Dr Rupy: I want to introduce the listeners to you actually, Catherine because we've met a couple of years ago now. I've been following your work for a little while. We've stayed in contact throughout this whole thing as well that's been burgeoning. You've done some incredible work at University of Bristol. But for you, how did everything start? How did you get into medicine? How did you get into the specialty that you now practice?
Dr Catherine Zalman: Well, I don't come from a medical family at all. It's really interesting. My dad was a physicist and so I think I grew up very much in the scientific paradigm, but both my parents are actually Hungarian and came to England and met and I was born in England. And I do think that's kind of related because in Hungary, you're not just a scientist. I think the arts and sort of music and and theatre and literature are very much woven into the fabric of life. So I think I think from the get-go, I had a notion that I wanted to do science, but that it was more than science. It's interesting how many people you meet in this more sort of bridging world who actually aren't purely English. It's it's interesting. I think lots of different cultures from around the world have got a lot to to say. So I so I didn't and I didn't set off to do medicine when I was in school. I think in fact it was my German teacher who said it's a good way you like the arts, you like science, have you ever thought of medicine because that kind of combines the two. And I went to I I did my undergraduate pre-clinical medicine, it was very pre-clinical then at Oxford, which is where I met Trevor Thompson who's now Professor Trevor Thompson at the University of Bristol. And it I think the very reductionist science of it really I found quite a turn off and we were memorising long lists of things and it didn't really seem very creative. We weren't it didn't seem as neat as pure science, neither did it seem as creative as the arts, but very fortuitously as a as a sort of second year medical student, an organisation I got a flyer just randomly in my inbox about an organisation called the British Holistic Medical Association which had just started up then and was running a conference in Oxford around cancer and childbirth and sort of holistic approaches. And I think I was just looking for interesting avenues and pitched up at this conference. And it was really a a life changer actually. I think I suddenly thought, gosh, I can combine the wonderful things I'm learning about in my medical training with some more sort of creative and and individual aspects. So I'm I'm not trying to see people as a sort of generalization, but I'm allowed to see them in their individuality as well as as the sort of bigger, bigger scientific principles and epidemiological principles that I'm that I'm learning about. So that was a real game changer. When I came down to London to do my clinical, I joined and then started running the London students group of the British Holistic Medical Association, which at the time was really interesting. We were meeting with students of all sorts of other healthcare disciplines and organising our own sort of education programs. So we'd have acupuncture students, nursing students, counselling and psychotherapy students, all coming together and it was a very fertile learning ground really. And I think before we'd become tribalised in our different disciplines, we could kind of meet together and see that actually we were all interested in a very similar aim, which is helping people get better, live well, be healthy, be happy. And that there were many different ways to do that. And I think luckily enough for me, it felt like I was learning two languages at the same time. And so I've always felt like I live on that bridge between the two worlds. And I think then through my medical career, I got very quickly interested in cancer medicine. And I thought I wanted to be an oncologist, did my MRCP, did a sort of moved to middle grade registrar in in medical oncology. And actually one sort of trigger made me think, well, maybe this isn't quite for me. I realised that actually working as part of a team of people and being able to develop a team culture where we could kind of bring together our collective wisdom and work together as a team developing a way of working as well as tools that we were using was really important. And I kept seeing in hospitals sort of junior doctors moving through and under and it's really hard and it's even harder now with the sort of working time directives and there isn't that sense of a firm that's a solid thing that you can work with. And so I had a a bit of a moment thinking, well, I love the tools that I'm using, but maybe there's other places. So I thought maybe of going into palliative care where the team seemed a bit more stable. And I did a year in general practice to kind of prepare me for that, having thought no way, when I went to medical school, I thought the one thing I know I don't want to be is a GP. But actually really enjoyed my year in general practice, surprised myself with how much cancer there was, of course, because we, you know, everybody there's so I felt like and also GP teams are really that. They I was lucky enough to work in two fantastic practices where the team ethos was fantastic, people looked after each other, they had really kind of created a mini culture. And I suddenly thought this is more possible here than in a big hospital where, you know, consultants can't choose their colleagues, they can't choose their managers, they can't choose their junior staff. So it ends up being a harder, harder sort of system to work with. So I ended up in general practice, working always quite part-time in general practice because I knew there were other things I wanted to do. I spent some time as the kind of medical director of the research Council for complementary medicine, which was a an organisation trying to promote good quality research into complementary medicine and disseminate the findings of good quality research that had already been published but wasn't widely known. And that was a really interesting thing. Again, my job was to kind of familiarise people with with what with the sort of from both both angles. So familiarising the complementary therapists about the benefits of good quality research and familiarising the doctors and the sort of orthodox conventional healthcare professionals with what there was to learn from other approaches. So that was that was fascinating. And then I got into medical education. I started being a GP course organiser, doing some work as an undergraduate lecturer at the University of Bristol. So I've always done GPing and and something else. And then started and and had always also known about this centre in Bristol, which at the time was called the Bristol Cancer Help Centre, which is now Penny Brohn UK, and is the organisation that I'm currently medical director of. And I think as a very newly qualified doctor interested in cancer but interested in more holistic approaches, I spent four months there as a volunteer, just between jobs. And it was a fascinating experience. At the time it was a private clinic and very much more on the alternative side. And this was back in the 1990s. And I was very fascinated to meet I I sort of joined initially as a sort of participant observer, joined as if I was somebody with cancer and kind of they let me just be with the groups that were that were learning and and coming together and getting get getting advice and input. And that was fascinating because I really got the patient perspective at that time. And some of those characters are are still sort of really clearly etched in my mind and some of the things that they told me at that point. But I knew that I didn't want to work in a private clinic and it was too alternative for me at the time. So I kept an interest, but over the years it moved and I think medicine has moved as well. It it started offering its services free or on donation only basis and started looking for sessional doctors and I signed up and worked there occasionally for a while and then and then actually got a substantive job and I'm now medical director there. And I'm really proud to say that I think what we do now is really offer integrative cancer care, which I think we'll talk more about, but you and I know that I think there are just fantastic strengths in what conventional medicine has achieved and can offer. And there are also huge gaps in what it can do as well. And that those gaps can sometimes, not always, be better addressed using either lifestyle approaches or complementary approaches. And actually often it is the combination, the intelligent combination of all of those different things that can really help people take take back some control over their own health, really feel connected and engaged and activated to to make a difference and to find the things that are going to work best for them and to create that individual package of care.
