Tag Archives: Death

Care failings contributed to death of woman in prison, inquest finds

A jury at the inquest of Sarah Reed, a mentally ill prisoner at HMP Holloway who took her life at the jail last year, has identified serious shortcomings in her care.

Reed was in prison awaiting medical reports about whether she was mentally fit to plead after being charged with assaulting a nurse in a secure psychiatric unit. The reports found she was unfit to plead, but Reed killed herself three days before they were due to be completed.

The jury concluded that Reed, 32, killed herself at a time when the balance of her mind was disturbed, but they were unsure whether she had intended to do so. They said a failure in management of her medication and the failure to conclude the fitness to plead assessment in a timely manner contributed to her subsequent death.

They also had concerns about suicide and self-harm report monitoring and believed that Reed did not receive adequate treatment in prison for her high levels of distress.

Deborah Coles, director of Inquest, a charity providing expertise on state-related deaths, condemned the fact that Reed was in prison at all, given her serious mental illness.

“Sarah Reed was a woman in torment, imprisoned for the sake of two medical assessments to confirm what was resoundingly clear, that she needed specialist care not prison. Her death was a result of multi-agency failures to protect a woman in crisis. Instead of providing her with adequate support, the prison treated her ill mental health as a discipline, control and containment issue,” Coles said.

The jury delivered its narrative verdict at the inquest at City of London coroner’s court after hearing almost three weeks of evidence before the assistant coroner Peter Thornton QC.

Reed was found dead on her bed at HMP Holloway, north London, on 11 January 2016. The prison closed last summer. She had a ligature around her neck made from a bed sheet.

Shortly before her death Reed had been top of a list of inmates waiting to be transferred to hospital. A letter to the Central and North West London healthcare NHS trust to start the process of getting her transferred to hospital was sent three days before her death.

In 2016 there were 22 deaths in women’s prisons in England and Wales – the highest number of female prison deaths since 1990. According to Ministry of Justice statistics, within the female prison estate there were 10 self-inflicted deaths at a rate of 2.6 per 1,000 prisoners in the year to March 2017. This was double the rate of 1.3 per 1,000 prisoners across both the male and female estates.

Coles added: “Serious mental health problems are endemic in women’s prisons, with deaths last year at an all-time high. They continue because of the failure of the governments to act. The legacy of Sarah’s death and the inhumane and degrading treatment she was subjected to must result in an end to the use of prison for women.

“The state’s responsibility for the deaths like Sarah’s goes beyond the prison walls and extends to failure to invest in specialist mental health services for women and provide alternatives to custody. More deaths will occur until we stop criminalising people in mental health crisis and invest in specialist community services for women.”

The inquest heard Reed was on remand for 90 days after she was charged with the assault on a psychiatric nurse in October 2015.

Prison officers and medical staff in C1, the prison’s mental health assessment wing, gave her a “low risk” rating despite writing in her records that day: “She is completely psychotic, aggressive towards staff, making comments about god and the devil. She started rolling around in the bed and screaming.”

Reed had been suffering from serious mental ill health since the death of her six-month old baby in 2003. She suffered from paranoid schizophrenia, emotional unstable personality disorder and an eating disorder. She spent many years in and out of mental health institutions and prisons.

Anti-psychotic medication she had previously been taking had been stopped on medical advice because of fears it could cause a heart attack.

Fellow prisoners gave evidence that she had complained about being bullied and one inmate heard her call out “they are going to kill me” and said she was becoming increasingly paranoid and was too ill to be in prison.

In a statement read out by the coroner at the opening of the inquest, Reed’s mother, Marylin Reed, paid tribute to her daughter. “Sarah was adored and loved by the whole of her family. She was very much treasured. Her death has been devastating for us.”

Care failings contributed to death of woman in prison, inquest finds

A jury at the inquest of Sarah Reed, a mentally ill prisoner at HMP Holloway who took her life at the jail last year, has identified serious shortcomings in her care.

Reed was in prison awaiting medical reports about whether she was mentally fit to plead after being charged with assaulting a nurse in a secure psychiatric unit. The reports found she was unfit to plead, but were not due to be finalised until three days after Reed killed herself.

The jury concluded that Reed killed herself at a time when the balance of her mind was disturbed, but they were unsure that she intended to do so. They said a failure in management of her medication and the failure to conclude the fitness to plead assessment in a timely manner contributed to her subsequent death. They also had concerns about suicide and self-harm report monitoring and believed that Reed did not receive adequate treatment in prison for her high levels of distress.

Deborah Coles, director of Inquest, a charity providing expertise on state-related deaths, condemned the fact that Reed was in prison at all, given her serious mental illness.

“Sarah Reed was a woman in torment, imprisoned for the sake of two medical assessments to confirm what was resoundingly clear, that she needed specialist care not prison. Her death was a result of multi-agency failures to protect a woman in crisis. Instead of providing her with adequate support, the prison treated her ill mental health as a discipline, control and containment issue,” Coles said.

The jury delivered its narrative verdict at the inquest at City of London coroner’s court after hearing almost three weeks of evidence before assistant coroner Peter Thornton QC.

Reed, 32, was found dead on her bed at HMP Holloway in north London on January 11 last year. The prison closed last summer. She had a ligature around her neck made from a bed sheet. Shortly before her death Reed was top of a list of inmates waiting to be transferred to hospital. A letter to the Central and North West London healthcare NHS trust to start the process of getting her transferred to hospital was sent three days before her death.

In 2016 there were a total of 22 deaths in women’s prisons in England and Wales – the highest number of female prison deaths since 1990. According to Ministry of Justice statistics, within the female prison estate there were 10 self-inflicted deaths at a rate of 2.6 per 1,000 prisoners in the year to March. This was double the rate of 1.3 per 1,000 prisoners across both the male and female estates.

Coles added: “Serious mental health problems are endemic in women’s prisons, with deaths last year at an all-time high. They continue because of the failure of the governments to act. The legacy of Sarah’s death and the inhumane and degrading treatment she was subjected to must result in an end to the use of prison for women.

“The state’s responsibility for the deaths like Sarah’s goes beyond the prison walls and extends to failure to invest in specialist mental health services for women and provide alternatives to custody. More deaths will occur until we stop criminalising people in mental health crisis and invest in specialist community services for women.”

The inquest heard Reed was on remand for 90 days after she was charged with the assault on a psychiatric nurse in October 2015.

Prison officers and medical staff in C1, the prison’s mental health assessment wing, gave her a “low risk” rating despite writing in her records that day: “She is completely psychotic, aggressive towards staff, making comments about God and the devil. She started rolling around in the bed and screaming.”

