Comparisons with Cuba

For the past ten days I have been your man in Havana; although I confess that it was not quite in the true Graham Greene style, insomuch as I was neither selling vacuum cleaners nor recruiting agents for the Secret Service (although, in keeping with Greene's fictional character, I did develop a distinct liking for a rum cocktail called a daiquiri). What I was actually doing (between the daiquiris) was comparing some interesting vital statistics; for the avoidance of any doubt, I am referring to the public health and economy type of statistics. The results of my enquiries make for some startling comparisons between Cuba and England (for example, I cannot find a decent daiquiri since returning to England).

    In economic terms, Cuba is officially recognised as a third world country; shortages of every commodity, from food and clothes, to computers and cars younger than 60 years old are common, and all Cuban households still have ration cards for every day essentials. Cuba's population in 2008 was 11.25 million in an island just half the size of the United Kingdom, or almost the same as that of England, and compares to a current population for England of just over 51 million. Most Cubans live in houses or apartments provided by the state, and the average monthly salary of 420 pesos (equivalent to about £13) leaves nothing for what we would consider to be the luxuries of life. By comparison, the 2008 average disposable income per household in London was £19,038 (£1,586 per month) and £12,543 (£1,045 per month) in the north-east of England (Office for National Statistics).

    Another newspaper recently ran an interesting article highlighting the North-South health divide in England (The Independent, 16 February 2011). The article reported on a study which has shown that people in the north have a 20% higher chance of dying before the age of 75 compared to those living in the south. This is despite £20bn being spent by the last government in an attempt to narrow the north-south divide. The cause has not been blamed on lifestyle factors such as smoking and drinking, but on the amount of disposable money available to a person.

    However, for me, having been to Cuba, there is something missing in the reasons given for the health and socio-economic problems facing us in England. According to the United Nation's 'crude death rate figures' for 2005-2010, Cuba, for all its economic difficulties, has an average life expectancy of 78.3 years (compared to 79.4 for the UK as a whole), and a mortality rate of 7.6 per 1,000 (compared to 9.9 per 1,000 for the UK). Infant mortality (which is always a sensitive indicator of good health care) is 5.1 per 1,000 births for Cuba, which is only slightly higher than the 4.8 per 1,000 for the UK. In Cuba, there are 5.9 doctors per 1,000 people, compared to 2.2 per 1,000 in the UK.

    Another interesting statistic concerns the literacy rate. In Cuba the literacy rate is 99.8%, compared to 99% in the UK (United Nations figures for 2009). The higher figure for Cuba has been due to a concerted education drive, with a 'literacy army' of teachers being sent into the poorer areas of Cuba.

    If the statistics are to be believed, money alone is not the answer to the UK's health problems. From personal observation, many Cubans live in basic accommodation, have little money, are overweight, smoke cigars, eat excessive quantities of sugar, and drink a lot of rum; yet they exude a sense of happiness, and enjoy longevity. For all his alleged faults, Fidel Castro seems to have got something right in Cuba that we are yet to achieve in England. Unless it is all down to the daiquiris; I might just explore that theory a little further.

 

This article was first published in the Scunthorpe Telegraph, Monday, 28^th February 2011.

Goodbye, Dr Finlay?

Writing in the 4^th century BC, the Greek philosopher Socrates came up with a piece of wisdom which seems an apt aphorism for these present, chastening times. He wrote:

'Remember that there is nothing stable in human affairs; therefore avoid undue elation in prosperity or undue depression in adversity'.

With the publication of the Health and Social Care Bill on the 19^th January, I am trying to remember those words of Socrates, although in this case I cannot help but think that there may be extremely good reasons to be justifiably pessimistic. Perhaps I am too cynical, having become worn down by three decades of sailing on the NHS sea of constant change and reform.

Nonetheless, I cannot help but fear for the future of the National Health Service; or more to the point, I fear for the intimate caring nature of the service which generations older than me will remember with some fondness through the rose-tinted characterisation of programmes such as Dr Finlay's Casebook. That said, I would be one of the first to say that even I was delighted not to have to work round the clock anymore when, as a general practitioner, I was able to stop night work and weekends a few years ago. After all, years of working 120 hour weeks do take their toll; I would not wish to return to such times.