Dr Rupy: Totally. I mean, I I love that word, the those words that you used, intelligent combinations of care. I think that's just a really good way of describing exactly what you do at Penny Brohn and and what other centres do as well. I just want to go back and just state that how progressive of your German teacher to make the combination of arts and your love of science and say, well, you should definitely go into medicine. And also the disappointment that you experienced during that which led to your ultimate specialty right now. And also on the subject of being progressive, I mean, holistic medicine back then would have been really, really left field from my from my understanding because even today, I think it's got a taboo around it that needs to be shaken off.
Dr Catherine Zalman: Yeah, I think you're right. And I think as I said, I was really lucky enough to fall into a kind of a a group of people who were also beginning to think in that way. And some of them were were really quite established in their fields, already professors or lead consultants at various units. There was also this movement with oncology called the British psychosocial oncology group that was gaining some traction looking at the mind body interactions. So there were a few organisations that I could I could sort of join. I think I would have found it very hard if I'd been a lone person. And I think this is this is an experience, I think of a lot of medics that I come across, especially students who are who are maybe feeling that there's maybe more more than medicine that they want to find out about, but are feeling a bit shut down and feeling a bit sort of like, is it just me? Am I am I am I the going mad? Or have I have I got the wrong end of the stick? And actually when you get people to meet together, I think there's strength in numbers and people can really tune into that.
Dr Rupy: Yeah. I'm aware that there's a fly buzzing.
Dr Catherine Zalman: Oh, don't worry about it. Are you sure? Is it going to pick up on the
Dr Rupy: I think people will realise that it's not it's not a professional setup we have, so it's all good. So it's it's interesting you say that about like the aspect of community and not being, you know, that that that cavalier person that that goes away from the pack and, you know, have you got the wrong end of the stick sort of thing? Because those are definitely feelings that I had when I started out my journey looking into nutrition a lot more. I was even embarrassed to talk about it actually. I I remember even with my cardiologist, I I didn't admit that I'd been doing lifestyle and dietary changes initially because for fear of ridicule if I was honest. And yeah, it's nice to, you know, for for trailblazers like yourself and and and Trevor, to have paved the way for a a younger generation of doctors who are coming out of medical school today to really aim for something and look forward to something and validate what I think we inherently know during medical school that there is more to the lists that we recite. And it's interesting that your Hungarian background, which is quite integrated in terms of the way you approach sciences and arts and everything. Because I've been recently listening to a lot of Gabor Maté's stuff and I believe he's Hungarian as well. So maybe there's something about the Hungarian culture that we need to learn a lot more from.
Dr Catherine Zalman: Well, I think I think in in Western, you know, in sort of Central Europe, Central, you know, there is much more of this kind of cure, nature cure kind of mentality still around and people go places just to let nature take its course and to sit in beautiful places and breathe clean air and sit in warm natural spring, you know, sort of thermal waters and things like that. So it's it's interesting. I think it's embedded in the culture a bit more. And certainly, I think Germany is a really interesting example where herbal medicine is is much more part of the mainstream. You don't, you know, it's not in England, you're really quite radical if you're if you're talking about herbal medicine and and I think it's such a shame because I think people really lose out. I think I think as well as professionals feeling isolated and a bit having to give up on ideas that they know to be true, as you say, when we come into medical school, it's so interesting how many medical students are already practicing yoga or doing some mindfulness. And it's kind of stamped out of them a little bit, isn't it? In a lot of places, you know, it's kind of like there is a pack mentality in medicine. And I think the same is true for patients. And I think often, you know, they they feel isolated like they're trying to find their own their own more than medicine recipes, but are not helped by the system. And actually when you get people together, there's an amazing synergy and an amazing sort of it's almost, yeah, maybe alchemy is a better word. Something something happens when you get people together who can support each other, who can say, you know, yes, and validate that approach. Yes, this does make sense and and I can also blaze the trail. And so that's why I think people like Lauren McDonald who, you know, who are sort of being a bit more public about the fact that they they are medically trained, they they appreciate, it's not that they're rejecting anything of medicine, but they're adding to it in a way that actually enhances their experience, enhances their well-being. And I think that's that's a great combination.
Dr Rupy: Absolutely. I think there's a lot of, you know, people who will benefit from just the knowledge that there are extra ways in which we can help people and it validates again people's general inquisition without fear of of ridicule. What let's dive in and and let's talk a bit about what exactly integrative oncology means to you and what people understand it to mean and if there are any sort of official definitions that we could discuss as well because I think people are fascinated by this subject and I I'm trying to be a big signpost for Penny Brohn as, you know, the the sort of benchmark, the standard by which all oncology centres should should aim towards. But yeah, let let's talk a bit about integrative oncology.
