Water Filtration 2. Systems

Here I attempt to summarise some of the options for providing safe water, both for disaster preparation and  for general travel in areas where there is limited access to potable water (or where you’d prefer not to have to buy bottled water).

It’s a delayed follow-up to my first post on water filters, which focussed on the rationale of ensuring that people (especially in disaster prone areas such as Ecuador) have water autonomy.  Both posts were inspired by my work following the Ecuadorian earthquake of April 2016.

The article is still far from comprehensive, but I’ll update it from time to time with new information as I get it (or remember it!)

A quick note on water supplies.

Regardless of which of these filters you use, they will all work better with water that has been pre-filtered to remove gross sediment and turbidity.  This can be done with something as unsophisticated as a t-shirt.

Also, be warned, none of these filters alone will remove heavy metals, pesticides, salt or other chemical contamination.  Additional activated carbon filters will help remove some chemical contamination, but their effectiveness depends on the dwell time (how long the water is in contact with the carbon) and the contact area – and commonly these are nowhere near enough to make a significant difference.  Thus, if your water supply is heavily contaminated with dangerous chemicals, you’ll need another way to get clean water.  For most people, the easiest and best way is to collect clean water for filtering is from the sky using something else most people have, a roof.  Even if this becomes contaminated with bacteria, the filters will deal with that for you.

Membrane Filters

This is a class of filters that includes those made by companies such as Sawyer and LifeStraw.  These filters, much like ceramic filters, work on a simple idea: contaminants such as bacteria and viruses are larger than a molecule of water, therefore to remove the contaminants, one needs a filter medium that has channels that are reliably larger than water but smaller than these contaminants.  There is an essential trade off in these filters: the smaller the channels, the slower the filtration, but the more types of contaminant it will remove.

These systems are mostly ‘gravity filters’ as they rely on the force of gravity to force the water through the filter.  This means that their speed does vary as a function of the relative hight of the water source (or pressure when driven by a tap).

A variety of companies use this technology, but Sawyer and LifeStraw stand out because their filters are rated to filter a huge amount of water – and are cleaned rather than replaced.  To confuse matters however, each company makes a large number of different filters or filter sets.  I’m going to cover the main ones below:

Sawyer

bucket2Sawyer’s filters come in two filtration levels.  The Point ZeroTWO (0.02 micron) filter will essentially filter all protozoa, bacteria and viruses, while the  PointONE (0.1 micron will filter bacteria and protozoa, but NOT viruses).  Each type of filter is sold in a variety of different setups: including systems that filter from one bag or bucket to another and systems that plug directly into your tap (faucet for you North Americans).

Following Ecuador’s devastating earthquake in April 2016, a variety of organisations brought down Sawyer filters to help.  These were invariably the PointONE bucket filter system.  The link I’ve provided is to a full set with tap adapter, but Sawyer generously provided a stripped down bucket system at a charity price of only $10 per filter, way below the normal cost of $50 for the full set.

Now these filters DO NOT filter viruses, so if there is any concern of viral infections, one should use the more expensive Point ZeroTWO systems.  In Ecuador, the risk of viral infection in the water source was considered minimal.  Other than being more expensive, these 0.02 filters are also much slower at filtering; while the 0.1 system can theoretically filter around 2000 litres per day, the 0.02 system can ‘only’ filter around 700l.  However, in both cases these number are theoretical, and rely on a constant source of non-turbid water with sufficient pressure.

CLEANING:  Depending on the level of contamination (sediment, bacteria, algae etc) in the water, the filter will need regular cleaning.  To test and demonstrate the filter to people on the coast, I spent two weeks drinking water filtered from a very green source of water in an abandoned swimming pool (I sadly neglected to take photos, but I did survive).  In this fairly extreme case, the filter became very slow after around 10 litres.  Cleaning of the filter is done by backwashing with clean water using a syringe or a plastic drinking bottle with an adapter.

This process is very simple, but it is perhaps the one major weak point of the filter.  When giving these filters out to poorly educated people, who may speak a different language from the donor, there are a variety of possibilities for problems: the person may not understand the initial instructions, they may not understand what constitutes uncontaminated water or even if they do understand at first, they may forget in time.  And of course, one needs to have a source of uncontaminated water and have all the relevant attachments in order to carry out the backwashing.

Pressure issues: When driven by a tap (or a high cistern), the pressure can easily be higher than that for which the filter is rated.  According to what I’ve read from Sawyer, the filter is designed to leak in such cases to prevent actual damage to the filter.  However, if unnoticed (this can easily happen) the leaking source water can contaminate the output as it drips down.

CONTROVERSY:  Sawyer claim that their filters are good for ‘up to 1,000,000 gallons’ (4 million litres).  However, this has been disputed by researchers from Tufts university (article here and presentation here), who claim that the filters may be seriously degraded within 24 months of use.  The quality of the science behind the claim, has however been disputed by Sawyer (here and here) and by other academics (see here).  While another study appears to support the real world benefits of using the Sawyer filter in Bolivia, it is worth noting that there do not seem to have been any proper long term field studies of the filters.

LifeStraw

LifestrawFamily-01LifeStraw’s eponymous filter is a straw for drinking directly out of rivers/ponds, and seems impractical for most real world uses, except travel emergencies.  However, LifeStraw also make a variety of filters designed for families and communities.  For example, the LifeStraw Family is rated for 18,000 litres and filters at 0.02 microns (removing virtually all bacteria and viruses from the water). I’ve seen the family version in action, and it’s looks good.  In particular, it has a clever integrated backflush mechanism that should eliminate the possibility of contamination while cleaning.  The retail price is around $80 on Amazon.

The community version is much larger and more expensive.  It is rated for around 70,000 litres.  I’ve never seen this version in action; it looks like a good product, but it’s relatively expensive and bulky.  On Amazon right now it costs over $500.  Like the family version, it comes with an integrated backflush, and it also comes with a pre-filter for sediment.

In the end, in Ecuador many groups chose to go with the Sawyer filters because they are extremely portable (one can just buy the filter and buy buckets in the destination area), but mostly because Sawyer has made them available so cheaply for charitable use.  One could buy 8 PointONE filters for the price of a LifeStraw Family filter.  I also now use one in my house in Ecuador for drinking water as it’s quicker and easier than the ceramic filter I had before.  The max flow rate of the Sawyer (which does not filter viruses) is 10 times that of the LifeStraw filters.  See here for a spreadsheet comparing the filters (a work in progress).

