71. Not going looking for trouble, rather, knowing where to find it.

DSC01039

I’d like to say he won’t hurt you. But statistics show it’s possible.

Remember the beginning of Three Days of the Condor, when Robert Redford goes out for a sandwich, and returns to find that an assassin has moved systematically from room to room with a machine gun and murdered all his colleagues? That was pretty much the scene I found when I visited my old workplace yesterday.

I’d like to think there was more to morale than petty behaviour behind the scenes. And that whatever the atmosphere, patient care wasn’t affected. But that is plainly ridiculous. Now that I am a patient more than I am a doctor, I’d rather my doctor wasn’t grumpy even before I tell him about my knees.

The NHS is an intensely tribal organisation, where the various power groups live within a precarious ceasefire. Only a thin membrane of etiquette stands between normal working and bouts of senseless slaughter. Sometimes it only takes one small incident – like shooting an Arch Duke – to set things off.

Etiquette is an intensely important aspect of medical culture. It’s history goes back to the middle ages, where practitioners were divided into three ‘medical estates’ – barber surgeons, apothecaries or physicians. Barbers had the sharp instruments and physicians had the sharp suits. Apothecaries, as now, had the shops on the high street. The professional codes of practice we have inherited are derived from power sharing agreements worked out centuries ago.

The thrust of recent changes has been the ascendency of Management, at the expense of the older professions like medicine and nursing. Like a new religion, or political party, managers have yet to establish a proper code of etiquette. Like the dog in the park, they jump up at people and leave muddy prints. Their owner tells them, fifty times a day, not to jump up at people, they’re not supposed to. But it takes a long time before a dog gets a firmware upgrade.

It’s unbearably rude to write about the position of the medical profession in terms of power relationships. As I write, I almost have to change fonts to something spidery, to reflect the delicacy of the discussion. Should we say, at least, that managers and doctors have an ambivalent relationship? Not love / hate exactly. More fear /loathing to be honest. This probably just reflects a wider unease about elitism in British society. The NHS is locked in a post-war time warp where snobby types need to be cut down to size. The NHS tends to regard eminent persons as ‘toffs’. If you’re a decent sort of toff, you can be a ‘boffin’. But just because you can recite the periodic table, including the rare earth metals, don’t think you can start telling anyone what to do, let alone bring your bike in your office.

I suspect other skilled technicians like engineers and pilots are still treated this way in their industries, apart from finance and banking, where elitism is positively glorified. I’d love to say something like, ‘it doesn’t take much to keep people happy, it’s the little things that matter: just bring back the lady with the tea trolley; let’s renew the subscription to The Guardian’. But I fear its gone too far. Max von Sydow is still lurking in the building. In fact he’s just reloading. But whose side is he on now?

 

Advertisements

70. Reporting soap shortages, before they get serious.

WP_20140711_002

A poster reminding people, in several ways, that they are too old.

 

The techno-thriller genre gave readers a thirst for irrelevant information. It wasn’t enough to say someone travelled on a Boeing 707. You had to hear about who made the engines, how the landing gear was inspected by a man with a set of tuning forks and how the pilot’s socks were monogrammed in alpaca by a silent order of nuns in Seattle.

The behind-the-scenes stuff became obligatory for thriller writers – quite a feat before the days of google. Presumably, Forsyth and Clancy spent huge amounts of time visiting airports, submarines and arms factories, asking people, ‘what does that yellow handle do?’

The most obvious spin-off has been the increased number of adjectives we find in grocery products. It’s not enough to say Oven Chips. You need to give them a bit of character development:  Maris Piper, thrice-fried, goose-fat oven chips, at the very least. And even then, you’ve said very little about the goose. People want detail nowadays.

Another consequence of the increased audience for background information is the ‘Troublehooter’ style of TV series, started by John Harvey Jones and continued by the likes of Gerry Robinson and Digby Jones.

A man in a striped shirt and hard hat wanders round a huge factory, shaking his head slightly, asking every now and then: what’s that thing for? As a TV show, it’s a tired formula. But, as a metaphor for personal growth, it’s got potential. The striped shirt man is a therapist of sorts. He’s an independent expert, but he’s neutral and polite. He’s robust and challenging, but he’s kind and might even hug you, though you’re still getting fired. Like a certain type of clinical psychologist, he’ll make you a flow chart, showing you which arrow is missing, such as the one between Theakston’s Old Peculiar and poverty.

