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Had Sherlock Holmes gone into medicine, he’d have been a dermatologist

There are hundreds of different rashes, each with tell-tale signs that, with careful observation, can lead clinicians to a diagnosis.

Robbie had had a sore throat and fluey symptoms, and the large patch of inflamed skin that appeared on one side of his abdomen hadn’t particularly bothered him, especially as it started to fade when he began to feel better. That morning, though, he’d woken to find himself covered in dozens of similar patches scattered all over his body.

He looked worried. Dermatological diseases aren’t often serious, but they can cause distressing symptoms such as itch, and they almost invariably have an impact on our psychology. Our skin is our interface with the world. When something goes wrong with it, it can create embarrassment and even shame – ancient notions of uncleanliness, sinfulness and contagion persist to this day. Robbie was in his early twenties; he wanted to be out playing the mating game. Were he to disrobe in front of a partner looking like this, they’d run a mile.

I asked a few questions as he unbuttoned his shirt. Two of the commonest dermatological conditions we see – eczema and psoriasis – have variants that might have fitted the bill, but they tend to run in families and Robbie had no affected relatives. One of my other hunches was confirmed as soon as I saw the rash. Lines of oval pinky-red patches swept symmetrically across his trunk in gentle curves, recalling the branches of a Christmas tree.

“It’s something called pityriasis rosea,’ I explained. The virus that had made him feel poorly also affects the skin. It starts with a single “herald patch”, just as Robbie had noticed, followed a week or two later by a dramatic outbreak of secondary lesions. These tend to be flat and salmon pink, and often have a ruff of fine scales around their edges. Robbie’s rash lacked this last feature – but it’s rare to see textbook cases of anything.

Dermatology is the branch of medicine Sherlock Holmes would have most relished were he, like Watson, to have become a doctor. There are hundreds of different rashes, each with tell-tale signs that, with careful observation, can lead clinicians to a diagnosis.

One of the most intriguing features of rashes is that they tend to have characteristic distributions. Coxsackievirus typically affects the extremities and the oral area, hence its colloquial name, “hand, foot and mouth disease”. Parvovirus homes in on the sides of the face; it’s known as “slapped-cheek syndrome”. The many different patterns of eczema also affect particular areas: atopic eczema inflames the insides of the elbows and behind the knees; seborrhoeic eczema presents along the sides of the nose, the eyebrows, and the front of the chin. An intensely itchy condition, lichen planus, has a predilection for the wrists, where it has a violet hue, and the insides of the cheeks, where it forms lacy white webs.

In a few instances, we understand why these characteristic distributions occur. Shingles, caused by reactivation of the chickenpox virus, reaches the skin by travelling along a single nerve: this results in a one-sided rash confined to the area – known as a dermatome – supplied by the affected nerve. The virus that caused Robbie’s pityriasis probably migrates in a similar way, although its “Christmas tree” distribution maps multiple dermatomes on both sides of the body.

For the most part, we have no idea why different rashes affect certain areas of skin and not others. With enough research we could develop some fascinating insights. However, it is unlikely this would enhance treatment, so such research will probably never be funded. I rather like the mystery of it all – it’s as though nature is playing us, dropping us little clues to help us make our diagnoses.

Many rashes we can do nothing about, but at least with the right diagnosis I could tell Robbie what to expect. He was pleased to hear his pityriasis would eventually get better, but dismayed to learn that it could take a few months and there was nothing we could do to hurry the process along. As he got up to leave, I sensed he’d resigned himself to an enforced pause in the mating game. 

This article first appeared in the 01 March 2018 issue of the New Statesman, The rise of the radical left

Photo: Getty
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I'm not going to be General Secretary, but the real fight to change Labour is only just beginning

If Labour gets serious about a new politics, imagine the possibilities.

For a second time, I was longlisted for the role of General Secretary of the Labour Party this week. For a second time, just as in 2011, I was eliminated in the first round. The final shortlist now consists of two veteran trade unionist women leaders, Jennie Formby of the Unite union and Christine Blower - formerly of the National Union of Teachers and the Socialist Party. I met them both yesterday at the interviews; I congratulate them, and look forward to hearing more about their ideas for Labour party renewal.

Last week in both the New Statesman and LabourList, I explained why I thought we needed a General Secretary “for the many”. I set out a manifesto of ideas to turn Labour into a twenty-first century campaigning movement, building on my experience with the Bernie Sanders campaign, Momentum, Crowdpac, 38 Degrees and other networked movements and platforms.

