Impact of mass breast cancer screening has been overrated

It has not been shown to affect women’s life expectancy overall, but does increase invasive interventions, say Susan Bewley, Nick Ross and Margaret McCartney of HealthWatch

The announcement that thousands missed out on mammography tests caused distress to many women and their families (Report, 4 May). The implication was that they now risked premature death from cancer. In fact, as many experts have been pointing out, mass screening for breast cancer has not been shown to have any impact on women’s life expectancy overall – but it does increase invasive interventions like mastectomy. This is why Prof Mike Baum, one of the first proponents of mass breast-cancer screening, now opposes it, as does the growing consensus among epidemiologists.

If Public Health England thinks otherwise, it should publish its modelled estimates so scientists and statisticians can check them. In the absence of good evidence it was disgraceful to suggest women died needlessly.

Jeremy Hunt has commissioned a professor of oncology and a cancer charity chief executive to undertake a rapid review but has confined them to narrow terms of reference that keep ministers and their advisers out of trouble. HealthWatch, the charity promoting evidence-based medicine, has long voiced concerns about both the breast screening programme and the associated age-extension trial. Women and their families deserve to have answers about who advised governments on screening policy, what evidence successive ministers were given (and not given), what political pressures were involved, and what monitoring and governance was put in place.

This is not just a question of IT failure but failures of the political system to adapt to new evidence. Mass breast-cancer screening might have seemed a good idea to many at the time but now owes more to politics and fashion than to science.
Prof Susan Bewley Professor of women’s health, King’s College London, and chair of trustees, HealthWatch, Nick Ross President, HealthWatch, Dr Margaret McCartney GP and patron, HealthWatch

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The response The Guardian declined to publish

This was in reply to an extraordinary article in The Guardian on 19th February but rejected by Sarah Johnson, Commissioning editor, Healthcare Network.

It is refreshing to hear a junior doctor strike out against the consensus, especially on a case which seems to have riled the whole medical profession.

Hadiza Bawa-Garba (above) is the trainee paediatrician who misdiagnosed sepsis leading to a six-year old boy’s death, and in an unsigned article a fellow-trainee said she deserved to be convicted of negligent manslaughter and struck off the medical register. It is a courageous view from someone who is equally vulnerable to having the wolves set loose should he or she make a similar mistake.

But the argument was disappointing – as was the decision of this brave warrior for his profession to hide behind anonymity. In fact the anonymity itself rather defeated the logic, which was that doctors must openly bear the consequences of their actions. The secrecy suggests that junior doctors now, as ever, feel a constant pressure to cover up and protect their backs.

In fact the whole thesis was comprehensively muddled. Our shadowy critic of Bawa-Garba says she deserved everything she got because the high court concluded her mistakes “were not simply honest errors”. The writer, while admitting to being ignorant of the details, has, “come to respect the decision of the court – so should my colleagues.” Yet that reasoning is immediately undermined, if not inverted, with the following confession: “I am not sure whether the criminal court is the best place to hold a medical professional to account, and I welcome Hunt’s belated review into medical manslaughter.”

As it happens I agree – I have followed criminal courts for decades and retain a healthy scepticism about their capacity to grasp expert evidence – but your correspondent can’t seriously expect us to respect the verdict of a court which he or she concedes is not the best place to consider such issues in the first place.

It gets worse. The writer goes on, and I quote this in full and in context: “Medical professionals who do their utmost for patients should not live in fear of legal action for honest mistakes. Bawa-Garba was let down by the system that she worked in. I, like many of my colleagues, do not believe she should have been convicted of manslaughter.”

Ah, I see. Or do I? Now, it seems, the author does not respect the decision of the court.

Then it gets more confusing still. We are told that, even though Bawa-Garba should not have been convicted, the GMC was right to strike her off because she was convicted. What matters is public confidence in the profession. So, even if she did not deserve a bullet, she should get one.

Actually this is also the GMC’s bewildering position. Charlie Massey, its chief executive, has conceded to me that Bawa-Garba’s is a competent doctor. Her colleagues speak well of her and she worked uneventfully for four years between the child’s death, which occasioned all this, and the CPS finally concluding she should be arraigned for trial. So your writer, like the GMC, acknowledges Bawa-Garba is a fall guy, a sacrificial lamb for the profession. Are we expected to regard this as justice?

It may be rough justice, I suppose, but, if so, our unsigned pundit believes that such cases will become more and more common: “I can safely say, without evidence but with confidence, that every doctor with sufficient experience has made multiple errors… (and that) as demand for services rises and budgets fall, maintaining standards in the health service will become increasingly challenging and the risk of errors will inevitably increase.”

I agree, but most of us who are concerned for patient safety draw precisely the opposite conclusion. The GMC cannot maintain public confidence by striking off more and more doctors. Indeed maintaining public confidence should not be its role at all, and with the government’s current review into healthcare regulation I hope this will be addressed. It is for the royal colleges or the BMA to do PR. The GMC’s job should be to ensure that all physicians and surgeons are properly qualified and competent.

The writer worries that, “members of the public would not allow a doctor convicted of manslaughter to treat their children”, but other doctors have returned to work after suffering such verdicts and have unblemished records since. The public seems to be happy to be treated by them; why not by Hadiza Bawa-Garba? In fact I can think of no doctor less likely to repeat the error that Bawa-Garba made than Bawa-Garba. It is not just wrong in principle to criminalise someone who was trying to save someone else’s life; it is bad in practice. We, the public, need to become more tolerant of genuine mistakes made by other people who are overworked, understaffed and under pressure. We need to understand that medical mistakes occur hundreds of times each day, sometimes with terrible consequences, and that if we want better protection we need a culture of openness, not one of punitiveness, cover-up and fear.

So, all in all, I don’t believe your contributor has a logical case to make, nor one that would contribute to public safety or public confidence.