Reed had been suffering from serious mental ill health since the death of her six-month old baby in 2003. She suffered from paranoid schizophrenia, emotional unstable personality disorder and an eating disorder. She spent many years in and out of mental health institutions and prisons.

Anti-psychotic medication she had previously been taking had been stopped on medical advice because of fears it could cause a heart attack.

Fellow prisoners gave evidence that she had complained about being bullied and one inmate heard her call out “they are going to kill me” and said she was becoming increasingly paranoid and was too ill to be in prison.

In a statement read out by the coroner at the opening of the inquest, Reed’s mother, Marylin Reed, paid tribute to the daughter she lost. “Sarah was adored and loved by the whole of her family. She was very much treasured. Her death has been devastating for us.”

Dementia and Alzheimer’s main cause of death for women, says Public Health England

Alzheimer’s disease and dementia are the biggest cause of death among women, according to a government report on the state of the nation’s health.

Public Health England (PHE)’s report, which uses population health data to produce a wide-ranging national report for the first time, suggests that while life expectancy has been steadily increasing – now 79.5 years for men and 83.1 years for women – more of those extra years are now spent in poor health.

Women can expect to live nearly a quarter of their lives in ill-health and men a fifth. The causes of death have shifted since the turn of the century, the analysis found, with the rise in deaths from dementia and Alzheimer’s the most significant features – alongside declines in other diseases.

Cause of death – women

“Since 2001, death rates from heart disease and stroke have halved for both males and females,” the report said. “Over the same time deaths from dementia and Alzheimer’s have increased by 60% in males and have doubled in females.”

In 2015, heart disease was the most common cause of death among men, but Alzheimer’s and dementia are now the most likely among women. These diseases are better diagnosed, while the prevention and treatment of heart disease have improved.

The report prompted warnings that investment in dementia research must not slow. Dr Matthew Norton, director of policy at Alzheimer’s Research UK, said: “To achieve the same successes as we have with other health conditions like heart disease and cancer, we need dementia research to remain a national priority. We have been able to make promising steps forward, thanks to a renewed focus, but we are not there yet.”

Cause of death – men

The PHE report also sheds light on the ailments that afflict people in earlier years. Lower back and neck pain are the biggest cause of ill-health in England, while obesity is the biggest risk factor for becoming unwell.

Where you live and how you live make a big difference to the likely length of your life and chances of good or poor health. Men and women in the most deprived areas can expect to spend 20 years fewer in good health compared with those living in the least deprived areas.

The PHE director of health improvement, John Newton, said: “For both men and women, almost half the population live in areas where healthy life expectancy is slightly less than the current state pension [age]. It is a slightly larger proportion of men than women … [but] a significant proportion of our population cannot expect to live in their pension age in good health.”

Diabetes, most of which is type 2 and linked to being overweight, has for the first time become one of the top 10 causes of ill-health and disability. The bill has been predicted to potentially cripple the NHS, which spends £14bn a year on testing and treatment.

Leading cause of morbidity

But lower back pain and neck pain are ranked ahead of diabetes. Part of that is down to the ageing population, but excess weight and lack of activity are also factors.

Among men, skin disorders, such as acne and psoriasis, are the second most common cause of ill-health, although they are three times less common than lower back and neck pain. Third among men and second among women is depression.

Lifestyle, poverty and education all make a difference to health. Among the medical risks are being overweight or obese and having high cholesterol. High BMI (body mass index, a measurement of obesity) can lead to heart disease, stroke, osteoarthritis, back pain, chronic kidney disease, diabetes and some cancers.

“Behavioural risks include smoking, alcohol and unsafe sex, while environmental and occupational risks include air pollution, unclean water and other risks due to the working or living environment,” said the report.

Dementia and Alzheimer’s main cause of death for women, says Public Health England

Alzheimer’s disease and dementia are the biggest cause of death among women, according to a government report on the state of the nation’s health.

Public Health England (PHE)’s report, which uses population health data to produce a wide-ranging national report for the first time, suggests that while life expectancy has been steadily increasing – now 79.5 years for men and 83.1 years for women – more of those extra years are now spent in poor health.

Women can expect to live nearly a quarter of their lives in ill-health and men a fifth. The causes of death have shifted since the turn of the century, the analysis found, with the rise in deaths from dementia and Alzheimer’s the most significant features – alongside declines in other diseases.

Cause of death – women

“Since 2001, death rates from heart disease and stroke have halved for both males and females,” the report said. “Over the same time deaths from dementia and Alzheimer’s have increased by 60% in males and have doubled in females.”

In 2015, heart disease was the most common cause of death among men, but Alzheimer’s and dementia are now the most likely among women. These diseases are better diagnosed, while the prevention and treatment of heart disease have improved.

The report prompted warnings that investment in dementia research must not slow. Dr Matthew Norton, director of policy at Alzheimer’s Research UK, said: “To achieve the same successes as we have with other health conditions like heart disease and cancer, we need dementia research to remain a national priority. We have been able to make promising steps forward, thanks to a renewed focus, but we are not there yet.”

Cause of death – men

The PHE report also sheds light on the ailments that afflict people in earlier years. Lower back and neck pain are the biggest cause of ill-health in England, while obesity is the biggest risk factor for becoming unwell.

Where you live and how you live make a big difference to the likely length of your life and chances of good or poor health. Men and women in the most deprived areas can expect to spend 20 years fewer in good health compared with those living in the least deprived areas.

The PHE director of health improvement, John Newton, said: “For both men and women, almost half the population live in areas where healthy life expectancy is slightly less than the current state pension [age]. It is a slightly larger proportion of women than men … [but] a significant proportion of our population cannot expect to live in their pension age in good health.”

Diabetes, most of which is type 2 and linked to being overweight, has for the first time become one of the top 10 causes of ill-health and disability. The bill has been predicted to potentially cripple the NHS, which spends £14bn a year on testing and treatment.

Leading cause of morbidity

But lower back pain and neck pain are ranked ahead of diabetes. Part of that is down to the ageing population, but excess weight and lack of activity are also factors.

Among men, skin disorders, such as acne and psoriasis, are the second most common cause of ill-health, although they are three times less common than lower back and neck pain. Third among men and second among women is depression.

Lifestyle, poverty and education all make a difference to health. Among the medical risks are being overweight or obese and having high cholesterol. High BMI (body mass index, a measurement of obesity) can lead to heart disease, stroke, osteoarthritis, back pain, chronic kidney disease, diabetes and some cancers.

“Behavioural risks include smoking, alcohol and unsafe sex, while environmental and occupational risks include air pollution, unclean water and other risks due to the working or living environment,” said the report.

Dementia and Alzheimer’s main cause of death for UK women

Alzheimer’s disease and dementia are the biggest cause of death among women, according to a government report on the state of the nation’s health.

