Confidence, contempt and cosmetic surgery

It’s been an instructive few weeks for finding out what the cosmetic surgery industry really thinks about women. This is the industry, remember, that wanted women to feel nice and confident about ourselves, with our neat little bags of silicone and our wrinkle-free foreheads. ‘Confidence starts with the Harley Medical Group,’ as one firm’s current advert would have it, with what sounds like quite a bit of chutzpah, in the circumstances.

So who’s confident in the industry now? The estimated 40,000 UK women who had breast implants filled with silicone intended for mattresses probably wouldn’t use that word. And if you think I’m having a gloat, far from it. I’m outraged on behalf of these women, who entered into a contract in the full expectation that they would be supplied with goods and services that were appropriate for the intended use. I have every sympathy with the women who’ve been left with these sub-grade implants, whether they needed implants after mastectomy, or whether they simply wanted to change the way they looked. Cosmetic surgery is marketed as a safe and effective choice, and people who choose it have every right to expect it to live up to the marketing.

The trouble is, as we’ve seen, the companies who are so keen to make a buck out of women’s insecurities are much less keen to carry the buck when things go wrong. The department of health quickly discovered that record-keeping in this arena is terrible, with many clinics unable to tell them what the rupture rates for the sub-standard implants were.

Actually, this is unsurprising. I spent some time this week trying to find out what the average rate of implant rupture is. According to the most reliable source I could find – the UK’s Medicines and Healthcare Products Regulatory Agency – there is ‘little information’ on rupture risk, generally. The lifespan of modern implants, they say, is ‘unknown’. The only evidence-based figures I could find (from EBM site Bandolier, dating from 2000) showed one in 10 implants is expected to have ruptured after 8 years, rising to more than nine in 10 after 20 years. So an 18-year-old girl wanting to ‘boost her confidence’ has a 1 in 10 chance of needing the implants removed or replaced before she’s 30, and will almost certainly have experienced implant failure by the age of 40. I don’t remember any of those glossy, smiley ads on the tube mentioning that.

Put the rupture rate aside for one moment. The goods supplied were sub-standard. They did not contain what they should have contained. In any other consumer field, surely, women would be able to take them back and exchange them for non-faulty goods, at no cost to themselves. Instead, we hear of clinics charging women even to look at their records and check which implants they had. While some clinics are replacing implants free of charge, some of the biggest groups, like Harley Medical Group, say there’s ‘no cause for concern‘ and are trying to blame it on the MHRA. Another big group, Transform, intend to charge women £2,800 to have them removed, never mind replaced. The department of health, admirably, has said any sub-standard implants provided on the NHS can be removed or replaced, if that’s what women want. And in the many cases where fly-by-night clinics have come and gone, or are refusing to fund treatment, the NHS will, as ever, pick up the tab.

We hardly needed to hear the boss of PIP, Jean-Claude Mas, insulting women who intended to sue the company as ‘money-grabbers’ to know how much contempt he and his firm had for women. But it has been interesting to watch the industry as a whole try to wriggle out of their moral obligations, while still mouthing platitudes about how much they care for their patients. If any good at all comes out of this horrible saga, it will be that we stop trusting people who want to make money out of our insecurities to have our best interests at heart.

UPDATE: Read the Department of Health’s statement on the situation, 10 Jan, here: http://www.egovmonitor.com/node/45228

UPDATE 2: Harley Medical Group confirm they won’t replace implants. Chairman Mel Braham (no oil painting himself, I notice) whines:  ”We’re an innocent victim like everyone else, we’re attempting to do our best for our patients… We can’t take on this whole thing on our own, especially when it wasn’t our fault.” Here’s a suggestion, Mr Braham – replace the implants using that budget you use to plaster the London Underground with adverts trying to make women feel inadequate.

UPDATE 3: On 25 January, Transform Medical Group announced it would remove implants free of charge. Replacement will cost £2,500. Also, the British Association of Aesthetic Plastic Surgeons have called for an end to advertising of cosmetic surgery.

What are the odds of that?

Roulette Wheel 08, by marc e marc

The front page of today’s Times announces a proposal that children should have ‘lessons in gambling’ at school. It’s enough to make the Methodist maiden aunts reach for the smelling salts, but actually it sounds quite a good idea to me.

Understanding risk is one of the toughest lessons we learn. Mostly, we make decisions based on our experience of what’s happened before, and our knowledge of what happens to other people we know. We take risk-based decisions every day on how long to give ourselves to walk to the train station, whether to eat that dodgy-looking hamburger, whether to cross the road on a day that Jeremy Clarkson might be driving through London.

