Category Archives: Heart Disease

Brain tree: why we replenish only some of our cells | Daniel Glaser

We are being treated to a spectacular display of autumn colour this year, but it isn’t only trees that share this pattern for periodic shedding and regrowth. Our own skin cells, for example, are renewed every month or so, but we replenish less than 10% of our bone each year. Certain types of human cells do not seem to regenerate at all and this includes brain cells. With a few exceptions (such as the hippocampus), we are born with all the brain we’ll ever have. Over childhood and into adolescence, extensive pruning of the connections between cells takes place. This neural topiary shapes all the systems of the brain. But once into adulthood, although some new connections are formed, the main structural change is the steady death of our brain cells.

Many aspects of life cause our cells to die off, including trauma, drug use, environmental pollutants, strokes… and that’s before we start on age-related diseases such as Alzheimer’s. Yet the quality of our brain function doesn’t decline for most of adulthood. Maybe as our cells decrease we learn to adapt, picking up tricks to help us to make the best of what we’ve got.

Dr Daniel Glaser is director of Science Gallery at King’s College London

Brain tree: why we replenish only some of our cells | Daniel Glaser

We are being treated to a spectacular display of autumn colour this year, but it isn’t only trees that share this pattern for periodic shedding and regrowth. Our own skin cells, for example, are renewed every month or so, but we replenish less than 10% of our bone each year. Certain types of human cells do not seem to regenerate at all and this includes brain cells. With a few exceptions (such as the hippocampus), we are born with all the brain we’ll ever have. Over childhood and into adolescence, extensive pruning of the connections between cells takes place. This neural topiary shapes all the systems of the brain. But once into adulthood, although some new connections are formed, the main structural change is the steady death of our brain cells.

Many aspects of life cause our cells to die off, including trauma, drug use, environmental pollutants, strokes… and that’s before we start on age-related diseases such as Alzheimer’s. Yet the quality of our brain function doesn’t decline for most of adulthood. Maybe as our cells decrease we learn to adapt, picking up tricks to help us to make the best of what we’ve got.

Dr Daniel Glaser is director of Science Gallery at King’s College London

Cross-party MPs request urgent non-partisan debate on future of NHS

Ninety MPs including several senior Tories have urged Theresa May to launch a cross-party convention on the future of the NHS and social care in England.

Sarah Wollaston, chair of the Commons health committee, organised a letter in conjunction with the Liberal Democrat former care minister Norman Lamb and Labour’s former shadow care minister Liz Kendall, that has been sent to the prime minister and the chancellor, Philip Hammond.

The MPs say the health system has been failing patients and they call on Hammond to ensure any moves to lift the public sector pay cap for NHS workers is not funded by raiding existing health budgets.

The signatories, one-third of whom are Conservative MPs, have said only a non-partisan debate can deliver a “sustainable settlement”. They say the failure of normal party politics to secure the future of the system means a non-partisan approach is the only way to ensure action is taken, particularly given that the government does not command a majority.

“The need for action is greater now than ever,” say the MPs, who include about 30 former ministers. “We understand that fixing this is immensely challenging and involves difficult choices.

“We all recognise, though, that patients and those needing care are too often failed by a system under considerable strain. We believe that together we owe a duty of care to the people of this country to confront the serious challenges to the NHS and the social care system.”

The Tory signatories include the former education secretary Nicky Morgan, the former international development secretary Andrew Mitchell, George Freeman, a former policy adviser to May, and the party grandee Sir Nicholas Soames.

The Labour MPs who have signed include Kendall, Chuka Umunna, Hilary Benn, Frank Field and Caroline Flint. Liberal Democrats signatories include the party leader, Sir Vince Cable, as well as Ed Davey and Tim Farron.

In a series of tweets Wollaston said:

Sarah Wollaston (@sarahwollaston)

. Govt also needs to focus on the long term, stop planning for health & social care in separate silos as this approach is setting us up for failure. Finance & workforce need urgent attention for the here & now but also for the long term & MPs from all Parties ready to engage

November 18, 2017

Sarah Wollaston (@sarahwollaston)

Current plans to kick social care into the long grass (again) & to separate planning for young and older adults creates even further fragmentation . Essential to think about whole system of NHS & Care

November 18, 2017

In the letter, MPs argue that only a cross-party NHS and social care convention where there can be a non-partisan debate can ensure a long-term settlement.

This was echoed by Wollaston in further comments in which she said: “The simple reality of a hung parliament means that all our constituents will be failed if long-term plans for NHS and [social] care funding do not command cross-party support.”

She added: “It’s better to take a joint approach to planning from the outset and actually deliver.”

Although MPs recognised that the challenge facing the government involved making difficult choices, they say “patients and those needing care are too often failed by a system under considerable strain”.

Lamb said: “Tribal politics has failed to provide a solution to the existential challenges facing the NHS and social care. We know that the current situation is unsustainable, and these pressures will only get worse as we contend with an ageing population and rising demand for care and treatment.

“This letter shows the strength of cross-party support for a new approach based on cooperation instead of political point-scoring. The fact that so many senior MPs and former cabinet ministers support this initiative is remarkable. Now the government must act on it.”

Kendall said: “Our population is ageing, more people need help and support and our care services desperately need more money to cope, yet any party that comes up with a significant proposal for funding social care risks their political opponents destroying them.

“We could carry on like this for yet another parliament, and yet another election, or we could face up to reality: we will only get lasting change if we secure a cross-party approach.”

According to NHS England chief executive, Simon Stevens, the fall per head in NHS funding means the health service will not be able to meet its routine waiting-time commitments.

Representatives from the Nuffield Trust, Health Foundation and King’s Fund said this year that austerity combined with increasing demand for services had created a “mounting toll on patient care”. They said there was growing evidence that access to some treatments was being rationed and that quality of care in some services was being diluted.

Solving the problem would mean a “steadily increasing share of national income would need to be spent on providing these services,” they said.

The UK spends 9.9% of GDP on the health budget – a considerably lower percentage than many other European nations.

Niall Dickson, chief executive of the NHS Confederation, which represents various organisations in the healthcare system, said promises to reform funding were being “kicked down the road”.

He said: “The government promised reform before the election, then said there would be a green paper before Christmas. Now it has been put off until summer next year – and even then we are not being promised firm commitments.”

A government spokesperson said: “We have announced a cross-government green paper on care and support for older people with input from a group of independent experts. We recognise that there is broad agreement across parliament that reform for social care is a priority and look forward to hearing a range of views.”

