Finland has found the answer to homelessness. It couldnt be simpler | Harry Quilter-Pinner

With the number of rough sleepers in Britain soaring, its time we got over our prejudices, writes Harry Quilter-Pinner, who works at the homelessness charity SCT

I was born in Liverpool and grew up on a council estate. I had a clean home, toys and nice meals as a kid. When I was nine years old, the sexual abuse started. My abusers made me feel special. They gave me gifts, moneys, cigarettes and sweets. When I was 13 I ran away from home and soon found myself in the murky world of prostitution on the streets. My life was out of control.

This is how it all started for Simon. I met him 23 years later at SCT, a local charity I help to run in east London that offers support to people who are homeless and face alcohol and drug addiction. He used to make me coffee every morning at the social enterprise cafe we run. In the intervening period he had spent years in and out of hostels and institutions, as well as long spells on the streets.

When I met him, Simon was sober and working for the first time in years. He said at the time that SCT offered me the opportunity to get my life back on track. Life is worth living now. Im looking forward to my future. Tragically, this future wasnt to be: soon afterwards he decided to return to the streets and died as a result.

I would like to be able to say that Simons story is an exception. But in reality it is all too familiar, as new statistics published by the Guardian showed on Wednesday. The number of homeless people dying on the streets or in temporary accommodation in the UK has more than doubled over the past five years to more than one per week. The average age of a rough sleeper when they die is 43, about half the UK life expectancy.

The tragedy is that its entirely within our power to do something about it: homelessness is not a choice made by the individual, it is a reality forced by government policy. As homelessness has rocketed in the UK up 134% since 2010 it has fallen by 35% in Finland over a similar period of time. The Finnish government is now aiming to abolish it altogether in the coming years.

I recently travelled to Finland to understand how it had done this. It turns out its solution is painfully simple and blindingly obvious: give homes to homeless people. As Juha Kaakinen, who has led much of the work on housing first in Finland, explained to me when I met him in Helsinki, this takes housing as a basic human right rather than being conditional on engaging in services for addictions or mental health.

This is fundamentally different to our model in the UK, where stable accommodation is only provided as a reward for engaging in treatment services. The problem with this is obvious if you stop and think about it: how do we expect people to address complex personal problems while exposed to the chaos of life on the streets?

Sceptics will argue that giving homes to homeless people is a recipe for disaster. Arent we just subsidising addiction? Wont we end up with huge bills when it all goes wrong? Dont people need an incentive to get their lives back on track and engage in services?

Actually, no. The evidence from Finland as well as numerous other pilot schemes across the world shows the opposite is true. When people are given homes, homelessness is radically reduced, engagement in support services goes up and recovery rates from addiction are comparable to a treatment first approach. Even more impressive is that there are overall savings for government, as peoples use of emergency health services and the criminal justice system is lessened.

At the last election, the government committed to pilot a housing first approach in the UK. This isnt good enough we dont need another pilot. During my time in Finland I didnt see one homeless person. Within a few hours of coming back to London I walked past more than 100 rough sleepers queuing for food in the rain, just a few minutes from parliament. What we need is action. Ending homelessness is eminently achievable if we have the moral capacity and will to take proper action. We must overcome our prejudices and our apathy. The status quo is simply not good enough.

Harry Quilter-Pinner is director of strategy at SCT, a homelessness and addictions charity in east London. He is also a research fellow at IPPR, the UKs progressive thinktank. He writes here in a personal capacity

Read more: https://www.theguardian.com/commentisfree/2018/apr/12/finland-homelessness-rough-sleepers-britain

About the boys: Tim Winton on how toxic masculinity is shackling men to misogyny

In an excerpt from a speech about his new book The Shepherds Hut, the author says it is men who need to step up and liberate boys from the race, the game, the fight

I dont have any grand theory about masculinity. But I know a bit about boys. Partly because Im at the beach and in the water a lot.

As a surfer you spend a lot of time bobbing about, waiting for something to happen. So eventually, you get talking. Or you listen to others talking. And I spend my work days alone, in a room with people who dont exist, so these maritime conversations make up the bulk of my social life. And most of the people in the water are younger than me, some by 50 years or more.

I like the teasing and the joking that goes on, the shy asymmetrical conversations, the fitful moments of mutual bewilderment and curiosity. A lot of the time Im just watching and listening. With affection. Indulgence. Amusement. Often puzzled, sometimes horrified. Interested, but careful, of course, not to appear too interested. And the wonderful thing about getting older something many women will understand is that after a certain age you become invisible. And for me, after years of being much too visible for my own comfort, this late life waterborne obscurity is a gift.

There are a lot more girls in the water these days, and hallellujah for that; I cant tell you how heartening this is. But I want to focus on the boys for a moment. For what a mystery a boy is. Even to a grown man. Perhaps especially to a grown man. And how easy it is to forget what beautiful creatures they are. Theres so much about them and in them thats lovely. Graceful. Dreamy. Vulnerable. Qualities we either dont notice, or simply blind ourselves to. You see, theres great native tenderness in children. In boys, as much as in girls. But so often I see boys having the tenderness shamed out of them.

Boys and young men are so routinely expected to betray their better natures, to smother their consciences, to renounce the best of themselves and submit to something low and mean. As if theres only one way of being a bloke, one valid interpretation of the part, the role, if you like. Theres a constant pressure to enlist, to pull on the uniform of misogyny and join the Shithead Army that enforces and polices sexism. And it grieves me to say its not just men pressing those kids into service.

These boys in the surf. The things they say to me! The stuff I hear them saying to their mates! Some of it makes you want to hug them. Some of it makes you want to cry. Some of it makes you ashamed to be a male. Especially the stuff they feel entitled or obliged to say about girls and women.

What Ive come to notice is that all these kids are rehearsing and projecting. Trying it on. Rehearsing their masculinity. Projecting their experimental versions of it. And wordlessly looking for cues the whole time. Not just from each other, but from older people around them, especially the men. Which can be heartbreaking to witness, to tell you the truth. Because the feedback they get is so damn unhelpful. If its well-meant its often feeble and half-hearted. Because good men dont always stick their necks out and make an effort.

True, the blokes around me in the water are there, like me, for respite, to escape complexity and responsibility for an hour or two, to save themselves from going mad in their working lives, but their dignified silence in response to misogynistic trash talk allows other messages, other poisonous postures to flourish. Too often, in my experience, the ways of men to boys lack all conviction, they lack a sense of responsibility and gravity. And I think they lack the solidity and coherence of tradition. Sadly, modernity has failed to replace traditional codes with anything explicit, or coherent or benign. Were left with values that are residual, fuzzy, accidental or sniggeringly conspiratorial.

Weve scraped our culture bare of ritual pathways to adulthood. There are lots of reasons for having clear-felled and burnt our own traditions since the 1960s, and some of them are very good reasons. But Im not sure what weve replaced them with. Weve left our young people to fend for themselves. We retain a kind of indulgent, patronising, approval of rites of passage in other cultures, including those of our first peoples, but the poverty of mainstream modern Australian rituals is astounding.

What are we left with? The sly first beer your uncle slips you. The 18th birthday party where the keg is the icon. Maybe the B&S ball, if you live in the bush. First drink, first root, first bog-lap in your mums Corolla. Call me a snob, but that strikes me as pretty thin stuff. This, surely, is cultural impoverishment. And in such a prosperous country. To my mind, thats salt rising to the surface, poisoning the future.

In the absence of explicit, widely-shared and enriching rites of passage, young men in particular are forced to make themselves up as they go along. Which usually means they put themselves together from spare parts, and the stuff closest to hand tends to be cheap and defective. And thats dangerous.

Toxic masculinity is a burden to men. Im not for a moment suggesting men and women suffer equally from misogyny, because thats clearly and fundamentally not true. And nobody needs to hear me mansplaining on the subject of the patriarchy. But I think we forget or simply dont notice the ways in which men, too, are shackled by misogyny. It narrows their lives. Distorts them. And that sort of damage radiates; it travels, just as trauma is embedded and travels and metastasizes in families. Slavery should have taught us that. The Stolen Generations are still teaching us. Misogyny, like racism, is one of the great engines of intergenerational trauma.

A man in manacles doesnt fully understand the threat he poses to others. Even as hes raging against his bonds. Especially as hes raging against his bonds. When youre bred for mastery, when youre trained to endure and fight and suppress empathy, how do you find your way in a world that cannot be mastered? How do you live a life in which all of us must eventually surrender and come to terms? Too many men are blunt instruments. Otherwise known, I guess, as tools. Because of poor training, theyre simply not fit for purpose. Because life is not a race, its not a game, and its not a fight.

Can we wean boys off machismo and misogyny? Will they ever relinquish the race, the game, the fight, and join the dance? I hope so. Because liberation a process of disarmament, reflection and renewal isnt just desirable, its desperately necessary. In our homes, in business, and clearly, and most clearly of all, in our politics.

Boy
The poverty of mainstream modern Australian rituals is astounding, writes Winton. Photograph: Andy Andrews/Getty Images

Children are born wild. And thats beautiful, its wondrous, regardless of gender. Even when theyre feral creatures, kids are reservoirs of tenderness and empathy. But some do turn into savages. And sadly most of those are boys. Theyre trained into it. Because of neglect or indulgence. And when we meet them in the street, and have them in our classrooms, and haul them into the courts, we recoil from them in horror and disgust. Our detention centres and jails are heaving with them. These wild colonial boys, theyre a terror to Australia. Real and imagined. But I worry about our revulsion for them, our desire to banish them from consciousness for their noncompliance, their mistakes, or their faithful adherence to the scripts that have been written for them.

Boys need help. And, yes, men need fixing Im mindful of that. Males arrive in our community on the coattails of an almost endless chain of unexamined privilege. I dont deny that for a second. But patriarchy is bondage for boys, too. It disfigures them. Even if theyre the last to notice. Even if they profit from it. And their disfigurement diminishes the ultimate prospects of all of us, wherever we are on the gender spectrum. I think we need to admit this.

But before we even get to that point, we have to acknowledge the awkward, implacable fact of their existence, especially those who most offend our sensibilities. We should resist our instinct or our ideological desire to cross the street to avoid them, our impulse to shut them down and shut them out and finally lock them up. We need to have higher expectations of them. Provide better modelling for them.

But before any of that is possible we need to attend to them. Yes, boys need their unexamined privilege curtailed. Just as they need certain proscribed privileges and behaviours made available to them. But the first step is to notice them. To find them worthy of our interest. As subjects, not objects. How else can we hope to take responsibility for them? And its men who need to step up and finally take their full share of that responsibility.

Read more: https://www.theguardian.com/books/2018/apr/09/about-the-boys-tim-winton-on-how-toxic-masculinity-is-shackling-men-to-misogyny

No hugging: are we living through a crisis of touch?

Strokes and hugs are being edged out of our lives, with doctors, teachers and colleagues increasingly hesitant about social touching. Is this hypervigilance of boundaries beginning to harm our mental health?

When did you last touch someone outside your family or intimate relationship? I dont mean a brush of the fingers when you took your parcel from the delivery guy. I mean: when did you pat the arm or back of a stranger, colleague or friend? My own touch diary says that I have touched five people to whom Im not related in the past seven days. One was a newborn and two were accidental (that was the delivery guy). Touch is the first sense humans develop in the womb, possessed even of 1.5cm embryos. But somewhere in adulthood what was instinctive to us as children has come to feel awkward, out of bounds.

In countless ways social touch is being nudged from our lives. In the UK, doctors were warned last month to avoid comforting patients with hugs lest they provoke legal action, and a government report found that foster carers were frightened to hug children in their care for the same reason. In the US the girl scouts caused a furore last December when it admonished parents for telling their daughters to hug relatives because she doesnt owe anyone a hug. Teachers hesitate to touch pupils. And in the UK, in a loneliness epidemic, half a million older people go at least five days a week without seeing or touching a soul.

Sensing this deficit, a touch industry is burgeoning in Europe, Australia and the US, where professional cuddlers operate workshops, parties and one-to-one sessions to soothe the touch-deprived. At Cuddle Up To Me, a cuddle retail centre in Portland, Oregon, clients browse a 72-cuddle menu. Poses includes the Alligator, the Mamma Bear and, less appealingly, the Tarantino. In Japan, a Tranquility chair has been developed, its soft arms wrapping the sitter in a floppy embrace.

Is this what a crisis of touch looks like? And if so, what do humans risk losing, when we lose touch?