Dr Catherine Zalman: Well, it's, you know, I think words can be such a such a help and such a hindrance. You know, I think for me, integrative oncology is the same really as integrative, you know, I'd call it integrative cancer care maybe. Oncology makes it sound like it's an ology that has to happen in a hospital and that has to be specialist in white coats with high-tech stuff. It absolutely doesn't. Integrative oncology is really integrative medicine as applied to a cancer situation. And I think we're seeing movements in integrative medicine, integrative rheumatology, integrative gastroenterology. So I think it's just sort of saying integrative approaches can be applied to all sorts of clinical situations. And I think cancer is one of the one of the best examples of where it can really make a difference and where it has, you know, people have been voting with their feet. People use people with cancer, overwhelming, you know, a majority of them, it depends how you are, how you actually define what integrative approaches are, but in different studies between 60 and 80% of people with a cancer diagnosis are doing something in addition to their conventional medicine. So people are voting with their feet, they're using it because sometimes because the the actual solutions, the conventional solutions in some situations are great, but in many leave leave a lot to be desired and not guarantees of cure. Also partly because they come at quite a high price. So the the toxicities of treatment can be quite considerable. So people are understandably looking for ways to reduce that toxicity or to find ways that they can help themselves. And also cancer is a kind of often a real crisis in people's lives. It's not something that many people can just sort of take in their stride and keep on going as normal. Often it does precipitate a bit of a stop and and a think and a reorientation in life. And that can be such that that can be such an opportunity. We often talk at at Penny Brohn as a crisis has these two elements. It's got the danger bit, but it's also got this fantastic opportunity. And if we can help people harness some of that opportunity, we turn what could otherwise be a really negative and damaging event, traumatic event into something which allows the possibility of growth. So integrative cancer care, integrative oncology is really, I think again, it's that intelligent combination of saying what are the things that can help this person deal with the impact of the cancer diagnosis, live as well as possible and live as long as possible going forward in a way that builds their resilience and builds their own capacity to move forward not just with the cancer but with life in general. And I think it's, you know, there are different areas. So there's obviously the conventional treatment that's going to be really helpful for them in many cases. In some cases, it's going to be a bit more in the balance. Is this helpful? Isn't it? And again, having some other alternatives or other things to bring to the table can be really helpful. So lifestyle medicine is is hugely important and and I think like you, I see that as a real connected web. You know, it's what you eat, it's how you move, it's how you sleep, it's how you rest, it's how you, it's how you think about the world, it's how you manage stress, the sort of everyday stresses of life, it's how you connect with the things that really matter to you in your life, both the people and the communities, but but also the passions and the and the sort of inspiration and where you draw your strength from. All of those things I think are are sort of lifestyle medicine and all of them have a have a a wonderful way of kind of supporting each other to to sort of and once they once one thing starts moving in the right direction, often it's small steps that can have a bit of a domino effect and can really start to change people's attitude and actually physical well-being. So even even people who aren't really necessarily even thinking about having their cancer cured can actually start to say, do you know what, but I feel I'm living better and I've and some of my most moving experiences at Penny Brohn have been talking with people who are close to death sometimes, but who just are living in such a vibrant and alive way that they say sometimes it's it's the most alive they've felt in their in their whole experience. And I think that's that's really key. And I think integrative oncology, integrative cancer care for me has another sort of dimension, which is this helping people to help themselves, but also supporting them, because it's a real roller coaster in terms of energy up and down. Sometimes the treatments or or the symptoms from the actual disease really take it out of you. And I think I do want to challenge this thing. We're not saying here's here's the sort of instructions, you go away and you sort your own cancer out. I think that's unfair and it puts far too much responsibility on the individual. So I think there's a lot that we can do to support people. And that can be again through their conventional oncology teams, but also through a wider network of other people, counsellors, nutritional therapists, exercise facilitators, complementary therapists who can give massage or acupuncture or or um treatments that can actually give the body a sort of feel-good experience in the middle of all of that um difficult and challenging treatment. So so I think integrative oncology, have I said all the aspects? So it's integrating a range of different approaches. I think it's um, which include conventional lifestyle and complementary. I think it's also really important to integrate that people feel themselves as integrated. So that often people are described the experience of going into hospital as if like they're all they're interested is in my body and in fact it's not even the whole of my body, it's the bit on the scan which um is either shrinking or growing or it's the blood marker that's showing my PSA going up or down. And I know it's not when you talk to the oncologist, that's not what they that's not what they really believe, but that is sort of how the system is expecting them to react. And so people often feel a bit like a slab of meat on a conveyor belt going through the system and really helping people to connect back to their body hasn't let them down. It's not it's not a sort of enemy territory and helping people make friends again and connect their minds, their bodies, their emotions, their spirits so that they feel like an integrated whole person going through this journey and they feel that their whole person experience is really valid. And then I think it's really the other bit of the integrating that I think is really important is integrating them at the centre of their own healthcare creation team. So really seeing them as expert in their own um in their own body, in their own experience and in their own inner knowledge of what works for them and what they feel is important and what their priorities are, really importantly.
Dr Rupy: I I really like the perspective there and I think especially right now, I think everyone can really resonate with that um which is the opportunity that comes out of crisis. We're going through a crisis globally at the moment, um, and there is something in the community, the global community that's experiencing it all together, which is strangely reassuring and comforting, which I think you're able to create in a in a centre like Penny Brohn because everyone in in there who's a client comes comes in and is experiencing cancer in some way. But the opportunity that's coming out of this, I think a lot of people are realising that that where there is tragedy, tragedy, there is the um uh potential for growth. Um, and and also I had no idea the numbers of people who are using integrative therapies alongside oncology. What what did you say it was around 70 or 80%?
Dr Catherine Zalman: Yeah. I mean, sometimes that's they're taking some vitamin supplements or they're, you know, taking a garlic supplement or taking some evening primrose oil or or some omega-3s. So it's not necessarily that they're embarking on a whole sort of program, but but very often they are seeing a a therapist or or you know, it depends again whether you include counselling and psychological approaches in that, but I think people are definitely seeing that they need more than just the surgery, radiotherapy, chemotherapy, drugs to help them get through this. Exercise medicine is something that's really coming to the fore.
Dr Rupy: Definitely. I was going to ask, so in terms of the suite of different integrative therapies that one can have offered to them, and and everyone's an individual in terms of which one they naturally resonate towards and which ones are more popular than others, but in terms of the suite, can we can we get a an idea of of what there is available for people, uh, even perhaps those who don't have access to uh Penny Brohn or a similar sort of centre?
