Review of “Oestrogen Matters” Avram Bluming and Carol Tavris, TLS 29th January 2019

In the current TLS I have a brief review of Bluming and Tavris’ book on HRT. The full text is available to subscribers; here is the first paragraph:

Few medical treatments have seen as stark a rise and fall as hormone replacement therapy (HRT). In the early 1940s, methods were developed to extract oestrogen from pregnant mares’ urine, and the resulting medication was named Premarin. Marketed from the 1950s for menopausal symptoms, HRT was catapulted into the public consciousness by the New York gynaecologist Robert Wilson’s bestseller Feminine Forever (1966), and made Ayerst Laboratories, who had developed Premarin and paid Wilson’s expenses for writing the book, extremely rich. HRT was hyped as a wonder drug adding years to life and life to years

Polio in Cork: Patrick Cockburn’s “The Broken Boy”, reviewed in the Guardian 09/07/05

 

A review I wrote for the Guardian 13 years ago of an oddly titled book by the son of the “84th most dangerous red in the world.” As I wrote, it is not entirely a memoir of the 1956 polio epidemic, nor is it an thorough history of the outbreak, but nevertheless it is an interesting read.

The Broken Boy
by Patrick Cockburn
320pp, Cape, £15.99

Writing about the house in which he grew up in Youghal, East Cork, Patrick Cockburn says it “owed its vigorous personality to our lack of money, which ensured that it never saw the hand of a contractor and was reconstructed piecemeal by my mother”. Cockburn’s engaging and witty book itself has a vigorous personality. It is far from the straightforward memoir of his experience of the 1956 polio epidemic in Cork suggested by the title and cover.
While being taken to see child casualties after the American bombing of Baghdad in 1998, Cockburn – a foreign correspondent – began to wonder about his own childhood experience of polio, and the epidemic about which he knew so little. Hardly any written accounts existed. In 1999, he began to interview those who remembered the outbreak, but the Chechen war and the world situation after September 11 combined to prevent him from continuing his research for some years.

This perhaps contributes to the somewhat disjointed feel of the book. Six of its 14 chapters deal with the 1956 epidemic. It begins with a six-year-old Cockburn waking with a headache and sore throat. The local doctor is called and the sensation of the stethoscope on his skin is one of the few clear memories Cockburn retains from the time. Three months earlier, in July, the epidemic had arrived in Cork city.

Cockburn was taken by ambulance to St Finbarr’s hospital in Cork city. Although terrified and uncomprehending, his memories of St Finbarr’s are sunnier than those of Gurranebraher, where children were transferred after the acute phase of the illness. Cockburn’s father, the radical journalist Claud Cockburn, wrote that children in Gurranebraher “seemed to be largely in the hands of maids – young country girls with no special training at all”. One reason for this was that female nurses, like any woman working in the public service at the time, had to resign on marriage – a glimpse of a very different Ireland from today’s.

Although Cockburn quotes doctors and physiotherapists critical of the handling of the outbreak, he himself seems curiously detached. The Salk vaccine had been field tested the year before, but was still unavailable and not entirely trusted by doctors. Quarantine was pointless, given that the majority of carriers of polio are asymptomatic. Some agitated for sporting events to be cancelled and for a form of temporary apartheid to be implemented against Corkonians – but though some politicians indulged in similar rhetoric, such sanctions were avoided.

Paradoxically, the victims of the Cork epidemic largely came from the more prosperous areas. This was because, in places where hygiene was poor, exposure to the virus was near-universal, and infants would be protected by maternal antibodies, so tended to have mild or asymptomatic forms of the illness. Improved water supply and sewage systems led to the loss of this immunity. Indeed, Cockburn argues, the outbreak could be seen as an early marker of Ireland’s later prosperity.

Cockburn writes well about his Anglo-Irish childhood, the tangled lives of his mother’s forebears and what Olivia Manning called “the usual Anglo-Irish sense of belonging nowhere”. His father Claud, described by Senator Joseph McCarthy as “the 84th most dangerous red in the world”, is a benign, rather impish spirit hovering over the book. As well as the affectionate personal memories of his father, Cockburn describes the absurdly detailed file kept on his father by British intelligence. For 20 years, with dutiful pedantry, agents followed him around recording who he met, where he went and what he did there.

