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INSIDE HEALTH 鈥� Programme 4.

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TX:听 23.01.18听 2100鈥�2130

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PRESENTER:听 MARK PORTER

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PRODUCER:听 FIONA HILL

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Porter

Hello. 听What causes ill health? 听Here at Inside Health we tend to focus on the more obvious culprits, like bacteria; viruses; and genetic mutations, but later today we turn our attention to more subtle influences, social factors like work or lack of it and deprivation.

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I hear from the former Chief Medical Officer for Scotland about the so called 鈥淕lasgow effect鈥�. Why is life expectancy so low in the region?

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And Margaret McCartney visits a clinic specialising in asbestos induced cancer, her home city having one of the highest rates in the world.

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But first, a bit of tech and a major advance in the world of prosthetic limbs.听 Artificial legs with microprocessor-controlled joints to improve mobility and stability.

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Around 6,000 people in the UK lose a leg every year due to vascular problems, trauma or diseases like sepsis and cancer and others are born without limbs. 听Most depend on an artificial leg to get around, but while Paralympians can make using one look easy, in reality it is anything but.听 听Far from waltzing around the Strictly ballroom floor many above knee amputees have to use two sticks to get about, and the limitations of the standard artificial knee means falls and stumbles are common.

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But microprocessor power is set to change that, and a new generation of intelligent knees is now going to be available for the first time on the NHS in England. 听You can already get them in Scotland and Northern Ireland.听 The new knees can adjust the stiffness of the joint to match the individual鈥檚 gait and activity, and even have an anti-stumble facility to reduce the likelihood of trips and falls.

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So, on a snowy winter鈥檚 day, I joined Imad Sedki, Consultant in Rehabilitation Medicine at the Royal National Orthopaedic Hospital in Stanmore, to find out just what difference they make.

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Sedki

The knee does not have any motorised parts and it has a computer in it that is monitoring the gait through sensors in the knee, I think hundreds or even thousands of times a second.听 And try to predict also what happens in the next step, so that it becomes softer or more stiff, depending on the person鈥檚 weight, speed or the surface they鈥檙e walking on.听 So, it鈥檚 much more clever but it is still passive, it鈥檚 still not going to allow people who cannot walk to walk, doesn鈥檛 replace the muscles, but it allows people who can walk to walk easier and to walk safer.

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Porter

Can you tailor the knee to the individual, in terms of its response?

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Sedki

Yes, some software you need to do a lot of tweaking in the beginning, when you set the knee up, others actually it does learn from the person, so as the person walks more and more the software is set to evolve itself or improve the settings depending on the person鈥檚 walking.

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Another thing that it does, if you, for example, carry a little bit of weight, so the mechanical knees do not know what the person鈥檚 weight, we have to set it up to match the person鈥檚 weight and if they carry a bag or something else then it becomes different.听 Microprocessor knees will adapt to these variables all the time and it鈥檚 clever in doing that.

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Porter

What do people notice who鈥檝e switched from the mechanical knee to this new variant?

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Sedki

The main comment I hear is that confidence improves, they are able to walk now on more difficult surfaces.听 The thinking of the walking is reduced, so the main comment from new prosthetic users is when they walk outdoors they have to look always at the ground and they cannot enjoy the scenery unless they stop and they look around.听 So, the thinking of the walking now moves from the brain to microprocessor-controlled knee, brain and then the person can think less about that.

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Porter

With three inches of snow and icy slush outside it is a challenging day for people with two good legs, but treacherous for someone with a prosthetic one. 听But Naitik Patel, one of Imad Sedki鈥檚 patients, has braved the conditions to tell us about his new microprocessor knee.

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Patel

This is the first winter using microprocessor knees actually and I think to a certain extent it is a psychological as well, it gives me a lot of confidence with these knees.听 I was thinking that if I can get a parking right outside the door it would be better but still I could walk up and there was some ice and it was 鈥� it was fine, it has made a lot of difference, nice, yeah.

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Porter

And when you were using a mechanical knee you were dependent on two sticks?