Public Health England (PHE)’s report, which uses population health data to produce a wide-ranging national report for the first time, suggests that while life expectancy has been steadily increasing – now 79.5 years for men and 83.1 years for women – more of those extra years are now spent in poor health.

Women can expect to live nearly a quarter of their lives in ill-health and men a fifth. The causes of death have shifted since the turn of the century, the analysis found, with the rise in deaths from dementia and Alzheimer’s the most significant features – alongside declines in other diseases.

Cause of death – women

“Since 2001, death rates from heart disease and stroke have halved for both males and females,” the report said. “Over the same time deaths from dementia and Alzheimer’s have increased by 60% in males and have doubled in females.”

In 2015, heart disease was the most common cause of death among men, but Alzheimer’s and dementia are now the most likely among women. These diseases are better diagnosed, while the prevention and treatment of heart disease have improved.

The report prompted warnings that investment in dementia research must not slow. Dr Matthew Norton, director of policy at Alzheimer’s Research UK, said: “To achieve the same successes as we have with other health conditions like heart disease and cancer, we need dementia research to remain a national priority. We have been able to make promising steps forward, thanks to a renewed focus, but we are not there yet.”

Cause of death – men

The PHE report also sheds light on the ailments that afflict people in earlier years. Lower back and neck pain are the biggest cause of ill-health in England, while obesity is the biggest risk factor for becoming unwell.

Where you live and how you live make a big difference to the likely length of your life and chances of good or poor health. Men and women in the most deprived areas can expect to spend 20 years fewer in good health compared with those living in the least deprived areas.

The PHE director of health improvement, John Newton, said: “For both men and women, almost half the population live in areas where healthy life expectancy is slightly less than the current state pension [age]. It is a slightly larger proportion of women than men … [but] a significant proportion of our population cannot expect to live in their pension age in good health.”

Diabetes, most of which is type 2 and linked to being overweight, has for the first time become one of the top 10 causes of ill-health and disability. The bill has been predicted to potentially cripple the NHS, which spends £14bn a year on testing and treatment.

Leading cause of morbidity

But lower back pain and neck pain are ranked ahead of diabetes. Part of that is down to the ageing population, but excess weight and lack of activity are also factors.

Among men, skin disorders, such as acne and psoriasis, are the second most common cause of ill-health, although they are three times less common than lower back and neck pain. Third among men and second among women is depression.

Lifestyle, poverty and education all make a difference to health. Among the medical risks are being overweight or obese and having high cholesterol. High BMI (body mass index, a measurement of obesity) can lead to heart disease, stroke, osteoarthritis, back pain, chronic kidney disease, diabetes and some cancers.

“Behavioural risks include smoking, alcohol and unsafe sex, while environmental and occupational risks include air pollution, unclean water and other risks due to the working or living environment,” said the report.

Diarrhoea, vomiting, sudden death … cholera’s nasty comeback

Mohammad Shubo is motionless when he is wheeled into the clinic. He had started experiencing diarrhoea and vomiting that morning; by evening, he had no pulse.

In an effort to rehydrate him quickly, the nurses give Shubo an IV of saline solution. His reanimation seems almost uncanny – within half an hour he is able to sit up and speak. He spends the next two days at the hospital to rehydrate and convalesce before returning to his cramped quarters. If Shubo had arrived at the clinic just 10 minutes later he would have died, a nurse says.

For those who have been fortunate enough not to see the effects of cholera first hand, David Sack, a professor of international health at the Johns Hopkins University Bloomberg School of Public Health, says Shubo’s case, which appears on a 2011 Al Jazeera documentary, gives “a good sense of the disease”. Thousands of patients develop the same symptoms as Shubo did, though not all are as lucky. Sack recalls a case from Uganda in which a woman was hospitalised with symptoms of cholera, but the hospital staff didn’t diagnose her properly, even though there was a cholera treatment facility on the hospital grounds. She was not closely monitored and died of dehydration overnight. Cases like this should never happen, Sack says. But clearly they do.

John Snow, the doctor who traced the source of cholera outbreaks in London in 1854.


John Snow, the doctor who traced the source of cholera outbreaks in London in 1854. Photograph: Alamy

In some parts of the world, including Europe and the US, cholera is so rare that it seems to have been eradicated. Some may see it as an “old world” disease, gone the way of the plague and smallpox. But it continues to devastate communities elsewhere, sometimes to pandemic proportions – an outbreak is raging in Yemen, where more than 246,000 cases and 1,500 deaths have been reported.

“Cholera is a brutal infection,” says Jason Harris, an associate professor of pediatrics at Massachusetts General Hospital. “Patients can go from looking healthy to dying quickly with cholera. It’s a scary disease.”

In the mid-1800s, as cholera swept across nearly every continent and killed thousands, scientists rushed to understand the disease. In 1854, a British doctor, John Snow, undertook the first epidemiological study that determined water from a pump on Broad Street was sickening Londoners with cholera (he didn’t discover the true reason why, however – at the time the disease was thought to be spread by miasma, not microbes). Then in 1884, a German researcher, Robert Koch, studied the intestines of deceased cholera patients in Egypt and India, concluding that the comma-shaped bacteria Vibrio cholerae he found there was the cause of the disease.

The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832


The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832. Photograph: Print Collector/Getty Images

In the years since, scientists have figured out a lot more about the biology of cholera. Snow was correct: Vibrio cholerae is transmitted through contaminated water. Within as little as 12 hours or as long as five days, some people who have ingested the bacteria will start to show symptoms – uncontrollable vomiting and diarrhoea. But 80% of those who ingest the bacteria do not, possibly because of an existing immunity.

The scariest part of the disease, Harris says, is the sheer speed with which a patient can decline. If the condition isn’t treated quickly, people can die of dehydration within hours of showing symptoms.

Dr. Robert Koch (seated) with his assistant Dr. Richard Pfeiffer


German researcher Robert Koch (seated) with his assistant, Richard Pfeiffer. Photograph: Bettmann Archive

“The amount of fluid loss from diarrhoea and vomiting [in patients] is shocking. It’s hard to believe unless you see it,” Harris says. It can be up to a litre per hour. And more people excreting the bacteria into water sources means more get infected, and it’s not hard to see how just a handful of cases could quickly balloon into an outbreak (there have been seven pandemics over the past two centuries), which can last decades.

The last pandemic started in Indonesia in the 1960s and spread across Asia and Africa before coming to Europe in 1973. By 1991, it had spread to Latin America, which had been free of cholera for more than a century. Around 400,000 reported cases and 4,000 deaths were reported in 16 countries of the Americas that year.

