Wednesday, 23 December 2015

The Magic of Portugal in Winter

Orange trees in Largo da Se Square, Faro
I went to Faro in December chasing custard tarts - pastéis de nata - but I stayed for oranges. They dangled in ripe abundance from trees in the new town and the old city, plump and ripe and as common as horse chestnuts in an English autumn. On a long walk inland, orange groves lined the dirt track and the roads. They were punctuated by parched almond trees whose bare branches cried out for water, but oranges and their green leaves pressed glossy and healthy against the protective link-fences and barbed wire. I ate oranges twice a day and knew that I had discovered the Platonic orange: its rich sweet fragrant juiciness was how an orange was meant to be, and I had no choice but to relegate forever the sad imitation found in British supermarkets.
Shells on Ilha Deserta

There was no more sublime place to share an orange than on an empty beach on Ilha Deserta, the 'deserted island', where a driftwood construction proclaims the southernmost point of Portugal. A boat-ride through wetlands away from the coast, in the summer Ilha Deserta throngs with sunbathers who gather for cold drinks at the island's one and only building, an expensive restaurant. In the winter a wild green sea beat down on the sand, the island was suffused with grey-bright light, and we were the only visitors. The mark of the summertime crowds was the occasional plastic bottle lying on the beach; the pounding of the sea had broken down or washed away the rest. Skeins of shell fragment nestled in the tide-grooves of the beach, but there were whole treasures to be found scattered among them too. We lingered over palm-sized thick shells with their edges smoothed by the angry water and pearly oysters with their outer black covering beaten away. In places shards of black mussel as big as kittens stuck out of the sand, and it was not hard to believe that the sea was sufficiently ferocious to wash up gigantic creatures from the depths of the ocean floor. On our walk back to the dock the tide was coming in, and every passing white-foamed wave thundered a little further up the shore, reclaiming the sand. 

We returned to the mainland nursing nature's bounty. From an empty ferry big enough for fifty, the sea and wetlands expanded languidly. The ugly tower blocks of new Faro and the glimmer of its marina were distant whispers on the horizon. In the wetlands oyster-catchers idly stalked the beach on their long legs, and cormorants and egrets plundered an inlet in a flurry of black and white wings. Surrounded by sea and sky I felt the limits of earth and walls and the everyday fall away, and slipped instead into an airy timelessness, where minutes were like hours and moving through space yielded only more space, empty and infinite. Peace was a Portuguese lagoon in winter. 

Ria Formosa Natural Park, Algarve
I found something similar the next day at the top of Faro's baroque cathedral in the old city. I had wandered around its deserted chapels and discovered as an afterthought the steps at the entrance leading up to the tower. They wound upwards in a tight spiral and I climbed in the hush of an empty stairwell, knowing that whatever waited at the top, I would be alone. I emerged onto a tower-top that was far higher than it appeared from the ground. Below me the orange trees of the square were reduced to small topiaries, and in front the sea spilled towards the wetlands and the bright sky. A smattering of small boats hugged the line of the shore. As I looked towards the city, a stork on top of its bell-tower nest refolded its wings and settled. Wood pigeons cooed from the rooftops below; it was the only sound, and for a long time I hovered, listening, in the giddy freedom of height and vista on a warm December afternoon. 

Monday, 16 November 2015

Fat Problems: Oils, Nuts, Seeds and Other Omegas

When I announced my intention to spend November eating a lot of beans and lentils, I was told I would probably wind up eating 'a lot of fat' for 'flavour.' Personally, I have nothing against fat. The low-fat mantras of the 1990s and early 2000s have given way in recent years - in extremis to the Atkins diet, but more generally to the idea that it's sugar that's ruining our waistlines, rather than fat. We need fats for our immune systems to work properly, and women need enough body fat to menstruate. But there's no doubt that there is too much fat circulating in the Western diet, and that much of this - far from being animal-sourced - comes in the form of plant oils. A couple of weeks ago, the BBC's Dr Michael Mosley presented evidence that instead of cooking with groundnut and sunflower oil, we should be using lard and dripping. Fat is back: but what kind? And what should vegans be eating?

Before starting my vegan adventure I had two main questions about fats. First, which oils have the highest smoke points for cooking? Smoking oils are carcinogenic, which is why re-using oil is a massive no-no (especially the kind with little black bits floating around in it, probably found in every kebab van or panini hole-in-the-wall you've ever patronised). Ideally we're meant to use high-smoke-point oils for high-temperature cooking. Recently coconut oil has risen in the ranks for its high smoke point, making it the oil of choice for roast sweet potatoes or Thai stir-fries. Although it contains a lot of saturated fat, this is apparently 'healthy' saturated fat. Coconut oil comes at a price, and you're probably more likely to use something like sunflower, soybean, or peanut oil, all of which smoke at pleasingly high temperatures and are full of polyunsaturates. Excellent, you think - especially if you're vegan.

