The Labour Party and mathematics

The British political system is once again gearing up for a general election following the parliamentary stalemate over Brexit.  Despite a referendum parliamentarians have appeared determined to frustrate the outcome, apparently on the basis that the people didn’t really know what they were voting for, so should be given a second chance (and reverse the original).

Of course there are other things than Brexit to be concerned about, and all the parties have promised a post-election splurge of gifts – more money for the health service, indeed more money for almost everything.

But where will it come from?

Taxes, or borrowing.  But the lessons of borrowing more than one can afford seem to have been forgotten.  Not only was austerity the only way of reducing the national debt, but politicians of all parties have been assiduous in advising individuals not to get into debt by overspending on credit cards, mortgages and so forth.  So it’s one rule for the populace and another for government.

But one proposal is astonishing.  The Labour Party has promised to introduce a 32-hour week.  As far as “our” NHS is concerned this is an interesting idea.

Currently there is a shortfall of staff almost across the board.  If the working week is reduced from 40 to 32 hours a minimum of a 20% increase in staff will be required to cover rotas.  Where will they come from?  Where will the money come from?  Staff costs represent about 70% of NHS spend, so to increase it at a stroke by 20% requires a total extra financial input of about 14%.  And that’s without developing new services, building new hospitals etc.  But that sort of increase is not what is on offer, so more cuts will be needed to balance the books!  So, actually it’s a bonkers idea, but then Diane Abbott has shown previously a rather tenuous grasp of maths.

And what about staff capability?  By reducing individual doctors’ exposure to acute medicine by 20% reduces their experience by the same amount, so they will become less skilled because they simply don’t see as much medicine.

OK, tax the rich until, as a previous Chancellor said (Denis Healey, Labour) the pips squeak.  Well, they won’t squeak.  They will up and leave.    And if businesses have to give away large chunks of shares to the workers they will move elsewhere – and if some are nationalised without compensation I would call it theft. I think it’s all called killing the goose that laid the golden egg.  The rich pay most of the tax as it is.


Oh boy.  What a mess.  We can only pray that the Bonkers Party is not elected.

Mad Medicine

Delighted to announce that my new book “Mad Medicine: Myths, Maxims and Mayhem in the National Health Service” is not available through Amazon.  It contains some of the essays on my blog but a lot more besides!


The very best diet

As a rheumatologist (and I am sure other doctors have the same experience) I was often asked about diets in arthritis.  Every new one that came along would usually be advertised in one newspaper or other and a cutting would be brandished for my opinion.  They were all somewhat different but many were exclusion diets, so you started with nothing (ie water only – at least no-one ever seemed to be “allergic” to water) and then gradually introduced groups of foods – cereals, dairy products, alcohol, meat etc.  The idea was that if your arthritis flared up then you were sensitive to something in the last group and should avoid it.

Many people tested these as scientifically as they could.  Given the innumerable other variables, like the weather, it was hardly surprising that none of the research proved that anything made arthritis worse.  I was hardly surprised either.  I used to tell patients that if they took all the diets , worked out what common factors were allowed in all of them and stuck to that they would be able to eat nothing but polished rice and chicken, and so would rapidly become vitamin-deficient, developing scurvy and beri-beri.

I was encouraged by the wise words of a Professor of nutrition, Arnold Bender.  He pointed out that a good diet required a balance of fat, protein and carbohydrate and that a McDonalds meal provided exactly that.  But of course most people who wish to go on a diet wish to lose weight, so what about them?  I have to say I found it quite depressing to be referred patients with “wear and tear” arthritis whose problem was that they were grossly overweight.  Many of them were quite depressed, too, as they were in pain but often were refused surgery because their gross obesity made them a very high surgical risk.  So what did I recommend?

EAT LESS!  Have the right balance, even eat what you normally eat, but less of it.  Try using a smaller plate to make the portion look bigger.  Serve your usual amount but don’t eat all of it, or once plated, put some back.  If weight comes from calories and calories come from food, then weight won’t be such a problem if you consume less food.  True, some things are worse than others; carbohydrate-rich foods satisfy you quickly but the effect wears off and you want more; fat sits around and makes you feel fuller, so you won’t want to raid the larder so fast.  Beer contains many calories, wine and spirits less, though still quite a bit.  But if your weight is high, but steady, if you eat less it will go down.