Then there are the more complicated decisions. Should I take out a fixed-rate mortgage, or gamble on interest rates staying low? Should we book the expensive holiday we want to take next year, or wait to see whether we’re both still in a job come next summer? Is it best for Dad to have a hip replacement now, or to try physiotherapy and medication first?

These are the sort of decisions where it really helps to understand risk. What are the chances of interest rates going up over the next 5 years?  How safe are our jobs? What are the chances of a good or bad outcome from hip replacement surgery?

Even if we can get reliable figures, we need to be able to interpret what they mean to us. Is a 10% risk of losing my job in the next year too high, or is that manageable? If the odds of an interest rate rise are 2:1, should I go for that fixed rate?

The trouble is, many of us struggle with understanding risk. I realised how tenuous my grasp of risk was when I noticed that 1 in 20 sounded a bigger risk to me, than 5 percent (yes, they’re exactly the same). Representing risk so that people can get a true understanding of it is an art as well as a science.

One man who knows more about this than most people is David Spiegelhalter, Cambridge Professor for the Understanding of Risk. I met David when he gave a terrific presentation at the Evidence 2011 conference last month, organised by BMJ Group and the Oxford Centre for Evidence-Based Medicine. This week I took a trip to Cambridge to meet him and his colleague Mike Pearson.

Measuring success in cancer screening

Breast cancer cells

One of the more polarised debates about healthcare – and one that shows no sign of reaching consensus – is whether screening healthy people for signs of cancer does more good than harm.

This month (breast cancer awareness month, in case you hadn’t noticed) has brought another flurry of accusations that breast cancer screening is either (a) a life-saver that no sane woman should refuse, or (b) a pointless exercise that leads to over-diagnosis, over-treatment and over-anxiety. Also this month, the US Preventative Task Force ruled that prostate cancer screening should not be used, because the benefits are, at best, small, and the test can lead to unnecessary harm. The ruling was met with howls of fury from doctors and patients who claimed the test had saved their lives.

Among the noise, it’s hard to know what and who to believe. For one thing, the estimates of the effects of cancer screening vary widely, depending on how you calculate the figures. I’ve more or less given up trying to follow all the calculations and recalculations of the effect of breast cancer screening. My hunch is that, if there is a protective effect, its a small one.

But an interesting debate in the BMJ (British Medical Journal) this week threw light on some of the controversy. The question sounded innocuous: Should we use ‘all cause’ mortality to judge the success of cancer screening programmes, or ‘disease specific’ mortality? In laymen’s terms, should you look at whether people who take part in cancer screening live longer overall, or should we just look at whether they are less likely to die from the cancer being screened for?

At first glance, that sounds straightforward. If you’re screening for bowel cancer, for example, you expect that to have an effect on how many people die of bowel cancer, not how many die of other things. It would seem unreasonable to expect screening to cut deaths overall.

But wait a bit. Many people who die after being diagnosed with bowel cancer won’t have ‘cancer’ on the death certificate.

The Undiagnosed – chronic fatigue syndrome and the search for a reason

Credit: Wellcome Library, London The four elements, four qualities, four humours, four seasons, and four ages of man. Airbrush by Lois Hague, 1991.

I’ve written before about chronic fatigue syndrome, also known as M.E. It’s a miserable illness, causing untold suffering to those who have it or care for someone who does. No-one knows exactly why it happens, which means treatments are largely stabs in the dark to see, empirically, what works.

So naturally, there was much excitement a couple of years ago when a group of researchers reported that they’d discovered that a larger-than-expected proportion of people with CFS were infected with a newly-identified form of virus, which they called xenotropic murine leukaemia virus-related virus (XMRV). Here, at last, was a cause people could understand, and a starting point for research. Anti-viral medicines could be tried; people with CFS could be tested for the virus.

Then it all started to unravel. Other researchers were unable to find XMRV in chronic fatigue syndrome patients. The DNA of the virus was unusually similar in different people. Some clever detective work proposed that the most likely cause for the findings was contamination in the laboratory, arising from work on a mouse cell line during prostate cancer research. Science, the journal that published the original study, asked the authors to retract it last year. A couple of weeks ago, it was partly retracted after some of the authors admitted that their samples were, indeed, contaminated. At the same time, Science published a new paper demonstrating that tests for XMRV were, at best, unreliable.