Dr Catherine Zalman: Yeah. So I mean, as you say, we're we're we're talking, we're recording this interview at a time of kind of COVID lockdown. So the physical um centre that we've operated from is actually physically closed because getting a lot of people with cancer together at a time like this is obviously really problematic. So there's a slightly before and and after um aspect of this question. So um, I think it so so at Penny Brohn, our our traditional, you know, what we've been offering people um is a mixture of self-management education. So we we run courses for people um where they often come and stay, but we can also do these um non-residentially as well. And part of the coming to coming and staying together for a couple of days and a couple of nights is what we talked about earlier, that kind of peer support and group bonding that happens of meeting people in similar situations, although we we don't um segregate on terms of what type of cancer necessarily or what stage of cancer. We're really talking about, we focus on the person. And I think we'll come back to this idea, you know, the cancer is the cancer, but it's growing in a terrain, in a soil. And the soil is is the sort of person and their lifestyle and their situation. So we focus much more on what we can do with the soil. And so in those education things, we'll talk about lifestyle, but we'll also introduce them to a range of different complementary approaches, exactly as you say, because different people will resonate with different ones. And we try to take a bit of a pragmatic evidence-informed approach. So that there there is a surprising amount of evidence around complementary therapies. And um, some of the things that are have have had more research activity, they're not necessarily the things that are the most effective because but maybe they're the easiest to research or the or the um closest to sort of medical paradigm. So there's a lot of research around acupuncture and how helpful that can be in reducing some of the symptoms and side effects um related to cancer treatment. There's some really interesting research in yoga and mindfulness and um some um in managing some of the psychological consequences of a cancer diagnosis, helping people to cope better. But intriguingly, some of the studies when they've the primary endpoint has been mental health outcomes, but actually when they've followed people up, there does seem to be a suggestion that people who are regularly engaging with some of these practices are living longer as well in 15-year follow-up studies, 20-year follow-up studies. So it's it's intriguing. Um, also, so I think body work in general can have a really useful role. So often people are very much in their heads in crisis mode. You know, we know that when when we have a kind of acute stress in our lives, all sorts of neurobiological changes happen in our brains which wire us to kind of go into fight flight mode and and sometimes that sort of cuts us off from our bodies. Um, and one of the best ways of re-engaging our relaxation response, increasing that vagal tone is to get a sort of positive body experience. So if somebody can start to kind of, you know, enjoy the physical touch of a massage or reflexology or shiatsu, those sorts of things, it can be incredibly helpful. We've also had a very interesting tradition since the centre started, it was actually started by two rather incredible women. One was Penny Brohn who had cancer herself, but the other was Pat Pilkington, a friend of hers who came from a a sort of spiritual healing um tradition. Her husband was a was a Church of England um uh clergyman and they ran a sort of healing practice from their church. And it's it's interesting because healing is a bit of a controversial issue and I think a lot of people in the word again, healing think people are being promised unrealistic hopes of total cure. And actually healing really the origin of the word just comes from making more whole. And I think it's a beautiful word and I think that the healing that we that has been practiced at at Penny Brohn right from the inception is is a sort of quiet place to just be. And I think it's offered, you know, the presence of somebody there just to hold that space and to and to sort of be with you while you connect with some of your inner inherent ability to sort of restore given the right conditions. And I think that's another coming back to what is integrative medicine and what is integrative cancer care. I think one of the other things that we've lost in medicine is this trust in the body's innate ability. And you know, day one of medical school, we're taught about homeostasis, we're taught about the incredible mechanisms in the body to kind of regulate if it gets too hot, we regulate to our temperature, if we get too acid, we regulate our acid-base buffers. It's incredible if our blood gets too thick, we operate all sorts of use cascades that that help thin our blood a little bit. And so, but but medicine kind of doesn't take advantage of that, doesn't harness that activity. And I think that's another thing that I think healing really just reminds people that they have got that um that ability. So again, it's not for everybody. Some people have a real, you know, don't don't aren't interested, don't like the idea of it, but it's a lovely thing to be able to offer among the range and the suite of things that that we do. Um, and you know, again, it's lovely to be able to offer reflexology if people aren't quite comfortable about having a whole body massage or taking their clothes off. It's really lovely to be able to offer counselling if people's immediate what's at the top of their head is I just, you know, I can't stop crying and I'm just an emotional wreck. It's lovely to be able to offer them that, but often then because we work as part of an integrative team, a counsellor might then start talking to them about, you know, I think maybe the way that you're eating is is contributing to some of the sort of anxiety symptoms you're getting. And maybe actually stopping and having a positive experience of a massage or something like that might help you get into your body where you can start to relax. So these things work wonderfully together if we can start to to encourage people to experiment. And it is very it's frustrating because there's no one size fits all, but that's the creative bit, isn't it? That's the that's the art where you're really trying to listen to what somebody's telling you about their view of the world and think, is this somebody who who really wants to take a pill and a medicine and who might really like to take some vitamins or like to see things as as food or is it somebody who is actually more more in their body and more tactile and who will respond to to physical touch. So we try and put people in touch with what what works for them. But there's but it is what's heartwarming is that there's, you know, there's evidence around the creative arts, getting people to to write, to draw, to dance, um, to to make music or listen to music. There's huge, you know, actually really important and very well-done studies in these things saying that it really can make a difference um as well as some of the other complementary therapies.
Dr Rupy: Definitely. I I I think to your point about offering people uh a range of different um options, it's it's really, really important that because I think we all have an inherent bias and my inherent bias is obviously nutrition and food and getting that sorted. But sometimes, you know, uh people's starting point might be improving sleep or improving their relationship with their family, for example, and healing that first. And and I love what you said about the uh homeostatic mechanisms, which is a medical term for maintaining equilibrium in the body. And it's something that I talked about in the last chapter or in both books, but particularly in the last chapter of my um second book, Eat to Beat Illness, where I I I literally took it head on using the same words, like we have these innate self-healing mechanisms and although that sounds very woo-woo and it sounds very left field, it's actually what goes on in your body. And I had no idea about the origins of the word healing and that makes me a lot more encouraging to use it actually because I I think that's exactly what we try to do with any aspect of medicine. Um, that's an awesome, awesome way of describing it. And and you mentioned the soil, um, and and and our terrain and and I I think even in a literal sense, our soil needs a lot more attention because the biome of our soil is being gradually eradicated via various uh through various means. But um, let let's talk a little bit about the soil actually and actually how uh different uh uh and the different uh number of ways in which we can improve people's people's soil and their terrain.