I leave you with yet another extraordinary inconsistency in the article – one I find simply inexplicable. Having congratulated the GMC for erasing Bawa-Garba from the medical directory, the writer says: “As a fellow junior doctor, I appreciate how easily errors are made and I will be the first to rise to Bawa-Garba’s defence.”

No you’re not, and you can’t have it both ways. Thousands of doctors, and lay people like me, rose to her defence, while you have simply risen to make a confusing counter-attack. Normally I admire people who are prepared to speak out against a prevailing fashion, but you make yourself sound like part of the problem, not the solution.

Schorstein Lecture

‘We’ve had enough of experts’: the enduring charm of quackery.

Delivered to Barts and the London School of Medicine William Harvey Day, 18 October 2017

Thank you for such a glowing build-up. I’m afraid I shall now considerably lower the tone.

You may or might know not that the Schorstein Lecture was proposed in the letters pages of the BMJ in 1907 to perpetuate the memory of the late Dr Schorstein, and was to be an “advanced course of lectures in clinical medicine” given by “a physician”.

Recent Schorstein Lectures have included: Syphilis and Aneurysm; and Abscess of the Brain in Association with Pulmonary Disease. There was one on Expectoration, and another on the Fate of the bulbus cordis in the human heart.

Prepare to be disappointed. It’s true I am a doctor – indeed a Fellow of the Royal College of Physicians. But alas, not a real one. Since I’m going to be talking to you about quackery, make no mistake. I am an honorary Fellow, a visiting professor. In short, I fail the Schorstein criteria on two counts out of two.

Actually, I warmly recommend sham qualifications like mine. They sound impressive but save you from having to know anything. But since I’m going to be talking to you about quackery, it’s important you know what my qualifications for talking to you are. None.

I doubt Dr Schorstein wd have approved; much less his friends and colleagues who put up the endowment for this lecture.

But since whoever invited me clearly knows I can’t enlighten you much on Syphilis and Aneurysm, I’ve been asked to address the question of how the scientific community relates to the broader context of society.

And that’s something I know a bit about. In fact it’s fascinated me for years.

My interest today, and I hope yours, is the boundary between easy thinking – fast, intuitive, barely conscious and which leads to quackery, prejudice, populism – and the stuff you have to work at: slow, calculating, conscious, which leads to science, maths, evidence and, above all, accepting contra-evidence (the stuff that challenges or undermines a truth you’ve long regarded as fundamental). It’s what Daniel Kahneman popularised in his book Thinking Fast and Thinking Slow.

If you recall, he refers to the 2 types of thinking as System 1 and System 2.

Type 1 thinking is quick. It’s rule of thumb, it’s accepting; it’s faith, it’s believing in a narrative: perhaps the literal truth of ancient scriptures – or for that matter, what you read in today’s newspaper. It’s a quick fix. It fits snugly with your world-view of life. It avoids cognitive dissonance. It’s been neatly summed up in America by Donald Trumps’ rejection of disagreeable information as ‘fake news’. Or in the UK by Michael Gove’s infamous outburst: ‘We’ve had enough of experts’.

System 1 thinking leads me to think Michael Gove is a buffoon. Would he have had enough of experts if he needed surgery, or someone to do the maintenance on the next aircraft he’s to fly on?

System 2 thinking leads me to doubt that someone of Michael Gove’s intelligence would really think such a thing. And it turns out he doesn’t.

In fact it turns out the phrase itself is a classic illustration of what one might call System 1 reporting: it was taken out of context. We all remember the juicy bits, not the other stuff.

What he actually said was in response to a comment that the leaders of the IFS, CBI, NHS and TUC all disagreed with him about Brexit.. His reply was, people have, ‘had enough of experts from organisations with acronyms saying that they know what is best and getting it consistently wrong’.

This, of course, has a very different meaning. He’s right: economic forecasters have often got things wrong. It was just unfortunate phrasing … because it invited a collective frenzy of Type 1 thinking.

And what is so fascinating, is how it caught on with the public. Brexit, of course, is a matter of faith. No one has done randomised trials of Britain in the EU and Britain outside it. No one has tested a hypothesis. It’s driven by ideology about national identity, not spreadsheets of economic formulae. Overnight Mr Gove became a champion of those who were pro-Brexit but didn’t bother with the details. Arguments about who’ll do pharmaceutical regulation, engineering standards, the future of financial services, the risks of inflation, the lack of any other trade deals… all these could be consigned to the box marked “Fake news”, or “Had enough of experts”.

Of course the dedicated Remainers also resorted to Type 1 and concluded Michael Gove was beneath contempt.

So, what has this to do with medicine?

I think a lot. I think it explains the enduring power of quackery in so-called alternative medicine: the mumbo-jumbo like homeopathy, the snake-oil salesmen like Vitabiotics who peddle pills without any credible evidence that their supplements do any good for the health of the people who buy them; or the outright fraudsters who claim to cure cancer with crystals or stem cells. It’s even better if you brand whatever you’re selling as reassuringly scientific. (The strapline for Vitabiotics is Science for Healthy Living.)

The gravitational pull of intuitive thinking is comforting and reassuring. You can cherry-pick your evidence, gloss over inconvenient facts. It’s the shortest route; it avoids a troublesome detour. It explains why many qualified doctors believe in this stuff. It explains the strange world of psychobabble psychotherapy, and I’m afraid it explains quite a bit of counselling too for which there is precious little evidence-base that it does more good than harm.

But it also explains why rotten and misguided ideas hang round the neck of conventional medicine for so long.

Even after Dr Schorstein’s death – well into the C20th – patients in Britain were still being bled, as they had been in the dark ages. Textbooks were recommending bloodletting right up to the 1923 edition Sir Wm Ostler’s The Principles and Practice of Medicine.

In fact medicine has a pretty disgraceful record of Type 1 thinking. Voltaire (or whoever it was) wasn’t entirely joking when he described the art of the great physician as keeping the patient amused until he either got better or died. For 2,000 years doctors either stuck pins into sick people, or purged and bled them – and that’s if they were lucky. They tried trepanning, sulphuric acid, and any number of appalling bits of flimflam because they couldn’t shake off almost religious dogma about how the body worked.