However, aside from all the glowing nostalgia of yesteryear, I genuinely fear for the role of the family doctor within the evolving world of the NHS. Note that I said 'family' doctor, for it is there that change is likely to be most felt by patients; perhaps more so than at any other level of the NHS. I have no doubt that the doctor who practises as a generalist will remain in demand, because it is within the general practice setting that the vast majority of health care takes place. What is likely to continue changing is the intimate knowledge a doctor gains of generations of families during his or her thirty or so years practising in the same town, seeing the same people year on year. The wisdom a doctor receives from older partners in respect to previous generations is invaluable when caring for subsequent generations of the same families. It is a form of 'corporate knowledge' which gets passed on from one practitioner to the next during tales told over a hastily snatched cup of coffee during the progress of the morning surgery, and then added to by further experience. I have often found such learned information of great assistance in forming a professional 'special relationship' with patients, which in turn enables a genuine degree of empathy to be offered in respect to the various ails and misfortunes which life presents to us all. That is something all the government reforms can never rebuild once it is lost to society.

Nevertheless, having expressed such a morose view of the future, there has been a source of humour amongst the 'on the hoof' proclamations from Westminster in recent times. The debacle over the influenza vaccines is the source of my amusement. GPs have been blamed by the Department of Health for the lack of vaccines this year. We get used to such blame-shifting, so no real concerns there. However, the government then went on to suggest that it might take the future ordering of the vaccines out of the hands of GPs to avoid future 'debacles' of the same nature. Will the wise readers of this column please explain to me how that sits alongside the concomitant drive to hand GPs control of 80% of the NHS budget? In medical politics truth remains stranger than fiction.

This article was first published in the Scunthorpe Telegraph, Thursday, 3^rd February 2011

Patients, Doctors and Writers

I have been called many things in my life and, although my memory likes to pretend otherwise, not all of them have been complimentary. However, one epithet that has cropped up several times in print over the past couple of months is that of 'literary GP'. That is one soubriquet I am happy to wear, feeling that my modest attempts at becoming known as a 'man of letters' just about scrapes through to justify the description. The part I find harder to consider is the very flattering, albeit hyped, comparison between me and great writers such as Wallace Stevens and T S Eliot; both of whom continued with day jobs whilst writing (they were a lawyer and banker respectively).

Nonetheless, the reporter who kindly made the above association within the Scunthorpe Telegraph (25 Nov 2010) not only fleetingly bolstered my ego (thank you), but additionally raised the question in my mind as to how many writers and poets are, or have been, medically qualified. A quick search of the literature revealed an estimate that, since 1930, about 0.0019% of doctors in the United States of America have also been poets (BMJ, 11 Dec 2010); which, I have to say, doesn't sound very many. Nonetheless, continuing the quest I came across several names, many of which will be commonly known.

One of the first, of course, was St Luke; a physician and writer of the gospel by the same name. Other, more contemporary names, include Oliver Goldsmith (The Vicar of Wakefield), John Keats (Ode to a Nightingale, etc.), Anton Chekhov (Russian playwright), Sir Arthur Conan Doyle (Sherlock Holmes stories), David Livingstone (travel writer), W. Somerset Maugham (Of Human Bondage), Axel Munthe (The Story of San Michele), William Carlos Williams (American prize-winning poet), A J Cronin (The Citadel), Graham Garden (The Goodies), Richard Gordon (Doctor in the House), and so it goes on. Needless to say, apart from the possession of a medical qualification, I cannot even begin to compare myself to any of the above (perhaps with the one tiny exception of Chekhov, whose birthday I share one hundred years later to the day). Realistically, I can only resign myself to the act of clutching at the coat tails of greatness.

