The Evening Hill Diaries: May 2023

Evening Hill Diaries Chapter 4

March 23rd, 2023

Today marks the third anniversary of the first UK lockdown. For most it will be a case of ‘Where on earth did those three years go?’ It seems curious to me that most commentators are now lamenting the complete denial of one’s civil rights to go out, to meet friends, and the adverse effects on healthcare, schooling, and the economy, whereas three years ago the government was being criticised for not locking down earlier. Comparisons were made with the extreme policies of Australia and New Zealand in particular, which greatly reduced the numbers of pandemic deaths. The later adverse effects were ignored at the time. The leadership of Anders Tegnell in Sweden (Civil Servant and Physician) is being applauded – a case of ‘Carry On Up The Coronavirus’. He advised against lockdown and despite a somewhat higher mortality rate than Norway or Finland, the country on the whole continued to function (but see my writings during lockdown which have some bearing on the reasons why the Swedes did lockdown better – national characteristics which probably do not apply to the UK population).

It is harsh to contemplate, but as an epidemiologist, one can see that the vast majority of victims of Covid-19 were frail in some way, either through advanced age or another medical problem (co-morbidity). I write this with some trepidation because others, and naturally those who have lost someone unexpectedly (young, fit, another normally recoverable illness) will disagree. These cases were rare, but: a (usually) acerbic physician at UCH cautioned us against an unsympathetic attitude to someone with a rare disease with the words, ‘It ain’t rare to the bird that’s got it.’ One has to temper the medical excitement of picking up a rare condition with the knowledge that the recipient of the rare condition may not share one’s enthusiasm. This is true of deaths of healthy subjects during the Covid-19 pandemic. Sadly, despite medical training, doctors today also commit this sin; and it is a sin. A friend whose newborn son was afflicted with in-utero cytomegalovirus infection, experienced a consultant paediatrician scarcely able to contain his excitement at the manifestation of hepatosplenomegaly and purpura*, who asked if he could ‘bring the medical students along’.

* Enlarged liver and spleen and a haemorrhagic rash due to low blood platelets.

A propos of this, the words of my urological surgeon come to mind, when I attended a postoperative appointment, and described my very significant problems with continence. He was sympathetic, but mentioned en passant that he had just seen one of his follow-up patients who had not ‘needed a single incontinence pad’. Of course, I do not doubt his words, but as you will agree if you have followed me thus far, to me they were of no reassurance or consequence!

I seem to have digressed. I apologise. As mentioned previously, in connection with the Isabel Oakeshott/Matt Hancock episode, other countries have already completed their assessment of the Covid-19 pandemic handling, whereas, in true British fashion, ours seems likely to run and run. A few things seem clear:

1. We didn’t have the means or the organisation to do enough testing early in the outbreak.

2. It took some time to work out the means and mechanisms of transmission.

3. Inevitably, it was a long time before we had any effective vaccine – though in comparison to any other scientific enterprise and development, the preventive vaccine programme came through in record time – perhaps a tenth of the time that a typical vaccine takes from conception to approval. One could debate this and the optimum response endlessly.

Full moon at Crichel Point

April 4th, 2023

After seemingly interminable rain in March (350% greater rainfall in Southern England than average; wettest March since 1981). early April, though cold, is sunny. Time to get out in the garden. Asparagus beginning to show its stalks. Woodpecker drumming this morning. Lindsay’s birthday on Saturday 1st April, and a tense game at Vitality Stadium with, eventually, a 2-1 win for AFC Bournemouth over Fulham. Tonight she is off to the postponed fixture with Brighton (Bournemouth lost 2-0).

Lindsay and Coco

During our recent trip to London, Lindsay went to ‘Orlando’, starring Emma Corrin (recently a big hit playing Princess Diana in ‘The Crown’). Emma has declared themselves (sic) gender neutral or non-binary. Lindsay reports that it was difficult to determine the sex of much of the audience, in what is a gender-fluid story of a play.

