Malaria control is the best bang for your charitable bucks - really?

‘For every complex problem there is a solution that is clear, simple, and completely wrong.’  ( H L Mencken. ) Is malaria control an example?

Zambia is an ‘epidemic’ malaria zone. This means that there is very little malaria in the height of the dry season when the relevant mosquito has no stagnant water to breed in. But the annual rains in December to March turn this flat valley into a mosquito paradise, which lasts well into June and July as water collects in pools locked in by the clay soil.  As a result the risk of contracting malaria is very high. In this small settlement of 10,000 or so, we are seeing hundreds of cases daily, and the risk to foreigners working here seems to be that one in 5 or 10 will get it in any one year even though they are all aware of the need to prevent the mosquito bites, and all use nets and repellent sprays.  Mostly the illness is like an extremely severe flu if treated promptly, but a few cases ( ?5%)become severe and there is a definite mortality rate.  Seeing adults with temperatures over 40 is a bit of a shock for a GP from the UK, and personally I am taking preventative drugs!

Worldwide it is estimated that malaria kills roughly half a million people a year, mostly in Africa, and mostly children.  Because malaria is a parasite, which gets inside human cells in the blood and the liver, it seems to be able to evade the immune system.

In other areas of the world drainage of wet areas has been very effective in eradicating the mosquito, but this would be impossible here.  So malaria control here has focused on insecticidal bednets and ready access to diagnosis and treatment in order to reduce the chance of the mosquito biting an infected patient. This is available from community volunteers in the villages as well as government clinics. According to Bill Gates if we work at it we can eradicate malaria (as we have smallpox). See https://www.gatesnotes.com/Health/Eradicating-Malaria-in-a-Generation

And http://www.gatesfoundation.org/What-We-Do/Global-Health/Malaria

But I have a sneaking suspicion that the main effect of our current efforts is to make this area i.e. the Luangwa valley inhabitable. 40 years ago there were very few people indeed living in this area, and I wonder if one reason might be that the risk of malaria was high and there was no treatment available.  Now we have both diagnosis and treatment easily available, and death rates are much lower but we have hugely increased the number of people who are living close to water which is full of anopheles mosquitoes.

So our efforts and those of the Gates foundation are no doubt at all saving huge numbers of lives in the short term. But it looks as if eradication will only happen if there is a real breakthrough in terms of vaccines, insecticides, or mass treatment.

An education solution maybe?

The problem of how to help poor African countries develop economically and help them get out of their grinding poverty - with hungry children, illiteracy, nights with no lighting, etc. confronts anyone who visits a country like Zambia. It ought to be possible to improve things, it is peaceful and not overpopulated, and it is easy to grow food and stuff like cotton to sell.  They do also have some natural resources in terms of copper and hydroelectric power.

So the standard theory is that they just need a bit of a leg up especially with improving literacy and education and malaria control, and then gradually growth and development will accelerate.

Education in particular has had huge help from Donors, and schools everywhere have signs indicating which particular charity or country has paid for their newest building. Many of the secondary pupils are sponsored by donors who pay for fees, books and even food.

But standards of education are dire. Class sizes are huge-not surprisingly,  with  the average age of the population of Zambia around 16, and an annual population growth rate of nearly 3%.  Many children miss school years intermittently due to lack of funds to buy uniforms and books. Then there are poor English language skills, lack of books, poor teacher training, and poor teacher motivation, which means that even secondary school pupils lack basic numeracy skills.  At the same time other parts of the world including India and China are leaping ahead in terms of their education especially in high tech areas. So Zambia is falling even more behind.

Is there any way of improving this situation? One possibly is to work outside the existing school system. Is one possible solution is Edulution. Using content from the US based online provider the Khan academy they employ coaches to help groups of 30 pupils in 3 hour sessions once a week throughout the year with their numeracy. Each pupil has a small tablet computer, which is linked to the coaches laptop. No internet connection is needed as the content is preloaded.  The  cost to sponsors is around $10 per month per pupil, which is much less than conventional school sponsorship. This system has recently been started in this area by the main local charity Projectluangwa.org and, at my recent visit to the local school, pupils and teachers and coaches seemed happy and enthusiastic. It is early days but after my visit I am cautiously enthusiastic that this is one situation where new technology may be at least part of the answer. 

