And then there were three ....

They say things go in threes don't they?

So when I read the email with the sad news that an internet friend had died of cancer, I wondered who the third one would be this year.

The young and lovely Sharon died on her birthday in April aged 37. Originally she had breast cancer, but it spread elsewhere and her death earlier this year marked the end of a very courageous and selfless fight against an unrelenting illness. I wrote about meeting Sharon and Fiona some twelve months ago here.

My partner pointed out that I had forgotten someone. Probably because I hadn't known him, but Partner had worked with a young man (let's call him T) in the construction industry who was diagnosed with lung cancer earlier this year. Six months or so later, he too was dead in his late 30s, again from rapidly spreading secondary cancers.

So that made Claudette the third one this year after all. For those of you who read Clouds and don't know her, here is some background info.

Claudette and I came to be friends, like so many of us, because we all had blogs about our dogs. Or rather dogs with blogs, ie we write from the perspective of our dogs.

I never met her. We started our dog blogs some four years ago, she starting Lacy Lulu's blog about six months after I had started one for Pippa, and she quickly found Pippa's.

She was one of his regular commenters back then in the days when comments ran to 20 or 30!!, and often, one of the first to comment on a new post.

Unlike Sharon, but like T, Claudette had lung cancer. I don't remember reading her very early post that said she had it, but oddly, I do remember reading about her having chronic obstructive pulmonary disease (COPD) and sent some well wishes to her for that.

A couple of years ago (where does time go in blogland??) she wrote about having a biopsy to assess how far the lung cancer had spread and the news wasn't good.

The trouble with having worked in cancer services is that you tend to look on the gloomy side. And there aren't too many bright sides to look on when it comes to lung cancer. I was saddened to read her news back then, and hoped against hope that she would still be with us for some time. And - she was.

Friends all around the world rallied round to keep her spirits up and let her know she was in our thoughts. Anne, Snowball's Jie jie in Singapore, gathered a few of us together to help make 1000 cranes. This is an eastern belief, apparently Japanese, that says making 1000 paper origami cranes grants a wish for someone, perhaps long life or recovery from illness or injury.

Not too difficult I thought, being an origami fan in my youth, until I couldn't find any origami paper to buy here in Gibraltar. But then I read that any paper would do, and with a little practice, I was happily ripping up magazines with colourful adverts to make lots of multicoloured cranes.

At the same time, Brooke from Australia, who with her partner, set up the dogs with blogs internet community, organised a rota for us all to send a small gift to Claudette, so that she received something each week. Not sure how well that worked in terms of timing given the postage from Europe to America but anyway, I packaged my gifts for Claudette in bubble wrap, a card, and sent my share of the cranes at the duly appointed week.

When I read the email telling me of her death, I thought sadly that the cranes hadn't worked after all. And then I thought, perhaps they had helped to give her some extra time. Who knows?

We mailed occasionally and we shared facebook pms too. It seems every tribute I have read to her talks about messages to so many people, so I don't know where she found the time. Perhaps that says something about her generosity and willingness to make time for everyone.

Claudette was a brave woman who shared the unpleasant details of her treatment, and the side effects, with us all. Like many other courageous people with cancer, she posted pictures of herself after chemo treatment, laughing and discussing the best choice of wig.

And, realising, there were many other people out there on our dog-related network who either had cancer, or had friends/relatives with cancer, or just needed some support, she set up a new group on facebook for people to share their experiences and knowledge.

What I will remember most about Claudette is probably her honesty and openness. Her friendliness to everyone. Her lack of judgment against others.

Most of all though, what I will miss, is her droll sense of humour. In spite of everything, and suffering lousy cancer treatment, she could still come out with some witty jokes and turns of phrase that cracked me up.

Claudette brought smiles to many peoples' faces and I guess that will be how she will be remembered. Someone who shared happiness and merriment and enjoyment of life even when she knew time was running out. Sweet dreams Claudette, and to Floyd, we send you our condolences.

Three other tributes to Claudette here: Maryann, Greg and Brooke, Bren

Meditation

Some millions of years ago I did an MBA with the Open University. It suited me at the time, work paid for the fees, and I was hungry and career motivated enough to fit it in at weekends and evenings.

There was one summer school that really stood out for me. It was near Peterborough at a hotel, and pretty reasonable accommodation. That always helps. So did the fact that on the last night I gaily flitted around the place being bought drinks by people I hadn't even met all week. Oops. I staggered back to my room, and I mean, really, really staggered.

We had an interesting group, ie during the week you all get assigned to a working group of eight or so people. We got on well, and one of the instructors said they were pretty amazed by how well we gelled together. As a group, we ate together, drank together, worked after hours together, and happily chatted away.

