Vogue, writes for the Sunday supplements on her wheat- and dairy-free diet. She favours almond milk and coconut water. Meanwhile, in an interview

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to promote her gluten-free, dairyfree, sugar-free cookbook It’s All Good, actress turned health guru Gwyneth Paltrow said, ‘Everyone in my family is intolerant to gluten and cow dairy.’

The morning I sat down to write this article, an email appeared in my inbox from a food blogger with the subject line: ‘Make your own pumpkin nut milk.’

Even the greedily carnivorous chef Hugh Fearnley-Whittingstall has had a change of heart in his new book River Cottage Light & Easy – a collection of wheat- and dairy-free recipes.

Is milk really so very bad for us?

Dr John Briffa, a practising doctor specialising in nutrition, reiterates that 90 per cent of northern Europeans — a category into which many Britons fall — can tolerate milk. ‘Spectator readers,’ he stresses, ‘can probably digest lactose quite well.’

He points out that most adults drink relatively little milk and that a splash in a cup of tea won’t do much harm. He recommends yogurts and cheeses as easier to digest, because in the fermentation process some of the lactose is broken down.

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So, is lactose intolerance a widespread problem? ‘Certainly not in Cumbria,’ says Dr Ross.

Manufacturers of dairy-free milks have a vested interest in persuading you that you are among the unlucky 10 per cent who cannot digest lactose, rather than the 90 per cent who can drink hot chocolate and eat ice cream with no ill effects.

Farming correspondent Graham Harvey regrets what has happened to milk — particularly milk production — in this country.

He is convinced we would be better drinking real, raw, unpasteurised milk. This tends to be easier to digest because the enzymes present in raw milk —

They’re all nuts… soy, coconut and rice milk isn’t milk at all, and lacks its benefits

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continued from page 25

He acknowledges, however, that in some patients — and here may lie the 10 per cent — eliminating milk and milk products can clear up unwanted digestive symptoms.

And what about the argument that the calcium in milk builds strong bones? Can cashew milk offer the same benefits?

Dr Briffa says that calcium is only one contributor to bone health and that we often overlook the importance of Vitamin D in bone strength.

Cumbrian GP Dr Angus Ross, however, worries that by going dairy-free, patients, particularly women, are risking brittle bone diseases like osteomalacia and osteoporosis.

‘It is wrong,’ he says, ‘for TV chefs to encourage people to omit particular food groups from their diet with no good reason.’ He is wary about faddy cookbooks, particularly those written by celebrities, which encourage elimination diets.

And it’s not just bone health.

One study, published in the Lancet in 2011, found that of 700 teenage girls surveyed across the UK, 70 per cent of them suffered iodine deficiency. The study found that girls who drank no milk at all had the lowest levels of iodine — particularly important for breast and ovary development.

It is wrong for TV chefs to encourage people to omit food groups with no good reason which are destroyed in the heattreating pasteurisation process — help the human body to digest lactose.

He regularly drives 30 miles across the Somerset Levels to buy the real thing straight from a farmer. If you live in town, there are farms like Emma’s Organic Dairy in Lancashire, which will courier creamy pints from grassfed cows to your doorstep.

There’s a lovely anecdote in the memoirs of Deborah Devonshire about the cook at Chatsworth, who was liberal with double cream. When warned about the health risks, the doughty cook replied: ‘They sell skimmed milk in my supermarket but I couldn’t look a cow in the face if I bought that.’

‘Excellent woman,’ concluded Debo. I imagine the cook would have felt even more strongly about spelt milk.

Unless you have very strong reasons to believe you are among the unfortunate 10 per cent who cannot tolerate cow’s milk, why deny yourself the pleasure of the real stuff for a meagre quinoa substitute?

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9 MAY 2015 | SPECTATOR HEALTH

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30/04/2015 12:42

Testing eastern promises in the chic heart of Paris This is a hotel spa with a difference. But can it help ease my psoriasis?

The Spa Inspector Mandarin Oriental Paris Visitors to the city of love are spoilt for choice when it comes to top-notch hotels. For that reason, demanding guests increasingly expect high-end spas that not only cater for those wishing to have a good massage or some nice beauty treatments, but which can also offer something more medical.

We report from one such hotel which is making a name for itself in offering some traditional eastern medicine in the heart of western culture.

THE PLACE Located just moments from the Louvre in the very centre of Paris, on the Rue St Honoré, one of its most fashionable streets, this stunning 1930s Art Deco building is home to one of Paris’s most luxurious hotels. And it also boasts one of the city’s largest hotel spas, which draws on Chinese medicine and tradition for its signature treatments. In the centre of the hotel is a tree-planted indoor garden where you can have breakfast or sit in the evening to sip champagne. As you’d expect, there’s also a large indoor pool and fitness centre with state-of-the-art gym equipment.

THE SYMPTOMS While this sleuth’s psoriasis has been a lifelong affliction, it had been calm for many years.

Then a period of stress after a family bereavement caused it to flare up. While a visit to the GP gave the Spa Inspector a useful prescription of topical creams, anything that can help further would be gratefully received…

THE TREATMENT The Mandarin Oriental Signature aims to redress anxiety and tiredness by using the Chinese principles of yin and yang. Their therapies begin with a relaxing body massage ritual that combines the powerful effects of oriental meridian massage with their own range of essential oils. These bring together the purest plant and flower oils from the East and West and, in keeping with Chinese tradition, each product is created according to the principles of the five elements.

They then tailor further

THE PROCESS The Spa Inspector’s medical history and medication was reviewed in an in-depth consultation. She was then sent off with a pot of green tea and bamboo body scrub and told to clean herself to within an inch of her life. It was therapeutic seeing the grime of the Paris streets vanish down the plughole. She was then moved to a room with ambient music and exotic fragrances to begin unwinding. Next was a rose petal bath. This was followed by a steam scrub to gently exfoliate the skin, and then wraps to enrich and hydrate the skin. Then she was given a full body massage. The entire

I was sent off with a pot of green tea and bamboo body scrub

THE VERDICT Everything about the experience was personal and tailored to the Spa Inspector’s problems. The staff were kind and thoughtful. Nothing was too much trouble and there were times when your reviewer thought she had died and gone to heaven. She has never felt healthier. A month later, the unsightly scaly patches have completely cleared up and she couldn’t be happier.

THE MEDICAL VIEW Dr Max Pemberton: Psoriasis is caused by the immune system and is not infectious.

While there are different types, it typically results in patches of scaly skin, sometimes over large areas of the body. It is common for the condition to wax and wane, so it’s difficult to know if the improvement was due to the Mandarin Oriental’s procedure. The creams the GP prescribed may also have been a big factor.

