You’ll find various musings and writings below.
My monthly Debrief was published in the new November 2019 issue° of the BJGP last week. This time the title was Bounded rationality for generalists. Inevitably, in writing a 600-700 word article a lot of stuff has to be dropped out or skimmed over. This month the article covers some thoughts around the work of Herbert Simon, bounded rationality, and the paradox of choice. It is an expression of alarm at the endless choices and decisions we are forced to make. I tentatively suggest it threatens the very viability of the medical profession.
I look on with some horror at the relentless production of evidence which often feels far beyond the ken of any one person. Often my thoughts are simply: Stop the world! I want to get off. Yet, I also recognise that the niches within which we work have gaps but my overriding emotion is one of anxiety. We have more evidence than we can use in a lifetime yet we’ve precious little time to reflect on it. What is this life, if full of care, We have no time to stand and stare? It’s the first line of the poem Leisure by WH Davies°. It is most assuredly not musing on the challenges of research implementation but it wouldn’t be a bad approach to take.
While I’m on the poetry kick, there is a touch of the Ozymandias° to evidence-based medicine. Look on my Works, ye Mighty, and despair! Who would dare speak against the edifice? Sometimes, it is a tyrant, one that towers over us and proclaims its own wonder, its very vastness unknowable, arrogant in its greatness. I don’t think the same fate as Ozymandias awaits but there’s a lurking hubris and a need to accommodate the stony realities of human nature.
I finished off this wonderful little audiobook this weekend. My vague sense of Varoufakis was that he was a disruptive, if not obstructive, rebel influence when Greece went through their agonising economics ruptures a few years ago. I’ve nothing concrete to base this on but it’s the impression, the ghost of an opinion, that lingers in my memory. Now, I look back and wonder how much of that has been driven by the media’s pen strokes, the picture they drew, and the prevailing blame climate that was foisted onto Greece. I feel some irritation as I suspect I’ve been duped. Perhaps not, but I certainly recognise that I’ve only had one side of the tale.
The premise of this book is that Varoufakis is giving an overview and brief history of capitalism and economics to his daughter. It works. It’s a neat mechanism to put the philosophies and contradictions in context. There is plenty of politics here as well and Varoufakis is quite plain speaking about his own opinions. I’m not far off them. More than anything, it makes me think that my view of the man was truly driven by the media and that annoys the hell out of me. One can only maintain sceptical thoughts about so many subjects at once – what can we trust in the newspapers and on the television? Is it all completely tainted? It’s a frightening thought. I am going to try to remedy my understanding around Greece – starting with other, longer and more detailed, books by Varoufakis and others about the crisis, starting with Adults in the Room.°
The late Alfred Wainwright° was the one that called the Howgills “sleeping elephants”. It’s a brilliant and much-used (overused?) description. You’ve seen them for sure. If you have ever driven north on the M6 then they slumber on your right as the motorway kicks up at the southern boundary of the Lake District. They are the first hills you see. And, coming south they mark the end of the uplands. You’ve also got the option of the southbound-only Killington services that enjoy a stunning view across Killington Lake to the Dales and Howgills beyond.
It was a beautiful sunny day. But I’m going to show these in black and white this time. I enjoyed a couple of hours over The Calf°(676m) and back home via Arant Haw. There was just a dusting of snow at the tops. I think that might be my first contact with snow this year.
I took my time and ambled up, jogging down. It is amazing how much more enjoyable the experience of being out is when you dial the effort back. It’s also very obvious that very little time is gained for going so much harder. So, why not kick back and enjoy the experience? (There is a counter-argument here about the benefits of high intensity exercise but, really, it’s not worth having. No one ever mused on life during a brutal interval – unless you count wishing you were dead…)
I just finished listening to the audiobook version of Engines of Privilege by Francis Green and David Kynaston.° So, first things first, I’m state school educated and I hadn’t been particularly militant about private schools. Yet looking back I can see that in the 1990s the majority of the people I knew at medical school were privately educated (though some were via bursaries and sponsorships). The 7% problem° has received coverage in recent years and I’ve become more and more gripped by the injustice and social division. How on earth can we have any positive impact on social mobility until we tackle it?
And I found myself having quite an emotional reaction to this book.
