Last year, author Kathleen Kerridge was fat-shamed by some commenters on social media after we published a video about her experience of poverty. Here, she argues that people should not judge a person’s need based on the size of their jeans. Getting fat is often a byproduct of being poor, she says, because a lot of cheap food that is filling is also unhealthy
New European cars with petrol engines will be allowed to overshoot a limit on toxic particulates emissions by 50% under a draft EU regulation backed by the UK and most other EU states.
Campaigners say that a simple €25 (£22) filter could drastically cut the pollution, but the Guardian has learned that car-makers have instead mounted a successful push for loopholes and legislative delay.
Bas Eickhout, a Green MEP on the European parliament’s environment committee and dieselgate inquiry panel, promised action to ensure that the lessons of the VW scandal were learned.
“With this ridiculous proposal, the EU’s member states are again trying to dilute EU laws at a terrible cost to human health. We will call on the European commission to come to the European parliament and explain themselves on this issue,” he said.
Particulate matter (PM) is the largest single contributor to the estimated 600,000 premature deaths across Europe from pollution-related heart and lung diseases each year. Children and the elderly are worst affected, and the associated health costs could be as high as €1.6tn a year in Europe, according to the World Health Organisation.
Although exhaust fumes from diesel and petrol engines are one of the largest sources of particulates emissions, most EU member states support raising the EU’s pollution standard 50% above the legal limit set down in the Euro 6 regulation. Behind the scenes, vehicle makers have pushed strongly for a staggering 300% over, according to material seen by the Guardian.
The draft regulation is still being discussed by EU member states and the auto industry has not given up hopes of wrenching further concessions on particulate emissions ahead of a final decision on 7 December.
One Powerpoint slide shown to EU expert groups by the European automobile manufacturers association (Acea) says that a 300% latitude in meeting the letter of the law would be “realistic” because of “measurement uncertainty” in emissions tests.
Florent Grelier, a clean vehicles engineer at the Transport and Environment (T&E) campaign group, told the Guardian she feared that EU attempts to improve air quality were being “bent to the will of the automotive industry”.
“This is a petrolgate scandal in the making,” she said. “Unless the European commission and governments establish strict test procedures to protect the industry from its own short-sightedness, within a few years we will see continuing high levels of particles killing hundreds of thousands of citizens prematurely.”
Under EU law, car-manufacturers are already obliged to use filters for diesel engines, but not for the rapidly-growing 40% of the petrol engine market which is made up by uncontrolled gasoline direct injection engines. These release more particulate matter than modern diesel cars.
Gasoline particulate filters could reduce these emissions by a factor of around 100, and would cost manufacturers just €25 per car, according to research by T&E. But car manufacturers have argued this would violate the principle of technology neutrality.
A spokesman for Acea declined to comment on the issue.
Calls by the auto industry for a delay in implementing the new regulation have been well received by several car-producing EU countries. Spain and Sweden argued for a one-year legislative delay that would push its introduction back to 2019, in minutes of a technical committee meeting earlier this month seen by the Guardian.
The UK took no formal position on when the new regulation should enter into force but warned of “unintended adverse effects” if PM limits were given a separate starting date to standards for another pollutant, nitriogen oxide (NOx) , which will now begin in 2019.
An EU group of national experts – the technical committee on motor vehicles – is now expected to sign off on the final proposal to amend the Euro 6 regulation for real world driving emissions, in December.
The issue of “conformity factors” – or compensating for uncertainties in emissions tests – last year led the committee to impose a NOx limit 110% higher than the one written into the Euro 6 regulations last year.
It’s clear that her symptoms are advancing and that she was right on the futility of further chemotherapy. She is having trouble staying awake, her appetite is deteriorating, and she is weaker by the day. This may well be our last appointment.
“We can get rid of a number of your medications,” I say, frowning at the long list that her daughter says is proving increasingly difficult to administer.
“Let’s do that,” she says joyfully.
So in one of my favourite acts, I slash half her list, explaining why as I go along.
But she stops me at the statin, an anti-cholesterol drug she was prescribed 20 years ago for a barely elevated cholesterol detected on an insurance test.
“I need that so I don’t die from a heart attack.”
