Tens of thousands of vulnerable people with dementia and learning disabilities are being detained unlawfully in hospitals and care homes across Britain, the Law Commission has said.
Replacing the “administrative and bureaucratic nightmare” system of deprivation of liberty safeguards (DoLS) would speed up checks and allow care workers to concentrate on those most at risk, the legal study recommends.
The report, laid before parliament on Monday, is an attempt to relieve pressure on the overburdened care system, which has been put under strain by the UK’s growing elderly population and a recent human rights court victory.
Individuals who lack sufficient mental capacity are subject to movement controls, usually for their own safety, which prevent them wandering off and getting into danger.
In 2014, a supreme court judgment dramatically expanded the definition of those who should be subject to DoLS checks beyond hospitals to care homes and other types of accommodation.
As a result, while there were 13,700 applications for deprivation of liberty in England in 2013-14 by 2015-16 that figure had risen to 195,840. The massive increase meant overburdened local authorities were unable to carry out checks within the period required or even at all.
The Law Commission, an independent body, was approached by the Department of Health to find a legal alternative. Its report cautions: “Local authorities are, in most cases, currently not issuing standard authorisations within anything like that timeframe, leaving people unlawfully deprived of their liberty and care homes exposed to civil liability.” A similar problem was found to exist in hospitals.
The DoLS system, if it worked, should enable patients and families to challenge any deprivation of freedom they believe is unjustified or excessively restrictive.
The commission proposes replacing DoLS with a liberty protection safeguards scheme. A draft bill implementing the legal changes is included in the report. It would allow previous assessments made in care plans to be relied on rather than requiring six sets of fresh assessments for each patient.
The report argues this would give “greater prominence” to individuals’ human rights at the initial stage at which care arrangements are being devised and reduce the number of costly applications to the court of Protection, which handles cases involving those deemed not to have mental capacity.
The liberty protection Safeguards scheme would cost about £236m a year, saving about £10m on current costs. The commission estimates, however, that if the DoLS system was working properly and every referral completed within time it would cost up to £2.2bn annually.
The commission found that in some cases vulnerable people were being deprived of liberty in their family home, although local authorities rarely have the capacity to carry out checks. In one case, door keys had been put into a safe and alarms rigged by the family to alert them if an elderly parent wandered out of the house.
Nicholas Paines QC, a law commissioner involved in drawing up the report, said: “It’s not right that people with dementia and learning disabilities are being denied their freedoms unlawfully. There are unnecessary costs and backlogs at every turn, and all too often family members are left without the support they need.
“The deprivation of liberty safeguards were designed at a time when considerably fewer people were considered deprived of their liberty. Now they are failing those they were set up to protect. The current system needs to be scrapped and replaced right away.
“We know there are enormous pressures on health and adult social care at the moment and our reforms will not only mean that everyone is given the protections they need, but could also deliver a saving to the taxpayer. That’s cash that can then be directly reinvested to support those most in need.”
A Department of Health spokesperson said: “This government is committed to protecting the rights of vulnerable people, that’s why we commissioned this review. We also gave local authorities £25m to help them manage pressures following the 2014 supreme court judgment.
“We thank the Law Commission for its detailed work and will be responding to these constructive recommendations in due course.”
Imagine this. You’ve suffered a debilitating mental illness, you’re admitted to hospital and, after weeks or months of treatment, you’re finally deemed stable enough to go home. Only, you can’t – the home you need in the community is not available.
As a psychiatrist, this is a situation I and many others around the country encounter almost daily. Even when patients are ready to leave hospital, a notable number don’t have the specialist supported housing they need to take that step.
Currently, around 60,000 people in England live in specialist mental health supported accommodation. They are there because of the severity of their condition, their level of vulnerability and their complex needs, which often include requiring support for everyday activities. Supported housing offers them the freedom to live as independently as possible, while also reducing their use of hospital beds, both in the mental health sector and in the acute, physical health sector.
With the right support from housing care staff alongside secondary mental health care rehabilitation and recovery services, many can and do achieve stability. Along with this, the opportunities to re-engage with family, education, work and their community are more within reach.
Without such provision, many people become stuck in highly restrictive, costly and more institutionalised care, such as hospital wards and care homes. These are often at great distances from their families and communities and require even more public funding. Supported housing provides that crucial interim step for those who need it, between hospital or residential care home, to people moving into their own flats with support coming in. This also often means the difference between living and staying well in the community, to becoming unwell again and requiring yet another hospital admission.
Money can be spent more efficiently when people are in the right setting for their level of need
Providers of supported housing for vulnerable people, including those with mental health conditions, have clearly communicated that the government’s proposed changes to how supported housing is funded will result in the closure of such services. Yet there does not appear to be a viable alternative for those most in need. Providers of supported housing have already been closing accommodation across England and halting the development of new, much needed provision.
The effects are already being seen on acute psychiatric wards, with increasing levels of delayed discharges, resulting in fewer available beds for those requiring acute emergency admission and an increasing number of people being sent hundreds of miles from home.
It has also been found that those who are sent far away for treatment are more likely to take their own lives upon returning home than those who are admitted to hospitals close to them.
The adequate provision of supported housing locally is crucial for many national policies and strategies to be realised. These include the five year forward view for mental health, the Crisp commission on acute adult psychiatric care and transforming care for people with learning disabilities, which all state the central importance of specialist supported housing to aid people’s recovery and to enable successful community living.
The health and social care system is made up of so many parts. The lack of a joined-up policy results in unintended consequences for patients, their families, services, commissioners who pay for care and society as a whole.
Money can be spent more efficiently when people are in the right setting for their level of need. For this to work, a system-wide approach across health and social care with adequate resources at each level, including supported housing, is vital. Especially for those whose lives depend on it.
If health regulators would fund a more joined-up way of working, then every person could receive the right care and support, in the right place, at the right time.
Dr Sri Kalidindi is head of the rehabilitation & social psychiatry faculty at the Royal College of Psychiatrists• Comments will be opened later
I stood in front of the ambulance bay door. My badge clutched in my hand, knuckles white, jaw clenched. I questioned my attempt at returning to work on this day. I stood in front of the doors grappling with a burning feeling in the pit of my stomach. I knew then, right there, that my career in the emergency department was over.
A quiet swollen presence of pain ran down every corridor. The night before, we lost a colleague to suicide. Some of us found the body. Some of us carried out the post mortem care. Some of us stood there as family filed in to the room. Some of us made the calls alerting fellow staff. Some of us, all of us, changed forever that night.
For some vocations, a bad day at the office means: “I dropped a carton of eggs” or “I broke the copier”. Some are more serious of course: “I really messed up a haircut” and the infamous “I crashed the company car”. In medicine, however, a bad day usually means, “We lost a toddler”; “A young family lost their baby”; “She will never walk again”; and “Time of death …”. The list could go on and on; the point is, the magnitude at which we affect the world of each individual person in healthcare is far different than most jobs. We take on the world, we attempt heroic measures, forgetting, we are indeed, so very human.
We study for years, sometimes decades, focusing our skill, perfecting it, to heal, to save, and to comfort. The team we do all these things with becomes a sort of family. You are all present on the worst days together. You share the sorrow, the shock, and the deep regret that everything you have dedicated your life to studying has failed you. You failed together. You failed in the worst way, but you have one another. You can share that dark humour, the memory of this fleeting moment. You can share together the memory of watching the doctor whisper something comforting, or that nurse hold the deceased family member’s hand. Each of you knows what it feels like, to pronounce a patient dead in one room, and in the very next room, moments later, help a three year old change into a hospital gown so that they can be evaluated thoroughly. You do all this with a smile on your face, never for a second letting on that in the next room, a tragedy they can’t imagine has just unfolded.
Eventually, it eats little holes in your soul. Sometimes there are nightmares, other times you stand in a quiet trauma room and feel the presence of every lost soul standing behind you as you scrub down a stretcher. Bigger and bigger it creeps, into you, never though are you afforded the right to go and lament to your friends over drinks, or weep at your place of worship. Never can you post on public media and share your sorrow. Never can you truly convey what it feels like to have dedicated your life to becoming an expert, but when you have a bad day, someone dies. You cannot ever make someone, who isn’t sunken knee deep into the profession, understand what that means.