I listened to the audiobook version and it has taken me far longer than usual to get through it. I just couldn’t stick with it. Not because I wasn’t impressed or engaged, but simply because I was so utterly infuriated and maddened by the evidence and detailing of the imbalances and the privilege. I was just upset by it. There’s no doubt which side of the fence Green and Kynaston are on (both private school educated it should be noted) but it feels, at least as they present it, as a normal and rational conclusion to oppose ‘the 7% problem’ on the basis of the evidence. I had to keep stopping after 20 minutes and then having a day or two off otherwise I found myself ruminating on it all. It’s powerful, if not downright toxic, stuff.
The problem with the public discussion is that it quickly gets ugly. My reaction is typical of the responses one can expect on all sides. Anger. Indignation. Outrage. G&K call for a debate that doesn’t stigmatise parents or accuse them of hypocrisy if they do send their children to private schools. When the system is so comprehensively loaded in favour of those who receive education in the independent sector it’s just not reasonable to expect parents to ignore that when deciding for their children. I agree that we need to work hard to de-individualise this discussion and throw out the endless anecdotal, n=1, spurious arguments.
They also appreciate that many parents who send their children to independent schools often make sacrifices to afford it. The super-rich Eton, Harrow etc are the exceptions and not the private school rule. I find it quite annoying when those institutions are trotted out as exemplars of class privilege. They are freaks, complete outliers, with vast resources at their disposal. It’s the independent schools further down the scale where some reform might be feasible. And, as G&K point out, it doesn’t have to involve a wholesale bulldozing of the independent sector. There are several measures that could be considered which would help tilt the scales.
This feeds into one of my golden rules for getting control of email in your life. There are several other elements I use to tame the email beast but this is one of the basic rules: Do not work out of your inbox.
To which I’ll add: not an online one anyway.
If you spend your life in your email inbox with new emails constantly pinging and popping then you are sentencing yourself to a life of email misery. You’ll almost certainly never get on top of anything. Worse, you make it harder to do all the other tasks well. We all need to refer to email conversations or documents as part of the process of larger pieces of work – but you can never really concentrate properly on those while you are getting intermittently disturbed and distracted. It’s just dismal.
It’s important to me that when I turn on my email app I can check past messages without new work coming in. That gets managed in batches at other times.
The only way to make that work is to be able to turn your email app offline.
It is the most basic function, yet it is crucial to email and your wellbeing.
Outlook is a dog. Not a lovely cute fun, puppy-like one. A grumpy snarling barely fit-for-purpose mutt. But at least it has a work offline button. As basic as it seems, I’m depressed about how few apps have these. Even the latest and greatest just don’t seem to regard it as important functionality. One could become cynical about this. Naturally, people making email apps want you to think of email as being tremendously important. They don’t want you to adopt a position where it is just a quick tool, one that doesn’t necessarily dominate your life. Could that be a factor in their unwillingness to just turn off email?
It makes me mad as hell. What I would actually like is an email app that allows you to turn each email account on and off at will. It’s very common for people to have more than one email account and it would be unbelievably helpful to be able control the flow of work with an account-specific offline button. A nice clear button and no chance of email sneaking through. I’m no programmer but how hard that can be?
In the meantime, here is my fix: use Radio Silence.°
Radio Silence lets you control which apps can access the internet. Mac only I’m afraid and I’m not sure of a PC equivalent – though I’m sure a quick Google will turn up some options.
Spark is a lovely email app° to use and they even have the utterly brilliant ‘send later’ functionality baked in. (I’ll write on that another time.) As good as Spark is, they also lack in the offline options, so I use Radio Silence° (well worth the $9) as my hack of choice. I have to open another app but it means I can securely turn off Spark and concentrate on the task in hand without the dreaded ‘boing’ of another email dinging in my brain.
It has taken me a while to get around to reading this. I did have a couple of false starts with it but, it’s such a stated classic, I wanted to persist. I’ve written down some of the quotes I highlighted. It is particularly well suited to fiction writers but there is plenty here for everyone. It’s not all my cup of char, some of the stories feel just a little strained, but Lamott does write beautifully and very honestly.
One reviewer on Amazon UK commented on the number of mentions of God. I don’t usually cope well with that either but BbB is certainly not a book that’s trying to convert. It just happens to be a big part of Lamott’s life. She’s also quite happy to be a potty-mouthed and demonstrably flawed person – and you have to love her for that.
– Writing and reading decrease our sense of isolation. They deepen and widen and expand our sense of life: they feed the soul.