In the east, of course, it was all about energy flows. If you were ill it was because your vitalism was disturbed as it flowed through a network of invisible channels called meridians. Here in the west it was your temperaments that were disturbed: the 4 humours that had to be rebalanced.

These theories weren’t entirely barking. Sometimes they were based on anatomical studies. And sometimes they just got the arrow of causation the wrong way round. For example, it seemed obvious that the heart was the seat of emotion. If you were frightened or excited, your heartbeat went up. According to Galen the heart was the organ most closely associated with the soul. We still say you’re close to my heart.

It was clear by the C17th that Galen may have got it wrong. In 1628 Wm Harvey, whom we celebrate today, published his now legendary treatise, On the Circulation of the Blood. The rest of Galenic medicine looked increasingly shaky too.

Famously, around the 1640s, the Flemish scientist van Helmont challenged the medical establishment to take:

“200 or 500 poor people with fevers, pleurisy etc. and divide them in two: let us cast lots so that one half of them fall to me and the other half to you. I shall cure them without blood-letting, you will do so according to your knowledge, and we shall see how many funerals each of us will have. The outcome of the contest shall be the reward of 300 florins.”

15 years later the Anglo-American chemist George Starkey made the same challenge in London: that he could cure more patients:

“without blood-letting, promiscuous purge or vomiting… without desiccation or cautery, without clyster (meaning enema) or suppository.”

He too wanted what we’d now call a randomised trial.

So how come it took 300 years for medicine to become scientific? How come a medical journal this year (the JRSM 3 months ago) could note, with some legitimacy, that:

“medicine’s conservatism, its reverence of authority and its still incomplete attachment to empirical observation and experiment lives on.”

I can vouch for that on a personal basis. I am president of Healthwatch (not the govt-quango but a small charity dedicated to evidence-based medicine). For the past 16yrs we’ve held a competition for medical students and trainee nurses inviting them to uncover obvious flaws in statements or in experimental protocols. There’s 500 quid if they get it right (thanks to Cambridge University Press) – and I handed out this year’s prizes last night. As it happens, this year was exceptional, but over the years the outcome has been lamentable. Of those who try their hand at it (presumably those who think they know about experimental methods) roughly 60% get it wrong. Many young doctors and nurses – often the 1st port of call for patients – can’t tell science from pseudoscience, even in their final year of training.

My guess is that they’ll carry their naivety into the surgery and through the entirety of their professional career. Which means that medicine’s conservatism, its reverence of authority and its still incomplete attachment to science will carry through to another generation. And since so much of medicine is about the rigour of science, and cautious management of uncertainty, I find that worrying.

What’s more, if we still have professional clinicians who can’t tell good evidence from bad, it’s little wonder that so many of their patients believe in quackery and woo.

Does it matter? Should we care that some doctors can’t make proper judgements from what they read in scientific journals? Is it important if at the fringes of medicine some clinicians dabble in a bit of flimflam? Does it matter that some parts of the NHS still pay for homeopathy, based on the idea that water has a memory – when we know it’s physically impossible for water to have a memory because its molecules are constantly bumping into one another – that’s what makes it a fluid! Does it matter that Victorian charlatanism is now a multibillion dollar global industry, pushing pills like Vitabiotics onto the worried well? (You can tell I’m a fan of Vitabiotics – their science, at least their science of persuasion, helps them pocket £100m a year from gullible consumers). Does it matter that two-thirds of the UK population believes in treatments for which systematic reviews conclude there is no condition for which they are convincingly effective?

I think it does.

Firstly, because this stuff is not just being peddled to the worried well, but to the worried sick.

Second, because it’s dishonest to lie to patients, dressing unproven remedies as cures. I’d say that’s even true when you hope for a placebo effect. The only exceptions can be in ethically approved trials to which participants have given informed consent. If you propose surgery – an appendectomy, for example – you should explain the potential complications and failure rate. Surely it’s the same with, say, acupuncture. Informed consent means the patient has a right to know not just that there’s a slight chance of infection – but more importantly that mostly it doesn’t work. Even in chronic pain, where there is some evidence of efficacy, even there the largest studies involving 18,000 patients have shown its effects are modest. What’s more the effects are the same even if the needles aren’t placed on the so-called meridians. So even if you’re seeking a placebo effect, it is surely ethically questionable not to tell patients the truth.

Third because pseudoscience imposes pressures to provide cake and circuses rather than better clinical outcomes. The NHS is already trapped in the headlights of populism. The last thing rational priority-setting needs is succumbing to the 30% of the public who say reflexology (ie treating the body through the feet) should be free on the NHS. (These figures are from a recent YouGov poll.) Money spent on quackery is money siphoned off treatments that work.

Fourth because quackery is intrinsically damaging to rationality. Type 1 thinking is knee-jerk thinking. It requires little information and is prey to misinformation. It nourishes primitive thinking and prejudice. It is the enemy of informed democracy, let alone informed consent.

Of course I know that what I’m saying is doomed to failure. I know perfectly well that I’m tilting at windmills. I know that a love of quackery is woven deep into the human psyche. Type 1 thinking is the basic way we think, the default decision-making process, the short-cut, by far the most cost-effective cognitive strategy, and – often – the only practical one.

If I hit my head on a wall it will hurt – for practical purposes the wall is solid. If you ask most people how radio signals get through the wall – and I’ve tried – you’re likely to provoke blank faces. Life’s too short to consider a wall as a vast empty canvass of nothingness populated by trillions of infinitesimally small atoms.

Similarly, with our perceptual processes. We seek meaningful images in random Rorschach ink-blot tests. We love optical illusions – in fact we rely on an optical illusion of motion when we go to the movies and watch a series of still-frame photographs that we call a film. We even try to believe the sometimes puerile story lines.