These days the disease does not have to be a death sentence. Doctors know how to treat cholera effectively. If a patient can reach a clinic in time, the treatment is fairly straightforward. With a rapid infusion of fluids and antibiotics, they are usually back to normal in a few days. There is also a vaccine, which is taken orally and can prevent infection in about 60% of people.

But this apparent simplicity is deceptive; all this knowledge isn’t the same as stopping the disease. “The map of cholera cases is pretty much a map of poverty,” says Dominique Legros, the team lead of the cholera group at the World Health Organization. “We still have cholera in places like Yemen because people don’t have access to safe water.” People living in poverty may know that drinking polluted water can get them sick, but they don’t have an alternative.

“Because of inequality and a lack of access to safe water and sanitation, more than a billion people are still at risk [of cholera],” Harris says.

So outbreaks continue. In some places, such as Zambia and Uganda, they are predictable, starting every year with the rainy season. But often, outbreaks can’t be anticipated. There are factors that can make an outbreak more likely – natural disasters can scatter infected people to contaminate more water sources and war can close clinics that might have helped citizens receive treatment or inhibit the import of necessary medication.

Engraving by William Heath showing a lady discovering the quality of the Thames water. By the 1820s, public concern was growing at the increasingly polluted water supply


An engraving by William Heath showing a lady discovering the quality of the Thames’s water. By the 1820s, public concern was growing at the increasingly polluted water supply. Photograph: Science & Society Picture Library/Getty Images

But these factors are hardly predictive. After the 2010 earthquake, for example, American epidemiologists concluded that Haiti was at low risk of a cholera outbreak; just a few months later, an epidemic was raging, in part because UN peacekeeping forces accidentally introduced the bacteria.

Years of political turmoil are fuelling the epidemic in Yemen. The situation is dire – the WHO estimates that nearly 250,000 people had been infected by the end of June, almost doubling previous estimates based on academic models. WHO officials are working with other non-profits and what remains of the national healthcare system to bring treatment to rural clinics to help people get treatment more quickly. This week, the International Coordinating Group allocated one million cholera vaccines to be sent to Yemen.

A girl is treated for a suspected cholera infection in Sanaa, Yemen


A girl is treated for a suspected cholera infection in Sanaa, Yemen. Photograph: Hani Mohammed/AP

These strategies, along with education campaigns so people at risk of cholera know how to treat their water (by boiling, or with chlorine tablets), can reduce the incidence of the disease. But these advances don’t address the main problem: a lack of access to clean water. So the solution to eradicating cholera then, doesn’t lie in the health sector. “Yes, you need to treat patients and prevent death,” Legros says. “But the long-term solution is in the development sector – giving people long-term access to sanitation.”

There are some countries in which this may soon be possible. But in others, such as South Sudan and Somalia, the prospect of bringing safe water to the entire population seems remote.

Until the day when everyone has access to clean water and sanitation, researchers will work to answer more questions about the disease. One that remains is how – or if – Vibrio cholerae persists in the environment. “In places like Chad or on the western African coast, we see almost no cholera cases for several years, then there’s a big outbreak. It’s difficult to explain,” Legros says. “Some people say there is a reservoir in the environment that is maintained over years, though we don’t know how, and suddenly it erupts again, though again we don’t know how.” Harris also wonders about how the evolution of Vibrio cholerae may have affected its virulence and ability to cause pandemics.

Women fill jerrycans with water from a well. In Somalia, where cholera outbreaks have killed hundreds of people, the looming famine threatens 6.2 million people, more than half the population


Somalians fill jerrycans with water from a well. In Somalia, where cholera has killed hundreds, the looming famine threatens 6.2 million people, more than half the population. Photograph: NurPhoto via Getty Images

As researchers work to answer these questions, and as nations move slowly towards improved infrastructure, public health officials will have to combat new outbreaks.

“I would hope that people appreciate how significant and serious a threat [cholera] is,” Harris says. “For people who think it’s a historical disease, they should know that it is still an important cause of morbidity and mortality around the world.”

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Diarrhoea, vomiting, sudden death … cholera’s nasty comeback

Mohammad Shubo is motionless when he is wheeled into the clinic. He had started experiencing diarrhoea and vomiting that morning; by evening, he had no pulse.

In an effort to rehydrate him quickly, the nurses give Shubo an IV of saline solution. His reanimation seems almost uncanny – within half an hour he is able to sit up and speak. He spends the next two days at the hospital to rehydrate and convalesce before returning to his cramped quarters. If Shubo had arrived at the clinic just 10 minutes later he would have died, a nurse says.

For those who have been fortunate enough not to see the effects of cholera first hand, David Sack, a professor of international health at the Johns Hopkins University Bloomberg School of Public Health, says Shubo’s case, which appears on a 2011 Al Jazeera documentary, gives “a good sense of the disease”. Thousands of patients develop the same symptoms as Shubo did, though not all are as lucky. Sack recalls a case from Uganda in which a woman was hospitalised with symptoms of cholera, but the hospital staff didn’t diagnose her properly, even though there was a cholera treatment facility on the hospital grounds. She was not closely monitored and died of dehydration overnight. Cases like this should never happen, Sack says. But clearly they do.

John Snow, the doctor who traced the source of cholera outbreaks in London in 1854.


John Snow, the doctor who traced the source of cholera outbreaks in London in 1854. Photograph: Alamy

In some parts of the world, including Europe and the US, cholera is so rare that it seems to have been eradicated. Some may see it as an “old world” disease, gone the way of the plague and smallpox. But it continues to devastate communities elsewhere, sometimes to pandemic proportions – an outbreak is raging in Yemen, where more than 246,000 cases and 1,500 deaths have been reported.

“Cholera is a brutal infection,” says Jason Harris, an associate professor of pediatrics at Massachusetts General Hospital. “Patients can go from looking healthy to dying quickly with cholera. It’s a scary disease.”

In the mid-1800s, as cholera swept across nearly every continent and killed thousands, scientists rushed to understand the disease. In 1854, a British doctor, John Snow, undertook the first epidemiological study that determined water from a pump on Broad Street was sickening Londoners with cholera (he didn’t discover the true reason why, however – at the time the disease was thought to be spread by miasma, not microbes). Then in 1884, a German researcher, Robert Koch, studied the intestines of deceased cholera patients in Egypt and India, concluding that the comma-shaped bacteria Vibrio cholerae he found there was the cause of the disease.

The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832


The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832. Photograph: Print Collector/Getty Images

In the years since, scientists have figured out a lot more about the biology of cholera. Snow was correct: Vibrio cholerae is transmitted through contaminated water. Within as little as 12 hours or as long as five days, some people who have ingested the bacteria will start to show symptoms – uncontrollable vomiting and diarrhoea. But 80% of those who ingest the bacteria do not, possibly because of an existing immunity.