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Patel

Yes, I had two because I wasn鈥檛 confident enough, the mechanical knees, if I stumble up on an uneven surface or something there was no way I can control the knee from bending and prevent a fall.听 So, these knees understands my body movement and it recognises a stumble and gives a security and that鈥檚 why I鈥檓 now more confident to walk with one stick and my other hand is free.

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Porter

Because a lot of us take having a free hand for granted, we carry a bag, we hold a drink, but actually for you that鈥檚 a big difference.

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Patel

It鈥檚 a big difference, it is a big difference actually.

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Sedki

Did you find yourself being able to walk a little bit longer distance outdoors or did that change?

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Patel

Oh yes actually I do walk a little bit longer distance.听 A couple of weeks back only I was in town and I walked quite a lot actually, on the Oxford Street and Regent Street area.听 So, yes, I could manage that.听 And getting up and down the stairs is much, much smoother for me now.听 The support I got from the physiotherapist here teach me the techniques.听 So, going up and down with these microprocessor knees is better than the mechanical knees, definitely, definitely.

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Sedki

So, there was certainly a learning curve鈥�

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Patel

Correct.

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Sedki

It鈥檚 not what you call plug and play, you have to actually learn how to use it.

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Patel

Yes, correct, yeah.

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Sedki

Very good.听 So, are there any downsides of these knees if at all, can you think of any negative things or some nuisances about the knees?

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Patel

Not that I can think of.听 The only thing is if I forget to charge it, the next day it鈥檚鈥�[laughing].听 That鈥檚 it, but it doesn鈥檛 happen that often, once it happened.

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Porter

Prosthetic legs with the new smart knees are expensive, but NHS England has been convinced by data suggesting that, in the right people, they are cost effective with the initial price being offset by reduced injuries due to falls, better general health due to increased activity, more independence and people being able to return to, and stay in, work. 听And NHS buying power has seen the cost fall from as much as 拢40,000 a leg, to closer to 拢10,000.

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NHS England鈥檚 decision has prompted a retro-fitting programme at specialist centres like Stanmore.

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Sedki

Most centres in the country now are looking at their patient group and then we select the patients who might be suitable for upgrades.听 And then we invite them for meetings with us to explain to them the benefits and the disadvantages of these knees.听 We then prioritise them depending on need.听 So, they will be the ones who have a lot of falls, for example, high risk of falls or high risk of an injury because of a fall, would be a priority.听 The ones who require the knees for [indistinct word] requirements would be lower priority.

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Porter

I expect you鈥檝e always wanted to be using these knees in your NHS practice, you鈥檝e known they鈥檙e out there, you know what they can do.听 How does it feel to finally have them at your disposal?

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Sedki

Oh, absolutely great, sometimes the patients would have an instant improvement.听 You can see something click and then the smile on the face.听 Some others would take a little bit longer to improve.听 But in most cases, they can tell that it鈥檚 going to be good from moment one and in some cases, there鈥檚 a very emotional day in the fitting room for all of us, for the whole team.

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Porter

Have other people noticed difference in you?

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Patel

Yes certainly, for the last couple of months in office when I walk around without sticks, everybody made a comment that yes you are walking much faster and much confidently and without sticks that made me proud as well, that yes, I鈥檝e achieved something.听 And people have recognised that.听 And also, I like food, so I started cooking and I can move around in the kitchen to go to different shelves and cook actually without any problem as such.听 Before鈥�

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Porter

With no sticks?

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Patel

With no sticks, of course, yes.听 So, I can carry a pot from one place to the dining area and things like that, it has helped me.听 So, it might be small things but it has made a lot of difference in the life actually.

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Porter

What about falls, has it made a difference to that?

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Patel

Since I鈥檝e been using this 鈥� June, July 鈥� I didn鈥檛 have any fall actually with these knees actually.

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Porter

The way you said that, looks like you had to think about it then鈥�

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Patel

No, yeah, I think鈥�

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Porter

Now you think about it you suddenly realise.

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Patel

Yeah exactly, I鈥檓 just surprisingly 鈥� actually I鈥檓 just thinking that in the last six months I haven鈥檛 had a fall actually.

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Porter

Naitik Patel, who appears very happy with his new smart knee.

