Tuesday, 9 October 2018

Placebos: more than fake drugs

I’ve been watching the BBC2 programme Horizon for over 50 years; it’s now in its 57th season and I have to say it continues to fascinate me in the same way as it did when a far-sighted David Attenborough introduced it all those years ago.

Recently, redoubtable medical journalist Dr Michael Mosley ran a trial on 100 people with chronic back pain. He pretended that half the group would get an active drug, the other half an inactive placebo. In fact everyone received the placebo, yet after 3 weeks, 45% of the group reported a significant improvement in their symptoms.

As a doctor I have seen the placebo response work on countless occasions. Obviously doctors cannot hoodwink their patients by giving them one while pretending it is active, though, amazingly, a number of patients improve even when they know they are getting the placebo. In fact some would argue that drugs which the doctors believe are active, such as Prozac, or old-school antibiotics, are actually working via this effect. And remembering that those drugs often have unpleasant side effects, it makes one wonder whether it might not be a better idea to give them a placebo to start with.

The most dramatic example of a placebo in action I have ever seen was at medical school, when a patient was injected with a dilute dextrose solution. Or that’s what she thought. In fact she was given plain, distilled water. But the reaction was astounding. Within a minute of the injection, the patient’s face became swollen and purple, she began to shake uncontrollably and within two minutes had collapsed unconscious. She experienced a phenomenon called “angio-oedema” a catastrophic reaction sometimes associated with severe allergy. But you can’t be allergic to water: our bodies are 90% water after all. So what happened? To be honest, nobody knew then and nobody knows now.

The placebo response is still poorly understood. In the test group above, why did 45% of the group experience an improvement, while 55% did not? The response is independent of age, IQ or social
background. As a doctor I’ve long recognised that if you give a patient something along with a forceful promise that it’s going to do the trick, it is far more likely to work than otherwise. If I was still working now, would I offer people placebos with the words: “Look, I know there’s nothing in this pill, but research has shown that even so, it often works”? You know, I think I might. And let’s face it, it’s no more or less than homoeopathists do every day of the week...

Saturday, 6 October 2018

Green Light for Brett

It now seems certain Brett Kavanaugh will win his nomination to the Supreme Court despite the allegations of sexual assault levelled against him by several women. At one level this is no bad thing. It would be a shame if a moment of alcohol fulled bad behaviour 36 years ago destroyed a man’s chances of reaching the highest office. But, rather than adopting a hectoring, defensive posture, it would have been nice if he’d said: “I do not remember the incident described by Dr Ford, but if on the night in question I behaved in a less than appropriate manner I apologise unreservedly.” Then he might have won more approval from the women currently most strident in condemning him.

In 1977 I was a young psychiatrist when I was asked to see a medical student who, during someone’s 21st biurthday celebrations took it upon himself to drink an entire bottle of vodka in one go. Hardly surprisingly he suffered a cardiac arrest and very nearly died. Even more surprisingly, he was remarkably unrepentant when I challenged him over his arrant stupidity. Amazingly, he persisted in thinking it was “a bit of a lark’ that had perhaps been taken a bit too far. As you can imagine, I tore him to shreds over the incident, not least over the amount of NHS resources that had been devoted to keeping such an idiotic person alive. That man is now in his 50s, if he is still alive, having modified his behaviour since those crazy days, and may have carved out a distinguished career in medicine. I don’t know. But I don’t think that moment of extreme recklessness should have destroyed his career.

There are 2 problems in the ‘Kavanaugh epsisode’ which trouble me, as an observer far from the land of the ‘Free’. The first is that Mr Kavanaugh, and his sponsor Donald Trump, have made no secret of their partisan, ultra-right wing agenda, and that the former will put these views into action once he becomes a member of the Supreme Court. I know this has happened before, and probably many times, but you would have thought that a neutral, impartial position would be what was required from any judge, never mind one in the highest court in the land. Now the decisions from that court will be coloured with a far-right hue for many years to come, and heaven help those people trying to pursue any kind of liberal agenda.

The second is about a huge banner unfurled by demonstrators in the Capitol building yesterday.
“BELIEVE ALL SURVIVORS!” It proclaimed, suggesting that professor Blasey-Ford, and, presumably, all other complainants of sexual abuse, should be believed, and unquestioningly. The only problem with that is, if my accuser had been believed unquestioningly, not just by the police and the CPS, which she was, but also by the jury, then I’d be in prison right now, 9 months into a life sentence for a series of terrible sex crimes - crimes that in truth did not take place. Unfortunately, we cannot, in the interest of justice, afford to believe all “survivors”. If we did, hundreds of innocent people, like myself, would be in prison. Rather we have to take all complainants seriously; I have no problem with that, but then investigate their claims impartially and objectively. I’m sorry, Me Too movement, but that’s the only way.