The scariest part of the disease, Harris says, is the sheer speed with which a patient can decline. If the condition isn’t treated quickly, people can die of dehydration within hours of showing symptoms.

Dr. Robert Koch (seated) with his assistant Dr. Richard Pfeiffer


German researcher Robert Koch (seated) with his assistant, Richard Pfeiffer. Photograph: Bettmann Archive

“The amount of fluid loss from diarrhoea and vomiting [in patients] is shocking. It’s hard to believe unless you see it,” Harris says. It can be up to a litre per hour. And more people excreting the bacteria into water sources means more get infected, and it’s not hard to see how just a handful of cases could quickly balloon into an outbreak (there have been seven pandemics over the past two centuries), which can last decades.

The last pandemic started in Indonesia in the 1960s and spread across Asia and Africa before coming to Europe in 1973. By 1991, it had spread to Latin America, which had been free of cholera for more than a century. Around 400,000 reported cases and 4,000 deaths were reported in 16 countries of the Americas that year.

These days the disease does not have to be a death sentence. Doctors know how to treat cholera effectively. If a patient can reach a clinic in time, the treatment is fairly straightforward. With a rapid infusion of fluids and antibiotics, they are usually back to normal in a few days. There is also a vaccine, which is taken orally and can prevent infection in about 60% of people.

But this apparent simplicity is deceptive; all this knowledge isn’t the same as stopping the disease. “The map of cholera cases is pretty much a map of poverty,” says Dominique Legros, the team lead of the cholera group at the World Health Organization. “We still have cholera in places like Yemen because people don’t have access to safe water.” People living in poverty may know that drinking polluted water can get them sick, but they don’t have an alternative.

“Because of inequality and a lack of access to safe water and sanitation, more than a billion people are still at risk [of cholera],” Harris says.

So outbreaks continue. In some places, such as Zambia and Uganda, they are predictable, starting every year with the rainy season. But often, outbreaks can’t be anticipated. There are factors that can make an outbreak more likely – natural disasters can scatter infected people to contaminate more water sources and war can close clinics that might have helped citizens receive treatment or inhibit the import of necessary medication.

Engraving by William Heath showing a lady discovering the quality of the Thames water. By the 1820s, public concern was growing at the increasingly polluted water supply


An engraving by William Heath showing a lady discovering the quality of the Thames’s water. By the 1820s, public concern was growing at the increasingly polluted water supply. Photograph: Science & Society Picture Library/Getty Images

But these factors are hardly predictive. After the 2010 earthquake, for example, American epidemiologists concluded that Haiti was at low risk of a cholera outbreak; just a few months later, an epidemic was raging, in part because UN peacekeeping forces accidentally introduced the bacteria.

Years of political turmoil are fuelling the epidemic in Yemen. The situation is dire – the WHO estimates that nearly 250,000 people had been infected by the end of June, almost doubling previous estimates based on academic models. WHO officials are working with other non-profits and what remains of the national healthcare system to bring treatment to rural clinics to help people get treatment more quickly. This week, the International Coordinating Group allocated one million cholera vaccines to be sent to Yemen.

A girl is treated for a suspected cholera infection in Sanaa, Yemen


A girl is treated for a suspected cholera infection in Sanaa, Yemen. Photograph: Hani Mohammed/AP

These strategies, along with education campaigns so people at risk of cholera know how to treat their water (by boiling, or with chlorine tablets), can reduce the incidence of the disease. But these advances don’t address the main problem: a lack of access to clean water. So the solution to eradicating cholera then, doesn’t lie in the health sector. “Yes, you need to treat patients and prevent death,” Legros says. “But the long-term solution is in the development sector – giving people long-term access to sanitation.”

There are some countries in which this may soon be possible. But in others, such as South Sudan and Somalia, the prospect of bringing safe water to the entire population seems remote.

Until the day when everyone has access to clean water and sanitation, researchers will work to answer more questions about the disease. One that remains is how – or if – Vibrio cholerae persists in the environment. “In places like Chad or on the western African coast, we see almost no cholera cases for several years, then there’s a big outbreak. It’s difficult to explain,” Legros says. “Some people say there is a reservoir in the environment that is maintained over years, though we don’t know how, and suddenly it erupts again, though again we don’t know how.” Harris also wonders about how the evolution of Vibrio cholerae may have affected its virulence and ability to cause pandemics.

Women fill jerrycans with water from a well. In Somalia, where cholera outbreaks have killed hundreds of people, the looming famine threatens 6.2 million people, more than half the population


Somalians fill jerrycans with water from a well. In Somalia, where cholera has killed hundreds, the looming famine threatens 6.2 million people, more than half the population. Photograph: NurPhoto via Getty Images

As researchers work to answer these questions, and as nations move slowly towards improved infrastructure, public health officials will have to combat new outbreaks.

“I would hope that people appreciate how significant and serious a threat [cholera] is,” Harris says. “For people who think it’s a historical disease, they should know that it is still an important cause of morbidity and mortality around the world.”

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Diarrhoea, vomiting, sudden death … cholera’s nasty comeback

Mohammad Shubo is motionless when he is wheeled into the clinic. He had started experiencing diarrhoea and vomiting that morning; by evening, he had no pulse.

In an effort to rehydrate him quickly, the nurses give Shubo an IV of saline solution. His reanimation seems almost uncanny – within half an hour he is able to sit up and speak. He spends the next two days at the hospital to rehydrate and convalesce before returning to his cramped quarters. If Shubo had arrived at the clinic just 10 minutes later he would have died, a nurse says.

For those who have been fortunate enough not to see the effects of cholera first hand, David Sack, a professor of international health at the Johns Hopkins University Bloomberg School of Public Health, says Shubo’s case, which appears on a 2011 Al Jazeera documentary, gives “a good sense of the disease”. Thousands of patients develop the same symptoms as Shubo did, though not all are as lucky. Sack recalls a case from Uganda in which a woman was hospitalised with symptoms of cholera, but the hospital staff didn’t diagnose her properly, even though there was a cholera treatment facility on the hospital grounds. She was not closely monitored and died of dehydration overnight. Cases like this should never happen, Sack says. But clearly they do.

John Snow, the doctor who traced the source of cholera outbreaks in London in 1854.


John Snow, the doctor who traced the source of cholera outbreaks in London in 1854. Photograph: Alamy

In some parts of the world, including Europe and the US, cholera is so rare that it seems to have been eradicated. Some may see it as an “old world” disease, gone the way of the plague and smallpox. But it continues to devastate communities elsewhere, sometimes to pandemic proportions – an outbreak is raging in Yemen, where more than 246,000 cases and 1,500 deaths have been reported.

