The Wry Observer’s Covid-19 update (128)

I did not intend to blog today, but “The Times” has driven me to it, with a large article identifying obesity as “the reason for Britain’s terrible toll” and a small piece noting that scientists have discovered that people with blood group A are at higher risk of contracting Covid-19.  What they mean of course is that there is a higher risk of developing Covid-19 from a SARS-CoV-2 infection.

I wrote as follows:

“Sir,

Obesity is a clear and long-recognised risk factor for a fatal outcome in Covid-19; the question is why.

I postulated at the beginning of May 2020 that it is due to increased levels of the hormone leptin, which is produced in fat cells, so the bigger the cells the more there is.  Leptin is inflammation-inducing, so it is possible, likely even, that raised levels may trigger the cytokine storm that is the dangerous part of SARS-CoV-2 infection.  I am not aware of any investigation of my hypothesis.

Similarly it is long recognised that Blood group A (which is commoner in people from Bangladesh) is linked to a chromosome 3 anomaly that raises the risk of cytokine storm. The link explains the increased risk of Covid-19 in some ethnic minorities.

Nothing new here, then, but I wish that people had listened to me earlier.”

With regard to the latter “The Times” has obviously forgotten that it reported this finding, albeit from another investigating group, on 12^th June last year, and it is confirmation if any were needed that Covid-19 is a cytokine storm syndrome.  As yet the “Annals of Internal Medicine” has not yet published my letter of August 2020 re leptin, but I have signed all the necessary permissions.  I almost wish I could get something wrong so I might come down to earth and stop being right, but I am, really, quite grounded, ever since I found that a job application I made (successfully I should add) had been annotated by one of the interviewers with the comment “Too clever by half?”. Onwards and upwards…

The Wry Observer’s Covid-19 update (127)

Were my dear Mother still alive (she died in 2010) she would have been 105 today, had of course she survived Covid-19 in her residential home.  The mist is slowly clearing, and I have done a paint touch-up job that needed doing (another due, but needs undercoat so will wait for my little brush to dry).  An outside table to erect in the passageway for guests in our holiday house next door; half a delivery of bean supports for the allotment but the other half was damaged and sent back by the carrier, so cannot do that yet though the bean area is rotavated nicely. One article accepted, and another turned down, so on I blog…

Another news item that made me cross; a report that oximetry is being used in Kent care homes to monitor residents and probably avoid hospitalisation if their O₂ saturation remains above 92%.  Now when did I suggest the widespread use of oximetry?  Oh yes.  May last year. Also while browsing came across an interesting article by Kotecha and colleagues confirming immunological cardiac damage from Covid-19 .  It’s at https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehab075/6140994. There are three possible pathways to damage and the paper has a nice slide showing these.

Now when did I suggest such a mechanism?  Oh yes.  April 22^nd.

I think I need to get out more.  If only.

The Wry Observer’s Covid-19 update (126): anniversary edition

Dear Blog,

Happy Anniversary!

It’s a year since the Wry Observer began observing the coronavirus panic, and perhaps it is finally coming under control.  Whether I should stop my diary is a moot point.  The frustrations of writing what I have tried to make a balanced commentary have been many; working out the mechanisms, working out the treatments, submitting my findings to the powers that be, being ignored, being proved right (usually several months later), watching as the wrong people make the wrong decisions.  I have made my own mistakes.  If you go back to the beginning you will see that I was fairly dismissive of SARS-CoV-2, thinking it little worse than “ordinary” flu.  Watching the rise of hospitalisations and deaths made me very concerned that my little poem about pandemics (Pandemic Polemic, reproduced in my verse collection “The Doctor’s Doggerel” (and subsequently in amended form in our local e-newspaper and the Lockdown Sceptics website) was over ironic in tone.  However, analysis of the number of deaths does suggest that overall the impact of SARS-CoV-2 has not been that much worse than the flu epidemic of 1968, if indeed it was worse at all.  And we didn’t have a huge fuss and economic shutdown/catastrophe then.  I have pointed out, without success, that one should not compare death rates month to month, but peak to peak, and condemned the presentation of statistics.  I suggested that the apparent high death rate compared to other countries was down to less exact analysis of whether Covid-19 was relevant or correctly recorded.  I have tried to get people to hear why some ethnic minorities are at higher risk of serious illness (genetics) and that obese people might be at risk because of higher levels of circulating leptin, a pro-inflammatory hormone.  I explained that many of the systemic complications are related to coagulation disorders; that home pulse oximeters would identify deteriorating patients earlier; that “Long Covid” was an immunological response in the central nervous system.  I outlined treatment regimens; that finding an effective treatment for Covid-19 would reduce coronavirus to something that really was little worse than flu; that you didn’t need to do trials for treatment of an already recognised condition for which the trial drugs were already in use.  I tried to explain why rheumatologists should be intimately involved at the highest committee levels, because they were the specialists who understood immunologically mediated disease. 