Sunday, 30 September 2018

September 2018 film review

THE HATEFUL EIGHT (2015) D- Quentin Tarantino
A traveller (Samuel L Jackson) on foot in the the American north west hails a passing stage coach, but once on board finds himself caught up in a sticky situation. The coach is already occupied by a bounty hunter of some sort (Kurt Russell) and his captive (Jennifer Jason Leigh) en route to a nearby township. But the coach is forced to seek shelter in a lonely trading post, inhabited, it seems, by an even more motley crew of bad people. Cut off from the outside world by a blizzard, our drama plays itself out inside this rundown shack that is all that separates the players from an icy death. And as this is a Tarantino film, we know there will be blood. But when, and whose?
           Tarantino’s films are always worth watching, his obsession with violence notwithstanding, and this is no exception. The atmosphere of threat and paranoia builds up nicely to a climax which disguises itself expertly, and all the players, especially Jennifer Jason Leigh are very strong. I always love it when an extravagantly beautiful woman such as JJL is happy, when the occasion demands it, to be made up to look like a hideous old hag. Chapeau!

HARD EIGHT (1997) D- P.T. Anderson
An obvious loser (a very youthful John C Reilly) is offered a helping hand by a much older man (an absolutely brilliant Phillip Baker Hall). At first the loser suspects this must be a gay thing, but it soon emerges the older man’s offer of help is genuine, though the reasons for his apparently spontaneous charity are not made clear. The two go to Vegas, where they operate a couple of scams to clip the casinos of some of their cash. Then the young guy meets and falls for cocktail waitress Gwyneth Paltrow. And once a woman is introduced into the mix, everything gets complicated, as it always does...
          This movie is terrific. With the dialogue pared to the bone, it comes over almost like a Raymond Carver short story, complete with the mystery and pathos which is so characteristic of that writer’s method. This was director PT Anderson’s debut feature film, and promised well for the future, though I’m not sure he has made a better film than this first effort. Brilliant.

RING OF BRIGHT WATER (1969) D- Jack Couffer
A writer (Bill Travers) sees an otter for sale in a pet shop and decides to take it with him to a remote crofter’s cottage in northern Scotland, where he plans to write a book about the Marsh Arabs. Soon, he and Mij, for lo that is the otter’s name, are getting on famously in the wilds of nowheresville. Enter Virginia McKenna, as the local GP to whom Bill takes a shine.
          One of the most celebrated British films of the 1960s, based on the book by Gavin Maxwell, and following the book fairly closely, this film was almost universally loved. It’s easy to see why. Although it has dated somewhat, the charm is all up there on the screen for us to enjoy even today.

WHISTLE DOWN THE WIND (1961) D- Bryan Forbes
A young girl (Hayley Mills) growing up on a farm in the north of England discovers a stranger in a barn. When she surprises him and asks who he is, the man (Alan Bates in a minimalist, but nonetheless brilliant display of acting) exclaims “Jesus Christ!”
          What happens next is written into the folklore of British cinema, as Mills, her siblings and a growing band of credulous schoolfriends convince themselves they are witnessing the Second Coming.
           I may have seen this film before, but if so it is probably 50 years or more since I did. Hence I was able to watch is afresh, and be quite stunned by the skill displayed all round - from the writing (the screenplay is by the renowned pair Keith Waterhouse and Willis Hall, from the book written by Mills’s mother, Mary Hayley Bell) to the highly skilled direction of Bryan Forbes, and then the acting, by both children and adults, which make the whole utterly convincing and deeply moving. I cried.

Saturday, 29 September 2018

September 2018 book review

TIME REGAINED, by Marcel Proust
At last we come to the final volume of Proust’s masterpiece, in which our ‘hero’ (actually he is a monster as much as anything else) re-emerges into high society after a long, self imposed exile. He finds its denizens much altered by time, as we see in this brief excerpt, where Marcel finds it impossible to reconcile the fair-haired girl he had known in his youth, who was famous for her elegant dancing, with the massive white-haired old lady “making her way through the room with an elephantine tread”:

“... to have succeeded in giving to this waltzer this huge body, in encumbering and retarding her movements by the adjustment of an invisible metronome, in substituting - with perhaps as sole common factor the cheeks, larger certainly now than in youth but already in those days blotched in red - for the feather-like girl this ventripotent old campaigner, it must have been necessary for life to accomplish a vaster work of dismantlement and reconstruction than is involved in the replacement of a steeple with a dome, and when one considered that this work had been effected not with tractable inorganic matter but with living flesh which can only change imperceptibly, the overwhelming contrast between the apparition before me and the creature that I remembered pushed back the existence of the latter into a past which was more than remote, that was almost unimaginable...”