We go through life approximating. And mostly it works. True there are problems of bias. In 2006 a friend of mine, the forensic psychologist Itiel Dror, sent fingerprints to 5 experts to eliminate them from a serious crime, and all 5 experts obliged. Some months later he sent them the same prints, this time seeking confirmation they came from the prime suspect. This time 4 of the 5 experts found a match. Even in science our preconceptions pose a fundamental danger.

The biggest risk comes once we’ve reached a decision. We’re reluctant to undo it, to accept we’re wrong. We all know we’re subject to confirmation bias – but even so we’re all still biased to believe we’re right. You can call it faith if you admire it, dogma if you doubt it, superstition if you disagree with it, or prejudice if you oppose it. But essentially it’s all the same way of thinking. It’s prejudice if you’re against Catholicism, it’s dogma if you think Catholicism’s stupid, it’s faith if you are a Catholic.

And if you instil a belief when someone’s young, that bias is likely – for good or ill – to persist for life. As someone (probably Aristotle) said, give me the child at 7 and I’ll give you the man. It works equally for prejudice and faith. A Protestant boy brought up on the Shankill Road in Belfast is likely to grow up to be a Protestant. And, if his parents are bigots, he’s also likely to be anti-Catholic. As the book of Jeremiah puts it: “The fathers have eaten sour grapes and the children’s teeth are set on edge.” Similarly a Brahmin girl in Calcutta will almost certainly grow up believing herself to be superior to other castes, and shunning the Untouchables.

We like to think we have all chosen our outlook on life. Often our outlook on life has chosen us.

This is uncomfortable, even outrageous, to anyone who does have faith – the idea that belief, devotion, prayer, is a defence-mechanism, type 1 thinking taken to extreme, and tantamount to a superstition. But as Alan Sokol, the particle physicist, puts it ‘Faith is the pseudo justification that people trot out when they want to make claims without the necessary evidence.’ To believe in an undefined god (or gods) is one thing. That requires no evidence. To believe in scriptures as the literal word of god is quite different; for where is the proof of authenticity; where, except in circular argument, is the evidence they represent the word of god? Similarly, to believe in an ill-defined god is one thing. But to bestow logical or testable powers to god is another. For example, to believe that god is all-powerful is simply illogical since it is mutually contradictory; even god can’t create something which is too big for him to lift – or if he can, he can’t lift it.

I know I am now venturing where many say you shouldn’t. It’s convenient to say that science and religion occupy different realms; that they are not remotely comparable. But of course they are. Science goes to great lengths to avoid the very pitfalls that religion encourages. As Karl Popper pointed out, bias is the enemy of science and we must always be aware that unconsciously, intuitively, we prefer confirmation to falsification. We have a profound tendency to gather and process information selectively; to confirm a hypothesis or preconception by looking for evidence that would validate our expectations; and to reject or ignore evidence that could contradict our beliefs.

Since intuitive thinking leads to selective information, contextual bias and even tunnel vision, it’s a paradox that many scientists celebrate faith as though it was intrinsically something noble.

Science is where you put your treasured idea on a pedestal and try to knock it over. If you can’t, then you invite your friends and rivals to knock it down. Faith and prejudice are where you put your treasured idea on a pedestal and bow down before it. You disparage people who try to knock it over, you call them unbelievers or infidels, and in centuries past – and in some cultures today – you put them to death. 500 years ago, for saying what I’m saying today, I’d have been burned at the stake. In some parts of the world I still would be.

Why am I saying all this? Why am I trespassing on hallowed ground, risking the displeasure of many in this room? It’s not to be controversial. On the contrary. It’s to help keep my own feet on the ground.

I’d like to think we could one day have a new Age of Reason where everyone is dispassionate and open-minded; where we’re all eternally open to new evidence. and where no-one takes intellectual short-cuts. But, as I say, I’d be tilting at windmills.

There is good reason for Type 1 thinking. There’s too much going on in the world for us to analyse it all. We simply have to take many things on faith. We buy newspapers that reinforce our existing stereotypes and throw slippers at the TV if it says something offensive to our views. We buy brands that we trust rather than look up the evidence every time we make a purchase. And talking of trust, maybe that is the key that unlocks the reason for all this – the reason that faith – and prejudice – are so hard-wired; why they’re so valuable to humankind.

In his remarkable book Sapiens, a biography of our branch of our species, Yuval Noah Harari proposes that it is our Type 1 thinking – our prejudices – that make us so successful; that creates for us a unique evolutionary advantage. Provided we share our prejudices – or faith (it doesn’t matter which) we form a bond. We’re all Sunni Muslim, or all Romans, or doctors, or socialists, or scientists, or racists; or we all believe that a US $ has intrinsic value – even though it’s just a piece of paper. This shared vision – creates a kinship. Whereas other apes are restricted to bands of a few dozen, we’ve learned to share visions and create trust with people we’ve never met before. We’re in the same team. Of course when that shared trust breaks down it can be nasty. That’s why civil wars tend to be the ugliest.

But is Harari right? Does our hard-wiring mean homo sapiens will always default to prejudice and faith; that science will always have an uphill struggle. Does it mean that prejudice and faith in society – and quackery in healthcare – are unassailable? Plainly they are not. And Harari himself is optimistic.

In his lifetime, and in mine, prejudice against women, homosexuals, Jews and black people has declined hugely. Incidentally, or maybe it’s coincidentally, so has faith in organised religion. More than half of Britons now say that for all intents and purposes they don’t believe in god.

Maybe we will progress to a time when even Prince Charles will see that homeopathy is nonsense. At least one person thinks we’re nearly there. In a new 30-part series for the BBC featuring religious artefacts from the British Museum, the museum’s former director, Neil McGregor, will argue that Britain is the first society in history to operate without shared religious beliefs and rituals at its heart. Maybe he’s right. Maybe the reasoning of science really will displace the pseudo-thinking that leads to quackery. Maybe we can help the process by not teaching children science as a set of disciplines like chemistry and physics but as a robust way of checking evidence which is equally applicable to history or, one of my own pet subjects, security and crime prevention.