“Not quite,” I say soothingly. “Statins exert their benefit over many years and we agree that now, it’s more important to maintain comfort.”
“I can’t imagine my day without my statin,” she declares, leaving me to wonder somewhat enviously how her cardiologist managed to evince such devout compliance for a questionable cause.
Just then her husband pipes up. He is a sprightly 74, still working, and unlike his wife, detests medications, including the statin he was prescribed after a serious heart attack some years ago.
“Well, I’ve decided that at 75, I am swapping the statin for sausages. From what I hear, the two are as bad as each other.”
She has heard this before because the wife adds with a smile, “At 75 or when I die, whichever happens sooner.”
I urge the husband to discuss his decision with his doctor before stopping treatment, I tell my patient to stop her statin and I bid them both a fond goodbye.
As they leave, I find myself thinking about many recent conversations I have had with patients about statins. With cancer patients who have a limited life expectancy, stopping the statin is both safe and right. But during my stints in general medicine, where we treat heart attacks, strokes and dementia, the answer is more nuanced.
Does everyone need a high-dose statin? How many will experience side effects? Is lifestyle modification a reasonable starting point or should every patient be commenced on a statin? The reality of most hospital management is that a drug is prescribed and the patient finds out as an afterthought. But if a statin, once started, is likely to become a lifelong drug, what considerations are important beforehand?
Many patients have heard of statins but awareness does not mean familiarity and it certainly does not mean being informed. For every person who trusts a doctor’s recommendation to take a statin, someone else suspects a conspiracy theory fuelling the prescription of the world’s highest-selling drug.
For the patient who wants to know more, things can get complicated. A cursory internet search warns that statins make women (but not men) more aggressive, accelerate ageing, damage stem cells, worsen heart disease, cause dementia and are “unhealthy and unethical” to prescribe.
Alongside are studies asserting that statins significantly reduce the incidence of heart attacks and strokes and improve mortality. Their benefits are evident within the first year of intake and accumulate over time, making them among the few drugs to have a dramatic impact on health outcomes. Considering that heart disease is the number one killer in many parts of the world, this is no ambit claim. But pity the hapless patient trying to make an informed choice – it’s hard to know which “expert” advice to heed because everyone sounds knowledgeable.
Very few patients needed to stop statins due to adverse effects.
When I recently prescribed a statin to a young woman with a heart attack and a host of coronary risk factors, she expressed concern. I explained that no drug was without side effects but a new, rigorous, non-industry funded, meta-analysis by the clinical trial service unit of Oxford University, shows that the benefits of statins have been underestimated and harms exaggerated. The results were published in the Lancet medical journal.
Treating 10,000 high-risk patients with a low-cost, generic statin for five years prevented 1,000 strokes and heart attacks and treating 10,000 lower-risk patients prevented 500. Of 10,000 patients, five might suffer muscle aches, up to 100 may develop diabetes and five to 10 may suffer a brain haemorrhage but these side-effects have been included in the estimate of the absolute benefit.
Very few patients needed to stop statins due to adverse effects. It may not be the absolute final word but the meta-analysis concludes that many problems have been misattributed to statins, therefore planting fear in the minds of those at high cardiovascular risk and dissuading them from taking a potentially life-saving drug.
But how did these rare toxicities garner so much attention in the first place?
In October 2013, the British Medical Journal, as part of its mission to promote rational prescribing, published a paper quoting the incidence of statin-related side effects being as high as 18% and thus concluding that statins did not provide an overall health benefit to those patients deemed at low risk. But the 18% figure was based on flawed research and it was apparent that even in the quoted research, the figure was closer to 9%, but without the inclusion of a placebo-controlled group, which meant even the 9% could not be genuinely attributed to statins. (The meta-analysis says that statins are “no less well-tolerated than placebo”).
Seven months later the BMJ corrected the erroneous statements but did not retract the entire paper. Sir Rory Collins, the lead author of the Oxford meta-analysis, warned at the time that without full retraction, doctors and patients would continue to be misinformed. It turns out he was prescient.
Medical journal editors … owe it to society to publish papers that “first do no harm”.