Now, you may well ask where all this is leading. The answer is right back to you, the reader. For, apart from being a patron of today's newspaper, you are also, or have been, or will be, a patient. All of the aforementioned writers and poets have had the benefit of dealing with that constant conundrum of how to make sense of the human condition. Patients have been the daily source of characters, stories, insights and inspiration that have in turn encouraged the production of some wonderful works of literature. Thanks to you all, that particular mine is inexhaustible. It is said that the world of fiction only contains seven basic plots. However, you all bring your own individual variations of those themes to the doorsteps of physician-writers, for which my writer colleagues and I should be most grateful. Whether we are patients, doctors or writers (or any combination of the three), we are all trying to understand what it is to live and be human. For me, the art of poetry is to distil that quest into the fewest and richest words possible. So next time you have to attend a surgery, just remember that your woes may actually be the inspiration for a great work of literature. Failing that, you might at least be helping to keep our draughty garrets warm.

This article was first published in the Scunthorpe Telegraph, Wednesday 26^th January 2011.

Preliminary Reflections of a Responsible Officer

It is now nine weeks since I, in my existing capacity as Medical Director for a Primary Care Trust (PCT), was appointed a Responsible Officer.

Now, I would like to pretend that the position was fiercely fought over, with many applicants of a high professional calibre, and that only by virtue of my greater skills and experience was the Appointments Board so impressed as to be eager to secure my services. As many other Responsible Officers will no doubt concur, the truth is actually far from the latter, and in most PCTs the existing Medical Directors have been shoe-horned into the role for the sake of expediency; essentially in order to meet the Government's deadline of having a Responsible Officer appointed by the 1^st January 2011. No doubt it has been the same process for the acute trusts.

Nonetheless, here I am. For the first time since retiring from my army commission eleven years ago, I am an officer again. Not only that, it is now official that I am a responsible one; a title which, for reasons best known to themselves, caused both my wife and my medical partners to unite in previously unknown depths of merriment.

However, despite the aforementioned cynicism, for the past three weeks I have dutifully donned my mantle of responsibility and sallied forth, prepared to be...well...responsible; and therein lies the problem. What, I have found myself asking on an almost daily basis, am I currently supposed to be responsible for? Feeling as though I am the epitome of the idiom 'all dressed up and nowhere to go', I have plundered such sobering documents as HM Government's 'The Medical Profession (Responsible Officers) Regulations 2010', the Department of Health's 'The Role of Responsible Officer: Closing the gap in Medical Regulation – Responsible Officer Guidance', and the General Medical Council's document 'Revalidation: The way ahead', searching for inspiration and guidance. It is true that there are, within the aforementioned formidable tomes, many pages of legalese and aspirational directions that are no doubt supposed to clarify the nature of the undertaking. However, with the general turmoil the NHS is currently enduring, along with the still less than clear future format for so-called 'strengthened GP appraisals', and indeed a continuing fog around the precise manner in which the process of revalidation will happen, the diligent fulfilment of the role of Responsible Officer seems to be a somewhat Sisyphean task.

Questions abound, not least of all: will the present Responsible Officers retain a role when the PCTs are abolished in 2013, and if so, to whom will they be answerable? Will they be employed by the GP Consortia, or linked through to the Commissioning Board? Other conundrums are: who revalidates the Responsible Officers?; can a Responsible Officer continue to act as an appraiser for GPs, on behalf of whom he (or she) will eventually provide statements to the GMC in respect to revalidation?; and can a Responsible Officer act on behalf of partners within his (or her) own practice? The more one considers the subject, the more the whole process is seen to be fraught with the huge potential for conflict of interest. Untangling these labyrinthine riddles is currently a challenge for the Strategic Health Authorities; thereby in itself lending an interesting extra dimension to their own Danse Macabre.

So, in summary, nine weeks into the job, I know from the Oxford English Dictionary that being responsible means that I have an 'obligation to do something' and that I now 'have control over someone'; other than that, I remains in a state of obfuscation. It will be fascinating to see how long it takes for enlightenment to occur. Meanwhile, I will endeavour to maintain the illusion of conscientious behaviour as befits my newly anointed status.

Postcard from Cuba

It is a land of fascinating dichotomies; a process that started in the arrivals hall, where tourists, supposedly vital to the economy of the island, are led through a complex customs and immigration process which takes two hours to complete.