I reported for the BMJ on the retraction and the latest research. It seems to me that the case for  XMRV as a cause of chronic  fatigue syndrome is closed. Two main thoughts occur. Firstly, the whole affair demonstrates how science is inherently self-correcting. The refusal of scientists to take anyone else’s word for it (in the motto of the Royal Society, Nullius in Verba) means experiments have to be replicable, and suspicion is immediately ignited when no-one but the original researchers can show their results. It’s why scientific research papers have to show their methodology; not just so we can look for flaws in the study, but so other scientists can see if they get the same results.

The more philosophical point is around the eagerness with which the XMRV explanation was taken up. Of course people wanted a cure – but even more, people wanted an explanation that made sense of why this dreadful thing had happened to them. A couple of hundred years ago, people might have blamed chronic fatigue symptoms on someone having a delicate constitution, or ‘nerves’. Four hundred years ago, it might have been blamed on an imbalance of the humours, or a misalignment of the heavens. Those explanations sound ridiculous to us today, and our explanations would sound ridiculous to people then.

The confidence trick of cosmetic surgery

I’m a troubled old feminist these days. Back in the ice age, when I read my first  Germaine Greer and chucked out Just 17 in favour of Spare Rib, cosmetic surgery was pretty straightforward. It was something you did if you were (a) horribly disfigured or (b) rich and vain.

Now it’s apparently a rite of passage, a confidence-booster, something you do for yourself, because you’re worth it. Last week, more! magazine said 70% of the 1000 young women they asked wanted to go under the knife, and as many as half were already planning to do so.

What struck me were the reasons. More than half said it was because they were unhappy with the way they look. And 35% said they thought it would improve their confidence.

So will it? Well, I work in evidence-based medicine, so I took a look at the literature. A quick PubMed search (the biggest database of published medical trials) threw up few studies even looking at this outcome.

There was one recent study, looking at 1500 Norwegian adolescents. About 5% of girls in the study had cosmetic surgery. The authors report: ‘…those who underwent surgery during the course of the study experienced a greater increase than other females in symptoms of depression and anxiety (t=2.07, p=0.04) and eating problems (t=2.71, p<0.01). ‘ In other words, those who had surgery got more depressed, more anxious, more likely to have an eating disorder. It’s an observational study, so we can’t prove that cosmetic surgery caused the problems. The girls who’d had surgery also had more anxiety, depression and self-harm before surgery. But surgery sure as hell didn’t seem to help.

And now for something really useful

Not a health food

The only health story you’re likely to have read this week is about chocolate. Is it good for your heart? Maybe, but we don’t really know. We need more, and better, studies. Not that they’ll make any difference, now that the chocolate=healthfood meme is so firmly established.

I’ve nothing against chocolate, and quite a lot for it, especially the Lindt extra-fine 70% stuff. I don’t need permission from my doctor to eat it, and neither do you. It’s stuffed with fat and sugar, of course, so how much of it you eat is between you and the bathroom scales. It might do something useful to your endovascular system, but isn’t that just a bonus? Mackerel and cabbage are good for you, but you don’t see that all over the front pages.

Anyway. The useful stuff that you won’t have read about elsewhere. How much do you know about your risk of getting a deep vein thrombosis (DVT)? It’s a particularly nasty condition that happens when a blood clot lodges in the deep veins of your legs, usually your calf. It causes not very pretty swelling and pain. If you’re really unlucky, it can travel up your blood vessels to your lung, causing a lethal pulmonary embolism.

DVT can be brought on by lengthy inactivity, such as sitting down for eight hours on a cramped flight, and certain medicines increase the chances of getting it. These include common medicines such as the contraceptive pill and HRT, as well as anti-psychotic drugs.

Some people are more vulnerable to it than others – older people, people who are overweight or smoke, or have certain chronic diseases – but it doesn’t just happen to old, unfit people. I know several people in their 30s who’ve had it, meaning they spend the next six months or so taking warfarin (a blood-thinning medicine that plays havoc with how much alcohol you can drink, among other inconveniences).

The difficulty is knowing how the risk affects you as an individual. I’m used to hearing from my GP that the pill increases the chances of a DVT, and being asked to confirm that I accept that. But what is my risk to start with? How much should I worry about this increased risk? Then there are long haul flights. Should I invest in flight stockings, or just wiggle my toes every so often? For older people or those with other medical conditions, the calculations get more complicated.

Luckily, some clever people* have put together this handy tool, the QThrombosis risk calculator. You can use it to work out your baseline risk of having a DVT over the next 5 years. You can play with it too, so I can see that the contraceptive pill makes no discernible difference to my personal, very low DVT risk. A useful bit of knowledge for my next GP appointment. If the risk was higher than I’d like, I could see what effect it would have if I lost a few pounds, or gave up smoking. Or changed sex, although that wouldn’t be especially practical.

