Pilot 11 by Chigwell School

CHIGWELL SCHOOL

the

Pilot

The Journal of Chigwell School Number 11 Michaelmas Term 2018

Jeff Koons, Metallic Venus (see Tomasz Cienkowski’s essay)

Welcome to Issue 11 of Chigwell School’s very own journal, the Pilot. Within lie pieces of writing that span a wide range of topics and age groups. I very much hope you enjoy what this edition to has to offer. Some may wonder what the point of this journal is apart from showing off what students can do? Truthfully, it is partly for that reason, as on reading what the Pilot has to offer you will see the hard work people have put into these pieces. I myself had the same question and so I did what I always do as a free-thinking individual and Googled it. This itself demonstrates why we do indeed write. It is to challenge questions and explore the capacity of our minds. The team behind the Pilot believe that age is just a number, as we kick things off with Sienna Agg’s exploration into whether Greek myths should be taught or not (much to Mr Lord’s dismay). We then move swiftly into the Howard essays, with Tomasz Cienkowski’s winning entry: What happens to Venus when the marble goddess turns metallic? Imogen Osborn then explores Virginia Woolf’s understanding and application of Ovidian metamorphosis, Leah Redmond discusses personalised medicine, and Erin Chakartash investigates the financial crisis, which ‘celebrates’ its 10th anniversary this year. To ease the transition into the Mitchell essays we have writing on antibiotics from Ada Wojtyna. The winning essay of the Mitchell competition sees Yasmin Antoniou tackle the role of the placebo effect in medicine, and, in a highly commended essay, Isabella Clark discusses whether anorexia nervosa is caused by nature or nurture. Throw in some economics, science and politics essays, along with some classical writing from Christopher Collins and Hassan Tanveer, and we have a collection of academic writing of which Chigwell can be proud. With poetry from both Suli Scatchard and Tamazeir Chaudhary, the Pilot is complete. Thank you for your time, Aman Patel

I would like to add my heartfelt thanks to the Pilot Editorial Committee: Aman Patel, Abi Whelan, Poppy Bradley, Christopher Collins and Suli Scatchard. The last two of these deserve particular credit, as they devoted long hours in their summer holidays to detailed and skilful editing of the essays and articles found in this issue. I thank them for their time. Chris Lord

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Contents Sienna Agg

Should Some Greek Myths Not Be Taught?

Tomasz Cienkowski What happens to Venus when the marble goddess turns metallic? Transformation of physical materials and of visual models in the ‘Metallic Venus’ by Jeff Koons (Howard Essay 2017-2018: Winner) 5 Imogen Osborn

Virginia Woolf’s understanding and application of Ovidian metamorphosis: did she develop the concept in her novels? (Howard Essay 2017-2018: Runner-up) 12

Leah Redmond

Should the NHS inject additional funds into the future of personalised medicine?

Erin Chakartash

To what extent was Wall Street’s 2008 banking crisis inevitable?

Suli Scatchard

L’infatigable Dessinateur du Ciel (poem)

Ada Wojtyna

First - Check!

Yasmin Antoniou

The Role of the Placebo Effect in Medicine (Mitchell Essay 2017-2018: Winner)

Isabella Clarke

To what extent is anorexia nervosa caused by nature not nurture? (Mitchell Essay 2017-2018: Highly Commended) 35

Tamazeir Choudhary Final Goodbyes (poem)

Aman Patel

The Big Four Accountancy Firms and their Oligopoly

Poppy Bradley

An Element of Competition

Abi Whelan

The Legacy of Margaret Thatcher

Julia Kotlarska

Why is the rule of law one of society’s foundations?

Christopher Collins How ‘historical’ is Herodotus’ account of Croesus’ reign? (National Classical Association GCSE Essay Prize: Winner.) 45 Hassan Tanveer

What aspects of the classical world do you think invading aliens from outer space would find most interesting, and why? 47  3 !

Should Some Greek Myths Not Be Taught? Sienna Agg There are many extraordinary and fascinating myths in the world. Full of action, love, mystery, cunning, and betrayal. It’s all there! Just hidden in a few dusty old books. Yes, I get that there might be a few inappropriate things in the myths, but that doesn’t mean you shouldn’t read them! Some people may argue that you can get bad habits from reading myths, but think of it as teaching you about life. Giving you the full experience, in just a book! Let’s take a look at Dionysus, before he became a full God he used to party, drink wine and have a good time! Some people say that this may get kids into drinking as it is described as ‘fun’. However, let’s take a reality check here, kids in year seven already know it’s bad to drink, it’s essentially telling a kid what they should and shouldn’t do. How about Hephaestus? The moment he was born his mother, Hera, chucked him right out of the window and off Mount Olympus (May I just say that it is said Olympus is way high in the sky, so that must have hurt). Now Hephaestus isn’t your average baby, he looks extremely ugly. But it’s not about what’s on the outside, is it kids? It’s about your heart. Hera has done many stupid things, I can tell you. But the biggest mistake she made was throwing Hephaestus away like garbage. I mean, that’s child cruelty right there! And Sisyphus, don’t get me started on him. The crazy guy tried to cheat Death! Literally! Now, let me tell you, he was cunning. It might as well have been his second name! Fooling Hades to get out of the Underworld and back on Earth? This was one of his gravest mistakes, Sisyphus had to learn the hard way in the fields of punishment. But luckily for you, you now know how to behave just by reading a few myths! You see, myths aren’t all bad. They teach things and stop us from experiencing them ourselves, first hand. So if you hear someone say “you shouldn’t read that...” God, make sure I never meet that person. I hope you found this information useful and that it helps you in life, because it sure helped me. Do you think myths should be taught? Or keep them hidden away like a secret?

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Howard Essay 2017-2018: Winner

What happens to Venus when the marble goddess turns metallic? Transformation of physical materials and of visual models in the ‘Metallic Venus’ by Jeff Koons Tomasz Cienkowski ‘Metallic Venus’ is a contemporary sculpture made of mirror-polished stainless steel that was presented publicly for the first time in 2012 in Frankfurt as a part of the exhibition “Jeff Koons. The Sculptor”. The figure underwent artistic transformations: white marble was replaced by turquoise steel, and the goddess’s body amalgamated two classical visual models. The central question is what happens to the goddess when she undergoes such transformations. This essay sets out to define further the place ancient art holds in modern visual culture and the ways in which classical representations of idealised bodies still affect our modern notion of beauty. The essay will contextualise Koon’s statue with reference to two ancient works – the Farnese Venus Callipyge and Venus of Knidos – and selected modern sculptures responding to the motif of Venus from the 20th and 21st centuries.

Consumptionist Venus

Figure 1 Jeff Koons, Metallic Venus, mirrorpolished stainless steel with transparent colour coating, live flowering plants, 2010

The glossy sculpture of mirror-polished steel that reflects its surroundings is an over-life sized, shining figure of the ancient goddess of beauty and love. The turquoise Venus is taking off her clothes, at once dynamically and clumsily, and so is uncovering the most intimate segments of her body – both front and back – which creates a strongly erotic tension. She strikes the viewer with artificial, almost plasmatic blue that may remind them of the vivid colours used in advertisements or even of nail varnish. The surface itself is a mirror-polished stainless steel that, as opposed to classical white marble, evokes the industrial production exemplified by, say, polished cars and the functionality of metallic objects in everyday use. Moreover, white petunias in a pot next to the goddess are real, fresh flowers that the artist dictates are to be provided daily by the gallery staff: they are thrown away in the evening and replaced again the next morning. Both this practice and the sculpture’s visual characteristics may be evocative of a consumptionist approach towards the object, an example of the ‘throwaway culture’ of modern capitalism. The impression of consumerist glamour pervades the

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sculpture. But I will argue that ‘Metallic Venus’ has much more to show: under the trivial cover of shining steel there is a complex and dynamic rethinking of the visual traditions of antiquity.

Ancient versus modern Venuses To understand this visual dialogue, one needs to appreciate Koons's inventive approach towards ancient models of his Venus. One possible point of comparison is the Venus aux belles fesses, a part of the Farnese collection. The pose of ‘Metallic Venus’ is very similar to the one of Venus Callipyge: not only is the setting of their legs strikingly familiar, but most importantly the gesture of deliberately lifting the robe and so uncovering the body, although not the same, also creates an impression of parallelism. The interplay between light and shadow, the plainness of the surface, and the vibrant texture of the goddess’s clothes further support the point of comparison.

Figure 2 Callipygian Venus (Venus with beautiful buttocks), white marble, dating from the time of Emperor Hadrian, National Archaeological Museum of Naples The ancient goddess does not look at the viewer or anything else around; with her head turned back, she gazes at her own body – or more precisely, her own buttocks. This is a visual device that also directs the sight of the viewer to Venus’s backside. The focus is no longer a face or an overall shape of her body, but one of the most sexualised segments of the female body. Furthermore, this gesture questions a more conventional relationship between the ancient viewer and the nude, objectified statues. While some ancient nude statues were based on ‘to-be-looked-at-ness’, a phenomenon where a woman is turned into an object of vision (a sight)1, the self-absorbed Venus Callipyge becomes a conductor. Furthermore, the tightly-tied girdle-knot strongly suggests that the lifting of the robe is not a stage in a normal process of undressing (the anasyrma

M. Squire, 2011, p.74-75.

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gesture); Venus’s fully aware aim is to expose the lower segment of her body.2 This observation inspires a conclusion that if nakedness is just being stripped down while nudity is a form of a dress3 , Venus aux belles fesses definitely exemplifies nudity. She uncovers her buttocks not as a stage of undressing, but (naming it colloquially) of a striptease. Not only does she seem to be objectified by choice in deliberately lifting her robe, but the goddess simply aspires to control the subject to look at her buttocks as she pleases. This independence and control over the viewer links to Venus’s religious authority, but even in lay terms expresses self-awareness of own body. However, Koons does not only retrace one single model of the classical body: he offers a more complex and challenging configuration.

Figure 3 Praxiteles, Aphrodite of Knidos, c. 350-340 BCE, Musei Vaticani, Rome Although the manner of lifting the robe comes from Venus Callipyge, Koons invited Venus of Knidos to become a part of his ‘Metallic Venus’ too. The Knidian ceramic jug covered with a piece of cloth was ironically transformed into a stand for a pot of white petunias. The composition of vertical lines of both the goddess’s shape and the stand remains strikingly similar. Likewise, the artist translated the language of the Knidian everyday reality to modern standards; as the jug with water and the piece of cloth next to the Aphrodite expressed a daily routine to the Greeks, the process of taking off one’s clothes is a daily routine to us. So, Metallic Venus takes from the Knidian goddess in the bottom part the stand for her flowers and in the upper part the expression of a woman’s daily routine. Koons, therefore, went even farther than Zeuxis: in his

G. Saflund, 1963, p. 45.

M. Squire, 2011, p. 76-77.

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ironic dialogue with ancient fetishisation of the female body, the artist idealised his sculpture using two other goddesses. Koons's self-ironic aim for idealised models of divine beauty further situates the expression of ‘Metallic Venus’ within the classical tradition. Take the legend of Zeuxis (Pliny the Elder, The Natural History)4 , a painter from Heraclea, who was given a task to paint an image of Helen of Troy – ‘a silent image that embodied the surpassing beauty of womanly form’.5 The question that instantly arose in his mind was: “Where to find a model?”. The artist supposedly selected five specimens in order to reproduce the best parts of each, since the beauty he was looking for was ‘unattainable’ for one woman. This paradigmatic tale illustrates artistic objectification: a woman is reduced to a line-up of fetishised segments, such as breasts, hips etc. ‘Metallic Venus’ rethinks such patterns of idealisation – not only is she a composite of two models, but these models are both goddesses! Zeuxis used five mortal maidens, while Koons decided to combine two goddesses – Venus Callipyge and Venus of Knidos. Koons, therefore, went even farther than Zeuxis: in his ironic sculpture with ancient fetishisation of the female body, he idealised his sculpture using two other goddesses.

Transforming physical materials Before further analysing the self-awareness of Koons's Venus about her own divine body, the physical transformation of marble turned into steel needs to be scrutinised. Following the aesthetical debate over the death of marble sculpture, one may think Koons replaced it in order to move as far away from ‘dead’ art as possible.6 Indeed, ancient sculpture partly gained its prestige thanks to the permanence of marble, whereas ‘the allegedly eternal quality conferred by it interfered with modern life characterized by its very evanescence’.7 However, it seems less the case that this is an escape from an apparently traditional ancient material if the supposed origins of the Venus Callipyge are taken into account. Some evidence available, such as the dead area between the lower left leg and the drapery, suggests that the Farnese statues is a marble paraphrase of a lost bronze original. If this were the case, this section would have a vital role in the marble statue as a support and reinforcement for the small volume of the leg, while in bronze it could simply stand free.8 Of course, Koons does not copy the ancient traditions: it is still polished steel, not the Locrian bronze. However, although the technique is not the same, metal builds a visual bridge between the age of ‘glass and steel’ and the ancient era, a bridge some would find unlikely to be constructed. Furthermore, the vivid colour of the surface creates another connection. In contrast to the predominantly white ancient statues in modern galleries, Koons's Venus hits the viewer with a shining, almost plasmatic blue. Again, one may think (not wrongly) that this gradient serves to bring out beautiful shapes of Venus’s body in pursuit of the tactile exploration of shape rather than of semblance and visual appearance.9 However, looking back at the origins of Greek and Roman sculptures in general provides a captivating perspective: ancient Greek and Roman sculpture throughout antiquity was largely polychromed.10 In many cases, even flesh wasn’t left blank, although colours disappeared because of conditional damage, such as light and air.11 4

Pliny the Elder, The Natural History, Book XXXV, Chapter 36

M. Squire, 2011, p. 81

L. Ostermark-Johansen, 2010, p. 181

K. Savage, 2010, p. 10

G. Saflund, 1963, p. 38-39

R. Panzanelli, E. Schmidt, K. Lapatin & A. Potts, 2008, (the last chapter by Alex Potts)

G. M. A. Richter & L. F. Hall, 1944, p. 235

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Again, although the synthetic blue is far from more naturalistic polychromies, this move away from white marble creates a complex connection – not only to consumer glamour, but also to ancient colourful sculptures. Therefore, Koons's dialogue with ancient visual traditions in his ‘Metallic Venus’ is not simply a process of adapting a traditional statue to standards of a modern art gallery; it is rediscovering the essentials of the ancient nude in modern galleries, or even conversely. Building a bridge between the visual culture of our times and the art of the ancient era not only proves there is room for modern art to find inspirations in academic scholarship of ancient material culture, but also poses a question as to whether we perhaps share even more than general visual traditions. Let us think closer of Koons's transforming of the classical models of the ‘Metallic Venus’ to further understand this process.