They were nice people in the group, easy to get on with, and no, I'm not in touch with any of them. Future contacts never even came up. Just as well, as I'm not a believer in the 'we'll meet up in 20 years time in Trafalgar Square' sort of syndrome.

One of my colleagues, Robert or whatever he was called, was talking about stress to me one evening before dinner. We did this whole thing well, you see. Drinks before dinner with our colleagues for casual chat. We were probably quite exclusive, in retrospect, with our own little corner and our select group.

'Why don't you try transcendental meditation?' he suggested. I respected whatever his name was, and liked him, so I didn't dismiss the idea although I knew fuck all about it and thought it was sort of hippy beatleish stuff.

Much later, I tried to get my boss to fork out for the TM course but he wouldn't have it. Stress, I said. Worth a try though. So I paid myself.

For my first appointment, I had to provide a piece of fresh fruit and a white handkerchief, maybe something else. Well, money obviously.

I sat on a plain chair in someone's room, closed my eyes, and was given a meditational word. I still use it. Or near enough, as it is the sound that matters, it was given verbally.

I practised on the metro. I practised in bed (or rather, on the futon at the time) and invariably fell back to sleep. I practised when I was going to sleep, that was an easy one.

I went for individual tuition and later for group sessions. To be honest it was not expensive. Partly because the tutor I used was independent from official TM stuff as he thought they were too expensive for most people.

One evening we were sitting in a somewhat tawdry hotel for a group med. Whacky huh? Eight or ten people sitting around a table together meditating.

The next minute, or rather five minutes or so, I floated on air. OK, I didn't do that. I have only ever done that many years ago when I got nice painkillers in hospital that blasted the shit out of me.

But I did experience a huge release of tension as everything suddenly lifted off my shoulders. Hard to describe. I shifted slightly in the plain chair and something went somewhere into the depths of Whitley Bay. And, well, I really did feel I was floating upwards.

Group meditation is meant to be more powerful because there are more people and more vibes. I went to some more group meetings. Never happened again. Maybe it was the seedy venue that made it work.

I still meditate and it still sends me to sleep. Thanks whatever your name was on the MBA summer school back near Peterborough.

And for those of you who want the nitty gritty. I think my group had all gone to bed that last night and I was in party mode. I've also always easily flitted, and fitted, into and out of, other groups. As it was an MBA course, back in the 80s there were an awful lot of men and not a lot of women. I had to pass so many people to get through the drinking areas. Nightmare, I tell you!

I fell into bed at something like 3am and promptly picked up the 'phone to report back to base to inform my partner I was pissed. He took a hell of a long time to answer. And then I went happily off to sleep.

The next morning I even turned up for breakfast. Uff, it was hard, but I was there. Didn't bother to go for the ghastly course wind-up stuff, just packed up and went home.

A great week, and the TM recommendation was so appreciated. Doesn't really matter what type of meditation you choose to try. As they say, don't knock it until you have tried it. TM works for me. Has done for nearly 20 years.

Fire alarms and wholemeal bread

Never a dull moment at the supermarket is there?

So the other day I tripped off as usual to see if there was anything new on the shelves, stock up with paracetamol products (joke), and give myself some exercise with the forty minute walk round trip. The walk is the best bit, I could cheerfully walk there and back without going inside, but needs must.

No sooner had I picked up a pack of chestnut mushrooms (we get through a lot of those) than there is a strange whooping noise.

I looked around puzzled. Was it an alarm? Fire? Bomb scare alert? (days of going to school near a high security prison and working in London kicking in here) or just some miserable electrical failure?

Staff started walking purposefully for the door but there was no screaming and yelling. Eventually customers followed them.

I was still near the door. I sadly put down my basket which had the last remaining punnet of chestnut mushrooms and hoped to hell no-one would nick it.

As I walked out I was fascinated to see people walking out with their trollies. With goods in, unpaid for. They didn't go anywhere but stood by the entrance. Eventually the penny dropped. Or rather the pound. Perhaps they didn't want anyone to nab their trolley and take it to the trolley park and retrieve their pound deposit. How sad. And I tell you if that was a real fire, my one pound coin would be the last thing on my mind. That's assuming I had a trolley which is most unlikely given that I never buy that much.

The staff trooped across to the far side of the car park. Two staff stood in each side of the entrance doorways to block any naughty customers sneaking back in (and nicking stuff no doubt).

One bright spark had the smart idea of asking if it was a real alarm or just a drill. It seemed it was a drill. Odd, I always associated Wednesday mornings with school fire drills. Things must have moved forward in life to Tuesdays. Just as well it was a drill really because the staff gaily marching off and leaving all the customers outside the entrance about to be engulfed by a conflagration wasn't very clever. I do hope in the event of a real alarm they will tell us all to move our arses, and fast.

