Editorial Note: This is part 2 of a 3 part lecture given on February 22 that began with Tweeting while Psychiatry Burns. The text and slides continue from last week. The slides for this part are Here. The numbering continues from last week.
When his office was ransacked, Delay’s world was turned upside down but psychiatry and doctors are still here – so we won, didn’t we?
We didn’t win. Both psychiatry and anti-psychiatry were swept away and replaced by a new corporate psychiatry. In 1967, the year before Delay was upended, JK Galbraith argued we no longer have free markets with companies making products we need. Instead corporations now shape our needs to meet their products (Slide 12). It works for cars, oil, and everything else, why would it not work for medicine? Prescription only status makes medicine easier than any other market – a comparatively few hearts and minds need to be won.
Within psychiatry, two factors played a part. One was the emergence of Big Science. This graph from 1974 (Slide 13) shows the correlation between affinity for D-2 receptors and the clinical potency of antipsychotics. It was one of the most famous images in modern psychiatry until replaced by fMRI scan images.
The image remains as accurate today as when it was first published. But these binding data introduce something else as well, for which neither Seeman nor Snyder, nor others who developed radiolabeled techniques can be held responsible. They introduced a new language, a language of Big Science. Where previously psychiatrists and antipsychiatrists and patients were using the same language, this no longer applied after 1974. After 1974, to get into the debate you had to have a manifold filter and a scintillation counter.
This as it turned out was not a science that worked in the interests of patients. No longer answerable it seems to how the patients in front of us actually looked, following the science, we moved on to megadose regimes of antipsychotics that may have harmed as many brains as were ever injured with psychosurgery. Science won’t necessarily save us, it must be applied with wisdom. We have moved into an era when we depend on our experts in a new way – we depend on them to be genuine. Conflict of interest began to play as an issue.
Another factor stems from figures like Rene Descartes (Slide 14), Blaise Pascal and others, who were behind the development of statistics and probability theory. This laid the basis for the Enlightenment.
Statistics initially referred to government statistics – a process of mapping peoples rather than just the land. This led on to the notion of the rule of the people by the people, the creation of social science and epidemiology, along with public health and insurance.
The same forces led around 1900 to the first attempts to map the human individual, their attitudes and abilities, personality, or intelligence. Sales such as the IQ scale led to new concepts of norms and deviations from those norms and psychologists emerged to take a place in the educational system, the legal system, and in the government of ourselves – it was this that underpinned the psychodynamic revolution (Slide 15).
This was not just the replacement of theology and philosophy – the qualitative sciences – by a new set of quantitative sciences. The new sciences set up something else. They set up a market in futures. A market in risks. We were on our way to becoming a Risk Society (Slide 16). In the case of the IQ test for instance, deviations from the norm were now something that predicted problems in the future. Parents sought out psychologists in order to improve the futures for their children. This was how we would govern ourselves in the future. Through the marketplace.
Drugs entered this new market in many different ways. The oral contraceptives for instance are clearly not for the treatment of disease. They were a means of managing risks. Where once, the risks of eternal damnation had been those that concerned people, now it was a much more immediate set of risks – we switched one set of future risks for another (Slide 17).
The best selling drugs in modern medicine don’t treat disease. They manage risks. This holds for the antihypertensives, the statins to lower lipids and other drugs (Slide 18). It holds for antidepressants, which have been sold on the back of efforts to reduce risks of suicide (Slide 19).
The development of probability theory also gave rise to clinical trials. We are now in an “Evidence Based Medicine” era. What can go wrong if we have clinical trial evidence to demonstrate what works and what doesn’t (Slide 20)?
But clinical trials in psychiatry have never shown that anything worked. Penicillin eradicated a major psychiatric disease without any clinical trial to show that it worked. Chlorpromazine and the antidepressants were all discovered without clinical trials. You don’t need a trial to show something works. Haloperidol and other agents worked for delirium and no one ever thought to do a clinical trial to support this. Anesthetics work without trials to show the point. Analgesics work and clinical trials aren’t needed to show this. Clinical trials nearly got in the way of us getting fluoxetine and sertraline.
Trials demonstrate treatment effects. In some cases, these effects are minimal. The majority of trials for sertraline and for fluoxetine failed to detect any treatment effect. In clinical practice many of us are under no doubt that these drugs do work. But if our drugs really worked, we shouldn’t have 3 times the number of patients detained now compared with before, 15 times the number of admissions and lengthier service bed stays for mood and other disorders that we have now. This isn’t what happened in the case of a treatment that works, such as penicillin for GPI.