All of this was to no effect whatever.  Government and “The Science” either failed or refused to listen.  I understand that armchair commentators may be irritating, but perhaps more attention should be paid to those who (1) have a sound understanding of the disease process, in this case SARS-CoV-2-induced cytokine storm, (2) those who have a decent track record in commentating (no apology – me), and (3) those who have both the above, but have the time to put proposals together.  To my chagrin much of my outline eventually came to pass.  Despite me, I fear, rather than because of me.  And months after it should have been put in place.

I tried.  I offered my help; I had no response.  I watched as the same specious arguments and theories were advanced despite the facts.  I learned that if you scream at the television for some reason those on it do not hear you, and if you write to them they do not read it.

I have also watched with some amusement as every attempt to act quickly is condemned by those who think action was precipitate, while every attempt to be cautious is condemned by those who think action should have been expedited.  Sometimes they appear to be the same people.  I have watched the tourists in my home town break all the rules on travel and social distancing.

But perhaps, despite all of this, the bad times are finally ending.  I did not expect a vaccine (indeed certainly not several of them) so quickly.  And maybe they are working – or maybe the latest wave (third, not second, if you look carefully at the UK graphs) is subsiding on its own, despite Kentish, South African and Brazilian variants, the latter two occurring in rather small numbers; if rabies got into the country in one small area, would you lock the whole nation down?  Maybe then killing all the dogs might be a rational approach, unlike the attempts to stop the plague in centuries past.

Roll on the public enquiry.  Of course, I might be most unwelcome as a witness…

The Wry Observer’s Covid-19 update (125)

Yesterday we went for a walk along the beach at Pett Level, heading west towards the end of Rye Bay, known as Cliff End, which is a sandstone cliff that is under assault from the sea.  As we walked a huge section fell off.  Quite dramatic, with a cloud of dust that hung for half a minute or more.  In the next twenty minutes a couple of further falls occurred, and you can see the brighter colour of the exposed remainder, which is very large.  We have never seen anything like it except on film, so it was quite exciting, even if it reminds us that even rocks and cliffs have a finite life.

There was a good, if rather depressing piece on the Lockdown Sceptics site by a retired senior nurse, Dr Ann Bradshaw (see https://lockdownsceptics.org/what-are-we-to-make-of-the-40-5-hospital-acquired-covid-infection/.  I responded as follows:

“There are many reasons why infections spread in hospitals, but they are not always hospital-acquired in the first place.  In my old hospital we had a major problem with MRSA.  Our bacteriologist did a study which showed that the majority of cases were hospital-identified, but not hospital-acquired.  In other words, the patients came in with it.

However, the reasons why infections spread in hospitals are as follows:

• Staff may not complete cleansing procedures before moving on to the next patient (this also applies in the community, where we saw district nurses using the same disposable gloves for different patients, thus protecting themselves but not the patients)
• Staff move between wards (filling in gaps, usually) taking organisms with them
• It’s impossible to isolate all patients because strict rules on single-sex wards and a lack of siderooms precludes this.  In extremis one should be able to put any patient on any ward, but managers would not usually allow it.  No mixed wards was an unbreakable rule
• Managers may also ignore good practice.  My rehab ward was occupied by patients at very high risk if they got an infection.  We introduced a rule that no non-rehab patient could be admitted either from home or from an acute bed unless they had tested negative for MRSA.  When beds were short this was overruled by duty managers.  When I publicised this I was threatened with disciplinary action for making false statements, which did not happen because I produced the correspondence trail.
• Many hospitals have closed ventilation systems.  That’s why many wards smell so bad.  If they smell, then bugs are in the air.  You cannot open the windows and often the air-conditioning is inoperative because of the risk of (or finding of) legionella.  In the very old days open fires ensured an airflow and the bugs got incinerated as they were sucked over the glowing coals

The “bare below the elbows” policy has no basis in research, indeed quite the opposite; it makes no difference.  When the Journal of the Royal College of Surgeons tried to initiate a debate on this it could not find a single surgeon to argue for the policy.  So it printed two against it.

What would be very interesting is to look and see what effect this pandemic has had on other infectious diseases that run riot in hospitals.  Norovirus is one (a hospital is much the same sort of environment as a cruise ship).  The other is Clostridium Difficile infection.  My guess is that the tightening up of washing, PPE, masks and staff containment should have had a massive impact on the incidence and prevalence of both, but certainly norovirus is as infectious as SARS-CoV-2, so if the hospital acquisition rate of this is as high as Dr Bradshaw suggests then maybe the incidence of the others has not fallen much.  The problem is that I cannot see an easy solution; there will always be asymptomatic Covid cases in non-Covid beds who will infect others before they are known to have it, and isolating them to make sure they haven’t will obstruct all non-Covid treatment.  My bottom line, therefore, is that (a) we cannot have a zero-Covid strategy because it is impossible (b) we will have to accept an ongoing SARS-CoV-2 load indefinitely, vaccines or no, and therefore (c) we must concentrate our effort on ensuring that those who develop Covid-19 get proper and prompt treatment.  It’s great to see that a regime of steroids and tocilizumab has been recommended.  It’s not so great when you learn that I proposed this regime (in emails to the CMO and CSO, and a letter posted to Matt Hancock) in April/May 2020.”