Many dieters find they seem to lose a lot of weight at the start, but then the loss slows right down.  This is because if you start eating a lot less you lose water for the first couple of weeks; you cannot expect to lose more than 1-2lb of “real” weight weekly.  So the best diet is less of what you fancy.

Apropos quirky things, I am highly amused that Gwyneth Paltrow chose to call her wacky business “Goop”.  See  I don’t know where the meaning of the word as someone out of touch with reality came from, but my father (who came from India) used the word fifty years ago to define a stupid idiot.  So did Gwyneth know this and use it ironically to define anyone who bought her strange substances?

Reductio ad absurdum

I have never been a snowflake fan, and my researches into facial injury in the aftermath of the first World War lead me to believe that the disabled servicemen of that time would be appalled by the passivity and blame culture that seems to be infecting the modern generation.  They were expected to suffer, and largely they didn’t, but got on with life.  I think it’s called pragmatism.  All this stuff about cultural appropriation is largely self-indulgent nonsense.  Imitation, says the proverb, is the sincerest form of flattery.  So what is wrong with cooking food from another culture, or dressing up in “foreign” clothes, or telling jokes about another race, or religion?  All my best jokes have an “us and them” feel.  Irish jokes (or, elsewhere, Polak jokes, or Parsi jokes – the themes are the same) are funny.  OK, there are some that are offensive and I wouldn’t tell them, but most are quite harmless. Flanders and Swann wrote a whole series of what would now be politically incorrect songs but they are FUNNY!

“The Welshman’s dishonest, he cheats when he can,

He’s little and dark more like monkey than man;

He works underground with a light in his hat

And he sings far too loud, far too often and flat…”

They aren’t exactly a serious comment on the subject, and anyway the best jokes are often told by their subjects.  Jewish jokes.  Dave Allen with Irish jokes (and some religious ones).  I will tell a Parsi joke later.

And how about no-one being able to dress up as a nurse unless they are one.  No more fancy dress for aspiring kids?  Of course, in this year’s London marathon a nurse was at first not allowed to claim the fastest nurse’s time because she “wasn’t wearing a nurse’s pinafore and cap”.  Ever seen an ITU or theatre nurse in either?  Caps went out with the ark, more’s the pity.  The poor woman was wearing a nurse’s outfit of scrubs.  At least the record-recorders had the sense to revoke their decision.

Another trope is that black parts must be played by black actors, or that gay characters cannot be played by straight ones.  That on the one hand has an oxymoronic relationship with Hamlet, or Othello, played by a woman in the name of sexual equality, and anyway when Shakespeare wrote “Othello” there weren’t any back actors, and I don’t suppose there were many Roman ones to play Julius Caesar, or Egyptians to be cleopatra, etc.  If you are at a single-sex school is the drama production to allow cross-dressing, or will you import opposite sex students to play the appropriate parts?  Nonsense!  I played Olivia in “Twelfth Night”.  Didn’t do the production any harm.  Didn’t do me any harm either.

Then there’s all this thing about slavery.  It always struck me as odd that the young man who wanted the bust of Cecil Rhodes removed from an Oxford College was here on a Rhodes scholarship.  Gift horses in mouth.  If you look carefully at the history of slavery you will find that many of the transported African slaves had actually been collected, and sold on, by other Africans.  It was how the world was.  It still is, in places.  We may judge it wrong now, but it wasn’t in the eighteenth century.  We should not judge the actions of the past by the morals of the present.

No-platforming must be used very carefully.  Banning speakers because you disagree with their views is fine when those views are overtly unacceptable, but it’s a fine line.  Certainly in some recent cases academics have been shouted down for reciting facts, but the suggestion that you should not let the facts get in the way of a good story is supposed to be an ironic statement, not something to be interpreted literally.  Indeed one is sometimes tempted to say to the (often young) protesters “Grow up!”  Don’t refuse to listen to another point of view; listen, and then rebut the arguments with better ones (or facts).  Mind you, the fixed mindsets of Internet trolls may make this a futile exercise.