However, some studies have shown that in mild cases, diet and lifestyle changes can improve psoriasis: exercise and cutting stress are particularly helpful. And treatments that hydrate and moisturise the skin can ameliorate the itchiness and dryness associated with the condition.

THE FEELGOOD FACTOR Complete luxury in beautiful surroundings. Whether or not you believe in the power of Chinese medicine, this treatment worked for the Spa Inspector and left her feeling so rejuvenated that she considered climbing the Eiffel tower. (Although she opted for some retail therapy in the end.)

THE DETAILS The Mandarin Oriental offers superior rooms from £635 per night. For bookings call 00800 28 28 38 38 or visit www. mandarinoriental.com/paris.

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treatments to any specific requirements of the client.

process took more than three hours.

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30/04/2015 13:01

Acne as an adult?

It really isn’t fair

More and more women suffer from it, writes Dr Ellie Cannon.

Teenagers’ remedies may not help, but other things will

A

t some time in our lives we all hark back to blissful, carefree teenage years. We conveniently forget the tricky parts like the awkwardness, the embarrassing unrequited love — and those horrendous spots. While most of us leave all of that thankfully in the past, a growing number of adults are revisiting one of the more painful parts of adolescence: acne. In fact as many as 44 per cent of women in the UK are now thought to be suffering from adult acne, as Professor Rino Cerio, consultant dermatologist at the Royal London Hospital, explains. ‘Adult acne is increasing in prevalence in women in particular,’ he says. ‘I’m seeing people come to me tearful, frustrated and with very poor ­ self-esteem.’

It is no surprise that in a recent survey by skincare experts Eau Thermale Avène, 44 per cent of sufferers felt they were too old to be dealing with this problem.

However, adult acne is actually a different condition to the teenage form. Adult acne mainly affects the face and the jawline, and causes large, deep red spots rather than the fine bumps and blackheads teenagers sport on their foreheads.

The main causes seem to be an overproduction of sebum or grease in the skin as well as an excess of dead skin cells: both of these feed the skin bacteria P. Acnes, allowing it to overcolonise and cause inflammation and spots.

Traditionally treatment of teenage acne has concentrated on abrasive topical treatments or

One cream contains a stealth ingredient which bacteria mistake for food

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antibiotics to clear the overgrowth of bacteria. The topical lotions we all bought as teenagers, such as benzoyl peroxide, work well for mild teenage acne but do little for the larger cystic spots that adult acne sufferers get. Adult acne sufferers need to look further, but help is available in both high street and prescription treatments.

Targeting the overgrowth of P. acnes, newer treatments for adult acne block the feeding cycle of the bacteria, preventing the formation of large inflammatory spots. The science is clever: the creams contain a stealth ingredient called Diolenyl which the bacteria mistake for their usual sebum-derived food. On contact, antibacterial and antiinflammatory agents are released, killing the bacteria rather than feeding it, and reducing the spots.

This technology is uniquely available from Eau Thermale Avène who appear to understand the fine balance between treating the acne without stripping the underlying healthy skin. One common complaint among acne sufferers is that treatments are too harsh for daily use.

A very visible skin disorder such as adult acne has a multitude of psychological and social effects, causing depression and low self-esteem and even going as far as to impact on employment and relationships.

There is an added layer of embarrassment when one is suffering from a teenage condition at a time when wrinkles should be the concern and this is a strong impetus to seek professional help. Doctors need to be very careful not to

underestimate this, seeing ‘just a skin condition’.

Adult acne can be very responsive to mainstream prescription medications. These would include antibiotic-based creams or long-term antibiotic tablets. These decolonise the skin removing the harmful bacteria.

But more and more we are seeing resistance in acne bacteria and patients can find themselves trialling a number of different courses before one works.

Because of the huge impact adult acne can have, it leads many to bypass the GP surgery and head straight to the dermatologist for a serious solution. Whereas teenage acne is often belittled as something we all go through in adolescence, adult acne is viewed by dermatologists as something that warrants significant treatment.

This explains why the controversial acne drug Roaccutane plays a role in adults with acne. Roaccutane is a drug used for severe cases of acne and is very useful in adult acne, particularly when other treatments have failed.

It is an effective but very toxic medication, sometimes cited as being responsible for suicides among patients taking it. However, it is difficult with a condition where there is a huge psychological burden to separate what is caused by the condition itself and what is caused by the treatment. No studies have proved a causal link between Roaccutane and depression, but clinicians are aware of an association. The fact that patients are willing to use the medication despite the reports perfectly illustrates what a huge burden adult acne can be.

Roaccutane is a chemical similar to Vitamin A, and it is not clear why this could cause depression. It is an effective treatment but prescribing it is a balancing act for clinicians and patients. The benefits and the risks have to be carefully weighed up: for the majority of patients, the side effects are minimal and the improvement in their skin significant. For someone entering their forties covered in ‘teenage’ spots, this is a very worthwhile consideration.

9 MAY 2015 | SPECTATOR HEALTH

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30/04/2015 12:44

What to eat

Can you count to five?

‘Five a day’ has to be the snappiest slogan in nutrition, writes Ian Marber — but the advice is more confusing than it looks

I

remember when one was guaranteed two things from London cabbies — a good journey and a good natter.

Once we’d done the weather, cyclists and the congestion charge, they would move on to ask what I did and, as soon as I mentioned ‘nutrition’, off they would go: ‘One minute they say, “Eat this” and the next it’s, “Don’t eat that”. And what about that five a day? You try being a cabbie and getting a salad. They want to live in the real world.’

The journey may still be good but the banter has stopped, because now cabbies are on the phone just like everyone else. For me it’s blessing really, as I used to dread having to defend every single nutrition-related story they might have heard about. Worse still is that the friendly cabbies were right: the messages did and do keep changing, which is one reason why dietary edicts can fail to influence the people who need them the most.

But what about five a day, probably the best-known nutrition message in history? Has that changed? The mantra itself was not the creation of some group of learned nutrition experts and public health officials who examined evidence and considered modern lifestyles before arriving at a simple saying. It actually began life in 1991 as a marketing slogan put together in a collaboration between the US National Cancer Institute and a commercially funded group of growers and farmers in California known as the Produce for Better Health Foundation.

While the message does of course have huge merit, it wasn’t based on any definitive research.

That hasn’t stopped it becoming lodged in our collective psyche. ‘Five a day’ may well be one of the most recognisable marketing slogans of all time,

giving ‘Because you’re worth it’ and ‘Only the crumbliest, flakiest chocolate’ a run for their money.