– If something inside you is real, we will probably find it interesting, and it will probably be universal. So you must risk placing real emotion at the center of your work. Write straight into the emotional center of things. Write toward vulnerability. Don’t worry about appearing sentimental. Worry about being unavailable; worry about being absent or fraudulent. Risk being unliked. Tell the truth as you understand it. If you’re a writer, you have a moral obligation to do this. And it is a revolutionary act—truth is always subversive.
– Annie Dillard has said that day by day you have to give the work before you all the best stuff you have, not saving up for later projects. If you give freely, there will always be more.
– Publication is not going to change your life or solve your problems. Publication will not make you more confident or more beautiful, and it will probably not make you any richer.
– To live as if we are dying gives us a chance to experience some real presence. Time is so full for people who are dying in a conscious way, full in the way that life is for children. They spend big round hours.
– I told her I thought she’d been very honest, and that this was totally commendable, but that you don’t always have to chop with the sword of truth. You can point with it, too.
– So much of writing is about sitting down and doing it every day, and so much of it is about getting into the custom of taking in everything that comes along, seeing it all as grist for the mill. This can be a very comforting habit, like biting your nails.
– I taped Hillel’s line to the wall by my desk: “I get up. I walk. I fall down. Meanwhile, I keep dancing.” The way I dance is by writing.
– My deepest belief is that to live as if we’re dying can set us free. Dying people teach you to pay attention and to forgive and not to sweat the small things.
– Writing is about hypnotizing yourself into believing in yourself, getting some work done, then unhypnotizing yourself and going over the material coldly.
– Sometimes intuition needs coaxing, because intuition is a little shy. But if you try not to crowd it, intuition often wafts up from the soul or subconscious, and then becomes a tiny fitful little flame. It will be blown out by too much compulsion and manic attention, but will burn quietly when watched with gentle concentration.
– If you have a message, as Samuel Goldwyn said, send a telegram.
– To be engrossed by something outside ourselves is a powerful antidote for the rational mind, the mind that so frequently has its head up its own ass—seeing things in such a narrow and darkly narcissistic way that it presents a colo-rectal theology, offering hope to no one.
– Fix instead on who your people are and how they feel toward one another, what they say, how they smell, whom they fear. Let your human beings follow the music they hear, and let it take them where it will.
– Find out what each character cares most about in the world because then you will have discovered what’s at stake. Find a way to express this discovery in action, and then let your people set about finding or holding onto or defending whatever it is
– Don’t worry about it. More will be revealed over time. In the meantime, can you see what your people look like? What sort of first impression do they make? What does each one care most about, want more than anything in the world? What are their secrets? How do they move, how do they smell? Everyone is walking around as an advertisement for who he or she is—so who is this person? Show us.
– it may help to remember this great line of Geneen Roth’s: that awareness is learning to keep yourself company
– Sometimes it actually gives them hope, and hope, as Chesterton said, is the power of being cheerful in circumstances that we know to be desperate.
I do record most of my exercise activities on Strava°. It does make a difference to the amount of training I get done. I record my runs and cycles on my smartphone using the Strava app and I add other entries, like weight training, manually as needed. I’ve been doing it for several years so I have built up a good record of my activities and patterns.
It has been very helpful to get me through periods when I’ve felt less like exercising or when I’ve picked up injuries. Helpful in the sense that I’ve been able to maintain a base level of exercise and achieve a huge amount of consistency. That consistency has been hugely important to me. Typically I do about 250 hours of exercise a year – about 20-21 hours per month. I get the occasional month where I do a little less (perhaps if I have one of those niggly calf injuries I went through a phase of getting or I’m on holiday) and sometimes more (usually when I get a bit more cycling in).
So, I like to watch it weekly and if I do less than four hours I feel a bit crotchety. If I do about six hours or more then that’s a heavy week and I usually feel noticeably more tired. Curiously, it now almost never happens that I do more than seven hours per week and those are rare weeks indeed. Which, by the standards of many amateurs, is quite modest. Of course, by the general standards of the population it is plenty.
I aim for about 20 hours per month. In October 2019, as you can see, I hit 21 hours 14 minutes. A good solid month. There was over 14 hours of fell running, just under five hours of weight training, and a couple of hours on a bike. I’m particularly happy as I went through a bad patch in the middle of the month. I was very low, very demotivated, just struggling. I’ve no idea if I had a bug, maybe a virus lurking in the background, or whether it was some stress reaction or mental health thing. Who knows? My habit was good enough that I was able to keep plugging away with the exercise and the black cloud drifted off again.