Hey, Marcel, people get old. Give ‘em a break. I look at myself in the mirror today and I see the same old git I have always seen. But then I look at a picture of myself taken in 1981, and the 2 images are, as above, almost impossible to reconcile.
           This revelation is what has come to be known as the “Proustian Moment” and is, I think, familiar to everyone. Not that it makes it any easier to bear...
           I promised myself this reading treat as part of my emotional recovery from the traumas I faced last year, and it has worked. For the second time in my life I have relished Proust’s sublime use of language, his dazzlingly witty dialogue and intricate dissection of the vagaries of time and memory. In his great novel Pale Fire (see next month’s review) Vladimir Nabokov, through his character Kinbote, says of Proust:

“...His huge, ghoulish fairy tale, an asparagus dream... adorable seascapes, melting avenues, light and shade effects rivalling those of the greatest English poets, a flora of metaphors - described - by Cocteau, I think - as a ‘mirage of suspended gardens’...”

Treat yourself royally, and see for yourself what a great work of literature looks like.

VERTIGO, by W.G. Sebald
A man goes on a tour of notable European sights; Verona, Lake Garda, his birthplace of “W”, in the heartlands of Bavaria and has a series of disturbing and hard-to-explain experiences along the way... Like this one, for instance, which takes place in Vienna:

“...On one occasion, in Gonagegasse, I even thought I recognised the poet Dante, banished from his home town on pain of being burned at the stake. For some considerable time he walked a short distance ahead of me, with the familiar cowl on his head, distinctly taller than the people on the street, yet he passed by them unnoticed. When I walked faster in order to catch him up he went down Heinrichgasse, but when I reached the corner he was nowhere to be seen. After one or two turns of this kind I began to sense in me a vague apprehension, which manifested itself as a feeling of vertigo...”

Vertigo is right. This book is one of the strangest, yet at the same time most beautiful, books I have ever encountered. You want to see it as a kind of nonfictional memoir, yet things keep happening, as in the above excerpt, which confound that prosaic notion. An astonishing piece of literature, which has no equivalent, except perhaps in Sebald’s other offerings. The real surprise is in how easy it is to read, despite the depths it plumbs...

AMERICAN GODS, by Neil Gaiman
A man known as Shadow is released from prison early so he may attend the funeral of his wife, killed in a car crash. On the way to his home town he is offered a job by a fellow-diner at a fast-food outlet who seems to have a supernatural knowledge of our hero’s life. The man’s name: “Mister Wednesday”.
          With absolutely nothing else going for him, Shadow agrees to accompany his new boss on his travels, performing such small tasks as his boss requires of him. There begins a bizarre journey into the American heartland, a heartland apparently peopled by mythical beings: gods, in fact. Gods brought with them by all the immigrants from all the lands of the Earth which now make up America. Forgotten now, but still real, and ready, in a kind of latter day Ragnarok, to do battle against the new gods, of money and greed, of interstate highway and urban sprawl...

Neil Gaiman’s Magnum Opus is a fascinating an intriguing read, funny, mysterious and terrifying by turns. I love a writer who can conjure an imaginary world, even one like this which is salted into the real one. On the whole, a worthwhile and satisfying experience.

A Question of Belief

For a few hours yesterday, the whole world’s attention was focused on the issue of historical sexual abuse. A candidate for one of the most important jobs in America, an appointment for life, remember, and his accuser, gave evidence before a panel of American senators. There seems little doubt who came over better in the public eye. She was measured, sober and restrained as she gave her testimony of what she recalled of an incident 36 years in the past. Her accuser, on the other hand, was angry, bitter and belligerent. “It’s a carve up!” He as good as said, citing such things as ‘the revenge of the Clintons’ and a liberal conspiracy to scupper his chances of becoming a Supreme Court judge, despite the passionate support of his President.

This case, as is the case with so many claims of historical sexual assault, comes down to he said/she said. Who do you believe? Is is right to believe her, because she came over as the voice of reason, and he came over as some hysterical bully? I think a jury of his peers would have to find him not guilty, if that is he was facing criminal charges, which of course he is not.The statute of limitations in the U.S. means no charges could be brought against him anyway.