They said MPs would be consulted on social care before the green paper policy statement next year. The government had already provided an additional £2bn to social care over the next three years, the spokesperson said, adding that the government was committed to making the sector sustainable.

‘It tears every part of your life away’: the truth about male infertility

James and Davina D’Souza met and fell in love in their early 20s. They got married five years later, and three years afterwards had saved enough to buy a family home in a quiet cul-de-sac in London. Then, when Davina was 29 and James 33, they started trying for a baby.

“I knew that the moment we bought a home, we’d start a family,” Davina tells me in their living room, beside shelves crammed with framed photos of nieces, nephews, cousins and siblings. “My parents live down the road, and if I needed help to raise a child, my mum would be here.”

“We thought about all of that stuff,” James adds. “The job, the future, the house, the home: we make things happen.”

But after a year of trying, nothing had happened. Davina went to their GP, who referred her for the kind of invasive tests that have become the norm for women who experience problems conceiving: she had an internal, transvaginal scan to check her womb for fibroids, and an HSG test, where dye was pushed into her fallopian tubes to see if they were blocked. Everything looked normal.

It was only then that anyone suggested testing James. He had his semen analysed, and was told that only 1% of his sperm were formed normally. Still, it only takes one, the consultant said. She told them not to worry and to carry on trying. Two years after Davina came off the pill, James was tested again. This time, he had no normally formed sperm at all.


Male sperm counts in the western world have declined by almost 60% in 40 years

“My first thought was, ‘Oh, it’s my fault,’” James says, quietly. He stares at the coffee table through his thick-framed glasses. “I felt helpless. No one was talking about this stuff. You’d go online and there was no male conversation. I’d Google ‘problems having a baby’ or ‘fertility issues’, and the websites that came up were all pink. I’d post in a forum and women would respond on behalf of their husbands. There was nothing for men.”

Though he may have felt it, James is not alone. Across the western world, men are facing a fertility crisis. A landmark study by the Hebrew University of Jerusalem, published in July, showed that among men from Europe, North America and Australia, sperm counts have declined by almost 60% in less than 40 years. Fertility specialists have described it as the most robust study of its kind (the researchers came to their conclusions after reviewing 185 previous studies involving 43,000 men from across the globe) and the findings are stark. Such a significant decline in male reproductive health over a relatively short period in such a specific population suggests there’s something in the way we live now that means it’s much harder for men to become fathers than a generation ago.

***

Until recently, the focus of both fertility experts and research scientists has been overwhelmingly on women’s bodies, while male reproductive health has been almost ignored. For decades, the average age of both fathers and mothers has been increasing, but it’s women who have felt the pressure of balancing the need to invest in their careers with the so-called “timebomb” of their own declining fertility. They have been encouraged to put family first and to change their lifestyles if they want to become mothers, at the same time as male fertility appears to have fallen off a cliff.

Davina says the consultant gynaecologist who was treating her and James had no hesitation about next steps. “She said, ‘James’s sperm results are in, and we think you should go for IVF.’ That was it. The NHS didn’t have any other options for us.” Indeed, the NHS couldn’t even fund any IVF in their area at that time, so they had to scrape the money together to go private. They spent more than £12,000 on two rounds of IVF, and were finally offered a third round on the NHS this year. But after nearly seven years of trying for a baby, they are still childless.

“IVF takes a huge physical, hormonal and emotional toll – on a woman,” James tells me. “Sometimes I felt totally powerless, ineffective. I questioned my masculinity, my sense of myself as a man, through those rounds of IVF.” During consultations, James felt the conversations were always directed at Davina. “I felt like I had to say, ‘I’m here.’ I’d deliberately ask a question to make my presence felt.”

On their first round of IVF, someone at the clinic recommended James take a vitamin supplement. It was the first time lifestyle factors had been mentioned. “That was when I realised, maybe there is something I can do,” he says between slurps of his own blend of bulletproof coffee (made with grass-fed butter, coconut oil and egg yolk). James, head of sixth form at a local school, is a fan of self-help books. He’s been on a high-fat, low-carbohydrate ketogenic diet for months and says it’s done him good: he’s slim and spry, but says he wasn’t always this way. He’s wearing a digital fitness tracker. But as someone who rarely drinks, has never smoked and doesn’t ride a bike, there were few lifestyle changes he could make, beyond taking colder showers and wearing looser underwear. Still, his sperm quality has improved.

At the moment, the couple’s fertility problems are unexplained. They decided against adoption when social workers said they’d have to use contraception during the process, because it wouldn’t be fair on an adopted child to move into a home with a new baby, and they aren’t prepared to stop trying just yet.

“We’ve talked about when we’re going to call it a day,” James says.

Davina glances at him with wet eyes. “It makes me sad to think we’ll be putting a cap on it.”

“But it regularly comes up,” he says. “We did actually say at the end of this year we’ll stop. I’ve been asking, ‘Why do we want to have children?’ We’ve decided it isn’t going to define us.”


I was horrified by the lack of investigation and appropriate management of male infertility, so I started my own clinic

“There is treatment for male infertility, but it’s certainly not in the fertility clinic,” says Sheryl Homa, scientific director of Andrology Solutions, the only clinic licensed by the Human Fertilisation & Embryology Authority to focus purely on male reproductive health in the UK. “Men are channelled from their GP with a semen analysis and sent straight to a gynaecologist in an IVF clinic. But gynaecologists are interested in the female reproductive tract.”

A former clinical embryologist, Homa once led IVF laboratories in both the private and public sectors. “I was quite horrified by the lack of investigation and appropriate management of male infertility,” she says, “so I decided to start my own clinic specifically to focus on male fertility diagnosis and investigation.” Male reproductive health is being assessed through semen analysis, which she argues has “a very poor correlation” with fertility. Instead of having their detailed medical history taken and a full physical examination, men are being given a cup and asked to produce a sample.

Homa says the leading cause of male infertility (around 40%) is varicocele (a clump of varicose veins in the testes). “It can be determined from a physical exam, and can certainly be ruled out by an ultrasound scan. All women get ultrasound scans; why aren’t men getting them?”

Varicoceles can be repaired by fairly simple surgery under local or general anaesthetic, leading to a significant improvement in a couple’s chances of successful natural or assisted conception. But many are going undiagnosed. “The NHS is carrying out far too many IVF treatments when they could be saving money by doing proper investigations in men.”

Homa says there is also some evidence linking “silent infections” – those with no symptoms, such as chlamydia in men – with delayed conception and an increased risk of miscarriage. But if a man is judged by his semen sample alone, there would be no way of addressing these hidden concerns.