The title The Broken Boy is slightly mystifying, as Cockburn doesn’t seem to have thought much about his polio experience until 1998. He does refer to “emotional scar tissue from polio” that he was aware of from an early age, but the nature of this emotional scarring isn’t at all clear. Though he spent a lot of time in school reading by himself, he writes “I was not solitary and made friends easily.” In fact, this is an oddly uplifting book. It is refreshing to read a disease memoir that is far more focused on the lives of those around the author than on trying to whip up sympathy or outrage.

Review of Oliver Sacks, “The River of Consciousness”, TLS 13th March 2018

I have a review in the current TLS of Oliver Sacks’ essay collection, “The River of Consciousness” . The full article is subscriber only so here is the opening….

Who is the most famous medical doctor in the world today? Until his death in 2015, a reasonable case could be made that it was Oliver Sacks. Portrayed by Robin Williams on screen, inspiring a Michael Nyman opera and plays by Peter Brook and Harold Pinter, Sacks took his followers far beyond the confines of neurology.

In their Foreword to The Rivers of Consciousness, a posthumously published collection of Sacks’s essays, the editors recount the time Sacks appeared in a Dutch documentary series, A Glorious Accident. Along with, among others, Daniel Dennett, Freeman Dyson and Stephen Jay Gould, Sacks discussed “the origin of life, the meaning of evolution, the nature of consciousness. In a lively discussion, one thing was clear: Sacks could move fluidly among all of the disciplines”. Specialists can have a suspicion of polymaths, and professionals can have a suspicion of those with a media profile. In his…

Review of Compulsive Acts, Elias Aboujaoude, 2008

This book did not impress me much at all. A far more readable and useful books on obsessions and compulsions is David Adam’s “The Man Who Couldn’t Stop” which I regularly recommend to patients. I did some book reviews for Fortean Times from 2003 til around 2008, I think this is likely to have been one of the last – none seem to have a life online but will turn up in various archives I have.

Compulsive Acts: A psychiatrists tales of ritual and obsession

The best that can be said of Elias Aboujaoude’s Compulsive Acts is that it’s an easy read. Director of the Impusive Control Disorders Unit at Stanford University School of Medicine, one would hope that Aboujaoude would give both the general and specialist reader some great insight into the world of compulsion. He ranges from obsessive-compulsive disorders to pathological gambling and problematic internet use, yet never really rises above the level of a decent magazine article, in say Time or Newsweek.

In his introduction Aboujaoude makes much of the weighty ethical dilemma facing him putting pen to paper. Clearly the issue of confidentiality looms over every medical writers wishing to make use of the material presenting every day. However Aboujaoude’s throat-clearing and disquisitions on storytelling in his Mediterranean ancestry serve to annoy when it finally comes to the writing itself. In his fictionalised composites, Aboujaoude adopts an irritatingly breezy style, as well as betraying a tin ear for dialogue and a weakness for twee framing devices (in particular his receptionist Aurora, an attempt at down-to-earth wisdom) Furthermore, the cases seem to progress neatly to their conclusions (not necessarily happy or successful ones) and lack real drama. One feels that Aboujaoude must have a decent book inside him – if only it could be compelled to come out.

3/10 – Far from compulsive

Hype, The Life Study and trying to do too much

A while back I reviewed Helen Pearson’s, “The Life Project” in the TLS. I had previously blogged on the perils of trying to do too much and mission creep and overload.

From the original draft of the review (published version differed slightly):

Pearson is laudably clear that the story of the birth cohorts is also a study of failure; the failure of the NHS to improve the inequality of health incomes between social classes, the failure of educational reforms and re-reforms to broach the similar academic achievement gap. Indeed, the book culminates in a failure which introduces a darker tone to the story of the birth cohort studies.