Emma is an attractive (I have used that word before – no hatemail please) slim, and when she wishes, androgynous, woman, who is doing extremely well as a model for Miu Miu and an additional clothes horse for Cartier jewellery. Allegedly 80% of her income is from sponsorship deals. While Lindsay was at the theatre, I was sitting in a doctor’s waiting room reading Emma’s interview in ‘Elle’ magazine. Very difficult to follow some of it because she regularly refers to herself as them/they. I do hope she does not follow the example of the (attractive) daughter of friends who has become ‘non-binary’ and has electively undergone ‘top surgery’ (you don’t want to know).

Here is they (Emma) – copyright obviously to Elle magazine.

Emma Corrin - front cover of Elle

A review by Peter Davidson of the Grand Tour journal (1820-1822) of the future Earl of Derby and prime minister of Great Britain records that he was ‘Gloriously unimpressed by what he saw. He was serene in his confidence that he deserved the best of everything and was thus endlessly disappointed.’ After the Battle of Waterloo, English grandees embarked on tours of the continent with boundless confidence and optimism. It seems that Edward Stanley (as he was) felt an acute sense of disappointment with any company that had not, like he, attended Eton and Christ Church (plus ça change in politics I hear you say). The review is titled ‘It could do with a lick of paint’, which well describes the reaction of the English aristocracy to the ruins of antiquity.

When a medical student at UCH, just up the road from the British Museum, we were invited to an evening tour of the basement containing some Grand Tour diaries and sketchbooks, not normally on display. I remember among these were beautiful watercolours by Turner. Probably the finest artefacts of the ‘Grand Tours’. Here is his remarkable picture of the Devil’s Bridge at St Gotthard, worked up from a sketch (copyright to the Tate).

Turner - The Devil's Bridge

Of more international importance, the Ukraine war rumbles on; Finland has today been admitted to NATO (Finland has an 800-mile border with Russia). Sweden’s entry was vetoed by Turkey. Donald Trump is about to appear in court in New York, indicted on a charge of paying hush money to a porn star (and mis-declaring it) with whom it is alleged he had an affair. It seems that it is not the payment of the hush money which is the issue! After Nicola Sturgeon’s resignation in Scotland, the new de facto first minister and leader of the SNP is Humza Yousaf (correct; you heard aright). Already christened* ‘Humza Youseless’, he has wedded himself to Sturgeon’s agenda for Scottish Independence, and also her unfortunate espousal of and preoccupation with, transgender rights. As a Scot with several hundred years of lineage, albeit of humble crofters, am I alone in finding a second generation Scot of Muslim origin a little presumptuous in these aims? He does have a stronger Scottish accent than I have however (as did Sean Connery who, once famous, did not live in Scotland, but in the Bahamas).

* A friend points out that it would be incorrect to describe Humza as christened anything – a nice and pedantic distinction.

And among the interesting trivia, hordes of dogs in New York are dying, or at the very least staggering around stoned, after cannabis is legalised and discarded joints and cannabis ‘gummies’ are frequently found on the streets. Apparently dogs are much more sensitive to cannabis than humans.

I was pleased to learn recently that scientific skulduggery and rivalry is well and thriving (for the best description of the race for a scientific prize see ‘The Double Helix’ by James D Watson, still alive at 95). Here I have to be extremely careful with names, or even identifiable details. A friend, a medical doctor, but an academic one, has recently had a paper accepted by Nature. For those not in the know, Nature is the world's premier scientific journal. Research which often later leads to Nobel Prize accolades is published there. This friend had been working for some years on research which (perhaps) provides new evidence about a common cause of a certain type of cancer. In the past, he has collaborated with researchers across the world on the topic. After the paper was accepted, but before publication, he was admonished by several U.S. colleagues whom he thought were friends. They urged him to withdraw the paper, claiming the findings ‘unproven’. Fortunately, he refused, and pointed out that only papers of the highest quality which pass stringent peer review were accepted by Nature. Only later did he discover that these same American researchers were exploring just the same avenue of investigation as his own team, and were merely upset that they weren’t the first to publish (his paper has now been published).

