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The Oxford Companion to the Body Eds Colin Blakemore, Sheila Jennett Oxford University Press, £39.50, pp 753 ISBN 0 19 852403 X Rating: ★★★★
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irst things first: this book is a hugely good read, whether you are looking for something specific or just browsing. You will learn the most weird and wonderful facts—as well as sound and up to date science—about the human body, and answers to almost any question.
Drug War Heresies: Learning from Other Vices, Times, and Places Robert J MacCoun, Peter Reuter Cambridge University Press, £18.95, pp 496 ISBN 0 521 79997 X Rating: ★★★★
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very week seems to bring a new report on the failure of current drug policy. Rising levels of serious drug problems put new pressures on old systems that can barely cope anyway. Schools, psychiatric hospitals, and prisons continue to face fresh challenges. People from most walks of life have a view on drug policy and legalisation. The views are not easily cast along old left and right wing political lines. Europeans generally think that European drug policy has been more pragmatic and sensible that of the United States. Robert MacCoun and Peter Reuter are senior American policy analysts who have attempted over the past decade to bring 108
Published as an authoritative guide to every aspect of the body, the Oxford Companion is beautifully presented, offering a wealth of scientific and popular information in an entertaining way. Compiled by section editors with, quite obviously, an excellent sense of humour as well as expertise covering the whole range of physiological sciences and the humanities, the book contains over 1000 headwords, ranging from “conception to resurrection; from kiss to orgasm; from codpieces to pubic wigs; from blood clotting to blood letting; from fasting to farting.” The plate section at the end contains illustrations of the alimentary, cardiovascular, respiratory, lymphatic, musculoskeletal, nervous, endocrine, and urogenital systems. The most diverse selection of line drawings, modern and old black and white and colour photographs, and scientific sketches and images support the entries and round off the perfect package. The book’s focus is intended to be on normal bodily function; it is not conceived
as a guide to health or medical education. General categories of disease and a few medical conditions and abnormalities are represented, but then so are cultural inventions such as beauty contests, executions, funeral practices, sociology, and theatre. Also included are historical and contemporary approaches to diagnosis and treatment, in the context of different cultures and religions, and of “complementary” therapies, as well as medical practice based on “conventional” clinical sciences. It can take up literally hours just to leaf around, finding out all you ever wanted to know about Islam, Bobbitry (remember the man whose severed member spawned a thousand jokes?), body snatchers, brassieres, and so forth. This volume is perfect for browsing, simultaneously comprehensive and eclectic, and great fun!
some rationality and measured perspective to drug policy choices. They root the drug debate within the broader context of the control of other social behaviours, such as gambling and prostitution. They also consider the issues of tobacco and alcohol. Gambling was illegal in many places for much of the 20th century. However, in the 18th century lotteries were an important source of revenue for governments, universities (Harvard, Princeton, and Yale), and colonial administrations. Reports of social corruption and personal misery led to the prohibition of gambling. However, prohibition itself was in turn identified as an important source of police corruption. Nowadays alcohol, tobacco, and gambling products are sold in markets that are subject to only modest regulation. Once social reforms diminish the controls on a behaviour there is a striking pressure to continue to liberalise the approach. In the case of gambling, tobacco, alcohol, and possibly cannabis, the vested financial interests have a strong lobbying effect, working assiduously to ensure further reduction in state control. MacCoun and Reuter calculate that in several European countries cannabis users have on average a 3% chance of being arrested. Overall they conclude that the law is not much of a deterrent. Instead they explore the possibility that prohibition may have the “forbidden fruit effect” and actually increase young people’s interest in illegal substances.
This book is without doubt the most scholarly and significant contribution to what has become a passionate but circular debate. MacCoun and Reuter’s analysis and balanced interpretation of the international experience of cannabis policies is timely. One of the striking things about the international comparison is how weak the links are between different countries’ actual policies and the current levels of cannabis use. This may result from the fact that many of the policies on the statutes are not actually implemented. Therefore variation between different countries’ policies may be substantially less than is claimed. If you are looking for simple answers you won’t find them here. However, this book provides a framework for thinking through the different policies and it achieves a masterly level of even handedness—except, possibly, on the subject of heroin prescribing. Here the authors are lured into coming off the policy analysts’ fence and recommending further extension of heroin prescribing as part of the international treatment response. Heroin really is a seductive drug, even for policy makers. However, overall this is an experts’ expert book and it is likely to become the classic text on drug policy reform.