Partha Kar, a consultant physician in Portsmouth, wrote a piece in the British Medical Journal (20^th February) titled “Losing one’s faith in leaders” (https://www.bmj.com/content/372/bmj.n424).  It’s worth a look.  I responded as follows:

“Dear Editor,

In one short article Partha Kar has effectively summarised the 100,000 words that I have written in my blog (https://bamjiinrye.wordpress.com) over the last year.  During that time I have argued that:

• It is as important to treat the consequences of SARS-CoV-2 infection as it is to try and kill the virus
• The treatments for the consequences (namely a cytokine storm) already exist, and therefore do not need trialling
• A regime of steroids and biologics is appropriate
• Home pulse oximetry may enable early prediction of deterioration
• Other tests (eg CRP, ferritin) may help predict a worsening outcome
• If one can reduce fatality by such means so that SARS-CoV-2 is no worse than flu, then the problem is largely solved
• Media presentations have used confusing or inappropriate statistics

Not only have I blogged, but I have sent details, suggested protocols and more to the CMO, CSO and Secretary of State.  I have never had any acknowledgement.  To my regret, tempered with relief that what I suggested has been adopted, in part, in dribs and drabs, I believe that most of my proposals should have been adopted eight or nine months ago, but were not because of a fundamental failure to understand the clinical problem of Covid-19.  This was because the wrong experts were making the decisions.  I offered to help, but heard nothing.  As a retired rheumatologist I had time to help, and experience of using steroids and biologics; wearing my secondary hat as a rehabilitationist I had experience of treating sepsis and adrenal failure in severely disabled patients – and had even treated a cytokine storm syndrome.

So like Dr Kar, my faith is lost, but it was lost a while back.

He writes “I’m done.  No one’s listening to my advice, and that’s why lives are being lost” – and I think he is right on both counts; no one is listening, and I consider some thousands of unnecessary deaths have occurred as a result.

But it would appear that there has been a closing of ears to suggestions.  A letter was written to Professor Neil Ferguson (not by me) which prompted the following response, in part:

“I presume you sent me this because you feel upset, angry, that no-one is listening, want to hurt me or change my mind. Or all of the above.

I and my colleagues and friends (John Edmunds, Jeremy Farrar, Marc Lipsitch, Christian Drosten, Patrick Vallance, Chris Whitty,…) get so many of these sort of emails that we barely notice anymore. Most get dumped into junk mail folders automatically nowadays.

But for a change, I thought I would reply to you. Not that I really expect it to change the alternative reality you seem to have got sucked into, but occasionally I feel I should try.”

Readers may have their own opinions about the tone of this, but I do at least now understand why my submissions have gone unanswered; they were consigned, unread, to junk folders.

What a pity.  Indeed I would go further, and suggest that such behaviour is unworthy of respectable scientists or clinicians.  Given the huge sums spent on Test and Trace and other initiatives, would it not have been possible for those emails and letters (and I concede there may have been thousands of them) to be triaged?

If it is not possible for concerned and informed clinicians to present and discuss their hypotheses with those in charge of managing a disease then medicine in this country has come to a pretty pass.  Dr Par thinks the leadership teams have failed us all.  I can only agree.  Whether we should disengage and sulk in our tents, however, is a different matter.  That is defeatist and I will not do it.  I hope that eventually someone up there will have the common decency to engage.”

I have only reproduced the first part of Ferguson’s letter, which I found quite offensive in its arrogance and dismissive tone.  It was printed in full on the Lockdown Sceptics site.  But if truly all of the legion of informed, as well as uninformed correspondent have had their offerings automatically filed as junk then it is unprofessional in the extreme.  Why should a cabal of colleagues and friends see fit to close their ears to others?  I think my response has made it clear enough that I think they have missed something important and, if I am right, that they truly have death if not blood on their hands.  In due course the public enquiry to come will hear me out.

Meanwhile today a roadmap (why not a plan?) has been laid out to end lockdown in stages., subject to the right conditions being met every four weeks.  If all goes well we may be free of constraints by early June.  We have booked a short break in Dorset thereafter.

The Wry Observer’s Covid-19 update (124)

Two things to read.