I called for a million-member recruitment drive, and the adoption of the new “big organising” techniques which combine digital and face-to-face campaigns, and have been pioneered by the Sanders movement, Momentum, Macron and the National Nurses Union in America. I set out the case for opening up the party machine in a radical but even-handed way, and shared ideas for building a deeper party democracy.

I noted innovations like the Taiwanese government’s use of online deliberation systems for surfacing differences, building consensus and finding practical policy solutions. Finally, I emphasised the importance of keeping Labour as a broad church, fostering more constructive internal discussions, and turning to face outward to the country. I gladly offer these renewing ideas to the next General Secretary of the party, and would be more than happy to team up with them.

Today I am launching, a new digital democracy platform for the Labour movement. It is inspired by experience from Taiwan, from Barcelona and beyond. The platform invites anyone to respond to others’ views and to add their own; then it starts to paint a visual picture of the different groupings within the movement and the relationships between them.

We have begun by asking a couple of simple questions: “What do we feel about the Labour party and movement? What’s good, and what’s more difficult?” Try it for yourself: the process is swift, fun and fascinating. Within a few days, we should have identified which viewpoints command the greatest support in the movement. We will report back regularly on this to the media.

The Labour movement is over 570,000 members, thousands of elected representatives, a dozen affiliated unions and millions of Labour voters. We may disagree on some things; but hopefully, we agree on far more. Labour Democracy is a new, independent and trustworthy platform for all of us to explore our differences more constructively, build common ground, and share ideas for the future. I believe Labour should be the political wing of the British people, as close to the 99 per cent as possible – and it will ultimately only be what we make of it together.

Yesterday I spoke over Skype with Audrey Tang, the hacker and Sunflower Movement leader who is now Digital Minister of Taiwan. Audrey is a transparent politician, so she has since posted a video of our conversation on YouTube. I recommend watching it if you are at all interested in the future of politics. It concludes with her reflections on my favourite Daoist principle, that true leadership leaves the people knowing that they have made change themselves.  

This General Secretary recruitment process has been troubled by significant irregularities, which I hope the party learns from. The story is considerably more complex and difficult than is generally understood. I have spent considerable time in the last week trying to shine greater light on the process in the media and social media, and encouraging the national executive committee, unions and politicians to run a more open and transparent process. I even started a petition to the NEC Officers group, calling for live-streamed debates among the candidates for this crucial and controversial party management role. I very much hope that there is no legal challenge.

Most importantly, the last week has exposed a significant fault line in Labour between the new left and the old left. When Jon Lansman of Momentum entered the contest against the “coronation candidate” Jennie Formby, many people read this as a fight between two factions of the old left. But Jon’s intent was always to open up a more genuine contest, and to encourage other candidates – particularly women – to come forward. Having played the role only he could play, he eventually withdrew with dignity. His public statements through this process have been reflective of the best of the new politics. And despite our very different political journeys, he kindly agreed to be one of my referees.

There has been plenty of the old transactional machine politics going on behind closed doors in the last couple of weeks. But out in the open, the new left movements and platforms have shown their strength and relevance. Momentum emailed all its members encouraging them to apply for the role. On Facebook Live, YouTube and podcasts like All The Best, the Novara Media network has been thoughtfully anatomising the contest and what it means for the future of the left. Even the controversial Skwawkbox blog finally agreed to cover my candidacy, and we had a constructive row about the leaked memo I wrote for Corbyn’s office back in December about how to win the next election using data, organising and every new tool in the box.

I am worried about the old left, because I feel it is stuck in a bunker, trapped in a paradigm of hierarchical power and control. The new left by contrast understands the power of networks to transform conversations and win hearts and minds.

The old left yanks at levers, and brokers influence through a politics of fear and incentives. But this tired game is of decreasing relevance in this day and age. The new left has the energy, the reach, the culture and the ideas to build a new common sense in this country, and to win decisive victory for Labour and progressives in the next general election – if the old left will partner with it. 

I am keen to help. So are many others. I hope we can start to have a more constructive and equal conversation in Labour soon. Otherwise an exodus may begin before long; and no-one wants that.

Paul Hilder is an expert on new politics and social change. He is a co-founder of Crowdpac, 38 Degrees and openDemocracy. He has played leadership roles at, Avaaz and Oxfam, and was a candidate for general secretary of Labour in 2011.