Passing over Watson and Crick, and their attempts to second guess Linus Pauling’s work, together with their (unacknowledged at the time) use of the X-ray crystallographic data of Rosalind Franklin, the most egregious example of the American Way of Science came to me early – during my time as a laboratory investigator in a hospital in upstate New York. The Will Rogers Hospital, funded by the entertainment industry, and at the time, not short of a few dollars, had a succession of ‘visiting firemen’ lecturers, one of whom (again, no names), was an extremely famous doctor in a laboratory specialty, author of multi-volume textbooks. In looks, he was a little like Donald Trump, heavily tanned, a tendency to jowls, and adorned with large, vulgar gold jewellery and fraternity rings. He marched in with an entourage, which included a suspiciously beautiful blonde ‘researcher’. He proceeded to lecture about recent advances in a specific condition, but about half way through, the talk went something like this:

‘Now I know not everybody agrees with this theory, but the evidence, as obtained in my laboratory, is completely clear. Now there is a doctor in England, in some tiny Institute (pronounced insti-toot) in some out of the way place like Birming- Ham, who has written papers on the subject. Unfortunately, what the journal which publishes him doesn’t say is that this doctor is suffering from certifiable mental illness. He writes a paper, full of incorrect theories; has a bit of a breakdown; goes into hospital; has a bit of shock therapy; comes out again and writes another paper. Off he goes into the loony bin again.’

And more in the same vein. To say that we were dumbfounded would be an understatement. Unbeknown to the Trump look-alike, the son of the doctor whom he had vilified, a British medical student, was sitting in the audience. My mentor, a distinguished Canadian haematologist, Al Zipursky, took us aside at the end. ‘I can only apologise, Andy’, he said. ‘Now you’ve seen the worst of American medicine’.

Have you noticed the now universal use of the word ‘So’ as an introductory preface to an answer? It is hard, grammatically, to categorize what it is that this little word is doing. Generally, it is in use as an adverb, classed as a ‘submodifier’, e.g. so fast, so colourfully, so easily. As a conjunction, it has multiple possibilities, for example, ‘I still had pain so I went to see a doctor’. In this case it means ‘therefore’ and is a genuine conjunction – a linking word. As an introductory word it has several uses, none of which are quite like the one I am speaking about. Examples are: ‘So that’s that’. (A concluding conjunction); ‘So what did you do today?’ (Introducing a question); ‘So I’m a policeman: what’s wrong with that?’ (Defensive introduction); ‘So, to the final’ (meaning the next step). None of these (in the dictionary) really correspond to the manner in which any person subjected to questioning, hostile or otherwise, uses ‘so’ as a prefatory word before answering the question. An example might be: ‘Why did you choose Rwanda as a location for would-be UK migrants?’ ‘So; the rationale behind the current situation with our influx of largely economic migrants is …’ It doesn’t matter if the answer is oblique in typical politician style, the ‘avoidance’ technique. Known as the ‘pivot’, the usual technique is to switch the question to the question that the recipient actually wants to answer. ‘So’ is used, whatever the type of answer, genuine or ‘pivot’. It seems as if the responder is frightened of the bareness of the reply, ‘The rationale behind the …’ A little hobby-horse. And moving on… You may have divined that Digression is my middle name. But here is something to put life into context. Alexandra Hall Hall, retired diplomat of some note, tweets, not always to my agreement, remarkably frequently. But here is a nice recent ‘Tweet’ of hers:

‘Oh my, how did I miss this shattering news? Why isn’t it being covered in all the top papers, and international media, who instead keep filling up their pages with depressing stories about war, refugees or climate change?’ The link is as follows: Cosmopolitan UK: ‘Kate Middleton breaks royal protocol with bold Easter manicure.’ trib.all/Z4M0dg4. If you don’t wish to look it up, it seems that she wore red nail varnish with a blue suit. And the world is OK (pun not intended) – Cosmopolitan is on the case.