But I won’t hold my breath. Immanuel Kant was overly-pessimistic, but not entirely wrong, when he said: “Out of the crooked timber of humanity, no straight thing was ever made.” Indeed, let’s go back to where we started, to Trump in America and Brexit with Michael Gove. In politics, at least, there are signs that as old allegiances fail, new ones take their place. But I don’t think they’ll last.

Personally I’m sanguine. If you take the long view, the very long view, then I don’t think this is a zero-sum game. Steven Pinker is convincing in his bestseller, The Better Angels of Our Nature, that over centuries and millennia humans have become less violent, more thoughtful, more tolerant of cognitive dissonance.

But at best it’s 2-steps forward, 1 step back.

I wish I could close by saying, don’t have nightmares do sleep well. But in medicine, as in every other aspect of human existence, reason will always have to struggle with unreason. As soon as you think you’re evidence-based you’ve succumbed to wishful thinking. The power of the intellectual short-cut is too beguiling.

In conventional medicine as in alternative treatments, you can’t escape the risk of bullshit. Being human we will never be entirely free of the enduring charm of quackery.

26 June 2016: the UK votes to leave the EU


Not since 1933 has a European democracy engaged in such self-indulgent and dangerous democratic vandalism.

This is an emotion-loaded moment and this is an emotionally-laden reaction. A more measured one will follow. Of course Brexit itself was driven by emotion, chiefly resentment, much more than it was inspired by hope or a vision for the future. The nation which was least shackled of all EU members convinced itself it was enslaved. The areas most dependent on EU handouts felt most ingratitude. Facts were trampled as though they had no more value than opinions.

But the market reaction speaks for itself, wiping 10% off people’s pensions and stripping the UK of its golden credit rating (and that alone will cost us far more than any savings from EU membership). We have betrayed our friends in Europe, we’re about to break up the United Kingdom and we will be lucky to win a single dispensation in our negotiations, all because the old and those who contribute least to our economy – including a majority of those who are a drain on it – betrayed the young and those who build our prosperity.


As Lord Ashcroft’s remarkable poll makes crystal clear, the retired and elderly, the fearful, mean-minded and unproductive have trumped the young, optimistic, open-minded and economically active. These are generalisations, of course, with many young and successful people expressing their dislike of immigration and many conservative country folk voting for Remain. But if anyone hoped the referendum would heal divisions it has aroused bitterness and created discord. Half the country has found itself on the wrong side of the referendum, and I guess that a good proportion of those who voted for Brexit now have regrets (or at any rate second thoughts).


Ironically the more prosperous and better educated are feather-bedded compared to the relatively disadvantaged. Those who found Brexit most appealing are the ones who will get most hurt.

The stock market has crashed, big businesses are reeling and foreign investors are frozen in their tracks, financial and manufacturing industries based here are already looking to relocate, and we will haemorrhage jobs as we are ejected from European institutions – including UK-centric institutions like the European Medicines Agency. And then there are all the unconsidered consequences such as a slump in tourism, one of our biggest exports, as we are expelled from the Europe-wide visa clearance scheme. The tumbling exchange rate will help exporters (so that’s why Dyson and Bamford wanted Brexit: to damage sterling) but from now on we have lost our seat at all the standard-setting institutions and Europe’s powerful bodies that make the rules for global trade. Worse still, hardly anyone in Whitehall has experience of negotiating bi-lateral trade treaties with other nations.


In any case – and this is no small matter – we have betrayed our partners, snubbed our closest allies, stimulated nationalists and far right extremists across the continent and done the work of Islamist fanatics by damaging the world’s economy and undermining Europe.

Here at home we will soon be plunged into constitutional crises. The SNP has already signalled a new call for breakaway, and heaven knows if the Brexit vote will reignite conflict in Northern Ireland. Across the kingdom people are more divided then before, not less, with many plunging into a state of disbelief and depression. I, for one, find myself feeling like a foreigner in my own country, bewildered at how the rural middle-classes could be so myopic, saddened at how working-class voters, once the model of progressiveness, could be drawn to the anti-immigrant rhetoric of UKIP. The very constituencies once thought Labour’s heartland, in the shipbuilding north-east and the coalmining valleys of Wales voted angrily with the toffs of Norfolk and the shires.


Perhaps we shouldn’t be surprised. We have seen the surge of right-wing and neo-fascist groups in France and even Germany and watched in amazement as the anti-intellectual demagoguery of Donald Trump propelled a loudmouth and inflammatory bigot towards the White House. Too many citizens feel powerless as the world changes around them in rising cadence. It is not that people don’t like change – far from it, we crave stimulation and dislike boredom – but when change happens we like to feel in control. We often don’t use our vote when we have it (for example, look at the elections for police and crime commissioners where almost none of us bothered) but even when we do few of us feel we have much influence. The constituencies for local councillors are now as big as they were 150 years ago for MPs. So never mind that the ‘unelected’ European Commission is said to be self-serving or out of control – it is appointed by elected government leaders and all its important decisions are subject to the European Parliament and to national vetoes – the sense of alienation transcends the technical realities.


Yet the return of sovereignty is a naïve illusion, a mirage in an increasingly interdependent and global world.

Worse, it is not as though the victors in this campaign have a clue about how to put globalisation back in its box. When the new leadership sweeps in it has no published plan and will have no answers to any of the problems it set out to solve, from immigration through fishing rights to the NHS, and it will face a battleground of crises of its own making.


We don’t have a parallel world so we cannot compare what actually happens with what would have happened, but we don’t need to be clairvoyants to recognise that our economy has taken a body blow and that the next few years will be bloody. Instead of increasing our authority and fighting our corner on assuming the Presidency of the European Council next year (due on July 1st) we will be pariahs.