The tool is based on sound science, which I analysed for the BMJ’s Best Health website. It shows that the drugs to really worry about are anti-psychotics, and the biggest risk of DVT is having been admitted to hospital recently, not hopping on a plane. I can imagine the tool being fantastically helpful for doctors, but it also helps anyone interested in taking responsibility for their own health.

I’d say it was idiot-proof, but on my first go I somehow muddled up inches and centimeters, professing myself to be about 60cms high, with a truly outrageous BMI. Even then my 5-year risk was less than 1%, which is quite reassuring in itself.

*Professors Julia Hippisley-Cox and Carol Coupland, of Nottingham University

Busy doing nothing

Caressa moored at Tichmarsh

The river flowed past us, slow and gentle, cocoa-brown with silt. Over our heads arched a magnificent Constable sky, piled high with clouds and shot through with pink and coral, as the sun slipped lower towards the horizon. We were surrounded by gentle Sussex marshlands, festooned with wading birds, while swallows (or is it swifts?) darted and swooped into the water.

We were sitting aboard an elegant 1966 teak and mahogany built sloop, Caressa, property of the Classic Sailing Club (based at Suffolk Yacht Harbour on the Orwell). Mugs of tea and slices of cakes in hand, we watched the sun go down. Only one small detail marred the idyllic scene – we’d been there since 4pm, when a misunderstanding over the route led to us burying Caressa’s keel firmly in several feet of soft mud. The tide was falling, and before long the river began to dry out all around. We would be there for some time.

There’s nothing like sailing for putting you in your place. The almost-complete reliance on the winds and tides engenders a proper respect for the natural world. One minute we’d been heading up the Walton backwaters, delighting in the seals and the bird life; the next we were staring in despair at the stern, gunning the engine in reverse, with complete futility. We were stuck, good and proper. A quick glance at the tide tables confirmed that low tide was more than two hours away, and it’d be at least another three after that before we were likely to float free.

As the tide fell, our position became more obviously risible. We’d attempted to cross a massive sandbank which almost obscured the entrance to the barely-navigable creek we’d been heading for. The boat dried out all around. Fortunately, thanks to the force with which we’d thrust ourselves into the soft mud, we were held almost entirely upright. Caressa usually turns heads for her sleek beauty, but we soon became a source of amusement for passing boats, heading safely up the main channel for the Titchmarsh Marina, almost within sight around the bend of the river.

Back on the move

So, six hours to wait. We began with a cup of tea, naturally. I stretched out in the late afternoon sunshine, pillowed my head on my sailing jacket and snoozed. Phil investigated the yacht’s broken satellite navigation system, fixing it after a couple of hours’ detective work with a volt meter. Bernie, the skipper, made tea and studied the chart. We ate cake. I read a medical research paper that I’d stuffed in my bag at the last minute, not really expecting to have time to look at it. I unearthed a copy of the Big Issue, which I buy every week and usually chuck away barely scanned. We talked.

When last, I wondered idly, had I knowingly spent 6 hours doing nothing? Train journeys busily reading newspapers or checking Twitter; lunch hours rushing round the supermarket; evenings attending to paperwork, or churning up and down the swimming pool, or – on a night off – gazing at the television, trying to quieten my brain. If ever there was a corrective to incessant activity, this was it.

The hours ticked by. The sky, that big Sussex sky over a flat and quiet landscape, flared with its sunset, then settled to an indigo dusk. The midges came out. More welcome, a local yachtsman paddled over on his inflatable to ask if we were all right, and stayed to chat for an hour or two. The tide turned, swinging around the boats on their moorings, pouring in faster, covering the mudflats, displacing the birds.

Eventually, around 8.30pm, with water lapping around the boat, we gunned up the engine. Nothing. We gave it another 10 minutes. Same thing. Another 15 minutes, then. We’d called ahead to sailing instructor Richard, who lives on a houseboat in Titchmarsh Marina, and he’d spoken to the yacht club bar. They were doing meals until 10pm, and would hold on for us. We looked anxiously at our watches. We had plenty of food to get by – but the thought of a proper meal and a beer was attractive.

Finally, around 9.30pm, we heaved ourselves off the bank and slowly, carefully, turned the boat to motor up the channel. No mistakes this time, and with Richard’s help we were soon moored alongside a pontoon. A minute before 10, we piled into the yacht club. Soon we were sitting outside, enjoying roast beef and a beer. That night I turned into my bunk and slept like a baby. It takes it out of you, doing nothing.