Rethinking idealisation Let us set off from the sculpture’s gesture: whereas the Farnese original sensually lifts the robe to deliberately uncover her buttocks, ‘Metallic Venus’ seems to be simply taking off her night gown or other garment. No matter what type of clothing it is, Koons's goddess is clumsily trying to take it off – as opposed to the ancient goddess, who almost manipulates her gesture (and, consequently, what the viewer sees) in a seemingly conscious manner. In terms of self-awareness of her own body, Metallic Venus does not seem to purportedly use her buttocks or any other part to attract attention or tease the viewer and so she might appear ‘liberated’ from the ancient sexualised theatre of playing with one’s own body in front of the viewer, as presented by the Farnese statue. In contrast to the ancient original that carefully manages the chiton and the robe to look as beautiful as possible in this game, she simply takes it off and does not seem to care whether the viewer is impressed by her buttocks or not. The act of dynamically taking off the clothing, as well as the impression of being less self-absorbed by her body, makes Koons's Venus appears much more ‘liberated’ (not to say freed) from the Farnese sexualised protocols of absorption with one’s own body. The impression of liberation from such an absorption is further enhanced by the white flowers standing next to her. As previously mentioned, the bunch of white petunias is provided daily by a museum worker – thrown away after the museum closes and replaced before the first viewer comes in. This process becomes a sort of ritual. However, even if the ‘worshipper’ realises that this act of bringing white flowers every single day to the goddess is a form of secular veneration, is Venus aware of being revered? Again, the goddess is somehow, ironically, struggling with some clumsiness to take off her gown rather than having in mind the worship ritual going on around her. Thus, the goddess seems either not to be aware of being venerated, or not to care about this makeshift form of reverence. Her self-consciousness of her own divinity provokes further questions. Moreover, not only does the statue seem to undermine the goddess’s consciousness of her own divine authority, but also any claims to individual identity at all. One should note an important feature of Metallic Venus starkly distinguishes her from Venus Callipyge and Venus of Knidos: the modern goddess hardly has facial features. Of course, she has a beautiful and round head, but on her face the viewer finds an almost flat surface. No eyes, no nose, no lips, no cheek bones. The impression of a ‘dissolving face’ can be compared to the “Muse” by Constantin Brâncuși (1876 – 1957), who tried to translate abstraction into the sculptural language. The series called ‘Sleeping Muse’ consists of multiple pieces made of bronze and marble that present an oval head of a muse; whereas some of the works have clearly marked parts of her face, such as eyebrows or nose, a couple of ‘Muses’ have almost ‘absent faces’.

The reference to the ‘Muse’ relies not only on metallic material and polished surface, but most importantly on the ‘dissolving features’ as a symbol of lack of self-consciousness. She is asleep and so has little selfawareness, as she is dreaming unaware of what is going on around her. Likewise, Venus’s ‘empty face’

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Figure 4 Constantin Brâncuși, Sleeping Muse II,  ca.1925, Kunsthaus Zürich transforms the goddess into more of a form than of a specific person. The sculpture turns into both a more universal and objectified form that finds its place in the mass culture of our times. She is no longer selfconscious of her own divinity, identity and body. Venus’s self fades away in this lack of self-awareness, in this lack of the individual self. But what is the reason that the ancient goddess loses her sense of her own identity and her selfconsciousness? As implied by the shining, plasma-like surface of stainless metal, Venus’s identity and awareness of the self seem to be drowned in unreal idealisation of the female body. In her case, idealisation based on two other goddesses. However, this transformation is not restricted only to the figure itself. The mirror-polished surface is not only able to reflect light: more importantly, ‘Metallic Venus’ reflects her spectator. It is crucial that Metallic Venus’s curved shapes and convex reflecting surfaces of the body work

Figure 5 Jeff Koons, Metallic Venus, mirror-polished stainless steel with transparent colour coating, live flowering plants, 2014

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like a curved mirror. As shown on the photo above, everything around Venus – walls, other artworks, people – is deformed. Thus, whenever the viewer approaches Venus, the goddess of beauty, their own image is deformed when reflected by her: either their head is too big, their waist is too large, or their legs are too short. Obviously, neither the Farnese Venus aux belles fesses nor the Knidian Aphrodite enjoyed such a polished surface to deform the spectators around, but they were curved mirrors too. The problem ‘Metallic Venus’ is trying to highlight is not only the idealisation and fetishisation of the human body, but also the means of judging one’s beauty in relation to unrealistic ideals. The message manifested in Venus is that if you look at yourself through the prism of idealism, you will always be deformed. As a result of such a degree of idealisation, Venus’s own identity and her awareness of the self fade away. Because of judging beauty in terms of unreal degrees of idealisation already deprived of individual features, Koons's statue shows how the viewer’s image of the self risks deformation through dangerous liaisons with classical and modern ideals.

Conclusions Although ‘Metallic Venus’ might be read merely as a product of Koons's fascination with consumerist glamour, the sculpture has much more to show in relation to classical scholarship. The transformation of physical materials – white marble into blue steel – is a consequence of a complex rediscovering of the ancient traditions of female nudity already present in the modern visual sphere rather than of throwing traditional ideas into current exhibitions out of any context. ‘Metallic Venus's shows there is room for antiquity in the visual culture of our times. Moreover, the transformations undergone by the sculpture are not limited to marble and metal. Koons's work being a visual model synthesising two other divine bodies – Venus Callipyge and Venus of Knidos – achieves a new degree of idealisation of the body. Such a high level of fetishisation is accompanied by dissolving Venus’s face; the goddess’s sense of her own identity as well as her self-awareness of her body fade away. The spectator, too, is deformed through the paranoia of idealisation – whenever they look at the Venus, they are deformed by the curved mirror of her perfectly unreal body. Idealisation both erases Venus's sense of self and deforms that of the viewer. The metallic goddess not only proves that ancient art is still compatible with our visual culture, but most importantly it serves to unmask the modern mechanisms of constructing beauty: if you look at yourself through the prism of idealised forms without taking the necessary caution, you will always believe yourself to be deformed.

Bibliography Gosta Saflund, 1963, Aphrodite Kallipygos Michael Squire, 2011, Art of the Body: Antiquity and its Legacy Kirk Varnedoe, 1994, New Acquisitions, MoMa Bulletin, No. 17, p. 17 Lene Ostermark-Johansen, 2010, The Arts in Victorian Literature, The Death of Sculpture, The Yearbook of English Studies, Vol. 40, p. 180-185 Roberta Panzanelli, Eike Schmidt, Kenneth Lapatin, Alex Potts, 2008, The Color of Life: Polychromy in Sculpture from Antiquity to the Present Robin Osborne, 2011, The History Written on the Classical Greek Body Elizabeth Prettejohn, 2012, The Modernity of Ancient Sculpture Kirk Savage, 2010, The Obsolescence of Sculpture, American Art Vol. 24 No. 1, p. 9-14 Lisa R. Brody and Carol E. Snow, 2010, Time Will Tell: Ethics and Choices in Conservation, A Mystery in Marble: Examining a Portrait Statue through Science and Art, Yale University Art Gallery Bulletin, p. 30-45 Gisela M. A. Richter and Lindsley F. Hall, 1944, Polychromy in Greek Sculpture, The Metropolitan Museum of Art Bulletin. New Series Vol. 2. No. 8, p. 233-240

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Howard Essay 2017-2018: Highly Commended

Virginia Woolf’s understanding and application of Ovidian metamorphosis: did she develop the concept in her novels? Imogen Osborn Metamorphosis, or ‘transformation’, is a “complicated, differentiated, intricate and multi-faceted concept” (Gallagher, 2009) that has proved irresistible to poets and novelists alike, from Ovid in 8 a.d. to Woolf in the early twentieth century. Ovid re-cultivated the scientific idea of metamorphosis – a transformation from “an immature form to an adult form” (Metamorphosis, 1911) – to create Ovidian metamorphosis: a spontaneous transformation of form or character, brought about with agency, which reflects an interior characteristic of what is being transformed. Ovid’s hexametric epic poem, a menagerie of metamorphoses, laid the foundations on which Woolf built two of her most significant novels. Life is constantly evolving, everything is subject to change, and metamorphosis “may thus be referred to as a concept; a figure, a todos or a theme, and can sometimes encompass all of those things at once”: a leading, versatile literary concept. Ovid’s application of this concept was applied to the exterior, with transformation embodied physically as a representation of the change going on inside. Woolf took this further, applying it to different environments and with differing degrees of subtlety – not only offering physical metamorphosis but also metamorphosis of concepts. In my essay, I intend to explore the themes in which Ovid and Woolf share a dialogue about the variety of transformation – nature, time, life, sexuality, and desire – by comparing Ovid’s Metamorphoses (8 A.D.) to Woolf’s To the Lighthouse (1927) and Orlando (1928), and discussing how Ovid’s original stories inspired and are integrated into Woolf’s novels. Further, I intend to comment on the extent to which Woolf develops Ovid’s own understanding and application of the theme to which he dedicated a “mythical didactic poem” (Wilhelm Schlegel, 1964). An author’s own understanding can be gleaned from their texts, and Ovid’s Metamorphoses is the important standard to which we compare Woolf’s understanding of the changes which underpin To The Lighthouse and Orlando: most importantly time in To The Lighthouse and Orlando’s hermaphroditic change in Orlando. Indeed, Galinsky proposes that metamorphosis is a final judgement on a character, “very meaningful because [it] sets in relief the true and lasting character of the persons involved” (Galinsky, 1975) – and I will propose my view, based on academic criticism, that Woolf has evolved the theme and shown the versatility of transformation with a more developed understanding and application. Nature continuously evolves. Strong natural phenomena carry the power to transform – as the sea erodes rocks and volcanoes burn landscapes, destructive transformation is constantly enforced in the world around us. Nature also constantly creates; a seed is nurtured into a tree. Thus, metamorphosis and nature are invariably linked: constant change is engendered continuously, and this was a source of inspiration for Ovid and, in turn, Woolf. Ovid correlates waves with the transformation of time. "Everything flows… time itself also glides. . . for neither the river, nor the swift hour can stop: but as wave impels wave, and as the prior wave is chased by the coming wave, and chases the one before, so time flees equally, and equally, follows, and is always new.” (XV: 176-198.)

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As waves wear away stones on the shore, time wears away human life. (Guth 1984). We can never relieve the passing of time and its effect on us. Woolf recalls “the sound of the sea at night” in St. Ives as an influential memory (Woolf, 1921): the sound of time moving through her childhood, taking her with it. Woolf felt a responsibility to “bring out a sense of life in opposition to fate – i.e. waves’ (Woolf 1926) a sense of the continuity of the natural world that lay, impervious, beyond death and loss” (Briggs, 2006) and does this through the character of Mrs. Ramsay, who is described as “boasting of her capacity to surround and protect” (Woolf, 1927, p.44) life. Mrs. Ramsay, the matriarchal figure in To The Lighthouse, is at the conjuncture of successful life and the dregs of old age. The waves for Mrs. Ramsay signify stability in her life: “The monotonous fall of the waves on the beach, which for the most part beat a measured and soothing tattoo to her thoughts seemed consolingly to repeat over and over again. . .” (p.20) She has become a matriarchal goddess surrounded by a large family and a loving husband, the products of a long and successful life; every second is a reminder of her fruitful existence, but the waves herald a threat as well as stability. “She realised. . . and heard dully, ominously, a wave fall” (p.45) Thus, another second is taken away from her life and added to her age. Woolf writes that “she looked in the glass” (p.10) – a reference to a Hardy poem on age and the passing of time: “I look into the glass / And view my wasted skin” (Hardy, 1976, p.81), which is itself similar to the transformation of Helen of Tyndareus who “when her glass / Shows every time worn wrinkle” (Ovid, XV: 229-262.) wept with sadness. The physical metamorphosis of age is an omen of the ultimate transformation that will take her: death. Death is the most destructive form of transformation, a concept which Woolf applies and understands while Ovid does not. Ovid posits that “nothing dies in the universe as a whole”, but repeated metamorphosis renews forms. Woolf, however, remodelled death as a destructive stepping stone and redefines metamorphosis as “a myth of genesis. . . a myth of growth and degradation” (Brunel, 1974). D. Gallagher concurs with this view, stating that “metamorphosis marks…a crisis often of death” (Gallagher, 2009, p.14). Mrs. Ramsay herself is transformed by death: “the lamps are extinguished”, and her death metamorphoses the house itself while nature looks on. “There came. . . imaginations of the strangest kind – of flesh turned to atoms which drove before the wind, of stars flashing in their hearts, of cliff, sea, cloud, and sky brought purposely together to assemble outwardly the scattered parts of the vision within.” In ‘Time Passes’, Woolf focuses only on the changes of the house in a quasi-Shakespearean ‘double-time scheme’ (Guth, 1984). Woolf’s descriptions become disassociated, disembodied transformations; they take place as if in a brain drifting further from the realm of reality and into a dream state – where time and individuality is malleable, and transformation is in free-fall. The dilapidation of the house is necessary for recreation to come. This is an evolution of Ovid’s link between metamorphosis and time, from constant transformation into a “cyclical time structure of death and rebirth” (Guth, 1984). Woolf also explores metamorphosis of identity and sexuality, discussing the Apollo and Daphne myth. Metamorphosis can be “a fantastic device for escapism” (Gallagher, 2009), and a refusal to compromise identity or yield to desire. Daphne’s metamorphosis into a non-sentient plant highlights the boundaries between male and female, strongly contrasting to Woolf’s deconstruction of gender boundaries. Daphne “in fear / Fled on and left him” (Ovid, I:496-563) – metamorphosis is granted to her as a kindness, to avoid the destruction of her identity and her relinquishment to Apollo’s desire. Whereas Ovid uses metamorphosis on Daphne to emphasise the tragedy of the hunted woman, Woolf uses Daphne as a “tool. . . to interrogate

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rather than reinforce gender roles” (Brown, 2002, p.204). After Orlando’s hermaphroditic change, she is confronted with the core “conflict, opposition and division” between men and women: “‘For nothing,’ she thought, ‘is more heavenly than to resist and to yield; to yield and to resist.’” Woolf uses this chiastic phrase not only to highlight the opposition between man and woman, the pursuer and the pursued, but to highlight the antithetical urges within Orlando. After her metamorphosis, Woolf makes Orlando’s inner androgynous conflict sound less tortuous but more “harmonious…for pursuit and flight are associated with ecstasy rather than distress.” (p.97). Woolf explicitly demonstrates this by referencing Apollo and Daphne: “The light airs which forever moved about the galleries stirred the blue and green arras, so that it looked as if the huntsmen were riding and Daphne flying”. Arguably, metamorphosis “needs to. . . reflect changes in appearance, personality or even outlook on life” (123helpme.com, 2017). When Orlando revisits the arras after her hermaphroditic change, the peaceful harmony between yielding and resistance has now become the “indomitable heart” (p.121) both of her home and the novel: a remodelling of the Daphne myth as a herald of the harmony between the sexes; she does this by artistic presentation on the arras in Orlando’s house. Indeed, in Ovid’s Metamorphoses, Apollo promises to “check [his] swift flight” to match Daphne’s. The “light airs” which move about the arras bring this promise to fruition. They must always move at the same speed, keeping male and female in harmonious compatibility. Woolf brings the two sides of the coin into the one face of Orlando, reverting the meaning behind Ovid’s metamorphosis of Daphne. Orlando metamorphoses into both the defiance and submission of females, a consummation which enables a commentary on the feminist movement beginning in her time. By amalgamating male and female experience, Woolf critiqued sexism. She critiqued Freud’s “penis envy” theory – the idea that a woman is subconsciously disappointed and ashamed at her lack of male genitalia31 (Freud and Hall, 1915). Orlando, naked, “looked himself up and down in a long looking-glass, without showing any signs of discomposure”. Within Orlando, the transformation of a love desire was discussed by Woolf, but not an idea which she developed by herself. The myth of Echo and Narcissus proved a great inspiration. “All that is lovely in himself he loves, and in his witless way he wants himself.”33 (Ovid, I: 407-435) The various loves and passions to which Orlando succumbs evolve and transform throughout the novel, and nature becomes embodied in a person to satisfy Orlando’s innermost desires. Orlando first falls in love with Sasha and “narcissism underlines [it]. . . he falls in love with the image of himself” (Adams, 2017). When Orlando promises herself to be the wife of nature, nature metamorphoses into a human with whom Orlando can experience his authentic sexual identity: Shel. Their “hermaphroditic paradigm” (Adams, 2017) allows them to experience reciprocal love. The transformation of Orlando’s desire from himself to Shel critiques social convention; an unconventional marriage joins “two different entities…into a harmonious whole” (Adams, 2017). The concept of reality causes friction when paired with metamorphosis, as transformations push the boundaries of normality. Metamorphosis exposes “the paradoxical nature of man, who is trapped in the material world but desires the spiritual…with physical renderings of ideas” (Gallagher, 2009). Ovid did not explore this but sometimes used metamorphosis purely to create a “fairy-tale world where the ordinary rules of Realism no longer operates” (Gallagher, 2009). Woolf, however, noted a key tension between metamorphosis and reality: the material and the immaterial. "It was believed in Bloomsbury that it was the