Ceramic Filters

copyright unknownThe first modern ceramic filter was ‘invented’ by Henry Doulton, who  devised the modern ceramic candle filter in 1827.  However, ceramics were reportedly used to filter water long before that (I’m still searching for a good article on this).  Ceramic filters generally come in two forms, the replaceable ‘candle’ (which includes the traditional Doulton version on the right and the modern plastic you can see below), and the ceramic pot.

Shop Bought.

In Ecuador where I’m based, ceramic filters are quite popular for household drinking water.

This is the standard model and can sometimes be bought in shops, and can always be bought online (see here).  It consists of two compartments and two filters.  The filter you can see in the upper (dirty water) compartment is the ceramic filter.  This will theoretically remove all bacteria and viruses.   The filter in the lower compartment contains a variety of components, including activated carbon to remove contaminants (the black stuff at the top) and others which I guess are supposed to introduce minerals into the water.

I used filters like this for a couple of years and they work fine.  The biggest disadvantage is that they are slow and require work to fill and maintain.  They can achieve around 1-2l/h (depending on age and amount of water in the top container), which is ok if you are organised, but you can’t expect to have water right away of you forget to fill it.  The containers will also develop algae if they are not regularly used and kept away from light.  Furthermore, as with all filters that store water, the clean water can become contaminated, so regular cleaning is recommended.  The cost is around £30 for a complete system and $6 for the filters ($12 for both), which need to replaced every 6 months or so.

Locally Manufactured pots

This is a very interesting option for low income countries – albeit perhaps less so since the introduction of other low cost alternatives.  This system in its ‘modern’ incarnation was developed in Guatemala in 1981 by Dr. Fernando Mazariego.  In 1986, Ron Rivera of  ‘Potters for Peace‘ collaborated with Mazariego to develop the technique and since then has been helping to export the idea around the world (for instance this in Cambodia, and I have contact details for manufacturers in Ecuador if anyone wants them).  These filters can be made by traditional potters using a technique which involves adding a fine inflammable material (such as finely ground rice or coconut husks) to the clay.  When the pots are fired, this material incinerates leaving fine channels in the pot, through which the water will filter, but through which the bacteria and viruses struggle to pass.  This process removes around 95% of the bacteria and viruses, which can be improved closer to 100% via the addition of colloidal silver.

The ceramic pots themselves are designed to sit easily into a standard plastic bucket which can be fitted with a tap (see image).

Locally manufactured pots have the advantage that they support the local community and likely have a reduced carbon footprint compared to imported versions.  They may be particular useful for use in very poor and isolated communities where imported systems are unlikely to be regularly available.  A possible downside is that the pots might not always be correctly manufactured – the rule of thumb is that if they have a flow rate of more than two to three litres per hour they are not working.  A scientific analysis of both this filter system and biosand systems can be downloaded here.   The ceramic pots may be bought for between $20 and $30.  Only the recent development of filters such as the Sawyer membrane filter have made this look like less of a good deal.

Whole house systems

Ceramic filters can also be bought to be plumbed in to service a whole house and can have pretty impressive flow rates with sufficient pressure.  This 0.9 micron system from Doulton (for example) has a flow rate of 1000l/hour at 40 PSI (1.4 Bar/14m head).  Note however the relatively large size of the filter.  This WILL let through some bacteria (and definitely viruses); it seems Doulton are is relying on only the bigger bacteria being pathogenic and say the filter removes 99.99%+ of these..

BioSand Filters

By OHorizons – ohorizons.org, CC BY 3.0

Another very interesting option.  BioSand filters are based on the slow sand filters that clean municipal water throughout the world, including that of major cities such as London.  They use both physical and biological methods to clean the water.  The physical is the sand, gravel and sometimes activated carbon.  This upper layer of find sand supports a biological top layer, known as a biofilm,  hypogeal layer or for those who like german words, Schmutzdecke.   The biofilm layer provides the bacterial reduction which can be up to 99% in a well functioning filter.  A new filter has a much lower efficiency, which gradually builds up over time.  Importantly these filters CAN NOT be used with municipal water supplies, as the chlorine will kill the biofilm.  The cost of a system is basically the cost of the container (generally a 50 gallon plastic water butt or a concrete alternative), the sand, some piping and a tap.   In total this might be $50 or so.

An unpublished analysis by Duke, Nordin & Mazumder suggests that biosand filters may be very useful as a first line treatment for water, perhaps for washing, cooking and showering (as they can quickly remove the majority of contamination and turbidity at circa 19l/h), but due to their variable efficiency at removing bacteria, should be complimented with ceramic filters for drinking water.  For further information see wikipedia and this construction manual from CAWST (Centre for Affordable Water and Sanitation Technology).

UV water treatment.

The bacteria and viruses in water can also be killed via UV light.  This is the basis of many pond treatment systems, but is also used for household water treatment and the portable Steripen.
The Steripen is a very popular water treatment system for backpackers.  Basically you put the steripen in a bottle of water, turn it on and stir the water.  The UV light does all the rest.

I’ve not used on, but it’s a pretty good solution assuming that you have a source of  non-turbid water.  Perhaps the best thing is that you will be certain as to whether it’s working or not (if the light comes on, it works and your water will be treated).  Some potential downsides are: 1. It is an active system, which means it can run out of batteries and may go wrong; 2. It can only treat a small amount of water at a time, making it best for individual use; 3. It needs clear water and will not filter or treat turbid water properly.  4.  There a plenty of reports of the Steripen being unreliable (among plenty of other singing it’s praises).  All in all, it’s an interesting alternative to filters for personal water treatment (if you a travelling where there is not a clean water supply, always carry a backup such as bleach drops).  The steripen retails for about £70/$70.

At a household level, it is possible to buy inline UV treatment lamps.  I’ve never used one personally, although I’ve seen one in action at the Brighton demonstration earthship (a UV filter is not very exciting to watch though).  These retail at around £500/$500 (see here for an example capable of 60l/h) . and require a source of electricity and yearly replacement of the lamps. While probably a good option for many, they may not make the best solution for disaster preparation (they would be vulnerable in an earthquake and not function without power).  They will also need pre-filtration in many cases.

That’s it for the moment.  More later.

I’m posting this now to make it available for feedback.  It’s not finished yet, but some people have been waiting for it, so I thought I’d get it posted.

Experiences of Psychosis on YouTube: Part 2:

This is a follow–up from the previous post on psychosis related media.  I’ll be adding any new media and recommendations here.  Starting with this one suggested by Rob and made by the Greater Manchester Mental Health Trust, as collaboration between service users and MH professionals.


It covers similar topics to the media I’ve published recently, but adds a specific regional identity, which may be important in helping to engage people.  As the makers say: “The aim of the film is to raise awareness, reduce stigma and encourage people to seek help early”.