Somewhat confusingly, the advice on how much fruit and vegetables to aim for daily differs around the world, despite the advice now being based on research that is globally available. In Britain we are advised to eat at least 400g (about a pound) of fruits and vegetables daily, or 80g (that’s three ounces) per portion: hence the five a day. In Finland the overall figure is 500g, and in Canada it rises to seven to ten portions — but there’s no

A smoothie counts as one portion. So do two smoothies, or a whole shop of beans holding back in Australia, where the official recommendation is for six 75g portions of vegetables and another two 150g servings of fruit.

And despite the familiarity of the ‘five a day’ slogan, we Brits aren’t taking heed.

A National Diet and Nutrition Survey published in 2012 showed that only 31 per cent of British adults aged between 19 and 64 get their five a day — and only 10 per cent of children.

But what are five portions of fruit and vegetables? The Livewell section of the NHS website advises that one small portion of fruit is two or more small plums or satsumas, seven strawberries or 14 cherries, while a medium-sized portion is an apple, banana or pear. A small portion counts as one of the five a day and a medium-sized one does too, possibly one and a bit. For vegetables, a raw tomato, three celery sticks or 5cm of cucumber

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will do it for salads —but for cooked food you’ll need two spears of broccoli or four heaped tablespoons of spinach or beans, but only three of carrots or peas. A smoothie counts as one portion, because they contain beneficial fibre, even though there are natural fruit sugars — but two smoothies still count as just one. (Fibre trumps fructose but only in the first glass it seems.) A 150ml glass of unsweetened juice counts as one, while the second one doesn’t count owing to the lack of fibre.

Beans count as one portion even if you eat an entire branch of Whole Foods.

Potatoes don’t count at all, unless they’re sweet potatoes. Well, that’s clear then.

The five-a-day mantra looked as if it was about to be updated last year after researchers at UCL analysed data from 16 worldwide studies of the eating habits of more than 800,000 people.

The outcome? Seven or more portions are required; aim for ten and not five; fruit juice shouldn’t count at all; frozen and canned food shouldn’t be included any more; vegetables have four times more value than fruit, as each portion of vegetables reduces risk of death by 16 per cent compared with 4 per cent for fruit.

However, the incidence of cardiovascular disease and cancers didn’t decrease in any meaningful way beyond the five a day. The cabbies were right about the confusion then, and surely that’s back to five a day?

Numbers aside, perhaps it’s time to update the slogan. The United States has moved away from numbers with a simple ‘Fruits & Veggies — More Matters’. Or we could go with a quote from In Defence of Food by Michael Pollan, a professor of journalism at the University of California in Berkeley: ‘Eat food. Not too much.

Mostly plants.’

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30/04/2015 11:13

Vision of the future There’s new hope for those suffering from Britain’s commonest cause of blindness, finds Sarah Rainey

O

n the wall in Ahmed El-Amir’s consulting room in the Harley Street Eye Clinic is a framed antique poster depicting the world in two halves. ‘L’Ancien Monde et Le Nouveau’, reads the script. There is much about the surroundings that reflects the former — the glittering chandelier; the stacks of glossy magazines; the plush sofas with their tasselled cushions; the ornate gold maritime clock by the door. But the trappings of antiquity are illusory. For Mr El-Amir is the embodiment of ‘le nouveau’ — and it’s in this very room that he’s helped to pioneer a treatment which is turning science fiction into reality.

Over the past four years, this bright young surgeon — Oxfordeducated and trained at the Moorfields Eye Hospital — has led the way in Britain when it comes to a groundbreaking new technique in the field of agerelated macular degeneration (AMD). This debilitating condition, the biggest cause of sight loss in developed countries, affects older patients, causing blind spots in their central vision.

It has no cure and, until recently, no restorative treatment was available either.

Building on ten years of international research, Mr El-Amir has developed a course of surgery that enables such patients to see again. He is also the only person in the world carrying out the procedure on people who’ve had previous eye surgery. ‘We have come so far,’ he explains. ‘As recently as eight or nine years ago, you would look at patients and say, “I’m sorry, there is nothing I can do.’’ ’ Mr El-Amir’s work involves implanting the world’s smallest telescope — 3.6mm in diameter by 4.4mm in length, roughly the size of a pea — into one eye. The telescope magnifies images by a factor of 2.7 and projects them beyond the damaged part of the eye (the macula) onto a wider area of healthy cells in the retina.

This improves both near and distance vision, while the other eye provides peripheral vision.

Discussions began in 2010, at a round table of global ophthalmic experts in Liverpool, when the inventors of the telescope (known as ‘CentraSight’, and developed by an American company called VisionCare Ophthalmic Technologies) began investigating ways of turning scientific theory into surgical practice. ‘It took about a minute for me to stick

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Until quite recently you would look at a patient and say, ‘I’m sorry, there’s nothing I can do’

my neck out and say I wanted to be the one to try it here,’ says Mr El-Amir. Just over a year later, after a series of clinical trials, he became the first person in Britain to carry out the surgery.

Since then, he has implanted telescopes into the eyes of 35 patients — and says his drive comes from seeing the drastic improvements this treatment makes to their quality of life.

‘My first case was a woman in her nineties — very fit, an avid sports viewer — who was in tears day 9 MAY 2015 | SPECTATOR HEALTH

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30/04/2015 13:45

DAILY TELEGRAPH

and night because she couldn’t see her great-grandchild’s face.

She was utterly distraught. I went through the pros and cons and told her it was possible it wouldn’t work. But it did. She was able to see her family again, and one of her most vivid moments was watching snooker on television and being able to see the ball hit the pocket.’

Mr El-Amir’s other patients have spanned a diverse range of backgrounds, nationalities and experiences. He has

treated sportsmen and women (including a world-class archer); newsreaders; doctors; farmers; and sufferers from France, Italy and as far afield as Egypt and Canada. All had been crippled by the onset of AMD, which can occur slowly (‘dry’ AMD) or come on rapidly, even overnight (‘wet’ AMD). Dame Judi Dench — who revealed a few years ago that, because of her own AMD, she was struggling to read scripts or recognise faces — has been one of the most forthright

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Top: Mr El-Amir in his surgery; above: the tiny telescope implant, balanced on a finger

campaigners for awareness of the illness. ‘Though I haven’t treated her, her description of the condition has made it really hit home,’ he says.

Unfortunately, not all AMD sufferers are suitable candidates for the procedure. There is a minimum age limit of 55, patients must have AMD in both eyes, and they should have been advised that other treatments will no longer help. Initially, another condition was that they must also not have had cataract surgery, but Mr El-Amir’s revolutionary approach meant that, by 2012, he was also carrying out surgery on patients who had had prior operations. He nicknames his version of the original treatment ‘MaculaScope’, and the second generation procedure ‘MaculaScope Plus’.