It could be helpful to get someone to troubleshoot your life. But what about businesses – can an outsider really understand them? Does expertise in the field really matter?

Troubleshooter appeals to people who like to look behind the scenes and are disappointed that Arthur Hailey died before he could write ‘NCP Car Park’. Ironically, the Troubleshooter himself is not the slightest bit concerned about forged composites or digital motors. He’s looking at the system as a whole. He’s drawing Venn diagrams and talking about Synchronicity, just as though it wasn’t the worst Police album.

Gerry Robinson wants the NHS to have more centralised reporting systems, like the food industry:

‘Imagine a McDonald’s in Leicester, say, where things are going wrong. Perhaps the wrong number of chicken nuggets are being handed out, or the washrooms aren’t supplied with soap. These problems would show up immediately via a weekly reporting system which compared its performance against every other McDonald’s in the country, and you’d have a senior manager down in days to sort out the problems’.

Gerry’s background is in catering, so he’s comfortable with that model.

But, senior managers never visit NHS units, partly for fear of infectious disease, but largely because it would never occur to them to do so. Boards and Hospitals are different planets, with different atmospheres and gravitational fields.

Whereas the coffee available to senior managers comes out of a capsule machine, the coffee provided to wards comes out of industrial size tins labelled Maxwell House. It’s Maxwell House, Jim, but not as we know it.

Whereas NHS management premises are carefully protected behind air-locked entry systems and fierce receptionists, anyone can walk, unchallenged, into most hospital departments, including intensive care units and even operating theatres. This fact is portrayed in countless thrillers, where assassins get a second chance to finish someone off by stealing a white coat and strolling in.

As further evidence that NHS Boards and Hospitals are separate worlds, consider the fact that boards comprise upwards of 12 members, only one of whom is a practicing clinician. Does Gerry not think this is a bit odd? Does he not realise that Boards and Clinicians, like matter and antimatter, must never come into contact with each other and if they do, the universe will be annihilated?

I am not a management guru. But even I can spot the key differences between Macdonald’s and the NHS, such as Product Range. Which leads me to ask: who troubleshoots the troubleshooters?  It suits managers to propagate the notion that it doesn’t matter much what the company does or makes, that you can move between Catering, Television, NHS and it’s all the same. But often, the detail is what matters most. John Harvey Jones forecast the demise of Morgan for instance – he just couldn’t understand how cars could be made of wood. It’s not a mistake Tom Clancy would have made. He’d have known all about the aerospace properties of ash.

Whereas thriller writers regard craftsmanship in awe, managers regard it in contempt. In a techno-thriller, the emperor’s new clothes would be made of kevlar. And the boss would know what the yellow handle did.

To be fair to John Harvey Jones he did tell the Chief Constable of South Yorkshire that his strategic plan was ‘a load of bloody cobblers’. This comment pretty much ended their foray into footwear repairs.

 

68. Getting told not to be so stochastic.

Image

A new design to discourage revolving door admissions

 

If you don’t use sub-headings nowadays, people will laugh at you. Reports, for instance, need to be have all the paragraphs and lines numbered.

For the time being, everything has to be written in fives or tens. If I had to write about my recent trip to Wakefield, for instance, it would go like this:

Five brilliant things about Wakefield:

  • Industry: If you buy a can of Coke anywhere across Wakefield and the north of England, the chances are it’s been manufactured using water from East Ardsley reservoir
  • Talent: Ed Balls visited Wakefield College recently where he had the opportunity to speak with senior College staff and also to try his hand at bread making with a group of talented catering students.
  • The Arts: Wakefield had a brilliant new art gallery called The Hepworth. It’s free but parking costs £4.50
  • Celebrity: Shadow Chancellor, Ed Balls, paid a visit to HC-One’s Carr Gate Care Home in Wakefield to spend time with his godmother, who is a resident there
  • Free speech: Outside the cathedral, a man is shouting loudly to himself, stating that something should be done about the smackheads.

The cathedral should be in the top 5 instead of Ed Balls, but it was closed, despite a large banner saying ‘the cathedral is open’. Smackhead trouble, I presume.