Aside from this, professors of psychiatry have been jailed for inventing patients, much of the scientific literature is now ghost written, many trials are not reported if the results don’t suit the companies sponsoring the study, while other trials are multiply reported making it difficult to work out how many trials there have been. Within the studies that are reported, data such as quality of life scales on antidepressants have been almost uniformly suppressed. More generally there is no access to the data. To call this science is misleading.
But these are not the most important consequences for medicine of clinical trials. The critical development is contained in the following quote from Max Hamilton in 1972 about his rating scale:
“it may be that we are witnessing a change as revolutionary as was the introduction of standardization and mass production in manufacture. Both have their positive and negative sides” (Slide 21).
Anyone who has used the Hamilton Rating Scale for Depression will wonder what is this man talking about when he talks about a revolutionary aspect to using a checklist like this. Maybe as a communist, he was sensitive to things that we are not sensitive to now.
Rating Scales have been such feature of psychiatric trials so long now that it is perhaps difficult to see that there are revolutionary aspects to what happened. We use these checklists in all walks of life from sexual behavior, to children’s behavior. Where once there was life’s rich variety, now our children fall outside all sorts of norms when checked against these lists. And when they do parents desperately want to bring their children back inside appropriate norms. We bring them to psychologists and to doctors.
The figures on treatment effects from rating scales used in our clinical trials have set up a new market. When you consider that as far back as 2000 we were treating children from the ages of 1 to 4 with “Prozac” and “Ritalin”, you realize that we are not treating diseases here (Slide 22). Pharma makes markets but until recently they have not sold psychotropic drugs to children. The explosion of drug use in children is a manifestation of the force that fills the sails of pharma marketing. It comes from us. What parent could not want to minimize future risks for their child?
Anorexia offers an analogy for what is involved (Slide 23). Clearly people have starved themselves for millennia for all kinds of reasons. But Anorexia nervosa emerged in 1873 a few years after the first weighing scales. Eating disorders increased in frequency in the 1920s when weighing scales migrated into drug stores complete with a plate featuring norms for ideal weight. In the 1960s, the frequency increased yet again with new variants mushrooming – as we all bought portable scales for our bathrooms.
Competing theories have focused on the possible psychodynamics of the problem, the biology of the problem, or socio-political aspects of the problems. None of these recognize the role of scales and norms for weight and deviations from the norm and an awareness that deviations in the direction of what had formerly been thought to be healthy and beautiful carried risks.
This problem applies to any situation in which we have a datastream frm one area of our life but not others. It applies to figures for GDP which run the risk of seriously distorting society in general. The problems seem likely to get worse with the proliferation of Health Apps.
But there is another consequence for medicine itself. Figures like scores on a Hamilton Scale set up algorithms – If X, then do Y. The figures drive the prescription of drugs. But the use of checklists like this looks scientific to managers who run health systems. They want staff to stick to checklist questions in clinical encounters rather than have doctors or nurses talk to patients. Its scientific after all in a way that conversations are not. And doing things this way means doctors can be replaced by nurses and pharmacists and everyone in the near future will be replaceable by robots.
Harold Shipman (Slide 24) was one of the greatest serial killers ever. He killed over 200 people with opioids. Shipman’s case illustrates that situations where trust is important can provide the conditions for extraordinary abuses.
One of the conditions where trust applies is in prescription only arrangements. This arrangement was introduced to restrict bad drugs but now applies exclusively to the good drugs. Since 1951, the idea is physicians would quarry information out of pharmaceutical companies on behalf of their patients and would provide the counter-balancing wisdom to market forces.
Since 1951, pharmaceutical companies have grown to be the most profitable on the planet. There has been a change from companies run by physicians and chemists to companies run by business managers who rotate in from Big Oil or Big Tobacco, advised by the same lawyers who advise Big Oil and Big Tobacco.
In the case of tobacco industry, it now seems clear the advice was not to research the hazards of smoking, as to do so would increase the legal liabilities of the corporations involved (Slide 25). Similar advice given to the managers of our pharmaceutical corporations would be completely incompatible with prescription-only arrangements. Advice like this converts prescription-only arrangements into a vehicle to deliver adverse medical consequences with legal impunity.