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artist's business to catch. . . ‘reality’, and [it] lay behind great works of art” (Johnstone, 1954), such as Lily Briscoe’s painting in To The Lighthouse. Lily’s painting is a cathartic expression of reality – the intimate connection yet utter separation from her companions. “That vision which she had seen clearly once. . . her picture. It was a question, she remembered, how to connect this mass on the right hand with that on the left. . . the danger was that. . . the unity of the whole might be broken” (Woolf, 1928) When painting brief moments of closeness or enlightenment with her counterparts, Lily encounters a monumental barrier; she reaches no complete union or understanding of them. The “mass” she is struggling to paint onto the canvas is the material reality before her: Mrs. Ramsay and James, mother and son, renaissance image of happiness and pure connection, who control Lily’s understanding of reality and paralyse her art. “In learning to draw, it is necessary to acquire the art of representing things according to the sensation, not according to the perception” (Russell, 1915); the immaterial, ‘real’ shape in front of Lily does not fit with her understanding of the world, a place which is “terrible, hostile, and quick to pounce on you if you gave it a chance.” (p.66). Metaphorically the oxymoronic image of mother and son contrasts the whistlestop, ruthless pace of time that brings degradation; she cannot bring her two understandings of reality together, and so concedes to draw them as a triangular “purple shadow” (p.59). After a hiatus, and Mrs. Ramsay’s death, Lily returns to her painting: The empty space of the purple triangle, empty as the house is without Mrs. Ramsay in it, does not form into space without her there. Without Mrs. Ramsay’s material form, Lily has the artistic license to challenge her. Therefore, the physical forms in front of her and their meanings, which Woolf has kept broken throughout the novel, can now become a union of the material and the immaterial – “inner moment and outer shape, the spell of beauty and the bare facts” (Guth, 1984). “With a sudden intensity, as if she saw it clear for a second, she drew a line there, in the centre. It was done; it was finished. Yes, she thought, laying down her brush in extreme fatigue, I have had my vision.” (Woolf, 1927, version in MS) “Before obsessed with arranging still-representational forms, Lily’s thoughts now play with absolute nonfiguration” (Collins, 2005), memories and concepts. She draws a line through “the centre” of the triangle, cutting through the obscurity and imbalance between the material and the immaterial, and the endless cycle of creation and destruction that makes up reality. Lily has successfully transformed reality, its two different sides welded into one. The shape of a triangle importantly combines the three most important metamorphic themes.

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The line Lily draws splits the triangle, showing that creation and destruction are two sides of the same coin; a geometrical simplification of reality. Reality becomes clarity for Lily when she sees demolition and fabrication as two symmetrical halves. Whereas Ovid makes no attempt to understand reality, Woolf thus explores it and creates a new line of thinking. Ovidian metamorphosis is focused on spontaneous physical transformation to mirror an inner trait or epiphany, and Woolf gleaned her understanding of metamorphosis entirely from Ovid. The themes of nature, time, androgyny, desire and life are explored by both, but Woolf develops them further. The passing of time fascinated and eluded Ovid, but he discusses it only conceptually. However, Woolf develops the idea by applying it to characters. Similarly, both authors understood nature as an important metamorphic agent. Yet Woolf again extends Ovid’s ideas and applies them in a subtler and more complex technique. Further, Woolf discusses desire and feminism using metamorphosis, deliberately making the wider point that societal conventions are capable of transformation and modernisation. Contrastingly, Ovid did not apply metamorphosis to wider issues, but sought only to explore the inexplicable and impossible. Though they share many themes, Ovid and Woolf are remarkably different in their conclusions about the properties and applications of metamorphosis. Woolf developed the concept while remaining true to Ovid’s work. “All the lives we ever lived and all the lives to be are full of trees and changing leaves” (Woolf, 1927): everything transforms. The beauty of metamorphosis as a literary technique is held in this most fundamental law: nothing will stay the same. “It is almost banal to say so yet it needs to be stressed continually: all is creation, all is change, all is flux, all is metamorphosis.” (Miller, 1944), a concept itself bound to evolve – and one which Woolf developed beyond Ovid with skill and subtlety.

Bibliography 123helpme.com. (2017). The Concept of Metamorphosis in Life and Literature :World Literature. [online] Available at: http://www.123helpme.com/view.asp?id=110100#continued [Accessed 8 Jun. 2017]. Adam, A. (2017). Metamorphosis of Space of Desire in Virginia Woolf`s Orlando, 1st ed. [online] Academia.edu. Available at: http://www.academia.edu/7296907/ Metamorphosis_of_Space_of_Desire_in_Virginia_Woolfs_Orlando [Accessed 5 Aug. 2017 August Wilhem Schlegel, Geschichte der klassischen Literatur (1802-1803), in Kritische Schriften und Briefe, ed. by Edgar Lohner (Stuttgart: Kohlhammer, 1964) Briggs, J. (2006). Virginia Woolf, 1st ed. London: Penguin Brown, S. (2002). The Metamorphosis of Ovid, 1st ed. London: Duckworth Brunel, P. (1974). Le Mythe de la Metamorphose, 1st ed. Paris: Colin Collins, L. (2005). Abstracting Intimacy: Lily Briscoe's Artistic Vision in To the Lighthouse. Donors Thesis Project. University of Tennessee Czarnecki, K. and Rohman, C. (2011). Virginia Woolf and the Natural World, 1st ed. Clemson, SC: Clemson University Digital Press Freud, S. and Hall, G. (2013). Introductory Lectures on Psychoanalysis, 2nd ed. Lawrence, KS: Digireads.com Publishing Galinsky, K. (1975). Ovid’s Metamorphoses, 1st ed. Berkeley: University of California Press Gallagher, D. (2009). Metamorphosis: Transformations of the Body and the Influence of Ovid's Metamorphoses on Germanic Literature of the Nineteenth and Twentieth Centuries (Internationale Forschungen zur allgemeinen und ve), 1st ed. New York: Editions Rodopi BV Guth, D. (1984). Virginia Woolf: Myth and ‘To The Lighthouse’ on JSTOR. [online] Jstor.org. Available at: http://www.jstor.org/25111615 [Accessed 18 Apr. 2017 Hardy, T. (1976). ‘I look into my glass’, Complete Poems of Thomas Hardy, 2nd ed. London: Macmillan James, W. (1950). The principles of psychology, 18th ed. New York: Dover Publications Johnstone, J. K. (1954). The Bloomsbury Group, 1st ed. London: Butter & Tanner Ltd Metamorphosis. (1911). In: The Concise Oxford Dictionary of Current English, 9th ed. Oxford: Clarendon Press, Oxford

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Miller, H. (2017). Henry Miller on Art, War, and the Future of Humanity. [online] Brain Pickings. Available at: https://www.brainpickings.org/2012/11/07/henry-miller-of-art-and-the-future/ [Accessed 12 Jul. 2017]. Ovidius Naso, P. and Melville, A. (1998). Metamorphoses, 2nd ed. Oxford: Oxford University Press Russell, B. (1915). The Analysis of Mind (Book), 1st ed. [online] Natural Thinker. Available at: http://www.naturalthinker.net/trl/texts/Russell,Bertrand/Philosophy/Bertrand%20Russell%20%20The%20Analysis%20of%20Mind.pdf [Accessed 27 Aug. 2017]. Woolf, V. (1921). The Diary of Virginia Woolf, eds. Anne Olivier Bell & Andrew McNeillie. London: Hogarth Press, 5 volumes, 22. Mar. 1921 Woolf, V. (1926). Holograph Draft, unpublished. 15. Jan. 1926 Woolf, V. (1982). Orlando. 6th ed. London: Granada Woolf, V. (2000). To The Lighthouse, 2nd ed. London: Penguin Books

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Howard Essay 2017-2018: Highly Commended

Should the NHS inject additional funds into the future of personalised medicine? Leah Redmond Please note some prices are quoted in dollars as they were unavailable directly in pounds. Approximations of the GBP equivalent are provided in the footnotes. In the past, doctors would diagnose patients relying purely on symptoms, family history and test results, yet now we have reached an era where genetic testing is providing a more accurate prognosis. Launched in 19481, the National Health Service (NHS) is rated the ‘most impressive overall healthcare system’2 out of 10 of the most developed countries in the world. It is grounded with 3 core principles: ‘meets the need of everyone, free at the point of delivery and based on clinical need, not the ability to pay.’3 With the future of personalised medicine growing closer by the minute, it seems only right for the NHS to be focused on making treatment plans optimised for each patient by analysing their genetics, assessing their lifestyle, and running test upon test to ensure correct diagnosis and treatment; however, it is not that simple. This essay will explain what personalised medicine is, why NHS investment is not automatic and then explore the potential benefits and issues which personalised medicine will rouse within the NHS. To begin assessing the viability of this project, one must first understand what personalised medicine is, how it works and why NHS investment is controversial. Personalised medicine is ‘the study of an individual’s unique biochemical and genetic makeup, in order to determine his susceptibility to disease or potential responses to treatment’.4 For the process to commence, a patient will first have their genome sequenced, which is where all the genes that instruct the cells on how they need to behave are mapped out. This is done by extracting a sample of deoxyribose nucleic acid (DNA) from the organism and cutting it into smaller fragments. Enzymes, which are a class of proteins, are then mixed with the sample to make copies of each smaller strand. The strands are then mixed with tagged DNA bases, which are the letters from which the DNA coding is composed. At each letter on the original strand a complementary base pair will attach itself (A to T, C to G) and when this process is complete a picture is taken of each fragment. The order of colours resulting from the tagged letters allows the computer to read the sequence and stitch all the fragments together5. The aim of personalised medicine is to compare the differences in the sequences between healthy and unhealthy patients, searching for the codes which may be causing the disease and treating patients accordingly. It is important to note that there are many differences between the genomes of all individuals, and not all these are consequential. It is the job of analysts to begin searching for the differences in coding which are responsible for causing diseases. Looking at the sequence

NHS UK

NHS 3 Core Principles

Medical Dictionary, Farlex and Partners

How to Sequence the Human Genome, Mark J Keil

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produced will allow medics to design personalised treatment plans for each patient, targeting their precise strain of the disease with detailed knowledge of how a person will react to a course of treatment before it is prescribed. Personalised medicine also considers the environmental factors influencing the lives of patients. For example, the management of Hepatitis C ‘relies upon a genetic response, but non-genetic factors such as age, obesity and alcohol consumption affect the treatment outcomes.’6 Currently, after diagnosis the course of treatment takes a more ‘trial and error approach’7 during which medicines are prescribed until the correct drug and dosage are found; the aim of personalised medicine is to avoid this process. It is helpful to analogise the process as one like visiting a tailor, as all treatment plans can be made exactly to measure. Considering the positive implementations of this method of treatment, it is difficult to understand why NHS funding is not automatically provided. The NHS was the ‘world’s first health service to launch a genomics medicine service’8 when it started the 100,000 Genome project, allowing it to sequence the genome of patients with rare genetic diseases and refer to these sequences during the diagnosis of other patients. This may suggest that as it is world renowned for genomic research, accelerating its research into personalised medicine may be an obvious path to take; however the NHS is currently in economic crisis. The total NHS funding was around £124 billion9 in 2017, with £100 billion of this being used simply to keep the trust running from day to day. This does not leave much money for research or new initiatives as it must also cover areas such as training, equipment, and education. The ‘five year forward view’ estimates that the NHS is short of £30 billion10 that it requires to continue meeting patient needs in the next five years, whilst the government is only prepared to provide an additional £10 billion11 across these years. Many funding announcements which may appear as additional funds are actually reassignment of funds already provided12, over which NHS employees have little control meaning the trust often do not have money to assign to other projects. There is a great concern that ‘more money will be diverted from transformation and transferred to reaching financial balance’13 which will have detrimental implications on both the day to day running of the NHS and future research projects. This data suggests the primary focus of the health service should be not on innovative research but instead on keeping the service running for those who need it. A compelling reason NHS funding would be beneficial to associate with personalised medicine is the recent discovery of the utility of biomarkers, as this is fast-tracking the success of personalised medicine. A biomarker is ‘a characteristic that is objectively measured and evaluated as an indicator of normal biological or pathogenic processes or pharmacological responses to a therapeutic intervention.’14 These are able to both diagnose a disease and examine the success of the treatment plan put into place, allowing medicine to continue to stride towards the prevention of the progression of a disease rather than a cure. A test called ‘rheumachec’ allows a sample of a patient’s blood to be tested for levels of rheumatoid, a general biomarker signalling the onset of rheumatoid arthritis. This can detect the disease ‘before the first symptomatic’15 , allowing for earlier therapy and the prevention of irreversible damage caused by the autoimmune disease. 6

Predicting HCV outcome, Navaneethan U, Kemmer N, Neff GW

What is personalised medicine? Dawn McMullan

Genomics and Personalised medicine, Gov UK

Spending on the NHS in England, Full Fact Team

BMA: NHS Funding & Efficiency Savings

Ibid.

Human Genetics Table 1

Human Genetics Table 3

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This is especially good as often this condition can go unnoticed due to its common symptoms including ‘painful joints, stiffness and fatigue.’16 Cases like this suggest the NHS should invest in personalised medicine due to its ability to prevent the progression of diseases which can otherwise go unnoticed. Drugs normally used to treat arthritis cost ‘$1,000-3,000’17 and only work in ‘2/3 cases’18 . This is a simple diagnostic test requiring only a small sample of blood, which could probably be taken during a routine GP appointment hence coming at no large additional cost to the health service. Using this test the NHS would be able to meet their core principle of ‘meeting the needs of everyone’19 without restricting the funding of other areas such as staffing. Despite this beneficial use, it is arguable that to use NHS funding for reasons like this is unfair when it could be used to research a generic treatment to benefit all sufferers. In England ‘at least 115,000 people suffer from Crohn’s disease, for which there is currently no cure.’20 Having the disease can also lead to increased chances of developing colon cancer and anaemia. A programme called IBD Bioresource is currently collecting genetic information from sufferers, however this is not necessarily personalised medicine as this will benefit a large group of people. Currently the only treatments for Crohn’s are drugs to reduce inflammation of the ileum, which is part of the small intestine, or to perform key hole surgery. A large risk of these treatments is that often the anti-inflammatory drugs are a class of immunosuppressants, leaving patients susceptible to contracting a communicable disease whilst on the course of treatment. Success stories such as that of the retro viral drugs currently being used to manage HIV show that with enough research a solution for diseases which may have previously been considered untreatable is possible. Investing in schemes such as one to find a cure or sustainable suppressant for Crohn’s disease would be beneficial to the NHS as it would display their belief in compassion, and also reduce the cost of hospital admittance from severe bouts of symptoms when maintenance treatment begins to fail. This would save money as consultations would have to occur much less frequently post diagnosis because the treatment could be prescribed immediately with appointments only for maintenance. This means more patients can be seen, reducing the strain of staff. A previous, positive use of personalised medicine was the research of the causes of severe sickness due to chemotherapy. In the 1980s, many cancer patients would begin to decline further chemotherapy due to the severe emesis (sickness). Chemotherapy is composed of a ‘cocktail’ of a variety of drugs, which each elicit different extremities of emesis. It was noticed that many patients would experience different reactions to the drugs, and there were some similarities within patients whose response did not follow the general trend. Resistant patients tended to be ‘male, Caucasian, over 60 years old, heavy smokers and alcohol dependent’21 whereas susceptible patients were generally ‘female, Caucasian or Afro Caribbean, 18-40 years old and nonsmokers or drinkers’22. This showed that genetics had to be contributing to the probability of emesis. Once these observations had been studied, the pharmacology made perfect sense as the emetic response had been triggered by the release of serotonin, which was activating 5-HT3 receptors. These receptors can be modulated by other chemicals; nicotine was found to lower the sensitivity whilst oestrogen greatly increased it. In the present day, adequate anti-emetic prophylaxis is always provided however without the analysis of the genetics contributing to the behaviours caused it would have been difficult to find the cause of this issue. 16 Arthritis

Research UK

Web MD, Biologics for RA Geri K Mertzger. Approximately £770-£2310

Web MD, Biologics for RA Geri K Mertzger

NHS 3 Core Principles

NICE Guideline CG152

Dr P Blower

Ibid.