Apart from saving the NHS money, there are important medical reasons why men should be thoroughly examined, Homa argues. “Semen parameters are a marker of underlying systemic illness: they might have diabetes, they might have kidney disease, they might have cardiac problems. It could be something much more serious that’s contributing to the problem.”

As for the possible reasons for falling sperm counts across the west, Homa mentions “all the chemicals and pesticides that we are exposed to in our environment”, as well as smoking, rising levels of obesity and increasingly sedentary lifestyles. But at the moment, ideas such as these – including hormones in the water and BPA in plastics that might mimic the effect of oestrogen inside the body – are just theories that make intuitive sense. In the absence of widespread research over time, no one can pinpoint exactly which factor or combination of factors is making the difference.

In the 10 years her clinic has been operating, Homa has seen demand for her services steadily rise. She says she gets “the fallout” from men who’ve been sent by their GP for multiple rounds of fertility treatments that fail, when IVF should be the last resort. But at the moment, National Institute for Health and Care Excellence (Nice) guidelines give GPs no option but to refer men with fertility problems to IVF clinics. “If there’s a female problem, the GP will refer them to a gynaecology clinic. If there’s a male problem, they need to be referring to a consultant urologist who deals with male infertility. But it’s just not happening.”

Gareth Down with his son, Reece


Gareth Down and his wife, Natalie, went through 10 rounds of IVF before their son, Reece, was born. Photograph: Harry Borden for the Guardian

In some ways, Gareth Down and his wife, Natalie, were lucky: they knew from the start that their problems conceiving were probably down to Gareth, because he had had surgery to remove benign lumps on his testes as a teenager, and always feared they might interfere with his chances of becoming a father. But after 10 cycles of IVF that cost them tens of thousands of pounds, and several miscarriages, “lucky” doesn’t feel like the right word.

“I always wanted kids,” says Gareth, 31. “My mum was a childminder, and I was brought up looking after kids, so from as young as I can remember, we’ve had a house full of them.” He and Natalie started trying for a baby six months before their wedding in 2010, and went to the GP a year later, when nothing had happened. Gareth was referred to a urologist, who confirmed that the surgery he’d had as a teen had affected his sperm production, and that he had azoospermia: a zero sperm count.

The Downs were determined to have children, but trying almost broke them. “It invades every part of your life,” Gareth says. “On a personal level, you have to confront the fact that you might not have a family. It affects you financially, as you try and save to fund the treatment. We had family fallouts because we couldn’t see newborn nieces and nephews – we just couldn’t be around babies. We changed jobs because time off with certain employers was difficult. I had quite a customer-facing job at one point, and when they were telling me about their problems, I was thinking, ‘You ain’t got problems.’” He pauses. “I don’t think there was any part of who we were that we held on to by the end. It tears just about every part of your life away.”

Gareth has just put his 16-month-old son, Reece, to bed while Natalie is still at work. Reece was conceived with donor sperm, on their 10th round of IVF, when Natalie had had enough of the heartache of fertility treatment and was convinced they should give up. After going through so much to have him, their first feeling when Reece was finally born was not joy, but disbelief. “It was surreal,” says Gareth. “I don’t think either of us could accept it was real and going to last. We’d had so many ups and downs that we couldn’t believe nothing bad was going to happen. We kept checking the cot to see if he was still there. It was weeks before we realised he was not going to be taken away from us.”


If any other part of your body wasn’t working properly, you’d seek advice. Slowly, those barriers are coming down

It was during their final attempt to have a baby that Gareth set up his closed, men-only Facebook group, Men’s Fertility Support. Over the years, Natalie had found a lot of comfort online, from forums and support pages to Facebook groups, and was surrounded by an international community of women going through the same experience. Gareth had tried to contribute in the same places, but never stuck around long. “There were no other men there to relate to what you were saying, or make you feel you could say what you meant – and that it wouldn’t be taken the wrong way by an audience that vastly outnumbered you.”

The 300 or so members of his group are a diverse mix of men, mostly from the UK. Some are just beginning to have problems with conception, others went through it decades ago; some never had a happy ending and are there to share their experiences that a life beyond trying to have a family is possible. Many members say it’s the only place they can be totally honest: the belief that the ability to father children is a marker of masculinity has left many unwilling to talk about their issues anywhere else.

“We do get women wanting to join,” Gareth tells me with a smile, “but we want a degree of privacy. It’s about having freedom to talk, to say, yes, those [IVF] hormones really do screw her up and it’s really tough. You need to be able to vent somewhere without causing offence to anyone you know.”

Everyone Gareth and Natalie told about their problems conceiving assumed the issue must be hers. “Every step of the way it was, ‘Poor Nat – what’s going on with her?’” But he hopes that men are starting to seek help. “If it was any other part of your body that wasn’t working properly, you’d seek advice. Slowly, those barriers are beginning to come down a bit.”

He wonders whether the new figures on declining sperm counts could have been coloured by this growth in awareness: fertility treatments are more in demand than ever, so more men are having their fertility investigated. “Are we just testing more, looking into things more?” he asks. “If you had fertility problems 40 years ago, you wouldn’t have wanted to confront it or had anywhere to go with it.”

Dr Xiao-Ping Zhai, the fertility specialist behind the Zhai Clinic, agrees. “We never really tested men in the past, and if you use the word ‘decline’, you have to have something to compare it to. In the past, people probably had problems, didn’t want to say they had problems, and didn’t have children.” Even though the Hebrew University of Jerusalem study is the best piece of research we’ve had so far, she points out, the data from 40 years ago is still very thin.

Trained both in western and traditional Chinese medicine, Zhai has a unique perspective on fertility treatment and, since she opened her Harley Street clinic more than 20 years ago, claims she’s had a great deal of success in helping couples conceive – even though many patients come to her out of desperation rather than faith in traditional medicine. It’s mainly women who call to make the appointments. “Eighty per cent of the time, the partner doesn’t even want to come along. They don’t think they have a problem.”

Rather than look at sperm counts, Zhai takes a full health MOT of all her patients, using diagnostics from Chinese medicine to find out which part of the body needs to be addressed: “You find that a lot of people have something that can’t be discovered on a scan or through mechanical investigation – what we’d call a functional problem.” Zhai offers a range of treatments according to the patient’s specific constitution, including acupuncture, herbal supplements and advice on lifestyle changes and diet. None of this is cheap: an initial consultation costs £250, and a four-week course of bespoke herbal supplements can cost up to £350.