One of his patients is Leslie Richardson, 87, a retired Post Office worker from Middlesex, who had surgery last July. ‘My sight was gradually getting weaker, and I had to give up driving,’ he explains. ‘That was a big blow — I couldn’t do my own shopping any more and started losing my independence.

Since the operation, my sight has improved and it’s getting better by the day. I’m really happy, as are my family.’

AMD is a huge problem in Britain: more than 600,000 people are registered with the disease and around a further 1.5 million are thought to be living with its early-onset stages. In an ageing population, with life expectancy steadily increasing, its spread is set to continue — and experts emphasise its devastating nature. ‘It takes a terrible toll on those it affects,’ warns Caroline Abrahams of Age UK; while Derek Rix of Action for Blind People describes it as ‘difficult and overwhelming’. Its effects range from physical disability to depression, from social isolation to thoughts of suicide.

There is no doubt of the urgency of finding a solution — but what makes Mr El-Amir’s procedure particularly special?

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continued from page 31

The answer, he believes, lies in the telescope he uses. Handmade in Israel from quartz crystal, the miniature mechanism is composed of 40 separate parts, together mimicking the function of a full-sized telescope. ‘There are three or four technicians who work to the same microscopic standard as jewellers putting diamonds in rings,’ he explains.

‘It’s very technologically complex.

And the next step, to disinfect it to make it aseptic, is even more exacting.’

Despite being so tiny, the telescope is still relatively large for an optical implant. In order to make space for it, Mr El-Amir uses a local anaesthetic to numb the eye and then creates a pocket by removing the eye’s natural lens. The implant is inserted behind the iris so it’s not noticeable; and the whole procedure takes between 60 and 90 minutes.

Prior to surgery, patients are required to pass a series of tests using an external telescope which replicates the effect of the implant, and afterwards they receive six weeks of rehabilitatory home visits from a specialist optometrist. They are given reading glasses to aid with near vision, and they learn how to combine the larger vision from the implanted eye with the peripheral vision from the unoperated one.

At present, surgery costs in the region of £11,000-£14,000, around £8,000 of which covers the telescope alone. The variation in price is due to the differing postsurgery needs of each patient.

By raising awareness of the

procedure, and increasing his pool of patients to 100, however, Mr El-Amir hopes to halve the cost by the end of 2016. Not only will this enable more people to afford the surgery, but it may increase its chances of being recommended by the National Institute for Health and Care Excellence (Nice) and eventually becoming available on the NHS. A report by Nice in 2009/2010 was favourable, and Mr El-Amir says his initial discussions with local healthcare providers have proved encouraging.

Others in the field are excited by such progress. ‘Any safe and effective intervention that enhances remaining vision and restores some sight will go a long way to improving our quality of life as we get older,’ says Mike Daw, chief executive of the National Eye Research Centre.

‘An innovation such as this obviously has potential.’

On the other hand, Cathy Yelf of the Macular Society, the UK’s leading charity in AMD support, raises concerns over

Above: if you have advanced AMD, this is how the world might appear to you

The telescope is handmade in Israel from quartz crystal and is made up of 40 separate parts

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the ‘tiny number of people’ the CentraSight implant can help, because of the difficulties that still remain. ‘This is certainly a way in which we are moving towards improving life for people whose vision has already gone,’ she acknowledges, ‘but many cannot cope with the enormous disparity in vision between one eye and the other. It requires scrupulous research if it is ever to become a mass solution.’

So what does the future hold?

The threat of AMD is, after all, one that hangs over everyone — and it is becoming clear that the quest to restore sight will require some thinking outside existing medical parameters. The broader picture is optimistic: optical surgery has vastly improved over the past decade, from treating glaucoma with eye drops to repairing failing vision with stem cell therapy. In the field of AMD, too, there have been major developments: in the dry form, a vitamin supplement called the Areds 2 Formula can be prescribed to significantly reduce eyesight loss; in the wet version, a solution can be injected to reduce blood vessel growth and slow the rate of disease for up to ten years.

As for the telescope — the epitome of a ‘cyborg’ solution to a human problem — the outlook is hopeful. ‘There is no stopping now,’ predicts Mr El-Amir. ‘The materials we use will develop to reduce glare; to sharpen colour perception. It could also become injectable, and therefore less invasive.’ He grins. Le nouveau beckons.

For more information, visit www. harleystreeteye.com 9 MAY 2015 | SPECTATOR HEALTH

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33

30/04/2015 11:56

A fear-free guide to post-mortems Expert insight

By Dr Suzy Lishman President of the Royal College of Pathologists

A post-mortem (also called an autopsy) is an examination performed after someone has died. There are two main reasons for performing a post-mortem in the UK. The most common is a coroner’s post-mortem, performed at the request of the coroner, usually to find out why someone has died when the cause is not known, perhaps because the death was sudden or the deceased had not seen a doctor recently.

The second type is a hospital or ‘consented’ post-mortem.

This is done at the request of the family or the doctors of the person who died and can be requested only if the cause of death is known. These look for things like the extent of disease or the response to treatment and help the doctors and family understand better what happened to the person who died.

DO I HAVE TO GIVE CONSENT FOR A FAMILY MEMBER TO HAVE A POST-MORTEM?

Consent is not required from the family for a coroner’s postmortem but the coroner’s officer

will usually work closely with relatives to make sure they understand what’s happening and when the funeral can take place.

Hospital post-mortems require the consent of the next of kin, and will not proceed without it.

Someone from the hospital, often the bereavement officer, will explain why the post-mortem is being requested, what it is hoped to learn, what it involves and when the results will be known.

Relatives have a chance to ask questions and may choose to limit the post-mortem to a particular part of the body, such as the head or chest. A standardised consent form has been developed to ensure that relatives have all the information they need and can be very clear about their wishes.

ARE POST-MORTEMS REALLY NECESSARY?

You might think post-mortems are no longer needed now that we have so much information available about people’s health during their lifetime. You might expect modern imaging techniques, such as MRI and CT scans, to enable doctors to find out exactly what’s wrong with someone before they die, and that a post-mortem is unlikely to add anything. Research has repeatedly shown that this is not the case — a significant number of post-mortems identify disease that wasn’t suspected during life and up to a quarter find disease that would have affected the patient’s treatment if it been identified before death.

Post-mortems are often called

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the ‘gold standard’, and are currently the best way to find out why someone died, providing valuable information for doctors and helping families understand exactly what happened.