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If genes which exhibit visible characteristics such as age and race have such a heavy influence on the reaction to a drug, it is likely that variation in the genetic coding without an obvious visible characteristic impacts a patient’s response too. The NHS strives to provide the ‘most effective, fair and sustainable use of finite resources.’23 This example of the use of genetic analysis to enhance treatment shows an effective use as patients who may otherwise refuse treatment were able to accept it with reduced adversities. However, it is arguable that this example is an unnecessary use of NHS resources as this is more pastoral than an integral part of treating a disease. The cost to sequence just one section of the genome is around $100024 , and once sequenced this information would still need to be linked with other information including the bacteria present within the patient’s bodies (their microbiome) and the chemical modifications affecting certain gene activity (their epigenome). Furthermore, additional costs would be met as this cost excludes the reagents, equipment, project management and quality control required. It cannot be ignored that if personalised medicine were to become main stream, a large proportion of clinicians would have to be trained to analyse genetic test results on a daily basis; further costs for the NHS to absorb. This suggests that such treatment goes against the NHS key principle of providing the ‘best value for taxpayers’ money’25 , for this money could instead be invested into a community project with positive outcomes. For example, projects such as the Diabetes Prevention Programme can access 26 million26 people at risk of developing type 2 diabetes designing a diet and exercise plan tailored to the individual, preventing the future need for targeted treatment. Currently it is believed diabetes has roots both in patient’s genome and lifestyle hence personalised treatment for the condition could well be on the horizon. It is preferable for the NHS to focus on projects able to target large groups of the population with a small cost per individual with the ability to prevent the need for future treatment. After all, prevention is better than cure. A good reason for investment is that the technology already exists. Machines such as the Illumina Novaseq 5000 cost $850,00027 and can ‘sequence a whole genome in just an hour’28. In addition, for diseases with a known location of mutation on the genome not the whole genome would not need to be sequenced. Considering that this initial investment of capital could be shared amongst many NHS institutions in an area, this is reasonable considering other savings it would make. Being able to make a precise prognosis would reduce the number of hospital admissions made each year and prevent the prescription of treatment unsuitable for the condition. For example, once a heart stent has been fitted a patient will receive a course of anti-clotting medication, usually clopidogrel. 30%29 of the world population have a mutation making them resistant to this drug, leaving them at risk of a heart attack due to the clot. Considering that ‘300-500 per million per population’30 in the UK are being fitted with a stent, many of them are at risk of developing a clot and then having to be admitted with a cardiac arrest. This mutation is easy to diagnose as its location is known hence will save the NHS money as they would not need to pay for a hospital stay and treatment of a cardiac arrest. The sequencer can also be used to see when treatments that may be costly such as antihypertension drugs may not work before they have been prescribed, as they can look for a known

NHS 7 Key Principles

Genome.gov. Approximately £770

NHS 7 Key Principles

NHS DPP

The San Diego Union Tribune

Ibid.

UF News

National Audit of Percutaneous Coronary Interventions Annual Report 2014

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mutation in a certain position. This supports the core principle of the NHS ‘meeting the needs of everyone’31 as patients can have confidence in their treatment plan. Despite this positive use of equipment, there are many moral issues. A patient may have an undiagnosed medical condition not related to the malady they are seeking treatment for, hence it would be difficult for clinicians whose area of expertise is not that of the alternate problem to make predictions from the sequence to query with experts in the field. Worse than this, they may not notice these other mutations as being negatively consequential hence will have a risk of not displaying the ‘highest standard of excellence and professionalism’32. Analysis of the genomes is largely based on comparison with other genomes, yet it is impossible to sketch the ‘perfect’ genome and hence be able to identify all dangerous mutations. Finding possible other sources of health issues will lead to a large increase of desired access to diagnostic techniques such as MRI and CT scans which could deprive other patients with greater needs for these systems such as suspected cancerous tumour for accessing them. This could also end up costing the NHS more money as they would have to invest in more diagnostics equipment and specialists. Screening one person’s genome may also highlight potential issues which could be hereditary, hence causing a wide spread panic among third party relatives. Considering the NHS is a public service, it would be hard for the government to consider whether other organisations such as the police should be granted access to these sequences when hunting down criminals. When one considers each of these ethical dilemmas, it is difficult to conclude if genome sequencing is moral. The concept of personalised medicine is appealing to NHS clinicians as they will be able to diagnose and treat the disease with fewer complications. The usage of biomarkers, prevention of unnecessary discomfort to patients and savings made by no longer prescribing ineffective treatment plans are attractive however it is arguable that this practise is unethical and the limited funds could be better spent. It is vital for this area of medical research to be developed across the next decade, yet at present there are few examples of genetic analysis leading to a wide spread breakthrough. Identifying common consequential mutations has located many future drug targets however at present more analysis techniques of the data, such as prediction algorithms, are required. Despite all of this, NHS funding into personalised medicine would most definitely be beneficial. Once the database of human genome profiles has expanded and analytical techniques have been developed, remarkable treatment plans could be put into place with higher success rates, therefore reducing unnecessary spending. Treatment will remain ‘free at point of delivery’33 due to savings made from the prevention of prescribing ineffective courses of medicines. ‘If you pair the right person with the right drug, you will be spending more money but to buy more health.’34

NHS Core principles

NHS 7 Key Principles

NHS 3 Core Principles

Dr Dhruv Kazi

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Bibliography NHS UK: NHS, ‘The NHS in England’, NHS Choices, accessed September 1st 2017, www.nhs.uk/ NHSEngland/thenhs/about/Pages/overview.aspx NHS 3 Core Principles: NHS, ‘Principles and values that guide the NHS’, NHS Choices, Accessed August 8th 2017, http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx Medical Dictionary, Farlex and Partners: Farlex and Partners, ‘Personalised medicine’, The Free Dictionary, accessed 31st July 2017, medical-dictionary.thefreedictionary.com/personalised+medicine How to sequence the human genome: YouTube, ‘How to sequence the human genome’, TED-Ed, accessed 31st July 2017, https://www.youtube.com/watch?v=MvuYATh7Y74 Predicting HCV Outcome: TherapAdv Gastroenterol, ‘Predicting the probable outcome of treatment in HCV patients’, Navaneethan U, Kemmer N, Neff GW Published 2009 September; 2(5): 287-302 What is personalised medicine?: Genome, ‘What is personalized medicine?’, Genome, Dawn McMullan, accessed 31st July 2017, http://genomemag.com/what-is-personalized-medicine/ #.WalYTSiGOuU Genomics and Personalised medicine, Gov UK: GovUK, ‘Genomics and Personalised medicine: how partnership with the UK can transform healthcare’, Accessed 8th August 2017, https://www.gov.uk/ government/ publications/the-uk-your-partner-for-genomics-and-personalised-medicine/genomics- andpersonalised-medicine-how-partnership-with-the-uk-can-transform-healthcare Spending on the NHS in England, Full Fact Team: Full Fact Team, ‘Spending on the NHS in England’, accessed 8th August 2017 https:// fullfact.org/health/spending-english-nhs/ BMA: NHS Funding & Efficiency Savings: BMA:NHS Funding and Efficiency Savings public document. Accessed 8th August 2017 Human Genetics Table 1: NCBI, ‘Table 1’, Important terms in biomarker studies, accessed 24th August 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432208/table/Tab1/ Human Genetics Table 3: NCBI, ‘Table 3’, Examples for biomarkers in current use, Accessed 24th August 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432208/table/Tab3/ Arthritis Research UK: Rheumatoid Arthritis, ‘What are the symptoms of arthritis?’, Arthritis Research UK, accessed 24th August 2017, http://www.arthritisresearchuk.org/arthritis-information/ conditions/rheumatoidarthritis.aspx Web MD, Biologics for RA Geri K Mertzger: Wed MD, ‘Biologics for RA: Costs and Insurance’, Geri K Metzger, accessed 24th August 2017, http://www.webmd.com/rheumatoid-arthritis/features/ra-biologicscost#1 NICE Guidline CG152: NICE Guidline CG152, 2012 quoted from the House of Commons Library Deabte Pack CDP-0043 ‘Treatment of Crohn’s & Colitis sufferers in Englans’ by Alex Adcock and Tom Powell accessed 24th August 2017 Dr P Blower: Primary source from email contact with Dr P Blower, pharmacologist NHS 7 Key Principles: NHS 7 Key Principles, ‘About the NHS’, NHS choices, accessed 15th August 2017, http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx genome.gov: Genome.gov, ‘The Cost of Sequencing a Human Genome’, National Human Genome Institute, Accessed 16th August 2017, https://www.genome.gov/27565109/ the-cost-of-sequencing-a-human-genome/ NHS DDP: ‘NHS Diabetes Prevention Programme’, NHS England, accessed 16th August 2017, https:// www.england.nhs.uk/diabetes/diabetes-prevention/ The San Diego Union Tribune: ‘New machines sequence genome in an hour, illumina announce’, Bradley J Fikes, The San Diego Union Tribune, accessed 15th August 2017, https:// www.england.nhs.uk/diabetes/ diabetes-prevention/ UF News: Science&wellness, ‘Personalized medicine drives better outcome for certain heart patients, Doug Bennett, UF News, accessed 15th August 2017, http://news.ufl.edu/ articles/2015/11/personalized-medicinedrives-better-outcomes-for-certain-heart- patients.php National Audit of Percutaneous Coronary Interventions: Annual Report 2014 accessed 15th August 2017 https://www.ucl.ac.uk/nicor/audits/ adultpercutaneous/documents/2014-annual-report.pdf Dr Dhruv Kazi: Personalised medicine, ‘Better results, but at what cost?’, CNBC, accessed 8th August 2017, https://www.ucl.ac.uk/nicor/audits/adultpercutaneous/documents/2014- annual-report.pdf

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Howard Essay 2017-2018: Highly Commended

To what extent was Wall Street’s 2008 banking crisis inevitable? Erin Chakartash The 2008 financial crisis affected individuals, firms and governments worldwide: it was truly ‘the global financial crisis’. A banking crisis in particular is a situation occurring within a fractional-reserve banking system - simply a system whereby banks tend to only keep a small proportion of their assets in cash. In this system, a large majority of clients withdraw cash from deposit accounts with a financial institution at the same time because there is speculation that the financial institution may become or is insolvent (unable to pay money owed); the clients then keep this cash or transfer it onto other assets - the most common being government bonds (Financial crisis of 2007–2008, 2017). If the clients transfer the funds to a different financial institution it is known to be a capital flight. As a banking crisis begins, it is clear to see that momentum can easily be generated: as more people withdraw cash, defaults become more common, activating further cash withdrawals; this can cause trauma for banks to the point where their cash supply becomes extinct, therefore causing bankruptcy (Financial crisis of 2007–2008, 2017). It is often argued that the main root of the financial crisis in its entirety was the subprime mortgage bubble. (Connor & Bernhardsson, 2016). Subprime mortgages are quite simply mortgages that are given to clients with lower credit ratings, thus the people to whom these mortgages belong have a higher than average chance of defaulting on their loan. These became so popular for a number of debatable reasons; however, one apparent reason was a result of the US government’s lax regulations, which led to predatory lending in the private sector - particularly after 2004 where anti-predatory state laws were overrode by the federal government. (Financial crisis of 2007–2008, 2017). A 2012 OECD study claimed that bank regulation reinforced the financial crisis by encouraging unconventional business practices; banks witnessed high levels of deregulation not just during the financial crisis, but many years before it too. Jimmy Carter’s Depository Institutions Deregulation and Monetary Control Act of 1980 (DIDMCA) eliminated numerous restrictions that banks initially had on their financial practices; more specifically, it broadened their lending powers, allowed credit unions and savings from loans to offer checkable deposits, and increased the deposit insurance limit from $40,000 to $100,000 in the US. (Financial crisis of 2007–2008, 2017). As rules became more relaxed it lessened depositors’ intensity of examination of lenders’ risk management policies. It is clear to see, therefore, that lenders were able to make riskier loans, but why did they want to make such loans? With respect to subprime loans at the time, many may have suspected that the borrowers would not be able to maintain their payments in the long run, meaning the loans were not going to be worth much (Rhee, 2014); however, as there were so many buyers of these loans, originators did not concern themselves with the potential long-term consequences of making them (Rhee, 2014). Once the loans were sold, the originators bore no risk so there was no incentive for them to study the long-term value of the loans; they were making big money and moral hazard was in place: one person took more risks because another person would bear the costs of those risks. From this point of view, it’s fair to assume the banking crisis was not inevitable, as deregulation of banking laws began to take its effect in 1980 and rules became continuously more relaxed for over two decades after, moral hazard began to take its toll, and it was possible to predict a future collapse of the banks due to the worryingly large amount of predatory loans banks were making.