To see the part one of this post, click here.

Experiences of Psychosis on YouTube

I’m back in media research mode now, and I’m teaching undergraduates about psychosis this week, hence the topic.  There are some exceptionally brave people who have posted on YouTube about their experiences of psychosis.  I’ve picked some of the most interesting material I could find and have summarised it below.  I’ve gone a bit further than normal and added quite a lot of my own reflections on the videos (I hope this is a good thing).  The list of videos below is far from exhaustive and as always I welcome any other suggestions and feedback from readers.

Maya Imani-Amani.

Schizophrenia: My Story.  In this video Maya briefly recounts her experience of developing voices and her diagnosis of schizophrenia at 17.  She tells of how her problems started with sexual abuse that began at age 10 and lasted for a decade.  In her early teens, she lost interest in the things she used to like (such as sports), and this led to her father taking her to a doctor.  Having told the doctor that she was thinking of suicide as he was admitted to hospital, at which point she told the doctors about the voices she was hearing.  She says that she now has 7 voices and discusses briefly how the voices evolved over time and how they relate to her experiences of abuse.  This story is one I have heard all too many times from clients over the years (and I only began my clinical training in 2009).  However, the familiarity of this story may mean that it will be particularly useful for all those who have similar stories.

This is just one of quite a few videos by Maya about her experience.  I’ve not watched them all, but those that I have all are excellent.  They are well paced, concise and compelling, which is not always the case on YouTube.

One of the more difficult things about these videos however is that they are done in ‘real-time’.  This is a real person, providing regular updates about their progress.  Thus, when she tells us that she is coming off medicine without her doctor’s knowledge or help, I cannot help but feel concerned for her.  And when we see her a month or so later (just two weeks before this post), struggling more with her voices (but still very coherent), this concern does not abate.

It seems that Maya is using YouTube to process her own experiences, and perhaps as a kind of therapy.  Beyond this, she is reaching out to her audience to form some social connection, as she notes that she has ‘no friends’ in the physical world.  We know that supportive social networks in the physical world are important in staying well, but in the absence of a strong physical network, perhaps online networks can provide some of this support.

Finally I notice that Maya has subscribed to rawsammi’s channel, which I covered some time ago in another blog post.  Rawsammi is another youtube poster, who talks about her diagnosis of bipolar disorder.  There’s definitely a good story to be told about how people are using youtube to connect with and support each other.

Autumn Likes Elephants.


Autumn is another YouTuber with a diagnosis of schizophrenia.  Like Maya above, she has a channel of videos all about her experience of schizophrenia.  In the video above, she tries to make sense of what caused her schizophrenia.  Her struggle in working this out mirrors the struggle of all clients, psychiatric professionals and researchers.  After many decades of research, we know there is no single clear cause of psychosis, but in most cases it is likely that a complex set of genetic and environmental causes are involved. This is not just a case of genes or environment, but gene-environment and environment-environment interactions (which I think I may write about in a future post).

Unlike Maya, she describes herself as having a “great childhood”, but that she remembers being paranoid and that she has been told by her parents that she was delusional as a child.  From a familial perspective, Autumn talks about how her great-aunt (and other relatives in her maternal line) experienced similar difficulties and thus may have carried genes for psychosis.

Interestingly, Autumn talks about how she was a quiet child and suggests that this may have made her symptoms less obvious than they might be in more outgoing people.  She says that this meant that her family did not notice anything being seriously wrong until she became very unwell.    Like many people I’ve met, stress at school and in her first year of college seems to have exacerbated Autumn’s problems (for many of my clients, the first year of University or exams seem to have been a trigger for manic or psychotic episodes).

Autumn says:

“I’m not a professional… but I can say I’m a professional on the schizophrenia illness because I’m a schizophrenic*”.

It’s a standard trope in psychology to say that while the psychologist is (hopefully) an expert in how the mind works, the person is an expert in themselves.  Trope or not, it’s very true, and the person’s own expertise is central to therapy working. Thats also why I’m interested in these videos; it’s my firm opinion that the people who experience these difficulties are the best people to explain the experience, both to other patients and to healthcare professionals.  Indeed I first started looking for such videos around 6 years ago in an attempt to open up conversations in group work on the psychiatric ward I was working on (LEO, which at least at the time, was a relatively enlightened and forward thinking place for helping young adults with psychosis).

(*I’m generally not keen on people calling other people ‘schizophrenics’ because it can be stigmatising and the label might overshadow the person’s essential humanity.  However, a person with a diagnosis has every right to describe themselves however they wish!)

Something else that Autumn mentions is vitamin B12 deficiency as a potential cause of psychosis symptoms, which is not something I’ve come across before.  However a (non-comprehensive) literature search, brings up a number of results, including this case study of a 16 year old boy.  For me, this is an important reminder to thoroughly check a person’s physical health when they present with psychological difficulties.

Finally I thought I’d point you towards Autumn’s art video, which I’ve not watched properly, but which perhaps reflects a common, but not universal, flip side of psychosis, creativity.

Schizophrenic On a Bad Day


In this video, IhaveSchizophrenia is currently experiencing auditory and visual hallucinations and he posted it in order to try and show what it’s like to function while having such symptoms. He has a voice that tells him do do things and not to do things (known as a command hallucination), and is seeing animals and letters on the wall.  His thoughts are somewhat disorganised and he says he is paranoid – as one might expect when having hallucinations.

Like the two vLoggers above, IhaveSchizophrenia, has a variety of different videos about his experiences of schizophrenia – indeed, he’s truly prolific, with dozens of videos. In the video “What Caused My Schizophrenia“, he talks about how his hallucinations started around age 5, and how they were not associated with any stress that he was aware of.  However, he then talks about how he was very severely bullied for many years and how the death of his grandfather had a serious impact and how he felt that this ‘pushed me over the edge’.  Again, well worth a watch.

Catatonic Schizophrenia


This is a bit of an odd video. It’s mostly a collection of older videos about people with catatonia.  Often these old videos can be rather uncomfortable viewing due to their low production values and questions about consent.  Nevertheless, I think the video provides a useful teaching tool on a symptom that is seen much less that it used to be.

What’s really odd about the video is that it comes with the disclaimer, yet..Screen Shot 2017-04-16 at 13.50.04the people who made the video chose to add spooky music with rather undermines the idea of respecting the patients.  In any case I include it as it could be useful as a teaching aid.

Auditory Hallucination Simulations

These two videos (here and here) attempt to simulate the experience of hearing voices and other auditory hallucinations (they are generally designed to be used with headphones to simulate the stereo nature of some hallucinations).  I usually try to check the comments before recommending any video, and in this case both videos were positively recommended by people who hear voices. Again, these videos should be useful as teaching aids.