The same with winning and losing.  To have school sports days where no-one loses is not a preparation for real life, is it?  Disappointments will happen.  Teaching kids that failure never happens is mad.  One fails driving tests; you fail to get the job(s) you apply for; you have failed relationships.  Your favourite football team loses matches.  Failure happens.  Get used to it!  And on the whole if it happens it’s your fault, not someone else’s.  You make mistakes.  That should not disqualify you from future activities (unless they are seriously awful) because you learn from them, and don’t make them again.  Or grow up, which may amount to the same thing.

Oh.  That Parsi joke – predicated on the assumption that Parsis, who live largely in the area around Mumbai and north of it, are superior to Gujeratis.  Like the Irish (or Polaks) being a bit simple.  I expect there are some similar Afrikaner jokes as well.  Are we to live in a jokeless, joyless world?

Six Parsis and six Gujaratis are travelling to Poona from Bombay.  They go to the ticket office.  The Gujaratis buy a ticket each and watch as the Parsis buy only one ticket between them.  They board the express.

The ticket inspector comes down the coach.  The Parsis all retreat to the toilet and cram themselves in, shutting the door behind them.  The inspector takes the Gujaratis’ tickets and they watch as the inspector knocks on the WC door.  It opens a crack, and an arm emerges holding the ticket. The inspector takes it and moves on down the train.

The Gujaratis think this is a quite clever idea. So, on the return, they decide to copy the Parsis  and save some money.  When they get to the station, they buy a single ticket for the return trip. But they learn that the express is stopping at Badlapur and they will need to take a local train for the last part of the journey.  To their astonishment, the Parsis don’t buy a ticket at all.

When they board the train, the Gujaratis cram into a toilet and the Parsis cram into the other across the carriage. The train departs.  Shortly afterward, one of the Parsis leaves his WC and walks over to the WC where the Gujaratis were hiding. He knocks on the door and says, “Ticket, please.”

The Gujaratis are thoroughly upset when they realise the subterfuge and decide they will try the same trick at Badlapur.  But they are totally confused when the Parsis buy a ticket each.  As the inspector comes down the train they set off for the WC.

Local trains don’t have toilets… Parsis are cleverer than Gujeratis!

Well, I think it’s funny…

A Brexit open letter to M.P.s

Dear all,

You have spent many hours being juvenile and petty, and it does not become you.  You appear to have forgotten a number of words and phrases:

Least bad


Dog in the manger

Force majeure (OK, some of you may not speak French)

There is no alternative

The Prime Minister’s deal on Brexit is far from perfect.  However that’s all that is on the table, and no amount of huffing and puffing is likely to change that, given that the UK is one nation against 27.  There has been a great deal of hot air over the imperfections.  Years have passed.  But if there is a better deal, where is it?  You have railed against the Prime Minister’s deal, and complained that two or more years have been wasted, but like Bert in the Bairnsfather cartoon, I say “If you know a better ‘ole, go to it”.  But you haven’t.  You too have wasted those years failing to come up with an alternative.  So maybe there isn’t a better deal.  What is better for some is worse for others.  Maybe this is the least bad deal, at least for now.  If, that is, we are going to get out at all.  For God’s sake take it.  Whatever Brexit we get there will be things that do not work and need to be changed.  So just be sensible and realise (and accept) that.  Get the thing done and worry about the details later when it’s clearer what there is to worry about.  All this posturing on principles is making the nation sick.  Listen to yourselves…

“We don’t like your deal”

“So what would you like?”

“Oh, we don’t know.  But you need to come up with something better.”

How pathetic is that?  It’s dog in the manger stuff.  It’s the sort of behaviour you expect from six-year-olds.

I feel for the PM.  One the one hand she has tried to keep Remainers on side, while on the other she has tried likewise with the hard Brexiteers.  I believe she has steered a reasonable middle course but by doing so has pleased no-one.  You might argue that she hasn’t consulted as much as you would like, but you might as well ask her to stand in a fish market with several dozen auctioneers all shouting at once while offering different stock.  She was always on a hiding to nothing, and her stance has been dignified.  She has, as firmly as was possible, committed herself to delivering Brexit even though she voted against it.  But while I can understand Remainers being difficult, still hoping for a delay and then a second referendum to overturn the decision, I cannot understand why Hard Brexiteers have adopted a course that has scuppered an orderly exit on March 29th.  Talk about shooting yourselves in the feet.  Pull yourselves together.  What happens after Brexit is a completely unknown quantity, from the amount of money we don’t put into the EU through to the effects on business, transport and so on.  So don’t pretend everything will be OK.  You don’t have the facts to back that up.  Neither, to be fair, have the Softies.  WE DON’T KNOW.  Get a grip and understand that.