First (a little delayed, but I have been too busy reading through Pepys’ diary to keep right up with “The Spectator) an excellent piece by Matt Ridley on viral evolution and mutation (6^th February, p.16, or https://www.spectator.co.uk/article/stresses-and-strains-the-evolution-of-covid-is-not-random). My confirmation bias kicks in again, and it helps to cement my view that eradication of the virus is an impossibility that we should forget about.

The second takes me back to something I said was not currently relevant, at least in a medical context – where the virus came from. Jonathan Latham and Alison Wilson of the Biosciences Resource Project have written a provocative piece titled “Why China and the WHO Will Never Find a Zoonotic Origin For the COVID-19 Pandemic Virus”. It’s at https://www.independentsciencenews.org/commentaries/why-china-and-the-who-will-never-find-a-zoonotic-origin-for-the-covid19-pandemic-virus/. It hypothesises that the epidemic began thanks to the accidental release of the virus from the laboratory in Wuhan. But given the smoke and mirrors surrounding the WHO “investigation” we will probably never know for certain. This hypothesis from scientists with an appropriate background is rather convincing and suggests that the likelihood of transmission directly through bats (or pangolins) is about 17,000 to 1 against. So I fear the pangolin merchants will say “Oh well, that’s all right then” and continue to traffic the poor innocent things. I don’t know quite why it upsets me so much; I have never seen a pangolin, much as I hoped to in Sri Lanka. We did see lots of mongooses which are also quite cute. To lighten the mood I include one of my photographs.

Meanwhile back at the ranch the number of hospital admissions, hospital inpatients and those in mechanical ventilation beds continues to decline.

I wrote an anguished email to Andrew Goddard, President of the Royal College of Physicians, with whom I have an ongoing dialogue because unlike the Department of Health wallahs he is courteous enough to respond to my missives. I asked what else I could do to get across my message that I know what they know, only months ahead. He replied as follows:

“I think one of the problems is there are so many false prophets around it makes the true ones hard to spot and thus they get ignored. I know that the CMO was being bombarded by emails in the first wave from all and sundry and (although am not sure) wonder if someone in his department screened emails. I struggled to keep up with emails (and still do) and the CMO must have had a log order or two more than me from the great British public. 

I’m not sure how to change the situation and in particular suspect SAGE will not change quickly. I found the membership of iSAGE as frustrating to understand and both are more about who you know than what you know. Getting people that challenge group think involved is hard and one of the things we must do in the ‘wash-up’ is figure out how we could have identified those voices earlier. 

I think you just have to keep banging the drum. Eventually people will stop and ask ‘what is that noise?’ I’ve found that it is only at the time you get really fed up with saying something again and again that people just begin to take notice (e.g. me and workforce over the past 13, yes 13, years).”

I hesitate to suggest that he is confirming that my voice is worth hearing, but will go on banging the drum. Nearly a year of banging so far; my first Covid blog was on February 29^th 2020. 11 days to go.

I am at least a tad more optimistic than my economics guru, who has written to me with his analysis and results of his Internet travels and said I could quote him non-attributably. I have interposed my comments.

“By pure chance I came across this guide on how to make your own Covid vacccine, in thebrowser.com (a mind enlarging site in its own right), and thought that you might fancy a challenge:

https://www.lesswrong.com/posts/niQ3heWwF6SydhS7R/making-vaccine”

[Not one for me, not least as quantities are not clearly specified and the risk of some awful reaction must be pretty high – but the science seems robust, even though if one is getting it for free it seems a waste of money.]

“Also, if you really fancy buying a Venetian doctors’ mask, there are plenty of them about and they do look pretty scary (we saw somebody the other day wearing the full Monty…an impressive sight indeed!)”

[Not sure Rye is ready for this.

I accused him of being bored if he had time to view random websites.]

“Many thanks for your email, and especially for your upbeat message to J, much appreciated indeed. We must start preparing for the reopening of the business for good, and get ready for what could be a tsunami of staycation demand! I leave the the turf wars among scientists and academics to scientists and academics, as I am more interested in economic and societal matters. Having said that, I look at the spot lockdowns in Melbourne and New Zealand with a great deal of anxiety, as I can see our masters (politicians, and now also scientists) taking great pleasure in switching on and off our local or regional Covid lifeline switches at will…we may well be condemned to live the rest of our lives under the sword of Damocles, which in turn may well preclude a proper blue sky recovery from taking shape.