Prescription only opioids are now linked to 30,000 deaths per year in the USA. This happens because clinical trials have been cleverly built into guidelines to mandate the use of opioids for minor pains where wisdom would say this was a bad idea. These trap doctors because their managers will now sack them if they don’t keep to guidelines. We have institutionalized Shipman.
I happen to believe that Prozac and other SSRIs can lead to suicide. These drugs may have been responsible for 1 death for every day that “Prozac” has been on the market in North America. Many of you will probably not agree with me on this – but you haven’t seen the information that I have seen. However we can all agree that there has been a controversy and since the controversy blew up, there has not been a single trial carried out to answer the questions of whether “Prozac” does cause suicide or not. Designed yes, carried out – no.
With the mapping of the human genome, we have the possibilities of creating new markets (Slide 26). We need this data and the data from clinical trials to govern ourselves. The genetic data will tell us about some of the underpinnings to our beliefs – why we believe some of the things we do in the religious and political domains. But the products of this research along with trial data will belong almost exclusively to pharmaceutical corporations, and at present this democratically important data is being deployed against the interests of democracy.
It is also increasingly been managed through organizations like Sense about Science who run Science Media Centers to ensure we are all fed the interpretation of the latest science that best suits corporate interests.
In Slide 27 you see another image of the future. In the course of the last 70 years, plastic surgery evolved into cosmetic surgery. Plastic surgery began as a set of reconstruction procedures aimed at restoring a person to their place in the social order. It evolved into cosmetic surgery when the reliability with which certain procedures could be carried out passed a certain quality threshold.
The word “quality” is pervasive in healthcare today. Quality in modern healthcare however does not refer to genunine interactions between two people as it did in the 1960s. Quality nowadays is used in an industrial sense to refer to the reproducibility of certain outcomes. Big Mac hamburgers are quality hamburgers in this sense — they are the same every time.
Viagra gives good indication of what will happen when we get to this stage. Viagra is a drug that produces quality outcomes – reproducible outcomes. When this happens, it becomes possible to abandon the disease concept. Pharma talks openly instead about lifestyle agents. This is the world that lies in store for us. It is not the world of traditional medicine, where drugs treat diseases to restore the social order. It is a world in which medical interventions will potentially change that order.
But cosmetic also suggests fake – that behind the appearances things might be rotting. The boxes that proliferate in healthcare today are being ticked ever more faithfully but behind the appearances our services are disintegrating.
This returns us to the picture of Delay and his colleagues (Slide 28). If some relatively minor person from the UK or US – a white man visited Delay with a research proposal – Pichot and Deniker would be summoned and might be left standing behind Delay for an hour while he discussed matters with the visitor – Pichot on the right and Deniker on the left.
This was not an experience that Deniker or Pichot experienced as some exquisite form of torture or as a humiliation. It was a different time. Honor and loyalty counted for more then than the search for individual authenticity we now have. The hierarchy and the collective was something these men believed in.
What this shows is that there are forces at play that can change not only the kinds of drugs we give, not only the conditions we think we are treating, but our very selves who are doing the giving. These forces can change us just as profoundly as we can be changed by a handful of LSD containing dust.
to be continued..
Copyright © Data Based Medicine Americas Ltd.
The wrong people are making a real stand which seems lost in translation across the pond ..
Rasputin March 6, 2017 at 11:32 am
This entire controversy confuses me. I’ve been pouring over countless books (yours included) and studies over the past six years. It seems clear that all these drugs are extremely harmful. Yet people like yourself always stop short of condemning their use completely.
Are the drugs helpful or not? If not, why is there no concerted effort to stop their use? Why don’t the knowledgeable people make a real stand?
Why all the waffling?
Any takers … ?
I’m wondering too, but my guess is that there is a large market for these drugs, harmful as they are. According to one mainstream psych doctor, whose website I stumbled across “for every one person who hated psychiatry, dozens if not hundreds of people come to my office begging for diagnoses and medical prescriptions.” I find it hard to trust any doctors now (shrinks especially) but he may have been honest about this.
There are many grateful consumers–happy to give away all adult responsibilities and do nothing but take pills for a living. Part of this is no doubt due to placebo effect and spell binding. These folks become vitriolic–sometimes violent–when they fear their precious suppliers may not be able to come through for them so they can get their fix.