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Contrastingly, the University of Warwick’s key features of the financial cycle states that the cycle begins with an upswing: house prices increase, causing household borrowing to increase, meaning bank borrowing will increase; this is a positive feedback process (Fuentes, 2016). The second stage of the cycle is that these upswings often end with a decrease in house prices and a banking crisis, because, as so many people borrow money from banks simultaneously and most of the capital in a bank is tied up in investments, the  bank's liquidity will sometimes fail to meet the consumer demand. There are also “stylised facts about the financial cycle” (Fuentes, 2016) – one of which is that “the inter-relationship between banks and housing is central to the financial Cycle; Peak of financial cycle often followed by banking crisis” (Fuentes, 2016). This is exactly what happened to trigger the banking crisis of 2008: subprime lending occurred, which was the peak of the inter-relationship between banks and housing as part of the financial cycle, thus the banking crisis followed. In respect to this, it can be argued that the banking crisis of 2008 was inevitable because there are key features of the financial cycle which dominate global finance; these key features align perfectly alongside what occurred on Wall Street in 2008 to convey the crisis had to happen as part of a cyclical process. Tantalisingly, there were some who came close to predicting the disaster of the crisis. Nouriel Roubini, chairman of Roubini Global Economics, was a New York University professor. In 2006, Roubini predicted there was a looming credit and housing bubble crisis in the US, so, in an address to the International Monetary Fund, he warned of the risk of a deep recession that was to be contagious to the rest of the world (Cooper, 2015). The reason being - there was a serious lack of market discipline (Cooper, 2015). It’s easy to agree with Roubini blaming a lack of market discipline, after all, as early as 1997, Federal Reserve chairman Alan Greenspan fought to maintain a completely unregulated derivatives market (Financial crisis of 2007– 2008, 2017); with a group of financial specialists he persuaded Bill Clinton to allow the self-regulation of the market when they enacted the Commodity Futures Modernisation Act of 2000. This was an over-the-counter market - trading was done directly between two parties without any supervision of the exchange. With there being real markets that took no records of exchanges, a lack of market discipline is clearly a valid reason for Roubini to have predicted such a drastic crisis. Similarly, Roubini also stated that conflicts of interest were what could trigger a banking crisis. Conflicts of interest can arise due to the relatively short horizons of political policy makers, for example, the conflict of interest arises between politicians’ short-term chances of re-election and the long-term benefit of the country/ community (Smaghi, 2009). The failure of Lehman Brothers is debatably one of the milestones of the banking crisis where this situation was prominent. After having spent significant amount of public money to contribute to the rescue of Fannie Mae and Freddie Mac, and other bailouts, the US treasury became severely constrained in its ability to use additional money to help yet another investment bank, whose misbehaviour was at the source of the crisis and whose managers had been accumulating fortunes. Though this is a less obvious reason to predict the crisis, Roubini was clearly correct, and with Lehman Brothers, the fourth largest investment bank in the US at the time (Investopedia Staff, 2017), filing for bankruptcy at the start of the crisis, it should have been easily seen that a banking crisis was very soon to sweep the nation. However, history suggests a trend in economic recessions: the UK has experienced one every decade for the past four decades, and the US is the same for the past six decades. Before 1940, both the US and the UK experienced recession every ten years too (Young, 2009); history would thus conclude that recessions simply are inevitable and it is the opinion of economist Tiffany Young that recessions often represent market corrections, and are not only inevitable but are to be welcomed in some scenarios so that factors of production can be transferred from inefficient uses to efficient ones. This means that recessions often solve a misallocation of resources to prevent the further deepening of a market failure, causing a market failure’s current situation to improve and, in respect to a banking crisis, the relationship between banks and housing would only improve, making a banking crisis either not occur or have a lesser impact than it previously had. Evidently, history connotes economic recessions as being part of a cycle, therefore banking crises are often formed along with them. Recessions and banking crises as a whole are debatably inevitable when looking at

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historic patterns, but, when left to run their own course, they are often thought to solve themselves too as part of an ongoing natural process. Regulators often attempt to limit the issue they are experiencing with rules that state requirements for capital and curbs on leverage, but such rules are always overtaken by financial innovation (Buttonwood, 2014); this was the case in respect to regulation on Wall Street in 2008. The innovation is difficult to assess beforehand, for example: unlike a prescribed drug, financial products cannot be tested in advance (Buttonwood, 2014). However, this is not to say that stopping the regulation of banks at the time of the crisis would have prevented it from happening, because banks were so unregulated as to allow the insurance deposit limit to reach $100,000 that some economists would argue they may as well have had no laws/regulations at all. If regulators were to have favoured a system based on general principles rather than a rule-based system, it would have resulted in mass uncertainty over what is permitted and what is not. On Wall Street during 2008, the American authorities responded to the crisis by opting for a highly complex regulatory regime, this prevented the uncertainty of a system based on general principles, but it is safe to say there was definitely still uncertainty on Wall Street (and the rest of the world) during the time of the crisis, because each new rule the authorities created worsened the burden for the regulators as well as the whole banking industry: “supervisors cannot hope to keep track of all infractions” (Buttonwood, 2014). The credibility of the regulatory system was reduced as rules began to be continuously evaded, thus Wall Street’s 2008 banking crisis may well have been inevitable because if the US used a general principle-based system, mass hysteria would have been prominent, but a rules-based system only caused the same thing – no type of regulatory system could have prevented this banking crisis from occurring. On the other hand, “The crisis was the result of human action and inaction, not of Mother Nature or computer models gone haywire,” (the Financial Crisis Inquiry Commission, 2012). “The captains of finance and the public stewards of our financial system ignored warnings and failed to question, understand and manage evolving risks within a system essential to the well-being of the American public. Theirs was a big miss, not a stumble.” (the Financial Crisis Inquiry Commission, 2012). Alan Greenspan was a free market advocate who persuaded Congress to strip the Commodity Futures Trading Commission (CFTC) of its power because someone named Brooksley Born who, from the moment she entered the CFTC, fought to rein in credit-swap derivatives (M., 2013) – this was a move that could have greatly lessened the impacts of Wall Street’s banking meltdown and the financial crisis, or even averted them completely. Greenspan fought to strip the CFTC of its power because of Born, with the dramatic irony of his reasoning being that her antiderivatives stance would “cause a financial crisis” (M., 2013). Congress sided with Greenspan to strip the CFTC of its powers but also force Born out – they did not only ignore the warnings she had given but also removed her from her job, “resulting in recession, mass-unemployment, skyrocketing prices, and half a decade of political instability” (M., 2013). Taken from an official report, it can be seen that, to the Financial Crisis Inquiry Commission, the banking crisis must not have been a one-off event due to natural processes, but a mass error caused by individuals that stood at the top of Wall Street’s financial sector and ignored multiple warnings – one figure famous for doing so being Alan Greenspan. On the contrary, Richard M. Salsman is the chief market strategist of InterMarket Forecasting Inc., and believes that the banking crisis of Wall Street, and the financial crisis as a whole, are much too often blamed on greed and free market capitalism. Salsman believes “the real cause – which has yet to be acknowledged, let alone curbed or removed – was government intervention in markets” (Salsman, 2013). After all, the Federal Reserve did manipulate interest rates and deregulated housing, banking and mortgages (Salsman, 2013), as we are aware from the vast amount of subprime lending that occurred to cause the collapse of massive investment banks at the time, such as Lehman Brothers. As years passed and the Federal Reserve intervened, moral hazard became continuously more prominent before the crisis, but the reason for this is because the government encouraged reckless financial practices through their regulations of housing, banking and mortgages. It was noticeable at the time that moral hazard was present and was a major concern, but if the steps were retraced back to the root of the issue one would find that the Federal Reserve actually

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created the problem is the first place by intervening too much with the free working markets, thus the banking crisis could have been inevitable because the Federal Reserve only attempted to improve the banking sector, but they ironically ended their attempt by doing the complete opposite – it was impossible to predict the outcome of their actions. In conclusion, Wall Street’s 2008 banking crisis was certainly a catastrophe which led to further disasters worldwide. It can be argued that the crisis was inevitable because of historic trends which illuminate recessions and crises as being part of an ongoing natural process within the financial cycle, as well as the reality of the situation being this: the Federal Reserve’s regulations triggered consequences in which nobody could have predicted exactly what would have happened. However, the fact that some did predict the banking crisis in general, and its knock-on effects, implies that these regulations were extremely risky to put into place, and the way those at the top of the financial system were so supportive of deregulation is a legitimate reason to argue that the crisis was not inevitable, but was, in fact, predictable. Overall, it can be concluded that the crisis was actually not inevitable because, despite crises and recessions being a natural part of the economic cycle, there was no need for a banking crisis in 2008 – one was simply created by moral hazard being triggered as a result of the overly generous amount of deregulation by the Federal Reserve, all for the self- indulgent CEOs of Wall Street’s banks at the time.

Bibliography Authers, J., & Smith, A. (2017, August 6). The warnings from history that Wall Street ignored. Financial Times. Buttonwood. (2014, January 25). The inevitability of instability. Economist.  Chan, S. (2011, January 25). Financial Crisis Was Avoidable, Inquiry Finds . The New York Times.  Connor, K., & Bernhardsson, E. (2016, November 4). loan officer commission. Retrieved from better: https://better.com/content/5-reasons-why-loan-officer-commission-is-bulls-t/  Conway, E. (2009, October 1). An inconvenient truth: financial crises are inevitable. Telegraph.  Cooper, C. (2015, July 7). 6 economists who predicted the global financial crisis. InTheBlack. Ferguson, C. (Director). (2011). Inside Job [Motion Picture].  Financial crisis of 2007–2008. (2017, August). Retrieved from Wikipedia: https://en.wikipedia.org/wiki/Financial_crisis_of_2007%E2%80%932008 Fuentes, S. P. (2016). Financial Crises. Retrieved from The University of Warwick: http://www2.warwick.ac.uk/about/london/study/warwick-summer-school/courses/banking/ 04_financial_crises.pdf  Harford, T. (2013). The Under Cover Economist Strikes Back. Great Britain: Abacus. Herlin, P. (2017, February 16). ENDLESS FINANCIAL CRISES ARE INEVITABLE – HERE’S WHY. Retrieved from Goldbroker: https://www.goldbroker.com/news/endless-financial- crises-are-inevitable-herewhy-1085 Investopedia Staff. (2017, February 16). Case Study: The Collapse of Lehman Brothers. Retrieved from Investopedia: http://www.investopedia.com/articles/economics/09/lehman-brothers-collapse.asp Ivashina, V., & Scharfstein, D. (2009, October). Bank Lending During the Financial Crisis of 2008. Retrieved from Moody’s: https://www.moodys.com/microsites/crc2010/papers/ivashina_jfe_paper.pdf Kansas, D. (2005). Complete Money & Investing Guidebook. New York City: Three Rivers Press.  M., M. (2013, October 8). 10 Deadly Warnings The World Ignored. Retrieved from Listverse: http://listverse.com/2013/10/08/10-deadly-warnings-the-world-ignored/  Rhee, J. (2014, March 18). Corporate Governance and Financial Regulation. Retrieved from Harvard Law School Forum: https://corpgov.law.harvard.edu/  Salsman, R. M. (2013, September 19). The Financial Crisis Was A Failure Of Government, Not Free Markets. Forbes.  Slovik, P. (2012, December 11). Systemically Important Banks and Capital Regulation Challenges. Retrieved from OECD iLibrary: http://www.oecd- ilibrary.org/economics/systemicallyimportant-banks-and-capital-regulation- challenges_5kg0ps8cq8q6-en Smaghi, L. B. (2009). Conflicts of Interest and the Financial Crisis. Retrieved from LorenzoBiniSmaghi:

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http://www.lorenzobinismaghi.com/documents/pubblicazioni/2009/ International%20Finance%20Conflicts%20of%20Interest.pdf  Swift, J. (2011, November 22). Lest We Forget: Why We Had A Financial Crisis. Forbes.  the Financial Crisis Inquiry Commission. (2012). Crisis on the Horizon. In The Financial Crisis Inquiry Report, Authorized Edition: Final Report of the National Commission on the Causes of the Financial and Economic Crisis in the United States (p. 576). New York City. Young, T. (2009). Are economic recessions inevitable? Retrieved from Res: http://www.res.org.uk/ SpringboardWebApp/userfiles/res/file/RESYE09-TiffanyYoung.pdf

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L’infatigable Dessinateur du Ciel Maurice du Matheray (1892-1955) was a dentist in the Canton of Vaud who also devoted time within a span of 40 years to producing thousands of drawings of the sun, the planets of Mars, Jupiter, the moon and the stars. A plaque hangs inside le Musée d’histoire des Sciences in Geneva, Switzerland. It reads ‘L’infatigable Dessinateur du Ciel’, ‘The person who never tired of drawing the sky’.

An entomological quiet became the setting for that night Reeds blew through their teeth A young boy lays on his side Trailing fingers into the water as it lapped at his wrist Watching constellations disintegrate into stardust at his brush Scattered wishes of children lost in the ripples. Sitting up, he swirls his net into the lake - distorted light falls through And yet again he is left empty handed. Yet another young boy who wanted to swallow the moon expecting to breathe lullabies. How many times had a child yearned for something they couldn’t have? His curiosity for space, astronomical manna for the mind. Could he ever collect the stars? Could he ever catch the comets that looked like thrown ends of angels’ cigarettes? An ethereal plea echoes in the earth beneath his feet To which he holds a hand to the sky As if to tell the universe to wait for him As if to throw his Fortunes to infinite boundaries

-I am but a small droplet in the great lake of the universe-My time here is only a passing to prepare me for my return-

Suli Scatchard

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First - Check! Ada Wojtyna It happened about six months ago. The unbearable earache suddenly trapped me just before my exams. Not only couldn’t I focus on revision, but I also was not able to do any simple tasks - a doctor’s appointment seemed inevitable. “I will prescribe you antibiotics,” the doctor announced after just a couple of minutes of interviewing and a brief examination. At first sight, his answer might have seemed justified, since painful symptoms may indicate bacterial inflammation, however… what if the infection was caused by a virus? How did the doctor know that it was caused by bacteria after such a short appointment? If you think that there is nothing to worry about, bear in mind that antibiotics only eliminate bacteria and have no effect on viruses. Their overuse will not result in the improvement of the patient’s state in the case of the viral illness and may only lead to one of the biggest issues of the 21st century - antibiotic resistance. By 2050, infections caused by bacteria resistant to antibiotics are estimated to be the major cause of death, even more common than cancer, which kills 8 million people every year. WHO estimated that in 2014 there were about 480,000 new cases of multidrug resistant tuberculosis, and about 50% of cases were treated successfully. Consequently, I strongly believe that society’s attitude towards antibiotics calls for a rapid change, both among the doctors and among the patients. The way in which a therapy is chosen requires a throughout rectification. A rapid development of that phenomenon is largely influenced by the overuse of antibiotics and over prescription of such remedies by medical staff. The experience I delineate in the introduction is an example of the widely applied approach towards the therapy choice all over the world. Additionally, more often than not, patients request a prescription of the antibacterial therapy themselves. Life under stress, work overload and constant pressure requires us, the 21st century society, to be constantly available and to be permanently ready to tick off consecutive tasks from our seemingly endless list of duties. Antibiotic therapy gives a projection of an instant recovery, and in turn acts as a tempting alternative for those in the constant rush. Since this issue presents a global challenge and may well result in an international health crisis in the upcoming years, steps need to be implemented immediately to inhibit its quick development. One of the solutions I would implement is the application of narrow-spectrum antibiotics to fight only pathogenic (disease causing) organisms. By using this method, resistant microorganisms will have restricted opportunities to spread due to the presence of other bacteria unaffected by the medicine. Although such approach has huge potential to stop the promotion of resistance without a need of resignation from antibiotic therapy, it requires the prior identification of a germ responsible for the inflammation. In consequence, each prescription of such a treatment should be preceded by the analysis of the patient’s body fluids to detect microorganisms. Therefore, each local surgery should be equipped with a device that provides a rapid and low-cost method of bacterial identification and consequently allows to choose a right drug targeted at a specific pathogen. Furthermore, all powers of science should be incorporated in the process of design and rectification of such processes to boost their availability worldwide. As a result, I am strongly involved in the promotion of this solution and raising awareness about antibiotic resistance. I decided to participate in the fight against antibiotic resistance and conducted my own research, which resulted in the design of the fast, green and cheap way of bacteria identification using their ‘fingerprints’ collected with Raman spectroscopy. The popularisation and industrialisation of my solution may find application in hospitals and will facilitate the choice of a narrow-spectrum antibiotic. I hope that in the near future the attitude of doctor and patients towards antibiotic therapy will change drastically. I would like each patient to be granted the possibility to undergo painless tests for microbial identification, and to be prescribed a drug suited for his or her medical conditions. Just a couple of additional seconds for the analysis may visibly change the world and saves millions of people’s lives in the future.