'Take no notice', says our Afro-Cuban guide; 'we want you to feel welcomed. It is very safe here; you can walk into the town in the evening without any fear.' Jorge, our native Hispano-Cuban driver, evidently doesn't feel quite the same degree of security, and is over-heard negotiating with a couple of local lads who, for a few pesos, will guard the car overnight.

Havana reinforces the perception of a living duality. The four-star hotel looked opulent in the fading light of day. However, we should have been prepared for the tea to turn peppermint green at breakfast the following morning when, the evening before, the barman was unable to mix a pina colada for the want of pineapple juice, the wash basin had no plug, the piping-hot water trickled from the showerhead and the electrical voltage dropped so low that unpacking became an impossible task. Black tea is evidently only one of many scarce commodities.

For an island which continues to have a political stand-off with the USA, the reverence of the people for the memory of the American writer, Ernest Hemingway, is intriguing. In places such as Cojímar he is almost revered; yet, though the country boasts a literacy rate greater than that of the United Kingdom, Hemingway's books, as with all printed materials, are hard to obtain and too expensive for the average Cuban, who battles with an economy of two currencies. Paid in worthless pesos, anything of value can only be purchased with the Convertible Peso; the currency of the tourist.

After a few days in Havana, the comparisons continued in Cienfuegos and Trinidad, which vie for the award of best preserved town. The central squares are surrounded by beautifully maintained colonial buildings of Spanish extract. However, the view from the hotel rooftop reveals a different story. The imposing historic facades take on the appearance of film sets as one observes the poverty of the shanty dwellings tightly clustered immediately behind the spacious and immaculately kept public spaces.

The motorways are also revealing. Passing though vast tracts of fertile land so inadequately farmed that food is still rationed, the tarmac stretches for mile upon empty mile, devoid of transport save for a few modern tourist taxis and a scattering of ponderous sixty-year-old Cadillacs; all eagerly hailed by gaggles of local villagers hopeful of a lift to work. Every so often, bill-boards carry reference to the ideals fostered by the revolution of the fifties, and the iconic image of the long-deceased Che Guevara continues to be used as an attempt to inspire the contemporary population; the current political leaders are only conspicuous by their invisibility.

Meanwhile, in numbers too great to count, the ubiquitous turkey vulture circles ominously overhead, like an American metaphor waiting for Castro.

Thought for the Day

It is not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is the most adaptable to change."
- Charles Darwin

Thought for the Day

'Remember that there is nothing stable in human affairs; therefore avoid undue elation in prosperity or undue depression in adversity.'

Socrates, Greek philosopher, 470-399 BC.

Warding Off the Bugs

'Hello, Doctor. How are you?'

It is a phrase which is rarely heard, but when it is forthcoming the questioner, usually in the form of a patient entering my consulting room, immediately scores a few points. After all, shouldn't it be the other way round? Isn't it my role to ask them how they are? The mere idea that someone is showing the slightest concern as to the well-being of their doctor is always received with a sense of gratification; although I usually have to ward off the desire to respond with a list of complaints: 'not too good – tired all the time, back ache and repetitive strain from over-use of this computer, stressed from too much work, and the Secretary of State for Health doesn't understand me...'

However, it is generally true that, as a profession, GPs are a fairly healthy group of professionals and when we do succumb, it is usually to something fairly dramatic like heart attacks, bleeding ulcers, brain tumours and so forth. Not for us the fortnight off with a box of tissues and a glass of lemon and honey. Which leads me to the question as to why that should be so? I, for one, cannot remember the last time I needed antibiotics for sinusitis, bronchitis, tonsillitis or some similar infection.

Now, I am not for one moment suggesting that GPs are somehow imbued with an invisible cloak of invincibility. It is not that the adornment of a stethoscope acts like a magic amulet, warding off all assault by infective bugs (in the same way as a red-cross arm band worn by army doctors wards off rockets fired from hundreds of miles away). Neither is it that we have a turbo-charged immune system, upgraded as a perk of passing our exams. The truth is fascinatingly simple, and I will now share the secret with you all as a perk of your patronage of this newspaper. It is:

WASH YOUR HANDS

There, I have said it. Now, you too have the power to be infection-free, and no longer need to spend Fridays trying to see a doctor for a course of antibiotics before the weekend.