Dr Catherine Zalman: Yeah, and and like you, I think it's I think let's not forget the real physical soil that on which our our food is grown and and how our relationship with that is inextricably linked. But I think this idea of soil and seed is such a useful um concept and you know, it's really not new. You know, in the 1880s, um Stephen Paget, who was a a British physician at the time, surgeon, I think he was actually, um was was talking about um how you can you can almost think of the the seed like a grain of wheat. It's not everywhere where it lands, will it actually be able to to grow and flourish. And there is this this terrain effect, this this soil effect. Um, and I think in the era of of of sort of our microbiological advances, that kind of got swept away, um, and we've got so excited about the idea that there were germs that we could identify that we could directly target, um, that 100 years of of sort of medical research and endeavour was really directed towards get rid of the germ, um, and identify and and sort of remove the germ. And we've and we've sort of lost our focus on the terrain, but it is now really coming back and I think it's so interesting that COVID really shows us this so so dramatically. For many people, COVID is a mild self-limiting illness for the majority of people, even people who've got comorbidities, you know, other conditions, other serious medical conditions, even even people who are in the middle of chemotherapy for advanced cancer can have a mild experience of COVID, but other people it can become a life-threatening and sometimes fatal illness. Now what if it was just down to the virus, we wouldn't see that variation. So soil is obviously crucial importance even in a massive, you know, pandemic situation like this, but certainly in a cancer setting. And what's so interesting is that now I think basic science research is really directing itself to to the the terrain. And we're seeing that things like an inflammatory environment. So if the body is generally um in a sort of pro-inflammatory state, and we can talk more about how that how that might arise, but there are definite markers. So there are blood, there are there are chemicals that one can measure in the blood, there are cell patterns that one can see, and we know that that is a much more fertile ground for a cancer to land in, um, than than another. We also know that certain hormone environments end up being a much easier place for a cancer to establish itself. So insulin resistance, um, and the sort of picture that we often see in the kind of metabolic syndrome, which we know is linked to diabetes and heart disease and obesity, that the hormones that are around in those sorts of situations tend to favour cancer growth and often actually end up being growth promoters for cancers which become super sensitive to some of these things. So it's no coincidence that many of the treatments that we've evolved are kind of hormone blockers, but actually if we can do our own hormonal therapy in a in a sense, um, and and actually change our internal hormonal environment, I think we can start doing that in a in a way which has far fewer side effects. Um, I think we're also seeing that the microbiome is is a hugely important part of the terrain which influences our immune systems and the state of our immune systems is obviously a hugely important for whether we develop cancer or not. I think another fact that a lot of people don't really appreciate is that having cancer cells in your body is a normal part of growth and development. So every healthy person walking around who will never be diagnosed with cancer in their lifetime, probably has a million cells that at any one time that have the potential to develop into cancer, but we also have an immune system that's designed to detect and destroy those cells. And it's a fantastically um beautiful again, homeostatic, it's it's designed, we know there's this problem as our cells multiply and divide, some of them will come off the production line faulty, but we've also evolved this wonderful mechanism which provided it's not overwhelmed, there aren't too many cancer cells or the immune system isn't malfunctioning or unable to do its job in some way, keeps a balance and actually keeps us healthy. So thinking about that if there are things that we are doing or things that are that are in our in our microbiome that aren't aren't well balanced, our immune systems may not be able to function at their best. And so that's something another environmental issue that that can then allow cancer to grow a little bit more easily. Um, and I think blood sugar, you can link that to the hormones as well, but but I think we know that in a in an environment where the blood sugar is not well controlled, that also allows um is is a more favourable environment for many cancers to grow. And and some of them, the seed and the soil, I think are both important. We need to study both. It's not like I'm saying only pay attention to the terrain. And and it's interesting, I've I've really enjoyed some of your recent podcasts. I was reflecting on the one that you the conversation that you had with George Monbiot about this kind of the the restoration dramas that we have. You know, he was talking about each each sort of political system that's come that that comes through has this has this story. And he says the only successful ones are ones where you you tell the story of how how powerful and what was his word, wonderful word, nefarious forces have kind of taken over the world and we're the righteous ones and we can overthrow it. But I'm wondering whether whether that's part of the problem that actually we feel we kind of tipping from one end of the seesaw to the other. And I really think the time has come for us to sit in the middle of the seesaw and say, it's not like we want to overthrow it. You've got some, you've got some real pieces of wisdom and and real things to bring to the party that are important, but it's just the extreme of that view isn't the whole picture, the extreme of this view isn't. And maybe actually rather than that sort of restoration drama, we need to get to a rebalancing story that that people can buy into. And I think it's one of the things that that saddens me is that this whole world is still so oppositional and still so siloed that people like you who are genuinely coming with important wisdom saying, look, my mum has cured a condition that wasn't really curable in a conventional way. I've also managed to get to cure my own heart condition through through food. Why should you feel embarrassed? Why should you feel that you've got something to hide and and feel that you might be criticised um by an establishment? And I think it's my my reflections on this over the years is because we've become a bit or that that side of things can become doctor bashing and say, okay, we'll get rid of the whole of medicine then. And and I think we've just got to avoid getting sucked into that that sort of drama because I think that alienates people and then that makes them feel more defensive and then we get into this kind of either or paradigm, whereas I'm a real believer in both and and I think we get the magic of the combination and the synergy that happens when you combine those things. If we can both put all put down our sort of weapons and say, let's come together, come to the table together, really at the end of the day, all we want is for people to feel healthier and happier. What have we got to offer and how can that work well together?
Dr Rupy: Yeah, I agree. But it's funny, isn't it? Because I I know that's exactly the way uh we should be positioning ourselves, but it's not as sexy, is it? It's not as sexy as as having like, you know, a wonder drug or a pill. Like I was reflecting on a conversation as you were talking about um, you know, balancing and actually the middle way. Uh, I was I was talking to um Professor David Sinclair, who is a geneticist, um, and he is a longevity researcher from Harvard. And his sole aim is to improve human lifespan as well as health span. So he really believes that we could be living until 200 plus years uh on this world, depending on the suite of medications. And and and something that's really um garnering a lot of attention are senolytics. Uh senolytics are medications for the listeners that uh remove senescent cells, which are these uh damaged or uh mute cells that just sort of hang around and an excessive amounts can cause excess inflammation that you were talking about, Catherine, which can be damaging for a number of reasons. It raises the risk of cancer, it raises the issues surrounding um uh malfunctioning of uh glucose regulation, which can lead to a whole bunch of other uh issues. But we also require senescent cells in some ways as well. Uh it's part of our healing mechanism. Um, and I I just think the way we think about things in medicine is so binary. It's so black or white. It's either this or that. It kind of fuels the uh the conversations that you're talking about. It kind of fuels the antagonism between different camps. And it's it's these different silos, whether it be within specialties or within, you know, conventional medicine versus integrated medicine. The very fact that we have to separate them with a different label speaks to the um the the lack of uh collaboration. And so it's funny and I think, you know, what we're doing right now is having this open and honest conversation, what I what I try and do with the podcast is is have a a suite of different people talking about different issues, just to demonstrate, you know, if you take it if you zoom out, it's all the same thing that we're trying to do really. It really and and and there are multiple ways in which to help people, but I think we just need to be a lot more open-minded as professionals, um, uh, because it yeah, it it can be quite an angry place otherwise.
Dr Catherine Zalman: Yeah. And definitely, you know, even with within the within complementary medicine, it can be unbelievably tribal as well and and it can be very reductionist, you know, so I think holistic doesn't necessarily, you know, mean that we've all got to go complementary at all. In fact, sometimes complementary medicine can be the most bigoted and sort of um um unhelpful. But but you've said something really interesting, how do we make it sexy? Because I think you're you're so right that it's not a sound bite, it's not a it's not a sort of um this turns the world upside down kind of thing. And I I'm I'm fascinated and this takes us into another sort of leap, but you know, I think evolutionarily, we obviously emerged as unicellular organisms that at some point decided that life was better and easier if they clubbed together, you know, and it's so interesting that in our bodies, we can have these different specialities, you know, we can have a muscle cell, we can have a nerve cell. It's not like they're competing to say, you know, I'm more important than you. Somehow there's there's a concerted sort of group think that can actually be for the better of the whole. And I just wonder what is it going to take? And sometimes you look at sort of ant colonies or insect colonies and you think maybe, you know, they seem to actually, you know, who knows what sort of arguments they're having inside the inside the ant hill, but um, but from the outside, it looks like a quite coordinated where there are some, you know, ants that are the the worker ants, some that are the sort of, you know, I don't know, the sort of ones who are important in reproducing. And so I'd love to I'd love to sort of think, you know, what is it that's going to actually get us to kind of collaborate and cooperate, um, more than compete. And it's interesting that, you know, the people reflecting on Darwin on his bed, you know, on his deathbed saying, you know, it's it's actually not about competition of the fittest, it is about collaboration and evolution together. So, so yeah, I'd I'd like to see it as an evolution of health rather than a health revolution. I think I think there's something about if we can grow grow organically towards each other, um, that would but but I totally agree that it's not a sexy message and I think I think one of the problems of this field is how do we how do we message it? Because it's complicated as well and it's like people want a clear answer. They want to know if I've got this problem, what do I do?