The kinship you establish with those with whom you share this camaraderie cannot be duplicated. They are a family that knows all your secrets of trauma and sorrow. There is something indescribably comforting in having these people know you at your worst moments, exhausted, angry, and sad.
The secrets within the hospital walls bonding us together are the same web, that when one of us succumbs to the beast of depression, is torn apart forever. None of us knows what cost our colleague and dear friend their life, it was never made clear. But our family, if you will, was severed to the core, doing the thing we did well together, without them, to them.
I still practise, in a different forum. I think of emergency department life every day. Now I realise how human each of us really is, there are no superheroes among us. Now when my team is becoming saturated, I actively seek out ways to alleviate that pressure, for myself, and for my team. On good days someone gets to live another day, but this doesn’t make the really bad days any easier.
In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here. If you would like to contribute to our Blood, sweat and tears series which is about memorable moments in a healthcare career, please read our guidelines and get in touch by emailing sarah.johnson@theguardian.com. If you’re a healthcare professional affected by the issues raised in this article, help and support is available from Support 4 Doctors.
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The quality and safety of social care services received by elderly and disabled people in England are in danger, as care homes close and providers pull out because they can no longer make enough money, the care watchdog has warned.
In a bleak assessment of the future of vital services that support millions of people, the Care Quality Commission (CQC) voiced alarm that the care sector as a whole is “at risk”.
Providers are in trouble because their costs have increased by up to 30% in the past year while their profit margins have fallen by more than 40%, it warned. It pinpoints the national living wage (NLW) and the inability of cash-strapped local councils to pay higher fees for these services as the main causes of a growing problem.
The number of care homes overall in England has fallen from 18,068 in September 2010 to 16,614 in July this year, at a time of growing need linked to the ageing population, according to figures released by the CQC.
The total number of beds available in care homes also fell between 2010 and 2016 from 255,289 to 235,799 this summer – a fall of 19,490. While the number of nursing homes increased slightly, from 4,387 to 4,623 in that time, more than one in 10 residential homes – for elderly, often frail, people – have closed. The total of those available has fallen from 13,681 to 11,991 – a drop of 1,690.
The many people who rely on care homes and receiving help in their own homes with washing, dressing and eating could be affected if more and more of the private companies that dominate the market go out of business, the CQC fears.
Andrea Sutcliffe, the CQC’s chief inspector of adult social care, was responding to the leak to the BBC of a recent internal briefing document that spells out how rises in providers’ costs and the squeeze on local councils’ budgets are leaving care services in an unsustainable position.
“We know that the adult social care sector faces many financial pressures which, worryingly, could undermine the quality and safety of care that people receive and rely upon every day,” said Sutcliffe.
She confirmed that information from care providers detailed in the CQC document “does highlight a concern that the long-term sustainability of high-quality care within this sector could be at risk. Given the impact this would have on people’s lives, it is important that we continue to monitor these trends closely.”
The document emerged less than 48 hours before the CQC, which is the NHS and social care watchdog for England, is due to present its annual report on performance and emerging issues, called State of Care, to parliament on Thursday. It is expected to highlight how worsening problems in social care are having a serious impact on the NHS, for example, by leading to patients who are fit to go being trapped in hospital because no package of social care support is available to allow that.
The regulator is worried that more and more home closures could leave needy, vulnerable older and disabled people with nowhere to go.
Its analysis document says that with care homes the “market position is undoubtedly hardening – increasing the pace of home closures”.
The CQC’s anxieties echo those voiced with increasing urgency in recent years by old people’s charities such as Age UK, the Local Government Association, health thinktanks and MPs that deep cuts to town hall budgets since 2011 have led to a major deterioration in social care at the same time as demand for it was increasing.
The CQC document, called “adult social care market insight” and based on data received from 39 major providers, states that: “This is a local authority-funded service user problem. Notwithstanding recent fee increases, the historic level of underfunding remains and in some cases has probably increased as a result of [the] national living wage.”
On the fees that councils pay providers either to care for individuals in a home or to help meet their basic needs while they are still living in their own home, it says: “Fees – At what point will the ongoing focus on fees adversely impact the quality of service being purchased?”
The CQC also warns that businesses have been left out of pocket by having to pay staff more because of the national living wage. It adds: “NLW – Provider sentiment suggests fee increases have generally not covered the cost of NLW. This position is unsustainable.”
It is also worried that the same pressures could push providers of domiciliary care to the wall. “Provider exit and large-scale contract handbacks demonstrate the fragility of this market. At what point can the replacement providers only make the returns work by compromising on the quality of care?” the briefing paper asks.
Barbara Keeley, Labour’s shadow minister for social care, said: “These figures are an alarming reminder of the desperate state of care services in this country. Despite all the spin from ministers, the Tories have left social care on the brink of collapse, with thousands of people’s care at risk as a result. It’s not enough to turn a blind eye to this crisis. We need ministers to step up and guarantee that they will properly fund care services. Anything less will be a betrayal to the most vulnerable in our society.”
Norman Lamb MP, a Liberal Democrat former health minister in the coalition government, urged ministers to prop up social care before the system collapses. “This briefing confirms that the care system is teetering on the brink of collapse. The government has known this for some considerable time yet still they refuse to act. The whole system is now living on borrowed time as more and more providers contemplate leaving publicly funded care and face going out of business because the sums don’t add up,” he told the Guardian.
“The real scandal is that we are rapidly moving to a position where you will be able to get great care if you can afford to pay privately – but if you can’t you will be left with nothing or substandard care. That situation is intolerable and a stain on our country. It would be grossly negligent and morally wrong for the government not to act now. There is an urgent need for additional emergency funding.”
Last November, housing staff at one housing association were confronted with a tenant claiming to have a bomb in his bag; in another incident, an officer from another housing provider claimed to have been held hostage by a man who believed there was an alien outside his home.
In both incidents, the tenants involved had mental health issues. Housing providers are concerned that growing numbers of tenants with mental health issues are ending up in general needs housing, where they do not receive the help provided in specialist supported housing. A recent survey by Inside Housing reveals a 14% fall in spending by councils on people with mental health issues in supported housing since 2011–12, based on 250 English councils that responded to Freedom of Information requests,
Between 2011 and 2017 there will have been a drop of nearly £7.3m in spend on people with mental health in supported housing by the 47 councils in England that responded fully to the survey. In 2011–12, those councils’ combined budget, including both commissioned services and those they pay for directly, was £50.9m; this year’s budget is £43.6m.
This squeeze on council spending has put pressure on other housing providers, including housing associations. “We have noticed councils are seeking to reduce the amount of specialist accommodation they procure for adults with mental illness,” says Alex Reeve, regional director of London supported housing at housing association Family Mosaic.
Supported housing has been operating within a constricted funding environment for years. Supporting People funding – a national programme for housing related support made available to councils in England – dropped from £1.8bn when it started in 2003 to £1.6bn in 2014–15. That equates to a 38% fall in real terms.
Ministers have given supported housing a one-year exemption from the 1% rent reduction announced in last year’s summer budget, while in September the government said it would transfer top-up money to councils for the service to counter its planned housing benefit cap.
But supported housing providers say the threat of funding cuts has already affected business. Among the 250 councils that responded at least in part to Inside Housing’s FOI requests, there is a wide range of provision for tenants with mental health conditions: some have specialist units, some do not; a handful have floating support for their general needs stock, most do not; others have budgets for specific conditions – such as hoarding – while others have no housing budget at all allocated to people with mental health needs
Chris Hampson, chief executive of Look Ahead, which provides care, support and housing services across London and the south-east, says councils are cutting back on supporting those with less serious mental health issues to concentrate on those with more acute needs. “A lot of the preventative services have been cut back,” says Hampson, who believes further cuts are to come.
This, he says, is short-sighted: “If you take money out of the lower-end preventative services, in the long run more money is spent because people end up back on the streets or in hospital.”