Non-random websites are there to educate us, random websites are there to entertain us…By the way, here is a great horizon-widening non-random website for you:

www.visualcapitalist.com

And how can I be bored? We are in the midst of a (so far largely) peaceful revolution that has its roots in the greedy capitalism of the 1980’s and 1990’s, and that was turbocharged by the financial crisis of 2008. The twin engines of capitalism and democracy that drive our society forward have failed to deliver for large swathes of the population…how about this: the lifetime earnings of the average salary man are £1,395,000, compared to the average annual emolument of a FTSE100 director (not CEO!) of £3,700,000, when the FTSE itself was in absolute negative territory over the ten year period to end 2020! Or this: on a good day, Elon Musk’s net worth can increase or decrease by US$ 10-20 billion (!) per day, when a US army private rank soldier makes $20,172 per year! But, thanks to technology, transparency has improved and social network effects have spiralled exponentially, triggering Brexit, Trumpism, Me-too, BLM, Take the Knee, Take down Wall Street etc…and the Covid lockdowns have only helped to cement these trends as people have all the time in the world to spend huge amount of time, effort and money on bringing about real change! And this is only the beginning, as all walks of life crumble and fall under the attack of the new millennial generation in the process of taking over all the levers of power. In the UK the battles lying ahead are obvious…top of my list would be a push to topple the Royal Family (following the inevitable death of the Queen), environmental issues, proper wealth redistribution, pushing back the tentacles of the State etc… Even the walls of the Rye citadel won’t be strong enough to resist this wave for change! And let’s not even begin to list the global battles that lie ahead….Sadly, we, in the top 1% of the population by wealth, are on the wrong side of history…it is our generation that is directly responsible for this state of affairs, we are a spent force, unwilling and unable to take up arms, directly in the eye of the storm, a bunch of armchair commentators and investors. All we can hope for is that things stay as they are for as long as possible…yes, we have become real conservatives with all that entails.

Apologies for this longer than intended email…”

There is something in what he says. We must ask ourselves whether the benefits of closing down the world for the sake of some deaths (and remember that the infection fatality rate is not that high – see Malcolm Kendrick’s analysis dated today at https://drmalcolmkendrick.org/author/drmalcolmkendrick/) outweigh the economic consequences. If I am right, as Mr Hancock now agrees, that we may relegate SARS-CoV-2 to not much more than flu, then I see little justification for further stop-and-start imprisonment.

Having read the comments on Malcolm’s piece I am perturbed to see that there is still a large number of anti-vaxxers repeating misleading information. All I can say is – I have had mine, you are welcome not to have yours and I just hope you don’t develop Covid-19.

The Wry Observer’s Covid-19 update (123)

Today’s “Daily Telegraph carries a long interview with Matt Hancock headlined “Exclusive: We hope to live with Covid like flu by end of the year, says Matt Hancock. Health Secretary believes vaccines and new drugs can turn virus into a treatable condition”

On 4th June I wrote to Mr Hancock (by post, because I didn’t trust email after my failure to engage with Whitty and Vallance) using almost exactly the same words, and provided a protocol to achieve the aim of turning Covid-19 into a relatively harmless disease. OK, so maybe some of those who have commentated on this are right, that it isn’t like flu because it’s much worse, but perhaps they have failed to consider the historical perspective of the Spanish Flu, which was possibly worse than Covid-19, though to be fair there were no treatment options then.

I didn’t put the covering letter up on the blog then, because it was repetitious, but to gain the full impact I have reproduced it here.

Dear Mr Hancock,

I have two questions.

If SARS-CoV-2 only ever caused a mild flu-like illness, would there have been the social, financial and medical catastrophe that we have seen this year?

The answer, of course, is no.

If it were possible to stop SARS-CoV-2 from transmuting into the Covid-19 syndrome and thus killing people, would it be possible to unlock the nation and revert to some sort of normality?

The answer, of course, is yes.

My analogy is HIV. When it first appeared and caused AIDS it caused panic and major disruption, because AIDS killed people. Now, because it can be treated, it no longer figures in the public consciousness as a problem infection. It has to some extent been possible to limit transmission, but a vaccine has not emerged after 40 years of looking.

It is, in my view, possible to stop SARS-CoV-2 from causing the Covid-19 syndrome. Much of the multisystem damage is caused not by the virus but by the development of a hyperimmune state – the so-called cytokine storm. Treatment of this should in theory prevent or at least mitigate a large percentage of cases of Covid-19. That treatment is available. Its components have been used not only in management of a cytokine storm cluster (the TG-1412 trial at Northwick Park Hospital in 2006) but also, widely, in rheumatological practice.

I was a consultant in rheumatology and rehabilitation for 31 years; author of a critical column in “Rheumatology” (the journal of the British Society for Rheumatology) for five years; and President of the Society from 2006-8. I have had two memoranda published as appendices to House of Commons Select Committee reports. I was the first advocate of early, high-dose combination chemotherapy in rheumatoid arthritis – suggesting that early, aggressive treatment would produce good results; it was some 25 years before this was accepted as mainstream practice. I was intimately involved in the development of guidelines for the use of biologic agents in inflammatory joint disease. I have served on the Council of the Royal College of Physicians. I have written and had published numerous articles and letters on many medical topics, and a book, “Mad Medicine” (a copy of which I sent to you) examining the NHS from a hospital perspective. If you read this I hope you might think it reasonable to describe me as a thoughtful, critical but positive commentator. Thus I am disappointed that the suggestions I have made to your Chief Medical Officer and Chief Scientist on the SARS-CoV-2 pandemic have passed without so much as an acknowledgement.