Despite the grim world news, I kept a close eye on the media and the newspapers on April 1st in case there was an original April Fool story. Mind you, some of the true stories have the flavour of something surreal. Frequently shared on WhatsApp groups, the video of a ‘self-driving bicycle’ was apparently a spoof dating back a few years. But it’s not quite so clear now. Allegedly the Chinese have developed such a bicycle. Watch this space – but don’t expect any more updates until about March 31st, 2024.

An image of a collapsed Durdle Door chimed with thoughts about the vulnerability of the Dorset coast, for at least a microsecond.

Durdle Door, Dorset - without its arch

Again, this image dates back a few years. It is going to happen someday. Just think of the famous ‘Azure Window’ on Gozo, a huge limestone arch, which did collapse on 8th March 2017. Sad that it couldn’t have waited another 24 days. I remember walking across this arch without trepidation as a 10-year-old boy in 1958. Four seemingly genuine stories appeared on 1st April. I am still uncertain as to their validity.

1. Newer emergency service sirens have been developed with slightly lower frequencies to better penetrate the sound proofing of modern cars. These ‘Rumbler’ sirens also allow better directional sensing of the emergency.

2. The much hated county boundary reorganisation of 1974 under Edward Heath’s government is to be at least partially dismantled. For example, Cumbria, previously Cumberland and Westmorland, will be replaced by two unitary authorities – Cumberland, and Westmorland & Furness.

3. RAF Cadets will be allowed to wear uniforms of either sex under new diversity rules. This is a long story and is best searched for online.

4. Methane production suppressants will be added to cattle feed to reduce the production of the greenhouse gas – one that is 25 times more potent as a reflected photon absorber than carbon dioxide. My own research indicates (as is frequently the case in the ‘heated’ debates which occur around climate change) that methane however is removed from the atmosphere very much more efficiently than carbon dioxide. This gives the average methane molecule a lifetime in our atmosphere of about 12 years. Carbon dioxide, already maximally oxidised, lasts over a century. Cows are the unwitting targets of attack by the Green (and Vegan) lobby. It seems that the methane comes mostly out of the top end of the cow – which is logical I suppose if you remember that the cow has four stomach compartments. Feed from natural grazing is largely broken down in the rumen, and methane and carbon dioxide are belched up before partially digested food moves on into the reticulum, omasum, abomasum and small intestine.

Despite the rather far-fetched scenario of special foods being given to cows to reduce methane production, this seems to be the most likely of the above stories to be true, since this article was published on April 2nd. The others – probably genuine, but in truth I don’t know.

A partial segue from the April Fool stories. There is increasing interest in the role of nitrous oxide as a greenhouse gas – apparently one molecule of N2O being 265 times worse than carbon dioxide as a heat retaining photon reflectant. I toured the new operating theatres at Poole Hospital yesterday – fantastic, state of the art, with all gases and suction devices piped directly into movable pillars to connect to anaesthetic machines. In medical practice, nitrous oxide can now be removed by exhalation of the gas into a Swedish invented device, a Mobile Destruction Unit. A catalytic process splits the N2O into constituent nitrogen and oxygen. Medical consumption of nitrous oxide is a tiny fraction of commercial production however, mainly generated in the production of nitric acid used to produce nitrate fertilisers. One slightly quirky feature of the new theatre block – an excellent view to the east of the building of St Mary’s church graveyard. There are fantastic air circulation systems, and one touch blinds which can shut out St Mary’s from view.

I think of my student days in the operating theatres at UCH, in the old red brick (cruciform) building where the windows looked out onto Gower Street. These could be opened in the summertime to achieve slightly cooler temperatures and to let the Bloomsbury bacteria permeate a little better. If there were too many students around the operating table it was sometimes a relief to inhale the cooler air and to watch the world come and go in and out of University College.

With regard to nitrous oxide, a new epidemic of inhaling it to get an instant high, is causing serious concern medically. The gas inactivates (by oxidation) vitamin B12, the key vitamin in the synthesis of many important body proteins, including nerve sheaths. Cyanocobalamin (the name explaining the remarkable fact that this vitamin has an atom of cobalt at its core) to give it the correct name, is a cofactor in various enzymic reactions, one of which is a key step in the production of the myelin nerve sheath proteins. Overuse of these cartridges, known as ‘Whippets’, possibly because of their use as a device for delivery of whipped cream, can cause severe and irreparable nerve damage. If you see these little silver canisters discarded somewhere, they are probably nitrous oxide containers.