Richard Colwill, media manager at mental health charity Sane, says the FOI results show the budgetary crisis across the board for mental health provision, which is of deep concern for the charity. “Mental health has always been a ‘Cinderella service’,” he explains, and cuts to services are a false economy: if what initially appears to be a tenancy problem is not addressed early, it can develop into a much more complex issue and they can find themselves supporting a customer experiencing mental health issues. “Care in the community only works if there is provision for people in the community,” he says. “Housing is a really big issue for us. Losing a home or being in fear of losing your home can be a trigger to push someone into crisis.”
While most councils have cut spending on mental health in supported accommodation, the FOI responses reveal some exceptions. In 2016–17 Ealing spent £1.6m on mental health in supported housing, up from £1.2m in 2011–12. “We recognise the benefits of supported living in enabling people to live as independently as possible in the borough while getting appropriate care from professionals,” a spokesperson for Ealing says. “We also find that supporting people to live in the local area near to family and friends can have a positive impact on their well-being.”
In Yorkshire, Wakefield council is another bucking the trend, with its supported housing mental health budget growing 15% in the past five years. It is also developing an innovative strategy to address the issue. Wakefield and District Housing has partnered with NHS Wakefield Clinical Commissioning Group to employ mental health support workers to work with tenants. The council, which still manages the local housing register, can give applicants with mental health needs extra priority. Jon Feasey, a service manager for vulnerable adults at Wakefield Council, says the council sees tackling mental health as an important frontline service. “It has a preventative outcome that can create real efficiencies by preventing homelessness.”
Feasey believes the right place for people with mental health needs is in the community but that people need support in their homes – including those with less acute mental health needs who can slip through the net. As well as preventing homelessness, the support can also help reduce unplanned hospital admissions, he says.
This is an edited extract from an article originally published by Inside Housing (£).
World Mental Health Day on 10 October focuses this year on psychological first aid and providing support to those in distress
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A chief constable has expressed deep concern that a patient with serious mental health problems had to sleep in the back of a police car in a hospital car park because there was no bed available for her.
Katie Simpkins, 23, from Corsham in Wiltshire, was detained under the Mental Health Act for her own safety but there was no hospital bed available in the whole of the county. Officers allowed Simpkins to sleep under a blanket in the back of their patrol car and watched over her until a bed became available.
She and her husband, Tristan Simpkins, 25, released a photograph of her in the back of the police car to try to raise awareness of the lack of beds available in such situations.
The chief constable of Wiltshire police, Mike Veale, said officers were often having to take responsibility for vulnerable people with mental health problems who ought to be in the care of health professionals.
He said that in the past week officers had persuaded a 17-year-old girl with schizophrenia to come down from the roof of a car park, only to be told there were no beds available for her anywhere in the county. He also said officers held a man in a cell for more than 48 hours because there was no mental health care facility available for him.
Veale said: “A police officer is not the appropriate person to be dealing with a vulnerable member of the public who has an illness and poses a real risk to their own health and wellbeing. My police officers and staff face difficult, stressful and sometimes dangerous situations every day. They are not trained to provide specialist care to people with complex problems. They don’t know the background of these people, their medical history or their personal details.
“These issues have always been here for the police, and not just in Wiltshire, but are becoming more acute as austerity bites and there is increased pressure on social care and healthcare services.”
Police had detained Simpkins under section 136 of the act early last Saturday when she suffered a mental health crisis. Her husband said police rang round but could not find a place for her in a mental health unit.
They took her into the custody suite at Melksham police station until later on Saturday afternoon, when officers were told a bed was available at Green Lane hospital in Devizes. However, when they got there at 5pm they were told it was not ready.
Tristan and Katie Simpkins. Photograph: Tristan Simpkins/PA
Mr Simpkins said: “The hospital suggested she go back to custody and they would call when it was ready, but the police officer said custody is not the right place for her. He didn’t want to risk her missing the bed so he said they’d wait, and he’d wait with us.
“Katie had her medication, became drowsy and he let her sleep in the back of the police car with her blanket. When I saw her lying in the back of the police car I felt frustrated, but I’ve become used to it. I feel hopeless.”
He praised the way the police had tried to help. “It wasn’t their fault they couldn’t get a bed but these officers were all really lovely with her,” he said. She was finally admitted at 9pm.
Angus Macpherson, the police and crime commissioner for Wiltshire and Swindon, said: “This is not an isolated incident. Such incidents are happening once or twice a month [in Wiltshire]. The picture of Katie Simpkins huddled beneath a blanket in the back of a Wiltshire police car has understandably caused concern to the public. I have said it before and I will say it again: custody is simply not the right place for someone in a mental health crisis.”
Avon and Wiltshire Mental Health Partnership NHS trust confirmed there were only two beds available for people detained under section 136, which gives police the power to take a person from a public space to a place of safety.
A trust spokesperson said: “We work closely with the police to ensure they know the availability of places of safety. In this instance we were unable to provide a bed straight away and there clearly could have been better communication. We apologise and will be mindful of this in the future. Once the matter came to our attention, we made contact with Mr Simpkins to give him and his wife our full support.”
Last month the government announced that the Avon and Wiltshire trust was among those that had successfully bid for a share of a £15m fund to improve provision of mental health places of safety.
A Department of Health spokesperson said: “When a person is experiencing a mental health crisis they need the right care, in the right place and at the right time. We are fully committed to improving mental health services across the country.”
A member of the pro-existence group Operation Rescue holds indicators reading through ‘Abortion is Murder’ in the course of a protest outdoors an abortion clinic in Buffalo, 1992. Photograph: Corbis
It really is not but seven o’clock on a Saturday morning in New York and I’m confronted by a group of individuals standing in front of a nondescript doorway, waving 4-foot high placards and shouting: “They murder babies here!” There are previously a dozen anti-abortion protesters outside the clinic and the day has barely started out.
Here to act as an “escort” – making certain sufferers, regardless of whether they are getting abortions or not, enter the clinic safely – I already come to feel intimidated. So, think about that you happen to be a female who has miscarried and a person shouts at you: “Carrying infants in your uterus is a present from God” or picture basically going to the medical doctor and becoming advised you happen to be “going to hell”. Think about becoming an African-American girl on your way to a women’s health clinic and currently being surrounded by folks screaming: “They want to kill black babies.”Can you think about how upsetting and emotionally traumatising that is for patients?
To aid these girls, volunteer organisations have sprung up in the US to provide help. When I’m inside the Selections Women’s Medical Center in Queens, Mary Lou Greenberg, the volunteer clinic escort director, gives me guidelines about privacy (for security, no one refers to anybody else by name) instructions on how to escort (strategy patients, gently inform them you happen to be with the clinic and that you happen to be there to guidebook them within) and warnings about proximity (never stand in front of, or block, a patient’s path by no means have get in touch with with a protester protect the patient by acting as a buffer). I am then handed a white health care coat (so as to be plainly noticeable to sufferers) and a big badge with “Alternatives Clinic Escort” on it. I come to feel like a strolling target – I am in the US, they have guns here. What if an anti-abortionist decided to allow off a handful of rounds?
Eliza, another escort, reinforces my be concerned. “I am aware that there has been poor violence outside other clinics, that folks have come in with guns, that individuals have died … They say: ‘The people in the white coats – they are butchers,’ so if some man is walking by and gets truly angry, we’re the ones who are going to get it.”
I am aware that my dread is practically nothing in contrast to the ladies who have, in a lot of instances, travelled excellent distances to attend the clinic and whose safety and safety we have a duty to defend. When we go outdoors, we escorts – a mixture of ladies and men between twenty and 60 many years previous, from a selection of backgrounds and professions – are outnumbered by protesters. The clinic regularly faces more than forty protesters a day.
Until now, my only knowledge with anti-abortionists had been with the (fairly) quiet protesters outside the Marie Stopes clinic in London’s Bloomsbury, who mostly pray and hand out objectionable leaflets right here, it is quite distinct. “You happen to be murdering youngsters!” shout the (primarily male) protesters as we wait, silently. But it is when a woman walks in the direction of the clinic that all hell breaks loose: she is quickly surrounded and screamed at.
Numerous instances I noticed patients crying as they had been shouted at. I could only try to get shut and offer you soothing words, but that doesn’t safeguard them from the abuse and aggression.