While there is no doubt that the response of the NHS to the pandemic has been astonishing, and the NHS was not, as a result, overwhelmed, that response, and continuing reaction, is predicated on the belief that Covid-19 will continue to kill people. I am aware that there are some drug trials running, but looking at the outlines on the NHSRA site I believe they do not conform to my principle of treating early and treating hard. In cancer and in inflammatory joint disease this approach has paid dividends. It is recognised that treating too late, and with too little, does not work. I fear the same is true with current trials on Covid-19.

If SARS-CoV-2 does not progress to Covid-19 then the job is done. We know that its manifestations can be minimal or even absent. Thus testing programmes will fail because people without symptoms will not get tested; vaccines may never happen, and even if they do they are a long way off. So the focus should be on treating Covid-19. The keys to successful treatment are (a) early identification of the development of Covid-19 and (b) the early administration of effective treatment that will prevent the cytokine storm. I am not alone in this belief; in particular, several senior and erudite rheumatology colleagues agree with me. And as both predictive tests and treatment regimes are already available, using investigations and drugs already in common use, it should be possible to turn SARS-CoV-2 from a tiger into a pussycat.

I have watched numerous press briefings. They (and the media) have fuelled panic and hysteria, not least because of the emphasis on precise numbers of tests, infections and deaths quoted and the minutiae of PPE procurement. But not one that I have seen has featured a practising clinician who might have outlined some of the medicine rather than the science. Not one has featured a clinician versed in the management of severe multisystem disease – as all rheumatologists are. But death is what people are scared of. If Covid-19 is no more than “a bit of flu” we can end lockdowns, quarantine, and economic shutdown. So the focus now should be on getting a rational and effective treatment regime in place; it may not stop all ICU admissions, but it should stop deaths. On that basis your experts are the wrong experts. Forget “R”; forget excess deaths (over the next year it is highly likely that there will be less deaths, a “cull of the susceptible” having occurred in the last four months). It is treatment to stop deaths that matters.

I attach my protocol. There is science behind it but for simplicity I have omitted references, though many may be found scattered in my 30-odd blogs (https://bamjiinrye.wordpress.com). The way forward could be positive, but it requires some bold decisions.

I look forward to your response and would be happy to help.

Having re-read my submission perhaps you will agree that I have a better understanding of this nasty virus, and what to do about it, than any of the government or SAGE committee members. I am retired. I have time (except when there are chores to do, or when accompanying my wife on our exercise walk. I am still happy to help. Mr Hancock, what are you waiting for? You spoke my very words – eight months late.

Apropos SAGE I did a head count.

Main Committee: 86 members
Scientific Pandemic Insights Group on Behaviours (SPI-B): 42 members
Scientific Pandemic Influenza Group on Modelling (SPI-M): 68 members
PHE Serology Working Group: 18 members
COVID-19 Clinical Information Network (CO-CIN): 9 members
Environmental Modelling Group (EMG): 14 members
Children’s Task and Finish Working Group (TFC): 36 members
Hospital Onset COVID-19 Working Group (HOCI): 20 members
Ethnicity Subgroup: 27 members
Social Care Working Group (SCWG): 30 members

There is some duplication, but perhaps someone who is within the NHS can tell me which of the members are either acute physicians or rheumatologists – those who deal with, and understand, the clinical features. I cannot see a single one, bar Mark Walport, who was once a rheumtologist. If you would like to visit https://www.gov.uk/government/publications/scientific-advisory-group-for-emergencies-sage-coronavirus-covid-19-response-membership/list-of-participants-of-sage-and-related-sub-groups and let me know I would be grateful.

If you read Hugh L’Etang’s book “Fit to Lead” you will note his views on the impossibility of making decisions in committees that have double-figure numbers of members. But 86?

And the second question is – why is there no clinical management subgroup? There’s a large ethnicity group (which has curiously failed to grasp the genetic susceptibility evidence). What sort of priorities are these. It’s mad medicine.

The Wry Observer’s Covid-19 update (122)

Yesterday several media outlets, including the BBC and “The Times”, reported on the success of trials of tocilizumab in the treatment of severe Covid-19, with experts “hailing” this as a great advance.

It is, but too late.

Yesterday evening I wrote to Rhys Blakely who penned “The Times” piece:

Dear Rhys,

Experts hail £500 drug that speeds Covid recovery and saves lives

is the headline of your piece in “The Times” this evening.

Well, well, well.

The facts are these.

SARS-CoV-2 causes a serious condition known as Covid-19.

Covid-19 is basically a cytokine storm syndrome (CSS), where the body’s immune system overreacts to a trigger.