However, Michael Mosley had to go and throw a spanner in the works with a study that compared the toxic compounds (aldehydes) produced by various oils when fried. The results were sobering. All those polyunsaturated oils that we've been thinking of as healthy are producing more toxic sludge at high temperatures than we realised. Olive oil, vilified for years because of its lower smoke point, actually produces many fewer aldehydes - and butter and lard are the real winners. Their high levels of monounsaturated and saturated fats are much more stable at high temperatures, and the few nasty compounds that they do produce are easier for our bodies to cope with. So vegans should be throwing away the sunflower oil, and stocking up on olive.

It gets even more complicated when I introduce my second question: which oils have the best balance of omega 3 and 6? The guidance varies about what ratio we need to meet in our consumption of these essential fatty acids. Some say the ideal is 1:1, others 4:1 or 3:1. It's suggested that modern-day Westerners eat a ratio of somewhere between 1:12 and 1:25. Basically, we are eating far too much omega 6 and not enough omega 3, largely thanks to processed foods containing large amounts of cheap omega-6-rich oils. Even the less-aldehyde-producing olive oil has an omega 3:6 ratio of 1:13. We might as well go back to butter, with a slightly more respectable 1:9, and we should certainly be avoiding processed foods.

Omega 3 is the reason we're told to eat two portions of oily fish per week. It has anti-inflammatory effects and protects our heart health; it's also supposed to support our brain functioning. Although a study involving dietary supplements recently called this into question, we know that pills do not stand up against a diet that consists of actual food. Vegans and vegetarians sing the praises of omega-3-rich flax and hemp seed, so I duly laid in both earlier this month: the hemp milk (delicious) boasted that a glassful provided 50% of my recommended daily intake of omega 3, and I bought a gigantic packet of flaxseeds from the trendy health food store in East Oxford, and stored them in a nice glass jar that looked like something straight out of a Naturally Sassy cookbook. I figured I was set for heart and brain health this November - but I was wrong.

The bad news for plant-eaters is that not all sources of omega 3 are created equal. We humans metabolise the essential bits of omega 3 far better from oily fish than from even the flaxiest of flax seeds. Salmon fat contains no omega 6, and the kind of helpful omega 3 (DHA) that gets to work right away without having to be converted in our bodies, slowly and wastefully, from the other less helpful kind (ALA) found in plant seeds. Apparently the conversion of ALA to DHA in our bodies is even more difficult for vegans and vegetarians, because we are more likely to be iron-deficient. Women of child-bearing age already have to contend with the fact that iron is much more bioavailable from meat than from plants - I've been drinking orange juice (Vitamin C) with my spinach all month to make this process more efficient. As I wrote last week, the network effect of cutting out substantial food groups increases our tendency to one or another nutritional deficiency. One deficiency ropes in another, and they wind up having a party. Slowly. In your arteries.

The imbalance of omegas is looking worse for vegans than for vegetarians because many butter substitutes are based on soybean or sunflower oil. A tasty enough sunflower spread is sitting in my fridge right now, and apparently it has an omega 3 to 6 ratio of 1:40. I don't necessarily want to switch to the soybean version, because I'm already drinking soya milk and eating tofu, and I don't want to eat too much soy - so it's back to the olive oil spread...assuming they've ditched the trans-fats. My brand of vegan diet just received another nudge away from the processed 'substitute' wagon. And don't get me started on the amount of 'xanthan gum' I must be consuming in my soya milk. I never signed up for 'xanthan gum'.

To cap it all, I was eating my omega-3-rich flaxseeds with oats for breakfast last weekend when I made the fatal mistake of Googling them. A few websites in, I discovered that when raw they contain a toxin similar to cyanide, and that for this reason one is not supposed to eat more than two spoonfuls a day. I spent the next half hour fishing out the damn flaxseeds. Then I read another website that said that the level of cyanide-esque toxins in flaxseeds are fine. You can't win. Also, avoid the internet at breakfast.

The take-home message for vegans on fats and oils? Avoid processed foods, cook your own, and cook it at lower temperatures. Use olive oil, and consider an algae-derived omega 3 supplement. Meanwhile, meat-eaters everywhere are descending on the lard and badgering their butchers for dripping: Waitrose, you have been warned.

Saturday, 7 November 2015

My World Vegan Month: a Sceptical Adventure in Meat-Free Eating

A few days after I had agreed to go vegan for November in honour of World Vegan Month, I was talking about it in the pub with my friend N. 'I think giving up things temporarily is quite good for one's character,' he said, 'even though I don't necessarily agree that avoiding animal products is always the right choice.'