Plus, despite the discrimination, some folks like being able to act like abusive jerks and then blaming it on their mental illness. This makes it hard on those who don’t like their MI labels and try to behave themselves.
The response from much of psychiatry was the same response as from psychoanalysts to criticism against psychotherapy. When the treatment failed to work, they claimed it was the disease not the treatment that was at fault. Similarly, psychiatry blamed the disease rather than the drugs. Just as we have since done with the SSRIs and suicide
How can anyone practicing psychiatry or psychotherapy not be ashamed of not spotting treatment induced problems. I would personally feel totally ashamed if I was a psychiatrist or psychotherapist and not spotted treatment induced problems in many of my patients. I would question my own judgement skills and be terrified of my lack of professional ability. Just like politicians have to when they do wrong psychiatrists and psychotherapists should do the same and resign. Its other peoples lives that they are destroying as a result of their “Pride”, “Selfishness” and “Greed”.
I once saw a psychotherapist who I was sent to see as a result of my behaviour on SSRIS who said to me. Think very carefully before you start psychotherapy because you may end up in A&E because of treatment. I asked her “Why would I end up in A&E if I had psychotherapy? She said we will open things up and make you delve so deeply it could make you suicidal. She then ended my consultation and told me to consider whether I would be ready for psychotherapy or not.
I was absolutely puzzled and disgusted at by her rudeness, I thought if that’s the way she spoke to and treated her patients then I think she is going to be the one that will one day end up in A&E not me. Who in their right mind would want a psychotherapist who spoke to them like that. I never went back not because I was afraid of ending up in A&E but because I knew she was not the right person to be able to help me.
Now that’s what I call a waffling career and they get paid pretty well by the tax payers for all that crap talk too.
Anne Marie, they don’t spot treatment induced problems because they are not looking for them, they have their script to work to, peppered with a good sprinkling of arrogant self assured self satisfaction, and worst of all, they don’t seem capable of thinking outside the box.
The latest ‘craze’ to cut down hospital waiting lists appears to be to label anyone remotely problematic as having borderline personality disorder, which is branded ‘untreatable’ and so can get the patient hoofed off their referral lists pronto. Maybe inadvertently not such a bad thing if it avoids them getting a psychotropic drug prescription. But not so good if people are left floundering in anxiety and stigma. And what about Aspbergers? Not a mental illness but so little understood or credited by psychiatrists and psychotherapists. Just a slightly different way of relating to the world and it’s stimulae. The more I learn about all these things, the more I feel thinking outside the box would be the most vital thing to teach trainee psychiatrists. One size definitely does not fit all, be it ‘diagnosis’ or offered medication.
Also, interestingly, would it be fair to say that many of us can cope with one stress at a time, but when submerged under two or three, the mind says ‘give me a break’ and shuts off into coping mode? Isn’t that likely to be the root cause of most anxiety? A sense of being exhausted and not able to cope. So if we don’t peel back the onion, look at these stresses and deal with them one by one, how on earth is a drug going to help us long term. It isn’t about ending up in A&E like your arrogant psychotherapist threatened, it’s about common sense and unpicking current worry, which lands on us all sometimes, uninvited, and just needs a bit of reasoned unravelling with compassion.
I actually thought I had been sent to see the psychotherapist because of the stress and trauma of what I had gone through on SSRIS over several years. I remember sitting in the waiting room with a huge bag full of SSRI information eager to show her all the research and stories I had printed out from the internet. She was having none of it and thought I was using it as an excuse and told me I was ill, I was so upset and absolutely livid. We did not get on at all, she was a loud mouth shouting at me with too much to say for herself and wouldn’t listen to me at all. It was if her attitude was (I am going to sort you out once and for all). I decided then that I would never go back to mental health again and went it alone. I was already at that time coming off SSRIS and going onto Mirtazapine.
To have gone through all that trauma I had on SSRIS and to stand up to these professional bullies whilst still trying to mentally recover was probably one of the hardest experiences of my life, but it payed off, I never fell into their trap of self blame and I recovered from it.
Go by your instincts if you feel their wrong then they probably are, you know yourself better than anyone.
Psychiatry is a disgusting profession and the people who work in it are brain washed and mentally ill themselves. They are part of the problem.
Your last paragraph, Anne Marie – Never a truer word said, in my opinion and from my experience!
