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.