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Glasgow, Scotland鈥檚 biggest city once had a well-deserved reputation as a leading centre for heavy industry, particularly ship building on the Clyde.听 But today it鈥檚 also become known for the poor health of its citizens, whose life expectancy falls well below that of people from similar cities across the UK. 听A disparity that has been called the Glasgow Effect 鈥� a term coined a decade ago to describe poor outcomes and inequality across the region.

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Sir Harry Burns is Professor of Global Public Health at the University of Strathclyde in Glasgow and a former Chief Medical Officer for Scotland.

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Burns

Compared to Liverpool and Manchester, Glasgow, in terms of premature mortality, mortality below the age of 70, however it鈥檚 defined, Glasgow has about a 30% higher premature mortality rate than these other two cities.听 And, all three cities had a collapse in industry and so on, so something was different about Glasgow compared to similar cities in England.听 And that provoked a huge amount of research and so on that continues to this day.

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Porter

And so far, what have we managed to uncover, what do you think is behind this, I mean, startlingly discrepancy?

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Burns

It鈥檚 complex and I mean that in a technical sense.听 We doctors were trained to think of cause and effect, diseases have a cause, if you find the cause you can maybe prevent the disease or treat it or whatever.听 But what we鈥檙e talking about here is a whole set of social and economic and environmental circumstances that have come together, I think, to create within people living in west central Scotland a very profound lack of the ability to hold on to wellbeing I think.听 And a lot of that you can trace back to the 1950s and 鈥�60s when industrial policy and housing policy and so on, really made a lot of really significant errors for the people in this area.

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Porter

What sort of errors?

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Burns

Well, collapse in heavy industry and those heavy industries were never adequately replaced and cities in England, you got consumer electronics, you got car factories and so on, none of that ever took hold in west central Scotland.听 The housing and planning was a disaster in Glasgow.听 Traditional housing was replaced in ways that shattered communities, that broke up communities that supported each other for many, many years and people would be dislocated all over Scotland.听 If you had a job, if you had skills, people were taken out to new towns and the people who didn鈥檛 have jobs and skills were left behind, thereby creating even more distress for the people who lived here.

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Porter

Looking at the causes of the premature mortality, what is it that鈥檚 claiming Glaswegians early?

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Burns

When we talk about reduced life expectancy we tend to assume that that鈥檚 because of increased risk of heart disease and cancer, because that tends to be what kills most people at the end of their lives.听 What colleagues at Glasgow University discovered was that the widest disparities in mortality did not occur in the 60s and 70s but instead occurred in the 20s and 30s and early 40s.听 It was young people and particularly young working age people when a gap in mortality between rich and poor was at its widest.听 And the causes of death in that group were predominantly drugs, alcohol, suicide, violence and accidents.听 So, it wasn鈥檛 things that were necessarily driven by diet and exercise, but it was socially determined causes of mortality.

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Porter

So, it wasn鈥檛 that the people in their 60s and 70s were necessarily dying five years early, it was that some people were dying 20, 30, 40 years early?

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Burns

Yeah, and these were people who were born in the 鈥�50s and 鈥�60s.听 They were born at this time of upheaval and uncertainty and increasing poverty and social dislocation and so on.听 And therefore, I began to look at the drivers of this kind of adverse outcome that occur in early life and the science behind that is really very powerful.听 Adverse childhood experiences, adversity in early life, leads to increase risk of substance misuse, increased risk of criminal convictions for violence and so on.听 But it also, and again this is data from the north of England, it also doubles your risk of chronic ill health in later life.

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Porter

It鈥檚 one thing researching a complex association like this, which sounds like it鈥檚 been going on for nigh on a decade now in earnest, but what can you do about it, what has been done about it?

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Burns

Well not nearly enough I would argue.听 As a surgeon in Glasgow I would often see patients come in with alcohol related gastrointestinal bleeding or pancreatitis or whatever and I鈥檇 say to them 鈥� unless you stop drinking you鈥檙e going to die.听 And their response would often be 鈥� I don鈥檛 care, life鈥檚 not very nice, I don鈥檛 care, drink makes me feel better.听 So, there was this sort of negativity.听 So, to do something about it we鈥檝e got to tackle that social and environmental and economic dislocation that people feel.听 And that requires all the public sector to work together to help people regain a sense of purpose and meaning in life and that鈥檚 not easy.