N's approach rather sums up mine: consumption is complicated, and the more you think about it, the more complicated it gets. For many, the ethic behind World Vegan Month is environmental. We eat more meat in the Western world than is sustainable long-term. Meat production uses vast amounts of resources - water, grain - that cannot help but contribute to man-made climate change. Greenhouse gas emissions from livestock make up 15% of global emissions. As global temperatures rise, small changes have big effects on land and people: flooding, displacement. Meanwhile, meat and dairy production indisputably raises ethical questions about the conditions of the animals themselves. Our food is so packaged and sanitised by the time it gets to us that news-stories about breaches in animal welfare are quite a shock: videos of chicken factories reveal the disorder and casual brutality that lie behind our neatly-packaged eggs. A shift away from meat and dairy consumption looks like a compassionate and pragmatic choice for greater environmental sustainability - which long-term at population levels means more human stability.

What's more, we eat more meat than is good for us. The WHO's report into carcinogenic foodstuffs last month revealed what we already basically knew: processed meats are bad. Red meat is a bit less bad. If cancer wasn't enough, how about our soaring cholesterol levels and propensity to mid-life heart attacks after a lifetime of mince, French fries, and sitting down all day, countered (so we hope) by Tough Mudder and triathlons? And delicious though a good steak is - well-seasoned and medium-rare, please - have you seen meat portion sizes in North America? I once sat and watched a friend calmly work his way through half a roast chicken at dinner. I don't think that was unusual, either.

Saskia Gregson-Williams, of 'Naturally Sassy'
By now a vegan diet is looking pretty good, right? Especially these days, when thanks to social media it's really taken off, and you don't just have to eat lettuce and endless humous on toast while chucking back vitamins for all the nutrients you're missing. Dairy-free supermarket products are fortified with iron and B12. Deliciously Ella, Naturally Sassy and Oh She Glows demonstrate inventive ways with nuts, soya, lentils, quinoa, sweet potatoes, Medjool dates, yeast extract, you name it. My New Roots strikes a blow for vegan diet variety by soaking whole grains. (A lot of this is actually delicious.) And that refrain from Michael Pollan has been running through my head for months: 'eat food, not too much, mostly plants.' It's all starting to make sense.

So what are my reservations? I have two: environmental- and health-related. The first is particularly about products that are protein-staples of the vegan or vegetarian cupboard: soy. Soya milk, tofu, tempeh, soy spreads, soy yoghurt. I find soy problematic because I don't believe that soy beans grown in North America, transported across the ocean, and processed to within an inch of their lives to make tofu can really have a lower carbon footprint - or be better for me - than a chicken breast from an ethics-conscious farm in Oxfordshire. Most soy products in the supermarket don't have their country of origin printed on the packaging, so I don't know whether my soy beans originate from France, or from the Midwest. The big environmental picture is persuasive; but I'd like to know how this interacts with eating local produce. Somebody somewhere has got to have a messy algorithm for this.

My second reservation is about health, and I think I can best sum it up in the words of another refrain: 'everything in moderation - including moderation.' One evening last summer I was talking to my biochemist sister about the explosion of vegan writers in social media. She pointed out that a number of successful vegan bloggers underwent their dietary conversions following health problems and poor diets. Deliciously Ella had severe postural orthostatic tachycardia, while Naturally Sassy - a ballet dancer - snacked daily on crisps and chocolate. 'It's no wonder she felt terrible,' E observed pithily. Both these ladies have excluded meat and dairy from their diets, and are now apparently in rude health, while Naturally Sassy also cuts out wheat and gluten. Their diets clearly work brilliantly for them as individuals; but should everyone else follow suit?

Buckwheat. Soak and blitz for gluten-free,
high-protein 'buckwheat porridge'.
Preoccupation with eating the right, 'healthy, natural' food has become something of a cultural fixation in recent years, while the vast array of 'healthy, natural' dietary supplements remain unregulated. The term 'orthorexia' has even been coined to describe an obsession with healthy diet. While attention to diet is commendable - not least in the interests of making ethical and health-promoting choices about what we consume - there's some evidence that this can backfire. For example, more people than ever before believe they have some kind of lactose or gluten intolerance. On the one hand (thanks, capitalism), this has resulted in a proliferation of products that cater for people with genuine specialist needs. But on the other, people are systematically and sometimes unnecessarily cutting out major food groups.