DO POST-MORTEMS DELAY THE FUNERAL?

Post-mortems are usually carried out within a day or two of death so they rarely affect the timing of funerals. Pathologists will usually prioritise post-mortems for members of religions that hold funerals quickly after death or if there is another reason why a delay is to be avoided. Coroners’ officers, hospital bereavement officers and pathologists are familiar with these circumstances and will do what they can to expedite the process.

WHAT DOES A POST-MORTEM INVOLVE?

A post-mortem is like a surgical operation performed after death. Pathologists (doctors who specialise in the study of disease) work with highly skilled anatomical pathology technologists (APTs) to examine the body in a dignified and respectful way. A long incision is made down the front of the body to enable the internal organs to be removed and examined. A single incision across the back of the head allows the top of the skull to be removed so that the brain can be examined. Organs are examined carefully with the naked eye and dissected to look for any abnormalities such as blood clots or tumours. If further 9 MAY 2015 | SPECTATOR HEALTH

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information is required, postagestamp-sized pieces of tissue may be retained for examination under the microscope or samples of body fluids taken for analysis in the laboratory.

WHAT HAPPENS TO THE ORGANS AFTERWARDS?

After being examined, the organs are returned to the body. Material is never retained without explicit consent from the coroner or next of kin.

The coroner might instruct the pathologist to perform further analysis on blood or a tissue sample; if this is the case the family will be informed. If the pathologist wants to keep tissue for research or teaching, they will only do so with written informed consent from the next of kin. Post-mortem facilities are regularly inspected to ensure that they work to the high standards set out by the Human Tissue Authority. When the examination is completed, APTs reconstruct the body in preparation for viewing by the family or collection by the funeral directors.

Once clothed, no sign of the post-mortem is visible.

IS IT LIKE ON TELEVISION?

There are a surprising number of TV shows featuring pathologists, from CSI and Silent Witness, where pathologists are the main characters, to dramas such as Sherlock and Lewis, where pathologists have important but less central roles. While there’s an element of truth in all these programmes, they are primarily developed for entertainment. I have been involved in checking several scripts for scientific accuracy. My experience is that writers make a big effort to ensure the science is accurate where possible but that storylines often include some science fiction to add to the drama. Even when the science is accurate, the way in which the lives of the pathologists is portrayed is usually some way from the truth. Pathologists don’t spend their time eating or smoking in the post-mortem room, interviewing witnesses or

WILL SCANS REPLACE CONVENTIONAL POST-MORTEMS?

In recent years post-mortem imaging has emerged as an alternative to the usual type of post-mortem. An MRI or CT scan is performed and a threedimensional computer-generated image of the body is manipulated by a pathologist and radiologist (specialist in X-rays and other imaging techniques) to look at the internal organs and skeleton.

The image can be rotated and viewed from different angles and organs sliced with a virtual scalpel. The cause of death can be found in many of these imaging post-mortems, particularly if it relates to something that’s clearly visible on the scan such as an aneurysm (enlarged blood vessel) or tumour. If no definite cause of death is found on the scan, additional tests may be performed, such as injecting dye into the blood vessels of the heart to look for blockages or taking small samples of body fluids or tissues to examine under the microscope.

Even if the cause of death is not apparent, scans can help target areas for investigation so that a full post-mortem is not required. The accuracy of postmortem imaging has improved considerably over the past 20 years and is likely to continue to do so. Post-mortem imaging is particularly popular with religious groups who prefer to avoid conventional post-mortems and traditionally hold funerals very quickly after death. The service is sometimes offered to all families but there is often a charge (there is no cost to the family for a conventional post-mortem). Imaging postmortems represent a significant advance and are likely to become increasingly available and more accurate. Pathologists continue to take ultimate responsibility for the final report and are closely involved in developing this technique further.

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chasing suspects — and they’re not all single!

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Five steps to happiness

Anxiety attacks can be defeated, says Patrick Strudwick, who’s been there, done that

L

ike Christmas, Eurovision and tube strikes, it happens too often — a phone call that begins: ‘Hi Patrick.

[Name] is having an anxiety meltdown. He/ she is off work, not functioning, and I’m really worried. Would you speak to them?’

And I do. People come to me because for ten years panic attacks stalked me, strangled me. My twenties were a writeoff. After I was brutally attacked in my home by burglars, everything was danger, my brain vibrated. I gasped, hysterical. I needed drugs. I was addicted to sleeping pills. I needed help. Nothing worked.

But then, after trying every treatment and medication imaginable, I recovered.

The lunacy was over. I may never quite grace the cover of Sanity Fair, but the beast was tamed. My friends and family know this. So, now, I’m the expert with no qualifications except bitter experience, the go-to for those special moments when you can no longer leave the house without ringing for an ambulance. This, then, is your cut-out-and-keep guide to giving anxiety the middle finger. Tape it to the fridge.

According to Anxiety UK, a tenth of us will be, at some point, disabled by an anxiety disorder. Many more stagger on unaided, quietly convinced that they are going mad and about to die. There are, in the broadest, commonest terms, two types of anxiety problem: generalised anxiety disorder, where the sufferer is regularly or constantly plagued by fear in various forms; and panic disorder, where dramatic, sometimes hysterical anxiety attacks beset the sufferer, typically causing hyperventilation, palpitations, shaking and sometimes even vomiting.

The Nice treatment guidelines recommend antidepressants, sedatives and group or individual psychotherapy for

these conditions. I have no real truck with this — what is available on the NHS is not enough. Recovery demands panoramic action. No single drug or treatment or life change will soothe your crazed soul. (And if anyone tells you to go to a support group for ‘anxiety management’, ignore them.

You do not learn to be calm by sitting with a dozen people who live in constant terror.)

Instead, draw a chart and divide it into five sections with five headings, enact everything under each five, and you will be sane again. Probably. But before we embark on this sanity pentagon, there is a crucial issue to grasp. Take yourself back to a recent anxious state: how does it feel? Like being invaded by a grotesque fear poison — an alien inhabiting you and making you horrifically on edge? Yes, of course it does. Anxiety’s greatest trick is to convince you it’s happening to you. It isn’t — you’re doing it. Yes, you. Sorry.

The single most important step in conquering the madness is to understand your role in it. If this sounds like I’m blaming you, you’re even more determined to be a victim than I was. Being a victim of your anxiety will not help you. Believing it’s just happening to you, like flu, will ensure it continues. Instead, you must accept that your every response to the initial sensation of fear that you’re currently involved in is exacerbating it.

But the great thing is, you can do something else. Starting to hyperventilate?