As followers of this blog know, I recently faced very serious charges of historical sexual assault, as the result of the allegations of a single female complainant. The case never came to court because the CPS finally faced up to the reality that my accuser had been caught out in one lie too many, and therefore her testimony could not be trusted. But had it gone to trial, it would have come down to the he said/she said scenario, with the jury having to make up their minds whose story they believed: her claims or my denials. Maybe in court her lies would have been exposed by my defence team, leaving the jury doubting her truthfulness. But they might have made a perverse decision, as juries often do, and thought: “All those terrible stories of rape and sexual assault: why would she make them up?”- and convict me on her word alone. It happens all the time.

Back to Mr Kavanaugh. The question really is not, should you send him to prison based on one woman’s claims, but is this the sort of man you would want to be sitting in judgement over his peers in the highest court in the land? And, the answer has to be, in the opinion of this observer at least, no.

Monday, 24 September 2018

Tiger Woods: chapeau!

When Tiger Woods’s wife could finally stand no more of his appalling behaviour (namely, screwing a succession of women who, oddly, closely resembled his spouse), his very public excoriation threatened to destroy his career. Then, as often happens in life, misfortune piled on misfortune, and he developed a severe back problem, not good for any golfer, never mind one who had looked like becoming the greatest of all time.

He dropped out of the world’s top 1000 players, and we all (certainly myself) thought it was all over.
“He’ll never win another tournament” I said, “let alone another major.” Well, the PGA Tour Championship is considered by many to be the unofficial 5th major, and yesterday he won it in magnificent style.

Pelagius loves a comeback kid. When Roger Federer fell victim to the Epstein Barr virus in 2008 this correspondent wrote him off, saying he would never win another big tournament. He went on to win another seven Grand Slams, proving me spectacularly wrong and securing his reputation as history’s greatest tennis player. Going a little further back, I will always remember the 1980 Moscow Olympics, when Seb Coe failed to win his favoured event, the 800 metres, losing to his great rival Steve Ovett. But a week later he came back to win the 1500 metres, his rival’s strongest event. I am not Coe’s biggest fan, but for that achievement alone he deserves to placed in the sporting Pantheon.

Now we can place Tiger Woods alongside those immortals of the Great Comeback. He has yet to win a Major, but, you know, I am no longer saying it’s never going to happen.

Monday, 10 September 2018

Sexism: alive and well in women’s tennis

As can be evidenced by Serena Williams’s treatment at the hands of a very senior (male) umpire at the final of the US Open on Saturday.

First, she was warned for coaching, a venial sin committed by almost every coach of the top players, men and women, the world over. Think of Rafa Nadal, for instance, who was coached by his uncle Tony on almost every point he ever played. Did he get penalised for it? Rarely if ever is the answer. Then she had a point docked for smashing her racket and finally, having called Carlos Ramos a ‘thief’ for stealing a point from her, was penalised by giving away a whole game. As she was already 4-3 down with her opponent, Naomi Osaka, next to serve, this was as good as gifting the match to her Japanese rival. But would this have happened to a man, or even a white woman? I doubt it.

After the match the great Billy Jean King noted that when men show anger they are only called ‘outspoken’, or at worst ‘passionate’, while women are labelled ‘hysterical’. She could have added that in the case of a black woman, they would be called ‘out of control’. This last point was underlined by a female tennis player on BBC’s Today Programme this morning (I’m sorry, I don’t know her name) who used this exact phrase in describing Serena’s behaviour on court. This attitude is despicable, being not only sexist, but racist too.

Let us look at men players again. Take Djokovic, for example. He is a master of gamesmanship.  Bending the rules as far as he can get away with, he is still admired (and rightly so) as a master of the game, and officials customarily cut him a lot of slack. Or let us look at Nadal again. Now, Rafa is a divine player to watch, but also agonising because he takes so long between points. 25 seconds is what he is allowed, yet he nearly always adds 10 more to that. How often is he warned, or even penalised about this? About as often as he loses 6-love 6-love is the answer.

Tennis is an aggressive game. Nobody ever won a game of tennis by being timid. Serena can be pretty scary on court, but then what about Sharapova’s 100 decibel scream? Did anyone ever penalise her for that? I’m old enough to remember Margaret Court, who could be extremely unpleasant at times. But they’re white...

Pelagius says: Leave Serena alone! She is arguably the greatest woman player of all time, and she didn’t achieve that by being the shy, retiring type. OK, if she breaks the rules, apply the disciplinary rules to her, but make sure you apply them to everyone else too.