Birte Twisselmann BMJ
[email protected]
Michael Farrell senior lecturer, National Addiction Centre, Institute of Psychiatry, London
[email protected] BMJ VOLUME 325
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reviews
Shipman ITV1, 9 July at 9 pm Rating: ★★★
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YTV/CHAMELEON TV
t’s a brave screenwriter who attempts to create a drama out of something as recent and horrific as the Shipman killings. The grief is too raw, the pain too acute. Such a screenwriter runs the risk of being accused of much more than just poor taste. Barely has the earth been allowed to settle over the last of the exhumed graves, the charge may go, before along comes some television crew, digging up fresh agony for the people of Hyde in Greater Manchester, the epicentre of Dr Fred’s killing fields. How did he get away with it for so long? Why didn’t somebody raise the alarm earlier? What was it actually like to be treated by someone like Harold Fred Shipman, one of the most notorious mass murderers of modern times, and perhaps the most inscrutable? How did he speak and behave towards his victims in the minutes and seconds before he pumped the fatal dose of diamorphine into their bodies? These are the kind of questions you would expect a docudrama to pose; and yet these are the same questions that, if not handled sensitively, could cause extreme offence. Shipman, however, almost went out of its way not to offend anyone. From its Coronation Street style opening sequence— offering an aerial view of a grimy, industrial north west—to its final shots—the unfathomable face of Shipman in his prison cell, a police detective lighting candles in a church for each one of the victims—this was in danger of being tentative, anodyne television. That’s not to say that it wasn’t informative or even moving in parts. But it was neither a great documentary nor a powerful drama. And yet, maybe Shipman—understated and dignified as it was—was the best programme
James Hazeldine and James Bolam in Shipman
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that anyone could have made in the circumstances. Screenwriter Michael Eaton has made quite a name for himself in factual television drama. He wrote the acclaimed Shoot to Kill, about the Royal Ulster Constabulary shootings in Armagh, and Why Lockerbie? about events that led to the bombing of Pan Am flight 103. Writing in the Guardian newspaper last week (1 July) Eaton defined two kinds of docudrama: the genre that attempts to “review contentious, problematic moments of our collective public history . . . to expose hidden injustice.” Shoot to Kill fits into that category. And then there is the kind of docudrama, like Shipman, that “tries to shine a beacon on to some apparently well known case, to delve beyond the surface of newspaper headlines . . . to reveal the emotional impact real events actually have upon those participants caught up in them.” Rather than focusing on the crimes (the few we did see had something of the eerie, deadpan quality of a Crimewatch reconstruction about them), Shipman focused on the first whispered suspicions about the popular Dr Fred (everyone knew him by his middle name), and the painstaking police investigation and exhumations. Central to this was the character of Stan Egerton (well acted by James Hazeldine), one of the detectives in charge of the case and a Hyde resident, who knew personally some of those who were caught up in the Shipman murders. It was through Egerton’s at times hostile clash with a patient community unable to comprehend that there could be anything untoward about their doctor, let alone that he could be guilty of murder, that one of the programme’s main themes—medical accountability—emerged. This wasn’t so much a community that was afraid to challenge the medical profession, but one that didn’t think it was right to do so. “It’s not for us to go around asking such things of a doctor,” said the local undertaker, dismissing his daughter’s suspicions over the high number of cremations among Shipman’s patients. “We are opening Pandora’s box,” said one of Stan’s colleagues at a crucial breakthrough in the investigation. Later, Stan reflected; “If you’ve got designs on becoming a mass murderer, you couldn’t get a better cover than general practitioner.” Shipman was definitely not murder served up as entertainment, but instead a work of legitimate social investigation, at times harrowing, at times somewhat dull. Perhaps the most difficult thing about it, probably for writer, producer, actor, and viewer alike, was the character of Shipman himself, played by former “Likely Lad” James Bolam. Shipman was the riddle at the centre of this docudrama—not only the riddle of why he killed, but also the riddle of what made him tick. Although Bolam may have convincingly combined elusiveness, arrogance, and (false?) bonhomie, the riddle, of course, remained unsolved. Trevor Jackson BMJ
[email protected]
NETLINES d Within the Obgyn.net website (“The universe of women’s health”), a useful page at www.obgyn.net/displayppt.asp allows visitors to download PowerPoint presentations. Several subspecialties are identified, and each of these sections contains a downloadable presentation with a brief description. Even if the subject matter is not of interest, sometimes it is helpful and even inspiring to see how other people assemble their presentations. If you don’t have access to the PowerPoint programme, there is a link for access to a free viewer. d The home page of the Health and Medical Informatics Digest (http://academic.son.wisc.edu/hmid/ home.htm) proudly proclaims that it has been helping surfers since 1995. In terms of internet history that is a long time, so it may be worth checking out the database. Like all good collections, this resource can be interrogated by searching on simple words (using Google’s famed engine) or just by looking at the catalogue, split into major subject categories. This is a fine and accessible collection and worth a visit. d Self help groups are an incredibly useful resource—many patients find them beneficial and supportive. But health professionals sometimes just