Four Patients with Schizophrenia

This is more of a classic teaching video.  It features four different people with a schizophrenia diagnosis who are all currently experiencing symptoms such as paranoia, delusions, problems with attention and cognitive function.  These videos always beg the question of informed consent, however as they are already available on YouTube, I guess we might as well make respectful use of them?

The video is actually compiled from the following sources (1,2,4) and one which I can’t find.

Living With Schizophrenia


A short US based documentary on schizophrenia focussing on recovery.  This one is a classic educational doc, with various talking heads, a patient advocate, a psychiatrist, a clinical psychologist, and various patients talking about their experiences.  It covers a variety of issues including how people can be helped by their family, the different types of symptoms a person might have, the behaviours associated with this, the use of medication.

I have a bit of an issue with this documentary however, stemming from an opening statement that:

Schizophrenia is a disorder of the brain.

My disagreement is nuanced, schizophrenia (accepting the diagnostic term for the moment) is indeed a disorder of the brain, just like depression and anxiety are disorders of the brain.  Just as one’s thoughts are clearly a function of the brain, problems with one’s thoughts will always be a function of the brain.  But schizophrenia is very clearly also a disorder of society, something that this documentary appears to totally miss.  As something of a response to this overly ‘medical model’ approach, which I’ve witnessed time and again, I’ve invented another diagnosis (somewhat tongue in cheek):

IED.  Inappropriate Environment Disorder.

Schizophrenia, like pretty much all the other psychiatric disorders might commonly fall under the category of IED.  Society often triggers psychosis, and then makes it worse by stigmatising the people it has hurt.  The fact that the documentary singularly fails to give real consideration to this is a real shame.   Nevertheless, it’s worth a watch, especially as an introduction to the topic.

I Am Not A Monster: Schizophrenia | Cecilia McGough

Another first person account of schizophrenia, this time a TED talk by Cecilia McGough, an astronomer diagnosed with schizophrenia.

In this talk, she briefly uses one of my favourite ways of demystifying auditory and visual hallucinations:  dreams.  Dreams (and daydreams) show that we all have an inbuilt capacity to conjure up realistic sounding conversations with other people who are not in the room with us and realistic seeming visions of people and objects that are not in the room with us… and when we are dreaming, we don’t realise that we are dreaming.

Strangely, mental health professionals often seemingly fall into the trap of thinking that voices are something bizarre and beyond the understanding of people who don’t experience them in waking life.  We almost start believing that these voices are indeed something supernatural.  They are not.  One possible explanation (which I generally subscribe to) of voices are that they are simply our normal inner world (albeit generally the negative side of it), but that the part of the brain that recognises this fact is somehow offline (like in dreaming) and thus the brain (which always tries to make sense of what it is experiencing), simply comes up with it’s best explanation of what’s happening.  Something like:

Subconscious Brain:  I notice that there are voices, but as far as I’m aware, I’m not currently generating these voices.  Also, I can’t see those people right now.  Therefore these voices must be from real entities that I can’t see.  That could mean: I’m hearing devils, someone has put speakers in the room, or that thoughts are being inserted into my head.
Conscious Owner of Brain: That’s really really scary.

A key part of the talk is about coming out as a person with schizophrenia.  And interestingly, after McGough came out, she found unbeknown to her, some of her friends also had the same diagnosis.  Her mission is to be a patient representative and to confront the stigma associated with the diagnosis.  As part of this she has started a non-profit organisation to help students with schizophrenia.

The voices in my head | Eleanor Longden

Sometimes it snows as late as May, but summer always comes eventually.

A tale of resilience, survival, empowerment and recovery.  Probably one of the world’s most watched talks on schizophrenia, for good reason.  Again the video is from TED, and has 1.4 million views on YouTube alone.

As so often, the ‘psychotic break’ happened in the first year of university.  In her case Eleanor experienced a voice constantly commenting on her activities in the third person, ‘neither sinister nor disturbing’ that seemed to be trying to communicating something about her inaccessible emotions.  In fact the voices only took on a negative connotation once she’d told a friend and observed the negative reaction.

Eleanor talks about how once a person has a diagnosis, often normal behaviours are misinterpreted as aspects of schizophrenia, as the are viewed though the aperture of the diagnosis.  She very clearly describes many of the negative consequences of receiving the diagnosis, from stupid throwaway comments from psychiatrists to physical and sexual assault.  At the same time she pays tribute to those that helped her recover and thrive.

Eleanor proposes that mental health professionals stop asking: ‘what’s wrong with you’, and start asking ‘when happened to you’.  I could not agree more.  She also argues (along with organisations such as inter voice) that voices are a “sane reaction to insane circumstances”, a functional coping mechanism.

Essential viewing

A tale of mental illness | Elyn Saks.

To Work and To Love.  My last video for the post (for the moment), and the third TED talk.  I’m too tired now to provide a good description, but be sure it’s worth a watch. Elyn Saks has a diagnosis of schizophrenia and is a professor of law, psychology and psychiatry – and author of the book The Centre Cannot Hold, which shamefully I’ve not read.  Yet.

Oh before I go, just one more quote… from Saks:

There are no schizophrenics, there are people with schizophrenia, and these people may be your spouse, they may be your child, they may be your neighbour, they may be your friend, they may be your co-worker.

Part 2:

I’ve decided to add new discoveries and suggestions to a separate part 2 post.  Click here to see!

Lithium and A Manic Episode on the Radio.

Screen Shot 2017-04-10 at 21.48.28

 

 

It’s been a while now.. but now back to the first purpose of this blog, to share interesting media items related to mental health.  This time something from the wonderful Radiolab.  Here, in a set of pieces called ‘Elements’, the team interview Jaime Low about her experiences with Lithium, and in the process play an old recording of one of her manic episodes.  Well worth a listen, and I think a good item for teaching and it seems also (according to the comments) for some people coming to terms with their diagnosis and medication.

 

Water Filtration and Autonomy

This post became a bit longer than I’d planned, so I’ve separated it into two parts:

Part 1. Some background to my research on filters.
Part 2.  A description of the various types of filters available and their pros and cons.  To be written!

Potable Water Everywhere.  Not Just a Dream.

Living in a country like Ecuador, where the quality of the tap water is far from assured, leads one to consider alternative options for obtaining healthy drinking water.  In Ecuador, one can generally trust that bottled water is of good quality – while in other countries, one must be more cautious, as bottles may just be filled with tap water.  Regardless, drinking bottled water has unnecessary costs, both financial and ecological.  Ecologically, transporting non-reusable plastic bottles of water is unjustifiable in the majority of situations.  Financially, buying bottled water all the time can be… well just silly.