You all seem to be under the impression that someone will suddenly come up with a deal that is acceptable to all here, and that all you then have to do is present it to the EU who will say “Jolly good chaps, we wondered if you would think of that”.  It won’t happen.  We have agonised for years.  What makes you think that they haven’t?  Yes, they may be run by a bunch of unelected bureaucrats whom we don’t much like, but they are in charge and the 27 other governments are behind them.  And don’t for a moment believe that all they are doing is pondering the Brexit conundrum.  There are other fish to fry – just as here there are all manner of other fish you should have in your pan.  Like policing, the NHS etc.

I voted to Remain, but acquiesce, albeit in some trepidation, in the majority decision to leave.  You have complained that the PM’s decisions to postpone votes, to re-present the same unacceptable proposals, has been a case of kicking the can sown the road.  But you are just as bad.  So stop it.  Vote for the deal you have been offered and tweak the worst bits later.  If they are worth tweaking, the EU will be only too pleased to help.

Trolls and censorship

Two cholesterol skeptics have recently been subjected to a Wikipedia trolling attack, with their entries being dissed and removed. The authors of the attacks are cowardly enough to hide behind pseudonyms and have tried to discredit their victims by suggesting that  their opinions are those of fringe lunatics.

That Wikipedia appears to have caved in to their demands for censorship is scandalous. One does not need to be a multipublished researcher to have sound opinions based on evidence. The trolling appears to be part of a sustained assault by vested interests against skeptics without any attempt to analyse or even read the scientific rationale they are setting out. The number of edits suggests a concerted trolling effort and its apparent success undermines the credibility of Wikipedia itself.

Wikipedia can restore its credibility by naming the anonymous trolls so that reasoned debate may continue.  Without that it will always be subject to the charge that it promulgates fake news. Which would be a pity as there is much to admire.

Now I know how Galileo felt

An astonishing article appeared in “The Guardian” on 30th October.  You can find it at  Basically it states that accepted wisdom over the dangers of cholesterol is correct, and those that seek to deny this are dangerous lunatics.  The article is shot through with snide digs at the deniers, implying they are not proper researchers because they don’t hold tenured posts, that their opinions are published in obscure or second-rate journals and that their views are as damaging as Andrew Wakefield’s views on MMR vaccine causing autism.

When Galileo (and Copernicus for that matter) first suggested, with good scientific evidence, that the earth went round the sun he was subjected to abuse, vilification and was ostracised.  Every attempt was made by the scientists of the day to rubbish his theory. Oh well, it was suggested, he isn’t a proper astronomer, so what does he know to produce a theory that all we experts refute categorically?

Sounds familiar, perhaps.

Let’s get a few things straight. I was a rheumatologist in my working life, so deferred to my cardiology colleagues on matters cardiac.  When I found my serum cholesterol was very high I consulted my GP and readily accepted the prescription of a statin.  I developed an odd inflammation in my shin shortly after the first statin.  The technical term was tenosynovitis of the tibialis anterior muscle; in lay terms this was pain on walking, with a peculiar grating feeling if I put my hand over my shin and worked the muscle.  I had never encountered this among the myriad soft tissue lesions I saw in my clinics so consulted the Internet, where I found a case report of the condition related to statin intake.  So I stopped my statin .  The problem went away.  I sought further advice.  My GP gave me another one.  This time within 24 hours I had developed severe shoulder and hip girdle muscle pains, so bad during the night that I was unable to sleep.  I attributed this to the new statin, and stopped that.  After an interval I was prescribed yet another.  I had no adverse effects for a couple of months, and then found I was struggling to climb hills and could not lift heavy garden items.  On a long slope I simply ran out of steam, and had to stop and wait a few minutes.  Normally I could lift two 50 litre bags of compost together; now i could not lift even one.

By this time I had discovered the existence of statin myalgia, so took myself to the hospital lab to get my blood checked.  My creatine kinase level (that’s an enzyme which goes up with muscle damage, or rhabdomyolysis) was significantly elevated.  I consulted a lipid specialist and we agreed I should not take them any more.  My cholesterol remains high.