In conclusion, Wakefield just cannot be itemised. There’s a square concrete gallery full of curvy shapes, on the banks of a river that seems to be flowing in several directions at once. It’s all a bit random.

Our response to complicated questions tends to be five simple answers. For example, surveys keep revealing that there are absolutely no available mental health beds in Britain, and patients are having to be sent to the International Space Station by rocket ship, as there are still vacancies in the sick bay.

Like most other mental health news, such revelations cause no reaction whatsoever, as mass readerships turn to more interesting news within a millisecond, like Desmond Morris’s scintillating analysis of why Kelly Brook is the most attractive female, ever.

Yet, ‘on the ground’, the bed drought is massively stressful for the agencies involved, not to mention the service users and their families. What might begin as a bad hair day, muddling your tablets and starting an accidental chip pan fire, ends up as a 200 mile trip to a private sector secure unit in Yorkshire.

Why the shortage of beds?

Here are some reasons. At first glance, as often seems to happen, there are exactly five:

  1. The number of beds has been reduced by at least 1700 over the last 3 years
  2. The population has increased
  3. Community services have been pruned along the lines of Norman Tebbit’s rose garden in March
  4. Agencies are increasingly risk-averse
  5. The hospitals are inefficient in their workings

At least, that’s the common sense explanation, based on an analogy with any other system. This week we had floods. And overcrowding on the railways. The prisons are overflowing again. Similar reasons – simple reasons, to do with not getting quarts out of, or into, pint pots. Researchers have analysed the flow through hospitals using so called ‘stochastic’ modelling, which is derived from the mathematical properties of random events.

Once hospital departments are more than 85% full, the system jams up, just like a Dyson. Mental health acute wards are more than 100% full all the time. All the leave beds are in use and occasionally, mattresses are put down in day rooms.

But the ‘bed crisis’ is not really a simple capacity issue. Like roads – with the single exception of the M181 into Scunthorpe – and housing, there will always be excess demand. But society is quite flexible in determining which marginal group goes to which marginal venue. My impression is that there are large numbers of semi-homeless people – sofa-surfers – existing in the penumbrae between prison, hospital, homeless projects and the public library. This group meanders between the different institutions, like a shallow stream, filling any gaps it finds. Some of them fall into the police, some fall into A and E. From there, a random selection fall into the mental health system. By accident, some get into the cathedral.

Managers know there is no ‘irreducible minimum’ for mental health beds.

Managers know that beds mean hospital staff and hospital staff are a nuisance. Managers love community services, because dispersed personnel manage themselves. They seldom meet to fight or plot.

Trust managers are continuing to close mental health beds, like sheepdogs that have tasted mutton. The impact of these changes is that if you are depressed, you are extremely unlikely to get admitted to a mental health unit.

And if you do get admitted, you will very quickly decide you weren’t feeling quite so bad after all and ask for another go at community care.

Luxury items like research centres, respite care, therapeutic communities, specialist units for resistant depression, alcohol rehab, etc, are just material for Michael Gove’s new history syllabus.

Here’s the bullet point version. It turns out there are five main points:

  • There’s a rising tide of homelessness
  • Depressed people, for better or worse, have been displaced from the residential part of the mental health system
  • People unable to manage themselves are milling about the country like fluid particles
  • Put away the Airfix Kit – it’s time for Stochastic Modelling.
  • If you have a cathedral, you need to check regularly for smackheads.

65. Sleepwalking blindfold, into an amorphous tapestry.

Image

Historians agree that modern times began in 1980, with the invention of Pac-Man.

When did it all go wrong? The answer it seems is 1980. And, to a lesser extent, 1988.

Certainly, quite a few things went wrong in 1980. John Lennon was murdered, the Iran / Iraq war began, Robert Mugabe was installed and worst of all, the post-it note went on sale. In mental health, our particular Chernobyl was an explosion of toxic diagnostic heterogeneity. 1980 saw the invention of the concept ‘major depression’ (MDD). With the publication of the DSM3 diagnostic manual, most emotion-based illnesses was fed into a diagnostic Magimix. This turned out to be very convenient for certain people. One, (sloppy) people who don’t like making diagnoses. Two, the (wicked) inventors and propagators of so-called SSRI antidepressants. Rampant heterogeneity was very inconvenient for anyone who wanted to investigate the possible causes and treatments of Depression. Edward Shorter explains the story much better than I can.*