I like to think the physical activity helped and got me through it.
I read Misha Glenny’s book Dark Market a good few years ago and it was a fascinating exploration of the dark web. The London Review of Books article in the title,is available online° at the moment but I have, thanks to a kind friend, a gift subscription to the LRB so I read it on old-fashioned paper.
The substance misuse clinics where I work in Blackpool are mostly filled with people with problems with heroin and crack cocaine. Alcohol, of course, and there are frequent problems with benzos, sometimes Spice, and the occasional amphetamines. Standard stuff. Party drugs don’t feature all that much although I don’t doubt our clients will have dabbled with them over the years. I also think that supply of drugs like heroin and crack is still relatively old-school – it’s hand-to-hand street (or near street) deals in the way it has been done for years. As Glenny and Lang suggest, this is the riskiest, with a worrying risk of getting caught or brutalised or simply ripped off.
Glenny and Lang go on to discuss the ‘county lines’ model and also the “urban full-service party supplier” with its emphasis on reliable courteous service and customer satisfaction. The fourth service and the main thrust of the article is the dark web. There’s an interesting angle that results in a kind of self-policing of quality – the admins of one site buy products themselves and get them tested. Clearly it is done for self-serving reasons but contaminated drugs or ones with highly variable purity can kill. The customers benefit.
One wonders where the drug trade on the dark web will lead. Apparently some 29% of illegal drugs are now bought online (though there is no reference for this and the way it is written in the article is a little ambiguous). It is almost impossible for law enforcement to shut it down permanently at present. That said, Glenny and Lang describe an elegant, and slightly convoluted, takedown used by law enforcement recently. Another will pop up soon. I wonder how much this kind of access to illicit drugs will increasingly normalise their use – it’s hard to predict but the relatively safe (safer anyway) access to drugs, where there is a reasonable expectation of quality, moves use into a much wider section of the population. That will ripple out through society in the years to come.
I only recently read this short editorial° from the former editor of the BMJ, Richard Smith. It was published in 2001 article and it has over 100 citations – which is remarkable and testament to how much it has resonated, and continues to resonate, with doctors. I think this may be the first time he refers to the ‘bogus contract’ and it is one that is memorable and easily recognisable to all doctors (and probably plenty of patients as well).
There is a mawkish sentimentality that many doctors cling onto – the classic painting by Luke Fildes is one that doctors get dewy-eyed over. Here is Smith’s pointed comment on that:
Luke Filde’s 19th century painting of a contemplative doctor alone with a sick child might now be replaced by a harassed doctor trying to park his car to get to a meeting on time.
Ouch. It is devastatingly accurate. He goes on to highlight that “curing a sick child” is a very different form of gratification to that which comes with attending a meeting and agreeing to take an “abused child into care”. I don’t think that’s entirely fair here as there was precious little curing going on by Filde’s doctor but it is certainly true that’s the romantic notion of it. The reality of modern medicine doesn’t come within a country mile of that idealised version.
The Great Idea series° from Penguin are lovely little books. They tuck under the elastic of my Leuchtturm1917 notebooks° and can go anywhere. There is, of course, little shortage of quotes from Seneca and some of these are very well known.
Here are a few that struck me. The first is well known.
“It is not that we have a short time to live, but that we waste a lot of it.”
I had not come across the next one before but it struck a note. Always casting around for new things is, in Seneca’s opinion, just as senseless as non-engagement. Sometimes we have to just be satisfied with what we have and work at that.
“They are in the same category, both those who are afflicted with fickleness, boredom, and a ceaseless change of purpose, and who always yearn for what they have left behind, and those who just yawn from apathy.”
Seneca had this to say on the past. He was a fan:
“It cannot be disturbed or snatched from us; it is an untroubled, everlasting possession.”
Of course, Seneca wasn’t quite so genned up on the modern nature of memory but it’s can be a comforting thought. Not everyone has fond recollections and it doesn’t account for those with traumas that blacken their lives.
“But life is very short and anxious for those who forget the past, neglect the present, and fear the future.”
“We must go for walks out of doors, so that the mind can be strengthened and invigorated by a clear sky and plenty of fresh air.”