When we cut these out of our diets unnecessarily, our gut adjusts, and the less able we are to tolerate wheat or gluten or dairy when we try them again. We find ourselves with a diet that's soy-centric or sweet potato-centric rather than meat-centric. Suddenly the environmental and health risks associated with consuming too much of one thing become about consuming too much of some other thing. Demand for water-glugging milk-alternative almonds, for example, is currently aggregating California's drought. Lurching from one extreme to another in search of the magic diet that will fix everything, we miss the simplicity of the middle way. 'Mostly plants,' said Michael Pollan. Mostly plants. Read that how you will.
Michael Pollan

So it's a little bit six-of-one and half-a-dozen-of-the-other, but I was determined to give Vegan November a shot. As I type, I'm six days in. I don't believe we all have to become vegan in order to make a dramatic difference to man-made climate change, or to increase our vegetable intake: a few vegan meals a week would make a significant contribution to both. I'm using World Vegan Month as an excuse to eat a more varied diet, rather than a more constricted one; to expand my cooking repertoire, eat well, and find out more about the food industry. I'll let you know how I get on.

Friday, 24 July 2015

An Education in Wildflowers

Earlier this year, the OUP published its latest edition of the Oxford Junior Dictionary to outcry from poets, novelists, and nature writers. According to the Guardian, the OJD's slippery slope from nature to culture began in 2007 with the disappearance of almond, blackberry, and crocus, and the elevation of analogue, block graph, and celebrity; the egregious omissions continued this year with the loss of catkin, cauliflower, chestnut, and clover, and the appearance of cut and paste, broadband, and analogue. 

Authors were horrified, and Margaret Atwood and Andrew Motion joined Robert MacFarlane and Helen MacDonald in decrying the OJD's piecemeal erosion of a vocabulary for nature. For MacFarlane there's a particular poignancy: his latest book Landmarks contains a glossary of thousands of old words used to describe aspects of landscape and weather. His point is that language is not passive; it does not merely describe what is there, but enables us to see what would otherwise go unremarked, unnoticed, forgotten. Without the word bugha, who would otherwise note 'a green, bow-shaped area of moor grass formed by the winding of a stream'? Would it occur to us that such a thing was witnessed by previous generations for so long that we even gave it a name? 

When I was ten, my year at school did a wildflower project throughout the summer term. We bought wildflower guides containing mysterious names and finely-drawn illustrations of flowers both common and scarce. We had to find, pick, and press them in cork flower-presses between sheets of newspaper and kitchen towel. I still remember the wafts of rotten vegetation that might greet my nose, if unlucky, as I unscrewed the tightly-wound fasteners. Fleshier flowers like yellow flag or scabious could be perilous, losing their vibrant colours and turning a grimy green-grey between the uncompromising cork sheets, but they were specimens nonetheless, and each new acquisition was wildly exciting. We wrote them up with their Latin names, date picked, flowering season and where we found them, and submitted them in hardback volumes at the end of term for an A, a B, or a C (extra marks for good presentation). 

Yellow Rattle
Most of my friends became pretty keen on wildflowers for the summer. I was outraged to receive a mere A instead of the coveted A+ (if only my parents had contributed, as hers did, the extra illustrating watercolours that helped my former best friend carry off the Wild Flower Project Prize), but summer 1998 was just the beginning. For years I knew anything that I might discover on a walk around Oxford: the different hemps and umbellifers in the ditches, the self-heal and speedwells of grassy lawns; I visited other parts of the country with great excitement because of what I might see in a different soil. I delighted in scarlet pimpernel in sandier ground, ladies' bedstraw in Dorset, my first orchids - common spotted - in the Cotswold Wildlife Park, wood anemones under flowering larches in Devon woodland. 

Over time the names began to fade, upstaged by other terminologies - historical, psychological, anthropological - but they were waiting, seared into my ten-year-old memory, to come to life when I paid them some attention. The joy of my early wildflower education hit me with particular potency this summer, when, after an intense period of computer screens, concepts and ideas, long days and short nights, I decided that I was on holiday. I piled my books in an unkempt pile on my desk, abandoned all attempts to organise my emails and looked out into the world to see what was there. I saw wildflowers

Hawkweed at the Nuneaton Arboretum
The riverbank where I went running was a wildflower riot. After the buttercups had exploded and faded, the mallow and figwort emerged, the creamy fluff of meadowsweet, blue love-in-a-mist and yellow hawkweed, burdock and vetch, purple loosestrife, poisonous water dropwort, and Himalayan balsam - the alien nature-lovers love to hate. In my partner's garden, buttercups and corydalis lit up the nooks and crannies of stone and fence, and delicate orange poppies lurked in shady corners. So far, so expected. But the wildflowers followed me in unlikely places wherever I went. Throughout July, from dual carriageways and train tracks I've stared idly out of the window and seen an endless preponderance of mallow and mullein, St John's wort, swathes of pink rosebay willowherb, bright farmer's menace ragwort, yellow-green wild fennel with its exuberant fronds, fleabane and wild snapdragons, toadflax and yellow corydalis. In a particularly good traffic jam a lone purple orchid rose, plump and healthy, from the straggling sun-bleached grass in the verge. 