However, we are where we are and we need to salvage what we can from the wreckage. One of the initiatives I’ve been funding is to promote evidence-based policy in government. We made progress under Cameron who personally indicated support and put me in touch with Cabinet Office people through whom we have some departments of State ready to sign up. We must fight to encourage the development of evidence-based public policy rather as doctors have increasingly embraced evidence-based medicine. It doesn’t inhibit politics, it doesn’t fight ideology; it simply asks that if civil servants (and by implication ministers) put up an idea, or quash one, they show their workings. We have a parallel movement in the US, led by Michael Bloomberg and I hope we will partner them here. We have just published a report [] by Sir Stephen Sedley, a former judge in the Court of Appeal, into the need for more rigour and transparency in government research.


If only an evidence basis had been the bedrock of the Brexit debate.

Yet the risk is that the new government will have new SPADS (‘special’ political advisors chosen because they are believers) and a new and more ideological outlook – one which thus far indicates it is more interested in bombast than evidence.

I can honestly say that I have never, not even when living in the turmoil of a quasi-civil war in Belfast, been so depressed about politics and human stupidity. Yes, the turmoil will in time die down. There will be a phoney war when it seems it might not be so bad after all. But history will regard June 2016 as an exercise in self-inflicted harm and the beginning of one of the most difficult periods of peacetime British history.

AirAsia QZ8501: how could it happen?

AirAsia QZ8501: how could it happen?
4 January 2014
(see also Air France Flight 447: ‘Damn it, we’re going to crash’ )

Yet again a jetliner has crashed into the sea, this time with the loss of 162 passengers and crew. How can this happen; and – since flying is supposed to be so safe – how big is the risk?


The easy part to answer is the risk. It is almost infinitesimal. Commercial jets have been getting safer and safer for fifty years (although there was a blip in the 1980s due to terrorism). Nowadays the odds of being killed on a flight with reputable airlines is about one in twenty million. Even with the worst performing carriers you could expect to take a million and a half flights before being involved in any event in which somebody was killed. The global fatality rate about 1,000 a year, compared to over 1,000,000 deaths on the road, so mile for mile or minute for minute flying is much safer than driving. But the aviation industry can’t rest on its laurels. Every crash makes headlines so with passenger numbers rising five per cent each year the safety factor has to grow by five per cent simply to keep pace.

Hence the AirAsia disaster is not just a terrible tragedy for those involved, but a huge worry for the industry in general.

The safety authorities – like Britain’s Air Accident Investigation Branch – are usually tight-lipped at times like these. Hasty inquiries can miss key facts and jump to unjustified conclusions, apart from which official verdicts can ruin careers and prompt multi-million dollar law suits. Accordingly they try to stick to facts and avoid public speculation, usually taking months and sometimes years before they issue their reports.

That doesn’t stop the media, of course, which respond to public anxiety and to the human impulse to make sense of uncertainty. This can lead to wild conjecture in the early days but usually reporting converges over time so that there are few surprises by the time the official reports are published.

Initial radar tracks indicate the plane gained altitude at an alarming rate. If this is borne out by data from the flight recorder it might explain the crash, perhaps through jammed control surfaces, with such ascent creating catastrophic damage to the airframe, or simply causing loss of forward speed.

And yet that doesn’t necessarily mean that the aircrew climbed too steeply to avoid the storm. The theory sounds credible because it was just such pilot error that caused the loss of AF447, the Air France Airbus that disappeared into the Atlantic in 2009. One pilot’s relentless anxiety to climb slowed the plane so much that it stalled and fell out of the sky. There is, in my view, an intrinsic risk in the Airbus design that contributed to the A447 tragedy – a design that makes it harder for one pilot to see what the other one is doing so the error wasn’t spotted by the flying officer’s colleagues until it was too late – but the Air France crash was so seminal that every airline beefed up training and every commercial pilot in the world would be allergic to the danger. It would be both astonishing and scandalous if AirAsia’s crew remained somehow unenlightened.

What seems more plausible is that the storm itself caused the aircraft to malfunction. Thunderstorms can generate enormous updraft, although it’s hard to imagine a  current so sustained that could lift a 70-tonne fully-laden airliner for more than a few seconds.

Big jets like an Airbus are remarkably robust. They can be hit by lightening, buffeted by turbulence, baked by sun on the tarmac and frozen at high altitude. Their engines are so reliable they almost never fail. They can cope with huge variations in air temperature, rain, snow and with rare exceptions even ingesting foreign object such as after bird strikes.

At least one weather event has proved dangerous – one that is hard to predict and largely invisible to radar.

When moist air rises rapidly above tropical sea, supercooled droplets of water can freeze when they encounter the cold surfaces of a high-flying airframe. This is rarely a problem because small ice particles melt on impact with the heated windscreen and vaporise in the engines. But sometimes convection storms can cause moisture to freeze so rapidly it forms crystals, and these so-called convective crystals have been known to cause damage to planes and temporary power loss.

Each engine on an A320-200 Airbus like AirAsia’s QZ8501 sucks in around a ton of air each second. A very heavy concentration of ice crystals could conceivably overcome the enormous momentum of the turbines and kill off forward thrust. The pilots would than have to glide the aircraft while they fought to revive the engines. They would have ample time to do so. A wide-bodied jet can glide about eight miles for every 1,000 feet of altitude. Famously, in 1982 a British Airways jumbo flew for 13 minutes without power after flying through volcanic ash. It was still at 13,000 feet when first one and then the other engines came back on line. If convective crystals had done for QZ8501 what volcanic ash had done for BA09 two decades earlier then, depending on the weather, the Airbus should have had a range of at least 50 or 60 miles.

If the engines couldn’t be re-started then Captain Iriyanto would have had no option but to try landing in the sea. That would be hard enough in tranquil conditions on flat-calm water, like the ditching of US Airways flight 1549 in the Hudson six years ago. But QZ8501 would have come down in tumultuous turbulence into mountainous waves. At more than 70 tonnes and 37-metres long it would not have stood a chance.