Teenage pregnancy - a problem solved?

The highest teenage pregnancy rate in Europe was the shameful statistic that the Blair government  decided to address. Teenagers having babies leads to all sorts of bad outcomes, high rates of prematurity and hence damaged babies requiring very expensive medical care, and also long term underemployment of the mothers, who are almost bound to remain on welfare payments and to need housing subsidies for many years. It is a medical and social disaster.  A big effort was made in schools and in the health service to provide contraception, particularly using hormone implants which work for several years (and cannot be forgotten.)

10 years later the number of teenage births has approximately halved to around 20 per 1000 girls per year. So we can clap ourselves on the back for a policy which really has achieved a worthwhile result.

But, if that is true, how can it be that very similar sharp declines  starting around 2007 have happened in other countries, such as New Zealand and the US, which did not have any major policy change in this area.  And the decline in the UK started slightly before the change in health policy. It has been suggested that it has been the rise of facebook etc. that has led to a decline in sexual activity see Telegraph article , but survey data do not support this.

It is of course impossible to look back at history and be sure of the causes of such trends. It may simply be a case of pregnancy becoming less fashionable, as also seems to be true of heavy drinking among teenagers.

In Zambia, the situation is different. The nationally the rate is about 150 i.e. over 7 times the UK figure, and about 28% of girls will become pregnant before their 19^th birthday. Pregnancy rate in Zambia

Near our clinic there is a secondary school.. Parents pay fees for their children to attend, and they need uniforms and books, and they cannot work, so we are talking about the upper socioeconomic levels of rural Zambian society.  And yet there have been a lot of pregnancies recently, and as a result the school decided that all 400 or so girls should have pregnancy tests! (Medical ethics are interpreted differently here).  7 of the girls tested positive, on top of those already found to be pregnant.

Just as in the UK, this will probably put an end to any prospect of further education for these girls. The girls will be out of school for a year or so with a huge effect on their eventual attainment.  

So why the difference?  The girls can attend the local health clinic for family planning. This is done at a specific clinic on a Monday.  At the clinic the staff say that there is free access to contraception with no questions asked: But that the pupils are put off coming by ‘stigma’.  Local charities would like to go into the schools and supply/push contraception, but this is strongly opposed by traditional Zambian society, which is dominated by Christianity.

Commute by bike to stay healthy - the Zambian way

The British Medical Journal published the findings of a huge research project last week comparing health outcomes for people in the UK who travel to work in different ways. They found that the 2% of people who regularly commuted by bike had a 40% lower death rate, a similar reduction in cancer deaths, and less than half the risk of dying of heart disease.  Regular walking commuters also had reduced risks of dying from heart disease.

Obviously some of this difference may be because the cyclists are healthier in the first place, but the differences are huge, and very statistically significant (i.e. very very unlikely to be a chance finding). So the potential benefit to the health of the UK from a large increase in ‘active’ commuting is massive. But how can this be done.

In rural Zambia, almost all journeys to work are on foot or by bike. The mass of cycling and walking commuters on the roads in the morning and evening would gladden the heart of any public health doctor.  If only the UK population would do the same. The difference is also very obvious when one looks at the muscles on display. The glutes, the six packs and particularly the back muscles of most Zambians would be the envy of many a pilates instructor.

So how have they managed to achieve this situation? And can we copy from them?

First of all they have very little alternative! There are a few cars that operate as taxis but they are unaffordable for the majority. Secondly, they have really taken on the bicycle in the last ten to fifteen years. They can buy cheap new bikes from china for $70 or so, and recycled bikes from the US and Europe for even less. They are used as much for transporting goods (especially huge bundles of firewood) as people.  The bicycle is ideal here as the terrain is pretty flat and paths between the tiny villages on the clay earth make an excellent flat surface.  There are also few people who live more than 10 km from their work.

So many of us cannot really follow their example.

Unfortunately it seems more likely that they are beginning to follow ours!

If you do have an office job in Zambia, or work for example as a safari guide, you will be sitting down most of the time, and there are very few opportunities to take recreational exercise unless you are young and fit enough to play for one of the many football teams. So economic development seems certain to worsen the outlook here for the ‘Diseases of affluence’, and we do often see slightly overweight office workers or housewives with pot bellies and diabetes and high BP.  And the toll from these diseases in terms of Strokes and Heart failure is bad now and certain to increase.