I write this preamble because the anti-Galileans of the cholesterol world talk blithely of a nocebo effect – one where you get a side-effect because you are expecting to get one. – which explains, in their eyes, the reports of side-effects that they claim are grossly exaggerated in numbers.  But you can’t suffer from a nocebo effect if you don’t expect it.  Neither can such an effect cause significant enzyme changes on blood tests.  Never mind; whatever the real incidence that’s not entirely relevant to this piece, but my experience led me to a new world of the cholesterol-heart hypothesis, and to the statin skeptic network called THINCS.  And we are, I believe, modern Galileos, whose questioning of received wisdom (if you can call it that) is beginning to lead to denigration and persecution.  Will we be proved right?  Let’s look at some facts.

It is undeniable that statins do reduce the risk of a major cardiac event.  But the first question is – by how much?  If you read the statin-favourable reports and research studies you will think that the risk reduction is around 50%, which is pretty impressive.  However you must ask first what the risk was in the first place.  If the risk is 4%, then a reduction of 50% means it becomes 2%.  So it’s not really very impressive at all.  Statistics are not easy; I have seen many examples of trials conducted by perfectly respectable researchers who have used the wrong statistical analysis method by accident (or ignorance) and not-so-respectable ones who find a method, or select data, so they produce an apparently significant result.  But quoting a risk reduction of 50% – the relative reduction – is deception when the absolute reduction is only 2%.  Why do people do this?  It makes the results look better, but in the end they start believing their own myths.  And if you look at the prolongation of life it amounts to a few days, let alone years.  Not a lot, as Paul Daniels would have said.

So the effects of statins are overstated and misrepresented.

The next question is why do statins reduce risk (although perhaps, as the reduction is so piddling, we shouldn’t bother).  But I did bother, because I found something that blew the whole cholesterol thing out of the water.

There is unimpeachable evidence that if you suffer from severe rheumatoid arthritis (RA) then your risk a a major cardiovascular event is very high – possibly even higher than if you are diabetic.  If you successfully treat the arthritis with so-called disease-modifying drugs, this risk reduces substantially.  But the cholesterol level in the blood goes up.

Here we have an oxymoron. Give statins, cholesterol falls and cardiac risk falls (a bit).  Give drugs that make RA patients better, cholesterol rises, but cardiac risk falls (quite a lot).  Explain.

For about seven years I put this paradox to rheumatologists, physicians and others. No-one could explain it.  They huffed and puffed and mumbled and came up with all manner of crazy theories.  So we have a Black Swan.  Received wisdom in the eighteenth century was that all swans were white. Then Australia was discovered and lo! there were black ones. So the received wisdom was wrong. It only takes a single contrary observation to destroy a theory.  In medicine one tests a theory exactly thus; you make a hypothesis, and set out to disprove it (it’s called a null hypothesis).  The null hypothesis is that statins  reduce cardiac risk because they reduce cholesterol.  Yet if we reduce cardiac risk by treating a disease characterised by inflammation, cholesterol goes up.  So the null hypothesis is by definition proved to be false.  You can have any number of things supporting a null hypothesis, but it takes just one that doesn’t to turn things over.

Enter Malcolm Kendrick, another cholesterol skeptic, a deep thinker, careful research analyst, and GP without some giant research department (therefore suspect in the eyes of the anti-Galileans). What if the mechanism of action of statins has nothing to do with cholesterol?  Suppose that cardiovascular risk is increased because of blood vessel inflammation and that statins reduce this?  Well.  It all fits, doesn’t it? And by golly there’s plenty of evidence for coronary artery inflammation.  You get it in RA and other connective tissue diseases.  You find it on pathological examination under a microscope.  And it explains otherwise inexplicable things.  Like – how does a large cholesterol molecule get through the blood vessel wall?  It can’t, if the wall is intact, because it’s too big.  But suppose the wall is damaged, and tries to repair itself, but the process doesn’t quite work.  Why, then you can find cholesterol the wrong side of the wall lining.  It’s there as part of an incomplete healing process.  It has nothing whatever to do with its concentration in the blood but will happen more often where there is blood vessel damage.  Oh, and by the way, that occurs in diabetics and smokers too.  There are an awful lot of scientists and cardiologists who find this hypothesis attractive, and despite asking the anti-Galileans to pick it to pieces for some reason they haven’t.  Perhaps they can’t but I would like to see them try.