CSS has other triggers, known for years.  There is a major textbook on CSS, which appeared in 2019.

Treatment for CSS was established before Covid-19 came along.

Therefore what Covid-19 does already has an established treatment,

Therefore trials are not necessary.

So what is there to hail about the new drug?  Only that the trial has proved what we already knew.

What is there to find fault with?  Only that I proposed the use of tocilizumab in April last year, first in my blog and later in a letter to the British Medical Journal  (28th April) and several communications with Chris Whitty and Matt Hancock, none of which received any acknowledgement. Further that I attempted to communicate my views in various letters to “The Times” which were not published.  The two most relevant are reproduced below:

Letter to “The Times”, 27th April:

Sir,

You report Dominic Raab as suggesting that drugs to treat coronavirus are… being explored “because, if we could get the death rate of this virus down… …to resemble something more like flu, it would be much more manageable”

There is a growing view that the serious consequences seen in some coronavirus patients are due to immune dysregulation known as a cytokine storm. The syndrome (CSS) occurs in patients with sepsis; has been recorded in patients with other coronaviruses; appears more likely to affect minority ethnic groups due to genetic predisposition; is associated with kidney complications now being reported with Covid-19; and is becoming the “best-fit” cause for fatality. It is treatable. Therapeutic options should target CSS rather than the virus itself. They include high dose steroids and drugs that block inflammatory chemicals known as interleukin-6 and interleukin 1-beta; these latter have been safely used in rheumatological practice for some years. If CSS can be successfully treated, or indeed pre-empted by using the drugs at the very first sign of developing CSS (probably indicated by a significant drop in oxygen levels) then Mr Raab’s goal is achieved. It does not then matter so much how many people acquire the virus; neither is there need to rush for a vaccine. Meanwhile, however, there is a compelling case to keep ethnic minority staff out of the front line.

Letter to “The Times”, 30th April:

Sir,

While it is encouraging that Remdesivir appears to inhibit the replication of coronavirus your report of the trial notes that death rates were reduced by a statistically insignificant amount. This is almost certainly because the serious deterioration resulting in ICU admission is nothing to do with the virus itself, but to what it does to the immune system – creating what is known as a cytokine storm – and to the lining cells in the body (endothelium). Once a storm has begun, switching off the virus will not stop it. What is required is treatment of the storm itself. Major anti-inflammatories such as high-dose steroid, drugs which interfere with the immune cascade and anticoagulants should switch off the immune overactivity. All of these exist and are in clinical use. If trials of these make it clear that the storm can be suppressed then the fatal consequences of Covid-19 will be substantially mitigated. Early administration is also essential, and tests are available that would enable clinicians to see who was going to develop a cytokine storm, and thus get hold of it before it had gone too far to be treated.

It now appears that my proposals, based on a sound knowledge of immunological disease in rheumatology (I was a consultant rheumatologist for 28 years, and served as President of the British Society for Rheumatology) have been vindicated by a trial (two, if you include that of dexamethasone) that was completely unnecessary.

If you are correct is estimating that there is between a 30 and 50% improvement in survival in severely ill patients I invite you to calculate the number of lives that might have been saved had my advice been taken in April last year.

Naturally I propose to give evidence at any subsequent public enquiry, where I will question why my communications were ignored by a committee of non-clinicians.  I will also be stating that in my view the trials were not necessary and that the delay occasioned by their conduction has resulted in many unnecessary deaths.

I invite you again to look at my blog where all my concerns – and there are many more – are documented.

I have copied this to Michelle Roberts at the BBC, as she bylined a similar story on the BBC News website.

Happy to discuss.

No reply from either recipient.

I wrote to “The Times today, as follows:

Sir,

The “hailing” of tocilizumab as of yesterday represents an egregious failure of scientific method and communication.

The severe disease known as Covid-19 is caused by a cytokine storm.  There are many other precipitants of this syndrome.  A textbook (published before the current pandemic) lists tocilizumab among treatment options.  It is not necessary to trial drugs when their use is already established.

In letters to the British Medical Journal, the Secretary of State, the Chief Medical Officer (and “The Times” I recommended the use of steroids and tocilizumab at the end of April 2020 – without response – and outlined why trials were not needed.  Some nine months later an unnecessary trial has proved my proposal was correct. How many deaths might have been avoided?  When I give evidence to the inevitable public inquiry into the handling of the pandemic I will be seeking explanations for why my advice was ignored.