Certain discrete entities, that should have been studied much more carefully, got lost in the new, amorphous tapestry of MDD. One of these was the notion of ‘biological symptoms’ such as appetite and weight loss, early waking and diurnal mood variation (DMV). The classic ‘melancholic’ patient felt much worse early in the morning. Studies of cortisol and other hormone levels throughout the day showed a changed pattern in most depressed people. Of particular interest was the finding that most depressed patients failed to reduce their cortisol levels even when given a steroid tablet the night before. This led to the ‘dexamethasone suppression test’ and other early attempts to find a definitive lab test for Depression. Old school psychiatrists regarded DMV as a cardinal symptom of melancholia. They separated melancholia from other types of depression with barbed wire, landmines and a no-fly zone.

Today, research into circadian rhythms in organisms and the body clock in humans is a major strand of research in life science. Gene expression studies are the way forward.  And this week, even the BBC acknowledged this by holding a ‘Day of the Body Clock’.

Quite what the editors had in mind for the body clock day remains a mystery. Each news program had to slot in a body clock item but the presenters looked bewildered as to why. We heard that sportsmen performed better in the evenings. Some brave schools are shifting their timetable for teenagers later into the day, when they are more likely to be awake, although the teachers are more likely to be asleep. More interestingly, scientists told us that society was guilty of a ‘supreme arrogance’ in trying to over-ride our need to get enough sleep. Prof Russell Foster, at the University of Oxford, said people were getting between one and two hours less sleep a night than 60 years ago. We were warned that ‘Modern life and 24-hour society mean many people are now “living against” their body clocks with damaging consequences for health and wellbeing’. Further support then for the Blur Theory – Modern Life is Rubbish. Sleep, like lunch and the concept of Melancholia, was abolished in the eighties.

Studies continue to reveal that a sub-group of depressed patients show an abnormal expression of clock genes. Several promising types of non – drug therapy for depression were based on trying to adjust the body clock: Sleep Deprivation, Phase Advance and Bright Light therapy. Unlike SSRI antidpressants, these are treatments that cost hardly anything and can easily be implemented at home. Also unlike SSRIs, these are treatments that no-one ever tries. The post-it note and Robert Mugabe are here to stay, but Shorter is correct to say that MDD must go: ‘melancholia and non-melancholic depression are quite separate illnesses’. I’m having the bumper stickers printed now.

The idea that deliberately reducing sleep can act as an antidepressant seems counter-intuitive. But it’s possible that the insomnia in depression is the body’s attempt to defend itself against low mood. Which means that society as a whole may be trying to stave off existential despair by staying up late.

*Edward Shorter, 2014, The 25th anniversary of the launch of prozac gives pause for thought: where did we go wrong? BJPsych, 204, 331-2.

63. Being a do be, not a don’t be.

Image

Voyeurism can be a problem for creatures that mate outdoors.

 

British psychiatry is a bullet-riddled corpse lying in the gutter, but people are still stopping by, from time to time, to give it another kicking.

It’s in a similar condition to other twentieth century institutions, like organised religion, nuclear power and the Co-op. They are zombies, but they are still staggering forwards, muttering incoherently.

The bullets come from many directions. No new drugs, no new therapies, massive cuts in hospital and community services. Very few medical graduates are coming forward to work in the speciality.

Attacking British psychiatry in 2014 is equivalent to laying into Workington F.C. for finishing bottom of the Conference League (North).

This time, the would-be assassins are a group called the Council for Evidence Based Psychiatry (CEP), who are attempting an anti-psychiatry re-launch, this time under an ‘evidence-based-medicine’ banner.  Some of their argument turns on the (lack of) benefits and dangers of antidepressant drugs.

None of this criticism is new, and like all negative campaigns, this one will fall victim to the ‘negative halo effect’ that surrounds mental health information. It’s guaranteed to make people hop channels. The media won’t be interested unless one of the following crops up: colourful brain scan, or samurai sword.

Like progressive rock, anti-psychiatry belongs to a former era. CEP might just as well attack any other long demised evil empire, such as the Soviet Union or the Barons, or Marlborough Man. They could still be yelling ‘Judas’ at Bob Dylan for ‘going electric’ in 1966. They are probably still worried about the fuel tanks on the Ford Pinto.