The idea of a pancake landing in heavy seas would account for the fact that large pieces of the fuselage appear to be intact at that bodies have been found floating on the surface. Had the aircraft fallen vertically, as some reports suggest, it would impacted the water as though hitting a concrete wall.

flight path

On the other hand an attempted landing assumes that the pilots had control. Why in that case was there no Mayday call? Why was the crash site so close to where the last radio contact was made, suggesting the Airbus really had dropped rapidly? This brings us back to those reports that the plane rose more like a fighter plane that a commercial airliner, perhaps caught in freak updrafts and downdrafts which threw it around the sky and then hurled it into the Java Sea.

We will know the answers soon. Unlike Air Malaysia’s MH370, still missing in the southern Indian Ocean, the AirAsia wreckage is in water shallow enough even for recreational divers. Only foul weather, with 4 metre waves, strong currents and poor visibility, has been frustrating efforts to locate and recover the flight recorders located near the tail. Horrifying though the crash has been, it will soon yield its secrets and, though of little consolation to those who have been bereaved, it will contribute to make flying even safer than it is already.

The rape of Richard Dawkins

The ‘rape’ of Richard Dawkins

Richard Dawkins, the biologist and proselytising humanist, used the sensitive subject of rape to illustrate a logical point: that “to judge something bad and something else very bad is not an endorsement of the lesser of two evils. Both are bad.” This proved too much for some, who prefer to think in absolutes, and others for whom sexual crimes must be subject to absolutist condemnation.

Professor Dawkins’s Tweets included, “Date rape is bad. Stranger rape at knifepoint is worse. If you think that’s an endorsement of date rape, go away and learn how to think,” and, “Mild pedophilia is bad. Violent pedophilia is worse. If you think that’s an endorsement of mild pedophilia, go away and learn how to think.”

Few of his critics appear to have read his explanation for choosing sex crimes to illustrate his point: just because they are so often taboo. “Rationalists like us should be free to follow moral philosophic questions without emotion swooping in to cut off all discussion, however hypothetical.”

Poor Richard Dawkins. The reaction to his comments on rape quickly turned to angry and sometimes gleeful vilification. The Twittersphere and blogs revelled in sneering condemnation and people will be reluctant to come to his defence because they themselves will be courting trouble and be caricatured as defenders of the indefensible.

The vituperation would have taken aback a lesser man than Dawkins, as it did me when I was rounded on a year ago, plummeting instantly as one writer described it from national treasure to public enemy number one. In my case the Mail on Sunday, having serialised my book on Crime, confected a story which made me out to be a rape-condoning misogynist, and quoted an especially wounding comment from Jo Wood, a highly respected rape crisis campaigner. The media pounced on me as they have on Dawkins. Actually having read my book Jo Wood told me she felt she had been set up, that my words, far from being misogynistic had been twisted into sound bites and that when read in context, they “actually strengthen the arguments for sexual violence crimes to be treated with the empathy and respect that victims demand.” She went on: “I would seriously suggest anyone who still supports the furore that has broken out – takes time out to READ THE BOOK.”

The Mail On Sunday offered a right of reply – which it promptly buried under a repeat of the allegations against me, and no other newspaper bothered to rebalance its portrayal.

This time even the redoubtable and usually thoughtful Shami Chakrabarti allowed herself to be dragged in to the fray. What is disconcerting is that someone of her perceptiveness, sensitivity and intelligence should appear ready to join a chorus of angry abuse. It was a reaction that brooks no argument, and she, of all people, should not seek to close down a debate.

Let’s be clear what Professor Dawkins has been saying: that some crimes can be worse than others and that some victims’ experiences of a crime can be more terrible than others. He is urging us to shun absolutism. Had he illustrated his argument by citing homicide he might have won general assent. Even the law, which sometimes require us to see the world as binary, acknowledges differences between culpable murder, manslaughter and infanticide. But it is dangerous to voice anything outside the new orthodoxy when it comes to rape.

Dawkins used the word “mild” to describe the least intrusive spectrum of paedophilia – perhaps meaning those who yearn but do not touch. Never mind that in the cool logic of a philosophy tutorial his choice of adjective might have been reasonable. In the world of social media, where reflexes are often framed by sound bites, it was tantamount to incitement. It was widely, and wrongly, assumed that he’d used the word to describe penetrative rape. The resulting furore was an ironic illustration of precisely what he was trying to convey: that there are gradations in almost every human behaviour and experience but that such nuances are too often elbowed out.

There are reasons to be especially sensitive in discussing any sexual crimes. For many years victims were discouraged from complaining and if they persisted they were frequently debased by the police and humiliated by the courts. The growth in recorded sexual offences is testament to greater confidence in the system but trial by jury remains as much a trial for the principal witness in rape cases as it is for the defendant. In some cultures victims dare not speak out at all. It is entirely reasonable to be critical of anyone who belittles the crime of rape.

But that does not mean that all rapes are the same. Only those who think in slogans can say otherwise and it is not helpful to anyone to insist on a one-size-fits-all platitude. Abusing Dawkins down does not help us to frame more appropriate ways to tackle what is in reality a multitude of problems. But it is also deeply patronising to many victims with diverse experiences.

In fact it is not just those whom Shami Chakrabarti calls “clunky” men of a certain age who think rape isn’t always of the same severity. Several female commentators have also provoked outrage with similar observations. But above all, listen to the victims. I have met and worked with victims over many years and they do not accord to a simplistic model and did not all experience the same degree of trauma, revulsion, self-blame, or any other standardised emotion that campaigners sometimes seem to want to attribute to them. Nor is the evidence just anecdotal. A large scale survey revealed that around half of women who had penetrative sex against their will did not consider themselves to have been raped. They are wrong, of course, on any definition, but are we to drown out their experiences because they do not comply with the way we think they should think? Are we to accuse them of foolishness, or of letting the side down, or – worse – of not being victim enough?