The next section deals with the industrial unrest of the Junior Doctors’ Strike. Feel free to skip over it.

‘Borne ceaselessly back into the past’; after my Governors’ meeting and hospital tour, I waited to be picked up outside the hospital. A group of perhaps 15 junior doctors on strike formed a picket line just a few yards from where I was. In a month or two it will be 50 years since I qualified as a junior doctor, into a world which was completely different from the present. The doctors are demanding an eye-watering 35% increase in pay. No other union, even the most aggressive, has had the temerity to demand this. (It seems that the newspapers are not quite correct, the aim is to increase to this amount over five years; and the ambition to claim that salaries should increase commensurate with RPI is not too unreasonable – after all, their student loans do!) I did not engage them in conversation or discussion.

I have ambivalent feelings about this current industrial action. Forgive me if I rehearse them here: Plenty of crusty old physicians and surgeons have been bombarding the newspapers with ‘When I was a House Physician’ (sometimes called a ‘Housedog’ with good reason) stories of how they worked 100 hours per week, etc, etc. And I did not see that I needed to add to the long-remembered travails of being ‘On the House’. In 1975, Junior Doctors took industrial action. Again, there was substantial public unrest and economic crisis. The government proposed creating an hourly rate scheme which would have led to a substantial reduction in overtime pay. Feelings were mixed, but action went ahead for some months, with an eventual ‘no detriment’ clause being introduced. I was working as an SHO in Nottingham at the time, and I remember the discussion in the doctors’ mess. Particularly impressive was the paediatric registrar, Roy …., who stood up and said something to the effect that, ‘When I qualified as a doctor, I accepted the work and the working conditions however tough they were. I would not now, and will never in the future, jeopardise the care I give to my patients by going on strike’. It made a deep impression. The collective feeling was that for better or worse, we were in a profession where, whatever the Machiavellian attitudes of the government, our patients should not suffer. Nottingham was one area which did not strike.

The 1975 strike differed from the current strike in that those who took action continued to work, but refused to do overtime. For many years the government relied on the goodwill of the profession to work unpaid overtime. All of this changed with the introduction of the European Working Hours directive* – a disaster in my view. To have to send interested students home because they had been in the hospital from 9am to 5pm was awful. The expectations of junior doctors have changed hugely. I heard one female junior being interviewed on TV. ‘I’m supposed to finish at 5pm’, she said, ‘And sometimes I don’t finish until 7pm!’ Oh dear… I sometimes think about Alan (Lord) Sugar, or Richard Branson in this context. I feel sure they worked and worked without any regard to time in their early years. I suspect they still do. It was a different world for us as juniors in the early 1970s. We lived in the hospital, and were more or less always available. I fear for the profession in the future if clinical experience and time on the wards or with patients is to be restricted in this way.

In the 1970s, few of us ‘on the house’ were married, whether male or female. A friend who was in medical school in Edinburgh recalls the residence in the hospital where he worked. Every morning at 7am, the housekeeper of the residence would tap on his door. ‘Here’s yer tea, Dr M…’, she would say. One morning, this friend who was (unusually for the time) married, had let his wife stay overnight in the residence. At 7am there was a tap on the door. ‘Here’s yer tea, Dr M…. – Oh! And would the wee nursey like one too?’

* Again, not quite correct. Overtime payments were introduced after the 1975 dispute. The then Health Secretary under Prime Minister Harold Wilson, Barbara Castle, claimed that there was nothing on which the medical profession was united. This had the opposite effect of uniting the profession. However, the system introduced was the so called UMT – the Unit of Medical Time, known as an Umptee. The bizarre rule of the Umptee was that overtime would be paid for every additional four hours worked – but the overtime rate was a fraction of the normal hourly rate (sic). Nonetheless, this set the tone for future discussions on working hours. In 1982, in a long debate in Parliament, Mrs Renée Short who chaired the select committee reporting on medical education, referred, as did others, to the desirability of restricting working hours of doctors to 80 hours per week. Interestingly, one of the discussants was Clement Freud, at that time MP for Isle of Ely.