Whether stuck in traffic, delayed on a train, carsick from reading, or my iPhone's battery fading, I settled back into my seat and watched the wildflowers go by, the names popping into mind many years after I first pored over my Collins Gem wildflower book. I'm in the MacFarlane camp: language is always more than language; it's history, knowledge, and power, a force in itself, and as children forget clover and cauliflower it seems ever more likely that the co-arising phenomena of nature poverty and food poverty will seep into the next generation. I sometimes wonder whether I might have been one of the last to be sent packing into the outdoors not for teamwork or self-improvement, charity mud-runs or weight loss, but for wildflowers. 

Birds' Foot Trefoil

Instructions for living a life.
Pay attention.
Be astonished.
Tell about it.
Mary Oliver

Tuesday, 24 March 2015

Lessons Learned From Not Buying (Many) Books

I was having tea with a former colleague, and we were talking about books. Her friend was 'kind of snobby' about what he read, and would only read the classics. He had worked out that if he had fifty years left to live, and he read one book a month for the rest of his life, he only had time to read six hundred more books in his lifetime. Hence, only the classics. 'It makes you think, doesn't it?' said my friend. 'I have way more than six hundred books on my shelves already!'

Sigh. Personally, if I were left to my own devices, I would be like the kids in the Road Dahl poem, 'Television':

What used the darling ones to do?

'How used they keep themselves contented

Before this monster was invented?'
Have you forgotten? Don't you know?
We'll say it very loud and slow:

THEY ... USED ... TO ... READ! They'd READ and READ,

AND READ and READ, and then proceed

To READ some more. Great Scott! Gadzooks!
One half their lives was reading books!
The nursery shelves held books galore!
Books cluttered up the nursery floor!
And in the bedroom, by the bed,
More books were waiting to be read!

Matilda, by Roald Dahl, illustrated by Quentin Blake
If I could, I would spend one half my life reading books. When I go on holiday, I've been known to average a novel a day (record: south of France, 2009). But as it is, I'm gainfully employed writing a DPhil thesis, I occasionally experience a social life, my shelves hold books galore, books clutter up my bedroom floor, and in my kitchen, on my bed, more books are waiting to be read. So for six months, I tried not to buy any more books. I did quite well. I probably managed on average to buy only one book a month, which makes the vast numbers that ordinarily creep up around me make a lot of sense. They don't just magically appear: they accumulate because when I'm not attempting to exercise self-control, I buy many, many more. 

Take my first trip to the Oxfam book-shop at the end of my experiment, in early March. I had not bought a book from Oxfam for six months. It had been a long time coming, so I took my time. I perused the fiction, slowly, carefully; I did the thing where I first check for the surnames that I usually look for, the authors I love but have not yet exhausted. Patchett. Irving. Tartt. Then I did the thing when I look through everything else anyway. Then I visited the travel section - and the social science section...and the religion section. I bought three books that day: Jon McGregor's Even the Dogs; Alice Munro's Lying Under the Apple Tree; and Richard Wilkinson and Kate Pickett's The Spirit Level: Why Equality is Better for Everyone. A few days later I returned and bought two more: Donna Tartt's The Little Friend, and Ian McEwan's Solar. This past weekend, I bought three of those beautiful tiny black and white Penguin 80th Anniversary Classics. That's just March, and March still has a few days standing. This is how it happens, I realise: this is how I have so many books. 

Penguin's 80th Anniversary 80p Classics

What I noticed, beginning to buy books again in earnest, was what makes me buy books. We often hear that consumerism is about filling a void, meeting a need. People shop to get something that they don't have. Shoes become proxies for love, earrings for friendship, cars for status. I'm sure that's often the case, and maybe it is often the case with me: I've written before about how books are more than just tangible comfort blankets; they are portals into other worlds, and when I buy them I feel the rules and regulations, the assumptions and prerequisites of my world loosen and become opaque, the possibilities become multiple. It's fair to say that I buy books when I feel stuck and confined, as much as when I just feel ignorant or in need of entertainment. 

But my book purchases in March have looked different. Before Oxfam trip number two, I had just had a lovely long lunch with a friend. Before that, I had been to an interesting seminar, and over the previous two days I had written almost six thousand words on my thesis. I was about to go to Devon on retreat for five days. I was feeling decidedly upbeat; I was tired but buzzing with the pleasures of good company, good food, intellectual stimulation. My book-buying felt celebratory - it was the cherry on the cake. I felt happy and free, and so my books were an affirmation of how interesting life was. Look at this slightly experimental novel! Here is this world-renowned Canadian short-story writer! Feminism makes life better for everyone! 