Misleading media reports followed and led to increased reticence among doctors to prescribe or even discuss statins and increased unwillingness among patients to take them. Statins were already being under-used but a new wave of adverse media meant a further reduction in use.
In the UK, 200,000 patients stopped taking statins. 60,000 fewer statin prescriptions were dispensed in Australia following a now-withdrawn television program. If those patients avoided statins for the next five years, researchers estimated that a few thousand would suffer a fatal heart attack or stroke. For a disease that kills 17 million people around the world each year, an ounce of prevention is not to be sniffed at.
So what does the statin saga teach us? For one, it underlines the power of the media and in turn, the responsibility of health reporters and newspaper editors to think twice before exploiting health news to suit their audience.
“Beloved grandma loses mind to cholesterol drug” and “How statins ruined my life” might be guaranteed click-bait but responsible reporting might instead discuss the dreadful statistic of one Australian dying of cardiovascular disease every 12 minutes and how to prevent it. Statins are no panacea but combined with diet, exercise and curbing cigarettes and alcohol, they have a role.
Second, it reminds medical journal editors that they owe it to society to publish papers that “first do no harm”. If Big Pharma can’t be trusted to provide unbiased data and to base advice on sensational tabloid fare makes a mockery of medicine, doctors must put their faith in someone to provide credible information.
There is an old joke that the majority of academic papers are read only by the author and the editor – this may be a little harsh but busy clinicians mostly flick through abstracts and note key points rather than read even a fraction of the million scientific papers published annually with an interrogating mind. It is up to journal editors to simplify the task and spell out the difference between interesting research and findings that transform patient care.
Finally, better health arises from better health literacy. In a free society, patients are allowed to make poor choices but the media shouldn’t facilitate it. Just this week an acquaintance asked me what I thought of her daughter’s “courageous” bid to not vaccinate her child for fear of “giving her autism”. I reminded her that the fraudulent data had long been exposed and retracted but she said she had seen it on the net and that was that. Dashing my hopes, she next took on statins.
“What do you make of the controversy?”
“There is no controversy,” I replied. “Read the report.”
“You would say that, wouldn’t you?”
Then, after a pause, “But seriously, did you see the story about the old lady who went mad on her statin?”
No, I didn’t. But newspaper editors, please take note!
It was a moment that mingled triumph with relief as the UK’s first double hand transplant patient awoke from a painstaking 12-hour operation with two new sets of fingers.
“It’s better than a lottery win because you feel whole again,” said Chris King as he recuperated at the Leeds General Infirmary. “They look absolutely tremendous,” he added. “They’re my hands. They really are my hands.”
But despite his joy at the successful surgery, the real test for King may just be beginning. Experience from previous such transplants suggests that the psychological challenges of bearing another person’s hands can be hard to cope with.
Clint Hallam, the patient who received the world’s first hand transplant 1998, claimed that he felt “mentally detached” from the new limb and had it removed three years later in a secret operation.
Nadey Hakim, a surgeon at Imperial College London who was involved in that operation, agrees that for some the psychological impact can be considerable.
Related: World-first skull and scalp transplant gives Texas man ‘new lease on life’
“For someone to use someone else’s hands to hold his wife, his kids – it is not easy,” he said. “I don’t think they will ever get used to it fully- they might claim they are used to it, but it is a very difficult task for anyone, even [for those which are] the strongest psychologically.”
King lost the four fingers of each hand in an accident three years ago. He received the double transplant in a lengthy operation conducted by a team of eight surgeons, led by Professor Simon Kay.
While around 80 hand transplants have taken place worldwide, King’s is the first double hand transplant to be carried out in the UK, and the first such procedure to be undertaken since the NHS launched its new hand transplant programme earlier this year.
Kay also carried out the UK’s first single hand transplant in 2012 when Mark Cahill, a former pub landlord, received a new right hand after his own became badly affected by gout and infection.
Cahill is enthusiastic about King’s operation. “I think it is fantastic, I am so happy for him,” he told the Guardian, adding that he hopes that the publicity will result in an increase in the number of donors to the hand transplant programme. “We have got plenty of people wanting hands, but not enough donors,” he said. That, he points out, could be down to the very visible nature of hands, which might make it especially hard for grieving families to give consent for donation. “I imagine it is heartbreaking,” he said.