We have just finished “National Health Week” in Zambia. One of the daily messages sent out to everyone with a mobile phone last week was ‘Exercise 3-4 times a week to reduce your risk of Heart Disease and Diabetes.’  Pretty hard to understand if you are subsistence farmer! And hard to understand in a society where for most people physical exercise is work, and rest is physical rest.

So the image of happy cycle commuters is great, but we cannot learn from Zambia how to get there. They may learn from us about the dangers of a sedentary society, but it will be a hard lesson.

The positive images we can try to follow, are those of Amsterdam and Copenhagen, where bikes exceed cars for commuter journeys.  To get there we just need to invest massively in cycle infrastructure,  regulate or tax car commuting, and get employers onside in terms of secure bike parking etc.

The baffling shortage of doctors training to be GPs

After new doctors have finished their 2 year foundation programme, mainly in hospitals, they can apply for GP training which takes 3 years half of which is in relevant hospital departments, after which they are able to pick and choose where to work as a GP,  as there are a huge number of vacancies. Salaries are high and practices are begging to get new doctors to replace the many who are retiring. Earnings are as good as for NHS specialists, there is no out of hours or weekend work and there is a guaranteed job at the end of it, which there is not for other specialties. For example, there are many trained anaesthetists who cannot get jobs. And in order to qualify as a specialist, you have to do a minimum of 6-7 years training,  with a lot of on unsocial hours work.

And GPs can run their own practices, and are thus more independent of NHS managers, who blight the life of many specialists. So obviously, with more money, nice hours, a much shorter training, and the promise of being able to run their own show, young doctors are likely to prefer to train as a GP.

Except they are not!

GP training programmes are undersubscribed despite many areas resorting to golden hellos of £20,000!  And extra rounds of recruitment. And the GP registrars on training schemes are very often put off by their training and few of them opt for full time GP work at the end of their 3 year programme. So when there should be a glut of applicants for GP vacancies there is a dearth, and nowhere near enough to replace all the GP's who have had a bellyful and a good pension and are retiring.

The whole basis of the NHS is threatened by understaffed GP practices. The OECD gives the NHS a good rating overall, but bad marks for many aspects of specialist care. They say the best thing about the NHS is that patients have a ' medical home' which helps coordinate care and stops specialists advice conflicting with each other. This will be less effective with understaffed practices, nurse practitioners, temporary locum doctors and generally poor continuity of care.

So whose fault is this?, and how can it be sorted?

There are a few possibilities. Press coverage from the Daily Mail is unflattering to GP's image. The pressure of regulation from the General Medical Council and the Care Quality Commission are tiresome and a bit threatening. The 'dumping' of work by hospitals onto GP's is increasing  . The rapidly rising risk and cost of complaints and being sued is off putting. However the main issue putting young doctors off is, somewhat amazingly, the Royal College of GP's, the organisation that is supposed to be encouraging quality General Practice, and their senior members who run the GP training schemes in the various ' deaneries' around the country.

These doctors and their staff became used to having lots of good applicants over the years and failed to realise that they gradually made the training schemes worse and less attractive in many ways. They  made the training much more rigid, and stopped the practice of giving credit for relevant experience. Thus a doctor who has been training in Emergency medicine and wants to switch to GP now has to do  another spell of Emergency work. They have reduced the flexibility which used to allow trainees and trainers the chance of choosing each other. Now many areas allocate the trainees to practices by a method which seems neither fair nor transparent. They have allowed the service demands of hospitals to trump the learning needs of trainees so that they are forced to work more than their fair share of nights and weekends than specialty trainees. The training process has become an elaborate tick box exercise with some very poor quality educational sessions. As practices have got busier in recent years some are demanding more work from trainees and spending less time and effort on debriefing and educating them. And trainees are forced to sign up for college membership and have to pay over £1000 a go for an arduous exam which has a high failure rate, and which has been severely criticised for being unfair to ethnic minorities (and males!). Repeated failure is, as one would expect, catastrophic for a medical career and leaves doctors with almost no options.
In short the RCGP have blindly and bit by bit for various reasons succeeded in putting off many of  our best and brightest young doctors from the idea of General Practice. They need to stop blaming other people and sort it out.