But IVF treatment on Harley Street costs even more, and Zhai says many of her patients arrive in the consulting room having already spent “lots of money. It’s to do with the culture here: in the UK, if a man has a problem, then the woman needs IVF.” IVF clinics can offer only what they specialise in.

In 2014, Zhai launched a national campaign to end the stigma attached to male infertility and improve the treatment choices offered to men. She called for a full parliamentary debate on male fertility issues, and on health secretary Jeremy Hunt to work with doctors to improve practice and treatment pathways for men within the NHS. But there has been no debate and no change in NHS strategy. “There are too few options for infertile patients,” Zhai says. “It will take a long, long time to overcome this culture.”

Gary Parsons


The doctor who rang with Gary Parsons’ sperm count results simply said it was ‘game over’. Photograph: Harry Borden for the Guardian

Gary and Kim Parsons went to their GP two years after Kim stopped taking the pill, when there was still no sign of pregnancy. “She went through all the regular tests – blood tests and then more invasive examinations – and everything came back A-OK,” says Gary, 36, from his home in Burnham-on-Sea. “Then it was my turn.” Like James, Gary had no physical examination and was asked only to produce a sample to check his sperm count. “That came back as a big fat zero. There was nothing to count.”

When the doctor rang to deliver the results, he said it was “game over”. Gary blinks in disbelief when he tells me this. “I really didn’t need any encouragement to feel more down about things, so that was an unfortunate turn of phrase.” Gary thinks this may have been because it was a conversation between men. “That extreme, direct way of communicating might have been the only way he thought he could get me to understand that this is not something where I could drink a kale smoothie and everything would be OK.”

Still, that’s what Gary tried, at first. Or, rather, he turned to vitamin supplements and a high-protein diet in the hope they could help. “I’m a vegetarian, so for a second I thought, ‘Oh no, I’m one of these anaemic, lentil-based stereotypes.’” But, ultimately, he knew this probably wouldn’t help because his count wasn’t low – it was zero. “There was nothing to improve. That’s the thing I’ve found hardest. Most problems I’ve had in my life I’ve overcome with either bloody-mindedness or effort, and that’s not this,” he says, shaking his head. “That’s not this.”

Gary’s infertility remains unexplained. The next step is for him to have a testicular sperm extraction procedure, to find out if he’s producing sperm that are being blocked, which could potentially be extracted for use in assisted conception. Three years after they started trying for a baby, this will be the first time he will be examined beyond blood tests and semen samples.

Without Gareth Down’s Facebook group, it would have been hard to find someone to talk to. Gary is a counsellor, and when he looked at who was registered with the British Infertility Counselling Association, the professional body for fertility counsellors in the UK, he found that the 46 registered practitioners were all women. Emotional support provision for men is “glaring in its absence”, he says. “It’s just a case of, ‘On your bike, son. Get on with it.’”

The way that men are treated as the secondary partner in infertility treatment could have worrying consequences, he says. “All the paperwork goes through the female. Everything is done through my wife. In meetings, it’s been very rare that I’ve even been able to get any eye contact from a consultant so far. It occurred to me that, should my wife leave me, I would have no mechanism for resolving this, or getting any questions answered, and that would have an impact in terms of maybe meeting someone new, or even knowing if I’m able to be a parent one day.”


Sperm production is a more complex process to understand than the menstrual cycle, and we haven’t done enough research

Edinburgh University professor Richard Sharpe, an expert in sperm count and male fertility, believes the University of Jerusalem study’s findings should be taken very seriously. “If something is having that big an effect – something in our environment, diet, lifestyle, and we don’t know what it is – what else might it be doing to us? We think of sperm counts as a fairly crude barometer of overall male health. It’s a warning shot across our bows.”

Sharpe has been specialising in male infertility for 25 years, but even he can offer only general hypotheses about what could have made sperm counts fall by 60% in little over a generation. He thinks diet and lifestyle are much more likely to be contributory factors than environmental chemicals such as pesticides, plastics and hormones in the water, because the evidence that they could induce such striking effects at low levels of exposure is unconvincing. But our understanding of the normal process of sperm production is “very poor, completely superficial”, he says. “It’s a much more complex process to understand than the menstrual cycle, and we haven’t done enough research.”

There is a chance that women might ultimately be behind the sudden drop in sperm count, Sharpe believes. His work has looked at the link between rates of maternal smoking and the use of painkillers during pregnancy, and the reduced sperm counts of sons in adulthood. A baby boy’s testes are formed during the first trimester, when many women don’t know they’re pregnant, and the period immediately after their formation is critical for the production of testosterone. What we are seeing now could be the expression of a generational problem: the fact that, since the 1970s, women are more likely than ever to smoke and take over-the-counter painkillers.

But, again, the evidence isn’t strong enough. “There are four studies that all show a significant association between maternal smoking and reduction in sperm counts in male offspring, so it’s plausible,” he says, “but it can’t explain the 60% fall, because not so many women smoke and smoke heavily.” A longitudinal study, over 20 years, would be needed to demonstrate the effects of maternal lifestyle on male fertility, but long-term research projects are inherently difficult to get funding for, unless public bodies think the issue is critically important. “Male fertility is not considered a high-priority issue, partly because there’s this perception that it’s a problem solved by assisted reproduction. That’s not treatment of the underlying issue behind male infertility. It’s simply ignoring it.”

We may be sleepwalking into a future where we become increasingly dependent on assisted reproduction, Sharpe argues, without fully understanding the long-term consequences of the technologies we’re relying upon. Researchers have already demonstrated in animals that it’s possible to make sperm out of other kinds of cell. “People are going to do this in humans – not in the UK, initially, but they will somewhere in the world. Those techniques are going to be applied in the fertility clinic, but we don’t have the knowledge to do it in a truly informed way, to know that it’s all safe, that there are no consequences.”

Whatever the reasons for our underinvestment in male fertility – lack of funding and research, male pride or the overemphasis on women in fertility treatment – it has huge implications for both men and women. “We’re flying blind to a large extent, and so far we’ve been ridiculously lucky,” Sharpe says. “It’s a perfect storm, at every level.”

Commenting on this piece? If you would like your comment to be considered for inclusion on Weekend magazine’s letters page in print, please email weekend@theguardian.com, including your name and address (not for publication).