Then the staff started moving back inside - and - what happens next? Desperate customers can't wait to get back to their shopping and start trying to push in front of them. Dear me!! As someone politely said, 'these people need to go back to their station' or something similar. What is it with people that they have to push back into the store?

Top tip. Always give yourself plenty of time when going to a supermarket on Tuesday in case they have a fire drill.

I found my mushrooms. Someone had moved my basket to stock up the table I had plonked it on, but it had been put tidily on the floor. I had put it on a table as I didn't want anyone to fall over it in the rush to get away from the fire.

Totally separately, I always used to take fire drills seriously. There is no point treating it like a joke because fire is no joke. I know. We had one in our house when I was a kid.

First things first. Shut the doors, preferably checking there is no-one in that room. It drove me up the wall when we had our fire drills at work and people wandered out of their offices without shutting their door. The whole point of a drill is to get it right if you ever need to do it for real, not treating it like 'just another fire drill so it doesn't matter.'

Yesterday it was Partner's turn to go to the super. As he was picking up some bread, he started listening to a customer sounding off to a bakery assistant about the fact that there was no organic wholemeal bread. Clearly if there isn't any bread out that means they don't have that dough mix in the store.

Bakery assistant patiently explained this. Ranty woman kept whingeing. BA suggested that she do what 'This gentleman had done, and buy organic white instead.' Ranty woman said it wasn't the same and her husband only liked wholemeal.

Partner helpfully said 'At least it's organic. Looks like another cranky day in Morrisons (ouch!!). Have a nice day.'

As he left, RW turned away and BA stuck her thumb up at Partner. I wouldn't have their job for worlds. What can they do if they have used all the dough and new supplies haven't come in? RW should bake her own I say.

And, it has to be said I did screw my nose up when he came in and said he had bought white because there wasn't any wholemeal ........

Paracetamol anyone?

I was idly standing in the supermarket checkout, as you do. It was fairly early in the morning, and most of the checkouts only had one person going through so I hit the nearest one that seemed to be nearly finished.

The woman was chatting to the cashier about I have no idea what. Then the cashier picked up the box of Lemsip and some other cold thingy.

'I can only sell you two of these because they contain paracetamol,' she explained.

We then all listened entranced to the customer's heart-rending tale of how her husband had a cold last week ['you know what men are like', she added] and she needed to stock up the store cupboard right that minute.

Really? Now having a cold is bad news but it isn't exactly the plague or ebola.

Then there was a problem. Not only did she have a pack of Lemsip and whatever else, she also had one of those bottles of something for a cold. You can tell I don't do cold remedies.

'Does this one contain paracetamol?' asked the cashier.

'Probably,' said Ms Cold Medicine Addict.

The cashier looked at the bottle and again explained that the store policy was to only sell two paracetamol products and that she couldn't go against that.

Ms CMA started to get upset and explained how utterly vital it was that morning to buy a load of cold medicines just in case somebody in the household caught a cold in the next few weeks.

Then she pointed out that only a week or a few days ago, she had bought not only two packets of Lemsip but two packets of ibuprofen as well, which was much stronger.

Now, I am no painkiller expert, having never bought one in my 50+ years of life, but as far as I know, paracetamol and ibuprofen are not the same thing. They may well both be analgesic (pain-relieving) active ingredients that are found in other medicines, but their chemical make-up is different. Apart from anything else, ibuprofen is a non-steroidal anti-inflammatory drug (NSAID) and paracetamol is not. So, unless the store had a policy on not selling more than two packs of ibuprofen in combination with paracetamol purchases, Ms CMA's comment was irrelevant.

When I got home I decided to look up this strange rationing of paracetamol-based products.

Apparently back in the last century (ha!) new regulations came into force in the UK in 1998 that limited the number of painkillers that could be sold in one packet to 16. This was to prevent the 200 or so accidental deaths and suicides that happen every year due to overdoses. It seemed the government hoped to reduce the number of deaths by 10% - that works out at 20 by my reckoning.

Now while I don't advocate overdosing for one minute, faffing around with tablet packaging, virtually doubling the price, and supposedly limiting the sales to potentially save 20 lives wouldn't be a priority on my government list of new laws.

Especially when anyone with half a brain would just visit endless shops if they really wanted to buy lots of paracetamol-based tablets.

And this thought occurred to me while I was listening to this amazing drama unfolding in front of me. Why is Ms CMA not just shutting up and going to another pharmacy for another few boxes or bottles of whatever?

Because she didn't have any cash. She only had her American Express card. And she didn't think a pharmacy would like her buying a couple of cold remedies on her card. Even the cashier had suggested she go over to the pharmacy branch of the store and buy a couple of extras.

Meanwhile, the till next to me had seen at least three customers through in the time I had been avidly listening to the pill opera. I contemplated moving my half dozen items across for speedy service. But no, I was too gripped to find out what happened next.