Stimulation - achieving a balance

There is a lot of evidence that the epidemic of Attention Deficit Hyperactivity Disorder in the developed world is an increasing problem, and that it may be caused by overstimulation of children, especially by exposure to ‘rapidly paced television programmes’.  These children become impulsive, do poorly at school, and are later on they are far more likely to have car crashes, get divorced, and go to prison.

And all of us in the developed world are now bombarded with input from TV, emails, texts, and social media. We have to tune out deliberately in order to get on with anything!

This seems to be one problem that we do not have in rural Zambia.  Most children here have no TV, no computers, no toys, no bikes, no mobile phones, no books, and no electricity for reading even if they had something to read. They lack even simple footballs – so they have to make them out of bits of plastic and tape and plastic bags. So going for a walk or bike ride through a rural village means dealing with a crowd of kids all keen to hold your hand and walk along with you as you are probably the most novel and interesting event of their day.

So we need more footballs in Zambia, and less TV in the UK. But how?

Peak 'Stuff'

Peak stuff  

Ikea has warned that in Europe we tend no longer to want to have more possessions, preferring to spend any spare cash on services and experiences. Services tend to be labour intensive and expensive in Europe, and with the oncoming demographic change in our society, this is likely to get worse.

We haven’t quite got to the same situation in Zambia. Here, ‘Stuff’ is highly prized and endlessly repaired, and imported goods that would be cheap by almost any standard are replaced by hand made craft produce that require many hours of patient labour. The population is growing and there are lots of young fit people who have no regular work.

Floor Mats are made from palm leaves that are divided into strips. Some of them are died black and then they are very skillfully folded into neat patterns. It takes a skilled man a day to make a mat, which he sells for about $2 US.  So his monthly income is $60 US! Bricks are made by finding the right sort of clay which is locally abundant, and pouring it into a mould and then firing the result in a brick oven using charcoal as a fuel.. Market gardeners cycle into market in the morning with huge home made baskets of vegetables on the back of the bike. There is lots of football played in the afternoons as it begins to cool down but the kid’s balls are home made from all sorts of stuff held together with sticky tape.

There are of course a few things that cannot easily be made by craftsmen. Shoes are important status symbols: none for the poor, flipflops for most, and the top layer of society ie teachers, nurses, safari guides etc have proper shoes, which are always smart.  Bicycles are used to transport goods and people. Commonly one sees huge bundles of firewood or a whole family on one bike. Dad rides with one child on the cross bar and wife and baby on the luggage carrier (yes South Luangwa is very flat!). Every 2 km or so along the roads is a cycle repair workshop, and they are always busy fixing the very cheap bikes ($70 US) that are imported from China. Mobile phones are an essential tool. They are all ‘pay as you go’  with vouchers costing as little as 10 cents. They do of course break regularly, and there is another whole industry with little booths selling airtime and spare parts and lots of young guys fixing them with primitive tools such as screwdrivers made from bicycle spokes. Plastic bowls for washing up and washing clothes, and metal saucepans for cooking are other essential imports.

The zietgiest that says that people’s time is cheap and that stuff is valuable has some unfortunate effects in the local health clinic, which has a tiny budget of $80 a month to spend on buying tools and equipment. This means that relatively well paid nurses (and volunteer doctors) spend time wandering around from room to room trying to locate rare items like a pair of scissors, or a weighing scales, or a thermometer, or a BP machine.

So we have something in abundance that they value and lack i.e. stuff, and they have something in abundance that we value and lack ie human labour. This is of course a classic economic example where trade could be of huge benefit to both parties. And to some extent this is what the hugely labour intensive safari holiday industry does, exchanging this labour for hard cash which Zambians use to buy more Stuff that they do really really need.  

The classic  trade would of course be agricultural produce from Africa to supply overcrowded Europe, but it is hampered by the tradition of small scale farming, ignorance, long supply lines, and tariffs and other restrictions.

We need some way of using African labour to meet our needs, and pay for it so that they can meet theirs.  Ideas are welcome!

Did we really expect our politicians Vote in favour of Assisted Dying?

So parliament have voted it down, despite overwhelming support (82%in a recent poll) for a change in the law on assisted dying.