Eliza tells me: “Someone was coming in for a stick to-up, as she had had an abortion the week ahead of, and she advised a protester, ‘My infant didn’t have a heartbeat, so we had to abort,’ and the protester responded by saying: ‘Oh, they lied to you. Your baby did have a heartbeat. It was alive and you killed your baby.’ The degree of hatred that is directed at these women – a good deal of whom aren’t even receiving abortions – is unconscionable. If you’ve not escorted, you don’t know how undesirable the intimidation can be.”
Another clinic escort, Cathy, adds, “It really is extremely nerve-racking. I’ve been bumped close to by them a great deal since I am trying to shield individuals. You always know there is a bit of a bodily risk – the possibility that they are going to break the rules 1st – and that is scary.”
Every person I spoke with was shocked at how bad anti-abortion harassment has grow to be and typically didn’t realise it was happening in a main city like New York, as opposed to the Bible belt in the deep south. Could the sort of harassment experienced in liberal cities this kind of as New York spread to the United kingdom?
“We have not reached a level in the United kingdom in which clinic escorts are essential however, although that isn’t going to suggest protesters will not trigger some females significant distress,” says Ann Furedi, chief executive of the British Pregnancy Advisory Services. “The number of protesters involved is fairly little, and inside the anti-selection motion itself there are a lot of who do not feel standing outdoors clinics targeting pregnant women is a moral or productive way to proceed. But numerous people are shocked this is happening here at all – we are a pro-option country and the fact a single girl must have a poster waved in her encounter and a leaflet thrust in her hand as she helps make her own decision to accessibility a legal healthcare support brings about concern.”
Furedi concedes that the United kingdom may well be heading in the direction of a lot more aggressive anti-abortion protesting. “The anti-option motion is more and more borrowing techniques from the US, whether it’s in the type of abortion clinic protests, demands for new laws on how clinics function, or calls for the prosecution of physicians – not for failing to care for ladies appropriately, but for failing to fill in paperwork accurately. So far they have been largely unsuccessful, but we require to be ever vigilant.”
Even though there aren’t but strategies in location to have escorts at British abortion clinics, additional protection of individuals is feasible. Kate Smurthwaite, comedian, activist and vice chair of Abortion Rights Uk tells me that the campaign’s “policy on all professional-selection exercise is guided by the wishes of clinic staff. If clinics do want help – counter-protests, clinic escorts – they can get in touch. We have a nationwide network of supporters and regional pro-choice groups that can be mobilised even at quick observe to assistance staff and services customers in whatever way is proper.”
Is being reactive, rather than proactive, the way forward? Greenberg at Options suggests that women’s rights have been undermined simply because “folks in the women’s motion who consider themselves professional-decision have not taken it on … General, the climate is such that it encourages these protesters to come out. This is element of a greater political battle … a war on women.”
It’s real that NHS care can be fragmented, with different teams or companies involved in delivery. Nevertheless, a wealth of investigation shows that the far more companies there are, the more fragmentation there is the more possibilities there are for error and confusion and the more most likely it is that vulnerable individuals will fall via the gap. As the Netherlands identified, dishing out cash to individuals to purchase their personal therapy is problematic.
Supporting individuals in establishing a prepare for their private spending budget will demand a large input from overall health care specialists. That is much more time away from patient care. As we have observed with personalized budgets for social care, which have been around for several many years, an completely new level of bureaucracy is created. And we have also observed in social care that a personalized price range final results in the very same regular of service or worse.
There are also concerns to be answered more than the validity and ethics of handing out taxpayers’ money – from NHS and social care funds – for the recipient to invest on remedies with no evidence base. Is it appropriate that funds is diverted from solutions so somebody can devote it on, say, Reiki healing? In addition to, provided that the amounts are comparatively little – at only about £1,000 per patient – the strategy is exploiting patients’ ignorance about how significantly wellness care genuinely charges.
An analysis of the strategy in the British Health care Journal raised multiple concerns, like what will come about when patients run out of cash. Simon Stevens has claimed that 1 of the motivating elements for introducing this policy is that it will decrease admissions to hospitals. But there is not a shred of proof to support this.
Personal overall health budgets have been piloted across the nation for a small percentage of patients, but there has been no randomised trial to see if they dwell up to the hype. Certainly it is worth a appropriate research prior to rolling out some thing that is going to expense billions of lbs and affect millions of people? It’s what would be anticipated of any new treatment.
Research by the Well being Foundation finds that there is no proof that the budgets boost overall health outcomes or conserve funds. So, if there’s no evidence they work and there is proof that they don’t, why is the NHS pushing ahead with the prepare? Could it be that this is merely a way of dressing up a resolute unwillingness to effectively fund NHS services, and cynically offering it to the public as “choice”?
——-
Obesity surgical treatment should not be a quick correct for a million individuals
Must a million much more people get obesity surgical procedure on the NHS? That is the prepare, in accordance to new draft guidance from the National Institute of Well being and Care Excellence (Good).
Anybody with a body mass index (BMI) of thirty – the threshold for getting obese – and diagnosed with Type two diabetes in the past decade could undergo gastric band surgical treatment or stomach stapling. This could suggest up to a million folks. At current, operations are presented only to folks with a BMI above forty.
I have grave reservations about this initiative. Certainly treating these people will support them get rid of bodyweight swiftly and tackle their diabetes. My concern, even though, is that it removes the incentive for folks to make lasting alterations to their consuming habits and diet program.
People like the idea of a quick correct, when in actuality weight problems surgical treatment has a host of attendant difficulties. As properly as dietary and dietary problems, rapid weight loss can end result in embarrassing, saggy skin.
Surgical procedure also generates complex psychological troubles in these who binge-eat and discover that, after surgical treatment, they are unable to do so. This kind of folks will need a great deal of assistance submit-surgery, and I’m not convinced that will happen.
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Flatly refuse the shoes
Contact me a uninteresting, kill-joy medic, but I can’t see the appeal in the latest footwear craze for ladies – heel-significantly less substantial heels.
Harry Potter star Emma Watson, along with the likes of Victoria Beckham, have been spotted sporting the heel-less shoes. I say sporting, but there is absolutely absolutely nothing sporting about seeing them wobble down the red carpet as they consider to balance on the balls of their feet and not topple backwards.
I was at a party final week and saw an individual sporting them – she invested most of the evening both holding someone’s arm or leaning against the wall for support.
All I could believe of was the danger of arthritis in her toes, of spinal issues and bunions. So bring back the flats.
Max Pemberton’s latest guide, The Physician Will See You Now, is published by Hodder. To buy a copy, call Telegraph Books on 0844 871 1515
On the corner of a bumpy, red-soil road in the rural town of Iganga in eastern Uganda, there lies a small store. A handful of people mill around the entrance in the glaring sun, waiting for their turn to enter. They are the main source of activity on this placid street, but their patient presence barely betrays the hubbub within.
Inside, almost a dozen people sit crammed on makeshift benches around two edges of the stifling room. Most of the remaining space is taken up by a shop counter, behind which are shelves piled high with vibrantly coloured health products covered in Chinese characters.
A couple of customers compete with a baby wailing as they read out lists of products to the shop attendants who pick them off the shelves. Every now and then, the door in the corner opens. Someone steps out, and the person sitting closest steps in.
Beyond that doorway is an even smaller room, windowless and illuminated by a single light. As I peer in, three people are undergoing diagnostic tests; a woman is standing on a machine that hums loudly as it vibrates, and a few more patients are waiting slumped along the wall.
Wasswa Zziwa Edrisa − or “Doctor Wasswa” as he is known here − stands in the centre wearing a fresh, chequered shirt on his back and an unwavering grin on his face.
“I will show you how we help so many people,” he says, beaming. “Let me show you the machines.”
‘Organ scanners’
“This is one of the scanners,” he explains, pointing to a piece of kit that looks a bit like a 1970s radio. “It shows everything. We can see if you have diabetes, kidney deficiencies, liver problems, eye problems. Everything.”
