I read Misha Glenny’s book Dark Market a good few years ago and it was a fascinating exploration of the dark web. The London Review of Books article in the title,is available online° at the moment but I have, thanks to a kind friend, a gift subscription to the LRB so I read it on old-fashioned paper.

The substance misuse clinics where I work in Blackpool are mostly filled with people with problems with heroin and crack cocaine. Alcohol, of course, and there are frequent problems with benzos, sometimes Spice, and the occasional amphetamines. Standard stuff. Party drugs don’t feature all that much although I don’t doubt our clients will have dabbled with them over the years. I also think that supply of drugs like heroin and crack is still relatively old-school - it’s hand-to-hand street (or near street) deals in the way it has been done for years. As Glenny and Lang suggest, this is the riskiest, with a worrying risk of getting caught or brutalised or simply ripped off.

Glenny and Lang go on to discuss the ‘county lines’ model and also the “urban full-service party supplier” with its emphasis on reliable courteous service and customer satisfaction. The fourth service and the main thrust of the article is the dark web. There’s an interesting angle that results in a kind of self-policing of quality - the admins of one site buy products themselves and get them tested. Clearly it is done for self-serving reasons but contaminated drugs or ones with highly variable purity can kill. The customers benefit.

One wonders where the drug trade on the dark web will lead. Apparently some 29% of illegal drugs are now bought online (though there is no reference for this and the way it is written in the article is a little ambiguous). It is almost impossible for law enforcement to shut it down permanently at present. That said, Glenny and Lang describe an elegant, and slightly convoluted, takedown used by law enforcement recently. Another will pop up soon. I wonder how much this kind of access to illicit drugs will increasingly normalise their use - it’s hard to predict but the relatively safe (safer anyway) access to drugs, where there is a reasonable expectation of quality, moves use into a much wider section of the population. That will ripple out through society in the years to come.

I only recently read this short editorial° from the former editor of the BMJ, Richard Smith. It was published in 2001 article and it has over 100 citations - which is remarkable and testament to how much it has resonated, and continues to resonate, with doctors. I think this may be the first time he refers to the ‘bogus contract’ and it is one that is memorable and easily recognisable to all doctors (and probably plenty of patients as well).

There is a mawkish sentimentality that many doctors cling onto - the classic painting by Luke Fildes is one that doctors get dewy-eyed over. Here is Smith’s pointed comment on that:

Luke Filde’s 19th century painting of a contemplative doctor alone with a sick child might now be replaced by a harassed doctor trying to park his car to get to a meeting on time.

Ouch. It is devastatingly accurate. He goes on to highlight that “curing a sick child” is a very different form of gratification to that which comes with attending a meeting and agreeing to take an “abused child into care”. I don’t think that’s entirely fair here as there was precious little curing going on by Filde’s doctor but it is certainly true that’s the romantic notion of it. The reality of modern medicine doesn’t come within a country mile of that idealised version.

The Great Idea series° from Penguin are lovely little books. They tuck under the elastic of my Leuchtturm1917 notebooks° and can go anywhere. There is, of course, little shortage of quotes from Seneca and some of these are very well known.

Here are a few that struck me. The first is well known.

“It is not that we have a short time to live, but that we waste a lot of it.”

I had not come across the next one before but it struck a note. Always casting around for new things is, in Seneca’s opinion, just as senseless as non-engagement. Sometimes we have to just be satisfied with what we have and work at that.

“They are in the same category, both those who are afflicted with fickleness, boredom, and a ceaseless change of purpose, and who always yearn for what they have left behind, and those who just yawn from apathy.”

Seneca had this to say on the past. He was a fan:

“It cannot be disturbed or snatched from us; it is an untroubled, everlasting possession.”

Of course, Seneca wasn’t quite so genned up on the modern nature of memory but it’s can be a comforting thought. Not everyone has fond recollections and it doesn’t account for those with traumas that blacken their lives.

“But life is very short and anxious for those who forget the past, neglect the present, and fear the future.”

“We must go for walks out of doors, so that the mind can be strengthened and invigorated by a clear sky and plenty of fresh air.”

Not much changed there in the past two thousand years. If ever there was a need for more walks it is now.

