 Well thank you ladies and gentlemen Hans, I hope I get at least 10 out of 12 as far as marking is concerned and it's a pleasure again to thank Hans and Gulchin for their wonderful hospitality and I'm glad to see many familiar faces here and I'd also like to thank Jay who has been so helpful to us down the years and also the hotel staff who've helped to make this conference. It's one of the most pleasant conferences that I've ever attended anyway. Well as advertised my subject this year is political correctness in the medical journals and it's easier to recognise political correctness than to define it. And what's more the matter with which it concerns itself changes from time to time and quite suddenly without any apparent central directions. It's a bit like fashion in the old days I remember that hems, the hems used to go up and down seemingly spontaneously and perhaps the study, the correct study of political correctness would be Balenciaga and Chanel and to find out how political correctness is decreed but at any rate it is a manifestation in my opinion of a kind of dictatorial not to say totalitarian ambition. And I'm reminded of what the Marquis de Cousteen said about Tsar Nicholas I and his regime in his book Russia in 1839, a book incidentally which was a wonderful guide or is a wonderful guide to 20th century totalitarianism which was written eight decades before that totalitarianism came into existence. Well Nicholas and his regime wrote Cousteen is both eagle and insect. They were Nicholas and the regime were eagle in the sense that they over flew society and surveyed it as a whole and they were insect in the sense that they insinuated themselves into the smallest crevices of life and surveyed everything from the bottom up as well as from the top down. No one could ever be quite sure that he was free of surveillance. Well political correctness or those who seek to impose it is a little like that. On the one hand they want to reform society in a fundamental way and on the other hand they want to reform or perhaps redeem is a better word our individual souls by making sure not so much that we think correctly but that we cannot think incorrectly. Language is therefore essential to their project and ambitions and even if in the long run they are thwarted in their ambitions they will in the meantime at least have had the pleasure of exerting power and causing a great deal of discomfort to people whom they do not despise or hate or fear. And there is after all a lot of pleasure to be had from making people uncomfortable and miserable. It's a great consolation for someone's own mediocrity. Now at first sight medical journals might not seem a very propitious target for political correctness after all if you go to the doctor with pneumonia the diagnosis and treatment is the same whatever the political or social opinions of the doctor but a moment's reflection will show that this is far from the end of the story that there is in fact a great deal of scope and material for political correctness in medicine which is actually a much vaster field than the simple interaction of a doctor with his patient. There are all kinds of considerations that make it a happy hunting ground for the political correct and nowhere is this more so than in medical journals. Incidentally I should preface my remarks by saying that I have no objection to the publication of any particular point of view much to the contrary. What I find distressing in the medical journals is the lack of any other point of view that is expressed in them as if the medical profession were the Albanian electorate in the good old days of Enver Hodger. Well in fact I'm going to refer only to the New England Journal of Medicine. First because it is one of the two or three most eminent medical journals general medical journals in the world and secondly because it's fairly typically in typical in this respect and third because I happen to have been writing a weekly commentary on it for the last several months which my wife says no one will be interested in publishing as a book and she's probably right and therefore I've taken a little of the material for this talk so that at least I haven't wasted my time entirely at least in my opinion I hope that will be your opinion too. But let me assure you that I could have derived the same material actually even more material from the Lancet as from the New England Journal and the Lancet is another very important medical journal. Indeed I don't know of any publication in the world that is more full of unctuous self-righteous utterly predictable sentiment than the Lancet. They quote themselves on the front they put the quotes from themselves on the front cover and this is an enormous contrast with the Lancet of the 1820s and 30s and 40s when its founder Thomas Wakeley fearlessly exposed genuine obvious abuses and evils with wit and passion. And in combative and uncompromising prose that make most of us here seem very mealy mouth indeed and of course he was sued many times for libel and it's a great pleasure to read it now and one of the things you realise is just how much freedom we have lost by comparison with the 1820s and 30s at least intellectuals have lost. Well let me start with the insect end of the insect to eagle spectrum. I take it from an interesting article in a very recent edition of the New England Journal and here I want to make it clear that I'm not claiming that the journals contain nothing but political correctness. That would be a gross exaggeration it would be absurd and there's much that is of