Jane and Anne Marie, I SO agree with you. I often wonder whether a psychiatrist realises the enormity of the power they wield, when speaking with (or at) a person in mental confusion, anxiety, need of guidance as to what is seemingly wrong with their current thinking.
It sickens me to think of the one sided balance of power between clinician and patient. I fully accept that medications may have already slewed the sufferer’s reasoning ability, and maybe their life’s circumstances have caused a lot of stress, sometimes of their own making, sometimes heaped upon them in too heavy a load because shit happens. But they are where they are, they are desperately in need of help, and in their vulnerability they reach out in trust to the ‘listening’ psychiatrist, the fount, to them at that moment, of all knowledge.
In the case of our son’s suicide, I know that RoAccutane-isotretinoin started the rot in his thinking. I accept that bullying about his appearance at school in his teen years had caused him concern. I more than accept that Seroxat (Paxil) had made him have even worse repetitive suicidal thoughts than those that RoAccutane sparked off. But it was the horrendous, terrifying, aggressive and bullying attitude of the Lead Home Treatment psychiatrist, who refused to listen to the history, good character, previous suffering and consistent constructive bravery of our son, that in our opinion, definitely killed him. We had watched our son keep struggling against the akathisia (although we didn’t have a name for it till RxISK enlightened us) for 11 long courageous years. But this arrogant psychiatrist, the man our son trusted and believed in, shouted at him and took away the last vestiges of his fragile self esteem. One might say he kicked this cowering respectful worried soul to death with his damning words. We sat in the room with other NHS members of his Team and watched it happen. We were all stunned, but no one dared say much back. I tried, politely, and was rubbished too.
So, yes, Jane and Anne Marie, it’s hard to call this a ‘profession’. In our son’s case, the word ‘executioner’ fits better. I guess however it’s an effective way of getting the queue for treatment down. How can this have been allowed to happen in a civilised world, I ask myself every wretched morning when I wake up to face another day without our dear and delightful son. It happened because we are all afraid of mental illness and we want these gods of psychiatry to give us the magic answers, restore normality in confused minds. So we make ourselves believe in their superior knowledge. We daren’t stand up to them and argue our case, for fear of igniting their wrath against our already suffering loved one. Maybe some, like Dr Healy, do have a great talent for assessment and problem solving. But so many others, as are often reported here, seem to have nothing to offer but arrogance and frustration.
Heather your comment left me feeling really sad. Just thinking of your son sitting in front of that psychiatrist being bullied. It makes me so sad and mad, if that was a domestic situation you could have someone charged with “Domestic or Emotional Abuse” for that, there is a new law come out here in the last year for it. It also covers Controlling and Coercive Behaviour.
Is it not Controlling and Coercive Behaviour when they treat a patient like this and deny them the truth and then bully them into blaming their illness and not the treatment, when it is not?
Trouble with Psychiatrists they have too much power more than the police I heard. They probably feel they are untouchable and above the law (hence where their arrogance comes from) and they get away with it.
Its all very creepy when you look at it.
I lost my mom to big pharma also. I am getting myself off of the drugs right now and working on a solution to stopping them. I’m sorry for your loss.
Psychiatry is indeed a “mental illness” and should be put on the front page of their beloved DSM bible. I don’t believe in the bio-model but what Glasser called “creative symptoming.” All those DSM manuals are certainly symptoms of some sort of creativity. (Though far from thrilling reads.) Unfortunately it’s not the psychiatrists who suffer from their own delusions but those dumb or desperate enough to pay one a visit. Then, Heaven help you! To all intents and purposes your life is over.
It is in a doctors interest to ensure that nothing topples him from his pedestal.Traditionally influences and medical practices the world health organisation figures suggest that in some develop countries there has in recent years ,ben a decrease in life expectancy and increase the mortality rate among young people.But the overriding, essential fact is that doctors have taken too much control for themselves convinced by their own professional propaganda, they have build a profession which has too much respect for therapy and not enough respect for healing.For the first time in history, we have a medical profession which has chosen to ignore the phenomenon of natural healing treatments
Th basic aim of most medical is to suppress any signs and symptoms of illness or distress as quickly and as effectively as possible.In fact, these days scientific medicine itself is responsible for the good percentage of disease.With all the fancy chemical and computerised equipment, we have, chronic,ashma, cancer diabetes virtually all degenerative diseases are known to mankind are thriving and medicine hasn’t affected their incidence one tiny pit.Recently other researchers have found that there is a natural tranquillizer in the human brain and that a powerful and effective morphine is released it has been shown to that when a person with infection develops a mild temperature and loss his appetite both symptoms are signs that the body is dealing with the infection itself.The hope of humanity lies in the prevention of degenerative and mental diseases, not in the care of their symptoms.Thank you for sharing
People are in silence, they do not speak out against it and no one is listening anyways, so the cancer grows, but eventually, “the sign flashed out its warning.”