Medicine, standards and the media

News of the World final issue

The media is engaged in a bout of breast-beating over standards. It may be entertaining, but it ignores some fundamental questions about how our media works. Put simply, standards are expensive. Who’s going to pay?

The frenzy over phone-hacking shows the extent to which some tabloid journalists would go for an exclusive story. The BBC commissioned a report into its own science reporting, which concluded that the corporation at times took ‘balance’ to ludicrous extremes. And the BMJ’s investigations editor wrote a much-noticed post about how to improve the quality of science journalism.

There are common themes. The pressures on newspaper journalists, at a time when circulations are falling, are greater than they’ve ever been. Without excusing the moral blindness at NOTW, the pressure that reporters would be under to maintain its position as the best-selling Sunday paper must have been immense. I can imagine how people grasped at any tool at their disposal, however reprehensible.

As circulation falls, and advertisers drift away, newspapers have less to spend editorially. They have fewer reporters, and those they employ are likely to have less experience and expertise. Specialist reporters, like the often splendid science journalists at papers like the Guardian and the Times, cost more. They’re the ones who know how to ask the difficult questions, like whether newly-published, controversial research is actually any good. They can spot when research results are flimsy, or biased, or out of kilter with everything else we know about a topic. But it’s far cheaper to employ keen new graduates who can turn around a press release and jazz it up with a quote from the researcher.

The worst I can do

Last night was the last Developing My Fiction class at Birkbeck. The six months have whizzed by and I feel I’ve learned an enormous amount. Any under-development in my fiction is now entirely my problem, and means I’ve not been listening properly.

To finish off the course, tutor Carol suggested we let rip with the worst fiction we could muster, full of unconvincing metaphors, infuriating changes of perspective, over-egged descriptions and relentless cliche. I enjoyed this more than any other exercise. In fact, I’m so proud of the appalling piece of writing I managed to spew out, I’ve decided to share it. This is, quite literally, the worst I can do. Read and despair.

The Hopeless Heart

After thinking about it for a very long time, Helen realised that she had fallen in love with Richard which was very sad because he was dead and she would never see him again.

Her heart aches at the thought, as if it would break.

‘I loved him, but he’s dead. He was the love of my life, but I will never see him again,’ she groaned in agony, out loud. She started to cry, tears pouring down her cheeks like a torrential river, until her shirt was soaking wet.

‘If only everything had been different and he hadn’t died in the first chapter. We could have worked together on solving the mystery and then we’d probably have got together at the end. I could have made him forget about his tragic past and he would have stopped drinking. It was probably my last chance of getting married, seeing that I’m over 30. Oh well, it’ll never happen now,’ exclaimed Helen, sadly, closing her big blue eyes that were ironically the colour of forget-me-nots.

She gazed at the river which was medium grey and dark, like her mood. Overhead, big black clouds gathered, mounting like elephants at an orgy at the zoo. The wind got up, whipping her shiny long blonde hair sadistically around her face, as if it wanted to hurt her too. It was getting cold, and Helen began to shake like an autumn leaf. The sunshine that had shone when she met him had disappeared, as if blotted out by the tragedy of his death.

‘It’s as if the sun has gone out of my life,’ explained Helen to a passing pigeon, which looked at her inquisitively and wondered what this strange woman was doing, talking to herself and getting wet in the rain that had just started. The pigeon wondered if she had any food. It was a bit hungry. The pigeon flew up into the sky, from where it could see the whole of the city. That put things into perspective a bit, it thought.

Dirt, hygiene and filth at Wellcome Collection

Monster Soup

Dirt: The filthy reality of everyday life, at the Wellcome Collection, opens with a warning. ‘This exhibition contains human remains,’ it says. It does. It also contains two of the most chilling exhibits I have seen.

It begins reassuringly, tamely, with some homely images. First up is what looks like a grimy sash window, dull with dust. The temptation to run your finger down the pane and clear the glass is strong. But this is a cast of a window, made out of grime itself, dirty all the way through.

It’s unsettling. But rounding the first corner, we’re transported to the charming, serene, orderly, blue-and-white world of Delft in 1683, where the tidy grid of streets is tiled in washable ceramics, and the paintings all testify to an obsession with sweeping away dirt. I found myself relaxing, half-wishing to recede into this world of gleaming cooking pots, sparkling windows and snowy linen. Not to mention the diligent servants, demonstrating their godliness with obedient industry.

I should know better. Another corner, and the microscope revealed what lurked in the sparkling water gushing from the pumps. As people of the time were horrified to discover, the water contained microbes, tiny animules, bugs and mini-monsters. Monster soup, as the William Health engraving (pictured) has it.