Wasswa explains that the test works using a traditional Chinese understanding of the body whereby different points of the hand relate to different internal organs. We watch as an attendant prods a patient’s left palm with a metal tip, making a little meter light up. When the light goes green, he explains, it means that part of the body is fine, but if it goes orange it indicates a problem.
Next, Wasswa points me to the corner where a woman is standing on a small machine and holding onto a pair of handlebars, to which she is harnessed. Her whole body blurs in the dim light as the platform beneath her vibrates rapidly, its droning buzz filling the room.
Similar machines can be found in many gyms these days and are meant to help tone muscle, but the uses Wasswa presents are quite different.
“This is a blood circulation massager,” he announces. “You see how she sweats. It opens the vessels and deals with paralysis. It helps people with stroke.”
A woman stands on a machine Wasswa claims ‘deals with paralysis’. Photograph: James Wan
Wasswa then shows me another diagnostics machine, this one connected to a laptop. As the patient holds on to an appliance plugged into the computer, pictures of different organs flash up on the screen for a few seconds each as a dial next to it oscillates erratically. After a minute, a one-page document pops up, detailing how well his organs are functioning.
In the airless room, Wasswa runs through a few more devices − a face pain remover, a blood pressure reducer, a necklace that removes radiation − before squeezing past bodies and chairs to get back to the first patient we met. By now his diagnostic test is complete. The patient tells me that he came to the store because of some mild pain around his mouth. Wasswa breaks the news that there are more serious things about which he ought to be concerned.
“He has a problem with his spleen,” says Wasswa. “At times, he gets constipation and some swelling in the legs and arms. There is also some paralysis in the legs. He gets headaches. At times he feels dizziness. His brain arteries need to be detoxified. He has kidney deficiencies. He has bad chest pain. He has high cholesterol. He has poor circulation. And he has problems with his stomach.”
The man looks young and healthy. Wasswa is not perturbed.
“He needs to improve his circulation by using our machines and he will need to take our products. If he uses them, he will be fine,” he says.
‘Radiation cure’
Back in the waiting-room-cum-pharmacy, Wasswa shows me some of these products. He picks goods off the shelves – capsules, toothpastes, body creams – and stacks them on the counter as he explains what they do.
“This takes away all the radiation in your body. This helps with diabetes. This treats ulcers. This is for slimming. This adds more white blood cells to your system. This is for people who are mentally disturbed,” he says.
“These medicines are good for everything,” he concludes finally, the pile of products on the counter now complete. “If you have cancer, we can help. If you have HIV, we can help. Even if you have a hernia or a tumour or appendicitis, you just take our products and they will disappear.”
Even if you have a hernia or a tumour or appendicitis, you just take our products and they will disappear
This small store in eastern Uganda employs a handful of staff and, according to Wasswa, receives dozens of people each day. Wasswa is also frequently heard on local radio advertising his services and has made quite a name for himself in the area.
Wasswa was previously a school teacher and says his parents were “peasants”, but now, in his 30s, he is anything but. These days, he drives a shiny four-wheel drive, wears sharp suits and travels around the world. All this makes him quite the exception in Iganga, but across Uganda this young man is by no means a solo pioneer and his store is by no means unique.
Similar stores can found all across the country, from Kasese in the west to Soroti in the east, and from Gulu in the north to Entebbe in the south. There are four outlets in the capital Kampala. All the stores offer the same diagnostic tests, stock the same range of products, and above their doors, there hangs the same innocuous green and orange sign which reads: “Tiens: Together We Share Health And Wealth.”
Tiens − also known as Tianshi − is a multinational company based 10,000 miles away in the Chinese metropolis of Tianjin. It was founded in 1995 by Li Jinyuan, who has since become a billionaire from the venture. The company has established branches in 110 countries, including 16 in Africa, employs over 10,000 staff globally, and reportedly enjoys net profits worth hundreds of millions of dollars each year.
Tiens in Uganda
Tiens first began tapping into the Ugandan market in 2003 and it has grown steadily ever since. There are now around 30 stores across the country. Its distributors regularly engage in outreach programmes to rural communities, and according to the company’s national chairperson, Kibuuka Mazinga Ambrose, Tiens-Uganda has an annual turnover of around $ 6m.
The company has even bought the most prominent advertising spot on the Health Ministry’s official calendar, despite no Tiens outlet being explicitly registered as a health facility.
People who come to the stores seek help for a whole range of conditions, but they tend to tell similar stories of how they arrived. Typically, they say that they first went to public health facilities (some told me they had even visited two or three), but were either not seen or found the treatment ineffective. Tiens is almost always a last resort. But in a country whose healthcare infrastructure is struggling and which, by some measures, ranks as one of the worst in the world, the last resort is often one that needs to be taken.
In many areas of Uganda public health facilities are virtually inaccessible, and those who do manage to reach them may find their walls crumbling, clinics under-staffed, and shelves empty of drugs. Although the government has promised to invest more in healthcare, much of the infrastructure is in decay. Doctors and nurses are over-worked and underpaid, and although services are meant to be free, in reality patients face many hidden costs.
In this context, stores such as Wasswa’s − with its quick turnaround, attentive staff and fully-stocked shelves − offer an appealing alternative. The conclusive diagnostic tests are highly convenient; attendants’ claims about the healing powers of Tiens products may well be reassuring; many patients say the fact the medicines travelled thousands of miles from China suggest they must work.
Satisfied customers
On the Friday morning after my tour of Wasswa’s clinic, the courtyard next to the outlet is packed. More than 100 people sit on plastic chairs facing forwards while latecomers lean against the back wall. A red tarpaulin sheet shields the crammed attendees from the sun and gives the whole atmosphere an eerie pink hue.
“Doctor Julius” stands at the front. He has just finished explaining the healing powers of Tiens toothpaste. As well as cleaning teeth, he says, it can be used to treat ulcers, skin problems and even angina, among many other conditions. He invites attendees who have used the product to give testimony. Four hands go up immediately.
“I had terrible problems with my teeth,” says the first speaker. “I went to see doctors but a new tooth had to be uprooted every week. When I started to use Tiens toothpaste, the pain went away.”
The next person tells a similar story. Two mothers relay how the toothpaste cleared up their respective children’s skin rashes and burns.
Every now and then over the next few hours, many more attendees are invited to recount their experiences of using Tien products. We hear how a man with back pain can now walk, how another man was cured of vertigo, and how a woman’s child was once bed-ridden but is now running around. At one point, Wasswa looks particularly pleased as a mother tells of how her young son − who she had taken to three public healthcare facilities before he was cured of cerebral malaria by Tiens − now wants to change his name to Doctor Wasswa.
At hospitals, they will ask you how you feel, but here, we tell you how you feel
“You see, these products work,” Wasswa announces after one of the testimonies. “At hospitals, they will ask you how you feel, but here, we tell you how you feel. At hospitals, they treat signs and symptoms. Here, we treat causes. At hospitals, they give you medicines made from chemicals which are harmful and can give you ulcers. Here, we use herbal medicines which have no side-effects.”
“This is real,” he continues. “This is Chinese herbal medicine based on 5,000 years of traditional medicine and it works.”
Personal experience
In Kampala, I test this out for myself. I visit a couple of the company’s stores, nestled in the city centre’s endless bustling plazas, and in one of them, managed by a man named Frank, I get tested.
Frank, the self-declared “best in the business” at doing diagnostic tests, seems thrilled at my presence and bundles me across to the end of the room. He sits me down and pulls across a thin curtain to give us a modicum of privacy from the handful of waiting patients. He takes out a battered looking hand-held device, pushes a 9-volt battery into its back, and plugs a wire into it that branches into two metal tips. He gives me one of the electrified points to hold in my right hand and says he will use the other to press points on my left palm. With a grave look on his face, Frank instructs me to tell him when I feel a tingling. This seems to be a more basic version of the first test I’d seen in Iganga.
To begin with, I report whenever I feel something, which is every single time the tip touches my hand, completing the basic electric circuit. Frank nods excitedly when I do so and explains that I have a serious problem in whichever part of my body he is testing. After a while, however, I decide to stop reporting every time I feel a tingling. Frank lets me get away with one, but after that he frowns when I stay silent and simply keeps the metal point on my hand until I give in, sometimes rubbing my hand and even licking the metal tip if I am being particularly resistant.