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Porter

A decade on, is there any glimmer of hope there, has there been any improvement, any change?

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Burns

Well, life expectancy is improving but the gap isn鈥檛 really narrowing much in terms of 鈥� there鈥檚 a 12-year gap in life expectancy between the most affluent 10% and the bottom 10% of males and it鈥檚 slightly 鈥� it鈥檚 about the same鈥�

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Porter

What about overall mortality, in terms of comparing with like cities in England?

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Burns

Well yes, premature deaths 鈥� deaths under the age of 75 鈥� the gap in deaths has reduced since about 2002.听 There are improvements in terms of that death rate in early life but it鈥檚 not happening nearly fast enough.

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Porter

I mean looking at the 2017 figures it鈥檚 still got the widest mortality 鈥� Glasgow 鈥� inequalities in western Europe.

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Burns

Oh yes, absolutely.

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Porter

And the lowest and most slowly improving life expectancy in western Europe.

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Burns

Yes, the life expectancy figures are much more comparable with eastern Europe.听 And the researchers looked at areas across Europe that had experienced the same kind of economic turn down in the 鈥�50s and鈥�60s and still found that they were improving things better than the west of Scotland.听 And again, in the areas we looked at we found that they had novel ways of supporting people and social cohesion and so on.听 I believe that a lot of the town planning mistakes that were made at that time underpin this, the history of Glasgow has been about doing things to people rather than doing things with people.

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Porter

How do you feel about the term itself 鈥� the Glasgow Effect?

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Burns

I don鈥檛 like it, it kind of implies something spooky is happening in Glasgow, there鈥檚 some kind of miasma coming off the Clyde that鈥檚 damaging people鈥檚 health and so on.听 I think that any other city that had precisely the same social and economic adversity that the west of Scotland faced in the 鈥�60s would have had the same kind of outcome.听 And so, there鈥檚 nothing peculiar about Glasgow it鈥檚 just we鈥檝e had a really, really bad dose of austerity 20, 30, 40 years before anyone else.

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Porter

Professor Sir Harry Burns highlighting an issue that I suspect will be all too familiar to Glasgow GP Margaret McCartney.

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McCartney

Yes, so I practise in the west end of Glasgow and I do have a foot in both camps, our practice area covers well off areas, not so well areas.听 And also accounts for a lot of people who would have worked in the shipyards down in Clydeside during the 1950s and 鈥�60s.

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Porter

Sir Harry Burns talked about the impact, Margaret, of de-industrialisation in Glasgow on public health but in a moment you鈥檙e going to be reporting on one of the consequences of industrialisation 鈥� the asbestos induced cancer mesothelioma.听 And Glasgow鈥檚 got a pretty poor record here too, hasn鈥檛 it?

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McCartney

It certainly does.听 Along with other areas in the UK that used asbestos a lot as an industrial material.听 So, Liverpool, Tyneside as well, these are kind of hotspots for later mesothelioma development.听 And asbestos was a highly sought-after material of its time 鈥� blue, white and brown 鈥� all used for different things because they are fantastic heat insulators, they鈥檙e light, strong.听 But it wasn鈥檛 until the 1950s and 鈥�60s that the link between asbestos and lung cancer began to be quite firmly established.

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Porter

And back in the day people just had no idea how dangerous asbestos would prove to be.

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McCartney

Well certainly, the real tragedy of asbestos is that there鈥檚 such a huge time lag between exposure and knowing that you鈥檝e been harmed by it, developing mesothelioma, there can be gaps of 20, 30, 40, 50 years even.听 So, Glasgow, for all these reasons, has developed a real specialism in looking after patients with mesothelioma.听 And I went to the Queen Elizabeth Hospital in Glasgow where I first met Robert Henderson, who was there with his daughter, Louise.

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Actuality

I鈥檓 just going to do your blood pressure and things.听 Is this your family.