This weekend, when I succumbed to the Penguins, I was feeling the residual joy of having settled and stilled within the deep-tissue metaphysical massage of insight meditation in the green hills of Devon. My tired brain had recouped enough energy to start throwing out creative ideas again. Lots of things looked possible. It sounds exhilarating, but it felt tranquil. I rested deeply in the slow-moving promise of the present moment, and part of that promise was: you could read a new book today - one you've never even heard of

I reached for the books. 

So, in the end, it's fairly simple: trying not to buy books has made me pay more attention to why I buy books. It's not just that that one has a nice cover, or that I know that author, or that this one is cheap, or that this one is about something that interests me. It's that books are both a promise and an affirmation of the complexity and multiplicity and possibility of the world I live in. When life gets a little monotonous, I buy books; when life is wondrous and textured, I buy books. In the act of acquiring a book, the timbre and texture of my own world feel enriched, even before I actually read the book.

I've learned in these past six months of reading but not buying (very many) that like they always said, much of it is about the journey, not the destination. What's strange is that buying and reading have slipped unexpectedly between the two: sometimes one feels like the journey, at other times the destination. It's a main critique of consumerism that to possess the shoes feels ultimately empty, unless you actually wear them, need them, make use out of them. Is it possible that buying and reading books sit on an inchoate merry-go-round, in which each are an end, but also a beginning? It's not that we have to read a book to make the purchase worth it. Sometimes we realise fifty pages in that it's a bad book, and that's just that. We don't have to struggle on regardless - especially if we've only got six hundred books left to live. Sometimes we cut our losses and walk away from the book. We were still delighted when we got it. 

Lingering over my books in Oxfam, I noticed that curiosity - that hinterland before knowledge - is rich and deep enough to make book-buying in itself an inherently pleasurable act. Curiosity is therefore, often, psychologically functional. It lifts an exhausted student out of flatness; it stimulates a happy one to creativity. It feels like a journey that in the micro-moment has some defined efficacy. Yet the pleasure of purchase passes if the book remains unread, static, dead weight. It can even become oppressive, a reminder of curiosity unfulfilled, and there is something slightly unsettling about an expansive library of the unread. 

I guess the slippage between buying and reading, journey and destination, promise and fulfilment means that all we can do is have good intentions, see what happens, and work from here-on-in. If I don't manage to read a book, it doesn't make me a fool for purchasing its promise. I will always buy (too many) books, and I will always enjoy buying books. But If I'm being very honest, right now - despite the delights of bookshops - I have a horrible cold, and the destination looks like a good book open in my lap and a cup of tea. I'm hoping to keep ahead of my purchases, and average two books a month for the rest of my life: I'll race you to it. 

Sunday, 22 March 2015

What Price Switching To Generic Medicines? The Case of The Contraceptive Pill

Amidst the budgetary pressures on the NHS these days, a tremendous amount of managerial effort goes into getting doctors to prescribe generic medicines - and plenty of press tries to get patients to take them. Four pills of the generic version of Viagra (erectile dysfunction drug sildenafil) cost just £3.40, compared with Pfizer's £26 treasure-trove. Yet patients bring generic sildenafil back to The Times' Dr Mark Porter, complaining that it doesn't work as well. 'Do yourself, and the NHS, a favour,' he says, 'and keep an open mind about generics.' Analysts estimated that if two thirds of the branded prescriptions for statins had been changed to generic forms, the NHS would have saved £200 million in 2011-12. Just statins! £200 million! No wonder doctors are pleading with their patients to keep an open mind.

In that plea, however, lies the problem, and the problem is not necessarily what you think. In response to Mark Porter's article, commenter Iolar Mara summed it up nicely:

'I take care of dispensing the myriad of medication that my mother takes on a daily basis...Frequently one or other medication is changed to a different "generic". All well and good, except it may not only be in entirely different packaging, may be a capsule rather than the tablet previously prescribed, may also be confusingly similar in colour to another medication. Instead of arriving in a blister pack, they may be loose in a tub, which requires Herculean efforts to push down and turn the lid to gain access. A task I confess that has defeated me more than once. Imagine therefore the confusion and frustration that an elderly patient may experience when faced with a small yellow capsule and a small white one with a large yellow band, or suddenly a tiny white tablet when previously it was a tiny blue one.'