Of course we are moving away from touch! exclaims Francis McGlone, a professor in neuroscience at Liverpool John Moores university and a leader in the field of affective touch. He is worried. We have demonised touch to a level at which it sparks off hysterical responses, it sparks off legislative processes, and this lack of touch is not good for mental health. He has heard of teachers asking children to stick on a plaster themselves, rather than touch them and risk a complaint. We seem to have been creating a touch-averse world, he says. Its time to recover the social power of touch.

Touch is commonly thought of as a single sense, but it is much more complex than that. Some nerve endings recognise itch, others vibration, pain, pressure and texture. And one exists solely to recognise a gentle stroking touch.

Illustration
Illustration by Harriet Lee-Merrion

Known as c tactile afferents, this last is the one that McGlone has studied for years. To find it, a needle is inserted into the skin to fish. Its like sitting on the banks of the river, McGlone says. Ones a pain fish. Ones an itch fish. Hours can pass before anyone catches a gentle touch nerve, but this elusive fibre has helped to teach scientists why humans need touch.

By watching the nerves discharge behaviour while the skin is stroked, scientists have learned that the optimum speed of a human caress is 3cm to 5cm a second.

This may sound like a diverting snippet of touch trivia, but its application is far-reaching. When a parent strokes a child, for instance, they are writing out the script that was laid down by 30 million years of evolution, McGlone says. We are destined to cuddle and stroke each other at predetermined velocities. The pleasantness encourages us to keep touching, nourishes babies and binds adults, and threads wellbeing into the fabric of our being. It could also teach us more about the touch-averse, including how and when autism and eating disorders develop, and even lead us to a cure for loneliness.

Last year, researchers from University College London showed that slow, gentle stroking by a stranger reduced feelings of social exclusion.

Bang on! McGlone says. This nerve fibre is responsible for so many aspects of our wellbeing across our lifespan. I call it the Higgs boson of the social brain. The missing particle that glues everything social together. Ironically, having been brought up in the 50s, when parental affection was thought to encourage mawkish children, he is himself sensitive to touch, and feels a gentle stroke like an electric shock.

As a society, we instinctively understand the power of touch. That is why, after the tragic shooting at his school, the head of Marjory Stoneman Douglas in Florida promised to hug each and every one of his 3,300 students. A single, small touch can change countless lives. Princess Diana knew this when she held the hand of an Aids patient in 1987. So did Barack Obama when he stooped to let a young black boy pat his hair, so that he could feel his own potential in the palm of his hand.

Tiffany Field founded the Touch Research Institute at Miami Medical School to study this neglected sense and its impact on health. She enjoys a weekly massage and happily lists the positive effects of being touched. We know from the science of what goes on under the skin that when the skin is moved, pressure receptors are stimulated, she says. This slows down heart rate, blood pressure and the release of cortisol, which gives people better control over their stress hormones.

Being touched increases the number of natural killer cells, the frontline of the immune system. Serotonin increases. Thats the bodys natural antidepressant. It enables deeper sleep, Field says. Her appraisal is borne out by the experience of Kira Cuddles from Cuddle Up To Me in Portland, who has to remind her clients to check for phone, keys, wallet. They leave with a dose of oxytocin. They are floating on a cloud.

Most basically of all, touch tells us who we are. That is why in the womb, McGlone says, with the amniotic fluid washing over it, the brain inside begins to realise, Ive got my body, and thats somebody elses. That developing brain has that sense of me rather than something else out there. If that doesnt happen, you get this almost locked-in syndrome.

Mary Carlson is 78. She worked as a student assistant with the legendary scientist Harry Harlow, whose experiments with monkeys found that the hankering for touch is so innate that an infant, removed from its mother, would cling to a cloth-covered wire surrogate rather than a cold wire one with milk. It would choose to feel nourished rather than be nourished.

Carlson met Harlow as a freshman. At the first lecture she attended, he came out hooting and running around on all fours. In his laboratory, she witnessed monkeys that as infants had been deprived of their mothers touch. In social groups, they would go off in a corner, self-grasping, staring into space. She saw similar patterns of behaviour in humans three decades later when she visited orphanages in Romania, a legacy of Ceausescus regime, where tens of thousands of infants were raised with minimal human touch.

For Carlson, touch is a sort of species recognition. Which suggests that without touch, humans may be, well, less human.

You just dont see people touching each other these days, Field complains. She has just come from a restaurant. And everybody was on their cellphones. At LaGuardia airport recently, she walked around the waiting area. Not a soul was touching another. Even two-year-olds were sitting in carriages with iPads on their laps. (Getting touch from their touch screens.) Then, at the Coconut Grove art festival, There were people bumping into each other because it was so packed. I heard people say, Im sorry! Excuse me! and move off in a way that made it look like they were really embarrassed.

Field is planning studies in restaurants and airports to document how little touch there is and how much distraction by social media. There is as yet no scientific data to connect declining touch to the rise of mobile technology or social media, but Fields descriptions of people wrapped in their own worlds rather than each other, sitting in isolation, bowed over screens, a huddle unto themselves, are evocative and familiar.

Do those atomised people who bounce off each other at art fairs before spinning away in shame, or those who sit day after day alone in their homes carry shades of Harlows monkeys self-soothing in the corner of their cages? And if so, where will our loss of touch lead us?

Kellie Payne, research and policy manager at the Campaign to End Loneliness, says that loneliness is fatal precisely because it puts people into a kind of defensive state where the levels of cortisol are raised. Having had negative experiences, they anticipate that their connection with people will also be negative, which makes it hard to reinstate contact. To add to the challenge for the elderly, touch sensation is in decline. According to David J Linden, author of Touch: The Science of Hand, Heart and Mind, Humans have their strongest touch sensation at around 20, after which it goes down by a percent a year for your whole life.

Field, meanwhile, is worried about the rise in paediatric pain syndromes, such as irritable bowel syndrome and fibromyalgia, previously common only in adults. She thinks this is due to stress and the absence of touch, and is also worried that kids are getting more and more aggressive because there is less and less touch.

This is what Im concerned about, McGlone says. If this evolutionary system is in any way disturbed or interrupted, brains are good at finding compensation. It could be drugs or alcohol … If you remove a reward system, the brain will try to find some other way to get that reward.

Humans love touch. We love it so much that the word has the power to sell a heap of products from soft-touch pillows to velvet touch tights, expert touch saucepans and even smooth, perfecting touch face creams. But touching each other in an age of pervasive and historical sexual abuse and harassment no longer feels safe.

There is a hypervigilance of boundaries that makes it hard to find the right approach. I think twice about hugging a colleague at work in a way that I didnt a couple of years ago, Linden says. Im thinking, maybe this is going to be misinterpreted. Maybe this is going to make somebody feel bad.

Touch even the gentlest kind processed by McGlones beloved c tactile afferents is never only about affection, warmth and care, but also about power. (Just watch Donald Trump greet world leaders.) The so-called Midas touch studies which have shown that diners gently touched on the arm by their server will leave a generous tip, or that people in a care home eat more if touched, illustrate the power of touch to persuade. Touch can retract as well as confer agency. It is not a universal good. It can exacerbate the symptoms of those with autism, and those who have experienced trauma or abuse.

At her home in north London, I meet Anna Fortes Mayer, who has run Cuddle Workshop since 2010. We sit on her red sofa and talk about how to broach touch. She is not tactile, but then we are strangers and her sofa is large.

I tell her about my touch diary: by now my yoga teacher has patted me and Ive collected a matchday hug from my daughters football coach. Its not much. Its really not, Fortes Mayer says, shaking her head. But whats a person to do? How can we build more touch into our lives?

For a start, Fortes Mayer advises against energetically leaning forward for a hug. She dislikes the phrases Do you want a hug?, Give us a hug and Can I have a hug?; they are all too, Who takes ownership here? (This is the mistake Kesha made with Jerry Seinfeld.) She suggests instead, Would you like to share a hug?

Encouraging self-consciousness of the ways in which people offer and invite touch has many benefits. But this kind of touch can never be impulsive, immediate, if it comes with explanatory notes. And touch that breaks protocol can feel more affecting. Consider the excitement when Meghan Markle preferred a hug to a handshake, or Michelle Obama slipped an arm around the Queens back. Even McGlone, despite that 1950s upbringing, on a walk through the park, was tickled to see a big rugby player type bloke offer his wife and then him a hug. (He was so touched, he started to explain about c tactile afferents.)

In Fortes Mayers hall, I put my shoes back on and with my hands at my sides ask, Anna, would you like to share a hug? She says yes and it feels good.

I will often place my hand on someones shoulder, Carlson says. I believe in touch. There are ways you can do it so it isnt demeaning.

Even stranger touch, when its wanted, is pretty good, Linden points out. Even petting your dog. Even petting a dog thats not yours. For the truly solitary, daily power walking stimulates pressure points. Its what Tiffany Field does. She also advocates yoga: Its moving your limbs against each other.

Of course, nobody thinks that a cure for loneliness will happen at a stroke, but maybe careful touch could bring it closer.

Read more: https://www.theguardian.com/society/2018/mar/07/crisis-touch-hugging-mental-health-strokes-cuddles

Yes, bacon really is killing us

The long read: Decades worth of research proves that chemicals used to make bacon do cause cancer. So how did the meat industry convince us it was safe?

There was a little cafe I used to go to that did the best bacon sandwiches. They came in a soft and pillowy white bap. The bacon, thick-cut from a local butcher, was midway between crispy and chewy. Ketchup and HP sauce were served in miniature jars with the sandwich, so you could dab on the exact amount you liked. That was all there was to it: just bread and bacon and sauce. Eating one of these sandwiches, as I did every few weeks, with a cup of strong coffee, felt like an uncomplicated pleasure.

And then, all of a sudden, the bacon sandwich stopped being quite so comforting. For a few weeks in October 2015, half the people I knew were talking about the news that eating bacon was now a proven cause of cancer. You couldnt miss the story: it was splashed large in every newspaper and all over the web. As one journalist wrote in Wired, Perhaps no two words together are more likely to set the internet aflame than BACON and CANCER. The BBC website announced, matter-of-factly, that Processed meats do cause cancer, while the Sun went with Banger out of Order and Killer in the Kitchen.

The source of the story was an announcement from the World Health Organization that processed meats were now classified as a group 1 carcinogen, meaning scientists were certain that there was sufficient evidence that they caused cancer, particularly colon cancer. The warning applied not just to British bacon but to Italian salami, Spanish chorizo, German bratwurst and myriad other foods.

Health scares are ten-a-penny, but this one was very hard to ignore. The WHO announcement came on advice from 22 cancer experts from 10 countries, who reviewed more than 400 studies on processed meat covering epidemiological data from hundreds of thousands of people. It was now possible to say that eat less processed meat, much like eat more vegetables, had become one of the very few absolutely incontrovertible pieces of evidence-based diet advice not simply another high-profile nutrition fad. As every news report highlighted, processed meat was now in a group of 120 proven carcinogens, alongside alcohol, asbestos and tobacco leading to a great many headlines blaring that bacon was as deadly as smoking.

The WHO advised that consuming 50g of processed meat a day equivalent to just a couple of rashers of bacon or one hotdog would raise the risk of getting bowel cancer by 18% over a lifetime. (Eating larger amounts raises your risk more.) Learning that your own risk of cancer has increased from something like 5% to something like 6% may not be frightening enough to put you off bacon sandwiches for ever. But learning that consumption of processed meat causes an additional 34,000 worldwide cancer deaths a year is much more chilling. According to Cancer Research UK, if no one ate processed or red meat in Britain, there would be 8,800 fewer cases of cancer. (That is four times the number of people killed annually on Britains roads.)

The news felt especially shocking because both ham and bacon are quintessentially British foods. Nearly a quarter of the adult population in Britain eats a ham sandwich for lunch on any given day, according to data from 2012 gathered by researchers Luke Yates and Alan Warde. To many consumers, bacon is not just a food; it is a repository of childhood memories, a totem of home. Surveys indicate that the smell of frying bacon is one of our favourite scents in the UK, along with cut grass and fresh bread. To be told that bacon had given millions of people cancer was a bit like finding out your granny had been secretly sprinkling arsenic on your morning toast.

Vegetarians might point out that the bacon sandwich should never have been seen as comforting. It is certainly no comfort for the pigs, most of whom are kept in squalid, cramped conditions. But for the rest of us, it was alarming to be told that these beloved foods might be contributing to thousands of needless human deaths. In the weeks following news of the WHO report, sales of bacon and sausages fell dramatically. British supermarkets reported a 3m drop in sales in just a fortnight. (It was very detrimental, said Kirsty Adams, the product developer for meat at Marks and Spencer.)