In the end, Frank writes out a list of around 25 health conditions including “liver disorder”, “STROKE”, and “enteric fever [severe typhoid]“, and prescribes a list of products that comes to over USH 1 million ($ 400).
I get tested. Frank writes out a list of around 25 health conditions including ‘liver disorder’, ‘STROKE’, and ‘enteric fever’, and prescribes a list of products that comes to over USH 1 million ($ 400)
Before committing to his costly regimen, I decide to get a second opinion.
In the bright, clean reception of Beijing Clinic, a private health facility in Kampala, I relate my experience to a young Ugandan doctor, who trained and qualified in China, specialising in traditional Chinese medicine. The doctor, who prefers not to be named, laughs as I explain the machines I saw in Iganga and the test I underwent in Kampala. “No machine can test all those things like they claim,” he says.
Next, I show him the Tiens Information Guide, a booklet from which it seems Julius and Wasswa get much of their information. On page three of the booklet, a short disclaimer warns: “Tianshi Company does not make any medical claims whatsoever.” However, the next 60 pages are filled with bold declarations about the powers of its products and instructions on how to treat different diseases.
The Chinese-trained doctor says this is not Chinese medicine as he knows it. He chuckles as he reads how Tiens medicines are supposed to treat about a dozen different conditions each, from preventing cancer to reversing impotence to promoting “the growth of children’s reproductive organs”.
But the doctor’s amusement turns to horror as he reaches the section of the booklet advising distributors on what steps to take when patients are suffering from different diseases.
If patients have already been given a diagnosis, the company guide offers clear and easy instructions on what they should be prescribed. Of the few hundred conditions listed − which span from Aids to Yellow Fever − a handful include the recommendation to “see a doctor”. But the rest just list a few products to be taken.
One of the most repeated claims is that because the products are herbal they have no side-effects. This is used to show their superiority to western medicines, which they say are made from chemicals and so can be harmful, but the claim is also used to suggest that there are no dangers involved in taking them.
“Even if I tell you to swallow one and you swallow four, there will be no problems,” Wasswa had insisted. But when put to the Chinese-trained doctor in Beijing Clinic, he just shakes his head.
At another private clinic in Kampala, Dr Wen, a highly experienced practitioner, is similarly concerned. “This is not medicine,” he says, “but it is still dangerous. Everything has side-effects. Even herbal medicines and herbal supplements used wrongly can kill.”
I contacted Uganda’s health minister, Ruhakana Rugunda, repeatedly for comment, but received no reply.
Supplements
Tiens products are not registered medicines. Some of the company’s goods have been registered with Uganda’s National Drugs Authority as food and dietary supplements.
Stories about the products not fully working are common, even among fans.
Back in Iganga, with the courtyard seminar over and Wasswa busy talking to a small circle of attendees eager to hear more, Sarah*, 25, moves towards the back of the courtyard closer to where I am sitting.
During the seminar, she had given testimony telling of how she’d taken her baby boy, who was suffering from sickle cell anaemia, to several hospitals before she came to Tiens. Many of those who told their stories directed them matter-of-factly at Julius or Wasswa, but Sarah had turned to face the crowd and spoken passionately as she’d explained how the products worked wonders.
The Tiens seminar. Photograph: James Wan
Asked a few more questions after the symposium, however, her story reveals itself to be far less straightforward. Her son is still ill. So ill, in fact, that she recently quit her nursing job to look after him full-time.
Sarah nevertheless insists that the Tiens medicines work and says the reason her son is still suffering is because his treatment is incomplete. She bought half the products the boy needs for a full recovery but is struggling to find the money to purchase the rest.
Sarah and Robert reveal that they have each spent USH 460,000 ($ 180) on products so far, paying in instalments from what they could borrow or scrape together
Robert, 30, tells a similar tale. He too claims to be a firm believer in the healing powers of Tiens, and acted as my translator throughout the seminar, seemingly on Wasswa’s instruction. Robert says he came to Tiens with kidney problems and maintains the products worked where hospital treatments failed. However, he admits that he is still in pain.
Firstly, he attributes this to the fact that his kidney treatment is incomplete; he too has had financial difficulties. Secondly, he explains that the Tiens diagnostic test revealed his kidneys are not his only problem; while his original condition may have improved, he now knows he is suffering from other conditions that need to be cured too.
Sarah and Robert reveal that they have each spent USH 460,000 ($ 180) on products so far, paying in instalments from what they could borrow or scrape together. Sarah says she needs USH 500,000 ($ 200) more to complete her son’s treatment, but doesn’t know where the money will come from given that she is now jobless and that the father of her son is in school. Robert says he needs around USH 200,000 ($ 80) more, but says that as a “peasant”, he too will struggle.
“I haven’t balanced it well,” he says, “but I hope it will balance out soon. I am still feeling pain.”
It is not a coincidence that Robert, Sarah and a few others who spoke to me had all purchased exactly USH 460,000 worth of products. Nor is it an inexplicable peculiarity that people with no reliable source of income had shelled out what little they had, and more, on Tiens products. After all, Tiens is more than just a supplier of health supplements.
Pyramid scheme
In the symposium in Iganga, once Julius had waxed lyrical about various products, it was time for Wasswa to take over the stage to talk about another benefit of Tiens. Though not before Julius had the opportunity to rouse the crowd.
After finishing his demonstration of Tiens’ disease-curing sanitary pads, Julius put down the product and strolled along the front of the courtyard before turning to face the audience. “Tianshi!” he shouted suddenly. “Together we share!” came back the reply on cue, a hundred voices amplified by the concrete walls. “Tianshi!” Julius proclaimed a second time, a little louder. “One dream!” came the soaring response. “Tianshi!” yelled the doctor a third time. “The best of all!!” bellowed the crowd.
Next, Julius taught the audience a new trick. Since all points in ours palms relate to different internal organs, he explained, clapping stimulates the whole body and works as a kind of “first aid”. He held his hands apart and, together with the crowd, clapped out a rhythm that crackled across the courtyard. Julius explained that the louder you clap, the greater the benefits to your internal organs, before holding out his hands and going again. And again.
Finally, looking satisfied, Julius completed his session and handed over to Wasswa.
“Tiens is not just good for your health,” the salesman proclaimed, taking to the stage, “it is also good for your wealth. If you register with Tiens, they will start to pay you. You come here for treatment, but over time, you will start to get a salary.”
Tiens is not just good for your health,” the salesman proclaimed, taking to the stage, “it is also good for your wealth”
Over the next few minutes, Wasswa explained that this is what he had done and that he was not only receiving thousands of dollars every month now, but had been taken on international trips by the company, received huge cash bonuses and been given a brand new car.
“When you reach a certain level, you start earning,” he said. “And it does not matter if you have no qualifications or education. Tiens does not care if you are educated. Tiens only cares how many products you buy and how many people you recruit.”
Wasswa said these words with a weighty earnestness, but they were not news to half the courtyard. Robert, Sarah and many others around them − all recognisable by the golden lion-shaped badges they were wearing − were not just Tiens patients, but members and distributors already. They were here on Wasswa’s instructions to give testimony and help convince others to join too. For these returning members, Tiens is not just a medical supplier, but a livelihood, an investment, and a chance to follow in Wasswa’s jet-setting footsteps.
When you reach a certain level, you start earning. And it does not matter if you have no qualifications or education. Tiens does not care if you are educated. Tiens only cares how many products you buy and how many people you recruit
Joining fee
Sitting behind his desk at the Tiens-Uganda headquarters, located at the top of King Fahd Plaza on a busy street in Kampala, Kibuuka Mazinga Ambrose is delighted to explain how the business model works in more detail.
“Anyone can join,” says the company chairperson, wearing a bright yellow Tiens-branded cap. “All you need to do is pay a small initial fee of $ 20.” Once you have done this, you can buy products at wholesale prices and sell them on at a profit. However, this is just the start, he says. You don’t get rich by selling a few bottles of herbal supplements. Under Tiens’ model, there are eight ranks and you need to move up the levels to really start enjoying the benefits.