don’t know what and where these groups are. Sure, a search engine could help locate them, but now—for UK doctors at least—there could be an easier solution to hand, and that is www.ukselfhelp.info. This is a simple alphabetical listing to the website or telephone number of a self help group. This is a great collection to know about. d Email is often used to transmit documents, images, and information. It has also been used for a while now to distribute newsletters, and one—on the subject of health technology—that is worth checking out can be found at www.headstar.com/futurehealth. The archive is available to view if you like it, follow the instructions to set up a free subscription for future editions. d Doctors need to know what effect diseases and disorders might have on patients’ fitness to drive. Now online help is available at www.dvla.gov.uk/ at_a_glance/content.htm. This is an authoritative resource from the UK based DVLA (Driving and Vehicle Licensing Agency). There are chapters on cardiovascular and neurological topics, and there is also an index of relevant medical conditions. The whole document is downloadable as a PDF.
Harry Brown general practitioner, Leeds
[email protected] We welcome suggestions for websites to be included in future Netlines. Readers should contact Harry Brown at the above email address.
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Death Channel 4, Tuesdays at 9 pm, 2 to 30 July Rating: ★★★★
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itles don’t come much more in your face than Death. This may, of course, deter some people, but this is a powerful and moving series. The first images that flashed before viewers’ eyes were those of corpses in coffins, funerals, and ashes being scattered. We know exactly where this series is headed. The vogue for “reality TV” is now entrenched, but TV doesn’t get more real than these five programmes, which follow 12 terminally ill people through their final months. The oncologists in the first programme struck me as a caring, hardworking bunch. They knew the limits of their specialty and were honest without being brutal. They set out the options and tried to give some idea of the balance between risk and benefit. If ever I need an oncologist, Dr Mark Bower will be up there with some of my colleagues—I would call him on the basis of his humane approach to his patients.
However, at one stage the stoical Nora was told: “We can either concentrate on shrinking the tumour or on controlling your symptoms.” Whoa, doc! You can do both, you know. Why do coffin lids have nails? To stop oncologists giving more chemotherapy, so the joke goes. Yet it became clear that the demand for chemo came from the patients. “You just want to bash on,” said Liz, a woman with ovarian cancer who parted with £7000 of her savings in order to bash on with paclitaxel (Taxol). When the cancer progressed she went for a phase I trial. The chemo was stopped four days before her death. The bashing on had clearly taken its toll. Her partner looked drained by the whole process. Nora, a devout Catholic, wasn’t ready for the Lord just yet and stuck it out into her ninth decade. Louise, a young woman with a brain tumour, knew when to say no and have time with her husband and daughter. If you thought a programme about terminal cancer might be grim, nonmalignant senescence is also there as a contender. That was the subject of the second programme in the series. It is a mark of both our success and our failure as a health service that the number of elderly patients is growing—they are surviving what used to kill them, so that the incidence of degenerative disease is increasing. We get through our
Growth hormone We have known about growth hormone for many years. Its
WEBSITE OF THE WEEK
Navin Chohan editor, studentBMJ nchohan@ bmj.com
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natural role in growth and maintaining body mass is well documented. As a study (p 70) and an editorial (p 58) in this week’s BMJ show there is interest in its use to treat potentially stunted growth. There has been little research into the effect of growth hormone therapy on adult height and the internet reflects this. Although there are a few good sites about growth hormone therapy for adults, these are likely to be of more use to general practitioners looking for somewhere to direct worried patients than to paediatricians and other specialists, who are likely to be already familiar with much of the information. One such site, which contains a concise account of growth hormone physiology and use, is http://arbl.cvmbs.colostate.edu/hbooks/pathphys/ endocrine/hypopit/gh.html. This site is actually part of an online textbook produced by Colorado State University in the United States and there are also sections on other hormones and diseases. The site is still being built so there are some pieces of information lacking. Another stop for information on pathologies and treatments in adults regarding human growth hormone is http://neurosurgery.mgh.harvard.edu/ e-f-944.htm, a site based at Harvard University and maintained by the Neuroendocrine Clinical Centre and Pituitary Tumor Centre. If your patients still want to know more, why not try The Pituitary Foundation? www.pituitary.org.uk/sitemap.shtml takes you to the foundation’s colourful homepage, where there are clear links to sections on human growth hormone deficiencies and replacement therapies. It’s worth noting that human growth hormone isn’t only used for growth problems. Patients are becoming ever more informed and they may ask you about the use of growth hormone in a strictly non-medical setting. For example, some companies now offer the promise of “rapid weight loss, younger looking skin, feeling revitalised and increased sexual potency.” You can visit www.flyhost.net/betterhealth to get an idea of the kind of things patients might want to know about. How exactly a “wrinkle reduction of 61%” is proven is unclear but the use of human growth hormone precursor for such things is apparently based on a study published in the New England Journal of Medicine in 1990 (http://content.nejm.org/cgi/content/abstract/323/1/1).