Generic medicines might cost much less upfront. The problem is that for patients on recurrent medication who are being switched to generic medicines, there is a hidden cost. The cost is how much disruption and error occurs in the duration of the time it takes for the patient to adjust to the different medicine - because 'taking medicine' is, in fact, quite a complex process. 'Patient adherence' is frequently cited by health professionals as a major problem in the efficacy of treatment. Patients simply don't take their medicine as prescribed - the right dosage, the right frequency, the right duration. Yet people who take repeat medication on a frequent basis know that what helps their own adherence is simple: familiarity. 

Familiarity is multi-faceted. It's the knowledge of what your medicine looks like (big pill, little pill, blue pill, white pill), feels like (in a bottle, in a packet), how it's taken (with water, with food, not with other pills), and how often it's taken (once a day, twice a day, within a four-hour window). It's also about what taking your medicine is tied in with: turning off the alarm and rolling over; your first forkful of breakfast; last thing at night before you switch the light off. Familiarity means there is less to remember. The moment there starts to be more to remember, more to think about, more to decide, that helpful complex of familiarity that means that you take your medicine in the same way without fail time and time again starts to dissipate. Perhaps your routine is broken by going on holiday, or a family emergency - or switching to a new pill that looks and feels different. A small change throws out the whole delicate and rather skilful system. Suddenly, for the first time in years, you forget your medicine. This has consequences: some are small, some are big, and some are costly. 

A good example of this is the contraceptive pill. The New York Times reported in late 2014 on research from Princeton University, showing the failure rates for different contraceptives after years of typical use. For every 100 women who have taken the pill for 3 years, 25 will have an unplanned pregnancy. After 7 years, that rises to 48 in every 100. Those are big numbers. The pill is far from fail-proof under ordinary circumstances, by which I mean women doing their best to take it correctly because they do not want to get pregnant. That rising number reflects the aggregate of all the tiny things that could go wrong in the complex system of Taking Medicine, over many years. 

These statistics interested (and scared the hell out of) me because I had happily and with no ill-effects taken the pill for 7 years. It had been the same pill, and it and I had become familiar friends. Taking my pill was the first thing I did every morning, so I always had a glass of water by my bed. I knew the instruction booklet backwards. I had a spare pack stashed in my purse in case of emergency ill-health or luggage disruption. The shape and size of the pack and the patterning of the pills within it - a neat loop around the outside - meant it was easy to take, especially after 7 years. It was familiar to me, and it had always done what it was meant to do. 

Then, six weeks ago, I picked up my repeat prescription and the pharmacist had dispensed me a different pill. It had a different name and came in a different packet. It looked different and it was distributed within the packet in a snake pattern, from left to right, to left to right. It had a different instruction booklet, which told me that ideally I should have started it five days before I picked it up from the pharmacy, as this is what you do when you switch to a different pill. Except I hadn't known to pick up the prescription in time, because I had not switched: someone had switched me and not told me about it. 

I had questions. If it was exactly the same drug, why should I have started it several days earlier than I would have done otherwise? Did I need to replace my emergency stash with a new, generic emergency stash? Why had I suddenly been switched after 7 years? 

The whole business bothered me, because I could feel that for all my familiarity with taking this type of medicine for a number of years, and my firm intention to continue to do so, the switch had slightly thrown my finely-honed Pill Taking system. I remembered it the first two days and then I had a bad night's sleep and forgot it for a few hours, which had never happened before. Somewhere between the novelty of holding, examining, and extracting a pill from this new packet in a slightly different way, and the bad night's sleep, my patient adherence had temporarily failed.

The problem in the case of the contraceptive pill is three-fold: the cost of 'non-adherence' is high - an unplanned pregnancy; adherence is a complex process; 'non-adherence' happens surprisingly often. This means that it's not enough, when doctors switch a woman's contraceptive pill, to ask her to have an open mind, because it is not just about having an open mind. The best defence against an unplanned pregnancy for a woman on the pill is the familiarity, reliability, and predictability of her pill-taking. The potential cost of that process's upheaval is huge - that's why women take it in the first place.

After thinking about it for a couple of days, I called the pharmacist to ask her my questions. She didn't know why the pill I had been dispensed had suddenly changed, because they have been dispensing 'generic' prescriptions for years. So it had just happened; it was random and banal, in the way that the start of something big and costly often is. Although it was not the start of such a thing for me, it was enough to make me sit and think about it for a while. 

When doctors consider switching a patient to a generic medicine, it seems to me that they must make a particular calculation: they need to weigh up the savings to the NHS versus the costs likely to be incurred for the patient in that critical period between novelty and familiarity. Does the patient struggle with their memory? Do they have difficulty with fine motor skills - will they struggle with the new bottle or the size of the pill? Do they travel a lot? Are they sleep-deprived women with small children? How can these costs be managed? To what extent might the costs of switching come back to bite the NHS? 