“Cholera is a brutal infection,” says Jason Harris, an associate professor of pediatrics at Massachusetts General Hospital. “Patients can go from looking healthy to dying quickly with cholera. It’s a scary disease.”

In the mid-1800s, as cholera swept across nearly every continent and killed thousands, scientists rushed to understand the disease. In 1854, a British doctor, John Snow, undertook the first epidemiological study that determined water from a pump on Broad Street was sickening Londoners with cholera (he didn’t discover the true reason why, however – at the time the disease was thought to be spread by miasma, not microbes). Then in 1884, a German researcher, Robert Koch, studied the intestines of deceased cholera patients in Egypt and India, concluding that the comma-shaped bacteria Vibrio cholerae he found there was the cause of the disease.

The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832


The Duke of Orleans visits the sick at L’Hotel-Dieu during France’s cholera epidemic in 1832. Photograph: Print Collector/Getty Images

In the years since, scientists have figured out a lot more about the biology of cholera. Snow was correct: Vibrio cholerae is transmitted through contaminated water. Within as little as 12 hours or as long as five days, some people who have ingested the bacteria will start to show symptoms – uncontrollable vomiting and diarrhoea. But 80% of those who ingest the bacteria do not, possibly because of an existing immunity.

The scariest part of the disease, Harris says, is the sheer speed with which a patient can decline. If the condition isn’t treated quickly, people can die of dehydration within hours of showing symptoms.

Dr. Robert Koch (seated) with his assistant Dr. Richard Pfeiffer


German researcher Robert Koch (seated) with his assistant, Richard Pfeiffer. Photograph: Bettmann Archive

“The amount of fluid loss from diarrhoea and vomiting [in patients] is shocking. It’s hard to believe unless you see it,” Harris says. It can be up to a litre per hour. And more people excreting the bacteria into water sources means more get infected, and it’s not hard to see how just a handful of cases could quickly balloon into an outbreak (there have been seven pandemics over the past two centuries), which can last decades.

The last pandemic started in Indonesia in the 1960s and spread across Asia and Africa before coming to Europe in 1973. By 1991, it had spread to Latin America, which had been free of cholera for more than a century. Around 400,000 reported cases and 4,000 deaths were reported in 16 countries of the Americas that year.

These days the disease does not have to be a death sentence. Doctors know how to treat cholera effectively. If a patient can reach a clinic in time, the treatment is fairly straightforward. With a rapid infusion of fluids and antibiotics, they are usually back to normal in a few days. There is also a vaccine, which is taken orally and can prevent infection in about 60% of people.

But this apparent simplicity is deceptive; all this knowledge isn’t the same as stopping the disease. “The map of cholera cases is pretty much a map of poverty,” says Dominique Legros, the team lead of the cholera group at the World Health Organization. “We still have cholera in places like Yemen because people don’t have access to safe water.” People living in poverty may know that drinking polluted water can get them sick, but they don’t have an alternative.

“Because of inequality and a lack of access to safe water and sanitation, more than a billion people are still at risk [of cholera],” Harris says.

So outbreaks continue. In some places, such as Zambia and Uganda, they are predictable, starting every year with the rainy season. But often, outbreaks can’t be anticipated. There are factors that can make an outbreak more likely – natural disasters can scatter infected people to contaminate more water sources and war can close clinics that might have helped citizens receive treatment or inhibit the import of necessary medication.

Engraving by William Heath showing a lady discovering the quality of the Thames water. By the 1820s, public concern was growing at the increasingly polluted water supply


An engraving by William Heath showing a lady discovering the quality of the Thames’s water. By the 1820s, public concern was growing at the increasingly polluted water supply. Photograph: Science & Society Picture Library/Getty Images

But these factors are hardly predictive. After the 2010 earthquake, for example, American epidemiologists concluded that Haiti was at low risk of a cholera outbreak; just a few months later, an epidemic was raging, in part because UN peacekeeping forces accidentally introduced the bacteria.

Years of political turmoil are fuelling the epidemic in Yemen. The situation is dire – the WHO estimates that nearly 250,000 people had been infected by the end of June, almost doubling previous estimates based on academic models. WHO officials are working with other non-profits and what remains of the national healthcare system to bring treatment to rural clinics to help people get treatment more quickly. This week, the International Coordinating Group allocated one million cholera vaccines to be sent to Yemen.

A girl is treated for a suspected cholera infection in Sanaa, Yemen


A girl is treated for a suspected cholera infection in Sanaa, Yemen. Photograph: Hani Mohammed/AP

These strategies, along with education campaigns so people at risk of cholera know how to treat their water (by boiling, or with chlorine tablets), can reduce the incidence of the disease. But these advances don’t address the main problem: a lack of access to clean water. So the solution to eradicating cholera then, doesn’t lie in the health sector. “Yes, you need to treat patients and prevent death,” Legros says. “But the long-term solution is in the development sector – giving people long-term access to sanitation.”

There are some countries in which this may soon be possible. But in others, such as South Sudan and Somalia, the prospect of bringing safe water to the entire population seems remote.

Until the day when everyone has access to clean water and sanitation, researchers will work to answer more questions about the disease. One that remains is how – or if – Vibrio cholerae persists in the environment. “In places like Chad or on the western African coast, we see almost no cholera cases for several years, then there’s a big outbreak. It’s difficult to explain,” Legros says. “Some people say there is a reservoir in the environment that is maintained over years, though we don’t know how, and suddenly it erupts again, though again we don’t know how.” Harris also wonders about how the evolution of Vibrio cholerae may have affected its virulence and ability to cause pandemics.

Women fill jerrycans with water from a well. In Somalia, where cholera outbreaks have killed hundreds of people, the looming famine threatens 6.2 million people, more than half the population


Somalians fill jerrycans with water from a well. In Somalia, where cholera has killed hundreds, the looming famine threatens 6.2 million people, more than half the population. Photograph: NurPhoto via Getty Images

As researchers work to answer these questions, and as nations move slowly towards improved infrastructure, public health officials will have to combat new outbreaks.

“I would hope that people appreciate how significant and serious a threat [cholera] is,” Harris says. “For people who think it’s a historical disease, they should know that it is still an important cause of morbidity and mortality around the world.”

Join our community of development professionals and humanitarians. Follow @GuardianGDP on Twitter.

How big tobacco has survived death and taxes

A casual observer could be forgiven for believing that the tobacco industry – for so long a fixture as permanent as its two main by-products, death and taxes – is itself on its last legs.

In the US, health officials have predicted that smoking rates in America could drop to as low as 5% by 2050, well within the lifetime of someone born today.

Last year, shareholders of UK-based Imperial Tobacco approved a decision to change the company’s century-old name to Imperial Brands, hinting at a move away from traditional cigarettes.