African swine fever (ASF) is cutting a swathe through the pig population. Who knew? There is a World Organisation for Animal Health°, which I will admit I didn’t know existed, and this is the fact that staggered me: they expect a quarter of the world’s pig population to die of African swine fever. As pig pandemics go this would seem to about as devastating as one can imagine. It all started in sub-Saharan Africa and has slowly spread out to neighbouring countries and pushing into Asia. There were confirmed outbreaks in Bulgaria and China in 2018.°

It is caused by a virus and has a near 100% fatality rate in affected pigs. The good news for us humans, ignoring the farming-related impacts, is that there is no apparent spread into our own species. There is no vaccine. As a pandemic virus African swine fever has plenty going for it - as well as direct contact spread it can also survive in processed animal meat for months. It seems its progress is inexorable and, closer to home, wild boar populations in Belgium have been found to have it. Will the UK be affected? It seems to be a when-not-if scenario. 

Given the incredible mass of humans on the planet, the increase in travel, and climate change with environments being altered, the chances of some pathogen making a leap from wild or domesticated animals to humans and ripping through us are high. I highly recommend David Quammen’s book Spillover° for more on this. It is brilliant. African swine fever may have gone under the radar, at least here in the UK, but the looming aporkcalypse could offer some interesting, if worrying, insights to the progression of a future pandemic.

I recently finished Seamus O’Mahony’s book Can Medicine Be Cured? He poses the title as a question and it is tempting to apply the principle that one should, as a matter of course, answer these kind of questions as ‘No’. And, indeed, O’Mahony offers little comfort that it can be answered positively. As a result, there may be some risk of despair in reading it.

Jane Rosamund Moore provided an excellent review for us at the BJGP.° O’Mahony takes a hammer to the medico-industrial machinery - the endless biomedical research and Human Genome Project, generally all regarded as A Good Thing, are all duly bashed. Like Moore I was particularly intrigued by O’Mahony’s account of the Mid-Staffs scandal and the contentious use of statistics.

In her review, Moore notes that O’Mahony comes across as a bit ranty. That feels like more of a problem in the back end of the book. For instance, I’m quite prepared to look critically at the evidence for bare-below-the-elbows infection control policies but there is a whiff of the old-school consultant when complaining about the abolition of white coats. The chapter on empathy and compassion wasn’t as compellingn and felt a little under-cooked. Worryingly, O’Mahony offers little in the way of solutions and we’re left with the end-of-career cry that it ‘was better in the old days’. Except O’Mahony wasn’t that impressed then either. How do we find another way? We get a few words at the end about readjusting our aims for people who are suffering but it’s cold comfort.

Overall, though, it’s an excellent book and one that challenges. And O’Mahony offers plenty of avenues for further exploration. We need contrarians. Perhaps one of the best in recent years is the redoubtable Richard Smith. Smith gets to a fundamental problem at the heart of the doctor-patient-system dynamic. O’Mahony writes:

Richard Smith, then editor of the British Medical Journal, wrote about the ‘bogus contract’ in 2001. This contract is based on patients believing that modern medicine can do remarkable things; the doctors can easily diagnose what is wrong, know everything it’s necessary to know, and can solve all problems, even social ones. Doctors know that these beliefs are childish, and that the contract is bogus.

I’ve been making an effort to commit some poetry to memory. I wouldn’t describe myself as an avid poetry fan, I have a very modest collection of books, but I do get an enormous pleasure from being able to recite a few verses from memory. It is deeply satisfying and they make good company.

I recently discovered a rather brilliant app, Memy°, for the iPhone. So, with apologies to Android users, I thought I’d race through a quick review of its features.

You can adjust the text size - I’ve gone very small here so you can get a feel for the way the app works. The poem is a classic, Ozymandias, by Percy Bysshe Shelley. (We used to have a tortoise called Percy named after the poet - a play on the last name of course. Ahem.)

There are three different methods to help you memorise and the one shown is the most common. You read the poem a few times and then the fun starts. The app blocks, randomly, a word from each line. Read it again until you are confident you know the missing words. You click a button and it then blocks two words from each line. Read again. And, so on. Keep going and you will, eventually, have it memorised. A long press anywhere on the screen gives you a brief glimpse.

More features

Folders. It has folders for organising your poems. The folder system is a little basic with no drag-and-drop and no bulk edit or move options. That’s all good when you only have a dozen poems. I’m planning to build my repertoire up over the coming months and years and I’d like to think there will be scores of poems in due course. It could get a little clunky. For the moment it works just nicely. 