value in them after all and there is medical progress in no small part because of the publication of these journals. They also have other defects for example to tendency to publish scientific reports which are clearly tainted by commercial corruption but that's another matter. Well the article to which I have referred concerns the effect of a follicle stimulating hormone FSH it's a pituitary hormone on obesity and in this case a mice it was the effect of obesity in mice. Now of course what happens to mice doesn't necessarily happen in man. I remember a lecture which I attended by a very eminent physiologist who was describing the biochemistry of rat brains and somebody said well that's very interesting Dr Smith but after all man is not a rat and the doctor on my right said oh yes he is. It was deeply heartfelt that anyway anyway the experiments with mice showed that if mice with access to in effect an infinite supply of food were treated with the substance that blocked the effects of FSH they did not grow fat as those did that were not treated with with the substance. So it seems that though you can't have your cake and eat it as the old English proverb says one day we will soon be able to have our cake and not grow fat which of course is much more desirable. Now where is the political correctness in all this you might ask well it was hidden in some wording and I'll read it to you three month old intact female and male mice were treated for eight weeks with intraperitoneal injections of FSH antibody or again. The FSH treatment resulted in significant decreases in fat mass in female and male mice. Now anyone with an ear for English for the English language which admittedly in my experience excludes most sub editors in both British and American publications who are chosen exclusively for their indifference to the euphony of language. Anyhow I say anyone with an ear for the English language knows that the natural occusion is male and female mice and not female and male mice and this is for reasons of language and not because anyone seriously supposes that male mice are more important or better than female mice and therefore ought to be mentioned first. Or we are trying to impose a patriarchal order on on laboratory mice and in fact if we were talking about their gonads we would say ovaries and testis testis not testis and ovaries for the same reason. The order is worth changing only if you think that the expression of male and female mice is in some convoluted sense derogatory to women. This is a very small thing in an otherwise interesting and unexceptionable article but it's the very smallness of the thing in which it's significant lies for it suggests that someone whether the authors themselves or quite possibly the sub editors of the journal have bothered to think about it. And this in itself suggests a kind of determination or even fanaticism that the minds or souls of readers of the journal must be reformed or cleans of the wrong ways of expressing themselves. And of course this thing kind of thing goes by default. It's insidious because no one can be bothered to oppose it and if you did try to oppose it you would be thought of as a bad person misogynist or something like that. And what applies incidentally to the New England Journal applies to practically all American university presses which increasingly seem to enforce a language code on their authors which sometimes is quite convoluted. And even on those who just because of their age could not possibly have used that language themselves so it's forced upon them. Well let me now mention something at the other end of the scale, the eagle end of the scale. So when I started my project that my wife thinks probably correctly is utterly futile because no one will want to publish it I straight away came across an article about the current cholera epidemic in Haiti. And this was interesting because while Haiti has never been a very healthy country rather the reverse indeed it's the unhealthiest country in all the Americas cholera had never been seen there until the year 2010. And in a way anyone who has been to poor France would actually find this rather surprising but nevertheless it is so there was no cholera in Haiti. In the article in the New England Journal about the Haiti epidemic there is a more subtle form of political correctness that is to say political correctness by omission. The second paragraph of an otherwise excellent article, it's a good article, was almost as interesting for what it did not say as for what it did say. The first sentence of the paragraph to which I refer reads as follows, cholera had not been recorded in Haiti until it was introduced in 2010. We then learn that the epidemic has caused 800,000 cases that is to say about in about eight or nine percent of the population with 10,000 deaths. And a death rate incidentally of one in 80 cases demonstrates that even in Haiti modern medical care has a long reach and beneficial effect. Because the death rate of cholera when first introduced into western countries in the 19th century was probably about 50%. So while we always lament the state of the world progress however uneven does actually sometimes happen. Now there's a fairly obvious question that you might have thought would be worth at least a glancing reference in the article by what or by whom was cholera introduced in Haiti in 2010. And on this question the article is completely silent as if it were an indelicate one to ask rather like who is your father of a child in a British slum. But for a medical audience the question