Since his own operation, Cahill says that not only has he been able to carry out everyday tasks and drive again, but just six weeks ago used his new hands to give CPR to his wife after she suffered a heart attack. “I wouldn’t have been able to do it without my transplanted hand because my other hand was so deformed, I wouldn’t have been able to put any pressure on her,” he said.
As well as taking immunosuppressants, Cahill has been undergoing physiotherapy since the operation to improve the movement in his new hand. But, he says, he has not had any problems in accepting his new appendage.
“I think I was in a fortunate position,” he said. “I had [one] hand amputated and another one put on, so I was never without a hand. It is probably more difficult for people who lose a hand.”
Indeed, doctors stress that how patients feel about the operation is crucial. “The psychological point of view is very, very important,” said Professor Jean-Paul Meningaud of the University Hospital Henri Mondor in Paris. “Otherwise you can have a patient that [is] going to stop taking the treatment.”
For Hallam, the psychological implications post-transplant were apparently so overwhelming that he was unable to live with his new hand. In contrast to King and Cahill, Hallam had been without a hand for many years when he was selected for the operation. He lost it after an accident in prison – where he was serving a sentence for writing bad cheques. One minute he was climbing a ladder with a circular saw, the next he was sprawled on the flood minus his hand. Surgeons attempted to reattach it, but the limb lost sensation and dexterity and had to be removed.
Related: Firefighter receives full face transplant in surgery called ‘historic’
But Hakim rejects Hallam’s claim that he felt psychologically detached from the replacement limb after the later surgery .
“[The hand] was removed 2.5 years [after the transplant], requested by the patient, because he did not have the means to pay for his immunosuppressants,” he said. “The arm itself was in good condition until he stopped taking his anti-rejection medication.”
Other transplants have proved more successful. Another of Hakim’s patients, who underwent a double arm transplant in the US in 2000, is said to be doing extremely well. “He still has, after 16 years, an excellent function of both hands,” said Hakim.
But Meningaud, who has conducted a number of face transplants, as well as the world’s first face and double hand transplant, says the drugs used to prevent rejection are a cause for concern.
“You are going to suffer the side-effects of the immunosuppressant treatments your whole life,” he said, adding that such drugs put patients at increased risk of certain cancers as well as other health issues, while large doses to combat acute rejection can result in kidney damage.
Meningaud says his opinion on face transplants has changed over time, having seen problems with rejection, infection, and even a suicide attempt by a patient. “At the beginning I did not imagine the toll would be so important,” he said.
For King though, the operation has been life-changing. “I could shout from the rooftops and celebrate it big time, which is what I’m going to do,” he told reporters after the operation.
For the surgeons too, the procedure can bring feelings of awe. “You see a dead hand which is completely white, no blood supply to it, no viability, all of a sudden getting the colour of a normal hand. It is incredible,” said Hakim. “It is a small miracle which truly you are looking at in ecstasy, looking at what nature has allowed us to do thanks to modern surgery.”
‘We had been constantly conscious that patients would be relying on us and we may possibly be the only make contact with they had with the outside world.’ Photograph: Sally and Richard Greenhill/Alamy
I was saddened to go through that district nurses are dealing with extinction yesterday. I was once a district nurse and extremely proud to be so, and six years in the past, soon after an abscess on my spine I also needed day-to-day visits from district nurses. Having been on the two sides of the fence, I can say this is a crucial service.
I worked in a rural spot as element of a six-nurse staff covering the twilight shift, from 8pm-midnight. Each evening, two nurses would meet at our nearby hospital to go by means of our listing of visits. On common we would have 9 to 10 visits per evening, and although some would be regular visits, most nights we would have additional visits that the day crew had not been capable to make or these when a GP asked us to call in on one particular of their individuals.
The care we presented was varied – we would help in end-of-lifestyle care, put somebody to bed, modify dressings, administer medicine or just assist someone to the toilet. Our nights have been planned with military precision, usually conscious that our patients have been relying on us and that really often we would be the only get in touch with they had with the outside word. Despite obtaining only a few hours to get round this kind of a large area with a lot of sufferers we never rushed, and always made time for those we have been caring for.