Use carrot and stick to tackle obesity crisis | Letters

The UK is the “most obese nation in western Europe” (Report, 11 November), and there is widespread agreement that a range of measures is required to address this problem. One such measure, the government’s proposed sugar tax on soft drinks, should therefore be commended, especially since it introduces the concept of using price policies to promote healthier eating. However, the policy is likely to be more effective if the stick of the sugar tax is balanced by a carrot of subsidies on fruit and vegetables, increased consumption of which protects against numerous disorders – notably heart disease, stroke and bowel cancer – and is likely to limit the rise in obesity. As the WHO pointed out in its 2015 report Using Price Policies to Promote Healthier Diets, “Taxes on sugar-sweetened beverages and targeted subsidies on fruit and vegetables emerge as the policy options with the greatest potential to induce positive changes in [food] consumption”. However, as the WHO says, extra government intervention will likely be required to bring the price of fruit and veg down to a level everyone can afford and provide the maximum benefit to all. This will require more research on price policy strategies of how to spend the tax on sugar-containing drinks – something which was not the remit of the government’s adviser, Public Health England.
Henry Leese
Windermere, Cumbria

Your report says correctly that the government’s childhood obesity strategy was heavily criticised “for its reliance on voluntary action by the food and drink industry and lack of restrictions on the marketing and advertising of junk food”. It was also criticised for making no reference to breastfeeding, or to the current inadequate restrictions on marketing and advertising of breastmilk substitutes that contravene the WHO code. Obesity begins in infancy, and it is no accident that the breastfeeding rate in Britain is among the lowest in Europe.
J Peter Greaves
London

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No, there hasn’t been a human ‘head transplant’, and there may never be

In February 2015, Sergio Canavero appeared in this very publication claiming a live human head will be successfully transplanted onto a donor human body within two years. He’s popped up in the media a lot since then, but two years and nine months later, how are things looking?

Well, he’s only gone and done it! As we can see in this Telegraph story from today, the world’s first human head transplant has been successfully carried out. Guess all those more timid neurobods who said it couldn’t be done (myself included) are feeling pretty foolish right now, eh?

Well, not quite. Because if you look past the triumphant and shocking headlines, the truth of the matter becomes very clear, very quickly. In the interest of full disclosure, I do not know Dr Sergio Canavero, he’s done nothing to me directly that I’m aware of. However, I’m now seriously doubting his motivations. I’ve discussed my reasons for this elsewhere before now, but here they are again in one place for ease of reading.

Monster, Monster1931: British actor Boris Karloff lowers his eyes as the Monster in a promotional portrait for director James Whale’s film, ‘Frankenstein’. (Photo by Hulton Archive/Getty Images)


Even the fictional Dr Frankenstein had a better success rate. Photograph: Hulton Archive/Getty Images

These “successful” procedures are anything but

Many of Canavero’s previous appearances in the media have been accompanied by claims of successful head transplant procedures. But, how are we defining “successful” here? Canavero’s definition seems to be extremely “generous” at best.

For instance, he recently claimed to have “successfully” performed a head transplant on a monkey. But did he? While the monkey head did apparently survive the procedure, it never regained consciousness, it was only kept alive for 20 hours for “ethical reasons” and there was no attempt made at connecting the spinal cord, so even if the monkey had survived long-term it would have been paralysed for life. So, it was a successful procedure, if you consider paralysis, lack of consciousness and a lifespan of less than a day as indicators of “success”.

There was also his “successful” rat head transplant, which involved grafting a severed rat head onto a different rat, a living one that still had its head. Exactly how this counts as a “transplant” is anyone’s guess. It’s adding a (functionally useless) appendage onto an otherwise healthy subject.

And this recent successful human head transplant? It was on corpses! Call me a perfectionist if you must, but I genuinely think that any surgical procedure where the patients or subjects die before it even starts is really stretching the definition of “success” to breaking point. Maybe the procedure did make a good show of “attaching” the nerves and blood vessels on the broad scale, but, so what? That’s just the start of what’s required for a working bodily system. There’s still a way to go. You can weld two halves of different cars together and call it a success if you like, but if the moment you turn the key in the ignition the whole thing explodes, most would be hard pressed to back you up on your brilliance.

Perhaps the techniques used to preserve the heads and attach them have some scientific value, but it’s still a far cry from the idea of someone wandering around with a fully functional body that isn’t the one they were born with. Canavero seems to have a habit of claiming barnstorming triumph based on negligible achievements, or even after making things much worse. He seems to be the neurosurgical equivalent of the UK Brexit negotiating team.

Note Pad With White Pages and Pen. Isolated on WhiteAMGFCK Note Pad With White Pages and Pen. Isolated on White


You’d expect copious details when it comes to performing a successful head transplant. Thus far, they’re strangely absent. Photograph: Alamy

The crucial details are strangely overlooked

The human body is not modular. You can’t swap bits around like you would Lego blocks, take a brick from castle and put it onto a pirate ship and have it work fine. There are copious obstacles to contend with when linking a head to body, even when they’re the same person’s. Doctors have, in recent years, “reattached” a severely damaged spinal cord in a young child, but the key-word is “damaged”, not “completely severed”; there’s enough connection still to work with, to repair and reinforce. And this is with a young child, with a still-developing nervous system better able to compensate. Even taking all this into account, and the advanced state of modern medicine, the successful procedure was considered borderline miraculous.

So, to attach a completely severed spinal cord, a fully developed adult one, onto a different one, one that’s maybe been dead for days? That’s, what, at least four further miracles required? And that’s not to take into account immune rejection, the fact that we don’t really know how to “fix” damaged nerves yet (let alone connect two unfamiliar halves) and the issue that everyone’s brain develops in tune with their body. The latter point means the “interface” between the two is relatively unique. You put the head of musician on the body of a builder, it may well prove to be like trying to play an Xbox game on a PlayStation. Except, infinitely more traumatic.

We don’t know for certain of course, because nobody has ever tried it. Canavero seems convinced he can do it, but thus far he’s offered no feasible explanation or science for his claims to be able to overcome these hurdles, beyond some token stuff about preserving tissues and ensuring blood supply during procedures. That’s a bit like someone claiming they can build a working fusion reactor and, when asked how, explains how they’re going to plumb in the toilets for the technicians. Arguably a useful step, but clearly not the main issue here.

TED X Brooklyn Event Karl Chu speakingBYR6N4 TED X Brooklyn Event Karl Chu speaking


TED Talks. Slick, inspiring, interesting, not exactly peer-reviewed. Photograph: Alamy Stock Photo

Hype before substance

I’ve said this before, even in a Wired article about Canavero’s previous claims, to the extent where I am considering trademarking it as “Burnett’s law”. Simply put; if someone’s making grand scientific claims but hasn’t provided robust evidence for them, yet they have done a TED talk, alarm bells should be ringing.