Launched in January 2015, the Life Study was supposed to follow 80,000 babies born in 2015 and intended to be a birth cohort for the “Olympic Children.” It had a government patron in David Willetts, who departure from politics in May 2015 perhaps set the stage for its collapse. Overstuffed antenatal clinics and a lack of health visitors meant that the Life Study’s participants would have to self-select. The optimistic scenario has 16,000 women signing up in the first eighteen months; in the first six months, 249 women did. By October 2015, just as Pearson was completing five years of work on this book, the study had officially been abandoned.

Along with the cancellation of the National Institute for Health’s National Children’s Study in December 2014, this made it clear that birth cohorts have been victims of their own success. An understandable tendency to include as much potentially useful information as possible seemed to have created massive, and ultimately unworkable cohorts. The Life Study would have generated vast data sets: “80,000 babies, warehouses of stool samples of placentas, gigabytes of video clips, several hundred thousand questionnaires and much more” (the history of the 1982 study repeated itself, perhaps.) Then there is the recruitment issue. Pregnant women volunteering for the Life Study would “travel to special recruitment centres set up for the study and then spend two hours there, answering questions and giving their samples of urine and blood.” Perhaps the surprise is that 249 pregnant women actually did volunteer for this.

Pearson’s book illustrates how tempting mission creep is. She recounts how birth cohorts went from obscure beginnings to official neglect with perpetual funding issues to suddenly becoming a crown jewel of British research. Indeed, as I observe in the review, while relatively few countries  have emulated the NHS’ structure and funding model, very many have tried to get on the birth cohort train.

This situation of an understandable enthusiasm and sudden fascination has parallels across health services and research. It is particularly a risk in eHealth and connected health, especially as the systems are inherently complex, and there is a great deal of fashionability to using technology more effectively in healthcare. It is one of those mom-and-apple-pie things, a god term, that can shut down critical thinking at times.

Megaprojects are seductive also in an age where the politics of funding research loom large. The big, “transformative” projects can squeeze out the less ambitious, less hype-y, more human-scale approaches. It can be another version of the Big Man theory of leadership.

Whatever we do, it is made up of a collection of tiny, often implicit actions, attitudes, near-reflexes, and is embedded in some kind of system beyond ourselves that is ultimately made up of other people performing and enacting a collection of tiny, often implicit actions, attitudes, and near-reflexes.

 

Review of “Casebook of Psychosomatic Medicine”, Bourgeois et al, IJPM 2011

The above review from the Irish Journal of Psychological Medicine follows on from my review of The Physician As Patient in the same journal. Both books were excellently written, and as time has gone by I appreciate their approach more deeply. As I say in the first paragraph, evidence based medicine and what could be called experience based medicine are often driven into a false dichotomy. Both these books possess wisdom in abundance, and wisdom based medicine is perhaps what we should all be aspiring to practice.  

Helen Pearson, “The Life Project”, Review in TLS 29/03/17

I have a review of Helen Pearson’s “The Life Project” on the UK birth cohort studies in the current TLS. The full article is behind a paywall so here is the preview:

Born to fail

SÉAMUS SWEENEY

To a non-Briton, the oft-repeated assertion that the NHS is “the envy of the world” can grate. If imitation is the sincerest form of envy, the world’s laggardly adoption of free-at-point-of-use health care is perhaps the truest mark of how much emotional investment the rest of the world really has in the UK’s health system. Early in The Life Project, her book on the British birth cohort studies, Helen Pearson describes them as “the envy of scientists all over the world”. In this case, envy is easier to precisely pinpoint; birth cohort studies have become all the epidemiological and social scientific rage in recent decades, especially around the turn of the millennium. My own daughter, born in 2008, is a member of the Economic and Social Research Institute’s “Growing Up in Ireland” birth cohort.

1946 is the Year Zero of birth cohorts. The low interwar birth rate had caused much…

 

 

A Spoonful of Medicine, Owen Gallagher

Published in 2004 in The Irish Catholic, my only publication there – the literary editor, Peter Costello, is the father of a friend. This is a somewhat sturdy review of an entertainingly straightforward little memoir. Perhaps this piece presaged more recent writings on medical memoirs.