But just when it looked as if this may be #Bacongeddon (one of many agonised bacon-related hashtags trending in October 2015), a second wave of stories flooded in. Their message was: panic over. For one thing, the analogy between bacon and smoking was misleading. Smoking tobacco and eating processed meat are both dangerous, but not on the same scale. To put it in context, around 86% of lung cancers are linked to smoking, whereas it seems that just 21% of bowel cancers can be attributed to eating processed or red meat. A few weeks after publishing the report, the WHO issued a clarification insisting it was not telling consumers to stop eating processed meat.

Meanwhile, the meat industry was busily insisting that there was nothing to see here. The North American Meat Institute, an industry lobby group, called the report dramatic and alarmist overreach. A whole tranche of articles insisted in a commonsense tone that it would be premature and foolish to ditch our meaty fry-ups just because of a little cancer scare.

Nearly three years on, it feels like business as usual for processed meats. Many of us seem to have got over our initial sense of alarm. Sales of bacon in the UK are buoyant, having risen 5% in the two years up to mid-2016. When I interviewed a product developer for Sainsburys supermarket last year, she said that one of the quickest ways to get British consumers to try a new product now was to add chorizo to it.

And yet the evidence linking bacon to cancer is stronger than ever. In January, a new large-scale study using data from 262,195 British women suggested that consuming just 9g of bacon a day less than a rasher could significantly raise the risk of developing breast cancer later in life. The studys lead author, Jill Pell from the Institute of Health and Wellbeing at Glasgow University, told me that while it can be counterproductive to push for total abstinence, the scientific evidence suggests it would be misleading for health authorities to set any safe dose for processed meat other than zero.

The real scandal of bacon, however, is that it didnt have to be anything like so damaging to our health. The part of the story we havent been told including by the WHO is that there were always other ways to manufacture these products that would make them significantly less carcinogenic. The fact that this is so little known is tribute to the power of the meat industry, which has for the past 40 years been engaged in a campaign of cover-ups and misdirection to rival the dirty tricks of Big Tobacco.


How do you choose a pack of bacon in a shop, assuming you are a meat eater? First, you opt for either the crispy fat of streaky or the leanness of back. Then you decide between smoked or unsmoked each version has its passionate defenders (I am of the unsmoked persuasion). Maybe you seek out a packet made from free-range or organic meat, or maybe your budget is squeezed and you search for any bacon on special offer. Either way, before you put the pack in your basket, you have one last look, to check if the meat is pink enough.

Since we eat with our eyes, the main way we judge the quality of cured meats is pinkness. Yet it is this very colour that we should be suspicious of, as the French journalist Guillaume Coudray explains in a book published in France last year called Cochonneries, a word that means both piggeries and rubbish or junk food. The subtitle is How Charcuterie Became a Poison. Cochonneries reads like a crime novel, in which the processed meat industry is the perpetrator and ordinary consumers are the victims.

The pinkness of bacon or cooked ham, or salami is a sign that it has been treated with chemicals, more specifically with nitrates and nitrites. It is the use of these chemicals that is widely believed to be the reason why processed meat is much more carcinogenic than unprocessed meat. Coudray argues that we should speak not of processed meat but nitro-meat.

Parma
Prosciutto di Parma has been produced without nitrates since 1993. Photograph: Stefano Rellandini/Reuters

Pure insane crazy madness is how Coudray described the continuing use of nitrates and nitrites in processed meats, in an email to me. The madness, in his view, is that it is possible to make bacon and ham in ways that would be less carcinogenic. The most basic way to cure any meat is to salt it either with a dry salt rub or a wet brine and to wait for time to do the rest. Coudray notes that ham and bacon manufacturers claim this old-fashioned way of curing isnt safe. But the real reason they reject it is cost: it takes much longer for processed meats to develop their flavour this way, which cuts into profits.

There is much confusion about what processed meat actually means, a confusion encouraged by the bacon industry, which benefits from us thinking there is no difference between a freshly minced lamb kofta and a pizza smothered in nitrate-cured pepperoni. Technically, processed meat means pork or beef that has been salted and cured, with or without smoking. A fresh pound of beef mince isnt processed. A hard stick of cured salami is.

The health risk of bacon is largely to do with two food additives: potassium nitrate (also known as saltpetre) and sodium nitrite. It is these that give salamis, bacons and cooked hams their alluring pink colour. Saltpetre sometimes called sal prunella has been used in some recipes for salted meats since ancient times. As Jane Grigson explains in Charcuterie and French Pork Cookery, saltpetre was traditionally used when brining hams to give them an attractive rosy appearance when otherwise it would be a murky greyish brown.

In earlier centuries, bacon-makers who used saltpetre did not understand that it converts to nitrite as the meat cures. It is this nitrite that allows the bacteria responsible for cured flavour to emerge quicker, by inhibiting the growth of other bacteria. But in the early 20th century, the meat industry found that the production of cured meats could be streamlined by adding sodium nitrite to the pork in pure form. In trade journals of the 1960s, the firms who sold nitrite powders to ham-makers spoke quite openly about how the main advantage was to increase profit margins by speeding up production. One French brand of sodium nitrite from the 60s was called Vitorose or quick-pink.

Nitro-chemicals have been less of a boon to consumers. In and of themselves, these chemicals are not carcinogenic. After all, nitrate is naturally present in many green vegetables, including celery and spinach, something that bacon manufacturers often jubilantly point out. As one British bacon-maker told me, Theres nitrate in lettuce and no one is telling us not to eat that!

But something different happens when nitrates are used in meat processing. When nitrates interact with certain components in red meat (haem iron, amines and amides), they form N-nitroso compounds, which cause cancer. The best known of these compounds is nitrosamine. This, as Guillaume Coudray explained to me in an email, is known to be carcinogenic even at a very low dose. Any time someone eats bacon, ham or other processed meat, their gut receives a dose of nitrosamines, which damage the cells in the lining of the bowel, and can lead to cancer.

You would not know it from the way bacon is sold, but scientists have known nitrosamines are carcinogenic for a very long time. More than 60 years ago, in 1956, two British researchers called Peter Magee and John Barnes found that when rats were fed dimethyl nitrosamine, they developed malignant liver tumours. By the 1970s, animal studies showed that small, repeated doses of nitrosamines and nitrosamides exactly the kind of regular dose a person might have when eating a daily breakfast of bacon were found to cause tumours in many organs including the liver, stomach, oesophagus, intestines, bladder, brain, lungs and kidneys.

Just because something is a carcinogen in rats and other mammals does not mean it will cause cancer in humans, but as far back as 1976, cancer scientist William Lijinsky argued that we must assume that these N-nitroso compounds found in meats such as bacon were also carcinogens for man. In the years since, researchers have gathered a massive body of evidence to lend weight to that assumption. In 1994, to take just one paper among hundreds on nitrosamines and cancer, two American epidemiologists found that eating hotdogs one or more times a week was associated with higher rates of childhood brain cancer, particularly for children who also had few vitamins in their diets.

In 1993, Parma ham producers in Italy made a collective decision to remove nitrates from their products and revert to using only salt, as in the old days. For the past 25 years, no nitrates or nitrites have been used in any Prosciutto di Parma. Even without nitrate or nitrite, the Parma ham stays a deep rosy-pink colour. We now know that the colour in Parma ham is totally harmless, a result of the enzyme reactions during the hams 18-month ageing process.

Slow-cured, nitrate-free, artisan hams are one thing, but what about mass-market meats? Eighteen months would be a long time to wait on hotdogs, as the food science expert Harold McGee comments. But there have always been recipes for nitrate-free bacon using nothing but salt and herbs. John Gower of Quiet Waters Farm, a pork producer who advises many British manufacturers of cured meats, confirms that nitrate is not a necessary ingredient in bacon: Its generally accepted that solid muscle products, as opposed to chopped meat products like salami, dont require the addition of nitrate for safety reasons.

Bacon is proof, if it were needed, that we cling to old comforts long after they have been proven harmful. The attachment of producers to nitrates in bacon is mostly cultural, says Gower. Bacon cured by traditional methods without nitrates and nitrites will lack what Gower calls that hard-to-define tang, that delicious almost metallic taste that makes bacon taste of bacon to British consumers. Bacon without nitrates, says Gower, is nothing but salt pork.

Given the harm of nitro-meat has been known for so long, the obvious question is why more has not been done to protect us from it. Corinna Hawkes, a professor of Food Policy at City University in London, has been predicting for years that processed meats will be the next sugar a food so harmful that there will be demands for government agencies to step in and protect us. Some day soon, Hawkes believes, consumers will finally wake up to the clear links between cancer and processed meat and say Why didnt someone tell me about this?


The most amazing thing about the bacon panic of 2015 was that it took so long for official public health advice to turn against processed meat. It could have happened 40 years earlier. The only time that the processed meat industry has looked seriously vulnerable was during the 1970s, a decade that saw the so-called war on nitrates in the US. In an era of Ralph Nader-style consumer activism, there was a gathering mood in favour of protecting shoppers against bacon which one prominent public health scientist called the most dangerous food in the supermarket. In 1973, Leo Freedman, the chief toxicologist of the US Food and Drug Administration, confirmed to the New York Times that nitrosamines are a carcinogen for humans although he also mentioned that he liked bacon as well as anybody.

The US meat industry realised it had to act fast to protect bacon against the cancer charge. The first attempts to fight back were simply to ridicule the scientists for over-reacting. In a 1975 article titled Factual look at bacon scare, Farmers Weekly insisted that a medium-weight man would have to consume more than 11 tonnes of bacon every single day to run the faintest risk of cancer. This was an outrageous fabrication.

But soon the meat lobby came up with a cleverer form of diversion. The AMI the American Meat Institute started to make the argument that the nitrate was only there for the consumers own safety, to ward off botulism a potentially fatal toxin sometimes produced by poorly preserved foods. The scientific director of the AMI argued that a single cup of botulism would be enough to wipe out every human on the planet. So, far from harming lives, bacon was actually saving them.

In 1977, the FDA and the US Department of Agriculture gave the meat industry three months to prove that nitrate and nitrite in bacon caused no harm. Without a satisfactory response, Coudray writes, these additives would have to be replaced 36 months later with non-carcinogenic methods. The meat industry could not prove that nitrosamines were not carcinogenic because it was already known that they were. Instead, the argument was made that nitrates and nitrites were utterly essential for the making of bacon, because without them bacon would cause thousands of deaths from botulism. In 1978, in response to the FDAs challenge, Richard Lyng, director of the AMI, argued that nitrites are to processed meat as yeast is to bread.

The meat industrys tactics in defending bacon have been right out of the tobacco industrys playbook, according to Marion Nestle, professor of nutrition and food studies at New York University. The first move is: attack the science. By the 1980s, the AMI was financing a group of scientists based at the University of Wisconsin. These meat researchers published a stream of articles casting doubt on the harmfulness of nitrates and exaggerating the risk from botulism of non-nitrated hams.

Does making ham without nitrite lead to botulism? If so, it is a little strange that in the 25 years that Parma ham has been made without nitrites, there has not been a single case of botulism associated with it. Almost all the cases of botulism from preserved food which are extremely rare have been the result of imperfectly preserved vegetables, such as bottled green beans, peas and mushrooms. The botulism argument was a smokescreen. The more that consumers could be made to feel that the harmfulness of nitrate and nitrite in bacon and ham was still a matter of debate, the more they could be encouraged to calm down and keep buying bacon.

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A bacon sandwich at a diner in Michigan. Photograph: Molly Riley/Reuters

The botulism pretext was very effective. The AMI managed to get the FDA to keep delaying its three-month ultimatum on nitrites until a new FDA commissioner was appointed in 1980 one more sympathetic to hotdogs. The nitrite ban was shelved. The only concession the industry had made was to limit the percentage of nitrites added to processed meat and to agree to add vitamin C, which would supposedly mitigate the formation of nitrosamines, although it does nothing to prevent the formation of another known carcinogen, nitrosyl-haem.

Over the years, the messages challenging the dangers of bacon have become ever more outlandish. An explainer article by the Meat Science and Muscle Biology lab at the University of Wisconsin argues that sodium nitrite is in fact critical for maintaining human health by controlling blood pressure, preventing memory loss, and accelerating wound healing. A French meat industry website, info-nitrites.fr, argues that the use of the right dose of nitrites in ham guarantees healthy and safe products, and insists that ham is an excellent food for children.

The bacon lobby has also found surprising allies among the natural foods brigade. Type nitrate cancer bacon into Google, and you will find a number of healthy eating articles, some of them written by advocates of the Paleo diet, arguing that bacon is actually a much-maligned health food. The writers often mention that vegetables are the primary source of nitrates, and that human saliva is high in nitrite. One widely shared article claims that giving up bacon would be as absurd as attempting to stop swallowing. Out of the mass of stuff on the internet defending the healthiness of bacon, it can be hard to tell which writers have fallen under the sway of the meat lobby, and which are simply clueless nutrition experts who dont know any better.