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Mitchell Essay 2017-2018: Winner

The Role of the Placebo Effect in Medicine Yasmin Antoniou “If you can believe fervently in your treatment, even though controlled tests show that it is quite useless, then your results are much better, your patients are much better, and your income is much better too.”1 These words by Richard Asher refer to the power of the placebo effect, a phenomenon which sees a recipient reporting an improvement in their condition, solely based on their personal expectations. The basic definition of a placebo (from the Latin placēbō, “I shall please”) is a substance or treatment with no active therapeutic effect, which may be given to a patient to deceive them into thinking that it is in fact an active treatment. E. Morton Jellinek is credited with first recognising the placebo effect in post-war 1946, when pharmaceutical chemicals were in short supply. Jellinek was asked by a headache remedy manufacturer to test whether their drug’s efficacy would be affected by the absence of one of the three constituent chemicals, which was running out. In order to investigate, Jellinek set up a complex trial with 199 subjects divided into four groups. Each group was given a different permutation of the drug, with one group being given a placebo to act as a scientific control, and then proceeded to take each drug for two weeks. At the end of the eightweek period, Jelinek found that 120 of the 199 participants had responded to the placebo drug, and therefore described this group of subjects as being “reactors to placebo”; the first time anyone had spoken of placebo responses. The placebo effect can be more effective for some conditions than others and has proven to work most strongly upon conditions such as pain, swelling, depression, anxiety and stomach ulcers. A phenomenon known as placebo analgesia, which is the ability of a placebo to reduce pain, can work in two different ways; either by the placebo initiating the release of endorphins (natural painkillers produced by the brain)2, or by altering the patient’s perception of pain. However, the introduction of a placebo can also, in some cases, have a detrimental effect on the health of the patient if they have negative expectations about their treatment. This is often referred to as the nocebo effect (from the Latin nocēbō, “I shall harm”), a term coined by Walter Kennedy in 1961 to denote the counterpart to the use of placebo. Common examples of placebo treatments include sugar pills, saline solution and distilled water- all of which provide no medicinal benefits but have been found to improve a patient’s condition. Studies show that the appearance of such placebos can have a measurable effect on how well they work. For instance, in 1972, Blackwell3 carried out an experiment to determine if the colour of a pill could make it more or less effective. Subjects were given either a blue or a pink pill during an hour-long lecture and were told they could be receiving either a stimulant or a sedative. Afterwards, when tested for alertness, it was found that those who had received the pink pill had been better at maintaining concentration than those having taken the blue pill. As the colour of these pills had no pharmacological significance, these findings must have been based solely on the cultural meanings of the colours; pink being alerting, whilst blue is calming. These ideas are

Richard Asher, Talking Sense

Cousins N, Head First

Blackwell B, Demonstration to medical students of placebo repress and non-drug factors

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constantly used by drug companies, with stimulant medications often coming in red, orange and yellow tablets, and antidepressants and tranquillisers largely being blue, green or purple.4 The form in which a placebo is administered can also make a great deal of difference, again, due to how the patient perceives different types of treatment. In 1970, chlordiazepoxide (a sedative), was found to be more effective in capsule form than in tablet form, simply because the capsule felt newer and perhaps more ‘sciencey’ at the time. This idea also applies to the route of administration of the drug5, with an injection being more effective than an oral tablet, as it is viewed as a much more dramatic intervention. In other cases, sham or placebo surgeries are carried out. These are surgical interventions in which the steps believed to be medically necessary are not carried out. The most common use of this method is as a scientific control in clinical trials as it can be used as a way of isolating the effects of anaesthesia, pre- and postoperative care and the surgical incision, all of which can affect the patient’s perception of how the surgery will alter their current condition, even though it will not be providing any ‘conventional’ medical treatment. In some cases, a sham-controlled intervention has proved that some surgical interventions, previously thought to be helpful, are in fact useless. For instance, it was believed that internal mammary ligation (the closing off of the internal thoracic artery in the heart) was able to improve blood flow to the heart, thus serving as a treatment for angina (a condition which causes severe pain in the chest due to an inadequate blood supply to the heart). This procedure was used for two decades before a controlled study showed that a sham surgery was just as effective in increasing blood flow to the heart.6 Double-blind, placebo-controlled clinical trials are medical studies involving human participants in which neither the patient nor the doctor is aware of who is being given an active treatment and who is being given a placebo. They can be very useful for testing whether a treatment is effective or not, as not only is the patient unaware if they have received a treatment, but they cannot be influenced by their doctor’s reactions or expectations as neither party has this information. Nearly all studies carried out in this way show an improvement in the placebo group, although they do not generally include an untreated group, so it is difficult to determine the size of the placebo effect in comparison to a totally untreated patient. The whole idea of the placebo effect is based upon the patient’s expectations and beliefs, which means that the doctor-patient relationship can play a very important part in how effectively a treatment works. This was demonstrated by Gryll and Katahn in 1978, when they gave patients sugar pills prior to a dental injection.7 The pills were given in one of two different ways: either with a positive reassurance that they were highly effective, or they were downplayed and said to have been found quite useless. Therefore, the pills handed out with the positive message were associated with less pain and less fear. Taking this idea even further, Gracely (1985) set up an experiment in an attempt to demonstrate how a doctor’s mannerisms could affect treatment outcomes by manipulating what groups of doctors believed they were administering through injections.8 This was set up as a standard double-blind trial for patients having their wisdom teeth extracted, with the possible treatments being fentanyl (a pain reducing drug), naloxone (a drug that can be expected to increase the pain of the procedure), or a placebo. For the first half of the experiment the doctors, but not the patients, were informed that, due to a supply problem, no patient would be receiving the pain-relieving fentanyl. Therefore, the patients thought they had a chance of receiving one of the three drugs, although the doctors knew there was no possibility of them receiving the pain-relieving drug. In the second group, the doctors and patients both had the same information and knew that they could be getting any of the three treatment options. Looking at the results, it can be seen that those in the first group reported much more pain than those in the 4

de Craen AJ, et al, Effect of colour of drugs

Grenfell RF, et al, Double blind study of the treatment of hypertension

Cobb LA, et al, An evaluation of internal-mammary-artery ligation by a double-blind technique

Gryll SL, Katahn M, Situational factors contributing to the placebo effect

Gracely RH, et al, Clinicians’ expectations influence placebo analgesia

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second group, which can only be due to their doctor’s unconscious actions. This study is particularly interesting as it shows just how significant such a subtle manipulation can be. It demonstrates that the patient is able to pick up on any small mannerisms, such as a slightly brighter smile or a slightly lowered tone of voice presented by the doctor, as they are unintentionally communicating their knowledge of the probability that the patient may not receive any pain relief. Another way doctors have been able to improve patient outcomes is by giving a firm, confident diagnosis, even if they are not certain about it. This was explored by Thomas in 19879 , when a group of patients were told, “I cannot be certain of what the matter is with you,” whilst another group were told they would be better within a few weeks. Consequently, two weeks later, only 39 per cent of the first group had recovered, compared to 64 per cent in the second group. As with all aspects of medicine, every individual reacts differently to placebo treatments, and for some people, a placebo is not effective at all. In a paper in 195510 , Henry K. Beecher suggested that placebo effects occurred in approximately 35% of people, although this paper has since been criticised for failing to distinguish between the placebo effect and other contributing factors, thus encouraging an inflated figure. Considerable research was carried out in the 1950s in order to determine if there was a specific personality that responded well to placebos, but no conclusion was reached. Factors found to increase the effectiveness of placebo treatments include the desire for pain relief of the patient and how far they are expecting the pain to be relieved following treatment. Furthermore, individual variation in response to analgesic placebos has been linked to regional neurochemical differences of the individuals experiencing pain.11 Patients with Alzheimer’s disease lose the capacity to be influenced by placebos, due to the loss of their prefrontal cortex dependent capacity to have expectations.12 ‑

The use of placebos has given rise to many ethical issues, although many notable medical organisations have endorsed it.13 The most frequent ethical problem raised is that the doctor is effectively deceiving the patient, and many people believe that a placebo will always be unethical due to the violation of a patient’s right to always be honestly and fully informed about treatment. Daniel Moerman stated, “The one thing of which we can be absolutely certain is that placebos do not cause placebo effects. Placebos are inert and don’t cause anything”.14 However, disclosing to a patient that they are receiving a placebo does not always diminish its effectiveness, as studies have shown that a placebo can work even when the patient is aware that it is not an active treatment. David Newman points out the “placebo paradox”15- it may be unethical to use a placebo, but also unethical “not to use something that heals”, which he suggests solving by making use of the placebo effect, only as long as the “one administering is honest, open, and believes in its potential healing power”. Today there are often circumstances in which people want treatment, but medicine has little to offer, for example: back pain, stress and the common cold. In these cases, going through a list of medical treatments will do little more than cause side effects, whereas a sugar pill seems a sensible option, as long as it is administered cautiously and without deceit. However, just as a placebo has unexpected benefits, it too can carry unexpected side effects16 , and can also, in some cases, promote the idea that a pill is a suitable solution to a social problem.

Thomas KB, General practice consultations

10 Beecher

HK, The powerful placebo

Zubieta JK, et al, Belief or need?

Benedetti F, et al, Loss of expectation

de Craen AJ, et al, Placebos and placebo effects in medicine

Moerman DE, Deconstructing the placebo effect and finding the meaning response

David H. Newman, Hippocrates’ Shadow

Shapiro AK, et al, Placebo induced side effects

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To justify the use of placebos in clinical practice, many guidelines are followed17, with perhaps the most important being that the physician is only concerned with the wellbeing of the patient and is not influenced by any economical, professional or emotional aspects. In addition to this, if the placebo is proven ineffective, the treatment should be immediately withdrawn as it can undermine the effectiveness of subsequent medications due to the patient’s expectations being lowered. A placebo should not be given in place of a treatment that can reasonably be expected to be more effective and should only be considered when a patient is not responding to any known active treatments, is suffering from side effects or is in a situation where a standard treatment does not exist. The patient has every right to ask questions concerning the nature and anticipated effects of the placebo treatment, and the doctor should respond honestly, providing all of the relevant information. In conclusion, the placebo effect can serve great purpose in many clinical situations, particularly in testing the effectiveness of other active treatments, and should therefore not be denied its rightful place in medical treatment. Ongoing research into the placebo effect continues to broaden our understanding and perhaps opens new doors for its use in future medical developments and treatments. Charles Mackay, a Scottish poet and journalist summed up the essence of the placebo effect eloquently: “The wonderful influence of imagination in the cure of disease is well known. A motion of the hand, or a glance of the eye, will throw a weak and credulous patient into a fit; and a pill made of bread, if taken with sufficient faith, will operate a cure better than all the drugs in the pharmacopoeia.”18

Bibliography Richard Asher, Talking Sense, Pitman Medical, London, 1972 Beecher HK, The powerful placebo, JAMA, 24 December 1955 Benedetti F, Arduino C, Costa S, Vighetti C, Tarenzi L, Rainero I, Asteggiano G, Loss of expectation- related mechanisms in Alzheimer’s disease makes analgesic therapies less effective Blackwell B, Bloomfield SS, Buncher CR, Demonstration to medical students of placebo repress and nondrug factors, Lancet, 10 June 1972 Cobb LA, Thomas GI, Dillard DH, Merendino KA, Bruce RA, An evaluation of internal-mammary-artery ligation by a double-blind technique, N Eng J Med, 28 May 1959 Norman Cousins, Head First, New York, 1989: E.P. Dutton, p 229-231 de Craen AJ, Roos PJ, Leonard de Vries A, et al, Effect of colour of drugs: systematic review of perceived effect of drugs and of their effectiveness, BMJ, 21-28 December 1996 de Craen AJ, Kaptchuk TJ, Tijssen JG, Kelijnen J, Placebos and placebo effects in medicine: historical overview, J R Soc Med Gracely RH, Dubner R, Deeter WR, Wolskee PJ, Clinicians’ expectations influence placebo analgesia, Lancet, 5 January 1985 Grenfell RF, Briggs AH, Holland WC, Double blind study of the treatment of hypertension, JAMA, 1961 Gryll SL, Katahn M, Situational factors contributing to the placebo effect, Psychopharmoacology, Berl Lichtenberg P, Heresco-Levy U, Nitzan U, The ethics of the placebo in clinical practice, Journal of Medical Ethics, Volume 30, Issue 6, 2004 Charles Mackay, Memoirs of extraordinary popular delusions and the madness of crowds, Richard Bentley, London, 1841 Moerman DE, Deconstructing the placebo effect and finding the meaning response, 2002 David H. Newman, Hippocrates’ Shadow: Secrets from the House of Medicine, 9 September 2008, Simon & Schuster Shapiro AK, Chassan J, Morris LA, Frick R, Placebo induced side effects, Journal of Operational Psychiatry Thomas KB, General practice consultations: is there any point inning positive?, BMJ, 9 May 1987 Zubieta JK, Yau WY, Scott DJ, Stohler CS, Belief or need? Accounting for individual variations in the neurochemistry of the placebo effect, Brain Behaviour Immunology  17

Lichtenberg P, et al, The ethics of the placebo in clinical practice

Charles Mackay, Memoirs of extraordinary popular delusions and the madness of crowds

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Mitchell Essay 2017-2018: Runner Up

To what extent is anorexia nervosa caused by nature not nurture? Isabella Clarke Anorexia nervosa is a disease characterized by an intense fear of gaining weight and a strong desire to be thin, which is achieved through restriction of food intake. Anorexia nervosa is bracketed under the term of an ‘eating disorder’, which are also defined by having abnormal eating habits. Other common eating disorders include bulimia nervosa, binge eating disorder, orthorexia nervosa, eating disorder not otherwise specified (EDNOS) and many more. However, anorexia nervosa is notoriously claimed to be the deadliest of eating disorders due to its alarming mortality rates, since one in five sufferers die1. In 2015, it was also reported that more than 725,500 people in the United Kingdom were affected by an eating disorder, with around 10% of the population suffering with anorexia nervosa2 . This has left a huge debate amongst many psychologists whom investigate what causes the disease as a way to help prevent it from developing. The nature versus nurture debate questions whether our human behaviour is determined by our genetic make-up or through the environment in which we exist. I decided to specifically investigate the extent to which the mental health condition anorexia nervosa is caused by our genes, as well as considering the degree to which our surroundings provoke the disease. However, due to the vast complexity of human behaviour, I aim not to take a reductionist approach by claiming that anorexia is influenced by either nature or nurture. Instead, I aim to carefully discuss both sides of the argument, due to its multifactorial nature. To an extent, it can be claimed that anorexia nervosa is greatly influenced by our innate, genetic inheritance. Astounding research has shown that ‘within the population, genetic factors account for over 50 per cent of the risk’3 . Recently, it has been found that biological processes suggest that many of the mechanisms that underlie anorexia are not conscious nor under wilful control. Instead, there is a network of biological systems such as the processing of information, emotions and organisation of behaviour which greatly contribute to the illness. Also, a large portion of these factors are fixed and part of our genetic makeup, supporting why many sufferers of anorexia or other eating disorders are more likely to have members in their family who also have complications around food. A study was carried out by psychologist Grice et. al in 2002 who found a strong genetic basis for anorexia. The study followed 192 families, but particularly focused on a sub-group of 37 families in which two members had been specifically diagnosed with the restrictive-type of anorexia. The results concluded that there was a susceptibility gene on chromosome one, as similar markers were found in the afflicted groups in each family. Thus, Grice et al’s research gives an acute basis for the link between anorexia and our genetic makeup. The study also has a high level of validity since it has been supported by numerous other investigations looking into the same field, for example, Scott-Van Zeeland et al’s research in 2013 and by Boraska et al in 2014.

https://www.b-eat.co.uk/about-beat/media-centre/information-and-statistics-about-eating-disorders

BEAT, The Costs of Eating Disorders – Social, Health AND Economic Impacts report, UK: PwC, 2015 Treasure, Janet, Gráinne Smith and Anna Crane, Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method, New York: Routledge, 2007 p19 3 ! 5 3