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Even globe-straddling colossus Philip Morris International (PMI), owner of brands including Marlboro, has set its stall out for a “smoke-free” future, where nicotine addicts get their fix from vaping and other non-tobacco products.

Yet, for all of these predictions, one thing has remained unchanged: Big Tobacco is thriving, profitable and increasing its sales.

Excluding China, where the market is monopolised by the state, five major companies dominate the global tobacco trade – Philip Morris International (PMI), British American Tobacco, Japan Tobacco, Imperial Brands and Altria (the former US assets of PMI).

Between them in 2016, they shipped 2.27tn cigarettes, more than 300 for every man, woman and child on the planet, racking up combined sales of $ 150bn (£115bn). Their combined profits reached $ 35bn (£27bn), allowing investors in those companies to receive dividends of $ 19bn (£14.5bn).

Various brands of Philip Morris International Inc.


Various brands of Philip Morris International Inc. Photograph: Bloomberg/Bloomberg via Getty Images

Of these giants, one of the most powerful is British American Tobacco (BAT), the London-based firm that can trace its history back to 1902.

Run from Globe House, its headquarters next to the Thames river, BAT sells its brands in 200 countries and is market leader in 55 of them.

Far from looking to a future beyond tobacco, BAT is doing perfectly well as it stands.

At its annual meeting in March, chairman Richard Burrows toasted a “vintage year”, as profits rose to £5.2bn ($ 6.7bn) allowing the company’s shareholders to take a dividend worth an additional 10%.

The rewards were so great because BAT’s sales show no signs of the industry’s much-vaunted decline. The company sold 665bn cigarettes in 2016, nearly 100 for every human on earth and 2bn more than it sold the year before.

Cigarette sales among its so-called Global Drive Brands – Dunhill, Kent, Lucky Strike, Pall Mall and Rothmans – jumped 7% to 346bn.

In the section of its accounts that details non-cigarette sales, which the company terms “next generation products”, there is nothing to see.

The numbers are so small that they are considered immaterial to its financial results and do not need to be disclosed under stock market rules.

Yet the company’s traditional business continues to generate big headlines and bigger numbers. By the end of the year, BAT is likely to have completed a landmark $ 49bn deal to buy the 57.8% of US tobacco giant Reynolds American that it does not already own. A simultaneous shareholder vote next Wednesday by both firms is expected to agree the deal at Reynolds HQ in Winston-Salem, North Carolina, and BAT in London.

British American Tobacco in Nairobi.


British American Tobacco in Nairobi. Photograph: David Levene for the Guardian

If US tobacco sales really are set to fall off a cliff, that would be a monumental strategic misstep.

But while the percentage of Americans who smoke is on the wane, the US remains a market with huge potential.

That’s because the population is rising, meaning that even as smoking rates decline in percentage terms, the actual number of smokers is relatively static at about 45 million people.

US cigarettes are also relatively cheap compared with prices in the UK, leaving some scope for the company to raise prices without losing customers.

Reynolds and BAT will also look to the future by pooling research on smokeless products, hoping to capture that growing market, though that won’t be the big money-spinner any time soon.

And then there is the developing world, where the rate at which governments and public opinion are turning against tobacco differ dramatically from wealthier economies.

Growth areas for tobacco industry in Africa and Middle East

A ‘defensive’ stock

BAT increased its revenues in every region bar Asia-Pacific last year, with the developing world doing more than its share of the heavy lifting.

Among the “key markets” listed in its annual report are Indonesia and Egypt – and for good reason.

The World Health Organisation projects smoking rates in Indonesia to increase by 2025, with the number of smokers growing from 73m to 97m based on current trends.

Egypt is another key market where smoking rates are projected to grow, with up to 21m Egyptians forecast to be smokers by 2025, compared to 14m in 2015.

One only has to look at BAT’s roster of investors for evidence of the confidence that well-informed institutions with deep pockets have in the future of cigarettes, even if that future is less bright in the West.

Worst countries by tobacco deaths

It’s a list that features nearly every major investment company in the world, testament to the safe bet that tobacco giants such as BAT offer to investors.

Top of the share register is BlackRock, the all-powerful asset manager that has a stake in nearly every major listed company in the world, managing investors’ funds of approximately $ 5.4tn, more than the economy of Japan.

Some way further down the list is Woodford Investment Management, run by Neil Woodford, a figure held in awe in London for his uncanny ability to make money.

He famously invests a huge chunk of his portfolio in tobacco, explaining that he is not paid to make moral judgments but to make money for clients.

Tobacco is attractive to investors – including councils in the UK – because it is seen as a “defensive” stock, in other words a good place to invest money that you are not prepared to lose.

The shares rarely decline in value even when times are tough and also deliver a steady income from annual dividends.

The huge rewards on offer for investors mean that those who manage the great behemoths of tobacco are also handsomely rewarded.

BAT chief executive Nicandro Durante is no exception. He was handed a package of cash and shares worth $ 10m (£7.6m) last year, taking his earnings over six years to a cool $ 44m (£34m).

When fellow directors are included, the 14-strong BAT boardroom enjoyed a combined $ 18m (£14m) payday in 2016.

A taxi driver smokes a cigarette while driving his cab in downtown Cairo, Egypt, on 6 July 2014.


A taxi driver smokes a cigarette while driving his cab in downtown Cairo, Egypt, on 6 July 2014. Photograph: Ben Curtis/AP

There are other perks. Durante gets free tax advice from the company, a personal driver and security for his homes, in London and Brazil.

Both executives and non-executives also have access to a walk-in GP clinic near BAT’s headquarters at Globe House in London, enjoying the benefits of a National Health Service that has been estimated to spend up to $ 6.5bn (£5bn) a year on smoking-related illnesses.

BAT’s board earn their corn as much for their network of connections as they do for their hard work.

Burrows is a former governor of Bank of Ireland, while senior independent director Kieran Poynter is a managing partner of Big Four accountancy PricewaterhouseCoopers and previously advised the UK’s Treasury.

Its non-executive directors boast a string of similar appointments at multinational companies. Savio Kwan, for instance, was chief operating officer of China’s largest internet business, Alibaba.

10 death deaths by proportion

Ann Godbehere ran the finances of Northern Rock after its bailout and also serves on the boards of mining giant Rio Tinto, Swiss bank UBS and insurer Prudential.

Nor does the company’s network of influence end there.

While it does not donate money directly to British political parties, it does funnel cash to influential right-leaning thinktank the Institute of Economic Affairs.

BAT gives the IEA around $ 52,000 (£40,000) a year, a sum equivalent to about 5% what the organisation pays its staff, some of whom appear frequently in the media to criticise tobacco control legislation such as plain packaging.