Either way, this misinformation has the potential to make thousands of people unwell. The mystifying part is why the rest of us have been so willing to accept the cover-up.


Our deepening knowledge of its harm has done very little to damage the comforting cultural associations of bacon. While I was researching this article, I felt a rising disgust at the repeated dishonesty of the processed meat industry. I thought about hospital wards and the horrible pain and indignity of bowel cancer. But then I remembered being in the kitchen with my father as a child on a Sunday morning, watching him fry bacon. When all the bacon was cooked, he would take a few squares of bread and fry them in the meaty fat until they had soaked up all its goodness.

In theory, our habit of eating salted and cured meats should have died out as soon as home refrigerators became widespread in the mid-20th century. But tastes in food are seldom rational, and millions of us are still hooked on the salty, smoky, umami savour of sizzling bacon.

We are sentimental about bacon in a way we never were with cigarettes, and this stops us from thinking straight. The widespread willingness to forgive pink, nitrated bacon for causing cancer illustrates how torn we feel when something beloved in our culture is proven to be detrimental to health. Our brains cant cope with the horrid feeling that bacon is not what we thought it was, and so we turn our anger outwards to the health gurus warning us of its hazards. The reaction of many consumers to the WHO report of 2015 was: hands off my bacon!

In 2010, the EU considered banning the use of nitrates in organic meats. Perhaps surprisingly, the British organic bacon industry vigorously opposed the proposed nitrates ban. Richard Jacobs, the late chief executive of Organic Farmers & Growers, an industry body, said that prohibiting nitrate and nitrite would have meant the collapse of a growing market for organic bacon.

Organic bacon produced with nitrates sounds like a contradiction in terms, given that most consumers of organic food buy it out of concerns for food safety. Having gone to the trouble of rearing pigs using free-range methods and giving them only organic feed, why would you then cure the meat in ways that make it carcinogenic? In Denmark, all organic bacon is nitrate-free. But the UK organic industry insisted that British shoppers would be unlikely to accept bacon that was greyish.

Then again, the slowness of consumers to lose our faith in pink bacon may partly be a response to the confusing way that the health message has been communicated to us. When it comes to processed meat, we have been misled not just by wild exaggerations of the food industry but by the caution of science.

On the WHO website, the harmfulness of nitrite-treated meats is explained so opaquely you could miss it altogether. In the middle of a paragraph on what makes red meat and processed meat increase the risk of cancer, it says: For instance, carcinogenic chemicals that form during meat processing include N-nitroso compounds. What this means, in plain English, is that nitrites make bacon more carcinogenic. But instead of spelling this out, the WHO moves swiftly on to the question of how both red and processed meats might cause cancer, after adding that it is not yet fully understood how cancer risk is increased.

The
The typical British sausage does not fall into the processed meat category. Photograph: Julian Smith/AAP

This caution has kept us as consumers unnecessarily in the dark. Consider sausages. For years, I believed that the unhealthiest part in a cooked English breakfast was the sausage, rather than the bacon. Before I started to research this article, Id have sworn that sausages fell squarely into the processed meat category. They are wrongly listed as such on the NHS website.

But the average British sausage as opposed to a hard sausage like a French saucisson is not cured, being made of nothing but fresh meat, breadcrumbs, herbs, salt and E223, a preservative that is non-carcinogenic. After much questioning, two expert spokespeople for the US National Cancer Institute confirmed to me that one might consider fresh sausages to be red meat and not processed meat, and thus only a probable carcinogen. (To me, the fact that most sausages are not processed meat was deeply cheering, and set me dancing around the kitchen with glee thinking about toad in the hole.)

In general, if you ask a cancer scientist to distinguish between the risks of eating different types of meat, they become understandably cagey. The two experts at the National Cancer Institute told me that meats containing nitrites and nitrates have consistently been associated with increased risk of colon cancer in human studies. But they added that it is difficult to separate nitrosamines from other possible carcinogens that may be present in processed meats like bacon. These other suspects include haem iron a substance that is abundant in all red meat, processed or not and heterocyclic amines: chemicals that form in meat during cooking. A piece of crispy, overcooked bacon will contain multiple carcinogens, and not all are due to the nitrates.

The problem with this reasoning, as I see it, is that it cant account for why processed meat is so much more closely linked to cancer than cooked red meat. For that, there remains no plausible explanation except for nitrates and nitrites. But looking for clear confirmation of this in the data is tricky, given that humans do not eat in labs under clinical observation.

Most of what we know about processed meat and cancer in humans comes from epidemiology the study of disease across whole populations. But epidemiologists do not ask the kind of detailed questions about food that the people who eat that food may like answers to. The epidemiological data based on surveys of what people eat is now devastatingly clear that diets high in processed meats lead to a higher incidence of cancer. But it cant tell us how or why or which meats are the best or worst. As Corinna Hawkes of City University comments, The researchers dont ask you if you are eating artisanal charcuterie from the local Italian deli or the cheapest hotdogs on the planet.

I would love to see data comparing the cancer risk of eating nitrate-free Parma ham with that of traditional bacon, but no epidemiologist has yet done such a study. The closest anyone has come was a French study from 2015, which found that consumption of nitrosylated haem iron as found in processed meats had a more direct association with colon cancer than the haem iron that is present in fresh red meat.

It may be possible that epidemiologists have not asked people more detailed questions about what kind of processed meats they eat because they assume there is no mass-market alternative to bacon made without nitrates or nitrites. But this is about to change.


The technology now exists to make the pink meats we love in a less damaging form, which raises the question of why the old kind is still so freely sold. Ever since the war on nitrates of the 1970s, US consumers have been more savvy about nitrates than those in Europe, and there is a lot of nitrate-free bacon on the market. The trouble, as Jill Pell remarks, is that most of the bacon labelled as nitrate-free in the US isnt nitrate-free. Its made with nitrates taken from celery extract, which may be natural, but produces exactly the same N-nitroso compounds in the meat. Under EU regulation, this bacon would not be allowed to be labelled nitrate-free.

Its the worst con Ive ever seen in my entire life, says Denis Lynn, the chair of Finnebrogue Artisan, a Northern Irish company that makes sausages for many UK supermarkets, including Marks & Spencer. For years, Lynn had been hoping to diversify into bacon and ham but, he says, I wasnt going to do it until we found a way to do it without nitrates.

When Lynn heard about a new process, developed in Spain, for making perfectly pink, nitrate-free bacon, he assumed it was another blind alley. In 2009, Juan de Dios Hernandez Canovas, a food scientist and the head of the food tech company Prosur, found that if he added certain fruit extracts to fresh pork, it stayed pink for a surprisingly long time.

In January 2018, Finnebrogue used this technology to launch genuinely nitrate-free bacon and ham in the UK. It is sold in Sainsburys and Waitrose as Naked Bacon and Naked Ham, and in M&S as made without nitrites. Kirsty Adams, who oversaw its launch at M&S, explains that its not really cured. Its more like a fresh salted pork injected with a fruit and vegetable extract, and is more perishable than an old-fashioned flitch of bacon but that doesnt matter, given that it is kept in a fridge. Because it is quick to produce, this is much more economically viable to make than some of the other nitrate-free options, such as slow-cured Parma ham. The bacon currently sells in Waitrose for 3 a pack, which is not the cheapest, but not prohibitive either.

I tried some of the Finnebrogue bacon from M&S. The back bacon tasted pleasant and mild, with a slight fruitiness. It didnt have the toothsome texture or smoky depth of a rasher of butchers dry-cured bacon, but Id happily buy it again as an alternative to nitro-meat. None of my family noticed the difference in a spaghetti amatriciana.

Nitrite-free bacon still sounds a bit fancy and niche, but there shouldnt be anything niche about the desire to eat food that doesnt raise your risk of cancer. Lynn says that when he first approached Prosur about the fruit extract, he asked how much they had sold to the other big bacon manufacturers during the two years they had been offering it in the UK. The answer was none. None of the big guys wanted to take it, claims Lynn. They said: It will make our other processed meats look dodgy.

But it also remains to be seen how much consumer demand there will be for nitrite- or nitrate-free bacon. For all the noise about bacon and cancer, it isnt easy to disentangle at a personal level just what kind of risk we are at when we eat a bacon sandwich. OK, so 34,000 people may die each year because of processed meat in their diet, but the odds are that it wont be you. I asked a series of cancer scientists whether they personally ate processed meat, and they all gave slightly different answers. Jill Pell said she was mostly vegetarian and ate processed meats very rarely. But when I asked Fabrice Pierre, a French expert on colon cancer and meat, if he eats ham, he replied: Yes, of course. But with vegetables at the same meal. (Pierres research at the Toxalim lab has shown him that some of the carcinogenic effects of ham can be offset by eating vegetables.)

Our endless doubt and confusion about what we should be eating have been a gift to the bacon industry. The cover-up about the harm of meat cured with nitrates and nitrites has been helped along by the scepticism many of us feel about all diet advice. At the height of the great bacon scare of 2015, lots of intelligent voices were saying that it was safe to ignore the new classification of processed meats as carcinogenic, because you cant trust anything these nutritionists say. Meanwhile, millions of consumers of ham and bacon, many of them children, are left unprotected. Perhaps the most extraordinary thing about this controversy is how little public outrage it has generated. Despite everything, most of us still treat bacon as a dear old friend.

In an ideal world, we would all be eating diets lower in meat, processed or otherwise, for the sake of sustainability and animal welfare as much as health. But in the world we actually live in, processed meats are still a normal, staple protein for millions of people who cant afford to swap a value pack of frying bacon for a few slivers of Prosciutto di Parma. Around half of all meat eaten in developed countries is now processed, according to researcher John Kearney, making it a far more universal habit than smoking.

The real victims in all this are not people like me who enjoy the occasional bacon-on-sourdough in a hipster cafe. The people who will be worst affected are those many on low incomes for whom the cancer risk from bacon is compounded by other risk factors such as eating low-fibre diets with few vegetables or wholegrains. In his book, Coudray points out that in coming years, millions more poor consumers will be affected by preventable colon cancer, as westernised processed meats conquer the developing world.

Last month, Michele Rivasi, a French MEP, launched a campaign in collaboration with Coudray demanding a ban of nitrites from all meat products across Europe. Given how vigorously the bacon industry has fought its corner thus far, a total ban on nitrites looks unlikely.

But there are other things that could be done about the risk of nitrites and nitrates in bacon, short of an absolute veto. Better information would be a start. As Corinna Hawkes points out, it is surprising that there hasnt been more of an effort from government to inform people about the risks of eating ham and bacon, perhaps through warning labels on processed meats. But where is the British politician brave enough to cast doubt on bacon?

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Read more: https://www.theguardian.com/news/2018/mar/01/bacon-cancer-processed-meats-nitrates-nitrites-sausages

NHS patients dying in hospital corridors, A&E doctors tell Theresa May

Doctors running 68 A&E departments tell PM patients are dying prematurely because staff are too busy to treat them

Patients are dying in hospital corridors during the ongoing winter crisis because the NHS is so underfunded and short-staffed that it cannot cope, senior doctors have warned Theresa May.

A&E units are under such intense strain that patients are at intolerable risk of being harmed by receiving poor care, specialists in emergency medicine from 68 hospitals have told the prime minister in a letter of unprecedented alarm.

In recent weeks some hospitals have become so overloaded that they have been looking after as many as 120 patients a day in corridors, with some dying prematurely as a result, the letter says.

The doctors, consultants who work in or run A&E units in England and Wales, have written to May to highlight the very serious concerns we have for the safety of our patients. This current level of safety compromise is at times intolerable, despite the best efforts of staff.

Conditions in many A&E units are so appalling that they could kill patients, claim the signatories, who work at both major teaching hospitals and smaller district general hospitals. They include Frimley health trust in Surrey, which May visited last week in an attempt to reassure the public that the NHS was coping well this winter.

As you will know a number of scientific publications have shown that crowded emergency departments are dangerous for patients. The longer that the patients stay in [the] emergency department after their treatment has been completed, the greater is their morbidity and associated morbidity, they write.

Their intervention came as new NHS figures showed that the percentage of patients being treated within four hours at hospital-based A&E units in England fell last month to its lowest-ever level 77.3%. The performance of all types of settings offering A&E-type care taken together, including walk-in centres and urgent care centres, was better but still the joint worst ever at 85.1% far below the politically important target of 95%.

Graph

Only three of the NHSs 137 acute trusts hit the 95% target, while 32 were at or below 70%. Blackpool teaching hospitals trust had by far the lowest performance, at 40.1%. The figures reinforced the warning to ministers on Thursday from NHS Providers that it would be impossible to deliver on their pledge that all hospitals would be achieving 95% by March.