An English doctor, distinguished pharmacologist Professor David Shand, whom I worked for in the United States, and who was around 10 or so years older than me, was a House Physician at Bart’s (St Bartholomew’s Hospital). He worked for the Professor of the Medical Unit, Sir Eric Scowen (born 1910). Very unusually for the early 1960s, David was married. His wife lived in a flat that they had rented, but as was customary at the time, David was on call all the time and the expectation was that one never left the hospital or the residence. If for some reason it was necessary to go out, somebody could usually cover for a few hours. One evening David was standing at the bus stop in Smithfield, when Professor Scowen walked by. He stopped, as if struck by a lightning bolt. He stared. Eventually, as if trying hard to recognise someone out of context, he said, ‘Shand, is it you?’ ‘Yes sir’ said David. ‘What are you doing Shand?’ said the Prof. ‘Just going home to see my wife, sir’, said David. ‘Very good, Shand’ said the Professor, and tottered off in bewilderment.

Another of those ‘in my day’ stories concerns a friend who was taught at St Mary’s by J Crawford Adams, known to generations of students as an author of very readable textbooks on Orthopaedics. Adams told him that when he was house surgeon, it was expected that one would never leave the hospital during the six months of tenure of the post. He did, for a period of two hours, and was so scared by the amount of traffic on the Edgware Road that he came straight back in again.

The situation in the United States is different. I worked there for two years (1981 – 1983). During that time there were no limits to working hours. My cardiology fellow colleagues did a one-month sojourn in the CCU (Coronary Care Unit). During that time they were never off duty. Things changed after a tragic case in New York in 1987, where an overworked and fatigued resident failed to recognise and treat a fatal (though rare) case of serotonin syndrome and the 18-year-old patient died. The resulting ‘Libby’s Law’, which came in a few years later restricted weekly working hours to 80 – a situation very different from the UK. But why are my feelings ambivalent? Firstly, because, year upon year, doctors in the national health service, which is publicly funded have had a supposedly independent review body. This is called (or was called) the DDRB – the doctors and dentists review body. The stated purpose of this body is to review other learned professions, those in particular who are allowed to set their own fees, to compare them, and to recommend an annual increase in doctors and dentists’ remuneration to keep pace with other professional fees and inflation. Over the many years that this has been in existence, the DDRB recommendations have never been fully implemented by government. This has led to enormous ill feeling, and is at least partly responsible for the catastrophic situation in NHS dental care. In addition, (and I am grateful to a junior writing in The Telegraph recently), the ‘on costs’ of actually functioning as a doctor have become huge – without any remuneration. Training for exams, continuing medical education courses, exam costs, appraisal costs, GMC costs, student loans, charges for parking etc have either been introduced or increased enormously. A friend (now a consultant) published his first payslip on Twitter the other day – alongside a current junior’s payslip. The dates were 2003 and 2023 – the uplift was minimal. But 35%? That seems remarkable, even by the standards of the most aggressive Trades Unions as mentioned before. I was intrigued however, standing outside the hospital, at the numerous signs of approbation – hooted horns and thumbs up from passing cars, and even cars stopping to hand over food and other goodies. I noticed that some of the placards were distinctly political, e.g. with slighting references to The Tories, and I did wonder whether the support was given in that vein (sorry about the pun) and therefore political. A friend also suggests that for whatever reason, the profession has lost its sense of vocation, and has become purely ‘a job’.

I cannot end on the Doctors’ Strike. I have either given too much space to it or too little. Many will have lost the will to live.

Rather, I celebrate the English countryside and the springtime, walking in West Dorset the other day. As I read this diary which takes us roughly to the end of April, I have noticed many non-sequiturs (evidence of a butterfly mind perhaps), so this ending seems in character.

Happy Summer 2023 – when it arrives.