We have a situation where the law is a nonsense, as prosecutors have said they will not prosecute Bona fide helpers who for example accompany people to Dignitas, but this is still a criminal act in law. So at present the right to choose when to die is limited to those with the resources and ability to travel to Switzerland, which is the only country to allow assisted suicide for non-residents.   For a poignant documentary on one man's journey see How to die - Simon's Choice. This BBC2 programme is available on the iplayer. 

But why do we expect the law to change first? In countless situations in the past (legalising suicide, abortion or homosexuality for example), the establishment has had to be forced to recognise that society has moved on, and that morals based on Religion have become irrelevant for the huge majority of people.

Anyone with an Internet connection and a bit of initiative can find out about and get hold of the necessary medication. This usually involves using horse sedatives which quickly induce unconsciousness and then death. An alternative is using a bag with gases such as Nitrogen or Helium (and no oxygen). Apparently people do not feel they are being suffocated.

Gradually, more and more people will make advance plans to avoid the fate of most people today, which is to spend their final days in a noisy hospital ward, in pain and distress.  They will arrange with friends and relatives how to administer the necessary medication, usually after saying a last goodbye to their families, in a probably very poignant celebration of their lives. They will put pressure on doctors and nurses to help them where it is necessary.

That we should have the right to die (subject to obvious safeguards) is now accepted by a large majority of the population in all developed countries except those where organised religion is strong. Sadly religious groups peddle false claims about alleged abuse of the law and the ‘slippery slope’ that would lead to patients feeling pressured into prematurely ending their lives. See Christian Medical Fellowship Twelve Reasons and Nine Myths about Euthanasia. These are not the reasons they oppose assisted dying, but they know that they cannot persuade people by saying what they actually believe, which is that we should be allowed to choose what to do with our lives in every respect, -except that of how we die -which must be decided only by God.

A patchwork of countries and states across the world now specifically permits assisted dying. Generally they are predominantly secular countries with a tradition of allowing direct democracy. At present they include the US states Oregon, Washington, California, and Vermont, as well as the Netherlands, Switzerland, and Belgium where almost 2 percent of deaths are now ‘voluntary’.  Several countries, most notably Canada and Germany, face the same situation as the UK in that those assisting suicide have been promised immunity from prosecution by the courts, making changes to the law necessary. As in the UK, it is a nettle that many legislators are very reluctant to grasp.

In France, President Hollande has shown a marked difference from UK politicians who tend to duck for cover when the issue is debated. Under his tenure, doctors have recently been allowed to use ‘terminal sedation’. It is still too early to say how much this will alter practice in France.

The process by which this last taboo will be banished will be expedited by brave people who make no secret of what they are doing and challenge the authorities to take action. It was a Dutch GP, Andries Postma and his GP wife Truus who, an unbelievable 60 years ago, helped their patient to die, with an injection of 200mg of morphine. They made no secret of what they had done and the police were informed. They were charged and found guilty, but given a suspended sentence in 1973. This then led to the formation of the Dutch Voluntary Euthanasia society, and gradually to the enlightened attitude that prevails in the Netherlands today. Assisted suicide and euthanasia became gradually more common and protocols were established for doctors to follow. This situation went on for about 20 years until the ‘Termination of Life on Request and Assisted Suicide Act’ was passed into law in 2002.

If we can be brave enough to follow their example, we can make the recent spineless parliamentary decision irrelevant, prevent a lot of pain and suffering, and give most people a good death.

Should we be Paranoid, or Infuriated?

Paranoid?

or Infuriated?

Much of the time, it seems that the obvious reason for the development of bizarre QOF target hoops through which we have to to jump, or absurdly unfair articles in the press about GP pay, is that some people really do have an axe to grind, and they are out to get us.

Typical suspects include politicians (and their cronies) trying to open up the NHS to competition from for-profit business, but the culprits can also include the media, the pharmaceutical industry and NHS bureaucrats.