Our emergency departments are not just under pressure, but in a state of emergency, said Dr Taj Hassan, the president of the Royal College of Emergency Medicine, which represents A&E doctors.

The NHS undertook unprecedented planning to help services cope with the annual spike in demand in December and January. Despite that, hospitals had a record number of emergency admissions last month 520,163, a 4.5% rise on the numbers admitted in December 2016.

A drive to free up 2,000-3,000 beds by 1 September, to avoid hospitals becoming dangerously full, appears to have failed. Separate NHS figures for last week show that 19 trusts were on 99% or 100% bed occupancy between 1 and 7 January. Three were completely full.

Average bed occupancy shot up last week to 95%, far higher than the 85% that experts say, and the NHS accepts, hospitals need to maintain in order to stop patients getting hospital-acquired infections such as MRSA or Clostridium difficile, or experiencing poor care.

Bed occupancy as high as 95% is a danger to patient safety, with around 7,000 fewer beds open than in the same period last year, said Hassan.

Drawing on their own experiences in recent weeks ,the doctors who signed the letter painted a stark picture of conditions inside A&E units. Common situations include over 50 patients at a time waiting beds in the emergency department [and] patients sleeping in clinics as makeshift wards.

A Department of Health and Social Care spokeswoman said in response to the letter: There has been a 68.7% increase in the number of A&E consultants since 2010, and the NHS was given top priority in the recent budget with an extra 2.8bn allocated over the next two years.

But we know there is a great deal of pressure in A&E departments, and we are grateful to all NHS staff for their incredible work in challenging circumstances. Thats why we recently announced the largest single increase in doctor training places in the history of the NHS a 25% expansion.

May stressed on Thursday that flu was a key factor in the intense strain that NHS services were facing. We have seen the extra pressures that the NHS has come under this year. One of the issues that determines the extent of that pressure is flu and we have seen in recent days an increase in the number of people presenting at A&E from flu, she said.

Q&A

Why is the NHS winter crisis so bad in 2017-18?

A combination of factors are at play. Hospitals have fewer beds than last year, so they are less able to deal with the recent, ongoing surge in illness. Last week, for example, the bed occupancy rate at 17 of Englands 153 acute hospital trusts was 98% or more, with the fullest Walsall healthcare trust 99.9% occupied.

NHS England admits that the service has been under sustained pressure [recently because of] high levels of respiratory illness, bed occupancy levels giving limited capacity to deal with demand surges, early indications of increasing flu prevalence and some reports suggesting a rise in the severity of illness among patients arriving at A&Es.

Many NHS bosses and senior doctors say that the pressure the NHS is under now is the heaviest it has ever been. We are seeing conditions that people have not experienced in their working lives, says Dr Taj Hassan, the president of the Royal College of Emergency Medicine.

The unprecedented nature of the measures that NHS bosses have told hospitals to take including cancelling tens of thousands of operations and outpatient appointments until at least the end of January underlines the seriousness of the situation facing NHS services, including ambulance crews and GP surgeries.

Read a full Q&A on the NHS winter crisis

Hours after she spoke, new figures from Public Health England confirmed that flu was putting a sharply increased burden on GP surgeries as well as hospitals.

Last week 758 peple around the UK were hospialised because of flu, up from 421 the week before. Of those, 240 were so sick they had to be admitted to an intensive care or a high dependency unit, up from 114. The number of people consulting a GP with flu-like symptoms almost doubled.

A further 27 people died of flu-related symptoms last week, three more than the week before, taking the toll of deaths this winter to 85.

Read more: https://www.theguardian.com/society/2018/jan/11/nhs-patients-dying-in-hospital-corridors-doctors-tell-theresa-may

Dont listen to Gwyneth Paltrow: keep your coffee well away from your rectum | Jen Gunter

The colonic irrigation and coffee enemas promoted on Paltrows website Goop are not merely unnecessary, they are potentially dangerous, writes obstetrician and gynaecologist Dr Jen Gunter

It seems January is Gwyneth Paltrows go-to month for promoting potentially dangerous things that should not go in or near an orifice. January 2015 brought us vagina steaming, January 2017 was jade eggs, and here we are in the early days of January 2018 and Goop.com is hawking coffee enemas and promoting colonic irrigation.

I suspect that GP and her pals at Goop.com believe people are especially vulnerable to buying quasi-medical items in the New Year as they have just released their latest detox and wellness guide complete with a multitude of products to help get you nowhere.

colon
Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. An advertisement on Goop.com.

One offers to help if youre looking to go deep on many levels. Ha ha, go deep. Nice play on words for a dangerous yet ineffective therapy. Goop.com is not selling a coffee machine, it is selling a coffee enema-making machine. That, my friends, is a messed-up way to make money. I know the people at Goop will either ignore the inquiries from reporters or release a statement saying the article is a conversation not a promotion and that they included the advice of a board-certified doctor, Dr Alejandro Junger, but any time you lend someone else your platform their ideas are now your ideas. That is why I never let anyone write guest posts for my blog. And lets be real, if you are selling the hardware to shoot coffee up your ass then you are promoting it as a therapy especially as Goop actually called the $135 coffee enema-making machine Dr Jungers pick. I mean come on.

The interview with Junger is filled with information that is unsupported both by the medical literature and by human anatomy and physiology. There is no data to suggest that a colonic helps with the elimination of the waste that is transiting the colon on its way out. That is what bowel movements do. There are no toxins to be cleansed or irrigated. That is fake medicine. A 2011 review on colonics concluded that doctors should advise patients that colon cleansing has no proven benefits and many adverse effects.

The idea that colonics are used in conjunction with a cleanse is beyond ridiculous. Junger tells us via Goop that a cleanse creates some kind of extra sticky mucus that blocks elimination of what needs to be disposed of (I will admit that hurt my brain more than a little). Dr Junger says this cleanse residue is a mucoid plaque, basically some kind of adherent, cleanse-induced super-glue that needs a colonic for removal. He supports this assertion not with published research, but by telling Goops readers to Google mucoid plaque.

No really. That is what he said. Google it. So I did. This is what came up first:

Mucoid plaque (or mucoid cap or rope) is a pseudoscientific term used by some alternative medicine advocates to describe what is claimed to be a combination of allegedly harmful mucus-like material and food residue that they say coats the gastrointestinal tract of most people.

Apparently, the term mucoid plaque was coined by Richard Anderson, who is a naturopath, not a gastroenterologist, so not a doctor who actually looks inside the colon. I looked mucoid plaques up in PubMed. Guess what? Nothing colon-related. There is not one study or even case-report describing this phenomenon. Apparently only doctors who sell cleanses and colonics can see them. I am fairly confident that if some gastroenterologist (actual colon doctor) found some crazy mucus that looked like drool from the alien queen that she or he would have taken pictures and written about it or discussed it at a conference.

If we needed cleanses to live and thus colonics to manage this alien-like mucous residue created by cleanses, how did we ever evolve? Wouldnt we have died out from these mysterious toxins? Wouldnt our rectums be different? Wouldnt we have invented irrigation tubing before the wheel? So many questions.

There is only a side mention in the Goop post of two of the many complications seen with colonics: colon perforation and damage to gastrointestinal bacteria. And as for coffee enemas? While Dr Kelly Brogan, Paltrows Aids-denialist doctor gal pal who is speaking at In Goop Health later this month, is also a huge fan, there is no data to suggest that coffee offers any benefit via the rectal route but there are plenty of reports of coffee enema-induced rectal burns.

So here are the facts. No one needs a cleanse. Ever. There are no waste products left behind in the colon that need removing just because or after a cleanse. If a cleanse did leave gross, adherent hunks of weird mucus then that would be a sign that the cleanse was damaging the colon. You know what creates excess, weird mucous? Irritation and inflammation.

There are serious risks to colonics such as bowel perforation, damaging the intestinal bacteria, abdominal pain, vomiting, electrolyte abnormalities and renal failure. There are also reports of serious infections, air embolisms, colitis, and rectal perforation. If you go to a spa and the equipment is not sterilised, infections can be transmitted via the tubing.

Coffee enemas and colonics offer no health benefit. The biology used to support these therapies is unsound and there can be very real complications. Keep the coffee out of your rectum and in your cup. It is only meant to access your colon from the top.

Dr Jen Gunter is an obstetrician, gynaecologist and pain medicine physician. This piece originally ran on Jen Gunters blog

Read more: https://www.theguardian.com/commentisfree/2018/jan/09/gwyneth-paltrow-goop-coffee-enema-colonic-irrigation

Is everything you think you know about depression wrong?

In this extract from his new book, Johann Hari, who took antidepressants for 14 years, calls for a new approach

In the 1970s, a truth was accidentally discovered about depression one that was quickly swept aside, because its implications were too inconvenient, and too explosive. American psychiatrists had produced a book that would lay out, in detail, all the symptoms of different mental illnesses, so they could be identified and treated in the same way across the United States. It was called the Diagnostic and Statistical Manual. In the latest edition, they laid out nine symptoms that a patient has to show to be diagnosed with depression like, for example, decreased interest in pleasure or persistent low mood. For a doctor to conclude you were depressed, you had to show five of these symptoms over several weeks.

The manual was sent out to doctors across the US and they began to use it to diagnose people. However, after a while they came back to the authors and pointed out something that was bothering them. If they followed this guide, they had to diagnose every grieving person who came to them as depressed and start giving them medical treatment. If you lose someone, it turns out that these symptoms will come to you automatically. So, the doctors wanted to know, are we supposed to start drugging all the bereaved people in America?

The authors conferred, and they decided that there would be a special clause added to the list of symptoms of depression. None of this applies, they said, if you have lost somebody you love in the past year. In that situation, all these symptoms are natural, and not a disorder. It was called the grief exception, and it seemed to resolve the problem.

Then, as the years and decades passed, doctors on the frontline started to come back with another question. All over the world, they were being encouraged to tell patients that depression is, in fact, just the result of a spontaneous chemical imbalance in your brain it is produced by low serotonin, or a natural lack of some other chemical. Its not caused by your life its caused by your broken brain. Some of the doctors began to ask how this fitted with the grief exception. If you agree that the symptoms of depression are a logical and understandable response to one set of life circumstances losing a loved one might they not be an understandable response to other situations? What about if you lose your job? What if you are stuck in a job that you hate for the next 40 years? What about if you are alone and friendless?

The grief exception seemed to have blasted a hole in the claim that the causes of depression are sealed away in your skull. It suggested that there are causes out here, in the world, and they needed to be investigated and solved there. This was a debate that mainstream psychiatry (with some exceptions) did not want to have. So, they responded in a simple way by whittling away the grief exception. With each new edition of the manual they reduced the period of grief that you were allowed before being labelled mentally ill down to a few months and then, finally, to nothing at all. Now, if your baby dies at 10am, your doctor can diagnose you with a mental illness at 10.01am and start drugging you straight away.

Dr Joanne Cacciatore, of Arizona State University, became a leading expert on the grief exception after her own baby, Cheyenne, died during childbirth. She had seen many grieving people being told that they were mentally ill for showing distress. She told me this debate reveals a key problem with how we talk about depression, anxiety and other forms of suffering: we dont, she said, consider context. We act like human distress can be assessed solely on a checklist that can be separated out from our lives, and labelled as brain diseases. If we started to take peoples actual lives into account when we treat depression and anxiety, Joanne explained, it would require an entire system overhaul. She told me that when you have a person with extreme human distress, [we need to] stop treating the symptoms. The symptoms are a messenger of a deeper problem. Lets get to the deeper problem.

*****

I was a teenager when I swallowed my first antidepressant. I was standing in the weak English sunshine, outside a pharmacy in a shopping centre in London. The tablet was white and small, and as I swallowed, it felt like a chemical kiss. That morning I had gone to see my doctor and I had told him crouched, embarrassed that pain was leaking out of me uncontrollably, like a bad smell, and I had felt this way for several years. In reply, he told me a story. There is a chemical called serotonin that makes people feel good, he said, and some people are naturally lacking it in their brains. You are clearly one of those people. There are now, thankfully, new drugs that will restore your serotonin level to that of a normal person. Take them, and you will be well. At last, I understood what had been happening to me, and why.

However, a few months into my drugging, something odd happened. The pain started to seep through again. Before long, I felt as bad as I had at the start. I went back to my doctor, and he told me that I was clearly on too low a dose. And so, 20 milligrams became 30 milligrams; the white pill became blue. I felt better for several months. And then the pain came back through once more. My dose kept being jacked up, until I was on 80mg, where it stayed for many years, with only a few short breaks. And still the pain broke back through.