'Shall I call the supervisor?' asked the cashier wearily.

'Yes please. I'm not happy with this. AT ALL,' said Ms CMA.

To be fair, she did keep apologising to me for the delay. Hey, free entertainment. I smiled nicely.

The supervisor appeared. We all listened to the same story about the whining poorly husband, the empty store cupboard, the possibility of even yet more colds in the next few days and the essential need to buy as much as possible this very minute. Oh and guests were turning up at quarter to ten. They probably had colds as well.

In spite of all those extenuating circumstances, the supervisor backed up her member of staff and repeated the two products only rule.

Supervisors get paid more to avoid confrontation and think smart. 'Shall I take these over to the pharmacist and see if they will let you buy all three?' she asked.

Ms CMA agreed. Off trotted the supervisor. The remaining items were all checked through the till and Ms CMA was given the bill.

Another problem. The cashier had rung through two of the paracetamol products and the supervisor had walked off with them. Ms CMA wasn't happy paying for them when she didn't have them in her sticky little hands.

Luckily the supervisor came back, and said - guess what? - the pharmacist wouldn't allow the sale of more than two products. I don't know how I kept a straight face.

And I'm thinking when I have a cold, I drink weak black tea, hot water and lemon, sometimes with honey, and if I could find the energy I might consider rushing out to buy a bottle of whisky to slug into it as well. I never do, but it's always an option. This reliance on Lemsip et al was fascinating me. I began to wonder what I was missing out on.

The cashier started ringing my items through. I wondered if I would be allowed to purchase toilet cleaner without ID or a prescription in case it could be toxic even though it was Ecover, but it went through without a murmur. So did the three bottles of cider for a fiver on special offer.

Ms CMA and the supervisor were still in deep discussion. I was still listening. Ms CMA repeated her assertion that she had been sold a million painkillers the previous week at the same store by someone else.

The supervisor looked very serious. 'If we find out who that was they will be in deep trouble,' she said ominously.

I could understand Ms CMA being racked off with what appeared like a bureaucratic petty store policy. Especially if she thought she had bought the same thing a short while before.

But hectoring and bullying the cashier was unreasonable and potentially putting someone else's job on the line because she wanted to prove her point and couldn't be arsed to go to another pharmacist to stock up that empty store cupboard was downright selfish. If the store has a policy, it isn't up to a cashier to break it and risk their job, and it is beyond the pale to dob someone in who may have sold you something in error previously.

In fact reading up on it, I doubt they did. An excellent thread here on a mountain biking forum for some bizarre reason !! pretty much summarises everything about the whole issue.

Must register on that forum. Wonder if they know as much about bikes?

Back to the checkout. Ms CMA and supervisor were still deep in discussion (?) I paid. 'Have a nice day,' I said, and grinned at the cashier. She smiled back.

Seriously though, and I guess most of my readers will know this. Cold medicines do not get rid of the cold. The analgesics lessen the headache and the other stuff decongests your nose for easier breathing.

I wonder what people did before Night Nurse and Lemsip? I use pine and eucalyptus essential oils for decongestion. The hot drinks I've already mentioned. Good food helps. Carnivores can indulge in beef tea or chicken soup, I tend to go for anything curried or with chilli/cayenne in it, a miso soup, or a vegetable soup. Headaches wear off, probably in a not dissimilar time to the effect of a painkiller.

There is life out there without cold remedies. But if you do choose to indulge in them, read the active ingredients listed on the packaging so you know what you are buying, and make sure you read the information leaflet so you don't accidentally overdose. No more than eight paracetamol in 24 hours. Shovelling in potentially dangerous drugs because you haven't informed yourself isn't clever.

To summarise:

1) I don't see any circumstances where it is acceptable to bully cashiers or supervisors, even though store policies can be frustrating for customers. If you do want to have a go at someone make sure it is at least a supervisor, or better still a manager - but not a checkout operator. They are not paid to make decisons about store policy and don't deserve to be the butt of our frustration.

2) If you take a load of paracetamol or any other painkillers for colds, please try to learn about what you are taking. Read the information leaflets and learn about active ingredients so you know what the risks are and what any adverse reactions may be. This applies to any drugs you may be taking, including prescription drugs. ALWAYS read the information leaflets. If you can't read or the print is too small, ask someone to read it out to you, or ask for a large print version (well, I live in hopes they may be available).

3) Consider using alternative ways of alleviating the pain involved with the common cold - which are usually a sore throat, throbbing head, blocked nose. Your cold isn't going to go away any faster or slower regardless of how many paracetamol or other cold remedies you take. And preferably stay at home, if possible, so you don't pass it on to someone else who really doesn't want your grotty cold.

Moving on

We all need to move on of course. Don't we?

From our memories, from things that didn't go right, from things that we couldn't influence.