Not much changed there in the past two thousand years. If ever there was a need for more walks it is now.
African swine fever (ASF) is cutting a swathe through the pig population. Who knew? There is a World Organisation for Animal Health°, which I will admit I didn’t know existed, and this is the fact that staggered me: they expect a quarter of the world’s pig population to die of African swine fever. As pig pandemics go this would seem to about as devastating as one can imagine. It all started in sub-Saharan Africa and has slowly spread out to neighbouring countries and pushing into Asia. There were confirmed outbreaks in Bulgaria and China in 2018.°
It is caused by a virus and has a near 100% fatality rate in affected pigs. The good news for us humans, ignoring the farming-related impacts, is that there is no apparent spread into our own species. There is no vaccine. As a pandemic virus African swine fever has plenty going for it – as well as direct contact spread it can also survive in processed animal meat for months. It seems its progress is inexorable and, closer to home, wild boar populations in Belgium have been found to have it. Will the UK be affected? It seems to be a when-not-if scenario.
Given the incredible mass of humans on the planet, the increase in travel, and climate change with environments being altered, the chances of some pathogen making a leap from wild or domesticated animals to humans and ripping through us are high. I highly recommend David Quammen’s book Spillover° for more on this. It is brilliant. African swine fever may have gone under the radar, at least here in the UK, but the looming aporkcalypse could offer some interesting, if worrying, insights to the progression of a future pandemic.
I recently finished Seamus O’Mahony’s book Can Medicine Be Cured? He poses the title as a question and it is tempting to apply the principle that one should, as a matter of course, answer these kind of questions as ‘No’. And, indeed, O’Mahony offers little comfort that it can be answered positively. As a result, there may be some risk of despair in reading it.
Jane Rosamund Moore provided an excellent review for us at the BJGP.° O’Mahony takes a hammer to the medico-industrial machinery – the endless biomedical research and Human Genome Project, generally all regarded as A Good Thing, are all duly bashed. Like Moore I was particularly intrigued by O’Mahony’s account of the Mid-Staffs scandal and the contentious use of statistics.
In her review, Moore notes that O’Mahony comes across as a bit ranty. That feels like more of a problem in the back end of the book. For instance, I’m quite prepared to look critically at the evidence for bare-below-the-elbows infection control policies but there is a whiff of the old-school consultant when complaining about the abolition of white coats. The chapter on empathy and compassion wasn’t as compellingn and felt a little under-cooked. Worryingly, O’Mahony offers little in the way of solutions and we’re left with the end-of-career cry that it ‘was better in the old days’. Except O’Mahony wasn’t that impressed then either. How do we find another way? We get a few words at the end about readjusting our aims for people who are suffering but it’s cold comfort.
Overall, though, it’s an excellent book and one that challenges. And O’Mahony offers plenty of avenues for further exploration. We need contrarians. Perhaps one of the best in recent years is the redoubtable Richard Smith. Smith gets to a fundamental problem at the heart of the doctor-patient-system dynamic. O’Mahony writes:
Richard Smith, then editor of the British Medical Journal, wrote about the ‘bogus contract’ in 2001. This contract is based on patients believing that modern medicine can do remarkable things; the doctors can easily diagnose what is wrong, know everything it’s necessary to know, and can solve all problems, even social ones. Doctors know that these beliefs are childish, and that the contract is bogus.
I’ve been making an effort to commit some poetry to memory. I wouldn’t describe myself as an avid poetry fan, I have a very modest collection of books, but I do get an enormous pleasure from being able to recite a few verses from memory. It is deeply satisfying and they make good company.
I recently discovered a rather brilliant app, Memy°, for the iPhone. So, with apologies to Android users, I thought I’d race through a quick review of its features.
You can adjust the text size – I’ve gone very small here so you can get a feel for the way the app works. The poem is a classic, Ozymandias, by Percy Bysshe Shelley. (We used to have a tortoise called Percy named after the poet – a play on the last name of course. Ahem.)
There are three different methods to help you memorise and the one shown is the most common. You read the poem a few times and then the fun starts. The app blocks, randomly, a word from each line. Read it again until you are confident you know the missing words. You click a button and it then blocks two words from each line. Read again. And, so on. Keep going and you will, eventually, have it memorised. A long press anywhere on the screen gives you a brief glimpse.
