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.

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.

Writing about medicine for the general public (as I do with colleagues on the BMJ site BestHealth), I feel a responsibility to get it right when we’re talking about risk. If a paper says that heading a football may cause brain damage, or coffee might lower your cancer risk, it’s important we talk about how big the risk or benefit is, and how likely it is that the research stands up. We’re also writing patient decision aids, to help people decide whether or not to have that hip replacement (see one we did earlier, on the NHS Direct site). We know the importance of using absolute risks rather than relative risks, and not framing information to influence people one way or another, but we’re keen to do better.

So it was immensely helpful to get David’s take on how best to use statistics to help people understand risk. Use of graphics is a great way to do this – see David’s website Understanding Uncertainty for more on this. But it was a quick, throwaway comment that made an immediate difference to the way we work.

When we give figures from papers to several decimal points, we think we’re being accurate – but actually, the figures aren’t that certain. The figure we’re giving is a point estimate, a ‘best guess’ based on the data in the study, but different trials are likely to give slightly (sometimes more than slightly) different results, because of the play of chance. So rounding figures from 8.7 or 23.4% to 9 or 23%, is not being sloppy – it’s actually better practice. The more precise the number we give, the more accurate the number sounds to the general public. This means we may be over-emphasising the reliability of the figures.

So, no more decimal points. And as for the gambling lessons – anything that teaches children how to understand the play of chance and to know when the odds are stacked against you are a good thing. By the way, David Spiegelhalter has calculated that your best bet to win enough to buy a sports car is roulette. Put mine on black.

Image: from marc e marc photostream on Flickr, with CCL.

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. They might die of pneumonia, while weakened from cancer and chemotherapy. They might die of a deep vein thrombosis, after bowel cancer surgery. Are these deaths caused by bowel cancer? Yes, probably. But they might not be included in your analysis, if you relied on cancer-specific mortality. By not recording deaths like this from people who’d been screened, you’d over-estimate the protective effect of screening.

And what about direct harm from screening? A positive fecal occult blood test often leads to a colonoscopy examination, to find out whether the positive test was caused by cancerous growths. Rarely, a colonoscopy may damage the bowel wall, creating a risk of septicaemia, or if you’re really unlucky, death. It’s not very likely. But if it happened, would it be included as a death from bowel cancer? Probably not, because the person being examined quite likely didn’t have bowel cancer. So this death would not be included in your analysis of how likely bowel cancer screening is to protect you from dying of bowel cancer. That seems wrong to me.

If, by contrast, you look at death from any cause, you have a nice, clean outcome that no-one can be confused by. People are either alive or not. The down-side is that, as deaths from individual cancers only account for a small proportion of overall mortality, you would need big, long-term studies to show any advantage. To date, no cancer screening programme has shown that it can improve all-cause mortality.

It might help to stand back and think about what we’re trying to achieve with cancer screening programmes. Is the idea simply to prevent deaths from one specific cause – in which case we’ll need lots of programmes to test for as many cancers as possible? Or is it to help us to live longer, healthier lives? The first might just be achievable through cancer screening programmes. The second is probably not.

It’s all explained in greater detail in the BMJ articles. NHS consultant physician James Penston says we should measure success by all-cause mortality. Robert Steele and David Brewster, respectively directors of the Scottish Bowel Cancer Screening Programme and the Scottish Cancer Registry, think not. What do you think?

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.

Illness has always been rooted in the culture and society that surrounds it. After a century when the triumph of antibiotics and antivirals took the terror away from many infectious diseases, small wonder we look to microbiology to explain a disease like chronic fatigue syndrome. It makes sense; we know much illness is caused by infectious agents and we’ve seen other illness cured by eradicating those agents. Unfortunately, if we’re wrong, then researchers will have spent an awful lot of time looking in the wrong place for the answer.

It reminds me of Joshua Ferris’ novel The Unnamed, where a New York lawyer and his family struggle to put a label on his sudden mysterious compulsions to walk for miles, in a direction seemingly not of his own choosing, through any sort of weather, much to the detriment of his health, personal safety and career. So ashamed is he of this undiagnosed compulsion, he prefers to lie to his colleagues that his wife has cancer, to explain his sudden disappearances. He submits himself to CT scans and experiments, quacks and New Age gurus, any sort of indignity that might allow him to understand and control what is happening.