Without wishing to cause an outbreak of obsessive-compulsive disorder in North Lincolnshire, you need to think smartly and realise that these crafty bugs are everywhere you go. They are on your office telephones and keyboards, the door handles to your favourite shops and cafes, the escalator handrail, the buttons in the lift, your friend's mobile phone, and the money in your pockets. We cannot steer clear of them. However, what we can do is to avoid transferring them to our nose and mouth, where they will thrive and you will suffer.

The simple rule is, do not touch food or drink, or let your fingers anywhere near your mouth or nose (even to rub or scratch it) unless you have recently washed your hands.

Simple, isn't it? Now, with the addition of a few years of studying, you too could be a healthy doctor.

This article was first published in the Scunthorpe Telegraph on Friday 17^th December 2010

Don’t Be A Winter Ostrich

There is something about winter that makes ostriches of so many people (except that at present they have to stick their heads in the snow rather than sand). Even after twenty years in general practice, it is something that never ceases to amaze me. What is it that I am speaking of? It is the simple issue of people not wishing to protect themselves against a potentially serious infection, and the infection I refer to is influenza.

As a doctor, it concerns me that less than 50% of the eligible population of North Lincolnshire have had the influenza vaccine this year. Put bluntly, being 'eligible' basically means that you have a significant risk of dying from influenza and its side-effects. So, if that is the case, why do people choose not to protect themselves? Simply assuming that you are super-immune to influenza simply because you have not caught it for so many years doesn't guarantee your survival. I have never had the misfortune to be knocked down by a car; but I still take the precaution of looking both ways before I step into the road; if I do not then one day my folly will catch me out, at which point it will be too late.

In an average winter, there are 25,400 more deaths in England and Wales than at other times of the year. The precise death rate depends on various factors, including the temperature. However, influenza is implicated in many of these deaths. The peak period is between December and March, so we are now entering that time; and as you are aware, it is very, very cold.

Everyone who has not been immunised has the chance of catching influenza. However, amongst those most at risk are children and adults with asthma or diabetes, those with heart disease, anyone whose immunity is reduced (e.g. because of treatment for cancer) people over the age of 65 years, and pregnant women. Anyone within those categories should seriously consider having the influenza vaccine as soon as possible. Carers and health professionals should also be setting the standard by getting themselves vaccinated; by not doing so, they are putting other people at added risk.

The serious side effects of influenza include bronchitis, pneumonia, exacerbation of asthma, convulsions, heart failure, and encephalitis (inflammation of the brain). I am sure that you would agree that none of these sound particularly trivial, and they are not. They are very distressing to the sufferer and the observer, and often cannot be cured. On the other hand, the side effects of the vaccine are usually very mild or non-existent despite all the myth surrounding it.

So, let us not think of the risk of death from influenza in terms of statistics. Consider instead individual human beings known to you. If you are not personally in the high risk categories, do you have a relative or friend who is? Have they been vaccinated against influenza this year? If not, start nagging them to go and get vaccinated. Let us face it, none of us would wish our elderly parents, our children with asthma or diabetes, our husband with heart disease, or our pregnant wife to be one of those 25,000 extra deaths this year. However, without the influenza vaccine, they are at significant risk of becoming one of them. I know I would not want that on my own conscience.

(This article was first published in the Scunthorpe Telegraph on Wednesday 8^th December 2010.)

Something for After School, Young Man?

One month ago, Pope Benedict XVI announced that the use of condoms may be morally justified 'when the sole intention' is to combat the spread of AIDS. My immediate response was to ask 'so what?'

As I am writing this column in my capacity as a physician, this is not the place for me to start a religious debate, and I certainly have no wish to upset anyone. However, whilst the Pope's edict may influence the use of condoms in parts of the world, I feel sure that it will do very little to improve condom usage in this country; especially amongst our younger members of society where such improvement is desperately needed.

Two months ago it was announced that the teenage pregnancy rate in the United Kingdom has fallen from 46.6 per 1,000 in 1998, to 40 per 1,000 in 2010. Whilst we should be pleased to make any improvement on this front, it remains deplorable that, in this country, there are 40,000 pregnancies per year in people under the age of 18 years. Although I am all for the United Kingdom taking the lead in respect to many issues the world's stage, having the highest teenage pregnancy rate in Europe is not an achievement to be particularly proud of.