Well, despite what you might think, you can deliberately slow your breathing down, sending potent messages to your brain that in fact there is no impending danger.

Telling yourself, ‘I’m having a heart attack, I’m terrified, I’m dying’? Tell yourself something else: ‘This is just silly anxiety. I’m fine. I will do calm instead.’

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Every single response to fear can be countered. But you have to accept fully that you are doing (it really is an action), and you can do something else. The reason this takes a lot of practice is because our mind and body are wired to respond dramatically to fear, for self-preservation. Flight, fight or freeze reactions kept us from being eaten.

Now they stop us going into Sainsbury’s or the tube, as ‘That’s where it happens.’ No, that’s where you’ve learnt to do it.

The first section in our chart is (1) therapy. Again, I apologise if this is not what you want to hear, but you need it.

You wouldn’t learn to fly a helicopter all by yourself, so how do you think you’re going to learn to be sane by yourself? There are two main approaches to consider. The first is the cognitive treatments, which examine your thought processes, how they create anxiety, and what you can do to intercept and change them. You will learn how you 9 MAY 2015 | SPECTATOR HEALTH

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became a master of madness and, in turn, how to kick it in the gut. There is, of course, cognitive behavioural therapy (CBT), loved by Nice, the NHS and researchers alike, as it proves effective again and again, quickly, and thus cheaply. Find someone with specific training in CBT — your GP can refer you.

The other approach is something called the Lightning Process. I am aware this sounds like some dreadful hippy shamanic ritual. But it is not. This three-day course saves people by teaching them how to think differently, more healthily. It deploys some aspects of CBT while combining it

Telling yourself, ‘I’m having a heart attack, I’m terrified’?

Tell yourself something else

with all sorts of other techniques, including visualisations, neurolinguistic programming (NLP) and hypnotherapy. A kind of 3D CBT. It was this that made me realise — ten years into anxiety — that I had a choice, that I could do and be something else.

The other approach is to go deeper, to look at your past and your subconscious, to understand how you got into this state.

With psychodynamic psychotherapy or psychoanalysis, or just counselling, you can start to understand who taught you to be anxious. Because someone did.

The second column is even more hippyish. I’m not going to apologise again; you will thank me in the end. So: try (2) yoga. Try pilates. They will at least have some effect. More useful, I suggest, is meditation, mindfulness and breathing techniques. Personally, I favour a method called Transformational Breathing as it’s quite tricky, thus forcing you to focus

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on your breath, taking the best from all three approaches. But you are not me.

Explore them all. Go to a class. Watch demonstrations on YouTube. It doesn’t matter. Just try it and continue; practice is everything. Remember, you’re learning to be sane. No one became a concert pianist after one attempt at Für Elise.

Next, exercise (3). Your brain and body, even without the madness, need it.

You need it more than anyone. All that adrenaline and cortisol coursing through your system all the time? They needs to go somewhere, and that will allow more calming hormones to be released. Some favour short intensive bursts of cardio.

Others prefer gentle resistance training.

Whatever works, do it, and do it regularly.

(4) Food and sleep come next. If you constantly down coffee and/or alcohol, you are asking for anxiety. Ease yourself off them. Similarly, eating a lot before you got to sleep will give you a fitful night, upping your chances of anxiety the next day.

Regulating your blood sugar is vital — the link between low blood sugar and anxiety is strong and well documented. One causes the other, a looping nightmare triggered by twin evils. Small, regular meals containing complex carbohydrates that release glucose slowly will help. Stay off the sugar.

Finally, assess your environment (5).

This is overlooked far too often. You need to look at your life — your job, your relationship, your lack of relationship, your home, your friends and family, your finances — and examine what is exerting pressure, what might be feeding into the anxiety loop. Bear in mind something else that is important about the nature of anxiety: in some regards it is not an emotion at all, but merely the surface response to another one. Sometimes we engage in anxiety as a distraction, to avoid something more painful. Perhaps your father never loved you and still tells you that you are nothing. Maybe your career is dull and boredom is intolerable for your intelligence. Is your partner undermining you? Whatever it is, it’s welcoming in anxiety like a trusted friend. I became a journalist because it turned out writing was sufficiently engaging to keep anxiety away.

It’s your life; drastic action may be needed to change it. By continuing as you are, you are sending yourself the message that you do not deserve happiness. If that is your core belief, you need therapy, fast.

This is a huge project, a mosaic of many pieces. Parts will fail. But overall, by fighting on all fronts, you will win. And there is no peace like victory.

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Sunshine on wrinkles Three quarters of skin deterioration is induced by light exposure.

Go figure, says Dr Justine Hextall

N

othing concentrates the mind of a 23-year-old medical student more than the failure to buy a drink in a bar. I was on my elective in Australia; a two-month period spent pursuing a career-enhancing topic of one’s choice. I chose sunshine, beach sports and alcohol. Sadly the last one was eluding me. Every Australian barman seemed to think I was no more than 16 years old. It’s hard to be sophisticated nursing lemonade.

While there I learnt to perform a mental adjustment, adding about seven years in age to everyone I met. Those looking 30 were probably my age. I concluded this was the effect of sun exposure.

From that time to the present day I have worn factor 50 sun cream every day, even when it’s raining in November.

If you’re a health page aficionado, you’ll be shouting about vitamin D, or lack thereof. Trust me, I have thought about it. I expose my arms and back to the sun for about 20 minutes. This amount of UVB exposure in summer is enough. I make sure I don’t burn, and I never sacrifice my face. I supplement with vitamin D3 in the winter months — not D2, it is less effective. Sunshine is a wonderful medicine.

It improves our sense of wellbeing, lowers blood pressure and treats a myriad of skin conditions. But like most medicaments, it depends how you take it.

You don’t need to persuade a dermatologist of the damage sunlight can do. Patients are surprised 38

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I wear factor 50 sun cream every day, even in November

when I point out that around 80 per cent of skin ageing is induced by light exposure. The demarcation between head and neck and trunk in some people is dramatic. Deeply tanned, lined Keith Richards lookalikes sometimes conceal alabaster-smoothskinned bodies beneath their clothing.

WHAT CAUSES US TO AGE?

The processes are multifactorial. The genetic theory of ageing is that our cells have a predetermined lifespan, coded by genes in the same way that, for example, our height is. This theory is borne out by studies that have shown identical twins to have similar lifespans, more so than non-twin siblings.

SO HOW IS LONGEVITY INHERITED?