Life is cyclical, empires rise and fall, so at the peak of its hubris, as they worship their neon god, we start to see the cracks in this new world.
“And ride the wave. Mental health is fashionable”
The gentle art..the president..
“But let’s have a go. A journalist writes a bad piece on antidepressants. I immediately write an email telling him that this is ridiculous, ill informed, prejudiced and will cause great harm and distress, and I will be complaining to the editor. And then delete it. Why?
Anne Marie, you have echoed our thoughts exactly. We have felt sad and mad ever since that terrible day in July 2012, when the Lead Home Treatment psychiatrist harranged our son in front of us in this terrible and undeserved way. You could see from the embarrassed facial expressions and body language of the other three members of the Home Treatment Team, that they were horrified too, but didn’t know what to do. Later we were given information by another psychiatrist who had worked with this arrogant, (dare I say, in our opinion, megalomanic man) that others had died on his watch from suicide, that he was well known by patients and staff alike as a terrifying bully in the NHS, but NO ONE DARED TO CHALLENGE HIM. He had got one psychiatrist dismissed when they took him to the GMC. We did the same, and he got off again.
I was looking back through my email exchanges with my son for that July 2012, because I needed some IT information he had sent me at the time – I had a new contract with China for some of my children’s book series and Olly had scanned the artwork and was sending it there for me. I came upon the email he wrote me, shortly after the horrendous confrontation with the Lead Home Treatment Team psychiatrist. It reads thus:-
I’m really sorry about how I am at the moment. I’m finding the thoughts are tormenting me all day, and memories are making me feel really sad and upset. The anxiety stays as the thoughts are the reality, no matter what anyone says. Also the reality of who I am and how I have behaved has hit home and shocked me to the core. I feel like I’m in my own World most of the time, with nothing to say. I want to escape it but I don’t know how. Everyone has been so nice to me always. I know I can’t talk to you at the moment, but it wanted to say how much I love you and think you’re the most wonderful mum and always have been.
I am doing my best to get through.
Lots of love
Why could he not talk to me? Because the Home Treatment Team social worker, doing the bidding of the above named psychiatrist, had told me and Olly’s dad off for listening to his suicidal thoughts, ‘which were attention-seeking’ and we were in their opinion, making him worse by listening to him! So I went away for a week or two, on their instructions! I cannot forgive myself for believing that they knew best. He was feeling so ill because the psychiatrist had told him to stop Venlafaxine stone dead, and of course, his terrible anxiety and feelings of worthlessness were springing from the appalling AKATHESIA he was pitchforked into, but he didn’t know that, and that at the time, nor did we.
Two months later he was dead. He had never treated anyone unkindly, he had never been thoughtless or attention-seeking. He was a beautiful soul, loved by everyone. But the confrontational psychiatrist decided otherwise, after two short interviews, and a refusal to listen to the history. He was a Master of NLP and he ‘knew’ the answer, just by watching body language and my making a snapshot ‘gut’ diagnosis. (!). And that man had the power. We did not have the knowledge. And, although he was away from the NHS for a few months after Olly’s death, he was back in harness again in 2014 treating patients with exactly the same approach. And no one can do anything to stop him. So, yes, Anne Marie, we feel sad and mad, and we’ve challenged the behaviour meted out to our son, leading to his death, by going to the CEO of our local NHS. Health and Care Trust, but our concerns have been batted away with condescending nonchalance. This is the world we live in now, and lives like Olly’s are being lost, every passing day. Because no one with any power in the NHS DARES to stand up to bullying psychiatrists, for fear of losing their livelihoods.
A piece which is brilliantly written – well worth reading and digesting. I particularly like the ‘as a herd we can succeed’ point – brings hope to our ‘herd’ here. Important to remember too that a ‘herd’ can only be as good as the sum of its determined individuals!