To be fair, there is a lot to be critical about in modern psychiatry. Many of the points made by CEP are manifestly true, much as the programs ‘grumpy old men / women’ make accurate observations about modern life. It’s easy to criticise and there’s so much to be critical about. But what is the aim? To rant and rave, or to get more resources for non-drug treatments? To do that, the battle has to be fought in the context of public attitudes towards mental health problems.

Back in the middle of the last century, some very creative and brave researchers attempted to find out what ‘ordinary people’ knew and felt about mental illness. There were a number of milestone studies, such as those by Shirley Star in Chicago, Cumming and Cumming in Canada, and Gatherer and Reid in England.

These studies found that people tended to stereotype the mentally unwell person as dangerous and unpredictable. They were slow and reluctant to consider someone to be mentally ill, but once they did, they tended to avoid that person. The aim of these researchers was to reduce stigma by designing public education programs. Sadly, no-one is paying attention to what they found out, which basically, was: 1. ‘stay positive’ and 2. don’t attempt to pretend that mental illness does not exist – people are hard-wired to believe that it does.

Attempts to alter people’s attitudes toward mental illness failed because of the negative halo effect. In the case of the Cummings, they were eventually forced to leave town, hence the name of their book, ‘Closed Ranks’.

The researchers attributed this to an attempt to advance the notion that mental illness was something that could happen to anyone. People just wouldn’t accept that.

Interestingly, now it is the psychiatrists and nurses who are closing ranks. The worry is that what remains of the mental health industry will turn in on itself, similar to police departments, such as the West Midlands Serious Crime Squad or LAPD after Rodney King.

One sign of this is the Royal College of Pyschiatrists’ accusing itself of institutional racism, following in the footsteps (smaller size, obviously) of the Metropolitan Police. Another sign is the defensive sort of response service users get from NHS Trusts in response to queries.  There are odd attempts at ‘whistle-blowing’, but in the NHS, that’s basically a one-way ticket to the Ecuadorian Embassy.

Closing ranks is not the answer, nor is smashing the system. Everyone knows that Psychiatry is the Cinderella specialty. The neglect, in all its forms, including poor quality treatments, is down to negative public attitudes. The Turning Away, as Floydians would put it. The solution, so obviously, is better media coverage.

Here’s an example of a positive strategy: in Liverpool, The Readers Organisation has been pursuing positive mental health by setting up Reading Groups for people with Depression*.

Results have been very promising, although the evidence base would doubtless fail to satisfy the CEP. Probably they will start to identify victims of literature instead: ‘Hi, I’m Charlie. I’ve been catatonic since I read Silas Marner’.

It’s already been shown that reading challenging literature causes bits of brain to light up in bright colours. Surely its time for a controlled trial of Wordsworth versus Prozac?

Although ‘ECT versus Titus Andronicus’ was turned down by the Ethical Committee.

 

 

*An investigation into the therapeutic benefits of

reading in relation to depression and well-being: http://www.thereader.org.uk/media/72227/Therapeutic_benefits_of_reading_final_report_March_2011.pdf

62. Displaying the pottery fish, with pride.

Image

My alarm clock rings to tell me it’s behavioural activation time, also known as Nike Therapy, which means just do something and think about it later, if ever.

My eventual aim is to re-write the classic publication ‘365 things to make and do’ in an updated style to suit these post-ironic times. Also, I’d like to add a 366th project before 2016, which is the next leap year.

Today’s project is to shred a few copies of the NICE guidelines for Depression, mix them with PVA and turn them into hats.

As I shred, I realise that these guidelines do mention the term ‘behavioural activation’ but don’t explain how to do it. They say nothing about arts, crafts, music or hats. Which is surprising, given that there is a long tradition of arts and music therapy in mental health.

My hypothesis is that people need to do something with their hands to feel properly human. Manual work, crafts and organised sport have declined, leaving the hands as mere vestiges of devices that once could dig or sew or fire an arrow. Most people still prefer a mouse to a touch screen, when there is a choice. Many people still prefer a manual gearbox, even though automatics are now superior in all respects.

I have another project coming along which is more complicated. This involves taking photos of bits of stained glass windows, printing them in different sizes, using all the different, clichéd image filters in Pixelmator (such as the ‘ennui’ tool), tearing them up and sticking them onto a collage, which in itself looks like a stained glass window.