One can apply the 'cui bono' test to pinpoint the guilty party among those who would benefit from any particular new imposition, and it commonly points to a likely suspect. This is known as the 'conspiracy theory' and it does have a lot going for it. However, there are examples where it seems to be very difficult to spot anyone who benefits. Not long ago, the NHS prescription charge was raised from £7.85 to £8.15. This means that in pharmacies and dispensing doctors' surgeries all over England, staff are counting out £1.85 in change over and over again; this involves a minimum of five coins, all of them different. Pharmacies have to pass all this money on to the NHS so they are understandably unwilling to bear the loss they would have if they allowed card payments.  Pharmacies now regularly run out of coins and have to go their local bank to get more, if they are lucky enough to have a branch nearby. If they can, staff will encourage punters to claim exemption. So they will have more work to do than if the charge was £8, but due to increased exemptions, the money raised is less than previously, meaning nobody benefits. So much for conspiracy.  For this, it seems another theory is needed - commonly known as the 'cock-up theory' (perfectly illustrated by the Health and Social Care Act, if you need an example). The most elegant expression of this is known as Hanlon's Razor, an adage stating: 'Never attribute to malice that which is adequately explained by stupidity.' But hang on, what is £8.15 in euros?

How much is safe to drink? Dame Sally boobs on booze

Dame Sally Davies tells us that ‘no level of alcohol consumption is safe’. Is she right? And why has the advice changed, and why is it different in different countries? Getting to the truth is tricky, and here is why. 

  

When she started the job as Chief Medical Officer Professor Dame Sally Davies – who was formerly one of the most specialised of super specialists – dealing with sickle cell disease- got on the wick of many doctors with her instructions. She said that we should lead by example in terms of lifestyle, and make every consultation count in terms of imposing an agenda of well meaning health advice on obesity etc. even when we are dealing with patients struggling with major medical problems.

Now she has really poured salt on the wound with her advice reducing the maximum safe limit for alcohol intake – especially with reference to cancer. For a while  GP’s will be getting an increase in patients presenting with minor symptoms who are terrified that they are caused by cancer which is related to their modest consumption of alcohol.

Meanwhile lots of health experts continue to insist that moderate drinking has overall health benefits, and guidance from around the world on safe levels of consumption varies widely even though the experts are looking at the same evidence. Surely, an issue which has been debated and studied by huge numbers of people for decades should have clearer answers.

Well, no actually. It is extremely difficult to be sure about issues such as this. The reason is that direct experimental evidence is very difficult to obtain – you could conceivably split imprisoned convicts into groups and administer alcohol in varying quantities – but it would not be allowed. Studying what happens to people in the population has a lot of potential errors and possible biases, and this is the reason why there is so much disagreement in interpreting the research that has been done. Similar issues apply to lots of other questions about the health effects of meat in the diet, sunlight, vitamin D, Hormone Replacement etc.

There are 4 sorts of evidence that are relevant to these sorts of issues and it is worth understanding each one as you usually need more than one type of evidence to really nail something as a probable causative factor in a certain disease. 

The easiest sort of evidence comes from large surveys of people with a particular disease asking them about their habits, occupations, drug use etc. and looking for statistical associations. This method is called a Retrospective Case Control study. It is quick and pretty good at excluding possible causes, but suffers from several possible sources of bias, which makes its positive conclusions about causation relatively unreliable. It is difficult to recall past habits correctly leading to ‘recall’ bias. (Although some studies get around this by searching health records for example for a history of medication use).  The control group who have responded to the request to take part in surveys may be unrepresentative of the general population in many ways. This is called ‘selection bias’. Lastly this sort of study can suffer severely from so called ‘confounding’ where some other causative factor that may be unknown and that is not being measured differs between the groups being compared. For example, lots of effort has been spent on comparing different sorts of occupations with the aim of working out to what extent ‘stress’ and poor job satisfaction causes disease. However it has been very difficult to rule out other factors such as smoking, poor diet, and lack of exercise as they tend to more common among lower status workers.

A more laborious, but more reliable method is to identify the suspected culprit at the start of the study and arrange to follow a cohort of subjects over a period of time and count the number of people falling ill in the separate groups. This is called a Prospective Cohort study and is much more reliable. However, it is still difficult to choose a control group that matches the study group who are being exposed to the risk or treatment, so that confounding and selection bias are still possible. ‘Recall’ bias is still possible if people lie about their habits – which is possible with questions about alcohol.  The other big problem is that it takes several years from when the study is started to the day the data is analysed.

One feature of both prospective and retrospective studies that strengthens their conclusions a lot is a so called ‘dose response’ effect. When the smoking habits of British doctors were studied back in the 1950s it was the fact that the risk of lung cancer strongly and progressively increased with increasing tobacco consumption that clinched the argument.