I started to research my book, Lost Connections: Uncovering The Real Causes of Depression and the Unexpected Solutions, because I was puzzled by two mysteries. Why was I still depressed when I was doing everything I had been told to do? I had identified the low serotonin in my brain, and I was boosting my serotonin levels yet I still felt awful. But there was a deeper mystery still. Why were so many other people across the western world feeling like me? Around one in five US adults are taking at least one drug for a psychiatric problem. In Britain, antidepressant prescriptions have doubled in a decade, to the point where now one in 11 of us drug ourselves to deal with these feelings. What has been causing depression and its twin, anxiety, to spiral in this way? I began to ask myself: could it really be that in our separate heads, all of us had brain chemistries that were spontaneously malfunctioning at the same time?

To find the answers, I ended up going on a 40,000-mile journey across the world and back. I talked to the leading social scientists investigating these questions, and to people who have been overcoming depression in unexpected ways from an Amish village in Indiana, to a Brazilian city that banned advertising and a laboratory in Baltimore conducting a startling wave of experiments. From these people, I learned the best scientific evidence about what really causes depression and anxiety. They taught me that it is not what we have been told it is up to now. I found there is evidence that seven specific factors in the way we are living today are causing depression and anxiety to rise alongside two real biological factors (such as your genes) that can combine with these forces to make it worse.

Once I learned this, I was able to see that a very different set of solutions to my depression and to our depression had been waiting for me all along.

To understand this different way of thinking, though, I had to first investigate the old story, the one that had given me so much relief at first. Professor Irving Kirsch at Harvard University is the Sherlock Holmes of chemical antidepressants the man who has scrutinised the evidence about giving drugs to depressed and anxious people most closely in the world. In the 1990s, he prescribed chemical antidepressants to his patients with confidence. He knew the published scientific evidence, and it was clear: it showed that 70% of people who took them got significantly better. He began to investigate this further, and put in a freedom of information request to get the data that the drug companies had been privately gathering into these drugs. He was confident that he would find all sorts of other positive effects but then he bumped into something peculiar.

Illustration
Illustration by Michael Driver.

We all know that when you take selfies, you take 30 pictures, throw away the 29 where you look bleary-eyed or double-chinned, and pick out the best one to be your Tinder profile picture. It turned out that the drug companies who fund almost all the research into these drugs were taking this approach to studying chemical antidepressants. They would fund huge numbers of studies, throw away all the ones that suggested the drugs had very limited effects, and then only release the ones that showed success. To give one example: in one trial, the drug was given to 245 patients, but the drug company published the results for only 27 of them. Those 27 patients happened to be the ones the drug seemed to work for. Suddenly, Professor Kirsch realised that the 70% figure couldnt be right.

It turns out that between 65 and 80% of people on antidepressants are depressed again within a year. I had thought that I was freakish for remaining depressed while on these drugs. In fact, Kirsch explained to me in Massachusetts, I was totally typical. These drugs are having a positive effect for some people but they clearly cant be the main solution for the majority of us, because were still depressed even when we take them. At the moment, we offer depressed people a menu with only one option on it. I certainly dont want to take anything off the menu but I realised, as I spent time with him, that we would have to expand the menu.

This led Professor Kirsch to ask a more basic question, one he was surprised to be asking. How do we know depression is even caused by low serotonin at all? When he began to dig, it turned out that the evidence was strikingly shaky. Professor Andrew Scull of Princeton, writing in the Lancet, explained that attributing depression to spontaneously low serotonin is deeply misleading and unscientific. Dr David Healy told me: There was never any basis for it, ever. It was just marketing copy.

I didnt want to hear this. Once you settle into a story about your pain, you are extremely reluctant to challenge it. It was like a leash I had put on my distress to keep it under some control. I feared that if I messed with the story I had lived with for so long, the pain would run wild, like an unchained animal. Yet the scientific evidence was showing me something clear, and I couldnt ignore it.

*****

So, what is really going on? When I interviewed social scientists all over the world from So Paulo to Sydney, from Los Angeles to London I started to see an unexpected picture emerge. We all know that every human being has basic physical needs: for food, for water, for shelter, for clean air. It turns out that, in the same way, all humans have certain basic psychological needs. We need to feel we belong. We need to feel valued. We need to feel were good at something. We need to feel we have a secure future. And there is growing evidence that our culture isnt meeting those psychological needs for many perhaps most people. I kept learning that, in very different ways, we have become disconnected from things we really need, and this deep disconnection is driving this epidemic of depression and anxiety all around us.

Lets look at one of those causes, and one of the solutions we can begin to see if we understand it differently. There is strong evidence that human beings need to feel their lives are meaningful that they are doing something with purpose that makes a difference. Its a natural psychological need. But between 2011 and 2012, the polling company Gallup conducted the most detailed study ever carried out of how people feel about the thing we spend most of our waking lives doing our paid work. They found that 13% of people say they are engaged in their work they find it meaningful and look forward to it. Some 63% say they are not engaged, which is defined as sleepwalking through their workday. And 24% are actively disengaged: they hate it.

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Antidepressant prescriptions have doubled over the last decade. Photograph: Anthony Devlin/PA

Most of the depressed and anxious people I know, I realised, are in the 87% who dont like their work. I started to dig around to see if there is any evidence that this might be related to depression. It turned out that a breakthrough had been made in answering this question in the 1970s, by an Australian scientist called Michael Marmot. He wanted to investigate what causes stress in the workplace and believed hed found the perfect lab in which to discover the answer: the British civil service, based in Whitehall. This small army of bureaucrats was divided into 19 different layers, from the permanent secretary at the top, down to the typists. What he wanted to know, at first, was: whos more likely to have a stress-related heart attack the big boss at the top, or somebody below him?

Everybody told him: youre wasting your time. Obviously, the boss is going to be more stressed because hes got more responsibility. But when Marmot published his results, he revealed the truth to be the exact opposite. The lower an employee ranked in the hierarchy, the higher their stress levels and likelihood of having a heart attack. Now he wanted to know: why?

And thats when, after two more years studying civil servants, he discovered the biggest factor. It turns out if you have no control over your work, you are far more likely to become stressed and, crucially, depressed. Humans have an innate need to feel that what we are doing, day-to-day, is meaningful. When you are controlled, you cant create meaning out of your work.

Suddenly, the depression of many of my friends, even those in fancy jobs who spend most of their waking hours feeling controlled and unappreciated started to look not like a problem with their brains, but a problem with their environments. There are, I discovered, many causes of depression like this. However, my journey was not simply about finding the reasons why we feel so bad. The core was about finding out how we can feel better how we can find real and lasting antidepressants that work for most of us, beyond only the packs of pills we have been offered as often the sole item on the menu for the depressed and anxious. I kept thinking about what Dr Cacciatore had taught me we have to deal with the deeper problems that are causing all this distress.

I found the beginnings of an answer to the epidemic of meaningless work in Baltimore. Meredith Mitchell used to wake up every morning with her heart racing with anxiety. She dreaded her office job. So she took a bold step one that lots of people thought was crazy. Her husband, Josh, and their friends had worked for years in a bike store, where they were ordered around and constantly felt insecure, Most of them were depressed. One day, they decided to set up their own bike store, but they wanted to run it differently. Instead of having one guy at the top giving orders, they would run it as a democratic co-operative. This meant they would make decisions collectively, they would share out the best and worst jobs and they would all, together, be the boss. It would be like a busy democratic tribe. When I went to their store Baltimore Bicycle Works the staff explained how, in this different environment, their persistent depression and anxiety had largely lifted.

Its not that their individual tasks had changed much. They fixed bikes before; they fix bikes now. But they had dealt with the unmet psychological needs that were making them feel so bad by giving themselves autonomy and control over their work. Josh had seen for himself that depressions are very often, as he put it, rational reactions to the situation, not some kind of biological break. He told me there is no need to run businesses anywhere in the old humiliating, depressing way we could move together, as a culture, to workers controlling their own workplaces.

*****

With each of the nine causes of depression and anxiety I learned about, I kept being taught startling facts and arguments like this that forced me to think differently. Professor John Cacioppo of Chicago University taught me that being acutely lonely is as stressful as being punched in the face by a stranger and massively increases your risk of depression. Dr Vincent Felitti in San Diego showed me that surviving severe childhood trauma makes you 3,100% more likely to attempt suicide as an adult. Professor Michael Chandler in Vancouver explained to me that if a community feels it has no control over the big decisions affecting it, the suicide rate will shoot up.

This new evidence forces us to seek out a very different kind of solution to our despair crisis. One person in particular helped me to unlock how to think about this. In the early days of the 21st century, a South African psychiatrist named Derek Summerfeld went to Cambodia, at a time when antidepressants were first being introduced there. He began to explain the concept to the doctors he met. They listened patiently and then told him they didnt need these new antidepressants, because they already had anti-depressants that work. He assumed they were talking about some kind of herbal remedy.

He asked them to explain, and they told him about a rice farmer they knew whose left leg was blown off by a landmine. He was fitted with a new limb, but he felt constantly anxious about the future, and was filled with despair. The doctors sat with him, and talked through his troubles. They realised that even with his new artificial limb, his old jobworking in the rice paddieswas leaving him constantly stressed and in physical pain, and that was making him want to just stop living. So they had an idea. They believed that if he became a dairy farmer, he could live differently. So they bought him a cow. In the months and years that followed, his life changed. His depressionwhich had been profoundwent away. You see, doctor, they told him, the cow was an antidepressant.

To them, finding an antidepressant didnt mean finding a way to change your brain chemistry. It meant finding a way to solve the problem that was causing the depression in the first place. We can do the same. Some of these solutions are things we can do as individuals, in our private lives. Some require bigger social shifts, which we can only achieve together, as citizens. But all of them require us to change our understanding of what depression and anxiety really are.

This is radical, but it is not, I discovered, a maverick position. In its official statement for World Health Day in 2017, the United Nations reviewed the best evidence and concluded that the dominant biomedical narrative of depression is based on biased and selective use of research outcomes that must be abandoned. We need to move from focusing on chemical imbalances, they said, to focusing more on power imbalances.

After I learned all this, and what it means for us all, I started to long for the power to go back in time and speak to my teenage self on the day he was told a story about his depression that was going to send him off in the wrong direction for so many years. I wanted to tell him: This pain you are feeling is not a pathology. Its not crazy. It is a signal that your natural psychological needs are not being met. It is a form of grief for yourself, and for the culture you live in going so wrong. I know how much it hurts. I know how deeply it cuts you. But you need to listen to this signal. We all need to listen to the people around us sending out this signal. It is telling you what is going wrong. It is telling you that you need to be connected in so many deep and stirring ways that you arent yet but you can be, one day.

If you are depressed and anxious, you are not a machine with malfunctioning parts. You are a human being with unmet needs. The only real way out of our epidemic of despair is for all of us, together, to begin to meet those human needs for deep connection, to the things that really matter in life.

This is an edited extract from Lost Connections: Uncovering the Real Causes of Depression and the Unexpected Solutions by Johann Hari, published by Bloomsbury on 11 January (16.99). To order a copy for 14.44 go to guardianbookshop.com or call 0330 333 6846. Free UK p&p over 10, online orders only. Phone orders min p&p of 1.99. It will be available in audio at audible.co.uk

Read more: https://www.theguardian.com/society/2018/jan/07/is-everything-you-think-you-know-about-depression-wrong-johann-hari-lost-connections

Excitement as trial shows Huntington’s drug could slow progress of disease

Hailed as enormously significant, results in groundbreaking trial are first time a drug has been shown to suppress effects of Huntingtons genetic mutation

A landmark trial for Huntingtons disease has announced positive results, suggesting that an experimental drug could become the first to slow the progression of the devastating genetic illness.

The results have been hailed as enormously significant because it is the first time any drug has been shown to suppress the effects of the Huntingtons mutation that causes irreversible damage to the brain. Current treatments only help with symptoms, rather than slowing the diseases progression.

Q&A

What is Huntington’s disease?

Huntingtons disease is a congenital degenerative condition caused by a single defective gene. Most patients are diagnosed in middle age, with symptoms including mood swings, irritability and depression. As the disease progresses, more serious symptoms can include involuntary jerky movements, cognitive difficulties and issues with speech and swallowing.

Currently there is no cure for Huntington’s, although drugs exist which help manage some of the symptoms. It is thought that about 12 people in 100,000 are affected by Huntington’s, and if a parent carries the faulty gene there is a 50% chance they will pass it on to their offspring.

Prof Sarah Tabrizi, director of University College Londons Huntingtons Disease Centre who led the phase 1 trial, said the results were beyond what Id ever hoped … The results of this trial are of ground-breaking importance for Huntingtons disease patients and families, she said.