Equally, it can be argued that biological factors such as the imbalance of hormones also contribute to the development of anorexia nervosa. Many whom suffer with anorexia use starvation as a form of coping mechanism in order to maintain a low weight characterized by a Body Mass Index of below 18.5 (according to the NHS guidelines)4. Starvation has a radical effect on our hormones, particularly serotonin, which is a vital hormone since it regulates our sleeping, mood and the digestive process. Therefore, starvation can dramatically reduce the level of serotonin in your brain producing strong hunger cues and symptoms of restlessness, which links to why many sufferers of anorexia tend to develop severe mood swings. This also goes hand in hand with why sufferers of anorexia have an increased chance of developing depression and anxiety. However, over time, the anorexic typically becomes accustomed to the effects of starvation, making it become an insidious addiction. Although many sufferers do report experiencing a feeling of euphoria when coping with prolonged restricting, a memoir of a recovered anorexic, Nancy Tucker, reported that she felt like ‘a hardened starvation addict’5 when she decided to drastically reduce her food intake to lose weight. However, our ability to survive despite not ingesting an adequate amount of nutrients can be traced back to our historical roots where the human species had to adapt to the circumstances of famine, particularly in Europe between 1315 and 1317 and so, this trait was then passed on to successive generations. Thus, it can be arguable as to whether our past ability to function on a scarce amount of food and abnormally low levels of serotonin has impacted us as a species today. Maybe if the human race had been unable to cope with the strain of starvation, we may not have associated being underweight with a positive feeling. Therefore, has our nature made it easier for our generation to use starvation as a form of self-medication, as a way to make us feel in control by losing weight quickly? Or is it the parameters of society that have suggested that we will only be accepted if we look a certain way? More so, one can consider the impact that toxic, body conscious society has on individuals, which could be potentially fuelling anorexia. The rise of dieting and the lingering quest to be thin has made it appear admirable to be perceived as having enough self-restraint to look skeletal. The phrase ‘nothing tastes as good as skinny feels’ coined by fashion model Kate Moss in 20096 has made it seem commendable for society, and in particular young women, to diet in order to feel accepted. This also links to the recent research linking evidently higher rates of anorexia to those in the modelling profession compared to other female students because it is seen as more “normal” for their body size to be smaller than in other groups; this is also the case for dance students (Garner and Garfinkel 1980). The account of fashion model Victorie Dauxerre describes how she was forced to eat a mere ‘three apples a day’7 in order to receive the seal of approval from demanding fashion designers. Despite Victoire being severely malnourished, the brutal modelling industry applauded her skeletal appearance. With this in mind, it can be proven why anorexia is usually more prevalent in artistic based careers, as well as how anorexia is more popular with females; since they account for the majority of the dance and modelling profession. Following the recent statistics of the population of individuals in the United Kingdom with eating disorders, only 11% of the 1.6 million people are male, meaning that females account for the other 89% of the figure8. Hence, the typical thin frame of many fashion models can easily be critiqued for warping predominantly 4

http://www.nhs.uk/Livewell/loseweight/Pages/height-weight-chart.aspx

Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015 p191

http://wwd.com/beauty-industry-news/beauty-features/kate-moss-the-waif-that-roared-2367932/

Dauxerre, Victoire, Size Zero: My Life as a Disappearing Model, London: William Collins, 2017

http://www.priorygroup.com/eating-disorders/statistics 3 ! 6

women’s and also men’s body image, leading them to descend into the dangerous clutch of an eating disorder. Despite the recent plea which aimed to prohibit both males and females being allowed to model if under a body mass index of 18.5, one can argue whether we are doing enough to prevent eating disorders developing in the modelling industry. It is only in the last two years that the French government has been able to establish a law which requires models to be declared medically healthy by a doctor in order to participate in fashion shows as well as requiring re-touched images by Photoshop to be clearly marked in magazines9 . Any of whom fails to do so can now be fined up to 75,000 euros and up to six months in jail. However, despite the French law offering a drastic improvement, it was mainly enforced due to the harrowing amount of deaths caused that the modelling industry has accounted for; caused by anorexia. The list of deaths includes the Brazilian model Ana Carolina Reston (2006), sisters Luisel (2006) and Eliana Ramos (2007), Israeli model Hila Elmalich (2007) and famous anorexia activist and fashion model Isabelle Caro (2010). Despite this horrifying amount of deaths caused by anorexia in the modelling industry, it is still not enough for other countries such as the United Kingdom to implement the same law as France. Thus, the modelling industry could be having a hugely detrimental effect to many individuals. On the other hand, from a model’s perspective, it can be questioned whether it is fair that we should feel the pressure to censor our career choices due to the impact it could possibly have on society. Should we not be free to choose whatever career path we desire to follow, as opposed to being restricted due to the negative effects of the images published? Consequently, the nature argument examines whether from an early onset we are likely to develop anorexia due to the unrealistic ideals set by the media. Even as children, we are endorsed with toys such as Barbie dolls aimed at young girls, and action figures for boys which frames their mental expectation of what they “should” look like. It was reported ‘when the Han Solo action figure based on the Star Wars movies first came out in the 1970’s’10, the figure set an unhealthy standard for adolescence, emphasizing the importance of leanness and ever-decreasing body fat, as opposed to displaying normal human proportions. Thus, it is arguable whether we are increasing the chances of future generations developing eating disorders from the distorted perception of perfection that they are indoctrinated with from the media. Should we be producing gender neutral toys so that young girls and boys do not feel the pressure to look or dress a particular way? Furthermore, the 2002 study by anthropologist Dr Anne Becker also reinforced the link between the media and upsurge in rates of anorexia, as well as other eating disorders. Becker et al.11 specifically looked at whether exposure to Western television would trigger disordered eating in two samples of Fijan girls aged between 16 and 17. The study measured the girls’ attitude towards food in 1995 through the standardised EAT-26 Questionnaire12 which was then followed by an individual semi-structured interview. The quantitative and qualitative data gathered then gave a baseline measure for Becker to analyse and compare the results and see whether she could accept her experimental hypothesis. Becker also repeated the same procedure in 1998 with a different sample of Fijan girls aged between 16 and 17, who had been exposed to the television for three years. The results were significant and gave evidence to suggest that prolonged exposure to Western television does affect behaviour around food. 69% of the girls claimed that they had dieted at some point in their lives, as well as 29.2% of the 1998 sample having reported to have used selfinduced vomiting as a technique to purge calories; compared to in 1995 where there were no records of self-

http://www.bbc.co.uk/news/world-europe-39821036

Lock, James and Daniel Le Grange, Help Your Teenager Beat an Eating Disorder, New York: The Guilford Press, 2005, p67 10

et al. = (and others)

http://www.drshepp.com/wp-content/uploads/2015/06/eatingattitudestest.pdf 3 ! 7

induced vomiting. The study also gave light to the impact of culture influencing eating disorders. In particular, Fiji has been a culture known for having strong notions of beauty and body shape, as well as having no previous history of anorexia. Thus, the results of Becker et al’s investigation can highlight the damaging effect of the media on teenage girls; the pressure to appear slim could easily influence one to start restricting their intake, which could consequently spiral into anorexia. On the other hand, it can also be argued that nurture alone does not cause anorexia due to the evidence provided by twin studies. Many psychologists use the study of twins as a way of separating the degree to which behaviour traits are triggered by either the environment or through our genes. In March 2000, psychologist Tracy Wade from Flinders University in Australia conducted a study investigating the rates of anorexia in monozygotic (MZ) and dizygotic (DZ) pairs of twins13 . The aim of the twin study was to examine the similarities and differences between MZ and DZ twin pairs to identify and delineate genetic and environmental causes for a particular trait; in this circumstance, abnormalities around eating. Wade assessed an opportunity sample of 2163 females and concluded that anorexia nervosa was estimated to have a heritability of 58%. This significantly suggests that genetic factors do contribute to anorexia since MZ twins share 100% of their DNA; as well as DZ twins sharing 50% of their DNA from their parents. Nevertheless, another factor to consider when assessing what causes anorexia is our childhood experience. Renowned psychologist Sigmund Freud is widely established as the founder of psychoanalysis, which is a set of therapeutic techniques that study the unconscious mind. The term ‘psychoanalysis’ was coined by Freud in France in 1986 and has now been utilized by psychologists ever since. When analysing what causes anorexia, Freud investigated the oral period in adolescence and claimed that ‘orally fixated people may develop a serious eating disorder, anorexia’14 since they may tend to eat when particularly stressed or lonely. The oral period in a child’s development corresponds to the child’s first concerns with nourishment; the child begins to understand their own frustrations of hunger and thirst. Therefore, a child may begin to suck his thumb even after having sucked his mother’s breast for milk, since he or she begins to understand that one can achieve that same feeling of satisfaction without his or her mother being present. Despite the habit of thumb sucking being regressed as the child matures, it still remains powerfully in the unconscious mind. Thus, if the adult goes back to sucking his/her thumb at a later period in their life, they may regress into a time of feeling younger, which may account for the need of sufferers of anorexia to become small again. The memoir of ‘Hunger and Hope’ by Nancy Tucker describes how she once felt ‘overwhelmed by the prospect of change… unprepared for the physical changes of puberty and the expectation of increased independence during adolescence’15. Thus, the term regression can be used to describe one returning to a point of fixation when a person is frustrated or frightened. Therefore, someone with anorexia, like Nancy, could use the fixation of being young and child-like again as a way of gaining control without being able to see themselves being consumed by the eating disorder. Freud’s hypothesis of anorexia sufferers trying to regress to a childlike state provides a convincing basis for the nature side of the argument. Equally, psychologists such as Hilda Bruch in 1980, also traced the origins of the illness in early childhood. Bruch claimed that anorexia is the result of poor parenting and the struggle of the child for independence from the mother. Therefore, in adolescence the child faces a struggle to break free from their mother causing the child to not develop self-reliance and become more sensitive to criticism than others. This then causes the child to feel ineffectual and so anorexia is the tool by which he or she can exert self-control through restricting their food intake. Thus, the mother’s continuing relationship problems 13

http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.157.3.469

Kahn, Michael, Basic Freud: Psychoanalytic Thought for the 21st Century, New York: Perseus Books, 2002, p43 14

Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015 p96 3 ! 8

with their child encourages the immaturity and leaves the mother more of a desire to retain dependence. As the sufferer of anorexia starts to stop eating, this avoids the consequences of puberty such as menstruation in girls, development of breasts and hair growth; more broadly avoiding the worries that arrive with adulthood. Therefore, Bruch’s explanation for anorexia accounts for why the illness is most commonly developed in males and females between the ages of 14 and 2516 and why anorexia is more likely to develop in families since the child can be predisposed by their parents negative or positive behaviour around food. In conclusion, one can argue that anorexia can strongly be proven to be caused by nature due to the research provided by science about our genetic make-up. However, it would be impossible to pinpoint the disease as a product of a single cause since equally, the nurture elements significantly give a basis as to why anorexia develops- such as the evidence of Bruch and Freud. Due to the illness being very personal, I focused specifically on anorexia nervosa to give a realistic depiction of the eating disorder. Despite the insidious nature of anorexia and the pain it has inflicted on my family and I, it has undoubtedly given me an invaluable insight into society which I am truly grateful for. Without the awareness of the factors that may have triggered my own experience of anorexia, such as our genetic inheritance, I certainly would not have the broad understanding of my illness that I have today. I would like to say that I am extremely hopeful in time, more will be done to help reduce the spread of all eating disorders and that those who are suffering are able to find a voice and speak out about their struggles.

Bibliography https://www.b-eat.co.uk/about-beat/media-centre/information-and-statistics-about-eating-disorders BEAT, The Costs of Eating Disorders – Social, Health AND Economic Impacts report, UK: PwC, 2015 Treasure, Janet, Gráinne Smith and Anna Crane, Skills-based Learning for Caring for a Loved One with an Eating Disorder: The New Maudsley Method, New York: Routledge, 2007 http://www.nhs.uk/Livewell/loseweight/Pages/height-weight-chart.aspx Tucker, Nancy, The Time In Between: A Memoir of Hunger and Hope, London: Icon, 2015 http://wwd.com/beauty-industry-news/beauty-features/kate-moss-the-waif-that-roared-2367932/ Dauxerre, Victoire, Size Zero: My Life as a Disappearing Model, London: William Collins, 2017 https://uncch.pure.elsevier.com/en/publications/twin-studies-of-eating-disorders-a-review http://www.priorygroup.com/eating-disorders/statistics Lock, James and Daniel Le Grange, Help Your Teenager Beat an Eating Disorder, New York: The Guilford Press, 2005 http://ajp.psychiatryonline.org/doi/abs/10.1176/appi.ajp.157.3.469 Kahn, Michael, Basic Freud: Psychoanalytic Thought for the 21st Century, New York: Perseus Books, 2002 http://www.anorexiabulimiacare.org.uk/about/about-eating-disorders https://www.edreferral.com/celebrities-ed Freeman, Christopher, Overcoming Anorexia Nervosa: A self-help guide using Cognitive Behavioural Techniques, London: Robinson, 2002 Barkham, Elizabeth, Anna Cave, Susan Harty, Annabel Jervis, Karren Smith, James Bailey and Esther O’Neil, Edexcel AS/A level Psychology, London: Pearson Education Limited, 2015 Gerhardt, Sue, Why Love Matters: how affection shapes a baby’s brain, London: Routledge, 2015 http://www.healthline.com/health/mental-health/serotonin#overview1 Woolf, Emma, The Ministry of Thin: How the pursuit of perfection got out of control, Chichester: Summersdale, 2013 Becker, Anne E., Rebecca A. Burwell, Stephen E. Gilman, David B. Herzog and Paul Hamburg, Eating behaviours and attitudes following prolonged exposure to television among ethnic Fijan adolescent girls, London: The Royal College of Psychiatrists http://bjp.rcpsych.org/content/bjprcpsych/185/5/363.full.pdf http://www.bbc.co.uk/news/world-europe-39821036 http://www.drshepp.com/wp-content/uploads/2015/06/eatingattitudestest.pdf

http://www.anorexiabulimiacare.org.uk/about/about-eating-disorders 3 ! 9

Final Goodbyes There’s a time when you realise You actually have to say goodbye And box up all the old memories of “The good old days” People bring up the old piano scores and the orchestra pieces The times where our youth was still blooming When the first kiss touched their lips And the last lovers finally break off to adventure into New worlds. Bitter-sweet memories of a time when you had a voice and a name Before you become another scratch on the board as another student who walked these halls And learned those mechanisms And painted these leaves. And when you step out of that final exam and breathe out Knowing you have nothing to do now You realise You have to say goodbye to a chapter in your life And start a new book, a new story And that bitter-sweet moment you do realise? You nod and walk pass the gates in a silent salute.