Dr Rupy: Well, this is what I wanted to talk to you about actually, about the the challenges in researching and demonstrating outcomes that can be convincing to the uh the the traditional medical paradigm of randomized control trials. And and also, I'm also interested in perhaps you haven't had, you know, one of those moments where you were skeptical about something and then and then suddenly because you it sounds like you you were very much in tune with what was going on with holistic medicine from a very young uh age in your clinical career. But um, I'm interested in how we move this forward in a way that's acceptable to everyone because as you know, there are challenges in in demonstrating how effective um these treatments can be.
Dr Catherine Zalman: Yeah, I think it's a really, really good question. And I think, you know, I've written a bit about and definitely thought, you know, the the randomized control trial at at best, especially the placebo, you know, the double blind placebo controlled randomized control trial is is brilliant if you're looking at one intervention, you know, it's brilliant methodology possible for a pill really where you can give a placebo pill where people can be blinded to it and where you're keeping everything else absolutely constant. But life life isn't like that and lifestyle interventions, it's so difficult to randomize somebody to a lifestyle intervention because if they want to do it, they'll do it. If they don't want to do it, they might be forced to do it and and grumpily and then actually that might affect the outcome and you might get a more negative, you know, if somebody's doing something against their better judgment or against their will, it could actually be come across as a negative thing even if actually it's not the intervention itself that's negative, it's just their attitude to it. So how do we how do we do this? And I think there are some really interesting models where you can use patient preference to sort of, you know, allow people to choose if they've got a strong preference, but for people in the middle, you can randomize them according to um a standard randomized control trial kind of methodology. That's an interesting one. You can also do black box research where they say, you know, where you allow a person to individualise their approach, but you just say this whole approach where people are allowed to kind of come up with their own program versus standard care. And you can that's quite an interesting model, but researchers really don't like it. And I've I've been, you know, trying to get um, you know, trying to have conversations with people where I say, you know, I think to separate out diet and exercise is such an artificial thing because they're so linked. But they are like, oh, but then we won't know what's working. And I was kind of like, well, you know, does it matter? If it's working, then can we not, you know, and then we won't know what to tell people. And and often, but the telling people is as if there is a one size fits all and it's, you know, you'll you'll be so aware of this with with food that I think trying to find a diet that suits everybody, it's just bonkers because we're all different and our metabolism is different, our cultures are different, our family situations are different. So, so how we can help people to understand the principles on which they can help build a nutritious sort of um eating eating pattern for them. I think that's that's all we can do. But I think we just need to have a different way of doing research. And I think it is coming. I think I think also patient-powered research where people, you know, I think you might have talked to Prof Rob Thomas about this, but I think he's somebody who's very active in the researching lifestyle. And he's come across all sorts of barriers to doing good quality research in this. You know, from ethics committees who don't believe that if it's not a drug, it will have a clinical outcome. So who are actually saying we don't want you to have clinical outcomes in your study because you're not your intervention isn't a drug. So it's kind of like, well, you're you're hampered at the get-go then if you can't even design the study to look for the things that you think are going to happen. So I think we need to we need to really um shift the way that we do research. And I think the encouraging thing is that practice-based evidence as opposed to evidence-based practice is on the rise. And I think actually using real world data, using, you know, collecting the data that people are gathering every day on their phones and on their on their fitbits and things like that, actually will be a much better way of looking at what people do and being able to to make some sensible sort of um synthesis to make a sensible synthesis of some of that information.
Dr Rupy: I I think that's a really good point you made there, Catherine, uh using social uh data or social experiments where uh people can measure and track themselves and obviously there there might be inherent issues with um uh the the validity of the data and you'd have to question it, um but certainly, you know, I've seen this in the um fasting world uh and and researchers looking at people who regularly intermittently fast and then following them up for a long period of time and people just sign into an app on their phone and say this is what I'm doing and these are my outcomes, these are my glucose uh uh monitoring um uh labels and stuff. So I I think there's definitely a way to uh galvanise research by finding different ways in which we can collect data um using apps and and using, you know, the suite of technology that we have in front of us. And never more so than now where people are used to doing things and having to adapt and think laterally about the way we used to do things before.
Dr Catherine Zalman: Absolutely. And I think it's also it gets round a sort of ethical issue because people are really consenting. You know, there are, I think another one of your fascinating podcast conversations was with with Jeff Rediger, wasn't it? Around the sort of spontaneous remissions and the things which kind of challenge our perceptions. And I think, you know, it's interesting, you've talked about skepticism and I and I like to think that I'm open-minded but not so open-minded that my brain's fall out. And I think at the at the bottom, I've always got kind of risk benefit in my mind. And if something doesn't feel particularly risky, I'm more likely to be open to the potential benefits of it. Um, if something is, you know, known to have a lot of toxicity, you know, there are some really weird and wacky um cancer cure um ideas out there on the internet that people can sometimes experiment with and be exposed to. And and I think one of my jobs is how to guide them to the most sensible things where the risk benefits are weighed as much towards the benefit and as little towards the risk as possible. Um, but I think I think it's, you know, people are taking risks. People people are voting with their feet and I think we should be capturing that data. And for me, it's it's so sad that there are there are people, you know, and we see that we see this and I would love to if anybody is listening to this podcast as an oncologist or a researcher who would like to actually think how we can record some of the data um where people are intensively changing their lifestyles, probably not telling their oncologist about it, just like you didn't tell your cardiologist. A lot of people are really frightened of telling their conventional teams for fear that they'll be either told to stop or just sort of rubbish a bit, well, if you want to carry on doing that, it probably won't make much difference, but yeah, go on if you want to. And that's sort of quite deflating when they've put in quite a lot of effort into it. So lots is going on behind the scenes and we are just not collecting that data. So I would love for to think how can we harness a group of of, you know, of people who are who are actually this practice-based evidence. This is actually something that's going on. We don't need ethical consent because they're doing it anyway. We just need to collect the data and see whether we can make some sense and comparing it with all the all the difficulties of, you know, non-randomized control trials are a nightmare as we as we all know, and you've got to absolutely make sure your cohorts are are comparable, but I think we're losing a lot of valuable information by not at least thinking how could we do that. And I would, you know, it's so interesting in in the COVID situation, as you know, it's it's a particular challenge for people with cancer because the risk benefit of some of their treatment is changing. If we're a lot of cancer treatments have a profound effect, temporary effect, usually and hopefully on the immune system, but are making people more vulnerable. So if it was a slightly marginal decision to have chemotherapy in the first place, often people are now being told we're not going to give you chemotherapy. I would love to see a study now that says, okay, we we could, you know, what are we going to do instead? And let's let's investigate lifestyle medicine in that and an intensive lifestyle change change sort of program. If people wanted to sign up for that, I would now is a time when it couldn't be better in a sense to to really do that sort of study.