Folders. It has folders for organising your poems. The folder system is a little basic with no drag-and-drop and no bulk edit or move options. That’s all good when you only have a dozen poems. I’m planning to build my repertoire up over the coming months and years and I’d like to think there will be scores of poems in due course. It could get a little clunky. For the moment it works just nicely.
Importing and exporting. You can import and export back ups. This is handy for getting your poetry collection from one device to another. Actually, my preference is to save poems as txt files in Dropbox and the app allows you to import these (as well as rtf, html, and PDFs).
Not just poems. You can also use it to learn other stuff. Actors will find it helpful and there is the facility to remove some lines and sections from the memorising algorithms – handy, as you don’t need to learn everyone else’s lines in a script.
What have I learned so far?
I had a headstart with some of these as I had learned them years ago. But some of them are new to me as well. I’m also going to use it to learn some quotes and I have my eyes on some of the classic Shakespeare speeches. Here are five I’ve got solid again:
Tomorrow, and tomorrow and tomorrow by Bill Shakespeare°(a Macbeth speech)
I read Richard Freeman book, The Line, last year when it came out. In July 2018 I sent an email to a magazine offering a review. I wondered if there were some serious professionalism concerns that had not yet been picked up. The jiffy bag story, the lost laptop, it all looked bad. I never wrote anything further and nothing was published. It wasn’t long after that the GMC eased in.
Sections of the book read like a long apologia – in the dictionary definition sense of being a statement of defence of one’s actions. It felt a lot like Freeman was already constructing a narrative of self-justification. And, I’m not particularly critical of that – it’s more-or-less nailed on human nature to do so. I wonder, given the revelations that are now emerging, whether the cognitive dissonance must have been off the scale and, more than anything, I feel sorry for Freeman. I’m inclined to believe he is, or at least was, what he said he was: a caring, person-oriented doctor. Given he has, by his own admission, lied then some bad decisions were made.
Reports are emerging° that Freeman has admitted he “told a lot of lies”. Obviously, the media are going to take an intense interest, particularly, if it offers any suggestion of impropriety on the part of Sky’s stellar cyclists. There’s a bit of me that worries that Freeman realises he was caught ‘bang to rights’ and is now coming clean to reduce his punishment, as can happen. A larger part of me hopes he is in a better place and had simply come to a policy of full disclosure as the best remedy for himself and others.
I’ve always been a little wary of doctors who get into sports medicine. It’s a discipline that has been obsessed for decades with the elites, the research is dominated by studies into young males, and there is very little to help the normal person in their life. It is also, I suspect, beguiling and many of the doctors enjoy that aspect. For me, and I love sport, it looks like an elaborate form of private medicine. Not my cup of chai. There is an intense culture around elite athletes and it’s one that I suspect could be all-enveloping. It would easy to get dragged into it. To make bad decisions. The GMC are alleging Freeman got some medication for the purposes of doping. We’ll see how it plays out. As per his sub-title, medicine and sport have certainly collided and he has been caught in the crash.
There is, as with society in general, increasing concern about planetary health amongst the medical profession. While clearly climate change can damage health it is not always immediately apparent how doctors themselves can help people make changes. Two main areas stand out: physical activity that reduces the use of vehicles; and a healthy diet that helps reduce the carbon cost of producing our food.
So, what is the evidence that a ‘healthy diet’ is better for the environment. All depends on how you define healthy of course. A new paper published in PNAS° has analysed it further, indeed, it’s described as the “most sophisticated analysis to date” in the Guardian but I’m guessing that’s reporting on the authors’ view in the press release.
They looked at 15 food groups, five major health outcomes, and five aspects of environment degradation. The food groups associated with the best health are all, with the exception of fish, the best for the environment. This lovely graphic from the Guardian° shows it best.
It’s easy to criticise journalists for their reporting of science – reducing complex research articles to short articles is always a bit fraught. And, to be fair to those who criticise, it is often done very badly indeed. The Guardian, while not completely immune from the siren call of clickbait, has to be commended for this graphic that rather brilliantly summarises the key findings. It reproduces one that is provided in the paper itself but it is good to see.
And one important point to make and I nearly missed myself – the y-axis is logarithmic. Those towards the top are orders of magnitude worse than those at the bottom.
The graphic also serves another function when it comes to giving dietary advice. The nature of evidence on diets doesn’t always sit well with the one-to-one consultation but encouraging people to consider pushing their diet towards that bottom left corner is a helpful message.