We would typically be asked to support with what would now be deemed non-nursing duties, this kind of as unblocking a sink, creating a note for the milkman, rehanging a curtain, or taking a piglet to the vets in the middle of the evening. Extremely rarely did we finish at midnight and at the end of every shift we would have to go back to our office to check out that no additional requests had come in, as this was just before the advent of the mobile telephone. Come hail, rain and snow we in no way missed a go to. In bad weather, blankets, a shovel and wellies grew to become a normal part of our uniform. Why? Because we were an important service, one particular that could be relied on.
Nursing is a vocation, and for me it was never about the money. I did not want to sit in front of a laptop filling out countless types or inputting numerous codes into a personal computer accounting for every single 2nd of my time. I desired to be out there supplying important care and guaranteeing that where feasible, a patient could stay in their personal property.
If district nurses are genuinely in danger of disappearing, what will occur to individuals that depend on this essential services? For the older individual who is not mobile and has a leg ulcer, how and the place will they go to have their dressing modified? For the mom crippled by MS who would like to stay inside her personal residence and sustain as significantly independence as attainable, how will she and her family cope? They could not have a pot of money to shell out for private care – will tasks like washing, obtaining dressed, help with personal hygiene now be left to her loved ones to deal with?
There has been a 47% drop in district nurses in the final decade. Support solutions are stretched to the limit, and appointments with practice nurses in GP surgeries are quite challenging to come by. A&E and minor injury centres are total to the brim, so what is the substitute for individuals who demand the crucial providers of the district nurse?
Where the woman says that the pregnancy is the result of rape, she would have to provide a police report as evidence before she could have the abortion.
Heavy sanctions would back up these provisions. A woman who forges the signature of an alleged father and a man who falsely claims to be the father in order to help a woman in getting an abortion would both be subject to criminal prosecution – as would the doctor who performs an abortions without the written consent of the father.
Wow! The Ohio bill is, apparently, very unlikely to pass into state law; but even if it is not going to shake our earth it looks, at least, as if it might be a straw in the wind. In its unequivocal radicalism, it eclipses all previous attempts to assert any rights of men in abortion.
I thought I was being daring in my 1992 book No More Sex War when I wrote:
“Women who choose to have an abortion might be a good deal better off if their men were required to endorse and support their decision. If the man agrees, the burden of the decision will be shared. If the man does not agree, he ought to be provided with a means to say so. His opinion ought, at least, to be registered and recorded. I’m not saying it ought to have any restraining force in law. I’m not saying a woman should be prevented from having an abortion if the father disapproves. I’m just saying he has a right to be heard.”
These tame suggestions got me hauled over the coals of the feminist orthodoxy on my way to a pelting in the stocks. Not for the first time. When, in 1989, The Times published a column of mine in which I mourned the absence of two aborted children whom I might have fathered, the paper received so many letters in response that they had to be run on full half-pages on consecutive days. Nineteen out of 20 of those correspondents furiously told me that, as a man, I had no right to express any opinion on abortion and I could keep my feelings of loss to myself.
When my book was published, I was summoned to the cellars of Broadcasting House for an inquisition at the hands of that Torquemada of Woman’s Hour, Jenni Murray. “A woman’s rights over her own body must be indisputable,” she thundered. “OK,” I answered. “But they are not the only rights at issue in a pregnancy” – a proposition which, to my surprise, she seemed to accept without demur.
That’s the bottom line. The woman’s right to choose is, obviously, not the only concern – despite the fury with which feminists have been insisting on that position for 50 years.
On top of the highly contentious question whether the foetus in the womb has philosophical, moral and legal rights which place a duty of care on the wider society, the inseminating man must clearly, undeniably have an active interest which ought to be established and recognised with legal rights. And then, too, the wider society which pays for the operation under the NHS in Britain should also save a say. Is it in the interests of taxpayers that 150,000+ abortions should be performed every year? Is it in the interests of the wider society that those lives – more or less equal to the annual figure for net migration in the UK – should be stilled?
Or are those questions only allowed in Ohio?