of the means of introduction of cholera into Haiti is at least one of passing interest. And we have long superseded the kind of explanation that it was just the confluence of the moon and Jupiter or Saturn or some such that did it. In fact it is virtually certain that it was Nepoli peacekeeping troops of the unfortunately named United Nations mission for the stabilisation of Haiti that introduced cholera into the country. When they left to Nepal there was a cholera epidemic raging there and when they arrived in Haiti the sanitary arrangements of their camp on the banks of the largest river in Haiti from which a very large proportion of the population draws its water were very primitive and they discharged their waste directly into that water which was the drinking water of the population. There's no reasonable doubt about this now and in fact there was no reasonable doubt about it for quite a long time. But interestingly there has been what I hesitate to call a conspiracy of silence about it in the major institutions of the world about it and I hesitate to use the word conspiracy because as soon as you do people ask you whether you've stopped taking your pills lately. Anyhow the United Nations the World Health Organisation and the Centre for Disease Control in Atlanta long refused to entertain at least in public or to consider and propound what was after all a fairly obvious and cogent possibility which turned out to be of course the truth. In what can only be called the cover up they were ably assisted both by the New England Journal and the Lancet and both by means of commission and omission they published theories which were clearly not as cogent and they refused to publish the theory that turned out to be correct. And they refused for a very long time and the theory was finally proved more or less to everyone's satisfaction by the doggedness of a lone French bacteriologist and epidemiologist from Marseille who was nevertheless obliged to publish his researchers in much more obscure publications which entered medical consciousness much more slowly and furthermore they published obviously flawed papers that offered alternative but very unlikely explanations. Well one can only speculate about the reasons for this conduct fear of provoking unrest in the Haitian population which had already suspected this connection itself that would be directed at peacekeepers might be one explanation but it's also possible that it was to preserve a world view in which intention is always more important than result. No one not at least on this side of psychosis at least I think I am on this side of psychosis suggests that cholera was introduced deliberately into Haiti though gross negligence was clearly involved. But the intention of the peacekeeping force apart from providing Nepal with some much needed foreign exchange was of course the keeping of the peace and who can be against the keeping of the peace but cholera epidemics give peacekeeping a bad name and no one but a monster would not wish peacekeeping efforts to continue and therefore one must be silent about where the cholera came from. To my knowledge no acknowledgement of error let alone of culpability has ever appeared in the New England Journal or the Lancer. Well it's very rarely that an issue goes by the New England Journal is a weekly by the way as is the Lancer without some manifestation or other of political correctness and again I don't mind this I don't mind if people have opinions which I think are absurd. But there is very rarely any opposition to it or any publication of anybody arguing against it. One senses immediately what is politically correct by one's instinctive knowledge that no other view will be allowed to appear in the publication and it is as likely that a politically incorrect article or should I say merely a non-correct article and incidentally I don't believe that what is correct is necessarily the diametric opposite of the politically correct. No it is as likely that the New England Journal would publish such an article as that Pravda would have published translations of the articles of Frerid Bastia. Well I confess that my own examination of the political correctness in the New England Journal is not scientific I have not for example developed a typology of its forms or analysed it by its subject matter. I've simply taken it as it comes week by week and I now have I ask you to believe this an extensive dossier on the subject. A recent example another recent example is an article by the director and her deputy of the National Institute on Drug Abuse with the title The Role of Science in addressing the opioid crisis. The authors begin with what is a kind of cross between a politically correct statement and a magical implantation. Opioid addiction is a chronic relapsing illness. Now when you come to think of it there's a considerable element of magical thinking in political correctness. If you change the way people speak about reality you will not only change that reality language being so important to human existence the way we speak actually will change reality in certain respects but change it in precisely and only the way that we want. Anyway the idea that opioid addiction is a chronic relapsing illness in the sense of say multiple sclerosis is a chronic relapsing illness is now a form of medical correctness that has passed into the sphere of political correctness. It's an unchallengeable truth to the extent that you never find anything that goes against that opinion and to do so is to lose or to put yourself on the margins