Importing and exporting. You can import and export back ups. This is handy for getting your poetry collection from one device to another. Actually, my preference is to save poems as txt files in Dropbox and the app allows you to import these (as well as rtf, html, and PDFs).

Not just poems. You can also use it to learn other stuff. Actors will find it helpful and there is the facility to remove some lines and sections from the memorising algorithms - handy, as you don’t need to learn everyone else’s lines in a script.

What have I learned so far?

I had a headstart with some of these as I had learned them years ago. But some of them are new to me as well. I’m also going to use it to learn some quotes and I have my eyes on some of the classic Shakespeare speeches. Here are five I’ve got solid again:

Ozymandias by Percy Bysshe Shelley°

Tomorrow, and tomorrow and tomorrow by Bill Shakespeare°(a Macbeth speech)

Invictus by William Ernest Henley°

Anthem for Doomed Youth by Wilfred Owen°

This Be The Verse by Philip Larkin°

I read Richard Freeman’s book, The Line, last year when it came out. In July 2018 I sent an email to a magazine offering a review. I wondered if there were some serious professionalism concerns that had not yet been picked up. The jiffy bag story, the lost laptop, it all looked bad. I never wrote anything further and nothing was published. It wasn’t long after that the GMC eased in.

Sections of the book read like a long apologia - in the dictionary definition sense of being a statement of defence of one’s actions. It felt a lot like Freeman was already constructing a narrative of self-justification. And, I’m not particularly critical of that - it’s more-or-less nailed on human nature to do so. I wonder, given the revelations that are now emerging, whether the cognitive dissonance must have been off the scale and, more than anything, I feel sorry for Freeman. I’m inclined to believe he is, or at least was, what he said he was: a caring, person-oriented doctor. Given he has, by his own admission, lied then some bad decisions were made.

Reports are emerging° that Freeman has admitted he “told a lot of lies”. Obviously, the media are going to take an intense interest, particularly, if it offers any suggestion of impropriety on the part of Sky’s stellar cyclists. There’s a bit of me that worries that Freeman realises he was caught ‘bang to rights’ and is now coming clean to reduce his punishment, as can happen. A larger part of me hopes he is in a better place and had simply come to a policy of full disclosure as the best remedy for himself and others.

I’ve always been a little wary of doctors who get into sports medicine. It’s a discipline that has been obsessed for decades with the elites, the research is dominated by studies into young males, and there is very little to help the normal person in their life. It is also, I suspect, beguiling and many of the doctors enjoy that aspect. For me, and I love sport, it looks like an elaborate form of private medicine. Not my cup of chai. There is an intense culture around elite athletes and it’s one that I suspect could be all-enveloping. It would easy to get dragged into it. To make bad decisions. The GMC are alleging Freeman got some medication for the purposes of doping. We’ll see how it plays out. As per his sub-title, medicine and sport have certainly collided and he has been caught in the crash.

There is, as with society in general, increasing concern about planetary health amongst the medical profession. While clearly climate change can damage health it is not always immediately apparent how doctors themselves can help people make changes. Two main areas stand out: physical activity that reduces the use of vehicles; and a healthy diet that helps reduce the carbon cost of producing our food.

So, what is the evidence that a ‘healthy diet’ is better for the environment. All depends on how you define healthy of course. A new paper published in PNAS° has analysed it further, indeed, it’s described as the “most sophisticated analysis to date” in the Guardian but I’m guessing that’s reporting on the authors’ view in the press release.

They looked at 15 food groups, five major health outcomes, and five aspects of environment degradation. The food groups associated with the best health are all, with the exception of fish, the best for the environment. This lovely graphic from the Guardian° shows it best.

It’s easy to criticise journalists for their reporting of science - reducing complex research articles to short articles is always a bit fraught. And, to be fair to those who criticise, it is often done very badly indeed. The Guardian, while not completely immune from the siren call of clickbait, has to be commended for this graphic that rather brilliantly summarises the key findings. It reproduces one that is provided in the paper itself but it is good to see.

And one important point to make and I nearly missed myself - the y-axis is logarithmic. Those towards the top are orders of magnitude worse than those at the bottom.

The graphic also serves another function when it comes to giving dietary advice. The nature of evidence on diets doesn’t always sit well with the one-to-one consultation but encouraging people to consider pushing their diet towards that bottom left corner is a helpful message.