There is a fine line between commemorating the past and dwelling in it.

Since my parents died, I have spent years dreaming about them, but recently, they have left me alone. So have the horrid work situations which also haunted my dreams.

Friends and lovers who are in the past? That's where they are consigned.

Old national wounds? Spain and Arab nations claiming each others countries? Because they possessed them years ago? I don't think so. Do Ceuta and Melilla want to be Morrocan? Does Andalucia want to be Arabic? And does Gibraltar want to be either Spanish or Muslim?

Do the Falkland Islanders want to be Argentinian?

As feminists, there is not much point commemorating our past victories when we are still stuck with our discriminational problems.

And for animal rights activists, there has been some progress over the years but it is small.

When this sort of activity happens - we still live in a sad and abusive society

http://www.bbc.co.uk/news/uk-scotland-glasgow-west-14817582

And finally, yes it was bad when the Twin Towers was hit, yes it was bad when Atocha station in Madrid was hit, and yes it was bad when London was hit as well.

Going over it every year doesn't help, it encourages resentment and hatred.

It is too raw and too recent. Reviving it every year really doesn't help.

Get rid of the vitriol and work out how to live together. Or at least in peace and without war.

Female suffrage? Equal rights anyone?

A friend posted something on FB about celebrating the anniversary of female suffrage.

The article was from an American newspaper dated yesterday because the 26 August 1920 was when women in America got the right to vote. (Link here and if you are really suffering from insomnia check out the comments)

Well that's good - America preceded the UK by some eight years. But being in a peevish mood I moaned about Americans celebrating their 81st anniversary of female suffrage. Hardly a 'special' anniversary, and as far as I could read - no-one died to further the cause of female suffrage in the USA.

One of my friends pointed out that we can all be parochial and it is good to share our experiences and history from different countries (OK she didnt say all that but I think that's what she meant - sorry A, if I misunderstood). I hold my hand up straightaway and confess to being parochial.

But who, British, has not sat in history classes studying 19th century social history for 'O' level without learning about the suffragettes? And that Emily Davison was killed under the king's horse at Epsom? And to be really honest, who remembers her name? - rather, we all remember the Pankhursts. If Emily died in the cause of women's suffrage, other women went to prison, went on hunger strike, and were force fed with tubes into their stomachs. These women fought and suffered to ensure that other women got the vote.

So my view of female suffrage is based - narrowly - on what I learned about my own country's history. The same friend who commented about our parochial mindsets also pointed out that perhaps the American suffrage was needed by the temperance movement to achieve Prohibition. Another interesting thought.

Anyway, moving swiftly on away from the UK and the USA - and onto New Zealand. For those of you who don't know, New Zealand has been a trail blazer in equal rights for women. Women in NZ were granted the right to vote back in September 1893, voting in their first election in November later that year.

Not only that but NZ can claim to having a woman mayor in the same year, the first time the office had been held anywhere by a woman in the British Empire. Good one New Zealand. For anyone interested in the right to vote, here is an interesting list of when women were granted suffrage across the world. I say granted, because - that's what it was/is - something that should be a right but happens to be granted by those in power who finally succomb to acknowledging they can no longer wriggle out of it. list

Back to NZ. If NZ was hot off the mark with giving the women the right to vote, they were hellish slow in giving women the top job of head of state - prime minister. Even the UK had managed it during the 20th century before NZ, although not, of course America, which still awaits a female leader in the 21st century. Confronting their prejudices head on, Americans chose a half black man in preference over the incredibly brilliant Hillary Clinton.

Hell, who wants a bright woman running the world? I did. And I was gutted when a load of my American feminist friends seemed to think that choosing a black man was such a right-on statement of their principles when they could have voted for Clinton. Bollocks. They should have worried less about their right-on racist-friendly credentials and just gone for the right person. I thought Clinton had some excellent ideas, was sound on so many issues and was such a serious contender to lead America - and truth be told, to lead the world, because let's not deny it, that's what America does. My perspective wasn't about - let's back the woman because she's a woman - or I would be espousing Michelle Bachmann or Sarah Palin as super duper candidates for anything and everything. Actually I wouldn't choose either of them to be the cashier at my local supermarket but that's just my view.

NZ's first woman prime minister was Jenny Shipley, came to power in 1997 and served until 1999. She was succeeded by Helen Clark who served until 2008. But if NZ was slow off the mark to have a woman prime minister, the country still managed to hit the record books as one of the few countries in the world to have had two female heads of government, and one of only two countries to have two female heads of government directly succeed the other.

A couple of soundbites about Shipley. A member of the NZ National Party, she was the first NZ PM to attend the gay and lesbian hero parade, and achieved the lowering of alcohol purchase age from 20 to 18. She now has business interests in China.