The results have also caused ripples of excitement across the scientific world because the drug, which is a synthetic strand of DNA, could potentially be adapted to target other incurable brain disorders such as Alzheimers and Parkinsons. The Swiss pharmaceutical giant Roche has paid a $45m licence fee to take the drug forward to clinical use.

Huntingtons is an incurable degenerative disease caused by a single gene defect that is passed down through families.

The first symptoms, which typically appear in middle age, include mood swings, anger and depression. Later patients develop uncontrolled jerky movements, dementia and ultimately paralysis. Some people die within a decade of diagnosis.

Most of our patients know whats in their future, said Ed Wild, a UCL scientist and consultant neurologist at the National Hospital for Neurology and Neurosurgery in London, who administered the drug in the trial.

The mutant Huntingtons gene contains instructions for cells to make a toxic protein, called huntingtin. This code is copied by a messenger molecule and dispatched to the cells protein-making machinery. The drug, called Ionis-HTTRx, works by intercepting the messenger molecule and destroying it before the harmful protein can be made, effectively silencing the effects of the mutant gene.

How the drug works to slow the progress of Huntington’s disease

To deliver the drug to the brain, it has to be injected into the fluid around the spine using a four-inch needle.

Prof John Hardy, a neuroscientist at UCL who was not involved in the trial, said: If Id have been asked five years ago if this could work, I would have absolutely said no. The fact that it does work is really remarkable.

The trial involved 46 men and women with early stage Huntingtons disease in the UK, Germany and Canada. The patients were given four spinal injections one month apart and the drug dose was increased at each session; roughly a quarter of participants had a placebo injection.

After being given the drug, the concentration of harmful protein in the spinal cord fluid dropped significantly and in proportion with the strength of the dose. This kind of closely matched relationship normally indicates a drug is having a powerful effect.

For the first time a drug has lowered the level of the toxic disease-causing protein in the nervous system, and the drug was safe and well-tolerated, said Tabrizi. This is probably the most significant moment in the history of Huntingtons since the gene [was isolated].

The trial was too small, and not long enough, to show whether patients clinical symptoms improved, but Roche is now expected to launch a major trial aimed at testing this.

If the future trial is successful, Tabrizi believes the drug could ultimately be used in people with the Huntingtons gene before they become ill, possibly stopping symptoms ever occurring. They may just need a pulse every three to four months, she said. One day we want to prevent the disease.

The drug, developed by the California biotech firm Ionis Pharmaceuticals, is a synthetic single strand of DNA customised to latch onto the huntingtin messenger molecule.

The unexpected success raises the tantalising possibility that a similar approach might work for other degenerative brain disorders. The drugs like Lego, said Wild. You can target [any protein].

For instance, a similar synthetic strand of DNA could be made to target the messenger that produces misshapen amyloid or tau proteins in Alzheimers.

Huntingtons alone is exciting enough, said Hardy, who first proposed that amyloid proteins play a central role in Alzheimers. I dont want to overstate this too much, but if it works for one, why cant it work for a lot of them? I am very, very excited.

Prof Giovanna Mallucci, associate director of UK Dementia Research Institute at the University of Cambridge, described the work as a tremendous step forward for individuals with Huntingtons disease and their families.

Clearly, there will be much interest into whether it can be applied to the treatment of other neurodegenerative diseases, like Alzheimers, she added. However, she said that in the case of most other disorders the genetic causes are complex and less well understood, making them potentially harder to target.

About 10,000 people in the UK have the condition and about 25,000 are at risk. Most people with Huntingtons inherited the gene from a parent, but about one in five patients have no known family history of the disease.

The full results of the trial are expected to be published in a scientific journal next year.

Read more: https://www.theguardian.com/science/2017/dec/11/excitement-as-huntingtons-drug-shown-to-slow-progress-of-devastating-disease

Why the UN is investigating extreme poverty in America, the world’s richest nation

At the heart of Philip Alstons special mission will be one question: can Americans enjoy fundamental human rights if theyre unable to meet basic living standards?

The United Nations monitor on extreme poverty and human rights has embarked on a coast-to-coast tour of the US to hold the worlds richest nation and its president to account for the hardships endured by Americas most vulnerable citizens.

The tour, which kicked off on Friday morning, will make stops in four states as well as Washington DC and the US territory of Puerto Rico. It will focus on several of the social and economic barriers that render the American dream merely a pipe dream to millions from homelessness in California to racial discrimination in the Deep South, cumulative neglect in Puerto Rico and the decline of industrial jobs in West Virginia.

With 41 million Americans officially in poverty according to the US Census Bureau (other estimates put that figure much higher), one aim of the UN mission will be to demonstrate that no country, however wealthy, is immune from human suffering induced by growing inequality. Nor is any nation, however powerful, beyond the reach of human rights law a message that the US government and Donald Trump might find hard to stomach given their tendency to regard internal affairs as sacrosanct.

The UN special rapporteur on extreme poverty and human rights, Philip Alston, is a feisty Australian and New York University law professor who has a fearsome track record of holding power to account. He tore a strip off the Saudi Arabian regime for its treatment of women months before the kingdom legalized their right to drive, denounced the Brazilian government for attacking the poor through austerity, and even excoriated the UN itself for importing cholera to Haiti.

The US is no stranger to Alstons withering tongue, having come under heavy criticism from him for its program of drone strikes on terrorist targets abroad. In his previous role as UN special rapporteur on extrajudicial executions, Alston blamed the Obama administration and the CIA for killing many innocent civilians in attacks he said were of dubious international legality.

United
United Nations Special Rapporteur on extreme poverty and human rights, Philip Alston. Photograph: Ng Han Guan/AP

Now Alston has set off on his sixth, and arguably most sensitive, visit as UN monitor on extreme poverty since he took up the position in June 2014. At the heart of his fact-finding tour will be a question that is causing increasing anxiety at a troubled time: is it possible, in one of the worlds leading democracies, to enjoy fundamental human rights such as political participation or voting rights if you are unable to meet basic living standards, let alone engage, as Thomas Jefferson put it, in the pursuit of happiness?

Despite great wealth in the US, there also exists great poverty and inequality, Alston said in remarks released before the start of the visit. The rapporteur said he intended to focus on the detrimental effects of poverty on the civil and political rights of Americans, given the United States consistent emphasis on the importance it attaches to these rights in its foreign policy, and given that it has ratified the International Covenant on Civil and Political Rights.

Poverty experts are watching the UN tour closely in the hope that it might draw public attention to a largely neglected but critical aspect of US society.

David Grusky, director of the Center on Poverty and Inequality at Stanford, said the visit had the potential to hold a mirror up to the country at a moment when globalization combined with a host of domestic policies have generated a vast gulf between rich and poor.

The US has an extraordinary ability to naturalize and accept the extreme poverty that exists even in the context of such extreme wealth, he said.

Grusky added that the US reaction to Alstons visit could go either way. It has the potential to open our eyes to what an outlier the US has become compared with the rest of the world, or it could precipitate an adverse reaction towards an outsider who has no legitimacy telling us what to do about internal US affairs.

Alstons findings will be announced in preliminary form in Washington on 15 December, and then presented as a full report to the UN human rights council in Geneva next June. An especially unpredictable element of the fallout will be how Trump himself receives the final report, given the presidents habit of lashing out at anyone perceived to criticize him or his administration.

Trump has also shown open disdain towards the world body. In the course of the 2016 presidential campaign he griped that we get nothing out of the United Nations other than good real-estate prices.

On the other hand, observers have been surprised that the White House has honored the invitation to host Alston after the initial offer was extended by Barack Obama. US diplomats on more than one occasion since Trumps inauguration have said they welcomed the UN party.

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Ruby Dee Rudolph in her home in Lowndes County. A recent study suggests that nearly one one in three people in Lowndes County have hookworm, a parasite normally found in poor, developing countries. Photograph: Bob Miller for The Guardian

Alston himself is reserving his comments until the end of the tour. But his published work suggests that he is likely to be a formidable critic of the new president. In a lecture he gave last year on the challenges posed by Trump and other modern populist leaders, he warned that their agenda was avowedly nationalistic, xenophobic, misogynistic, and explicitly antagonistic to all or much of the human rights agenda.

Alston concluded the speech by saying: These are extraordinarily dangerous times, unprecedentedly so in my lifetime. The response is really up to us.

The UN poverty tour falls at a singularly tense moment for the US. In its 2016 state of the nation review, the Stanford Center on Poverty and Inequality placed the US rank at the bottom of the league table of 10 well-off countries, in terms of the extent of its income and wealth inequality.

It also found that the US hit rock bottom in terms of the safety net it offers struggling families, and is one of the worst offenders in terms of the ability of low-income families to lift themselves out of poverty a stark contrast to the much-vaunted myth of the American dream.

To some extent, Trumps focus on making America great again a political jingo that in itself contains an element of criticism of the state of the nation chimes with the UNs concern about extreme poverty. His call for greater prosperity for white working Americans in declining manufacturing areas that proved so vital to his election victory will be echoed in Alstons visit to the depressed coal-producing state of West Virginia, which backed Trump in 2016 by a resounding 69%.

In many other ways, though, the Trump administration in its first year has taken a radically hostile approach towards communities in need. He has tried, so far unsuccessfully, to abolish Obamacare in a move that would deprive millions of low-income families of healthcare insurance, was widely criticized for his lackluster response to the hurricane disaster in Puerto Rico that has left thousands homeless and without power, and is currently pushing a tax reform that would benefit one group above all others: the super rich.

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A man who lost his home during Hurricane Maria in September sits on a cot at a school turned shelter in Canovanas. Photograph: Alvin Baez/Reuters

The US poses an especially challenging subject for the UN special rapporteur because unlike all other industrialized nations, it fails to recognize fundamental social and economic rights such as the right to healthcare, a roof over your head or food to keep hunger at bay. The federal government has consistently refused to sign up to the international covenant on economic, social and cultural rights arguing that these matters are best left to individual states.

Such an emphasis on states rights has spawned a patchwork of provision for low-income families across the country. Republican-controlled states in the Deep South provide relatively little help to those struggling from unemployment and lack of ready cash, while more assistance is likely to be forthcoming in bigger coastal cities.

By contrast, raging house prices and gentrification is fueling a homelessness crisis in liberal cities such as Los Angeles and San Francisco the first stop next week of the UN tour.

Martha Davis, a law professor specializing in US human rights at Northeastern University, said that such vast regional variations present the UN monitor with a huge opportunity. Unlike other international officials, he has the ability to move freely at both federal and state levels and be equally critical of both.

Theres a lot that Philip Alston can say about basic inequality that goes to the heart of the rights that he is reviewing, Davis said.

Read more: https://www.theguardian.com/world/2017/dec/01/un-extreme-poverty-america-special-rapporteur

A journey through a land of extreme poverty: welcome to America

The UNs Philip Alston is an expert on deprivation and he wants to know why 41m Americans are living in poverty. The Guardian joined him on a special two-week mission into the dark heart of the worlds richest nation

Los Angeles, California, 5 December

You got a choice to make, man. You could go straight on to heaven. Or you could turn right, into that.

We are in Los Angeles, in the heart of one of Americas wealthiest cities, and General Dogon, dressed in black, is our tour guide. Alongside him strolls another tall man, grey-haired and sprucely decked out in jeans and suit jacket. Professor Philip Alston is an Australian academic with a formal title: UN special rapporteur on extreme poverty and human rights.

General Dogon, himself a veteran of these Skid Row streets, strides along, stepping over a dead rat without comment and skirting round a body wrapped in a worn orange blanket lying on the sidewalk.

The two men carry on for block after block after block of tatty tents and improvised tarpaulin shelters. Men and women are gathered outside the structures, squatting or sleeping, some in groups, most alone like extras in a low-budget dystopian movie.

We come to an intersection, which is when General Dogon stops and presents his guest with the choice. He points straight ahead to the end of the street, where the glistening skyscrapers of downtown LA rise up in a promise of divine riches.

Heaven.

Then he turns to the right, revealing the black power tattoo on his neck, and leads our gaze back into Skid Row bang in the center of LAs downtown. That way lies 50 blocks of concentrated human humiliation. A nightmare in plain view, in the city of dreams.

Alston turns right.

Philip
Philip Alston in downtown LA. Photograph: Dan Tuffs for the Guardian

So begins a two-week journey into the dark side of the American Dream. The spotlight of the UN monitor, an independent arbiter of human rights standards across the globe, has fallen on this occasion on the US, culminating on Friday with the release of his initial report in Washington.