Chief among those staff is director-general Mark Littlewood, a former press spokesman for the Liberal Democrats and one-time adviser to David Cameron.

Littlewood has been a vocal critic of tobacco control legislation such as the ban on smoking in pubs, as well as plain packaging.

The IEA has also received funding from Philip Morris International and Japan Tobacco International.

The BAT bosses

Nicandro Durante – chief executive

Nicandro Durante joined Brazilian subsidiary Souza Cruz in 1981, and rose through the ranks over three decades until he was appointed chief executive in 2011.

He had impressed the company’s senior management during a two-year stint as regional director for Africa and the Middle East, key areas of future growth for tobacco companies facing up to declining smoking rates in more developed economies.

Born to Italian parents in 1956 in Sao Paulo, he played football for the city’s Corinthians team in his teens before going into business.

Married with two children, Durante stopped smoking cigarettes in favour of cigars, but has no qualms about tobacco, which he described as a “very ethical” industry in a 2012 interview with the Financial Times.

In 2015, he fielded allegations from a former employee in Kenya that BAT bribed officials for various purposes, including the undermining of tobacco control laws.

BAT denies any wrongdoing. A spokesperson said: “We will not tolerate improper conduct in our business anywhere in the world and take any allegations of misconduct extremely seriously. We are investigating, through external legal advisors, allegations of misconduct and are liaising with the Serious Fraud Office and other relevant authorities.”

In 2016, Durante was handed a package of cash and shares worth $ 10m (£7.6m), taking his earnings over the past six years to a cool ($ 44m) £34m.

Burrows is credited with turning Jameson whiskey into an internationally-recognised brand.


Burrows is credited with turning Jameson whiskey into an internationally-recognised brand. Photograph: Alamy

Richard Burrows – chairman

Addressing BAT’s shareholders earlier in 2017, Burrows toasted a “vintage year”, in which the company shrugged off bribery allegations in late 2015 to record rising profits.

Some investors were less keen on Burrows when he was named chairman in 2009.

Burrows had resigned as governor of Bank of Ireland, leaving the lender in dire straits, with big losses and mounting debt threatening its very survival.

Tens of thousands of the bank’s mortgage customers were plunged into negative equity and the lender eventually needed a state bailout that enraged many Irish people.

As the bosses of rival lenders faced public opprobrium for their stewardship of the country’s banking sector, Burrows got out just in time, landing the chairmanship of BAT in 2010.

But BAT wasn’t concerned by his record in banking, looking instead to his 22 years with Irish Distillers, during which time he was credited with turning Jameson whiskey into an internationally-recognised brand.

The Dubliner, 71, is a non-smoker who is married with four children and enjoys sailing and rugby.

He is also chairman of investment company Craven House Capital, whose assets includes beachfront land in Brazil. He is a non-executive director of Rentokil and Carlsberg.

Kieran Poynter – senior independent director

After a near 40-year career with global accounting giant PwC, which put him among the ranks of the UK’s best-paid accountants, Kieran Poynter joined BAT’s board as senior independent director.

He brought with him valuable connections, having served as an adviser to former UK chancellor of the exchequer Alistair Darling.

Poynter, a Chelsea FC season ticket holder, is a former director of the salubrious Royal Automobile Club, the gentleman’s club on London’s Pall Mall.

He also sits on the board of F&C Asset Management and IAG, the parent company of British Airways.

Ben Stevens – finance director

Ben Stevens looks after BAT’s money, and has spoken about how the company is growing market share and looking for acquisitions in Asia and North Africa.

Part of his role is trying to convince governments not to raise excise duty on cigarettes too quickly, according to an interview he gave with financialdirector.co.uk.

In the same interview, he referred to the need to have a “thick skin” because of the number of people “bashing tobacco companies”.

Stevens gave up smoking nearly 30 years ago, two years before joining the company. But said in 2013 that profits would come from “combustible tobacco” for the near future.

My patient is 93 and has pneumonia. It’s time to talk about her death

Mrs S is 93 years old and has severe pneumonia. She is sitting up in bed, with a big unwieldy mask strapped to her nose and mouth like a facehugger from Alien. This device is all that keeps her from lapsing into a coma. I sit at her bedside. We have just met. I am here to talk to her about her death.

As the medical registrar for a big hospital, I am often called in to help by other specialties when trouble arrives. Some days, by the time I’m summoned, trouble has already got its feet under the table. On rare days, I really am there to save lives. Other days, I feel like the grim reaper, stalking the halls like death in a pencil skirt.

As our knowledge continues to advance, and the menu of available treatments continues to expand, we can do more and more to keep people alive. But every day in hospitals up and down the country, the debate continues to rage as to what we should do. It’s a discussion that sounds like it should have a simple answer. Patients want to live; families want to do their best for their loved ones; doctors don’t like to lose and it’s easy to default to a “Do everything that you can” mindset.

But doing everything doesn’t come without cost. There’s the downpayment of pain and suffering, whether in the form of gruelling chemotherapy regimes, or ribs cracked by CPR. Patients can end up sacrificing their comfort, their independence and their dignity, pursuing brutal treatments with slim odds of ever being well.

In my first year out of medical school, I worked for a bluff, take-no-prisoners surgeon and cared for Mrs L. Mrs L was tiny and bird-like but full of sass. She loved musicals and would sing snatches on the ward. Cancer was clogging up Mrs L’s guts like a clump of hair clogs a drain. There was no hope for a cure. Her operation was performed so she could eat.

The procedure went well, but in the days and weeks that followed, Mrs L became more and more tired. Her pain grew worse. She slept more and showed no interest in food. What she wanted, she confided in us, one morning, was to die.

“Nonsense,” the surgeon bellowed. “You just need to get up and about. Eat something!”

The surgeon refused to even consider Mrs L’s wishes or the possibility that her life might be coming to an end. If her heart were to stop, he instructed, we were to jump on her chest and do CPR. If she couldn’t eat, we could always tube feed her. Late one evening, I found myself, on his instructions, jabbing Mrs L over and over to try and get a needle into her vein. Mrs L cried, but I was too afraid of him to stop.

I swore right then that I would not become a doctor like him.

Now I’m here with Mrs S talking about what she wants.

She is one of the easy ones. She’s self-possessed, her family are all around her. There’s no weighing up of the possibilities, no grim calculation of risk versus reward. She tells us exactly what she thinks of the cumbersome ventilator mask, and she knows what she wants.

“I’m ready to go,” she tells us.

Later, she sends her family away. She says she is tired and that she can’t go properly when they are all here watching her. I meet her son in the corridor. I talk about what’s important now, about how best to maintain her comfort and her dignity. “Thank you, doctor,” he says, but he’s crying. I leave him and slip away. There are more patients to see and maybe some lives to save.

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