I don’t know what Canavero’s confidence is based on. Nobody seems to. He hasn’t published anything that would warrant it thus far. Note his recent “successful” human head transplant claims, which you can read about in the Telegraph before he’s published the actual results, as stated in the article.

Why do that? Why tell the newspapers before you tell your peers? If your procedure is rigorous and reliable enough, the data should reflect that. When scientists, particularly self-styled “mavericks”, court publicity but desperately avoid scrutiny, that’s never an encouraging sign.

Going by the Telegraph article, Canavero claims that the next step will be to attempt a transplant with someone in a vegetative state or similar. He also claims to have plenty of volunteers for this. Exactly how coma patients actively volunteered for this radical procedure is anyone’s guess.

There’s no mention yet of attempting it in a conscious person, despite there being actual volunteers for that. I strongly suspect there never will be. Trying it with a conscious, thinking person means it absolutely has to be 100% effective for them to remain in this state after the transplant is done. This would mean finding workable solutions to all the considerable obstacles presented by the very concept of a head transplant.

If I’m wrong about this then I’ll gladly take back everything and apologise, but nothing Canavero has said or done thus far leads me to think he has any idea about how to do this.

Dean Burnett is fully aware that the procedure should logically be called a “body transplant” but that’s not how it’s usually described, so has used the more common terms. His book The Idiot Brain is available now, in the UK and US and elsewhere.

No, there hasn’t been a human ‘head transplant’, and there may never be

In February 2015, Sergio Canavero appeared in this very publication claiming a live human head will be successfully transplanted onto a donor human body within two years. He’s popped up in the media a lot since then, but two years and nine months later, how are things looking?

Well, he’s only gone and done it! As we can see in this Telegraph story from today, the world’s first human head transplant has been successfully carried out. Guess all those more timid neurobods who said it couldn’t be done (myself included) are feeling pretty foolish right now, eh?

Well, not quite. Because if you look past the triumphant and shocking headlines, the truth of the matter becomes very clear, very quickly. In the interest of full disclosure, I do not know Dr Sergio Canavero, he’s done nothing to me directly that I’m aware of. However, I’m now seriously doubting his motivations. I’ve discussed my reasons for this elsewhere before now, but here they are again in one place for ease of reading.

Monster, Monster1931: British actor Boris Karloff lowers his eyes as the Monster in a promotional portrait for director James Whale’s film, ‘Frankenstein’. (Photo by Hulton Archive/Getty Images)


Even the fictional Dr Frankenstein had a better success rate. Photograph: Hulton Archive/Getty Images

These “successful” procedures are anything but

Many of Canavero’s previous appearances in the media have been accompanied by claims of successful head transplant procedures. But, how are we defining “successful” here? Canavero’s definition seems to be extremely “generous” at best.

For instance, he recently claimed to have “successfully” performed a head transplant on a monkey. But did he? While the monkey head did apparently survive the procedure, it never regained consciousness, it was only kept alive for 20 hours for “ethical reasons” and there was no attempt made at connecting the spinal cord, so even if the monkey had survived long-term it would have been paralysed for life. So, it was a successful procedure, if you consider paralysis, lack of consciousness and a lifespan of less than a day as indicators of “success”.

There was also his “successful” rat head transplant, which involved grafting a severed rat head onto a different rat, a living one that still had its head. Exactly how this counts as a “transplant” is anyone’s guess. It’s adding a (functionally useless) appendage onto an otherwise healthy subject.

And this recent successful human head transplant? It was on corpses! Call me a perfectionist if you must, but I genuinely think that any surgical procedure where the patients or subjects die before it even starts is really stretching the definition of “success” to breaking point. Maybe the procedure did make a good show of “attaching” the nerves and blood vessels on the broad scale, but, so what? That’s just the start of what’s required for a working bodily system. There’s still a way to go. You can weld two halves of different cars together and call it a success if you like, but if the moment you turn the key in the ignition the whole thing explodes, most would be hard pressed to back you up on your brilliance.

Perhaps the techniques used to preserve the heads and attach them have some scientific value, but it’s still a far cry from the idea of someone wandering around with a fully functional body that isn’t the one they were born with. Canavero seems to have a habit of claiming barnstorming triumph based on negligible achievements, or even after making things much worse. He seems to be the neurosurgical equivalent of the UK Brexit negotiating team.

Note Pad With White Pages and Pen. Isolated on WhiteAMGFCK Note Pad With White Pages and Pen. Isolated on White


You’d expect copious details when it comes to performing a successful head transplant. Thus far, they’re strangely absent. Photograph: Alamy

The crucial details are strangely overlooked

The human body is not modular. You can’t swap bits around like you would Lego blocks, take a brick from castle and put it onto a pirate ship and have it work fine. There are copious obstacles to contend with when linking a head to body, even when they’re the same person’s. Doctors have, in recent years, “reattached” a severely damaged spinal cord in a young child, but the key-word is “damaged”, not “completely severed”; there’s enough connection still to work with, to repair and reinforce. And this is with a young child, with a still-developing nervous system better able to compensate. Even taking all this into account, and the advanced state of modern medicine, the successful procedure was considered borderline miraculous.

So, to attach a completely severed spinal cord, a fully developed adult one, onto a different one, one that’s maybe been dead for days? That’s, what, at least four further miracles required? And that’s not to take into account immune rejection, the fact that we don’t really know how to “fix” damaged nerves yet (let alone connect two unfamiliar halves) and the issue that everyone’s brain develops in tune with their body. The latter point means the “interface” between the two is relatively unique. You put the head of musician on the body of a builder, it may well prove to be like trying to play an Xbox game on a PlayStation. Except, infinitely more traumatic.

We don’t know for certain of course, because nobody has ever tried it. Canavero seems convinced he can do it, but thus far he’s offered no feasible explanation or science for his claims to be able to overcome these hurdles, beyond some token stuff about preserving tissues and ensuring blood supply during procedures. That’s a bit like someone claiming they can build a working fusion reactor and, when asked how, explains how they’re going to plumb in the toilets for the technicians. Arguably a useful step, but clearly not the main issue here.

TED X Brooklyn Event Karl Chu speakingBYR6N4 TED X Brooklyn Event Karl Chu speaking


TED Talks. Slick, inspiring, interesting, not exactly peer-reviewed. Photograph: Alamy Stock Photo

Hype before substance

I’ve said this before, even in a Wired article about Canavero’s previous claims, to the extent where I am considering trademarking it as “Burnett’s law”. Simply put; if someone’s making grand scientific claims but hasn’t provided robust evidence for them, yet they have done a TED talk, alarm bells should be ringing.