His fact-finding mission into the richest nation the world has ever known has led him to investigate the tragedy at its core: the 41 million people who officially live in poverty.

Of those, nine million have zero cash income they do not receive a cent in sustenance.

Alstons epic journey has taken him from coast to coast, deprivation to deprivation. Starting in LA and San Francisco, sweeping through the Deep South, traveling on to the colonial stain of Puerto Rico then back to the stricken coal country of West Virginia, he has explored the collateral damage of Americas reliance on private enterprise to the exclusion of public help.

The Guardian had unprecedented access to the UN envoy, following him as he crossed the country, attending all his main stops and witnessing the extreme poverty he is investigating firsthand.

Think of it as payback time. As the UN special rapporteur himself put it: Washington is very keen for me to point out the poverty and human rights failings in other countries. This time Im in the US.

David
David Busch, who is currently homeless on Venice beach, in Los Angeles. Photograph: Dan Tuffs for the Guardian


The tour comes at a critical moment for America and the world. It began on the day that Republicans in the US Senate voted for sweeping tax cuts that will deliver a bonanza for the super wealthy while in time raising taxes on many lower-income families. The changes will exacerbate wealth inequality that is already the most extreme in any industrialized nation, with three men Bill Gates, Jeff Bezos and Warren Buffet owning as much as half of the entire American people.

A few days into the UN visit, Republican leaders took a giant leap further. They announced plans to slash key social programs in what amounts to an assault on the already threadbare welfare state.

Look up! Look at those banks, the cranes, the luxury condos going up, exclaimed General Dogon, who used to be homeless on Skid Row and now works as a local activist with Lacan. Down here, theres nothing. You see the tents back to back, theres no place for folks to go.

California made a suitable starting point for the UN visit. It epitomizes both the vast wealth generated in the tech boom for the 0.001%, and the resulting surge in housing costs that has sent homelessness soaring. Los Angeles, the city with by far the largest population of street dwellers in the country, is grappling with crisis numbers that increased 25% this past year to 55,000.

Ressy Finley, 41, was busy sterilizing the white bucket she uses to slop out in her tent in which she has lived on and off for more than a decade. She keeps her living area, a mass of worn mattresses and blankets and a few motley possessions, as clean as she can in a losing battle against rats and cockroaches. She also endures waves of bed bugs, and has large welts on her shoulder to prove it.

She receives no formal income, and what she makes on recycling bottles and cans is no way enough to afford the average rents of $1,400 a month for a tiny one-bedroom. A friend brings her food every couple of days, the rest of the time she relies on nearby missions.

She cried twice in the course of our short conversation, once when she recalled how her infant son was taken from her arms by social workers because of her drug habit (he is now 14; she has never seen him again). The second time was when she alluded to the sexual abuse that set her as a child on the path towards drugs and homelessness.

Given all that, its remarkable how positive Finley remains. What does she think of the American Dream, the idea that everyone can make it if they try hard enough? She replies instantly: I know Im going to make it.

A 41-year-old woman living on the sidewalk in Skid Row going to make it?

Sure I will, so long as I keep the faith.

What does making it mean to her?

I want to be a writer, a poet, an entrepreneur, a therapist.

Ressy
Ressy Finley, who lives in a tent on 6th Street in Downtown LA. Photograph: Dan Tuffs for the Guardian

Robert Chambers occupies the next patch of sidewalk along from Finleys. Hes created an area around his tent out of wooden pallets, what passes in Skid Row for a cottage garden.

He has a sign up saying Homeless Writers Coalition, the name of a group he runs to give homeless people dignity against what he calls the animalistic aspects of their lives. Hes referring not least to the lack of public bathrooms that forces people to relieve themselves on the streets.

LA authorities have promised to provide more access to toilets, a critical issue given the deadly outbreak of Hepatitis A that began in San Diego and is spreading on the west coast claiming 21 lives mainly through lack of sanitation in homeless encampments. At night local parks and amenities are closed specifically to keep homeless people out.

Skid Row has had the use of nine toilets at night for 1,800 street-faring people. Thats a ratio well below that mandated by the UN in its camps for Syrian refugees.

Its inhuman actually, and eventually in the end you will acquire animalistic psychology, Chambers said.

He has been living on the streets for almost a year, having violated his parole terms for drug possession and in turn being turfed out of his low-cost apartment. Theres no help for him now, he said, no question of making it.

The safety net? It has too many holes in it for me.

Of all the people who crossed paths with the UN monitor, Chambers was the most dismissive of the American Dream. People dont realize its never getting better, theres no recovery for people like us. Im 67, I have a heart condition, I shouldnt be out here. I might not be too much longer.

That was a lot of bad karma to absorb on day one, and it rattled even as seasoned a student of hardship as Alston. As UN special rapporteur, hes reported on dire poverty and its impact on human rights in Saudi Arabia and China among other places. But Skid Row?

I was feeling pretty depressed, he told the Guardian later. The endless drumbeat of horror stories. At a certain point you do wonder what can anyone do about this, let alone me.

And then he took a flight up to San Francisco, to the Tenderloin district where homeless people congregate, and walked into St Boniface church.

What he saw there was an analgesic for his soul.

San Francisco, California, 6 December

The
The Gubbio project at St Boniface in San Francisco. The church opens its doors every weekday at 6am to allow homeless people to rest until 3pm. Photograph: David Levene for the Guardian


About 70 homeless people were quietly sleeping in pews at the back of the church, as they are allowed to do every weekday morning, with worshippers praying harmoniously in front of them. The church welcomes them in as part of the Catholic concept of extending the helping hand.

I found the church surprisingly uplifting, Alston said. It was such a simple scene and such an obvious idea. It struck me Christianity, what the hell is it about if its not this?

It was a rare drop of altruism on the west coast, competing against a sea of hostility. More than 500 anti-homeless laws have been passed in Californian cities in recent years. At a federal level, Ben Carson, the neurosurgeon who Donald Trump appointed US housing secretary, is decimating government spending on affordable housing.

Perhaps the most telling detail: apart from St Boniface and its sister church, no other place of worship in San Francisco welcomes homeless people. In fact, many have begun, even at this season of goodwill, to lock their doors to all comers simply so as to exclude homeless people.

As Tiny Gray-Garcia, herself on the streets, described it to Alston, there is a prevailing attitude that she and her peers have to contend with every day. She called it the violence of looking away.

Coy
Coy Catley, 63, in her homeless box made of cardboard sheets on a sidewalk of Tenderloin, San Francisco. Photograph: Ed Pilkington for the Guardian


That cruel streak the violence of looking away has been a feature of American life since the nations founding. The casting off the yoke of overweening government (the British monarchy) came to be equated in the minds of many Americans with states rights and the individualistic idea of making it on your own a view that is fine for those fortunate enough to do so, less happy if youre born on the wrong side of the tracks.

Countering that has been the conviction that society must protect its own against the vagaries of hunger or unemployment that informed Franklin Roosevelts New Deal and the Great Society of Lyndon Johnson. But in recent times the prevailing winds have blown strongly in the youre on your own, buddy direction. Ronald Reagan set the trend with his 1980s tax cuts, followed by Bill Clinton, whose 1996 decision to scrap welfare payments for low-income families is still punishing millions of Americans.

The cumulative attack has left struggling families, including the 15 million children who are officially in poverty, with dramatically less support than in any other industrialized economy. Now they face perhaps the greatest threat of all.

As Alston himself has written in an essay on Trumps populism and the aggressive challenge it poses to human rights: These are extraordinarily dangerous times. Almost anything seems possible.

Lowndes County, Alabama, 9 December

Aaron
Aaron Thigpen discusses the poor sewage conditions in Butler County. Improper treatment has put the population at risk of diseases long believed to be extinct in the US. Photograph: Bob Miller for the Guardian


Trumps undermining of human rights, combined with the Republican threat to pare back welfare programs next year in order to pay for some of the tax cuts for the rich they are rushing through Congress, will hurt African Americans disproportionately.

Black people are 13% of the US population, but 23% of those officially in poverty and 39% of the homeless.

The racial element of Americas poverty crisis is seen nowhere more clearly than in the Deep South, where the open wounds of slavery continue to bleed. The UN special rapporteur chose as his next stop the Black Belt, the term that originally referred to the rich dark soil that exists in a band across Alabama but over time came to describe its majority African American population.

The link between soil type and demographics was not coincidental. Cotton was found to thrive in this fertile land, and that in turn spawned a trade in slaves to pick the crop. Their descendants still live in the Black Belt, still mired in poverty among the worst in the union.

You can trace the history of Americas shame, from slave times to the present day, in a set of simple graphs. The first shows the cotton-friendly soil of the Black Belt, then the slave population, followed by modern black residence and todays extreme poverty they all occupy the exact same half-moon across Alabama.

There are numerous ways you could parse the present parlous state of Alabamas black community. Perhaps the starkest is the fact that in the Black Belt so many families still have no access to sanitation. Thousands of people continue to live among open sewers of the sort normally associated with the developing world.

The crisis was revealed by the Guardian earlier this year to have led to an ongoing endemic of hookworm, an intestinal parasite that is transmitted through human waste. It is found in Africa and South Asia, but had been assumed eradicated in the US years ago.

Yet here the worm still is, sucking the blood of poor people, in the home state of Trumps US attorney general Jeff Sessions.

A disease of the developing world thriving in the worlds richest country.

The open sewerage problem is especially acute in Lowndes County, a majority black community that was an epicenter of the civil rights movement having been the setting of Martin Luther Kings Selma to Montgomery voting rights march in 1965.

Philp
Philp Alston talks to a resident. Many families in Butler and Lowndes counties choose to live with open sewer systems made from PVC pipe. Photograph: Bob Miller for the Guardian

Despite its proud history, Catherine Flowers estimates that 70% of households in the area either straight pipe their waste directly onto open ground, or have defective septic tanks incapable of dealing with heavy rains.

When her group, Alabama Center for Rural Enterprise (Acre), pressed local authorities to do something about it, officials invested $6m in extending waste treatment systems to primarily white-owned businesses while bypassing overwhelmingly black households.

Thats a glaring example of injustice, Flowers said. People who cannot afford their own systems are left to their own devices while businesses who do have the money are given public services.

Walter, a Lowndes County resident who asked not to give his last name for fear that his water supply would be cut off as a reprisal for speaking out, lives with the daily consequences of such public neglect. You get a good hard rain and it backs up into the house.

Thats a polite way of saying that sewage gurgles up into his kitchen sink, hand basin and bath, filling the house with a sickly-sweet stench.

Given these circumstances, what does he think of the ideology that anyone can make it if they try?

I suppose they could if they had the chance, Walter said. He paused, then added: Folks arent given the chance.

Had he been born white, would his sewerage problems have been fixed by now?

After another pause, he said: Not being racist, but yeah, they would.

Round the back of Walters house the true iniquity of the situation reveals itself. The yard is laced with small channels running from neighboring houses along which dark liquid flows. It congregates in viscous pools directly underneath the mobile home in which Walters son, daughter-in-law and 16-year-old granddaughter live.

It is the ultimate image of the lot of Alabamas impoverished rural black community. As American citizens they are as fully entitled to life, liberty and the pursuit of happiness. Its just that they are surrounded by pools of excrement.

This week, the Black Belt bit back. On Tuesday a new line was added to that simple graphic, showing exactly the same half-moon across Alabama except this time it was not black but blue.

blue belt south

It depicted the army of African American voters who turned out against the odds to send Doug Jones to the US Senate, the first Democrat from Alabama to do so in a generation. It delivered a bloody nose to his opponent, the alleged child molester Roy Moore, and his puppetmasters Steve Bannon and Donald Trump.

It was arguably the most important expression of black political muscle in the region since Kings 1965 march. If the previous entries in the graphic could be labeled soil, slavery and poverty, this one should be captioned empowerment.

Guayama, Puerto Rico, 10 December

So how does Alston view the role of UN rapporteur and his visit? His full report on the US will be released next May before being presented to the UN human rights council in Geneva.

Nobody expects much to come of that: the world body has no teeth with which to enforce good behavior on recalcitrant governments. But Alston hopes that his visit will have an impact by shaming the US into reflecting on its values.

My role is to hold governments to account, he said. If the US administration doesnt want to talk about the right to housing, healthcare or food, then there are still basic human rights standards that have to be met. Its my job to point that out.

Alstons previous investigations into extreme poverty in places like Mauritania pulled no punches. We can expect the same tough love when it comes to his analysis of Puerto Rico, the next stop on his journey into Americas dark side.

Three months after Maria, the devastation wrought by the hurricane has been well documented. It tore 70,000 homes to shreds, brought industry to a standstill and caused a total blackout of the island that continues to cause havoc.