Owen Gallagher
A Spoonful of Medicine: Tales of an Irish Doctor
(Barny Books, Hough On the Hill, Grantham, Lincolshire, £5.99)
Reviewed by Seamus Sweeney

The public have a seemingly inexhaustible appetite for medicine, as can be seen in the TV schedules and the bookshops. There are two definite strains in medical drama. One is the hard-nosed likes of ER, or Samuel Shem’s House of God. These revel in the gory, the seamy, the adrenaline-fuelled, the sleep-deprived and the dramatic. The other sorts, as exemplified by The Royal, are exercises in gentle nostalgia and anecdote. A Spoonful of Medicine, Dr Owen Gallagher’s memoir of his time as a junior doctor, tends more towards the latter school, although it avoids sentimentality and cheap nostalgia.

This book is a collection of stories from Dr Gallagher’s years as a recent medical graduate in the late 60s and early 70s, particularly in accident and emergency, in paediatrics and in psychiatry.
Some anecdotes bear the hallmarks of much polishing over the years, and certainly some of the dialogue is rather unbelievable, with the characters coming out with perfectly grammatical paragraphs and overly pat witty repartee. There are several lapses on the part of the sub-editors, which lead to distracting typos and occasional confusion as to what precisely is happening on occasion.

However, these seem rather churlish caveats about what is a warm-hearted, entertaining book. The stories, while comic and sharply observed, are never cruel and Gallagher’s compassion comes through without ever becoming sanctimonious. Particularly in the final series of stories from his time in psychiatry, we sense his admiration and respect for certain of his patients’ bravery and approach to life.

It was a far different Ireland then, and it was also a far different medical practice. Certainly its impossible to conceive a character like Dr Moore, protagonist of one of the most memorable sections, being produced by today’s medical schools. Dr Moore was a GP whose practice revolved around the schedules of the racetrack rather than any notion of patient convenience. Moore had honed his system until the least possible amount of time was spent with the patients, with anything at all worrying referred to accident and emergency post haste. Dr Gallagher, working in the nearby A&E, bore the brunt of this extra work.

One patient recalled Moore completely ignoring his complaints, preferring to listen to the radio broadcast of a horse race, and then telling him to get himself down to the pub for a couple of pints and a few cigarettes, as “your complaint is mainly in your head, anyway.” Moore never asked a patient to undress, and would listen with his stethoscope over even the heaviest clothing. It may come as no surprise that his patients were all very fond of Dr Moore, who never kept case notes as he knew all the patients from living in the same community as them. Dr. Gallagher too came to appreciate his more endearing qualities.

It certainly is a long way from that to the obsession with targets and mission statements that marks modern health services. This book is not a sociological tract and it would be unfair to expect a deep analysis of the relative pros and cons of the health system, or indeed society as a whole, then and now. There is however a sense of loss at the passing of a certain pace of life and a certain approach to social interaction. Modern practice seems much more rushed and impersonal.

The book could also have been subtitled “what they don’t teach you in medical school.” If the book has a “moral”, it is that much of the education in human nature that makes a good doctor takes place far from the lecture hall or library. It is an enjoyable account of how one doctor acquired that education.

Review of The Physician As Patient, Myers & Gabbard, Irish Journal of Psychological Medicine 2008

The html version of this isn’t available, so rather unusually here is an image of my review of this book.  I have had reason to return  to this topic  of late.

A Natural History of Families. Scott Forbes. TLS January 2006

I would agree with Scott Forbes that any attempt to explain social behaviour without any reference to a Darwinian framework is futile. However using nothing but a Darwinian framework is also unsatisfactory, and as the closing paragraphs of this review make clear, evolutionary psychology’s tendency to just-so stories is something I have always found suspect (I recall reading a very unconvincing paper on experimental methods in some area of evolutionary psychology which I must dig up) . The Huxley quote “in every hedge & every copse battle murder & sudden death are the order of the day” seems germane to some of my recent maunderings on nature writing.

“We are not mice” – slightly too cute as a summing up line. We are biological entities, with our location in the animal kingdom in a phylogeny of our own making and probably masking the continuum nature of species. We are animals, but are we “just” animals?