One genetic theory of ageing revolves around 9 MAY 2015 | SPECTATOR HEALTH

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telomeres. These are repeated segments of DNA which sit at the end of chromosomes. The number of repeats in a telomere determines the lifespan of a cell. The longer the telomere, the longer the lifespan.

Telomeres shorten with each reproduction of a cell. Once they have been reduced to a certain size, the cell reaches a crisis point. It can divide no more, and it dies. So the length of the telomere that you are born with determines the lifespan of your cells.

Of course, it’s not that simple. The processes of cell growth and division that exist in all living things involve a complex sequence of events prone to error with time; changes in the genetic blueprint known as mutations. The effect of mutational change may be a degradation of the information being passed on; in terms of ageing, consider the slackening of blood vessels, the loosening of the jawline. Occasionally

mutations may result in the genesis of a cancer; something more prevalent in the older population.

Non-genetic theories of ageing relate to environmental exposures, or ‘wear and tear’ — for example sun exposure and smoking. Loss of elasticity in skin, tendons and blood vessels due to damage of the collagen that forms an integral part in the structure of our skin. The immune system has been implicated in ageing — a process whereby it starts to attack our own cells. And there is evidence that sugars bind to and cause damage to cells in a process called glycation.

It is well known that ultraviolet (UV) light causes skin damage. But one common misconception is if we are not suffering sunburn, then we are not damaging our skin. This isn’t true. UV-B

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Shore thing: leave sunbathing to reptiles or end up looking like one

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(UV-Burning) causes skin redness and blistering in excess, but UV-A (UV-Ageing), while not causing obvious damage at the time, causes skin cancer and is more destructive in terms of skin ageing. UV-A damages our skin’s deeper layers, affecting the structures that keep it firm and youthful.

Other wavelengths from the sun such as Infrared-A penetrate deep into the skin. These rays cause free radical damage that cause the upregulation of an enzyme called MMP-1 that we know breaks down collagen and elastin. This same enzyme is upregulated by smoking and explains the similar skin changes we see in smokers. Most conventional sun creams do not contain the antioxidants that protect the skin against infrared damage, but a new brand called Ladival Sun Protection does offer this.

What makes us look older? Wrinkling isn’t top of the list. A study published in 2014 in Clinical, Cosmetic and Investigational Dermatology gathered 120 female participants aged 41 to 49 and had six dermatologists determine the signs of age. Loss of volume around the nose and mouth, followed by skin redness, pigmentary changes and skin texture all came above wrinkling as a marker of age.

Look at the face of your dermatologist or surgeon.

This may be their ideal – but is it yours?

SO HOW DOES ONE STAY LOOKING YOUNG?

Wear a broad-spectrum sun block, such as Ladival, that protects against UVB, UVA and Infrared-A to reduce sun ageing. Leave sunbathing to reptiles or you’ll end up looking like one. If you are in the sun, sit with your back to it, seek shade and wear a widebrimmed hat and UV-protective sunglasses. Sort out a good skincare regime. Use a very gentle skin wash: keeping your skin pH slightly acidic protects your skin barrier, which reduces redness and keeps skin hydrated and youthful. Drink water, preferably

with lemon in the morning. Eat plenty of fruit and vegetables. Regular exercise at least three times a week will make an enormous difference.

For the platinum anti-ageing customer, consider the discussion at the annual American Academy of Dermatology meeting in March 2015. The focus was on light-reflective sun creams and antioxidant supplements to mitigate against free radical damage caused by sunlight, smoking and pollution. We need plenty of vitamins C and E and carotenoids. Also start looking for niacin, soy, resveratrol, coffee berry and lycopene. The consensus seemed to be that by reducing inflammation and free radical damage to skin, we not only slowed down but also reversed some of the signs of ageing.

For those considering a more interventionist approach, take this approach. Look at the face of your dermatologist or surgeon. Remember that this is their ideal, but is it yours? Personally I don’t want to be so tight and shiny that I look like I’ve been embalmed. Also, remember everything is relative; plumped 18-year-old lips will make a 50-year-old face look 70 unless it too has been, shall we say, refreshed.

Human beings are expert at facial recognition.

The fusiform gyrus in the temporal lobe is devoted to it. We are programmed to recognise the smallest changes. An overtreated face becomes blank, identikit, antithetical to the human perception of beauty. Clever tweaking, with an emphasis on skin glow, works wonders. But less is always more.

Who better to end with than Socrates? When he said ‘beauty is a short-lived tyranny’, he clearly didn’t realise that, given the chance, it seems women and increasingly men are in it for the long haul.

Dr Justine Hextall FRCP is a consultant dermatologist.

UV and infrared penetration into the layers of the skin

UVB rays

Infrared and UVA rays

Sunscreen Epidermis

Dermis

Hypodermis

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Sex and relationships

Happiness is…

… different for men and women, say Christine Webber and Dr David Delvin. Which is where the trouble begins

H

appiness has become a serious health issue. If you Google the words ‘happiness and longevity’ you’ll get over a million results — and while many of the claims will be spurious, you’ll find plenty of scientific evidence that being happy is good for you and probably helps you live longer.

Whether or not this convinces you, you almost certainly want to be happy anyway.

So what are the basic ingredients for happiness? And do the same ones work for both genders?

A study in the rather sweetly named Journal of Happiness Studies has reported that when asked what made them happy, three of the four things men mentioned far more often than women did were sport, being liked and having a good social life (doubtless involving alcohol). The fourth, you may not be surprised to hear, was sexual activity — which does appear from all the studies to be undeniably important in keeping the average man happy.

But is it as important to the happiness of women?

Increasingly, women do want a satisfying sex life too, and many now have the same opportunities as men for finding willing partners. Their contentment, however, is quite a complex matter.

One of us (CW) conducted a survey among women about what they wanted from life. Perhaps predictably, a loving relationship came top of the wish list.

But they also wanted much more time and space for themselves, plus contact with children and grandchildren and lots of holidays. Additionally, and very importantly, they wanted to be taken seriously and listened to.

Until the second world war, malefemale relationships hadn’t changed much since Jane Austen’s day when there was a

definite quid pro quo: men were provided with food, sex and laundry and women acquired status and security. But as women have become more educated and able to provide for themselves, they often expect less in the way of financial provision but much more equality, companionship, romance, love and conversation.

Byron believed that ‘Man’s love is of man’s life a thing apart/ ’Tis woman’s whole existence.’ Yet what we’ve learned in our consulting room suggests that men’s relationships are now more integral to their lives and happiness than they once were, while women’s relationships are no longer their entire reason for living.