CHANNEL 4
reviews
Stoical: Nora
cancer and heart disease only to face arthritis, dementia, and osteoporosis. So we watched Norman and Mrs B cope with the vicissitudes of life in a nursing home. In a few decades the population pyramid will be turned on its head—there will be legions of us declining slowly. The third programme in the series, “You’re Better Off With Cancer” (to be broadcast next Tuesday), compares and contrasts the treatment of Keith and Den. Keith has advanced colon cancer, Den has endstage heart failure. The genuine injustice of the disparity of services offered to Keith and Den is clear. Endstage heart failure carries a worse prognosis than many cancers, and it was obvious that no one knew when to say “Stop!” with each admission to coronary care. Yet the contrast and the rhetoric are overplayed—meaningful specialist palliative care is far from universal for patients with cancer: those who get it are still the “elite dying.” The striking thing about this series is the intimacy with death. The filming is never intrusive, even in the last hours. There is a sense of care about how people’s final stages are portrayed. The dying and their carers have a voice and can speak for themselves. This is not new ground—among others, journalist John Diamond covered it in his columns in the Times and his book C. Because Cowards Get Cancer Too—but Death is about ordinary people. Their very ordinariness is what makes them representative of so many others. The subjects are followed over two years, which anyone doing research with the dying will tell you is some achievement. Later programmes complete the collection by focusing on uncertainties of prognosis and on bereavement. Death is followed in the schedules by the inanity-fest that is Big Brother. I couldn’t care less whether PJ or Kate gets evicted from the house after seeing Liz, Nora, and Louise face eviction from their own lives. If tears don’t come to you through the course of this series, there may be something wrong with your emotional apparatus. If you are not moved to do more about the unrelieved suffering of dying patients, there is something seriously wrong. Paul Keeley SIGN research fellow Beatson Oncology Centre, Glasgow
[email protected] BMJ VOLUME 325
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reviews
PERSONAL VIEW
SOUNDINGS
Pipe dreams
The royal touch
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Here in Auchendreich we are accustomed to the presence of royalty but never take it for granted. So the usual meticulous preparations, combined with exceptional May sunshine, ensured that the opening of the new Auchendreich Royal Infirmary was the highlight of the recent jubilee tour of Scotland. Setting aside minor damage to the brand new royal Bentley in an incident with a JCB still working on the approach to the grand entrance, the whole thing seems to have gone off remarkably well: not least the last minute change of route necessitated by the sudden ingress of sewage into the MRI suite. The only slightly untoward aspect of the 17 minute visit arose when royal enjoyment of a tableau vivant representing Auchendreich nurses at work in uniforms dating from 1872 to the present day was threatened by a picket-line of more than 50 angry WRVS volunteers. Royal visits remain a vibrant part of NHS life in Scotland, and in their afterglow we go about our business with new resolve and good cheer; although we would be the first to admit that our long awaited one-site PFI acute re-provision has not been without its minor hiccups. With the local difficulties in the MRI suite resolved, and similar issues in neonatal intensive care being tackled with an expertise acquired over several such incidents, we are now getting on with the work of providing world class health care for all who need it. The imaginative purchase of a not-quite-derelict barracks complex—once the HQ of the long-disbanded Princess Marina’s Own Auchendreich Fusiliers—gives us hope in tackling the challenge of delayed discharge. And the arrival of a team of German orthopods in a deal that includes six Portakabins and an inflatable operating theatre means that our 1999 waiting list targets will now be met in 2003. The WRVS problem remains. Their feelings are strong but—in the PFI environment—irrelevant. Only one unit in our much admired retail mall was still to let, and they were bidding against both our former chaplaincy—now the PFI’s choral/spiritual entertainment cost centre—and Starbucks; and in the fair and open competition that characterises the modern NHS, Starbucks won hands down. So, like the chaplain, the WRVS must now get real, think serious flag days and big coffee mornings, and try again in the next bidding round. We wish them well.