While I have long used water filters on my travels, two things focussed my mind on water treatment in 2016.  The first was that I was lucky enough to have the opportunity to help build an ‘Earthship’ school in Uruguay in February.  The second was the devastating earthquake that hit the coast of Ecuador on the 16th April.  Both made me think very seriously about one concept in particular: autonomy.  What has become very clear to me over the last year, is that with a combination of fairly basic technology and education, access to cheap clean water for everyone can be more than an aspiration, it can be a reality.

What’s an Earthship?

Earthship in El Bolson, Argentina.
Earthship in El Bolson, Argentina.

The ‘Earthship‘ was dreamed up by the North American architect, Michael Reynolds.  To cut a fascinating story short (sorry)*, Mike was fed up with the wasteful way in which buildings are constructed and run, and thus decided to make something better; this journey eventually led to the Earthship.  Key to the Earthship design are two concepts: 1. Using other peoples’ junk, and 2.  Finding a way to live autonomously and ‘sustainably’.  Mike believes that an Earthship should ‘encounter’ the world, not use it up, nor contaminate it.

Mike on site at the school build

Put briefly, an Earthship is a house that collects its own energy and water, that uses its water intelligently and efficiently and which treats its grey and black-water waste as a resource to enrich it’s environment.  Perhaps most importantly for areas with large temperature ranges, it uses passive solar gain and thermal  mass to do all its heating and cooling.   Often people who live in Earthships also grow a fair amount of their own food.  Importantly, the house does not need to be connected to electricity, gas or water networks.  This has huge advantages for both the environment and for those who live in the house.  In particular once you have built an Earthship (or similar design), you are free from having to pay for electricity, heating, cooling water and sewage treatment.  You now ‘just’ have to think about how to pay for healthcare, education, food and perhaps some fuel for cooking.  Most relevant to us right now however, is how an earthship deals with water, of which more later.

Potable water on the coast of Ecuador.

Before the April 16th Earthquake, people on the coast of Ecuador either relied on rudimentary water collection (pretty rare in Ecuador), rivers, municipal water supplies or bottled water/coke**.  Following the earthquake, those people who were reliant on municipal supplies of piped water found themselves with nothing other than sea water and dirty, untreated river water.  They most certainly did not have control over their own water supply.   Fortunately a rapid reaction by the people of Ecuador meant that supplies of food and water were immediately on their way to the coast, brought by people in their own pick-up trucks.  Indeed, many Ford F150 trucks got their first day’s real work – and went off to do something more appropriate than shopping in Supermaxi and driving to the bar.

It was a beautiful display of shared humanity, but also somewhat absurd.  The shops of Quito were immediately emptied of all their bottled water as millions of bottles, big and small, were shipped to the coast – for weeks and weeks.  In the process the supermarkets and water companies received an lovely earthquake bonus.

Things could have been much worse.

Although the earthquake was devastating and although the death and destruction was magnified by terrible building control, things could have been much worse.  If the epicentre of this earthquake had been somewhere else, such Guayaquil or Quito, we would have been looking at a totally different scale of disaster.  At the time, Quito’s local volcano, Cotapaxi was also threatening to erupt or unleash deadly lahars..  In a worst case scenario, a combination of eruption and earthquake would certainly have overwhelmed the country’s very limited and unprepared emergency resources – and would have left many many people to survive on their own for much longer.

How things can be better with autonomy.

An autonomous house does not rely on functioning municipal water systems. Thus it is the perfect ‘ship’ for surviving after an earthquake (assuming the building survives – which is another topic).  Ruptured pipes?  No problem.  Contaminated rivers?  No problem.

In an Earthship, rainwater is captured from the roof and stored in cisterns, which then feed a Water Organising Module (WOM).  The WOM is a series of  progressively finer filters, which clean the water for washing and, with the finest filter, for drinking.  Such a system has a number of advantages over relying on municipal water.  Firstly, water captured from the rain is about as reliably non-contaminated as one can find.  A municipal water supply can be contaminated at many points, from the input, through the processing stage, though to the delivery pipes.  This contamination can be accidental or deliberate.  When collecting rainwater, the only possible sources of contamination are the atmosphere, the rooftop, the cisterns and the filters.  The only one of these over which the owner has no control is the atmosphere.  Secondly, short of your cisterns being damaged, you will always have water available.

Would an Earthship system be suitable for Ecuador, especially at the coast which is very dry?

p2060657-edit
Cisterns for the school

The Earthship concept was conceived in Taos, New Mexico, a place with just 50cm of rain per year, most of which comes in torrential downpours.  This is enough to classify Taos as a high altitude desert, yet an Earthship in Taos can collect and treat enough water from its roof to drink, wash and shower all year round.  By way of comparison, Quito gets 100cm and Pedernales, which was close to the epicentre of the earthquake, gets 92cm.  This suggests there is not reason we can’t do the same on the coast of Ecuador, at least in the wetter areas.

I’d consider the Earthship rooftop collection system as the ideal solution for most places, however the full system has one serious limitation – price.  Firstly, one must design a decent rooftop collector with sufficient surface area and which must be made of suitable materials (long lasting, non-contaminating).  Secondly, one needs a large storage capacity, normally in the form of a set of cisterns, which can be expensive.  Thirdly, one needs a filter and pump system.  A second limitation is that all of this needs maintenance – and maintenance requires both understanding and motivation.  This is where a lot of well intentioned NGOs fail… they provide expensive systems that end up being abandoned for lack of local buy in.  Fortunately, however, there are an almost infinite way of adjusting the systems to local requirements.

After the earthquake

Two days after the earthquake, I went down to the coast with a group of local Ecuadorians and a fellow immigrant to bring supplies help build shelters on the coast.  As well as a bunch of shovels, saws and other tools, I had my trusty Sawyer filter.  This meant that instead of using the water that was being taken to give to those affected, I could filter my own water.  It also meant that in the worst case scenario of getting stranded and/or injured in an aftershock, I would have access to clean drinking water as long as I had a source of non-saline water.  One of the sources of water I used was a swimming pool, which got progressively greener as the weeks went on.. but which made a lovely example for demonstrating the filter to local people.  The water goes in green and comes out clear.  I’m just sad now I did not take any pictures.

Seeing the need for potable water, and seeing the incredible waste involved in bringing millions upon millions of tiny plastic water bottles down to the coast, the first thing I did upon my return to Quito was start researching as to what was available in Ecuador by way of water filters.  At the same time, a variety of groups and people started to bring water filters down to the coast (for example Waves for Water).  The majority of these small filter systems came from Sawyer or LifeStraw.