Even now, plenty of CFS patients are still clinging to the hope that XMRV or a similar virus really will turn out to be the cause of their suffering. Some talk of conspiracies by mainstream medicine, to suppress or discredit the initial research. It seems we can bear a lot in life, if we know what to call it. Even if that name is as long as xenotropic murine leukaemia virus-related virus – and even if the name turns out to be wrong.

UPDATE: 28 December 2011: The journal Science has fully retracted the XMRV article, citing numerous concerns. You can see the retraction here.

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.

I also found a small German study of women having breast implants. They were surveyed before, then six months after surgery. Perhaps not surprisingly, they said they felt more attractive and reported an improvement in their sex lives. However, the authors add: ‘The only topic that exhibited next to no change was the series of questions dealing with insecurity/anxiety’.

Now, from what I remember, just about all teenage girls are unhappy with the way they look. It’s a sad truth you only recognise when you’re knocking on a bit, that you probably looked your most lovely and fresh-faced in the years that you were most consumed with self-doubt. But back in those terrible days of worrying about my big nose and flat chest, the assumption was that you did your best with what you’d got. Some girls were pretty, some were bright, some were pant-wettingly funny. Che sera. I don’t remember anyone saving up for a boob job.

It’s this confidence business that really bothers me. Isn’t confidence something that you gain, over time, as you gain skills and experience and loving relationships? Doesn’t that sort of confidence – in your ability to speak fluent French, manage your bank account, earn your living or cook a decent risotto – have to be earned?

I struggle to see how having a couple of bags of silicone inserted under your nipples can do anything for your confidence. Who’s feeding young women this crap anyway? Who’s telling them that how they look matters more than what they can do, that their bodies are not good enough the way they are? And where did this insidious myth come from, that slicing up your body or injecting poison into your face is something you do for yourself? If women accept that their own faces or bodies need sculpting into an approved model, what the hell does that say to our daughters?

You’re right. I’m angry.  Lots of women worry about their looks. But where’s the evidence that cosmetic surgery helps build confidence in anyone’s appearance? As I found, there doesn’t seem to be any. If cosmetic surgery is so damn empowering, why do people start with one ‘procedure’ – then decide maybe to have something else ‘corrected’, and a little more to ‘maintain’ their increasingly artificial appearance? Learning to live with, look after, and even like our own bodies is a better bet for long-term body confidence.

I know whereof I speak. The big nose – still there. I love it; it gives my face a presence it wouldn’t have with some cute little button. The flat chest never did ‘fill out’, despite the school nurse’s promises. I’ve lived a life free of men talking to my chest instead of my face, and still managed to find plenty of congenial male company. (Actually one bloke did that once – I thought I’d spilt something down my top).

If I’d been offered a magic pill to ‘fix’ those things when I was 17, I might just have taken it. I might even have been happier for a while. But I wonder if I’d still be as happy now? I did consider a boob job once, fleetingly, when I was 29 and single and at a low ebb. I had the money; there was no-one to judge me. I decided to learn Spanish, instead.

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

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.

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.

And the reporters who do want to dig around a story know full well that if they don’t publish before their rivals, they’re the ones who’ll be in trouble. With 24-hour publication on the web, that means that you need to have your story ready to go at the instant the embargo on the research is lifted. Too bad if you’ve not been able to get hold of a copy of the original research to scrutinise, or speak to the top expert on the subject.

None of this is by way of excuse. If journalism is for anything, its for asking the awkward questions, having a suspicious mind, refusing to take a story at face value. As science writer Ed Yong comments on the BMJ piece, journalists shouldn’t be ‘passive observers’ but ‘the final filter that stops misinformation from reaching the public’.

There’s a lot of discussion on the net about whether that role has been taken over by science bloggers, or whether its something still done by ‘conventional’ journalists. That seems a false distinction to me, and irrelevant. If you’re writing about science in the media, you do so because you want to add to the debate. Some people do it well, some less well. The forum is not the point.