established as a bane in the life of every arts icture a hospital corridor stretching coordinator. But if trolleys, say, are such a big out into the distance with, at regular problem, then why not use art to solve that intervals, ward doors leading off to the problem? How about redesigning or decoratright. The corridor is dominated by heavy ing the trolleys or their immediate environpipes, suspended from the ceiling, running its ment, perhaps seeing the trolleys themselves whole length. At intervals, their course as mobile works of art, or design the wall as a becomes confused—merging, separating, specific backdrop to the trolleys? then merging again, like railway lines passing Every so often, art gets damaged; people through a hideously complicated junction. are not perfect. Sometimes the damage is I am in this corridor—one of a group of deliberate and, if this is a persistent problem, health professionals and artists, refugees art should look to its own solutions. Why not from a local health and arts conference. We invite a physical response to the art, incorpoare listening, with varying degrees of concenrate graffiti as an essential element, or make tration, to an earnest member of the hospital some parts removable? Maybe make more staff as he draws our attention to a series of temporary works of art, give it away bit by bit fairly undistinguished woodcarvings, or make it “shuffleable”? mounted on the wall adjaI am not arguing that art cent to each ward entrance. The value of the in health should be limited Unfortunately, however to interior design, architecattractive the carvings arts in health ture, or environmental art. might be in their own right, needs to be There has, and always will be, and however subtly the an essential place for indiartists have incorporated recognised at all vidual works. But the setting references to the name of levels must be respected, and this each ward, here they are may mean more than its visual or physical overwhelmed, and overwhelmed totally, by aspects. As important are the social conditheir environment—inevitable losers in an tions, and the professional needs of staff. unequal struggle. Whoever thought that this Hospitals can also be places where we could be a fair contest was dreaming: pipe (patients, relatives, staff, visitors) learn about dreams indeed! health; they do not have to be mere body I also have pipe dreams, but my dreams workshops where we go for repairs or spare foresee the time when art will be used more parts. Most health professionals would agree sensibly, in partnership with the immediate (their training invariably emphasises health surroundings, to the benefit of both. Why promotion), but they are rarely supported didn’t the artist make the pipes the practically in this aim by the buildings in centrepiece of the work? Why not celebrate which they work or the materials provided. their form and presence? OK, so there are noticeboards in some waitIn recent years there has been considering areas and corridors, with leaflets yellowable interest in how health settings can be ing discreetly. There may even be racks of improved through the use of the arts. Howfree leaflets. But how often do you see ever, despite the best efforts of many artists, anyone read the leaflets or take them off the work has often been simply added to already racks? To make the transition from body unsatisfactory situations in the hope that the shop to health education requires imaginaart would offer some salvation. Using the tion and commitment. arts as a sticking plaster to cover up health Art can be beautiful in its own right, and blemishes is, at best, risky and, at worst, a it can beautify otherwise ugly surroundings. clear waste of time and money. But this should not be the limit of our ambiThere is a tendency for hospital managtions. Encouraging thoughtfulness about ers, arts coordinators, and artists themselves health and illness needs new approaches, to want to see and commission discrete art different kinds of spaces, and marriages works: objects of beauty that can be owned, between odd bedfellows. Partnerships prized, and shown off to visitors (and which between hospitals and the art sector can may increase in value too). As often as not, create unusual opportunities and promote the impact of the work is so diminished it a more reflective community. becomes embarrassing—awkward and out of The value of the arts in health needs to be place. Aesthetically and financially dubious, recognised at all levels and at all stages—in this approach strengthens the perception of designs for new hospitals, staff development the arts as something separate from the programmes, links with community organisa“real” function of the hospital or clinic. tions, care planning for patients. In too few There is another way, but it requires us to places are the arts being integrated in imagitake a step backwards, to rethink the native and inventive ways. relationship between arts and health. Trolleys parked in front of expensive Terry Smyth head of faculty of music, arts, and murals or mosaics, staff who seem indifferent health, Colchester Institute, Colchester, and pathway to the art they have around them, vending leader: MA in health and the arts
[email protected] machines, vandalism—each of these is well BMJ VOLUME 325
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Colin Douglas doctor and novelist, Edinburgh
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