I would prefer to explain this as follows: Statin use (A) causes a small reduction in cardiac risk (B).  A also causes a fall in cholesterol (C).  A leads to B, and A leads to C.  But that does not mean that C leads to B.  A fall in cholesterol is more likely to be a side-effect, or epiphenomenon – something clearly observable but irrelevant.

Another question of mine has been why you find cholesterol deposits in arteries, but not in veins, where the pressure is less and the flow can be sluggish.  If cholesterol was to be deposited anywhere it ought to be here, like silt in a river. Explain. (Actually don’t bother, because there’s more coming that makes that unnecessary).

So statins work by reducing inflammation; that they reduce cholesterol is by the by.  Now I don’t really care whether severe statin side-effects occur in 20 % or 2% but others do, on the basis that if patients cannot take a statin they MUST HAVE SOMETHING!!!  You would be amazed at the number of people I saw with clear-cut statin side-effects (effect occurs, stop, effect disappears, restart, effect reappears – that’s called re-challenge, and QED for cause and effect) who were otld, 0redered even, to carry on because otherwise they would DIE!

So a new injectable drug was produced called evolucumab.  Its cholesterol-lowering effects are remarkable.  It’s far, far better than a statin.  It’s also very, very expensive.  Does it reduce cardiac events far, far better than a statin?  No!  Why not? Perhaps it doesn’t have any anti-inflammatory properties, but we won’t know in all probability as the major trial looking at outcomes was terminated early.  The death rate in those on the active drug was higher.  There is a suspicion that it would have been higher still if the trial had continued.  Even Sir Richard Thompson, past president of the Royal College of Physicians, said any benefit was “amazingly small”.  So here is another oxymoron.  Statins reduce cholesterol a bit and reduce cardiac events a bit.  Evolucumab reduces cholesterol a lot but doesn’t reduce cardiac events.  Explain.

Well, the obvious explanation is that any cardiac benefits of statins have nothing to do with cholesterol.

Next question.  Where does cholesterol come from?

You thought you ate it, didn’t you?  It’s in all that butter and other saturated fat that forms such a large part of your diet.  Actually it’s not that large a part, but anyway most of the cholesterol you find in the bloodstream (80% or so) is made in the liver.  From what, you ask? How about carbohydrate?  Whatever, an increase in dietary cholesterol slows the liver’s own production (this is called homeostasis).  So fiddling with your cholesterol intake is not much use, as your liver will defy your good intentions and simply make more.  If your level is high, probably your genes made you that way.

I wonder whether you are beginning to doubt received wisdom.  It is interesting, if sad, that the whole concept of cholesterol irrelevance was effectively proposed several decades ago by Dr John Yudkin, who saw sugar as the villain, but who was himself vilified and ostracised.  And the work of Ancel Keys who was key (sorry) to the adoption of the cholesterol-heart hypothesis, was fatally flawed.  Out of the countries from which demographic data was analysed he picked those that best fitted his hypothesis.  Had he used it all he would not have found any significant correlation.  Indeed most of the trials looking at serum cholesterol and heart disease conducted before 2000 have methodological flaws.  Confine reviews to trials after that date and even the relative risk improvement begins to look unexciting.

So there it is.  The hypothesis is based on shaky data analysis, falls over under intense scrutiny because of inherent contradictions and is also suspect because some of the later trials cannot be independently assessed.  Sceptics have persuaded erudite journals that trial data should be made available for independent analysis.  Yet one of the most strident anti-Galileans, Sir Rory Collins, refuses to do this for his own work.  If it’s so cast iron right, what is there to hide, one might ask.  And what need is there for the anti-Galileans to make snide remarks questioning the credibility and integrity of their critics? Likening us to the disgraced Andrew Wakefield, who has fooled people with fraudulent data, is frankly offensive.  We have faked no data, falsified no trials, merely picked major holes in those of others.  We have raised no scares, unlike those who have accused us of killing people by telling them to stop their statins.

What did Socrates say?  “When the debate is lost, slander becomes the tool of the loser.”

Remember: all of us sceptics were reared on the heart-cholesterol hypothesis but it is us who have been open-minded enough to question its validity.  If we are wrong, give us the evidence.  Prove that our hypothesis has fatal flaws.  In other words, put up or shut up.