And on Clark - she was a member of the Labour Party and served as prime minister for three terms. In 2009 she became Administrator of the UN Development Programme - and the first woman to lead this. Another milestone for Kiwi women.

I had better mention Australia as they are pretty near neighbours. After NZ granted the vote to women back in the 19th century, the Australian states followed pretty soon afterwards. At this point I have to mention Julia Gillard - how many of you (non-Antipodean friends) have heard of her? I hadn't. She is the first woman prime minister of Aus. Born in Wales, I might add, Barry, actually. Only the second prime minister of Australia who was born outside Aus.

Gillard has some interesting views. Pro-choice ie supporting women's rights to abortion, but, she doesn't support gay marriage. She wants a sustainable Australia - which translates to anti-immigration. And she wants a republican Australia. Just to add, Quentin Bryce is the first woman Governor General of Australia. (Who she? I hear you ask)

When I was a kiddy in the 70s, women prime minsters were all the rage. Bandaranaike ( I never did know her first name), Indira Gandhi, and Golda Meir. I was indoctrinated with my father's skewed views - 'better a bad prime minister than a good woman pm'. This from the man who became a devoted follower of Margaret Thatcher. Of course, he dismissed Bandaranaike, Gandhi, and Meir. They came from third world counties or something like that.

Hello daddy. These third world countries, Sri Lanka (then Ceylon), and India, that were inhabited by wogs, happened to be part of the British Empire or supported by it, and well, the truth is, their populations weren't as sexist as you were. Electing a woman as head of state was not a marker of a country's stupidity. Israel was clearly an anomaly in the scheme of things, as my father had some good Jewish pals, and obviously they would never have knowingly voted for a woman prime minister.

But looking at the list of women leaders in the world, I am amazed to see that of the early prime ministers, the first one was an acting German Jewish woman in the Ukraine - Evheniya Bohdanivna Bosch, the next three were the trio I mentioned above, then, there was Élisabeth Domitién, from the Central African Republic, who was premier minister from 75/76 - I had never heard of her - and then, we get to Margaret Thatcher. Only the sixth woman prime minister in the world. And to be really blunt, the first one from an influential western country.

list here .... to be continued .... because this is enough for now

Surviving

I thought a brief explanation about survival rates might be helpful.

Before I started working in the health service, I had no idea what the concept meant. I figured it meant you either lived for ever or you died. But on joining the health service, I learned pretty quickly.

An 80% survival rate doesn't mean that eight of ten people will live for ever and a day after being diagnosed with X illness or disease. It refers to a five-year period. Not that you will necessarily live out your so-called normal life until 70 or 80 or 90 or whatever. Just that you have a good chance of being alive five years after diagnosis. And that doesn't even get into the issues of reoccurrence or metastatic cancer for example.

I must say as with a lot of communication, the NHS (UK health service) has improved its presentation of statistics. You can actually look up five year survival rates for cancer. - Here for anyone interested. If you look at that cursory weblink, you will note that breast cancer survival rates are above 80% which is a good thing. Similarly the rate for testicular cancer is 97% and prostate cancer is 80%. Malignant melanoma is between 80 and 90%.

Why then are people jumping on bandwagons to promote our awareness of any of those cancers?? Pancreatic cancer has a survival rate of less than 4%. Liver cancer is similar - the graphs I looked at didn't mention the rate and also used one year survival rates because they look better. Lung cancer is around 8%. As is oesophageal cancer. Stomach cancer - 15%. Ovarian cancer is one of the baddies too but that is a whopping 40 odd %. Colorectal is one of the three 'common cancers' along with lung and breast. The survival rate for colorectal is just over 50% - that is really poor. When do we hear about any of those cancers??

Pause for a quick anecdote. We sold one of our houses to a medic. An eye surgeon. He had a Land Rover so mostly Partner and he talked Landies. But at some point they flipped onto a clinical discussion and Partner pointed out that survival rates were based over a five year period. Eye surgeon/Landy friend was bemused and asked how Partner knew that. Pretty obvious really given the fact I was responsible for cancer services. Then 'Well yes but not many people know that." Maybe not, but they should. Telling people they have a survival rate of 80% or 20% or whatever - without telling them it is over five years is downright misleading. The Mayo clinic - as ever - has a good and clear article here.

Now, while I am on about survival rates, I need to mention lead time bias. I was rather up on this at one point and could quote every relevant piece of research under the sun. Put very simply - lead time bias is about the difference between the start of your illness and when it is diagnosed or discovered, and the perceived impact earlier detection has on survival rates. Actually for once, Wiki puts it incredibly well. Check it out here.