We also saw donations of larger scale systems from countries around the world.  Not that you’d know much about this, as the government seemed keen to take credit for all the work done by other organisations.  Here I should note that the apparent lack of emergency planning by the Ecuadorian government was fairly shocking.  But that’s another post.

It immediately became apparent to me, that all these different smaller organisations were doing pretty much the same thing, but without any coordination.  I therefore tried to put people in touch via WhatsApp and eventually via a Facebook group, which remains active.  If you are interested in joining us, please have a look here.  The group is dedicated to joining all people working with potable water and sanitation in Ecuador.

Delivering the promise of the filters is not easy.

LifeStraw Filter in El Matal
LifeStraw Filter in El Matal

Our group received a small donation of Sawyer filters and an offer of many more.  However, having attempted to train local people in the use of the filters, we realised that getting people to use the filters and use them well was not going to be easy.  Not all of the filters we handed out were actually used, and it was not clear that they were going to be used correctly.  Part of the problem was that in the town of El Matal, in which we were building shelters, people had been given free bottled water, and later, free tanks of potable water.  This, although very welcome, reduced the incentive to use the filters.  We thus decided to hold off until things had settled down before trying again.

We did anticipate these problems, as they are to be expected when such things are delivered rapidly AFTER a natural disaster.  Post-disaster is exactly the wrong time to be delivering new technologies.  The recipients are very unlikely to be in the right frame of mind to want even more change in their lives.  More than anything, they want things to go back to normal.  Thus the best time to deliver these initiatives is likely when people are more settled.

This is not to say that some of the water filters provides were used extremely effectively.  Some of ours were, and various filters provided by other organisations were clearly well set up and well used.  The LifeStraw filter pictured above, was one example of a well organised filter point.  A specific person had been given responsibility, there were clear instructions (in the right language) and a banner clearly advertising where people could get clean water.

Today at the coast.

All of which brings us to today, 8 months after the earthquake.  Having returned to my native Britain for several months, I’m somewhat out of date on how the filter systems that have been provided by the various groups are being used today.  I have my doubts that many of them will be in daily use, but we will need to do more research to find out.

Which means what?

Which means the real work starts now.  Hundreds, if not thousands of water filters have been delivered to the coast, all of which are suitable to provide a family with clean drinking water for years.  The challenge (IMHO!) is to provide workable, cheap systems for collecting and filtering the water.  But perhaps more important is the formidable process of providing proper education about sanitation and correct use of the filters we have provided.

Part Two To Follow:

Part two will actually be the more useful bit for most people. It’s here.

 

 

*It’s definitely worth learning more about Earthships. An easy way to do this is to watch the film Garbage Warrior.

**Believe it or not, I’ve met people on the coast who don’t drink water, but just drink soft drinks.  Often coke is cheaper than bottled water.

How Universities Work: Deciding Executive Pay.

My priors / declaration of bias. Those who know me, know I have had my disagreements with the executive of King’s College London, the university at which I did my last three degrees, and to which I am still affiliated.  As a one time student rep and environmental activist, I found the then executive less than consistently helpful (I was not alone).   So I might be biased.


My plan is to write a series of short articles about certain aspects of governance in Universities.  The first is one that always interested me: Executive Pay.  Specifically, who decides what the vice-principal (VP, sometimes called a vice-chancellor) gets paid.  I’m going to focus on KCL, as it’s ‘closest to my heart’.  Details may vary from university to university but my impression is that there are more similarities than differences.

How much do they get paid.  Although the pay of the vice-principal of a UK university is supposed to be public knowledge (and should be found in the university’s annual accounts) it’s often hard to find out what it really is -try searching on the KCL website!  Fortunately the good folks at University and College Union do a good job of making it easier and you can find their report here.  This report is clearly the result of a lot of work and many Freedom of Information requests (FoIs).  FoIs are a vital tool which empower citizens to find out how the power structures around them are working, but these citizen powers are constantly under threat.  Incidentally you might be interested to know KCL spent £250,000 in order to prevent having to make the salaries of its other top earners public.

Ed's on the left (photo credit KCL)
Ed’s on the left (photo credit KCL)

As of 2016, the VP of KCL, Professor Byrne, earned £458,000, up from the £324,000 earned by his predecessor.  Apparently a large amount of this rise was due to included relocation costs.  Extensive relocation costs are apparently something an executive can expect to receive.  How many of you have received a nice relocation package?  I should note I have no particular feelings for or against Professor Byrne, I know nothing about his ideas of policies for KCL.  Here I’m only interested in how these systems work.

Who decides the level of pay and how? This is the most interesting question for me, because it has implications for future trends in executive pay.

Executive pay at a university is generally set by a remuneration committee.  The first details I could find from the KCL remuneration committee were from 2013.  At that time, the remuneration committee consisted of Lord Douro, Dr Angela Dean (previously an international financier with Morgan Stanley) Mr Jamie Ritblat (a very wealthy businessman) and Rory Tapner (the CEO of Coutts, ‘The Queen’s bank’).  You’ll note that in 2003 there were no representatives of KCL staff nor students.

The remuneration committee has changed since then.  Perhaps it’s more representative of the KCL rank and file?  So who do we have now:

Sir Geidt (photo KCL)

Sir Christopher Geidt.  The Private Secretary to Queen Elizabeth II since September 2007.  Alumnus of KCL.  Privy Counsellor

dr_angela_dean-2
Dr Angela Dean (photo HRF)

Dr Angela Dean. The KCL blurb says: “Dr Dean has spent most of her career in international finance and worked as a Managing Director for Morgan Stanley for over 20 years. She holds a DPhil from Somerville College, Oxford”.

Mr D'Souza.
Mr D’Souza (photo KCL)

Mr Michael D’Souza.  The KCL blurb says: “Mr D’Souza is an independent Senior Advisor at the Bank of England’s Prudential Regulatory Authority. His key focus includes corporate governance, risk management & culture and firm-wide recovery & resolution. Mr D’Souza was previously Managing Director & Chief Risk Officer for the international CFO division and the Chief Recovery & Resolution Planning Officer for Bank of America Merrill Lynch….”

Mr Goswell (photo KCL)
Mr Goswell (photo KCL)

Mr Paul Goswell. The KCL blurb says: Paul is the Managing Director of Delancey, a real estate business with a long track record of investing in, developing and managing commercial and residential properties in London and the rest of the UK.
Note: Delancy was founded by Jamie Ritblat’s (previous committee member) father.

And finally.  In attendance at the meetings, the VP.

