Changing landscapes

Home is where the heart is.

Pliny the elder (23-79 AD)

Roman lawyer and natural philosopher.

The word ‘exile’, ‘emigrant’ and’immigrant ‘are all difficult to define. In countries where English is the spoken language, the three words are interchangeable in common parlance. It’s somewhat similar to ‘symptoms’ and ‘signs’ in medicine. These words are often incorrectly used. I have even come across an eminent English wine writer, who ascribed ‘symptoms’ to vines and their progeny. Somewhat strange, unless the said vines/grapes could speak [1]. However, because the words are so commonly misused, a number of us who try and use them correctly are probably fighting a losing battle.

The word ‘exile’ usually means a person who has been banned from their own country for political reasons. However, in the ‘Middle Ages’ people were often exiled within their own country as a form of punishment. Emigrants are usually thought of as people who leave their country for economic reasons, or in times of war. Two of the best known examples of ‘exiles’, in Western culture, are Dante Alighieri in Italy, who died in Ravenna [Fig. 1] having been exiled from Florence and James Joyce [Fig. 2] in Ireland. Joyce, although not strictly-speaking an exile as he apparently left Ireland because he found the atmosphere stifling with the dominance of the Roman Catholic Church. He did, however, write a play called ‘Exiles’. Somewhere in the mix is the word ‘refugee’, a person who leaves their country of origin and does not wish to return because of fear of oppression or war. The UNHCR (United Nations High Commission for Refugees), at the end of 2021 claimed that 89.3 million people had been forcibly displaced. The world is indeed a troubled place.

Fig. 1: Dante Alighieri.

Dante Alighieri’s tomb in Ravenna, Italy. Wikipedia. Photograph by Camillo Morigia. Creative Commons Attribution-Share Alike 4.0 International license.

Fig. 2: James Joyce.

Statue of James Joyce in Trieste, Italy. Photograph by Shaun McCann.

What has this to do with haematology? It depends on where the refugees have come from and where they settle. There are certain parts of the world in which qualitative and quantitative disorders of haemoglobin synthesis are frequent and yet these disorders may not exist in significant numbers in the countries in which they settle. This, therefore, presents a challenge to healthcare workers and health services. Qualitative disorders of haemoglobin synthesis, such as sickle cell disease (SCD) and its variants, require extensive medical services including pre-natal care, care of children and adults, together with genetic counselling. This requires organisation of medical services especially in countries which have little experience in dealing with such problems. A less obvious problem is the avoidance of ghettoization. In countries where these disorders are rare, and health authorities are reluctant to provide accommodation this can result in many people with similar disorders living in proximity to each other.

On the other hand, healthcare workers need to see a number of patients with these disorders to attain adequate experience. The solution to this problem requires political dexterity and a degree of social nuance. Countries in which these disorders are endemic need to educate and help inexperienced healthcare workers to establish such services.

Countries in which quantitative disorders of haemoglobin synthesis, thalassaemia and all its variants, are prevalent, pose similar problems if healthcare workers in host countries are inexperienced. So, countries which have a large influx of refugees from such areas often have difficulty in providing such services.

I think most haematologists will agree that genetic engineering (gene therapy and gene editing) and immunotherapy are probably the major examples of changing landscapes in recent years. Immunotherapy for Acute Myeloid Leukaemia (AML) was in vogue in the 1970s [2] in an effort to prevent disease relapse. Unfortunately, it was unsuccessful and death from relapsed leukaemia continues to be a major problem in spite of haemopoietic cell transplantation (HCT). As technical problems continue to be addressed, a major question remains to be answered: what is the long-term efficacy of treatment such as CAR T-Cell therapy for malignant disease? Also the profound lymphopenia associated with immunotherapy may predispose patients to severe viral infections such as SARS Co-2-virus.

What has this got to do with wine? Quite a lot, really. The origin of Vitis Vinifera (the common vine cultivated in Europe) is probably somewhere in present-day Iran and most certainly in the Middle East. It is likely that the Phoenicians (Carthaginians), who were excellent sailors and a very sophisticated ethnic group, brought wine to Greece and from there to Italy and eventually to the rest of the world. Unfortunately, the Romans affected such retribution on the Carthaginians after the 3rd Punic war that we have to rely on the accounts of the Greeks and Romans. Without the movement of people together with their culinary skills, there is no doubt the world would be a poorer place.

The making of wine (essentially the interaction of fungus on the grape skin and sugar in the grape to make alcohol) has gone through many iterations. Initially wine was fermented in amphorae [Fig. 3] or cement tanks. This was followed by the invention of wooden barrels for fermentation and eventually by stainless steel. The use of amphorae has returned and cement tanks are still used by some producers.

Fig. 3: Amphorae.

Amphorae for storing/fermenting wine, Populonia, Tuscany, Italy. Photograph by Brenda Moore McCann.

The widespread use of glass bottles in the 17th century [3] was an effort to standardise volumes of wine in containers. Heavier wine bottles were eventually introduced to withstand the the pressure generated in champagne and many sparkling wines, as ‘ordinary’ bottles frequently exploded! [4].

The fact that sparkling wine, sometimes referred to as champagne, is now manufactured in England comes as no surprise to wine-drinkers, and a number of well-known French champagne houses have declared an interest in making English sparkling wine. What did come as a surprise to me was the content of Jancis Robinson’s article in the FTWeekend 17/18 December 2022 [5]. In it she claims that the well-known French wine-maker M Chapoutier plans to make wine from the Chasselas grape in the Scilly Isles. I was totally unfamiliar with this grape although it apparently makes delicious wine in Switzerland and Chapoutier thinks ‘it may become the British grape not just the Swiss one’. The granite soil of the Scilly Isles is particularly suited to this grape so, let’s hope the wines are a success and no too expensive.

The other great change to occur is the experimentation with various types of closure and wine containers. While many of us are quite satisfied, in fact enchanted, with traditional corks, there are many competitors including plastic, and so-called twist tops. However, wine drinkers are a relatively conservative lot, so, traditional corks will probably be around for some time yet.

I have spent 4 months in Tuscany and can assure you that Chianti Classico (C.C.) from 2020 is drinking very well at present. I have only tasted one example of C.C from 2021, and it was excellent.

Happy drinking in 2023 and let’s hope 2023 will be a good year for patients with haematological disorders and wine-drinkers.