Basically for example, if you are diagnosed with breast cancer from the screening programme, you may well find out that you have cancer sooner than you would if the cancer was diagnosed when symptoms appeared (normally small lumps in the breast/axilla areas). When the cancer is diagnosed doesn't affect the overall life expectancy (and therein lies a whole issue about waiting times) but it can skew survival rate figures if it is detected early. If you are diagnosed earlier - you may well 'appear' to live longer. But life expectancy isn't or shouldn't be dated from diagnosis, it is from when the disease starts. There is a huge difference there. Anyway, check out the Wiki link because the diagram on there explains it very simply. Wiki also points out the additional impact of mental anxiety of earlier diagnosis.

Let's go back to survival rates and lead time bias. For women diagnosed with breast cancer in 2001-2006, five-year relative survival rates have reached 82% (England only) compared with only 52% thirty years earlier in 1971-75. Ten year survival rates for women diagnosed with cervical cancer have improved from around 46% in the 1970s to 64% for the latest period.

Lead time bias anyone given the screening programmes??

Cancer - and that time of year

Oh dear. It is that time of year where women start posting crass comments on facebook about the colour (of their bra), the state (of their hair), where they like it (left their handbag) and now the latest one, which I can't possibly reveal - or remember - what it is.

If anyone is interested mine were white, long and messy, and hidden under piles of clothes.

All to raise awareness of breast cancer.

Do you know anyone who hasn't had breast cancer? Unlikely.

UK stats for 2008 say that of all cancers in women, 31% are for breast cancer. Or a different statistic says that the risk of developing breast cancer is i in 8, ie 12%. You can do anything with statistics.

I have met some great patients with breast cancer, have some lovely friends who have had breast cancer, and I can't begin to know how they manage to smile and keep going every day after their crap treatment, and everything that really goes with a cancer diagnosis.

But what gripes me about this facebook trivialisation is that I don't see how it helps anyone.

Why does making a sexually suggestive comment raise awareness of breast cancer? Why do we need to raise awareness of breast - or any other - cancer?

What we need to do is generate a little more knowledge and empathy.

There is nothing funny or light-hearted about being diagnosed with a potentially life-threatening disease.

Openness, honesty, and supporting friends seems to me to be a far better way to go.

Three friends come to mind immediately - one who has set up a facebook support group for cancer survivors and caregivers, another, who has posed for photographs bald and naked. Another has used her talented skills to help other women with chemo problems find the right wigs while they are going through hair loss.

To me, that is what raising awareness of cancer is about.

Health service rationing

Everyone knows health care is rationed. Don't they?

Whether it is funded, or not funded, by government or insurance companies - or you pay for it privately - it is still rationed because money is finite. It is just not possible to fund every medical treatment under the sun, and people who complain about that are amazingly naive. The difficulty comes when deciding exactly what to ration and how to do it.

Here are a few random tales, all of which were publicised for whatever reason at some point so I'm not breaking any confidences. Let's start with breast implants. I was happily sitting at my desk when the 'phone rang. It never stopped all day. When I put it down it rang again, and my secretary was in and out all day with messages from newspapers, radio and tv stations all wanting me to call them back.

Why? Because one of our local GPs had referred a patient for breast enlargement so that she would be more successful as a topless model. Some background. Well, naturally the NHS isn't - or wasn't - some sort of support agency to the Job Centre. It's prime function is not one that offers surgery to anyone and everyone who feels they might do better in life if they were 'better' looking. Or perhaps, looked different would be a more appropriate description.

And indeed, being referred for surgery to help her topless modelling career wasn't how the doctor got the referral through. His patient was suffering from low self-esteem due to her small breasts. If she didn't have depression then, no doubt it would set in later. The operation cost slightly over two grand. Not huge in the scheme of things.

Working in public sector press and media I found it useful to not have a view on things. It made it much easier to churn out my party line, and not get involved in any discussions and - say the wrong thing. This GP wasn't a fundholder so it fell to the health authority to fork out the £2K+ - and that's why I spent all day politely telling every media caller that a) we couldn't go into detail about individual patients and b) it was up to every doctor to exercise their clinical judgement appropriately when referring patients for surgery etc etc etc. I was quite happy with this line and it was dutifully repeated by everyone who called me when they published or broadcast it.

Some years later on, I can allow myself an opinion. In no particular order:

1) I still think it is up to each and every doctor to decide what is the right treatment for their patient. Up to the patient then to decide whether to take it up.

2) Suffering from lack of self-esteem and/or depression is not good. Just because mental illness isn't obviously visible doesn't negate from the seriousness of the illness and the trauma that people suffer. People who are mentally ill and fall in and out of big black holes do not have a good time - and like other chronic illnesses - it is always with them.

3) I have probably also had low self-esteem from having small breasts, although becoming a topless model wasn't high on my list of career choices. It is not nice to pass people in the street and hear them saying they can't decide whether you are a girl or a boy. Not helped by the fact I was tall and had shortish hair. Then there are the ones who quite bluntly tell you that you have small breasts, that you are flat-chested, that you look like a boy, and that you don't look remotely sexy. And this last point is the issue.