Again, thanks to Maren Meinhardt for providing me with the published text.

 

A NATURAL HISTORY OF FAMILIES. Scott Forbes. 228pp. Princeton University Press.

Pounds 17.95 (US $27.95). – 0 691 09482 9.

You see a meadow rich in flower & foliage and your memory rests upon it as an image of peaceful beauty. It is a delusion . . . . not a moment passes in that holocaust, in every hedge & every copse battle murder & sudden death are the order of the day.

Thus T. H. Huxley punctured a fond illusion that many hold about “nature”.
A Natural History of Families, Scott Forbes’s account of what behavioural ecologists have learned about family dynamics, is concerned with linking this knowledge to an understanding of human family life. Forbes attacks the perceived arrogance of sociologists dismissive of sociobiological insights:

“The perspective that we can explain human behaviour without a Darwinian foundation -still the distorted view of many in the social sciences -is hubris”, he writes, though he acknowledges that “linking animal to human behaviour is no simple task . . . (and) has not yet helped me in resolving the seemingly endless disputes with my sons”.

In the animal kingdom, parents tend to create more offspring than they can raise to maturity -“parental optimism”. In cases of obligatory brood reduction, at least one offspring invariably dies. For instance, Harpy eagles lay two eggs, and once one has hatched, bury the other. Among Pelicans and Boobies, the first chick to hatch wages a war to the death against the second-born (and therefore smaller) chick. These species practise a form of insurance, reminiscent of the traditional hope for “an heir and a spare”, except with added infanticide. Primogeniture is the human behaviour most obviously similar to the concepts of “core” and “marginal” broods that Forbes discusses. The core brood is the one that survives, while the survival of the marginal is at best a bonus. If something happens to the core, one of the marginal offspring can be promoted and then have a much greater chance of survival.

Infanticide and siblicide may seem, at first, wilful behaviours from an evolutionary point of view. Darwin himself wrote, in The Descent of Man, that “the instincts of the lower animals are never so perverted as to lead them regularly to destroy their own offspring”. Here Darwin nodded, according to Forbes, and both sentimentality and a failure to recognize the true nature of genetic conflict still blind us. Genetic conflict does not occur only between organisms but within organisms. Many phenomena of human pregnancy -for instance, morning sickness, pre-eclampsia and gestational diabetes -Forbes describes in terms of genetic conflict between mother and fetus, or even between the fetus’s own paternal and maternal genetic inheritances.

An astonishing number of human pregnancies are spontaneously terminated, usually before the mother is aware that she may be pregnant. The figure rises from 50 per cent at age twenty-five to 96 per cent at forty. Forbes describes evolutionary reasons for these phenomena, with mothers “screening” their offspring before continuing with pregnancy. Furthermore, many more multiple conceptions occur than multiple births. Forbes suggests that the “vanishing twin” phenomenon is analogous to the brood-reduction phenomena seen more clearly in other animals.

Forbes’s writing is lively and generally clear, though at times rather irritatingly jocular (one tires of references to “mom and dad”). He explains evolutionary theory lucidly and well, though not perhaps clearly enough for an absolute beginner. Some may find that, while his opening chapter uses many examples from the animal kingdom, his later ones lean rather heavily on a more abstract discussion of genetic and evolutionary theory. However, Forbes is good at explaining the subtlety and frequent counter-intuitiveness of current thinking on these topics.

While Darwin is surely essential to an understanding of the complexities of family life, there is more to human family behaviour than primogeniture and infanticide. As with many who seek to apply Darwinian frames to human behaviour, Forbes makes the no doubt true observation that revulsion at the infanticidal practices of the Spartans, and the general sentimentality of the “family myth”, are a consequence of insulation from the rougher aspects of existence. But what does this self-insulation -which seems to be unique to our species -tell us?

Male mice routinely kill off offspring that are not their own. Female mice spontaneously abort unborn pups on smelling a strange male during pregnancy. As is well known, infanticide and abuse of all kinds are more commonly perpetrated by step-parents than genetic parents. But “more commonly” does not mean “commonly”.

We are not mice. Scott Forbes, thankfully, is well aware of this fact.