Some countries take a more sophisticated view, with a graduated judicial approach which recognises differences between sexual assault and, say, aggravated assault with a weapon. We should go further and finally accept that conventional adversarial trials are not always the appropriate way to tackle intimate violence.

For more on this see the thoughtful response in The Times by Carol Sarler, who has been a victim both of date rape and serious sexual assault by a stranger, and who points out that, “they are so obviously different”.

Sexual harassment and predation will not be tackled through shouting down people like Richard Dawkins. If ever there was a subject that should recoil from insults and deserves rational reflection this is it.


Medical Innovation Bill

From The Daily Telegraph 2 June 2014

The ‘Saatchi Bill’: can a PR guru cure cancer?

Lord Saatchi’s medican innovations Bill won’t encourage good research – and, in its original form, could have opened the door for dangerous quackery

By Nick Ross

Lord Saatchi has promoted a private Bill whose supporters have implied it might help to cure cancer. Unsurprisingly his idea has drawn a lot of approval from the public, and even from the Telegraph. After all, who could be against innovation in medicine?

Sadly the Bill is misnamed and misguided. It will not promote invention, it will not help cure cancer or any other disease and it could be harmful. Thankfully it is being substantially revised, but even so it could well set the clock back.

How is that possible?

The answer is that Lord Saatchi, though a grieving widower and a PR genius, is not a medical researcher, or even a scientist. He believes that doctors are held back from prescribing innovative treatments out of fear of litigation. Many have told him there is an “invisible red light” which holds them back. But it is a fantasy, and if some doctors misunderstand the facts they need to be better advised. Neither he nor his supporters can cite a single instance where legitimate research has been hampered in this way. Medical research faces too much red tape but it is not besieged by hyena lawyers. The NHS Litigation Authority says such claims are vanishingly rare. In fact clinical research accounts for only 0.01 per cent of NHSLA payments, and these were cases where recklessness was alleged. The biggest defence group in the world which defends doctors against litigation is the Medical Protection Society and it too opposes the Bill. It says bluntly it has “seen no evidence that a fear of clinical negligence claims is holding back medical innovation”.

It wouldn’t be so bad if the Bill was simply unnecessary, but as first drafted it was positively dangerous. It proposed to give clinicians legal immunity if they try new things out. But breakthroughs in medical research are made systematically, one step at a time involving scrupulous trials with ethical oversight and peer review. It would be reckless to return to the age freelance have-a-go heroes who experiment on their patients. This would undermine evidence-based medicine.

ntil this week the Bill required that there must be “plausible reasons why the proposed treatment might be effective”. But it did not require scientifically plausible reasons. To quacks, faith healers, fools and conmen (and sadly even some qualified physicians) almost anything is plausible, including meridians, spirits, water memory and laying on of hands.

In any case, plausible theories can be, and have often proved to be, spectacularly and fatally misleading. Laying babies to sleep on their stomachs (so they don’t ingest vomit) was a plausible idea that resulted in thousands of cot deaths. Dozens of other half-baked ideas – giving oxygen to premature babies or steroids for brain injury – have taught how persuasively dangerous credible notions can be.

Maurice Saatchi invited me to discuss my concerns with him three months ago and graciously accepted that the Bill should be amended (a) to avoid opening the flood gates to quackery or to buccaneering experimentation on vulnerable patients; and (b) to provide for the essential importance of disseminating results.

Meanwhile, the magnificence of the Saatchi marketing machine has overshadowed the fact that bulk of the medical research community has since come out against the Bill including the NHS Health Research Authority, the Academy of Medical Royal Colleges, medical research charities such as Cancer Research UK, the General Medical Council, the Medical Protection Society the British Pharmacological Society and senior lawyers like Robert Francis QC. [You can see a selection of the opponents here.]

To his great credit Maurice Saatchi has been listening. His new version is to be published on Thursday and it will embody fundamental changes. For a start it will specifically exclude research – the very thing it was touted to be liberating. And, thank heavens, it will now require consultation with appropriately qualified colleagues, including any relevant multidisciplinary team. Of course if appropriately qualified doctors and multi-disciplinary teams are all outside the scientific consensus, as is the case in dubious clinics in Switzerland and Mexico for example, even downright quackery would be covered by this clause. But above all the revised Bill is likely to retreat from its founding principle, which was to insulate doctors from common law. It will now specifically acknowledge that nothing in the Bill is intended to stop patients suing doctors for negligence.

In essence then, the revised Bill will simply allow doctors to do what they can do already, which is to try out last-ditch remedies. But there will be an advance. Although it is not yet in the one-and-a-half-page draft to be published this week, his staff have made me a “copper-bottomed” promise that Lord Saatchi will make further amendments to seek to collect results of all these desperate measures and will disseminate results.

Since more work is to be done maybe the Bill could yet be turned to much greater advantage. I have proposed to Lord Saatchi that he could rebalance the Bill to tackle the real problem of healthcare litigation. This is the 99.99 per cent of claims that have nothing to do with innovation but drain the health service of £2.25 billion a year, are of serious concern to clinicians, create a burden on legal aid and cause a great deal of personal distress. Claims against surgeons and physicians range from the spurious, sometimes whipped up to a froth by greedy lawyers, to the tragic, which damaged patients sometimes find hard to pursue; but all of them are hugely expensive and a big distraction. The legal costs can dwarf the actual damages awards and they very frequently deter health authorities from challenging questionable claims.

Claims should first go to mediation or arbitration with some right of appeal to an ombudsman. The ombudsman’s decision would be binding but in turn he or she could, if a case was thought to be particularly serious or of public importance, refer the matter to the courts.

There are good precedents for legally binding arbitration, and the ombudsman system is well-established and highly regarded. But in any case the principles of reconciliation and escalation would be a big advance on the damaging adversarial process we now have. And it could save the NHS a ten figure sum each year.

Meanwhile a Bill which promises to free us from unnecessary restraint, and is riding the surf of a brilliant publicity campaign, misses the big picture to solve a problem which is largely just one of perception.


Saatchi debate March 2015