For both genders, though, adults in

Women’s contentment is quite a complex matter relationships tend to be happier than those who are not. A 2013 study on the nation’s wellbeing by the Office of National Statistics showed that married people, or those in civil partnerships, were the happiest, rating their life satisfaction on average at 7.8 out of 10. Cohabiting couples came next with 7.6, followed by widowed or single people with an average of 7.25. Last came divorced and separated adults who rated their happiness at 6.8.

So relationships have great potential to increase happiness — but they can also be a huge source of unhappiness.

Most men who are extricating themselves from unhappy relationships tell us that there was insufficient sex — particularly of the joyously passionate variety. As a result, they report feeling unwanted and undervalued. And those men we see who are being rejected in the

Christine Webber’s ebook Get the Happiness Habit, published by Bloomsbury Reader, is out now.

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marital bed often believe that the reason for this is physical. They say: ‘I expect her new lover has much bigger equipment.’

Or: ‘When do you think she began to find my penis inadequate?’

The truth is that most women leave men for very different reasons, though when we point this out, the average male looks unconvinced. In fact, our female patients generally tell us they’re ending a relationship because of a lack of communication and companionship — and because they’ve never felt ‘listened to’.

One couple we saw recently typified what can go wrong. The man demanded that we ‘fix’ his partner so that she’d be as enthusiastic about sex as when they had met a decade before. She told us that he showed no interest in her, and that she did not feel inclined to have regular sex with him until he treated her like a person rather than a plaything. The breaking point had occurred not long before when he’d poured her a cup of coffee one morning. This roused her to fury because he hadn’t noticed she’d stopped drinking it five years ago. On such trifles are whole families torn apart.

After years of treating people’s sex and relationships problems, we believe that a heck of a lot of unhappiness could be avoided if adults focused on what they like about their partners, rather than on their shortcomings. We’re also convinced that couples would be much happier if men took the trouble to ask about their partner’s day — and listened to what she said — and if women routinely and enthusiastically said: ‘How would you fancy making love later?’

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Well worried

At your convenience There’s nothing more discombobulating than a night visit to someone else’s toilet, confesses Maureen Lipman

F

ive weeks on tour with Harvey the play, followed by a week at home and two days at a spa hotel with my chap, has discombobulated my nocturnal wanderings. I can’t remember which side of the bedroom leads to the bathroom, where the light switch is and, frankly, whether I’m alone or there’s another mound in the bed when I finally find my way back to it at 4 a.m., piercingly awake.

Then there’s the loo. Up on a carpeted rostrum or sunk into a meaningless marble rectangle? Does the seat slowly descend or crash resoundingly? On one recent trip to Loo-Loo Land, bleary from too much herbal sleep-tincture, I managed to trap my thumb between the seat and the toilet rim and sit down on it heavily. It was excruciating, and I did what one always does when in pain and alone: nothing.

Just sat there, throbbing, with a daft expression on my face and a single tear rolling down my cheek. My character in Harvey, the socially conscious Veta Louise Simmons, bore a fat navy-blue thumbnail from Malvern to the opening night at the Haymarket.

Which leads me to the flush. Push button, two settings or ensconced behind the lid and requiring two hands? Irritating enough in daylight, positively dangerous when accompanied by the hooting of owls. A broad flat button on the top of the cistern, a stiffly resisting handle on the side or the mock-Edwardian chain-andporcelain dongle you get in a ‘boutique hotel’ — i.e. a former pickle factory which let Laurence Llewelyn-Bowen in with a lorryload of Farrow & Ball?

Theatre toilets, of course, are always archaic. Two cubicles at most in the ladies’ and ten women crossing their legs as the men skip back to the auditorium and the curtain goes up. Most of these theatres

were built when women still wore corsets and vast hooped skirts. I often wonder if they didn’t sport some kind of device under there, so they could quietly relieve themselves at their seats while Beerbohm Tree was giving his Richard III. Once, on an island vacation, we met a merry family on the beach with a holiday home nearby. They invited us for tea, during which I excused myself to go to the euphemism. Sitting there in mid-flow, I glanced up at the mirrored door to see their whole family and mine standing inches away, pointing and laughing at me.

I almost passed out. In truth it was a twoway mirror on the door; I could see them but they couldn’t, it turned out, see me.

It was their little private joke for guests.

I glanced at the mirrored door to see the whole family pointing and laughing at me This guest went into rictus, couldn’t move for 15 minutes and spent the rest of the holiday avoiding her merry hosts.

Toilets have evolved surprisingly slowly since the 16th century, when John Harington, courtier, writer and master of art, invented the flushing water closet and installed one for Queen Bess (who wasn’t impressed). Except, that is, in Japan.

The Japanese, so up-front about saunas and showering, are notoriously coy about excretion. Their lavatories have a remotecontrolled seat that not only plays white noise to cover the dark noise, but also thoughtfully warms your bum.

A heated loo seat is genius. Remember your grandmother’s frozen lavvy in the outhouse with the wind whistling through

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the open window, spiders lurking and squares of the Daily Mirror hanging from the wall on a string? Later that night, if you were especially flexible, you could read ‘Ruby Murray’s “Softly Softly” Climbs the Charts!’ printed blurrily on your own backside.

And cut seamlessly from that scene, scored by a brass band, to your puzzling introduction to a bidet on your first hotel holiday. ‘It’s to wash out your smalls,’ said my mother — and she meant it. My children, more well-travelled, never questioned the bidet in the hotel bathroom. Indeed, on holiday in the 1980s in Cyprus, where the pop song ‘Last Night a DJ Saved My Life’ played nightly during the buffet dinner, my seven-year-old son asked, ‘But how? How did the bidet save her life?’

In 2015, as driverless cars prepare to hit the roads and people 3D-print their own loft extensions, I marvel that we still have toilet cubicles so poky that to get out you have to back up against the loo and take a contortionist’s squeeze round the inwardly opening door, before bursting forth across an empty space the size of a squash court to get to the sinks. The sinks. Do the taps gush forth when they sense your approach and will they ever turn off again? Is the hand dryer a slow weak blast that takes six minutes to bake soap onto your hands or the terrifying dipping-in one that flays the skin from your bones? I could go on — don’t get me started on loo rolls: I would need 50 different samples, a cute labrador puppy and someone to origami the last sheet to really make the point.

Perhaps the truth is that we’re ambivalent about progress. Give me an empathetic bathroom designer — but don’t ring too many changes. In the middle of the night, I like to know where I am.

9 MAY 2015 | SPECTATOR HEALTH

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30/04/2015 11:25

‘The “my cat/dog/alpaca smelled my cancer” trope is well-established, but it is, as far as I can see, codswallop.’

For health news without the hysteria, read the Spectator Health blog.

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