The first few levels can be reached simply by buying more products, which essentially brings with it a small discount on goods. However, to get to the bigger rewards, you need to start recruiting others. This way, you receive a commission whenever they make purchases and also get rewarded if they recruit their own followers.
Tiens refers to itself as a “multi-level marketing” scheme. The more people you recruit and the more they recruit in turn, the higher you move up the rankings, and soon you can just sit back and watch as the commissions roll in. Furthermore, once you’ve reached the 8-star level and keep growing your network, you will eventually become a Bronze Lion, then a Silver Lion, then a Gold Lion, and enjoy rewards of cash prizes, international trips, a brand new 4×4 car, a luxury yacht, a private jet, and finally a “Luxurious Villa Palace”.
“It’s all about growing your network; their success is your success,” says Ambrose cheerily. “Tiens does not care who you are. Anyone can do it, and there is no limit on what you can earn.”
As the Tiens guide puts it, joining the company means: “You stop struggling financially,” there is “little risk of losing”, and “if you work for five years you can retire.”
According the company website, over 200,000 Ugandans have joined Tiens, eclipsing the number of government school teachers in the country
According the company website, over 200,000 Ugandans have joined Tiens, eclipsing even the number of government school teachers in the country.
Given Uganda’s high rates of unemployment − youth unemployment is over 80% according to some estimates − the appeal of membership is clear. Decent jobs are scarce and rags-to-riches stories like Wasswa’s are even scarcer.
The company’s image is significantly helped by the Ugandan government. Not only does Tiens advertise on the Health Ministry’s calendar, but according to Wasswa, around 10 MPs are members of the company. At the Iganga seminar, Stephen Wante, the mayor of Bugembe, made a guest appearance. In 2011 meanwhile, vice-president Edward Ssekandi officiated a ceremony in which a distributor was awarded a car and organised for Tiens to donate some of its products to a government health centre. A photograph of the Ssekandi shaking hands with Tiens’ president also has pride of place on the company website.
Given Uganda’s high rates of unemployment − youth unemployment is over 80% according to some estimates − the appeal of membership is clear
However, at the Tiens headquarters, where members can print out their balance sheets, most leave the office holding spreadsheets indicating that they are owed almost nothing, if anything at all. Back in Iganga, several members who had joined several months ago, attended every biweekly seminar, bought lots of products, and gone on recruitment drives, revealed that they had not earned any notable income either. It seems many others have also abandoned the scheme after finding they could not make it work.
According to most Tiens members − both those who are profiting and those who aren’t − the reason for these failures is simple: the individual did not work hard enough. When I asked Sarah why she thought she hadn’t made any money after being a member for five months, for example, she hesitated before Robert chipped in to say “it means she is not performing well”. Yet Robert had barely received any income either, despite having been a member for six months and having recruited nine people. Other members who had yet to make money also suggested their situation was down to bad luck or poor performance.
I asked Wasswa how long it typically takes to break even. “Some people can take a month, but sometimes maybe two months,” he replied.
What if someone has been working hard but hasn’t started getting an income after six months, I followed up. “Six months?” Wasswa exclaimed. “No, it’s rare. Very rare. If someone is serious, they should be on a high level and earning well after six months.”
I looked at the three recruits who all just stared at the floor.
Not only does each distributor have to compete with 200,000 other sellers as well as 30 well-established stores, it doesn’t make economic sense for customers to buy from individual members when they could sign up to Tiens themselves and get much lower prices anyway.
This is perhaps why Wasswa and other recruiters barely even mention selling products and why the emphasis instead is very heavily on “growing your network”. The incentives for signing up new members are higher than those for sales; the training sessions teach recruits how to sell membership rather than goods; and the Tiens guide’s main advice is a six-step plan of how to “make a name list of at least 100 in a shortest time possible”.
A Tiens Uganda booklet. Photograph: James Wan
I later contacted Ambrose, Wasswa and Jamba George, another 8-star recruiter, for their response to the points made in this article, but they all declined to comment. The manager of Tiens-Uganda, a Chinese expatriate, and the company’s global headquarters in Tianjin also declined to comment.
It should also be noted that Tiens is not just in Uganda, nor is it the only scheme of its kind. While Tiens’ presence on the continent seems to be particularly strong in west Africa, Ethiopia and Zimbabwe, the company also has offices in many western countries, though its products are marketed more directly as food supplements and “wellness equipment’”.
Last hope
Back in the courtyard in Iganga, Robert is listing the products he was prescribed six months ago. Like so many others faced with Uganda’s struggling healthcare system, Robert ended up seeking alternatives and eventually ended up at Wasswa’s busy but welcoming clinic.
The products worked, Robert insists. Up to a point. He just wishes, he says, that he could finish the treatment and be fully cured of his kidney problems as well as the other health conditions detected by the diagnostic test he underwent. But he cannot afford it.
Robert has no other work − he says there are hardly any jobs available in the area − and has five children to support. When he joined the company half a year ago, he thought Tiens was the answer to all his prayers, but he is still in pain and deeper in debt.
“Money is a problem, he says. “It is not easy to recruit people and I spend USH12,000 ($ 5) every week on transport to come to these seminars.”
I ask him why he is still part of the company despite losing money each week. He pauses for a moment before answering, “I believe I will balance my accounts soon. And I am close to moving up to the next level when I will be able to earn more.”
He explains that a technical misunderstanding delayed him moving up a rank, but that it should be sorted out soon. I point out that even if he moves up a level and earns slightly more than now, he will still be earning a tiny fraction of what he has invested. He nods in agreement, but adds, with a faint smile, “But with Tiens, time is on your side.”
But what if it still doesn’t work out, I push. What if Wasswa is the exception that proves the rule? What if it never works out?
Robert looks me in the eye for a few seconds before gazing out across the courtyard where a few groups of attendees are still standing around chatting.
“If the money defeats me, ” he says quietly, turning back to me, “I will disappear.”
* some names have been changed to protect interviewees’ identities.
This article was made possible by a grant from the China-Africa Reporting Project managed by the Journalism Department of the University of Witwatersrand
Colleges are being urged to quit pupils from making use of playgrounds at lunchtime and workers to stay away from cycling, operating or strolling to perform throughout rush hour in the areas of England worst impacted by the ongoing rise in pollution.
The government, public well being medical professionals and authorities in pollution are also advising older people and those with a heart or lung problem such as asthma to avoid working out outside and use a gymnasium instead.
One particular professional explained the threat to overall health was so wonderful that even normally wholesome people who exercising outdoors, this kind of as cyclists, may finish up with a sore throat or cough until finally the pollution eases.
For component of Wednesday, East Anglia knowledgeable “very large” levels of pollution – the highest on a ten-level scale – with “substantial” readings recorded in the south-east. Levels were reasonable to substantial in a lot of England from Cheshire to north Devon, the Division of the Setting, Foods and Rural Affairs (Defra) explained.
The surge in smog that started final weekend is expected to carry higher ranges on Thursday in East Anglia and the Midlands, which includes Lincolnshire, eastern parts of Wales as well as Wirral and parts of coastal north-west England and south-west Scotland, but moderate or minimal elsewhere.
The pollution is anticipated to ease from Friday, as cleaner south-westerly winds arrive, however there may be reasonable levels in south-west England, Kent, North Yorkshire and parts of southern Scotland. The entire of the United kingdom is anticipated to return to low amounts by the weekend.
A few colleges in London kept pupils indoors at lunchtime on Wednesday to lessen their publicity to the smog. Their action prompted Professor Frank Kelly, a leading government adviser on air pollution, to state that the policy was wise for colleges in the worst affected regions.
Banning pupils’ access to outside recreational regions throughout the school day could reduce the number of asthma attacks and even stay away from some establishing probably lifelong lung damage, said Kelly.
“As a general response this is a very good strategy as kids have a tendency to run all around outside and therefore breathe deeper. Therefore, on days like this they will be aspiring a great deal more pollution if outside than when they are breathing normally (hopefully) inside,” stated Kelly, who is professor of environmental wellness at King’s College London, chair of the Department of Health’s Committee on the Medical Effects of Air Pollution and a member of Defra’s air high quality professional group.