So what do you note about these appointments?  Two things really strike me: Firstly, apart from the VP, there is no representation from KCL staff or students.  None.  Secondly, the members of the committee do not represent the reality of the world inhabited by normal KCL staff and students.  They are all very much a part of the current ‘British Elite’.

The committee members come from a world in which it’s important to defend the principle of ever higher pay, even if the evidence of even a correlation with performance fails to impress.   What’s more, when many are worried about the commodification and privatisation of our universities, and fed up with the proliferation of unstable contracts for staff, (here and here for example) these are not necessarily the people to fight our corner.  I don’t object to having a respected member of the business community on the committee.  But every member?

When even the current government is making noises about executive pay restraint, when high powered, highly paid executives were the ones responsible for 2008 financial crash, from which normal people are still suffering, can this be right?  Teresa May, the British Prime Minister, made representative boards a promise of her leadership campaign (although that’s now been diluted) – yet right now, we don’t even have representation on a university pay committee?

Ok but at least KCL is open and transparent so we can find out what the rationale is behind the  remuneration committees thinking?  No.  According to the University College Union report on VP pay, KCL does not publish the minutes of the committee, nor does it surrender them to FoI requests.  We don’t get to know.

Until I wrote this, I did not know anything about the makeup or procedures of KCL’s remuneration committee.  I simply felt, like many staff and students, that our interests and indeed our values are not represented higher up. What I have found has done nothing to shake this feeling.

But Fergus, there is some representation of staff and students, the VP himself comes to the committee?  Surely his job is to represent us?

I’ll answer this by way of an anecdote about how information flows in universities.

When I was chair of the Institute of Psychiatry (IoP, now IoPPN) Student Forum, part of my agenda was to push for the IoP and KCL to take its sustainability commitments seriously.  At the time, the IoP did not even recycle (but we were successful in helping to change this – or at least, it changed!), let alone do anything to reduce its energy waste.  I’d liaised with various members of the KCL estates department who were keen to improve things, but who were frustrated that nobody was listening.  They agreed that extra pressure from below would be welcome.  Following a discussion with the forum and various staff I was advised to speak to the then Dean of the IoP, who kindly agreed to meet me.  I asked him if he might help me get our message to the VP, as he might listen to the Dean of the IoP more than to the Student Forum.  What do you think he told me?

“My job is not to petition my boss.”

This felt a little like a punch in the stomach, so winded, I made my excuses and left his office.  When I relaxed, I realised what he was telling me:  Information flows from the executive downwards, not the other way.  Given such a system, how can we possibly expect the interests of students and staff to be represented?  The system simply does not allow it.

(A final disclaimer.  I’m no expert in how universities work.  I’m giving the view from the bottom, as a student, student rep and post doc).  On the other hand, I’ve sat on many committees and talked with many people, so although I’ve been looking from the bottom, I’ve had a pair of binoculars and a stethoscope).

The Reproducibility Crisis in Psychology

http://blog.f1000research.com/2014/04/04/reproducibility-tweetchat-recap/
http://blog.f1000research.com/2014/04/04/reproducibility-tweetchat-recap/

Yesterday I gave a talk at the University of San Fransisco, Quito about the reproducibility crisis in psychology (and most science).  This was at the invite of the Quito Brain and Behaviour Lab.  I decided to give this talk rather than one on my own research as I think it’s really important for all researchers, but especially those at the beginning of their career.

Psychology faces serious issues and they need to be fixed.  The good news is that we can fix the most serious of these issues relatively easily, if we actually try.  There is some resistance from some in the old guard, but this can be overcome.  Anyway, I’ll expand on this in an update, for now the purpose of this entry is mostly to make the slides available for those who were at the talk.

Here they are:  Repro Crisis  They will be updated as and when I revisit them.

After Reading This, Your Brain Will Never Be The Same

Brainnetwork-e1436746440606-1024x1024
In the best tradition of such articles, this image has no real connection to the content.

After reading this, your brain will quite simply never be the same again.  My ideas, transformed by my brain into a series of muscle stimulating electro-chemical nerve impulses and transferred by my fingers into my computer’s systems, will have been launched across  the internet’s intricate web, eventually spawning a torrent of photons that will have streamed though your eyes and onto your retinae, unleashing another chain of bio-electro-chemical reactions of almost unimaginable complexity.

Your brain networks will have been activated and deactivated; hormones secreted and metabolised; neurotransmitters released, sucked up, converted and degraded; your genome read; proteins synthesised, cut up and stuck back together, synapses formed and broken – and at the trendy edge of science, your brain cells will have experienced epigenetic change.  None of this is fully reversible.  You’ll likely never be able to completely forget that you read this, no matter how hard you try. In fact, the harder you try to forget, the more these words will worm their way into your biology.

Sorry about that.

Of course, although this is all incredible, it’s also absolutely normal.  There is nothing very special about these words.  Your brain is being changed all the time, by everything and anything that stimulates any of your various different senses.  And should you for any reason, find yourself in a sensory deprivation tank, well, your brain will self-stimulate to a quite worrying extent.  The cascades of psycho-bio-electro-chemical events will never stop.

Well, only once.

So next time you read an headline like:  Doctors Explain How Hiking Actually Changes Our Brains or Science Proves Premarital Sex Rewires the Brain, I suggest the best response is a yawn (well actually, my recommended response to that second link is a bit more than a yawn; indeed I recommend you activate your ‘disgust at the hijacking of science to promote your own agenda’ network.  If you’ve not developed such a network yet, please do.).

None of this is to say that the science behind these headlines is not interesting or important.  It often is.  Almost as often as it’s misrepresented to get the most advertising revenue possible.

(By the way, if you doubt that my words permanently altered your brain, ask yourself, if they did not, how it is that you can still remember what I wrote, and how is it that you’ll most likely still recognise those words in a year’s time?)

Now this blog post has been at the back of my mind for a while.  I was finally inspired to actually write it today when I read Vaughan Bell’s critique of Critical mental health‘.  Which brings me to the ever present question of ‘Biological’ Vs. ‘Psychological’.

I’m often asked whether a problem is biological or psychological in origin, and quite often, when I first see a client, they tell me that their doctor told them something along the lines of:

“You have a chemical imbalance in your brain, which we can try and fix with this medication”.

This is the kind of thing that upsets me*.  For me, it’s a problematic misuse of ‘biological’ theories of mental function, and I have a number of concerns with this kind of explanation:

Firstly, the doctor has absolutely no idea whether what they said is true. Setting aside the wider debate about whether antidepressants and anxiolytics do what they claim to do, without running a test, one cannot know whether another person’s brain chemicals are ‘unbalanced’ (whatever that might mean); and frankly, we don’t even have any meaningful tests to tell us whether this might be true.  It occurs to me, that the doctor in this case is misusing science to convince their patient to take a medication.