I don’t know what Canavero’s confidence is based on. Nobody seems to. He hasn’t published anything that would warrant it thus far. Note his recent “successful” human head transplant claims, which you can read about in the Telegraph before he’s published the actual results, as stated in the article.

Why do that? Why tell the newspapers before you tell your peers? If your procedure is rigorous and reliable enough, the data should reflect that. When scientists, particularly self-styled “mavericks”, court publicity but desperately avoid scrutiny, that’s never an encouraging sign.

Going by the Telegraph article, Canavero claims that the next step will be to attempt a transplant with someone in a vegetative state or similar. He also claims to have plenty of volunteers for this. Exactly how coma patients actively volunteered for this radical procedure is anyone’s guess.

There’s no mention yet of attempting it in a conscious person, despite there being actual volunteers for that. I strongly suspect there never will be. Trying it with a conscious, thinking person means it absolutely has to be 100% effective for them to remain in this state after the transplant is done. This would mean finding workable solutions to all the considerable obstacles presented by the very concept of a head transplant.

If I’m wrong about this then I’ll gladly take back everything and apologise, but nothing Canavero has said or done thus far leads me to think he has any idea about how to do this.

Dean Burnett is fully aware that the procedure should logically be called a “body transplant” but that’s not how it’s usually described, so has used the more common terms. His book The Idiot Brain is available now, in the UK and US and elsewhere.

What can Britain learn from the US on links between economic distress and poor health?

Theresa May, in her first speech as prime minister, stood on the steps of Downing Street and referred to the glaring injustice of gaps in life expectancy and declared her intention to solve it by governing for everyone. I had a moment of hope for concerted action to increase health equity. That’s not looking bright at the moment; the government’s attention is elsewhere.

For many young people in Britain today – what with student debts, rental costs, the decline in home ownership, the gig economy and the economic uncertainties of Brexit – times are challenging.

A 15-year-old boy expects to be immortal, but evidence shows that expectation is less justified in the UK than in more than a score of other countries. The probability that a 15-year-old boy will die before his 60th birthday is 85 out of 1,000 in the UK. Is that a lot? It is higher than the best, Switzerland, at 61 per 1,000.

The UK ranks 22nd among all 185 countries for which the World Health Organisation reports this measure. Not terrible, but worse than Spain, Italy, Malta, Singapore, the United Arab Emirates, the Maldives, the Nordic countries, the Netherlands and Japan.


The US has a disastrous level of health for young and middle-aged adults

My colleagues and I at University College London’s Institute of Health Equity recently drew attention to the fact that the rise of life expectancy in the UK has stalled – a much more marked slowdown than in other European countries. Most of that levelling off is because of deaths at older ages.

I want here to focus on younger adults. You may ask why I worry about 61 in Switzerland compared with 85 in the UK. It seems like a small difference. But these figures represent something deeper: the quality of social conditions, how we are doing as a society. In the UK, we are not doing so well.

The US is doing worse. It ranks 44th on the probability that a 15-year-old boy will die before his 60th birthday. Mostly, this is not due to healthcare issues. The US spends more on healthcare, per person, than any other country, but has a disastrous level of health for young and middle-aged adults.

It is worth focusing on the US because it may have lessons for the UK. Anne Case and Angus Deaton of Princeton University recently updated their 2015 report showing that there has been a big rise in mortality rates among non-Hispanic whites; a rise that that was not seen in Hispanics or African Americans. The causes: poisonings from drugs and alcohol – in part, caused by medical care, because of over-prescription of opioids; suicides; and chronic liver disease, which is commonly alcohol-related. This adds to the toll of violent deaths. Medical care will not address the underlying social angst that gives rise to these causes of death.

Two important features of this US mortality in non-Hispanic whites have lessons for the UK. First, the fewer the years of education, the steeper the mortality increase, thus contributing to increase in health inequalities.

Second, Shannon Monnat of Penn State University looked at the geographic distribution of deaths from drugs, alcohol and suicide (pdf), and found that the greater the economic distress of an area, the higher the mortality rate. Monnat found, in the industrial midwest particularly, the higher the rate of these deaths the greater the 2016 vote for Trump, compared with Romney four years earlier. Trump didn’t cause these deaths, but these deaths may have caused Trump. More precisely, economic distress led both to death by drugs, alcohol and suicide and a greater likelihood of voting Trump.

In the UK we do not have the same appalling toll of drug and alcohol deaths, but we do see higher mortality in areas of economic distress. People in those areas were more likely to vote Brexit – perhaps prompted by the same dissatisfactions that led to the Trump vote in the US.

There is, though, much that can and is being done at local level. In London, for example, there has been a sharp reduction in inequalities (pdf) between children from poor families and the average in early child development and educational performance.

Coventry has become a “Marmot city”. It has taken the recommendations from my 2010 health inequalities review, Fair Society, Healthy Lives, and is implementing the recommendations.

Elsewhere, in addition to dedicated doctors and nurses, occupational therapists are supporting older people to remain independent at home. In the West Midlands and Merseyside, fire services are, as they put it, improving lives to save lives; they use their time and community commitment to get young people active, look after their homes, support older people and engage with improving people’s social lives.

None of this should let central government off the hook. We need an end to austerity, a reversal of plans to make the tax and benefit system less progressive, and real attention to regional inequalities. But the action of dedicated professionals at local level is an inspiring example of what can be done.

  • Michael Marmot is professor of epidemiology at University College London. He will be speaking at the King’s Fund annual conference on 29 and 30 November 2017

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‘We are a force to be reckoned with’: voices of newly qualified nurses

‘I finish most shifts feeling guilty and remember things I didn’t have time to do’

Nursing isn’t what I expected it to be, there’s never enough time for patient contact which really saddens me. Nurses are now mainly office-based and have to delegate the patient contact to healthcare workers. I often class a good shift as one where I have managed to sit down and talk to someone who needed me. I finish most shifts feeling guilty and wake up in the middle of the night and remember things I didn’t have time to do. The stress of the job is unbelievable.