For some reason I’m having trouble (as though it was the printer’s fault rather than incompetence on my part) getting them printed at the right size, so they are coming out like postage stamps instead of A4.

If I had to give this activity an hourly rating for mood improvement, I’d have to rank it slightly below checking the lawn for cat faeces, collecting it on a special trowel and flinging it over the garden fence onto the railway line. But it might improve.

Either the picture is going to be postcard size, saving a lot of PVA, or I’m going to have to ask a teenager how to resize the images. Or perhaps find an art therapist, just to check whether this whole activity is artistic or not.

There are no art or music therapists in my local area and come to think of it, none in the hospital where I work. This demise of arts and crafts based therapies has been insidious and largely unreported. This seems like a pity, and I wonder who’s to blame.

Somewhere or other, the mental health establishment has got the idea that ‘therapy’ has to involve a bus journey across town to speak to a person in an office for about an hour once a week for about 20 weeks. True, these activities are evidence-based to an extent. It’s just that the evidence has been collected along narrow strands of enquiry, being derived mainly from a ‘clinic’ context.

No-one has bothered to see whether listening to good music or watching football or making rhubarb crumble can treat Depression effectively. And imagine the practical difficulties in conducting such studies.

Therapies where numerical ratings are intrinsic, such as computerised CBT, have the advantage in terms of generating evidence of improvement. They have largely taken over from other modalities, leaving a long queue of psychoanalysts at Jobcentre Plus.

There’s perhaps a lesson to be learned from Interpersonal Psychotherapy, (IPT). This therapy was invented by Klerman, Weissman and colleagues in the eighties. It’s a standardised approach with a proper instruction manual, which makes it amenable to testing. In particular, it was tested against drug therapy – in those days mainly tricyclic antidepressants.

Its designers were highly scientific individuals with an excellent grasp of the various different ‘models’ of Depression: biological, family, cognitive, psychoanalytic, feminist etc. They knew how to fund and conduct controlled trials and publish the evidence properly. And thus IPT is one of the two types of therapy that NICE bother to endorse.

Compare that approach with a study by Mike Crawford in 2012, purporting to show that weekly attendance at a group arts project had no benefit for patients. I quote:

‘Members of activities groups were offered activities that did not involve the use of art or craft materials’.

My italics, meaning ‘why on earth not?’ It’s not the full Blue Peter, not without the sticky-back plastic.

This is what the new version of ‘365 Things’ should try and achieve – a standardised arts and crafts therapy manual. So we can finally show that meaningful activity is good for people. Each task should be spelled out clearly, like in Marguerite Patten’s 1000 favourite recipes.

And include proper materials like policy documents, shredders, glue and paint. For a long time the surest way to upset an occupational therapist was to mention basket weaving. Now, I say it’s about time for a raffia revival. And it’s time to display the pottery fish, if you’re lucky enough to have one.

Image

 

 Detail from Queen of Heaven, by M Healey, 1933, St Brendan’s Cathedral, Loughrea

60. Finding more cultured friends.

Image Bonnie and Clyde – eggs can be killers.

Pretty soon, the most coveted dinner party guests will be microbiologists. If you know any, you should cultivate them. Germs are coming back into fashion.

A lot of people have problems accepting that humans don’t contain any rare or precious elements, except metaphorically, like pearls of wisdom. No gold inside us, no platinum, no diamonds. No titanium, amber or crystals. Mostly water and cheap stuff, like carbon, nitrogen, sulphur and rust.

But there’s worse to come – a large part of us is not human at all – we are nine tenths made of bacteria – at least in terms of the number of cells. The gut ‘microbiotica’ is our largest organ, and possibly our most intelligent one. If the human body is run by a board of directors, the brain might be chairman, but the largest stakeholder is the colon. Definitely not a silent partner. Scientists have shown that the communication network between the gut and brain is a superhighway, the vagus nerve being the M1-near-Luton of all nerve pathways. Many neurotransmitters exist in the gut as well as the brain, and many of them were found in the gut first, such as cholecystokinin, a peptide hormone.