The most reliable evidence comes when the researcher is able to randomly select a group of subjects, and expose them to the relevant factor, while keeping the ‘control’ group unexposed. This is called a RCT or randomised controlled trial, and is accepted as the most reliable evidence. However, it is expensive, and usually has far fewer participants, and it can often be criticized as not being relevant to the ‘real world’.

The 4^th very important line of evidence is called ‘biological plausibility’. This is when there is evidence that the factor under suspicion has some known effect on the organ concerned. For example it is experimentally provable that a small concentration of CO2 in air will reduce the transmission of infra red radiation – so that the mechanism of man made climate change is clear.

If we have evidence of all 4 types pointing in the same direction then the case is very strong. Unfortunately that is not common and there are many subjects where we are not even close. We know that we have to be distrustful of conclusions based on one type of study alone as this has led to some famous errors in the past. The most famous example is that of Vitamin C. Retrospective studies showed that consuming fruit and veg was associated with much better health outcomes, and everyone thought that it must the anti-oxidant Vitamin C that was the important ingredient.  However, when Randomised Controlled studies were done with half the subjects taking a supplement, they showed no benefit whatever. We now think that people who eat fruit and veg are generally more careful with their health, and perhaps there are other chemicals rather that make the difference.

And so to Alcohol. We must of course first make clear that we are not talking about 5+ drinks a day or 35+units per week. It is abundantly clear that this does a lot of harm, raises blood pressure, leads to violence, social disorder, harms mental health etc etc. Everyone thinks of liver cirrhosis but this is actually fairly rare from alcohol and requires a much higher intake.

But is low to moderate consumption harmful - or possibly beneficial?

Retrospective studies have generally failed to show that mortality is increased, which is against a major harmful effect, but have suggested an increased cancer risk, but a reduction in heart disease.  One of the big problems with such studies is that smokers tend to drink more alcohol, and it is difficult to disentangle the effect of each. But in the last 10 years or so there have been some prospective studies which have probably produced more reliable evidence. There have only been a few of these and the results have varied which has led to fierce argument over their interpretation. The issues are whether Cancer risk is increased, and if so how much, and whether Heart Disease is prevented by low or moderate intake.

I myself am influenced by the 4^th sort of evidence, which is whether there is a likely mechanism that fits the facts observed. It does look as the effect of alcohol on cholesterol and also on blood clotting might well explain a protective effect, and it fits in well with the results of the trials. But the Sally Davies faction say that the observed beneficial effect is an artefact due to the tendency of some teetotallers to be reformed alcoholics so that their bad outcomes worsen the picture for the whole group of non drinkers. Perhaps I am biased but I do feel that they would not make similar arguments if the results came out in their favour, and the protective effect has been observed in countless studies. The size of the protection is not trivial – about a 10-20% reduction in heart attacks, which is as more than low dose aspirin. For comparison consistently taking a statin drug will reduce risk by around 30%.

As far as Cancer is concerned, the strongest effect is that on cancers of the mouth and throat and oesophagus. Here the smoking confounding is the big problem. A large prospective US study concluded that the effect of alcohol was confined to smokers.

Unfortunately, there is another result which is far less palatable (joke). That is that there is a pretty definite effect on Breast Cancer risk. Since this is a common and serious disease this has to be taken seriously. I had thought that alcohol intake might lead to obesity and that might explain the statistical correlation but they have looked at that and decided that drinking and obesity don’t actually go together that much in women. Overall, it is estimated that about 10% of all breast cancers are caused by alcohol.  So If all women stopped drinking altogether we would have 10% fewer cases. The mechanism is thought to be that alcohol affects the metabolism of female sex hormones in the liver.

Whether other solid cancers such as bowel and prostate cancer are affected by low to moderate alcohol intake is disputed. Some large studies have failed to show an effect. In a large recent prospective US study there was no statistically significant definite evidence of an increase in cancer in non smoking men.  

The new guidelines proclaimed by Sally Davies suggest the same limits for men and women. This disagrees with almost all other national guidelines on the subject and all the basic science about how men and women handle alcohol.

If there is a risk for women of breast cancer which seems likely, what can be done to reduce it?

 First of all be lucky.  Failing that you can stay slim, take exercise daily, and have babies and breastfeed them for a long time. In terms of preventative drugs there is a lot of interest in good old aspirin.

And if you are a man? -------------------- See you down the pub!