Dr Rupy: Absolutely. Yeah, I totally agree. I mean, like Dean Ornish did some incredible stuff at the end of the 90s, I believe, with prostate cancer, but unfortunately, it hasn't really been uh repeated in a way that can be proven. And I suppose there were some fundamental flaws with the actual paper because they did a whole bunch of different things, but one thing that really stood out to me was the fact that they gave them vitamin supplements as well as all the other things, which I can understand the uh the ideas behind it, but if you're looking to change people's opinions, then that's really that's really tough when you've you've done that as well. You you'd almost want to have the luxury of time and expense and everything else and be able to repeat it with extra additions to that same study rather than just throwing everything into it. But I can understand why they'd want to do that to get the best outcomes if any as possible.
Dr Catherine Zalman: Yes. And it is that tricky thing of you want to prove the case and then sort of dissect out what are the active ingredients, but recognizing that I think placebo has a big part to play in this and actually allowing, you know, I think we've also got to recognize, I think that's another whole thing about the sort of mind body connection with with all of this, you know, when you eat something that you think is good for you, I I think I'm, you know, I think it must have a a better effect than eating something that you think is is going to poison you. Um, so so um, so I think I think the challenges for research are are real, but they're not insurmountable. And I think I think our our most intelligent minds now should recognize, as we are recognizing the importance of the soil and the terrain, recognize that actually we need a research methodology that works for that, not just for the seed because I think the the germ theory and and sort of pharmaceutical interventions have led our research methodology down one particular avenue. It's great for that, but we need to broaden out.
Dr Rupy: Yeah, I agree. And what you just said about eating and stuff, if you believe it's uh poisonous or toxic to you, my mom always used to tell me, you know, you should never eat if you're in a stressed state or you're angry. There's no point. Just don't eat and just eat later. And I I totally believe that. I really do.
Dr Catherine Zalman: Yeah. And again, that comes back to this integrative approach because it's so lovely to be able to, you know, food is powerful medicine as you as you really know, but it can also be a massive stressor for people, especially people with cancer who read something that says eat, you know, eat to starve cancer and and suddenly food becomes a constant sort of battleground of I I don't know what I should be eating, I don't know where whether I should follow what I want to be eating and and to be able to to step back and say, well, actually, let's if food is becoming stressful, let's focus on some other areas, um, get the basics right. And I I love your approach of just so many different dietary approaches out there, but they have got quite a few basics in common, haven't they? And and I think let's let's get those basics right because we're probably got 85% of the way there with that, maybe even 90% of the way there. And then the the final tweaks are are the other stuff. But if you're stressed, even the good stuff isn't isn't going to be absorbed. Um, you you're you're I love seeing this whole picture and thinking, a, where what are the easiest things that we can change? Because I think when people are in a crisis, you really want some first aid approaches. What are the things that we can reach for quickly and easily that are going to be enjoyable and going to be sustainable? Um, the low hanging fruit and and and things maybe that you've done in the past that you've enjoyed or that you've found boost your resilience or boost your happiness or or make you feel stronger and and more sort of grounded. So thinking back to what's worked for you in the past, what's worked in your culture or your family, what are your what are your, you know, traditions of things that are going to help. And then thinking about what areas need, what what are your strengths that we can really play to? That's really important because I think everybody comes to this with some sort of some inner strengths and inner assets and whether it's that they live in a beautiful place where they've got nature on their doorstep or whether they've got a wonderful um relationship with their their dog that is is a sort of source of nourishment or whether they already have some great, they're already quite sporty and they can play on that. Whatever it is, really support and build on their assets, but also identify areas where they need a little bit more support and where maybe there's quite a lot to gain. So if somebody's up for it, you know, I often it's really important and this is the other two-edged sword, isn't it, when you're starting to talk to people about about positive lifestyle changes they could make, it's quite easy to then for people to then feel blamed for their illness and feel guilty and responsible and that then adds an extra layer of stress and an extra thing for them to beat themselves up about. And how we can how we phrase it in a way which like we don't, especially with cancer, nobody will ever know why an individual gets cancer. There's it's almost always a multi-factorial thing. You know, it's probably a little bit of genetics maybe sometimes, you know, not as much as we used to think probably, but but all sorts of environmental factors, all sorts of, you know, just luck and happenstance at a particular time. So there's no point kind of going over what I could have done and would it be different if and we all know people who've smoked 20 a day and lived to be 90 and died of something completely, you know, been run over by a bus or whatever it is. So, so there's there's no point I don't think going back in a in a guilty sort of guilt-inducing way, but I think moving people forwards and saying, well, you've but whatever's the cause of it, we've actually got potentially a lot to gain here because actually starting from this point, we could get to here and that could make a really, really sort of big difference and small changes, um, particularly in people and I think Dean Ornish showed this really clearly that it wasn't just for people who were already well, eating well, who could make a few more improvements. Actually, the biggest change he saw were in some of the sort of um cohorts where people had had really never thought that lifestyle was important at all in their health and they could make really big changes.
Dr Rupy: Yeah, absolutely. Catherine, this has been great chatting to you, honestly.