For decades, people were brought up to believe germs were the bad guys. After all, millions of people used to die of infectious diseases like cholera and tuberculosis, and these diseases are still prevalent in much of the world. Although such diseases are controlled mainly by public health measures rather than antibiotics, there is an awareness that resistant organisms are threatening to launch another era of infectious diseases. Already, there have been massive problems controlling outrageous punk – rocker organisms like clostridium difficile (the clue’s in the name).

I’m going to just introduce the phrase ‘faecal transplant’ and get it over with. But that’s how clostridium difficile can be treated. And that’s why there’s a website called ‘the power of poop’. The cure for bad bacteria is good bacteria. I don’t want to upset any readers who are germ phobic, though I expect they are already spraying dettol over the touchscreen and putting on a new pair of Marigolds. A small number of germs have got the others a bad name, just like badgers. We are going to have to stop killing them and start hugging them more. We will see a revolution in the yogurt industry similar to the real ale phenomenon of the seventies. Instead of Ski type products that have been sterilised and given an absurdly-soon sell by date, we will have yogurt with a bit of fizz to it with a ‘best after 2016’ label.

It’s been a while since I treated someone with a germ phobia, but I have a lasting memory of standing next to someone in their home, both of us with our hands pressed against the slimy surface of a kitchen sink, keeping them there for 20 minutes, time for anxiety levels to die down, doing some hands-on behavioural therapy. On this occasion I realised why Cognitive Behaviour Therapy was taking over – because it could provide a massive short cut. Rather than change the actual behaviour, why not look at the thinking behind the behaviour instead? This lady thought that even one germ could kill you. So, hands still pressed into the slime, we talked a bit about the germ theory of disease. People tend to assume that germs cause diseases by infecting people. This is only partly true, in that we have a powerful immune system, so that even the most aggressive organisms will not cause illness in everyone, or even a majority of people. There has to be a chink in the immunological armour, plus a sizable number of germs in the infective boarding party. This concept is called the minimum infective dose, which is usually millions of bacteria. One germ is hardly ever enough to cause an infection. In fact, landing on a human body is one of the worst things that can happen to a germ. It’s equivalent to being the first person up the ladder in an attempt to storm a castle. There are many kinds of immune response, equivalent to boiling oil. So that’s what I told her. It’s true that people can still catch cholera or tetanus, but statistically the chances of catching anything lethal from a sink in Edgbaston is national-lottery-level low (south of Hagley Road, anyway).

The problem for today though, is how to take a rational position on personal hygiene. Last week, at the seaside, I saw a child drop the ice cream out of a cornet onto the beach, only to be retrieved and replaced on the cornet and given back to the child without even a wipe. The child appeared to accept this without reaction or comment. Was the parent doing the child a favour in terms of building up immunity, or recklessly courting a nasty infection? Luckily, most germs will not get through the multiple defences of the upper GI tract, like the concentrated hydrochloric acid in the stomach. That seems to be a problem for so called macrobiotic remedies, which often fail to reach the minimal infective dose. Food outlets are stringently controlled for hygiene. In our cafe shop for instance, the volunteers had to put on plastic gloves between touching the food and the money, which slowed them down enormously, particularly if they had impaired fine movement.

This week however there has been renewed interest in raw milk, even suggesting that it may have health benefits long term. Yet, googling ‘raw milk’ suggests that it’s one of the most dangerous groceries, up there with eggs, peanuts and cantaloupes, in the food-borne infection league. All this makes it difficult to know what to tell germ phobics, in terms of psycho-education.  Recently a microbiologist told me not to eat potatoes that have gone a little bit soft or started sprouting. Apparently, they can contain very dangerous toxins. I confess, I never suspected the humble potato could be a mass murderer, though I was not surprised about cantaloupes, whatever they are.

People’s attitudes and behaviours around food hygiene seem to vary tremendously. Some of it comes down to ‘locus of control’ issues, and general perceptions of environmental threat. In the absence of a testable consensus on hygiene, we might just have to go back to old school marigolds-off behavioural therapy. If it turns out, as seems likely*, that ‘good bacteria’ can treat a range of diseases, possibly including Depression, some very careful marketing is going to be needed. For instance, the corporate colour scheme should definitely not be brown. It’s just a gut instinct.

* Dinan TG and Cryan JF, 2013, Melancholic Microbes: a link between gut bacteria and depression.  Neurogastroenterol Motil, 25, 713-719