What does matter for the future of science in the media is how to fund people to do it properly. If the public at large won’t pay for science reporting (be it online subscriptions, through taxes for the BBC, or handing over cash for newspapers), and the advertisers have all disappeared to Google ads, and Mr Murdoch will no longer subsidise his quality newspapers with Sky Sport money – what happens?

Without wanting to be morbid, I think we could be about to find out. There are some great bloggers out there dissecting science for love, not money. But relying on their continuing goodwill seems unreasonable. The mainstream media are restricted, more and more, to what the researchers themselves decide to tell us (see Margaret McCartney in the BMJ on how the media reported a recent acupuncture study).

There are plenty of ways we can improve standards of science reporting (and other reporting) in the media. But they don’t all come for free.

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.

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.

The Thames monster soup fed a terrifying epidemic in 19th century London. The physician John Snow is a hero to anyone interested in public health or epidemiology, or just in the applications of stats and mapping to solve medical mysteries. I pored over his 1854 Cholera Map, showing how the deaths from this horrible disease centred on Broad Street, Soho, and the famous Broad Street pump.

There were some startling exhibits in this section. The ‘epidemic ambulance’, a black-clad box that was clearly more of a coffin than an ambulance. An innoculous-looking glass phial of white liquid, which proved on closer inspection to be a sample of ‘rice water’ excrement from 1853. Cholera causes such a violent, dehydrating purging of the body that water pours from the bowels, cloudy white like water that’s had rice cooked in it. I don’t know how long cholera bacteria live, but I backed away from that little vial.

Gradually, the weapons of modern science against these diseases of squalor became familiar. Sewerage systems, like the plans for Bazalgette’s Victorian triumph, are on display. There are maps, graphs, statistics and reports, from Chadwick and Mayhew, on poverty, sanitary conditions and mortality figures. By contrast was the array of Londoners who made their living from dirt – mudlarks, rubbish carters, scavengers, bone-grubbers and the strong-stomached night men.

Joseph Lister’s discovery of the importance of sterile conditions was demonstrated with a mock-up of a ward from his Glasgow Hospital, and some hair-raising drawings of ‘hospital gangrene’ caused by the use of unclean instruments. Gradually, you felt, things were looking up.

By the time you move into the section on the 1930 International Hygiene Exhibition, held in Dresden in 1930, you start to relax into a modern world of soap, toothpaste, healthy diet and rational dress, where the causes of disease were addressed by the wonders of modern science. A poster urging precautions against TB celebrated the virtues of Light And Air In the Home! Across the aisle, photos and plans show Britain’s modern wonders, the Finsbury Park Health Centre and the Peckham Pioneer Health Centre, with its swimming pool and showers. Who could possibly object?

At which point, the true filth in this exhibition reaches out and slaps you around the face. It was, apparently, a short step from bodily hygiene to racial hygiene and the perverted doctrine of the eugenicists. Posters no longer advertised toothpaste, but the need for ‘cleansing of the nation’s ethnic body’. Hideous caricatures accuse Jews of spreading TB. The diagrams, statistics and graphs of the 19th century are put to more sinister use, promoting the foul propaganda of the Nazi party, of which the Dresden Hygiene Museum was soon a willing proponent.

Two exhibits in particular were hard to view, never mind comprehend. One was a children’s book, promoting hatred of Jews through grotesque drawings and links to disease. The other was a graph showing the numbers of ‘disinfections’ – murders – carried out at four gas chambers in 1941. They didn’t just do this dreadful thing; they calmly measured and recorded it.

I’ve been twice to this exhibition. It’s all good, and the sections on Delhi, Kolkata and the Fresh Kills landfill site at New York are also interesting. But I’ve never been able to focus on anything else, past that evil little graph. There are human remains in Dirt, yes. There’s a vial of choleric excrement, and exhibits made out of human shit. But there’s nothing as filthy as that graph that purports to demonstrate disinfection.

Dirt is at the Wellcome Collection until 31 August. Image courtesy of Wellcome Images.