Dr Catherine Zalman: It's been really enjoyable, Rupy. I do, I mean, I'd love you've you've asked me kind of what people what can people get at Penny Brohn? And I did just want to sort of talk a little bit about how how COVID has kind of been a bit of a a crisis growth point for us. It's really interesting how how we've tried to recognize, obviously there's been a danger to people with cancer and a danger to our organisation. I mean, both in terms of what services we can physically provide to people, but also all of our fundraising activities have been shut down literally overnight. We do an awful lot of group activities, you know, sponsored walks, marathons, you know, fundraising events where people are in a in a tent all together type of thing and that's been literally decimated. So, so the vast majority of our staff are being furloughed at the moment while we're trying to kind of regroup and work out what kind of future can we have. But the out of that has come this amazing opportunity. We've put a lot of what we could do online and we're now finding that actually numbers of people that we're seeing are increasing because we're being able to reach people, you know, who we otherwise wouldn't have been able to physically come to our centre. Um, and and so it's been wonderful. Numbers are increasing. We're seeing people doing exercise classes from their from their beds as well as from their bedrooms. You know, people who are maybe in the middle of treatment who are shielding, who wouldn't able been able to get out. We're we're running a lot of sort of on Zoom, we're doing some fantastic um physical activity, relaxation sessions, nutrition know-how sessions. I'm doing a a regular weekly um talk and discussion around issues in in integrative cancer care. But we're also offering telephone and Zoom one-to-ones for people so that they can the our counselling is going on. We're doing individual um physical activity um sessions where people who want to be a bit more physically active but don't know how can have a one-to-one sort of um session, nutritional therapy one-to-ones, doctor one-to-ones where we can again, people who've trying to make sense of how do I combine these approaches safely and sensibly can use our expertise. And all of this we're offering at the moment um, you know, on a donation only basis. We're really hoping to get our self-management course, which is a bit more of a sort of um structured course online in in modular bits so that we can people can dip in and actually start to start to learn a bit more how they can support themselves. So it is it is fantastic because suddenly we've seen why didn't why weren't we doing this before? Because actually, you know, we can get to so many people, we can record it, people can use it flexibly. And one of the things that we know is that it's got to fit around people's lives and people's treatment schedules and things like that. So actually it's been it's been great. You know, it's a challenge for if technology is not your thing, but actually for a lot of people now, we've been catapulted into a into a world where we're able to communicate and and learn and and sort of socialize online. So, so that's been great for us.
Dr Rupy: That's fantastic. I'm I'm really glad to hear that because it it would be my uh aim and my wish for everyone to have had the experience of going to Penny Brohn, uh either as a visitor or as a client. And when I went there, I remember I was struck by the serenity of it, the peacefulness of it, the invitingness of it. I mean, it's also because you're very lucky with the spot that you're in in in the part of the UK, uh Bristol, which is just so tranquil and incredible to look at. Um, but the the services and everything, the fact that you can scale it up across the country or even globally as well, I can imagine. You know, I I I think it's it's again, to the first thing that we talked about in our conversation, the opportunity that comes out of this crisis could be huge, absolutely huge for you guys. So I'm so glad that that's happening at Penny Brohn. That's brilliant.
Dr Catherine Zalman: It is brilliant. And and another really positive thing is that we've I do want to put a a bit of a shout out. We've talked quite a lot about the sort of siloed world of of medicine and how it does feel either or, but there are pioneers within medicine, as you know, you've you've mentioned Rob Thomas, but but um, we Penny Brohn has has got a partnership with Genesis Care, who are a private oncology provider. But and it's, you know, it's interesting because I think in the UK, we probably lag a bit behind Europe and maybe the states in terms of adopting some of these things which are more established. And I think one of the reasons for that is that our NHS is so slow to change, you know, and we don't have that sort of consumer pressure that I think motivates the development of services in certainly in the states. So each of the major cancer centres in the states now, Memorial Sloan Kettering, MD Anderson, have got a department of integrative oncology embedded within their their their centres because they know that if they didn't, patients would go across to some other centre. That's what people want. So we're a bit slower on the uptake, but Genesis Care, again, probably, you know, more patient focused and and and sort of able to respond to that, have got a partnership with Penny Brohn where they've recruited and and and sort of embedded a Penny Brohn well-being consultant in each of their centres. So it's an opt-out thing. So everybody who comes through their services will get a well-being consultation which will definitely talk about this sort of soil thing as well. And they're they're starting to get gyms in all their cancer centres so that exercise medicine is really a part of that, starting to talk about nutrition, starting to talk about stress management. So that's been fantastic. And also through their networks, we've been able to reach quite a few more professionals as well as as well as patients. And and now, you know, hopefully with the online that will that will continue to expand as well.
Dr Rupy: Yeah, well, I'm so glad to hear that that kind of work is accelerating with your collaborations. And you're right, you know, it is good to shout out, I think that it's not us or them or it's not, you know, as archaic as uh some people have been led it to be. A lot more people are getting interested in this.
Dr Catherine Zalman: Yeah. And and a lot of people are coming saying my oncologist told me to come to Penny Brohn or my oncologist is really supportive of what I'm doing. So we are definitely seeing a sea change and I think, you know, that's really important to recognize as well. And I think I don't want this to be in any way sort of, you know, oncologist don't aren't interested in this sort of thing. I think it's just really hard. There's so much research coming out that that they have to kind of to keep up to date in their fields, you can see why they're not then branching out to read literature in yoga and Tai Chi, but many of them are beginning to to appreciate that some of these things have got something to offer and are being open-minded enough to say, I may not know the expert, be the expert in that, but you know, I'll support you to go and find the things that that make a difference for you.
Dr Rupy: That's brilliant. That's brilliant. That's really good to hear. Well, thanks so much, Catherine. Honestly, this was brilliant. Really was a pleasure.
Dr Catherine Zalman: Have a look at the Penny Brohn website. If people can make a donation to help us carry on this sort of work, as I say, it's really we don't know yet whether we will be able to survive. It really does depend quite how long this goes on for and how we'll how we think that we can start generating income. There on the on the um website, there's there's ways in which you can find out more about our our activities, more about sort of what we what we do, but also very importantly, if anybody feels motivated to support us, even just a sort of 5 pound donation can go a long way. And we are really seeing how how cost effective some of these interventions can be now that we can reach lots of people. So, so if people are interested, they we can there that we're on Facebook, Instagram, Twitter, there's the website. Um, if people want to just text um event to 70145, that that just will give us a 5 pound donation, which every little tiny bit makes such a difference at this time that it's really, really helpful. So
Dr Rupy: That's brilliant. That's brilliant. That's really good to hear.
Dr Catherine Zalman: Well, thanks, Rupy.