Secondly, and connecting back to the beginning of today’s blog, it feeds into a wider problem, which is the tendency to separate the biological and the psychological.  I don’t see this as the doctor’s fault, it’s simply a tendency we have in today’s society, and which is reflected in every article expressing surprise that hiking, sex or meditating changes the brain.

There are significant consequences of labelling a problem ‘psychological’ or ‘biological’ and these vary from problem to problem, culture to culture and person to person.  It’s hard to know how an individual may respond to the idea that their brain is unbalanced and needs medication to make it better (hopefully a doctor will also indicate that psychology might also help this person, but that’s certainly not a given).  For some, it may be useful to have a ‘biological’ explanation, but for others, it may take away any sense of agency, any sense that they can do something about their condition other than take a medication (a good topic for a post to come).

There are indeed meaningful ways in which we can say a mental health difficulty may have a significant ‘biological’ cause (as in psychosis and chromosome 22q11.2 deletion syndrome, which Vaughan references), or may have a clear ‘environmental’ trigger, such as when a person develops Post Traumatic Stress Disorder (PTSD) following a trauma**.

Yet when it comes to ‘psychological’ vs ‘biological’, there is no sensible way to separate the two.  As I hope I may persuaded you earlier, anything and everything that you experience changes your biology, both temporarily and permanently .  If this was not the case, you’d experience nothing, you’d have no memories of what happened to you, and psychological therapy would have no purpose.

Thus I believe that we should stop trying to separate the biological from the psychological and learn to always recognise the two as different levels of explanation for the same thing.  Perhaps if we can do that, we might finally stop being surprised that exercise could make a person not only fitter, but also mentally healthier, and that this would be reflected in changes in the brain.  And perhaps it would stop us giving trite explanations like ‘your brain chemistry is unbalanced’.

(As usual, feedback of any polite kind very welcome.  That includes comments on writing style, grammar, spelling, as well as agreements and disagreements.  Be as pedantic as you like).


Footnotes:
* Of course I never know exactly what the doctor has said, and of course, I’m sure they have done it with the best of intentions.

**As always, in nature vs nurture, in both cases, the story is likely more complex.

“When I stopped hearing the voices in my head”

In today’s Guardian there is a lovely short article by ‘Anonymous’ about what it is like to hear voices.  Well worth a read for those struggling with the same issues, or those trying to understand the experience of voice hearing.

The author’s story is very familiar to me, the stress of going university seemingly bringing on a severe depression while later, with the added stress of exams, the voices appear.  I’ve been told this story many times, often by people who I interviewed for the Maudsley Bipolar Twin Study, and then more recently by my clients.  My recollection is that the majority of those who’ve related this particular sequence of events were women, but perhaps this was random or recall bias.

The author, via some combination of medication and therapy reports that she no longer hears voices, and that she has found a way to cultivate a supportive inner voice in their place.  No point in me saying more, read what she has to say!

(I assumed the author was a woman from the photo, but it’s just a stock image, so who knows).

 

“The patient did not respond to the drug”

 

From http://www.acphospitalist.org/weekly/archives/2011/3/23/
http://www.acphospitalist.org/weekly/archives/2011/3/23/

Today, a colleague sent me a press release for an exciting new treatment for psychotic symptoms based on a compound extracted from cannabis (CBD – Cannabidiol).  This work by GWPharm follows up on some work I was vaguely involved in at the IoPPN, King’s College London.  Encouragingly it suggests that CBD might be an effective, and importantly a much more tolerable treatment for psychotic symptoms than those we already have.

But that’s not really the point of this article.  The point is that in the press release we see the following:

… in 88 patients with schizophrenia who had previously failed to respond adequately to first line anti-psychotic medications.

This is one of my big bugbears.  Glossing over the fact I’m not keen on the diagnosis ‘schizophrenia’, what’s the problem?  This is normal, this is how medical professionals really talk about their patients and their drugs.  I’ve heard it hundreds of times in ward rounds, read it hundreds of times in papers.

The problem is that the patient did not:

FAIL to RESPOND.

The drug:

FAILED to WORK

The patient was not inappropriate for the drug, the drug was inappropriate for the patient.  Drugs are supposed to be designed to target specific difficulties faced by a patient, whether than be insulin to replace what is missing in diabetes or aspirin to prevent pain transmission or blood clotting.  In ‘schizophrenia’ we face the problem that we still don’t know the aetiology of the person’s problems, and each person is different, probably because ‘schizophrenia’ simply does not exist in the same way as type I diabetes.  The simple fact is, that if the drug does not work, it’s because it is targeting the wrong mechanism.

campingchair2A random story by way of analogy:  I once went on a camping trip with my brother.  When we put the borrowed tent in the car, I remarked to my brother that the tent, which came in two bags, was remarkably light and small.  For the next six hours, I thought nothing more of it; not until  we turned up at the campsite, and started to set up camp next to our relatives’ warm cosy camper van.  Exited to be out camping, I pulled the first part of the tent from its bag – it looked remarkably like a folding chair.  Somewhat desperate, I hoped the the tent was even smaller and more lightweight than I’d imagined, and tried the second bag.  A second chair popped out.  We were left in Devon cold, with two chairs to shelter us from the elements.

Did I blame the chairs for not being tents?  Of course not!  When we were left cold and demoralised, did I blame my body for not responding to the ‘tents’?   Of course not, I blamed the provider (me, my brother or the friend who lent the ‘tent’, depending on my mood) for not providing the right solution for the problem at hand.

What are we doing when we say the patient did not respond?  We are clearly placing the blame on the patient.  Yet we should be placing the blame on the state of the science, or on our poor understanding of the patient’s condition.

If the drug does not work, it’s not actually the drug’s fault (drugs are not sentient as far as I know), but I’d much rather say that the drug did not work, than the patient did not respond.  This places the onus on us to improve our treatment

Before I finish, therapy does not get a free pass.  We can also find papers that say: “the patient did not respond to therapy”.  Rubbish!  The therapy did not help the patient.  It was the wrong therapy, the therapy was delivered incorrectly, or it was some other of the many factors that can affect the outcome of therapy.

If you are a medical professional who uses such phrases, I implore you to think about the implications of this stultified, automatic way of speaking and writing.  Further I encourage you to suggest your colleagues do the same.  Language is important, it shapes our beliefs and our actions, it shapes the way we see ourselves, and it shapes the way we see our patients.