What on earth is it about our (male) society that imposes such conditioning on women they feel they need to have surgery to get bigger breasts? Or that the aspirations of a young woman are to become a topless model? I know that appearances are important and that we are all judged on them. But women are judged in a different fashion.

We all know the ideal woman. She has a slim but curvaceous body. Long well formed pins, reaching right up to her cute and firm arse. Oh, I should add that those pins are immaculately smooth and shaved every day so that a chiffon scarf will drop straight down them. She has long sexy hair, big eyes, and a beautiful Colgate pearly white smile. And naturally her breasts are NOT small, but just the perfect size, firm with a suitable amount of cleavage for men to peer down.

Who creates this ideal woman? Men. She's not a woman. She's a sex object. And anyone who wants breast enlarging surgery is sadly conditioned to believe all this. They are buying into the male fantasy of the perfect woman sex object. And they aren't doing any favours to women who don't want to be judged on the size of their breasts. A few years ago I met someone who had undergone breast enlargement and had her eyes tucked. She looked top heavy and the skin around her eyes was so tight. I think she could have spent her partner's money more wisely.

So these days, I would be sadly disappointed to hear about any GP referring their patient for breast enlargement. For whatever reason. It seems to me to be treating the symptom and not the cause, but maybe that's what medics do. Some helpful counselling and assertiveness skills would be a lot more helpful - IMO.

Some of the longest waiting lists in my NHS days were for plastic surgery - and the two critical areas were for burns, and for reconstructive surgery following breast cancer mastectomies. Technically I suppose one could argue that reconstructive surgery is similar to breast enlargement and could well involve self-esteem issues - but at the end of the day, I don't think there is any comparison between a woman who has gone through surgery and chemotherapy, that was not something of their choosing and a young woman wanting bigger tits so she can appear on page 3. Incidentally, I read later that her modelling career didn't last long. So, in terms of rationing - I would not want to see the NHS spending money on breast enlargement for women, whether for self-esteem issues or not. There are other ways to gain self-esteem.

Onto another controversial area. Fertility treatment. We decided that we needed to introduce criteria for this service. Which is another way of saying rationing the service. We put a paper to the board with extremely tight criteria. The chief executive had primed the chair about it. She was expected to approve the paper.

But she had been lobbied by some of the local fertility action groups. And - she told me in confidence, and quite a few others as well - that she had been unable to have children back in the days when fertility treatment didn't happen on the NHS. So when it got to the critical moment at the board meeting - she deferred the decision for consultation with our local groups. Great, another two months of indecision.

The proposal got watered down of course. The age limit went up to nearly 40 (conception is less likely as you get older so treatment for older women was less effective), we had a clause requiring residency in the area for a couple of years, something about a stable relationship, and there was probably something about only three goes at it, or something similar.

Out of those of us who originally discussed it, there was me - the only woman, and some 40 or 50 year-old men, who had children. Not exactly the most empathetic group for infertile women. Yes, we heard about the angst. The emotional trauma for women who couldn't fulfil their lives by not having a baby. The sheer mental distress of it all and how it affected their relationships. And how wonderful it was for those who did eventually conceive. That's great. Because in a world of limited resources - you stand up and tell someone who is being deprived a few months of life for an expensive cancer drug that your need for an IVF baby comes first. I couldn't.

Next up came screening for Down's Syndrome. But by then I think we had lost the will to ration, and this really was just a long-winded exercise to write down some firm criteria about when and whether pregnant women should have blood tests, ultrasound tests or amniocentesis.

But a few years later, with a change of directors - rationing picked up its lively head again and we decided to hold a public meeting and discuss how to spend our so-called development monies. These were peanuts in the scheme of things as virtually 90% of the budget is already spoken for as soon as it is allocated. Those of us responsible for some of the key services - maternity and child health, elderly services, mental health services, cardiothoracic medicine, and cancer - were asked to present our 'case' for investing in our service.

I have to say it was rather a tabloid exercise. Asking people to decide how to spend money based on a few presentations over a couple of hours? I didn't present my case. I asked a clinical director for cancer services and a breast cancer patient to make the case. I figured they could do a lot better than I could have done. They did. We 'won' the debate. Always choose the right people to give the message. And there ends my mixed post on rationing.

In theory it should be based on clinical effectiveness - ie don't provide services that don't work. Secondly, don't provide expensive services that either don't work or when there is a cheaper and as effective service available.

Most people don't want to accept, or don't like the fact that rationing exists. They also don't want to make the decisions themselves but they sure as hell want to blame those of us who can't make a health service budget into the bottomless pot of gold at the end of the rainbow.