The pay conditions really anger me. Working in mental health can be a risky job where staff are assaulted and have to face quite a lot of abuse. I do not think it is fair that I only get paid around £10 an hour, which is a lot less than my friends who do low-level administration work in offices where they get paid to answer the phone. The government is relying on the good nature of nurses to continue doing their job because they care.
Kate Clayton, 15 months post-qualified, mental health nurse, Staffordshire

‘Nurses are a force to be reckoned with – I think that has become more prominent in recent years’

Before I began nursing I didn’t really see nurses as specialists or professors. It was only during my nursing studies and hospital placements that I began to realise the breadth of opportunities within nursing and the new found confidence nurses have. Nowadays we all work as a multidisciplinary team (MDT) and nurses work more closely with doctors and allied healthcare professionals. We, as nurses, are encouraged to speak up, ask questions and play a bigger part in the MDT and in our patients’ care plans. We also now have so many different opportunities for nurses like specialist roles, research and education. I think in the future we will see a lot more nurses going on to do the likes of PhDs and more specialist training. We are a force to be reckoned with and I think that has definitely become more prominent in recent years.
Bebhinn O’Dowd, 12 months post-qualified, critical care research nurse (specialising in major trauma), London

‘We are constantly working more hours than we should because it’s so short-staffed’

There is so much responsibility in modern nursing. You literally have people’s lives in your hands. It’s a big burden for a 22-year-old. Some older nurses have told me that in the past we would have been slowly fed into the system instead of being thrown in and immediately pushed to the limits. We are constantly working more hours than we ever should because it’s so short-staffed.


It seems more of an uphill battle to get what is deserved and to get the kind of respect nurses used to get

Liv Webster

Pay is of course something my friends and I rant about and some people who I studied nursing with have already changed their career path – we’re not even 18 months qualified. A lot are being pushed into private sectors and agency work so the NHS is losing valuable members of the team who can’t deal with the pay when they have families to support. Having said that I absolutely love my job and wouldn’t do anything else.
Ella Clarke-Billings, 14 months post qualified, surgical nurse, London

‘I didn’t realise the monumental amount of paperwork that nursing incorporated’

I went straight into the private sector due to more opportunity. I would have preferred to work for the NHS at the time but in my specialism I found it very hard to get into. I wanted to be a liaison nurse, which is a role to support people with a learning disability while they are in hospital, but people don’t seem to leave those jobs once they’re in them as they are so good to have. There is definitely more room for climbing the ladder in the NHS but that’s not what interests me. For me, getting the right healthcare for my service users and supporting them to have the best quality life they can is what’s most important. It’s why I wanted to become a nurse – to be the voice for those that couldn’t be heard and that’s what I can do in the company I work for.

I didn’t realise the monumental amount of paperwork that nursing incorporated. I definitely thought it would be more hands-on than it is. It seems more of an uphill battle to get what is deserved and to get the kind of respect nurses used to get, especially in my specialty which other health professionals seem to deem as useless. People don’t view learning disability nurses as proper nurses as we deal a lot with the social side and not just the medical side of care. I have even had family members joke that I’m not a proper nurse; when you aren’t given that level of respect it can really deflate you.
Liv Webster, 15 months post-qualified, learning disabilities nurse, Lichfield

‘Coming into nursing is different but it’s important to see it as a vocation rather than a job’

Nursing has certainly changed since I started in the early 1970s. The introduction of technology has had a big impact. I’ve seen the introduction of electronic health records, email and e-learning, and this kind of innovation has helped improve the practice of learning for the benefit of patients and carers. Many nurses had to adapt to the change and for some it was a difficult time as they did not have the computer skills required. For new nurses this will never be a problem as the way they study is academic and they have been brought up with technology.

But ultimately a good new nurse will have the same core skills and qualities, such as empathy and compassion, as when I trained. Coming into nursing now is different but it is even more important now that those entering see it as a vocation rather than a job. It is a hard career albeit rewarding.
Helen Smith, 41 years post qualified, mental health matron and ward manager, West Midlands

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The real saboteurs are the Tory Brexiters destroying the NHS | Owen Jones

Who are the real saboteurs? Is it those who want Brexit to be properly scrutinised by parliament to prevent a disastrous deal which could wreck the economy and shred social provision? Those were, after all, the saboteurs who needed crushing according to the Daily Mail when Theresa May called her calamitous snap election. Or are the real saboteurs those who – through bigotry, twisted ideological zealotry and outright stupidity – are damaging the fabric of the public services we all depend on?

Britain’s National Health Service is propped up by 12,000 doctors from the European Economic Area. Without them, our most treasured national institution – which brings us into the world, mends us when we are sick or injured, cares for us in our final moments – would collapse. So it should be of some concern to us, to put it mildly, that nearly half of them are considering leaving the country, and a fifth have already made actual plans to do so.

What a twisted irony. The leave campaigners made a calculated decision to win the EU referendum with a toxic mixture of lies and bigotry. One of the most striking falsehoods was an extra £350m a week for the NHS after we left: instead it’s being emptied out of desperately needed doctors.

And can you blame them for wanting to leave? We’ve now had years of vitriolic scapegoating of immigrants to deflect responsibility from the banks, the tax-dodgers, the unaccountable corporations, the poverty-paying employers, the rip-off landlords, the neoliberal politicians, and all the other vested interests who have unleashed misery and insecurity upon this country. The positive contribution of immigrants was all but banished from public discussion. The campaign reached a crescendo during the referendum, with immigrants variously portrayed as potential criminals, rapists, murderers and terrorists, validating every bigot in Britain and resulting in a surge in hate crimes on the streets. I wonder why European doctors don’t feel particularly welcome right now?

This is about the worst possible time to haemorrhage doctors. The NHS is enduring the longest squeeze in its funding as a proportion of GDP since its foundation; it’s being fragmented by marketisation and privatisation; it’s under growing pressure because of decimated social care budgets while citizens continue to live longer. Plunging morale – because of privatisation, staff shortages and cuts – is affecting all doctors, regardless of where they’re born: a recent study suggested two-thirds are considering leaving. The consequence? We’re having to look abroad for more doctors. This is a recurring irony of Conservative rule. After the first five years of the coalition government, drastic cuts to nurse training places led the NHS to look for one in four nurses abroad.

How have we allowed the bigots and xenophobes of our unhinged tabloid press and political elite to inflict so much damage? Rather than making our live-saving foreign doctors feel unwelcome, surely we should be focusing on how we can tax the booming wealthy individuals and big businesses so we can invest more in our NHS? It should be abundantly clear who the real saboteurs are. They have already inflicted incalculable damage to our social fabric, our public services, our economy, and our international standing. The question is: how do we prevent them from inflicting even more damage?

Owen Jones is a Guardian columnist