Tamazeir Choudhary

4 ! 0

The Big Four Accountancy Firms and their Oligopoly Aman Patel Following the collapse of the British construction company Carillion, big questions have been asked about the competency of the ‘big four’ accountancy firms: KPMG, Deloitte, EY and PwC. The Financial Reporting Council (the accountancy watchdog) have launched a probe investigating the fall of Carillion and how it was allowed to happen by these firms, all of which at one time or another had worked for the doomed construction company. The damning report has suggested that the Competition and Markets Authority consider a potential breakup of this oligopoly, whose existence was described as "undeniable" by the UK chairman of KPMG. Two possible scenarios of a breakup are: forcing each of the big firms to split up into smaller firms or forcing them to split their consulting and auditing functions. The latter scenario seems a lot more feasible than the former, because there can be clear conflicts of interest between these functions. The case of Carillion provides a great example of this. Although it was KPMG who signed off their accounts in a 2016 external audit, Deloitte have also worked for the firm as internal auditors. Further, PwC advised the construction company on their pension debts. To make matters worse it is now PwC executives who have been controversially selected to be "special managers" in the costly liquidation process of the company, which could lead to tens of millions of future profits for PwC. It is clear to see how the varied roles that can be played by different accountancy firms in influencing the strategy and accounts of top British firms can easily lead to conflicts of interest. However, is a break up the right plan of action? A disadvantage of a breakup is the UK focus. Although this debate has been sparked by the fall of a UK firm and the debate itself is taking place in the UK, the emphasis needs to shift to a more international perspective. One of the reasons that the firms have gotten so large is owing to the fact that they are global firms. Whether or not the industry’s current status is a problem is debatable, but the fact is that breaking up the UK operations of the firms will not have much of an effect. They will remain massive firms in a "cosy club" regardless of UK-only action. 4 ! 1

An Element of Competition Poppy Bradley When I was trying to think of an idea for something to write in the Pilot, I began to consider the subjects I could cover. Perhaps something related to my studies, extending my knowledge from the classroom. So, where would I start? Biology, Chemistry, Physics or Maths? Many people have become nervous at the sound of my A-Level choices, but I’m having a ball. I am one of a few people that have been ‘brave’ enough to choose such a combination, yet something has never seemed quite right. There is a never-ending debate about which science is better! I won’t mention any names, but there is certainly interdepartmental competition, and a certain degree of ‘nerdy banter’ (if I were ever to pen such a term!) But why is there rivalry within science? And what consequences does it have, both for the scientific process and for those who work within it? History is riddled with examples of scientific rivalry. Infamous disputes include that between Newton and Leibniz over calculus; Watson and Crick challenging Pauling over the structure of DNA; and Darwin becoming worried after hearing Russell had begun to hypothesise ideas similar to his own. But perhaps this could be a good thing. Having healthy competition has been suggested to help reduce confirmation bias, where one searches for evidence in order to confirm one’s existing beliefs and ideas. Even if scientists are less willing to challenge their own ideas, competing scientists would certainly jump at the chance to do this. So, perhaps competition within science acts as a positive catalyst for more rigorous research. A multidisciplinary approach to science is becoming more and more important each day, with several breakthroughs being made thanks to the teamwork between scientists from across a broad spectrum. A great example of this is the discovery of the Higgs boson by the teams at CERN. The project involved 6,000 physicists, and cost more than $10 billion – with competition between two rival research groups, Atlas and CMS. In the end, Atlas’ data utilised “1,000 trillion proton-proton collisions, 240,000 Higgs bosons, 350 pairs of gamma rays and 8 sets of lightweight particles from the lepton channel.” You can understand why so many physicists needed to work together on this project: the scale of it was huge. But the significance of the discovery was worth even more. So, what can we learn from a history of competition? Some might apply Darwin’s theory of natural selection: those with the better adapted characteristics are more likely to thrive in this ‘survival of the fittest’ environment. Indeed, within science, there is competition both for funding to run research projects and to come to conclusions first. Would things become dull if this competitive element were removed? Personally, I don’t think so. While it can be exciting to watch the development of projects and to see ‘breakthroughs’ popping up in the news, it would be counterproductive if this competition actually led to a step back in the research. If anything, having multiple people working on the same idea would only benefit its development. Indeed, the rigorous peer review process ensures research can really be challenged, and having different teams collaborate on the same idea from varied perspectives is more than likely to improve the chances of success. That would help the whole world benefit. Mary Disis puts it nicely: “Adherence to current thinking and funding mechanisms will only perpetuate the dominant organisational characteristic of our academic health centres: 500 independent fiefdoms united by a common air conditioning system. We can be more than that.”

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The Legacy of Margaret Thatcher Abi Whelan Margaret Thatcher was one of Britain’s most polarising prime ministers. To some, she was a monster; to others, she was one of Britain’s best leaders. No matter your opinion, however, one thing is undeniable and that is that her legacy is still felt today. From the closing of coal mines to privatisation, the effects of Mrs Thatcher’s policies can still be seen in many communities across Britain today. However, nowhere is her legacy more prominent than in the reduction of the power of trade unions. Following the 1981 miners’ strike, Mrs Thatcher was determined that the government would never again be held hostage to the demands of trade unions. The British Government began to stockpile coal, and over the next 3 years introduced legislation to restrict the ability of unions to hold national strikes. The government were determined that they would not be forced to the negotiating table again. Mrs Thatcher’s anticipation of another strike allowed her (and her government) to prepare for it. Tightened regulations and the stopping of welfare for those on strike meant that miners often could not afford to continue striking and would have to go back to work. This removal of opposition by gradually breaking strikes made the NUM appear as though they were disorganised and made their leadership appear ineffective. However, the government did more than just make the NUM appear ineffective – they rendered them helpless. As a national ballot had not been held to decide whether to hold strikes, the union was able to be sued. This caused divisions within regional areas of the NUM: some striking miners who wished to go back to work were now able to sue the NUM – and did. In August 1984, two Yorkshire miners took the Yorkshire NUM to court for calling an ‘official’ strike without a ballot. Arthur Scargill and the NUM were fined for not showing and, upon refusing to pay the fine, all £11 million of the NUM’s assets were sequestered. The NUM could no longer claim to represent the miners because they had just been sued by the same people they were supposed to represent. Margaret Thatcher weakened the unions firstly through legislation but also through winning her battle with the coal miners and the NUM. Although the legislation passed to prevent strikes undoubtedly played a role (and removed much of the influence of the unions through preventing strikes), it was her skill in preparation for the strikes and capitalisation on the divisions within the unions that led to the weakening of the power of trade unions within Britain. This is because, whilst legislation provided legal challenges to the power of the NUM, the divisions provided practical challenges that were much harder to overcome.

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Why is the rule of law one of society’s foundations? Julia Kotlarska How can we differentiate a lawful democracy from a totalitarian country? Some may argue that we may do so by using the concept of the rule of law. The idea that is so often viewed as omnipresent and deeply incorporated in the framework of society’s universally respected norms seems to have become more and more ambiguous as a result of its uncertain and complex structure. Does it therefore mean that the principle of the rule of law has been weakened due to the constant exploitation of this expression, or has it actually been strengthened by different pieces of legislation? The concept of the rule of law is usually associated with Professor A. V. Dicey, who created the premise of three primary principles constituting the rule of law.1 However, the idea on which the rule of law is based can be linked to some of Aristotle’s works, where the philosopher states that ‘it is better for the law to rule than one of the citizens’2 – mirroring the notions endorsed by Dicey. It could be argued that the broad room for subjective interpretation of the expression gives rise to ideologically-based abuse of it. Nonetheless, the global significance of the rule of law seems to suggest that it, as a concept, is seen as consequential and vital for modern society. International documents enhance the concept of the rule of law: the 1950 European Convention on Human Rights directly points to the link between governments and the rule of law. Moreover, the implementation of the Constitutional Reform Act, which mentions the rule of law as a constitutional principle, makes the concept part of British statute. The existence of these legal instruments proves that it is not the concrete definition of the expression ‘the rule of law’ that is necessary to attain lawfulness, but the interpretation made in reference to specific cases. This allows the concept to evolve and take into account changing political and socioeconomic circumstances. After all, most citizens would prefer to live in a state which is willing to operate under the principle of the rule of law than in one that is immersed in lawlessness and chaos.

1 A.

V. Dicey, An Introduction to the Study of the Law of the Constitution (1885: 9th edn., Macmillan, 1945), p. 188 Aristotle’s Politics and Athenian Constitution, ed. and trans. John Warrington (J. M. Dent, 1959), book III, s. 1287, p. 97. 2

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How ‘historical’ is Herodotus’ account of Croesus’ reign? Christopher Collins This essay was the winner in the national Classical Association GCSE Essay Prize. In his De Legibus, Cicero became the first to crown Herodotus “father of history” – yet conceded that even Herodotus told “innumerable fables”. At the outset of his Histories, Herodotus states the aim of his enquiries (ἱστορίης, from which derives the English word ‘history’) as to immortalise the “great and marvellous deeds” of both “the Greeks and the barbarians”. This impartial focus on the deeds of all ἄνθρωποι, rather than exclusively those of the gods or Greeks, represented a marked modernisation of the old mythic tradition. Why, then, have many informally dubbed Herodotus “father of lies”? Perhaps the greatest example of this duality – of Herodotus as historian and as fabulist – is his account of Croesus’ reign. Aspects of Herodotus’ account share many characteristics of modern historical writing, occasionally suggesting admirable historical method – even from the opening of his account of Croesus’ reign. Herodotus uses precise facts, in both geography and chronology: for instance, he describes Croesus’ kingdom as comprising “all the peoples to the west of the river Halys” (ἐθνέων τῶν ἐντός Ἅλυος ποταµοῦ); and writes, less verifiably, that the Heraclids ruled for “505 years”. The River Halys (the modern Kızılırmak) is a real place, and hence we note an immediate contrast between Herodotus and, say, Homer – whose Odyssey contains countless settings which modern scholars are yet to locate – which portrays him as a credible authority. More significantly, Herodotus’ account demonstrates acceptance of the doctrine of causation – the cornerstone of modern history – in recognising the far-reaching effects of human, as opposed to divine, action: for example, noting that “all Greeks were free” (πάντες Ἕλληνες ἦσαν ἐλεύθεροι) before Croesus, implying he caused the loss of this freedom. Further, Herodotus distances himself from accounts he deems dubious – having Solon introduce, for instance, the fantastical story of Cleobis and Biton with the words “especially this story is told” (καὶ δὴ καὶ λέγεται ὅδε ὁ λόγος). Here, the use of the repetitive idiom καὶ δὴ καὶ, and the cognates λέγεται and λόγος, emphasise that it is a story worth telling – but the passive λέγεται makes clear that Herodotus, being unable to attest to its truth, is presciently mindful of his professional integrity and historical method. Herodotus is moderately supported by archaeological evidence. Numerous gifts bearing Croesus’ name (akin to those described in 1.51) have indeed been unearthed at Delphi, and the museum there displays two ancient statues purportedly of ‘Cleobis and Biton’. However, whilst a famous amphora by Myson (of c. 500-490BC) at the Louvre shows Croesus atop the pyre, it does not indicate whether Croesus was alive when he left it! Despite this, elements of Herodotus’ style have often been compared to Homer: the ancient critic Longinus called him homerikotatos. Notably, he uses a Homeric style of character naming: thus the man whom Solon names as ὀλβιώτατον is both noted principally for his noble end, and called Τέλλος (cf. τέλος = “end”). One observes also that Cleobis and Biton are described as Ἀργεῖοι – the Argives being a common name for Greek fighters in the Iliad, emphasising the brothers’ heroism. 4 ! 5

Further, the exchange between Solon and Croesus stands out as an example of Herodotus employing the Homeric structure of long conversations and speeches in preference to indirect statements. This resemblance to old-style Greek storytelling, although entertaining for the reader, arguably undermines the credibility of Herodotus’ account as serious history. The historicity of Herodotus’ account is further called into question by the deus ex machina employed to save Croesus from the flames. Herodotus thrice refers to Croesus’ invocation of Apollo (with ἐπιβώσασθαι, and the polyptotic ἐπικαλεόµενον and ἐπικαλέεσθαι) – it is as if Herodotus is openly flaunting this breach of his initial commitment to focus on the ἄνθρωποι, not the gods. Contrastingly, the Nabonidus Chronicle (col. II. 15-17 – a key contemporary source) asserts more credibly that Cyrus succeeded in killing Croesus. Indeed, de Selincourt (1962, p. 64) writes that Herodotus was prone to “credulity about oracles” – if it is the case that Herodotus was convinced on his travels to Delphi that (in the words of Bacchylides) Croesus was saved “for his piety” then eyebrows should rightly be raised because the sudden death of such a major donor would have arguably been highly embarrassing for the oracle. Thonemann (2016) further elucidates that Herodotus’ account is internally inconsistent, seemingly unable to decide if Croesus believed merely the Delphic oracle, or also that of Amphiaraus – alternating between singular and plural references to the ‘true oracle(s!)’. Undoubtedly, Herodotus’ respect for ancient religious tradition makes him less credible for modern readers – one cannot both believe in the modern doctrine of causation and that Croesus’ downfall was caused by ἐκ θεοῦ νέµεσις. To conclude, aspects of Herodotus’ account of Croesus’ reign are highly questionable to the modern eye. The claimed meeting between Croesus and Solon is at best chronologically improbable (de Selincourt 1962, p. 89) and one of its key messages, the emphatic double-comparative ἄµεινον εἴη ἀνθρώπῳ τεθνάναι µᾶλλον ἢ ζώειν (‘it can be better for a man to die than to live’), is arguably inconsistent with Solon’s own verses on long life and ‘the ten ages of man’. Herodotus’ occasionally Homeric style of writing, coupled with his acceptance of myth (e.g. that Lydia was once ruled by Hercules’ descendants) and reporting of divine intervention as fact, suggests that his work cannot truly be classified as academic history. However, Herodotus did not set out to write history as we know it – but rather to present the fruits of his enquiries, which he does in an engaging and detailed manner that is broadly supported by archaeological evidence and which at times can demonstrate (for his era) true foresight into modern historiography. Indeed, Herodotus’ account has become “so famous and so well-attested” (to quote Plutarch’s Solon) and is – from a literary perspective – so masterfully told that he has achieved his aim of immortalising it. In that sense, if not strictly historical, Herodotus’ account of Croesus’ reign is certainly of historic significance.

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What aspects of the classical world do you think invading aliens from outer space would find most interesting, and why? Hassan Tanveer The aspects which I think the Aliens would find most interesting about us would be our long history, as I imagine that their curiosity would be piqued when they found out that children nowadays are learning a lot about what happened before their time. The invaders would probably see it as a weakness that we should only look forward if we want to achieve substantial progress, but they are wrong, they are ignorant to the way we think, because, although we look back, we still progress steadily forward. This shows that we are intelligent beings, and that the Aliens must have considered us a possible threat or they would not even bother invading Earth. We humans can look back and learn from mistakes which earlier humans made, and progress forward carrying that knowledge with us all the way. The Aliens would be curious about it because day by day we are getting, maybe not physically but intellectually, stronger by learning from our ancestors. Also, it is in the Aliens’ best interest to be curious about our history, especially if they want to suppress any rebellions and keep possession of Earth. The moment they fully understand our great history, they will crush anything that stands in their way - may it be humans or other Alien races. I think that they would be particularly interested in learning about Greek Mythology as a various number of great people existed in that time like Hercules, Theseus, and Perseus, but I think that the Aliens, instead of focusing on every single hero, would focus on either Perseus or Hercules, because they know we are smart creatures but they don’t want to overestimate us as Perseus, after killing Medusa and slaying a sea monster, actually lives a happy life whereas most others die. They would consider Perseus because even after completing some amazing feats he lives a happy life. They also don’t want to overestimate us and would also focus on Hercules, who is considered the strongest Greek hero, but having said this he did murder his family; some people say Hera drove him into madness, but I think that she just pushed him to the point where he couldn’t take it - we already know he had anger issues when he killed his music teacher who hit him. Honestly, I think that if I was in the Aliens’ position I would just focus on Perseus, because even if someone had a tiny achievement, and was far weaker than another, but still came back alive, you would assume that their way of thinking is far superior to others, but Perseus, he completed massive achievements and only participated in necessary conflicts and stayed alive doing so. Therefore, I think they should only be focusing on Perseus, but it’s better for us if they waste their time while we build up our forces.

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