Pupils with asthma may want to use their inhalers, whilst these with other breathing problems could suffer serious harm if exposed to the large level of pollution becoming noticed in London, he warned.
“Besides people kids whose asthma could be exacerbated by pollution and who would then need to have to increase their medication, the major issue is associated to pollution publicity on a continual basis as current proof indicates that lung growth is restricted. If there is no subsequent catch-up lung development then this respiratory deficit is carried forward by means of life.”
Bowes and Chesterfield principal colleges in Enfield, north London, stored kids within on Wednesday .
“When schools are faced with conditions like these we have to make a decision what is very best for children. In the absence of any formal tips from government, we made a decision to preserve young children inside as a precaution,” explained Tom Sheldon, chair of governors at the two colleges, which are close to the usually congested North Circular Street.
“But we can not do this for ever, and in London we encounter the significantly wider problem of bad air quality every day. The Saharan dust will pass, but London will proceed to fail its citizens on air top quality. Children’s building lungs are at particular danger, the two lengthy- and short-term.”
Eight-yr-previous George Stewart had an asthma assault in the course of his half-mile walk to college in Eltham, south-east London, on Wednesday morning. His mother, Leanne, stated: “It truly is usually quite an easy stroll but I am nonetheless breathless now. I could come to feel my chest acquiring tighter and tighter, and my son had to stop and have his inhaler I went light-headed and had to get a bus back. It is only half a mile and I generally do it twice a day, no dilemma. … I’ve never had that issue before. My son felt like the air was not acquiring into his lungs, so I’m worried about him these days.”
The British Lung Basis warned that the heavy air pollution could have “a significant affect” on, and induce coughing and breathlessness between folks with situations this kind of as asthma and persistent obstructive pulmonary ailment.
This kind of individuals “need to keep away from strenuous physical exercise outdoors, particularly close to pollution hotspots this kind of as hectic roads”, stated Dr Keith Prowse, the charity’s honorary health care adviser. “If they cycle, run or stroll to function, commuting at instances other than rush hour or along backstreets is also a good idea.”
Ellie Highwood, professor of climate physics at Reading through University, mentioned the pollution was the outcome of small particulates (atmospheric aerosols) that come from traffic, fossil fuel burning, agricultural practices and, a lot more unusually, dust from the Sahara.” High levels of the pollutant PM2.five meant that “men and women with present lung or heart situations should consider care, and even healthier individuals doing strenuous bodily exercise outside, such as cycling, might recognize a sore throat or cough.”
A key outbreak of infectious ailment could sweep via the country and leave thousands dead or sick since hospitals are not able to test existence-saving remedies swiftly adequate, senior medical professionals have advised the Guardian.
Profound delays in the approvals procedure for clinical trials imply medical doctors face months of form-filling and administrative checks that make it unattainable to run essential tests in good time, mentioned Jeremy Farrar, in his very first main interview as director of the Wellcome Trust.
Farrar, a planet skilled on infectious diseases at Oxford University, has taken over from Sir Mark Walport, who left the medical charity to turn out to be the government’s chief science adviser.
Farrar’s warning is backed by other senior figures such as Sir Michael Rawlins, president of the Royal Society of Medication, and Prof Peter Openshaw, who suggested the government during the pandemic flu outbreak in 2009.
Farrar explained the unwieldy method puts public overall health at threat, particularly when pandemic flu and other infectious ailments strike, due to the fact doctors have no concept which interventions work.
“The programs we have got in area are not match for function when the scenario is moving quickly,” explained Farrar. “We have nothing at all that permits us to reply in true time.”
The Department of Health on Monday accepted proposals from the Health Analysis Authority to streamline clinical trials, but some foremost professionals argue that far far more function is required within the NHS to fast-track trials in an emergency.
An emerging infection such as bird flu, Sars or pandemic influenza could spread across Britain and burn up itself out within the area of eight weeks. But medical professionals hoping to test medication or other interventions in sufferers can face delays of more than a year just before they can recruit a single situation.
The delays mean that physicians have almost no hope of finding out which treatment options may save lives throughout a dangerous outbreak simply because sufferers will have recovered or died by the time a trial can begin.
Farrar explained the technique essential a radical overhaul so emergency trials could launch within 24 hours of an epidemic emerging. “Receiving this information early on is crucial to inform what we do and how we treat sufferers. With no it we are completely in the dark,” he said.
Pandemic influenza is deemed the most severe civil emergency chance that Britain faces, but other infections, such as novel coronaviruses and the alarming rise of drug-resistant pathogens, are also a severe threat.
Clinical trials need to have formal approval from the NHS and other bodies prior to physicians can recruit patients, but the procedure is held up at practically each and every stage. Researchers must apply for grants, submit examine protocols and patient consent varieties, gain ethical approval, discover hospitals with the correct amenities, equipment, supplies, staff and sufferers, and then signal legal contracts with them all.
The process is automatically thorough to protect patients and hospitals from litigation. Trials can go spectacularly wrong, as occurred in 2006 when 6 young men were almost killed by an experimental drug in a trial at Northwick Park hospital in north London.
The 2002 Sars pandemic killed 774 individuals and contaminated a lot more than eight,000. Had the virus not been contained it could have killed far more. The purpose the death toll was not higher was that patients have been most infectious when they had been most sick, so isolating the sick stopped the virus spreading.
“There is no doubt we were very fortunate with Sars,” explained Farrar. “But nobody is aware of exactly where it has gone and we do not have a vaccine. If it have been to come back tomorrow and I acquired contaminated, the medical professional treating me would not have a clue which drug, if any, to give me.”
Without challenging evidence, the government’s preparedness rests on educated guesses. The Division of Wellness spent £424m stockpiling Tamiflu (oseltamivir) for a flu pandemic. But the lack of trials in sick sufferers means medical professionals disagree on how properly the drug works.
A 2011 report from the Academy of Medical Sciences (AMS) raised main considerations about delays to clinical trials. The report quoted Cancer Investigation Uk information that discovered the standard time taken to launch a trial and deal with the initial patient was a staggering 621 days. The bulk of that time was spent obtaining NHS approval. The time has come down since, to all around 18 months, but has not improved considerably in the previous year or so.
Sir Michael Rawlins, president of the Royal Society of Medicine, who chaired the report, mentioned progress was disappointing. “It truly is going in the proper route, but it really is painfully slow,” he explained.
The Health Study Authority was set up in response to the AMS report and charged with streamlining approval occasions. It has currently reduce delays that held up ethical approval. One change was to hold weekly meetings of ethical committees to think about and approve trials submitted in the days beforehand, and a system for convening ethical committees practically when a trial is urgent. One particular trial to look at the impact of a vaccine in pandemic influenza acquired ethical approval in two days.
But the major delays are not with ethical approval, but indicator-off from the NHS centres that host trials. It is right here that the HRA proposals aim to make their biggest influence. Alternatively of personal NHS hospitals duplicating every other’s perform by independently reviewing, querying and ultimately approving a trial, the HRA will act as a central authority, offering a single sign-off for all participating hospitals.
Relieved of that workload, hospitals can target on the practicalities, such as acquiring trial medication and generating confident sufferers are enrolled. If the wellness division agrees to the programs, a basic trial could be accepted inside of 25 days.
“We will give researchers a great deal more self confidence that the NHS can react if the HRA is carrying out the greater portion of the approving,” mentioned Janet Wisely, chief executive of the HRA.
She mentioned that in the long run, they ought to be able to approve emergency trials inside 24 hrs. “If you are intending to treat someone in a 24-hour timeframe then research need to match that. It really is a challenge, but it’s what we must aim for,” she explained.
Farrar needs much more trials pre-authorized so that physicians can begin emergency tests in individuals the second an outbreak is identified. “We need generic protocols which have been pre-authorized by ethics committees and institutions at a nationwide level. All the information, from what samples to consider to the kinds we’d record patient data on, would be openly obtainable. Then, in an emergency, a group that has worked on the leading 3 or 4 interventions can start enrolling patients inside 24 hrs,” he said. “There are groups making an attempt to address this, but it truly is nowhere close to there but.”