of moral scientific and professional respectability and yet it's obvious rubbish. But you can't engage in any public discussion of the matter at least in any important medical forum. The authors say among many other things in the past few decades we have made remarkable strides in our understanding of the biologic mechanisms that underline pain and addiction. And strictly speaking that might be so. But what the article rather omits to mention is that their institute has presided while it has spent 20 billion dollars of taxpayers money soon as the American Center once said we'll be talking real money. They have presided over what is probably the largest mass poisoning in American history and namely the current mass poisoning by opioids which bring about more than 30,000 deaths in the United States a year as well as the addiction of two or three million people. And I should point out that the United States has lost more than twice as many people to opioid overdose since the year 2000 as it has lost in all its military actions since the end of the Second World War put together. Now apparently we understand the biological mechanisms extremely well but I doubt that the irony of this understanding going along with what is a really a very serious public health problem the irony of it will ever make its way into the pages of the New England Journal. In the week following the addition in which the article about cholera appeared there was an article about online review of doctors title transparency and trust online patient reviews of physicians. We read in impeccably bureaucratic type of prose that anyone who has worked in a modern organization public or private will at once recognize. Patient reviews offer clinicians valuable performance feedback for learning and improving both individually and across the system. Receptivity to performance feedback which depends heavily on physicians acceptance of the data's validity facilitates a culture of continuous learning and patient centeredness. Now I mean we get all this build I mean I I used to measure my my circulars in inches daily and this is the kind of stuff we had day in day out. Now what follows is a completely un-nuanced incomium to such performance feedback as it's presently conducted overlooking entirely entirely the possible drawbacks. Bear in mind that they've said we must accept the validity of what is said. Now of course transparency and trust are good and desirable things whether they're entirely compatible is another question. When I leave that aside note that in this passage the wish is mistaken for the deed. Receptivity to performance feedback facilitates a culture of continuous learning etc not might lead to or at its best could lead to but simply and boldly that it does lead to though no evidence whatsoever is offered of this supposed fact. Now Dr Shipman who was a British family doctor who is thought to have murdered 200 of his patients was very highly regarded by his patients. And if at the time of his activities I'll call them that the kind of trip advisor performance feedback had existed they would the people would have said well he's got a very good bedside manner. And he's always willing to listen and here I must tell you that while I was in Manchester a little while ago I bought in a second hand book shop a small second hand book shop a slim volume that Dr Shipman had been asked by a medical journal to review. At this time he was nearly at the end of his murderous career and he had reviewed it and the book was titled understanding the new complaints procedure in the National Health Service. And in the forward to the book the chief medical officer which is Britain's equivalent of the American surgeon general and the chief medical officer wrote we have now learned how to weed out under performing doctors. So that makes you wonder rather what kind of performance he was hoping for. Anyhow in an example given of transparency and trust in the article were patients reviews of a surgeon. Two favourable and one unfavourable and the latter said she did not seem as concerned with my illness as I was. Now of course when I go to my doctors would say possible symptoms of cancer I don't want him to be as concerned with them as I. I want him to take a dispassionate view of them and possibly to cure me. But many of the readers of the above review might think that it is an important and significant criticism of the surgeon especially as we live in deeply sentimental times. Now I'm not going to deal with the other possible objections to this approach. But what is important is that once high sounding words are introduced thought seems to cease and as I have said the wish is taken for the deed or the fact and no discussion ensues or more importantly is allowed to ensue. Among other things political correctness including that in the medical journals is a desire that life should be both simple and perfect and without ambiguity. It's in patients with complexity and in a world denuded of religious belief it is the replacement of virtue as conduct by virtue as correctness of opinion and the utterance of the correct words. And we live in a culture in which the warning of the Earl of Kent to King Lear before he makes his disastrous decision these words have been forgotten all the significance. Nor are they empty hearted whose low sound reverbs no hollowness. In other words people utter sentiments are not necessarily the people who feel the sentiments most deeply but in the medical journals I'm afraid there is a lot of reverberation of hollowness. Thank you very much.