If the potential costs are relatively high, as I believe they are in the case of the ever-political contraceptive pillthe switch should be controlled. Women should be informed, their questions answered, their preferences explored. It needn't be much - but it could make all the difference. 

So, statin-users, contraceptive-takers, Viagra-poppers, let's do our best to take our medicine 'properly' and to keep our minds open: we are grateful for the wonders and privileges of national healthcare, we want the best for our health, and we don't want to see the NHS crippled by cash shortages. But the gap between 'our best' and perfect 'adherence' needs filling with medical sympathy and systemic skill. Patient adherence is a jigsaw, not a tick-box, and several parties can play. 

Saturday, 28 February 2015

How To Make Popcorn Like An East Oxford Hipster

If you live in East Oxford, with its Victorian terraces and closely-knitted streets, charming potholes and rambling creepers, you are currently living in the best bit of the city for anyone with any fondness at all for food. You will have watched the regeneration of its local eateries in the past few years with grateful wonderment: Oxfork, The Chester Arms, Oli's Thai - we always knew we could get a good meal down the Cowley Road, but the demand for good food has seeped south and restauranteurs have gone with it. Meanwhile, you probably buy your aubergines from the super-ethical Cultivate Veg Van on a Thursday, and of late you will have started to pick up your organic yoghurt, almond milk, and spelt pasta from Wild Honey, the health food shop that's just moved in next to the Magic Cafe (cloaks encouraged). At home you probably snack on tofu raspberry milkshakes and tahini-dipped flatbreads. You generally pop round to your local South Asian grocery store for bags of cashews as big as your head, packages of cumin seeds that would sow a cumin farm, or dried anchovies to flavour your stocks for soup. Then you wind up in the Magdalen Arms, stroking your beard, scribbling poetry, periodically pushing your hipster glasses further up your nose, drinking your local ale into the realization that you are completely, utterly, broke.

Let's be honest here - barring the fantastic, wallet-saving South Asian groceries, buying into the East Oxford professional lifestyle costs a packet. The gloriously healthy-sounding and apparently nutrient-packed foodstuffs in kitchen cupboards round here (tahini! Pulped roasted sesame seeds! I feel healthier just writing it!) are a far cry from the Tesco Value kidney beans that were a more common feature of the cupboards I glimpsed when I was the other side of twenty-five. Nonetheless here I am, still a student, still wanting to eat well, still partial to gastronomic experiment - and on the hunt for the affordable. Enter: Hipster Popcorn.

Two of my most culinarily talented vegetarian friends introduced me to this a few months ago and it was so good I practically ate the entire bowl. We have two upfront pricey ingredients: coconut oil, £5 or £6 for about 300ml; and nutritional yeast flakes, a popular vegan supplement for its cheesy taste, £2.75, from Wild Honey. Then we have a packet of popping corn, 500g, for about £1.20 from the Co-op. Popcorn is one of those things that we pay absurd amounts of money for - whether it's a couple of quid in the supermarket for 50g of something dipped in a dozen different preservatives, or even more than that at the Odeon. The extraordinary thing about making your own popcorn is that a small number of kernels make vast quantities, so this packet will last you a while. It's a magical thing to make with children - keeping them away from the very hot pan.

Here goes, to make a snack of savoury popcorn for two people:

1) Heat a tablespoon of waxy coconut oil - solid at room temperature - in a pan on a high heat, until it's all melted.

2) Drop in three or four kernels, put the lid on, and wait.

3) When they start to pop, pour in 1/4 cup (American) of popcorn kernels, and remove from the heat.

4) Count 30 seconds while keeping these kernels off the heat. This brings them all down to roughly the same temperature, so that when they pop, they do so at about the same time - avoiding any burnt popcorn.

5) After 30 seconds, place back on the high heat, keep the lid on, and wait.

6) As they start to pop, gently shake the pan on the hob. The popping will get ferocious. It's great fun to watch if your pan has a glass lid - but keep the lid on firmly, as the popcorn will spit.

7) When the pops diminish with about two seconds in between each one, take the popcorn off the heat and pour immediately into a large bowl. Season liberally with two tablespoons of the nutritional yeast, for a cheesy flavour packed with B Vitamins, or with salt, pepper, and paprika.

Voila! Your 500g packet of kernels will last ages (wrapped up firmly so the kernels don't go stale), your vegan friends will thank you, and you will enjoy all the benefits of the B Vitamins and reduced carcinogen intake thanks to the high smoke-point of the coconut oil. If I were you, I'd pop it in a tupperware and sneak it into the Ultimate Picture Palace this weekend.