Unfortunately (in respect to condoms), the majority of our young people are not influenced by the traditional teachings of the Roman Catholic Church. Neither (speaking from a Northern Lincolnshire perspective) are they greatly influenced by the risk of contracting AIDS, as the incidence of the latter is mercifully low in this region compared to some of our cities, and very low compared to certain countries in Africa. Nor do our teenagers particularly concern themselves with preventing other forms of venereal disease; except that is, in respect to Chlamydia infections. Though, with the latter, my perspective is that we also seem to have got the message over in the wrong way. Anecdotally, I come across teenagers informing me that they have responsibly taken another Chlamydia test (note the word 'another') as they have recently changed partners. Yes, that is good news to a point. However, if they were to use condoms in the first place then there would not be the same need for the Chlamydia tests. We are not doing very well in communicating the real messages.

The truth is, our sex education program is not working. Yes, there is a place for moralistic debate and reasoning, greater parental responsibility and informing youngsters of the health risks. However, there is also the pressing need to make condoms 'cool' in the eyes of those most influenced by fashion. Regardless of society's laws, or the best of moralistic and religious teaching, sex happens and will continue to happen within an hormonally fuelled younger generation.

Thus far, we health and social educationalists have got it wrong. Perhaps our sporting and celebrity heroes are the people to recruit in a renewed drive to relegate us from the top of this particular league table.

(This article was first published in the Scunthorpe Telegraph, Friday 3^rd December 2010)

Do You Have a Mo?

For one brief moment this month I thought I was a trendsetter; a man of the moment; a fifty-year-old icon of fashion.

What was the cause of the delusion that I had become a leading light in the world of masculine style? It was the realisation that upper lips were becoming hirsute; or at least some male ones were. As someone who has sported lip foliage ever since my teenage days (apart from when fellow students shaved it off during a university Rag Week in 1980), I was happy to form the advance party of 21^st century masculine chic.

Then I read about 'Movember'; the Canadian-based movement to raise awareness of prostate cancer. Now, for older readers of this column, the name Little Mo may bring back memories of the 1950s tennis star, Maureen Connolly. However, younger readers may be more familiar with the character from the soap opera, EastEnders. Nonetheless, I suspect that neither group will immediately guess that 'mo' is slang for moustache, and that these chaps are therefore in the process of sprouting a 'little mo'; hence the renaming of last month as Movember; witty people those Canadians.

So, you may well be asking what all the fuss (or fuzz?) is about. It involves the recognition that 35,000 men per year develop prostate cancer. It is the second most common cancer in men, with a 1-in-13 lifetime chance of developing it. 90% of cases occur in men over the age of 60, and there is a 2.5 times greater chance of developing it if there is a family history of prostate cancer.

That makes for some cheerful reading, doesn't it? However, before you decide all is lost, there are certain things you can do to help reduce your individual risk or improve your chance of responding successfully to treatment. Preventative measures include adopting the healthy lifestyle we keep hearing about, which means eating less saturated fat, meat and dairy products; all of which adversely influence the risk of prostate cancer.

The next action is not to ignore any urinary symptoms. Whilst problems with urinary flow and middle-of-the-night 'calls of nature' are familiar to many older men, do not ignore such issues, and certainly do not ignore the presence of blood in the urine: go and have a chat with your GP. Not all of these symptoms suggest prostate cancer, and (except for bleeding) may be caused by age-related growth of the prostate. However, your GP may recommend a blood test and possibly a scan; neither test being unpleasant to have.

Oh, and how is your sex life, chaps? According to Italian scientists, a healthy sex life makes men live longer. Apparently, sexual activity reduces the risk of heart disease and diabetes, and helps to avoid prostate problems.

So, gentlemen, although the month of Movember is now over, still give consideration to your prostate and go to it! I will leave you to decide whether that means growing a winter moustache; you may find some of the alternative activities are more enticing...

(This article was first published in the Scunthorpe Telegraph on Thursday 25th November 2010)