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I am Louise, his daughter.

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McCartney

I met Robert a couple of months ago when he鈥檇 been admitted to the Queen Elizabeth Hospital with an infection. 听After retiring from 26 years in the police service he鈥檇 kept fit. 听He did half marathons, he cycled and he swam.听 But just over a year ago, he didn鈥檛 feel well.

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Henderson

I found myself being a bit breathless and my own GP, they said they thought it was just an infection I鈥檇 picked up, just go home and rest.听 Then over January I wasn鈥檛 getting any better and I had to go for a CT scan and it came back that there was a thickening of the lining of the pleural lining, which is a sign of asbestos.听 And they started talking about mesothelioma, which I鈥檇 never heard about.听 And I was like why on earth did I get that, I don鈥檛 know what you鈥檙e talking about.听 And they said it鈥檚 regarding asbestos, people that鈥檚 become exposed to it.

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McCartney

Robert is a patient of Dr Kevin Blyth, a respiratory consultant who runs the pleural diseases service here at the Queen Elizabeth. 听He also coordinates a mesothelioma service across the west of Scotland. There鈥檙e many ways, he says, that people with mesothelioma were originally exposed to asbestos.

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Blyth

It鈥檚 not just the classic shipyard worker.听 We have people who were domestic electricians, domestic plumbers who鈥檝e taken walls apart, or taken bits out of ducting to get to what they need to do and it鈥檚 been unknown to them it鈥檚 asbestos.听 You know you hear guys, especially in the Clyde estuary, where they lived near shipyards and the dust was everywhere, it was an environmental pollutant essentially.听 And you hear stories of them 鈥� the kids out the back making essentially almost like papier-m芒ch茅 balls out of asbestos and throwing it around or asbestos footballs.听 The dangers were not known.听

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McCartney

You might have been working in a job that involved contact with asbestos 30 or 40 years ago and they wouldn鈥檛 have developed the cancer until the present time.

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Blyth

Yes, yes and the conversations I have with people in clinic and we鈥檒l ask patients about asbestos and quite often they will say yes, but then their next sentence will be 鈥� but that was ages ago.听 That story鈥檚 very common.

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Henderson

I was an apprentice electrician, five years is the most I鈥檇 have been exposed to anything and they say that it doesn鈥檛 take 鈥� it鈥檚 not a time factor, it鈥檚 just where you were and the asbestos fibres that obviously I breathed in.

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Louise

What age would you have been then?

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Henderson

Oh, between say 16 and 21.

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McCartney

And if you don鈥檛 mind me asking 鈥� what age are you now Mr Henderson?

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Henderson

Oh, my goodness, 68.

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McCartney

Okay, so it was a long time ago in other words.

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Henderson

It was a long, long time ago yeah.

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McCartney

A long time indeed. 听More than 50 years since he could have been exposed to asbestos fibres. I ask Kevin whether there are cases of mesothelioma where there are no known exposures to inhaling the fibres.

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Blyth

Eighty percent of our patients will describe an exposure episode but there are patients in whom there is no exposure history and particularly it鈥檚 women 鈥� spouses, mothers 鈥� the classic is the wife who may have washed her husband鈥檚 clothes or occasionally her son鈥檚 clothes 鈥� overalls from work 鈥� and she will have developed mesothelioma from that exposure.

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McCartney

And were you aware when you were a young apprentice, working as an electrician, were you aware of asbestos then, had you even heard of it?

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Henderson

No one at that time had any idea.听 I didn鈥檛 even know we worked with asbestos.

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Blyth

Mesothelioma affects the lining of the lungs, so it鈥檚 not a lung disease as such.听 So, the asbestos fibres have essentially been inhaled, they have then penetrated the surface, the outside surface of the lung and they鈥檝e got into the pleural space, which is a very narrow membrane that surrounds the lung and the inside of the ribcage, that essentially lubricates the lung when we breathe and the fibres get into that space and they set up this chronic inflammatory process that eventually ends in a cancer.

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McCartney

Like Robert, most patients with mesothelioma first notice breathlessness and that鈥檚 because of this build-up of fluid between the lung and the ribcage. 听But diagnosis is tricky, not just because the pleural space is hard to reach.

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Blyth

The fluid samples will quite often not definitely show there are mesothelioma cancer cells.听 And so, what you need to be able to do is to get into the space with a telescope, visualise the lining of the space and take biopsies to prove what鈥檚 going on.

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McNicol

I鈥檓 Boyd McNicol.听 I鈥檝e got mesothelioma and it came as a bit of a blow because a very serious and life changing diagnosis that I got.

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McCartney

Boyd鈥檚 come in for a check-up with his wife Helen. He was diagnosed with mesothelioma almost 18 months ago. 听By the time Boyd came to this clinic he had a tiny capacity left in his lungs, which were full of fluid. 听A pleural drain was fitted.

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McNicol

Now the fluid comes out by a little kit that arrives.听 And my good lady wife, Helen here, she hooks me up and tucks me away again when it鈥檚 finish.

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Helen

I assist very ably, very regularly, it鈥檚 very routine.

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McNicol

I would describe it as a pit stop.

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McCartney

In his 20s as a young art teacher, Boyd couldn鈥檛 have known that the very fabric of the school building in the east end of Glasgow was full of asbestos.

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McNicol

There was a wee flight of stairs as you came in the door, decorative kind of aertex finish, and the tall ones would jump up and give this a punch.听 There was powdery stuff coming down out of that.

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McCartney

And that was asbestos.

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McNicol

I thought it was just aertex.

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McCartney

So, you were working in a school and there was a hole in the roof effectively.

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McNicol

There was a hole in the roof.

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McCartney

And there was powder coming down from it and that was kind of activated by kids playing in it and things as well.

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McNicol

Oh, the headmaster made an announcement to the children 鈥� don鈥檛 touch it 鈥� and of course you can鈥檛 do that with school kids, it became a game after that, they jumped higher, they punched more.

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McCartney

Boyd鈥檚 doing really well with his chest drain. 听He鈥檚 not in pain, he鈥檚 getting fitter again and he an even can run for a bus. 听But his was a relatively early diagnosis. 听Survival rates for mesothelioma haven鈥檛 improved much for years. 听The standard treatment for mesothelioma is chemotherapy, which works for some patients but Kevin Blyth would be the first to admit not nearly good enough.

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Blyth

All of us who work in mesothelioma accept that the outcomes from chemotherapy are not what we want.听 I think we should be offering patients access to a clinical trial of something which has got a good chance of working better than chemotherapy.听 And so, that鈥檚 what we try and do.听 Trials are not for everyone but we need to get to a point where we can cure mesothelioma.

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Henderson

I was told there was no cure.听 They didn鈥檛 know of anything just now that could cure it.听 But you鈥檝e got to keep on hoping that there鈥檚 something down the line.听 There鈥檚 a cure somewhere.

听

McCartney

In terms of where we are with mesothelioma cases, we鈥檝e got this time lag period, have we reached the peak yet do you think or is there more to come?

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Blyth

Well I think the disease is going to be around in the UK for many decades to come.听 So, we probably have or are approaching the peak in the UK but the tail off is going to be relatively slow and so we need to have services and care for patients over the next few decades that reflect that.

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McNicol

I鈥檓 not sad at all actually, I鈥檓 quite enjoying myself at the moment.听 But don鈥檛 let your listeners think that I鈥檓 flippant about it in any way.听 Don鈥檛 think for a minute that I鈥檓 brave, nothing brave about getting told something like this, bloody awful and I鈥檓 as scared as the next guy.

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Porter

A candid Boyd McNicol.

听

We also heard from Robert Henderson who was having treatment for his mesothelioma and I am sad to report that he passed away earlier this month.

听

Margaret McCartney was talking to Dr Kevin Blyth and there are more details on mesothelioma on our website.听 Where you can also listen to a longer version of Margaret鈥檚 report on our weekly podcast.

听

Just time to tell you about next week when we investigate progress made in efforts to reduce the number of hospital patients dying from blood clots.听 Has the pendulum now swung too far in the opposite direction?

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ENDS