I cannot understand why there was any delay in introducing tocilizumab.  In Cron’s textbook (published, as I have said before, prior to this pandemic) there are 12 references to the use of tocilizumab in various forms of cytokine storm syndrome, ranging from haemophagocytic lymphohistiocytosis and Macrophage Activation Syndrome to virally triggered CSS.  If you know what the problem is, the cause is an irrelevance; you treat the problem.  The data was out there.  I had flagged it.  In fact I had flagged it not just with the Secretary of State (by post), the Chief Medical Officer, the Chief Scientific Officer and a member of the SAGE committee, but also with Jeremy Hunt, Chair of the House of Commons Select Committee, the BMJ in a number of communications (as in previous blogs), the Lancet, the Royal College of Physicians and more.  I did have a response from Andrew Goddard, College President, who is a gentleman, the SAGE member and Jeremy Hunt’s assistant, but not from any of the other individuals. And the responses did not take up my concern

And I flagged it last April.

If it is now being suggested that anywhere between 30 and 50% of hospitalised patients might have their lives saved by steroids and tocilizumab then I would ask how many lives have been lost by ignoring my advice from April last.  Hundreds? Thousands? It is a disgrace.

I was amused though to find a message in my inbox from the Annals of Internal Medicine saying they wish to print a short response I submitted back in August 2020 asking whether anyone had investigated the role of leptin in the predisposition of obese patients to get bad Covid-19.  So better late than never on that one.

Deaths falling; positive tests falling (the last percentage positive from Ourworldindata, from February 3^rd, is 3.4%).  Vaccinated population rising.  I think the light at the end of the tunnel is really the end of the tunnel, and not a train coming the other way this time.

The Wry Observer’s Covid-19 update (121)

I was pointed at a good exposition of the “Lies, Damn Lies and Statistics” meme in relation to Covid-19.  It questions (much as I did last April) the basis for calling Covid deaths deaths from Covid rather than with it. See https://architectsforsocialhousing.co.uk/2021/01/27/lies-damned-lies-and-statistics-manufacturing-the-crisis/.  Meanwhile “case” numbers are still falling… we are now doing better than any of the major European nations.  Is that lockdown-related, or something else? Too early, I think, for vaccination to have had an effect but it is grimly satisfying to see the EU states falling out over their poor rates, which are thanks to the inbuilt inertia of implementation inherent in its monolithic structure.

The Wry Observer’s Covid-19 update (120)

The Lockdown Sceptics and Quillette websites have become a vehicle for a bit of a ding-dong between Christopher Snowdon and Toby Young, each using slightly different statistics to justify their opinions.  I posted this on Quillette:

The question is: do lockdowns work?

Actually that depends on how you define lockdown and how you define work.  If lockdown means total quarantining of the whole population, then it will work (probably).  But as a previous correspondent has pointed out that means putting everyone under house arrest.  If lockdown means a sort of partial, largely voluntary isolation then it won’t, because there will always be people out and about, spreading virus inadvertently, taking it in and out of hospital (look at the stories of how many people actually acquire it in hospital), bringing it into the country (by all means isolate air passengers; what about the truck drivers?).  Even if one family member goes to the shops they could bring it home, and if the home has lots of people in it then they could all get it.  Thus, although what we have is called a lockdown, it isn’t.

What do we mean by “work”?  If we mean elimination of the virus, dream on.  It will get in somehow from somewhere; bear in mind that although everyone thinks the virus came to the UK from Wuhan, in reality it came from France, Spain and Italy.  The only virus ever eradicated is smallpox.  Coronaviruses mutate and there are dozens of them.  Neither is there any need to take drastic measures to combat something that isn’t dangerous.

If we mean reduce the prevalence of the virus, then yes, it does work.  Somewhat, given the caveats above.  That in turn will reduce the numbers of pateints ending up in hospital, which was the original aim of the first lockdown.  But there again what has happened this winter is that people are dying of something that’s been identified, but not dying of “ordinary” flu.  So from the point of view of deaths the excess from Covid-19 is counterbalanced by the much smaller number of flu victims.  Compare the death rate now with that in 2008-9 or 2010-11; its not that different.  Did we lock down then?  No.

In terms of whether lockdowns and reductions in incidence are cause and effect my answer would be partly.  It’s not possible to prove unless you have a population that isn’t locked down to compare with. But the case numbers remain obscure.  Two reasons. 

First, false positives.  A recent FoI request was put in to ask how many cycles were being used in the PCR test (bear in mind, answers up to 30, OK, between 30 and 40 a bit iffy, over 40, junk, and that’s the WHO speaking, not me).  I put the same request in 2 months back and never had an answer; this time there is still no answer for England – with obfuscation as to why – but for Wales?  45 cycles.  So the portentous tones of Mr Drakeford are spouting policy based on junk.

Secondly the absolute numbers are useless.  There was much angst as the figures rose and rose.  But as a percentage of tests done they did not; bar a week or so the percentage of positives remained fairly level.  test 200,000 and get 20,000 positives is the same percentage as testing 600,000 and getting 60,000 positives.  But at the last count 3rd February, as results take a couple of days to come through) there were 801,949 tests done and 15,450 positives. That’s just 1.9%!  And anyway positive tests are not cases.

We can manipulate the stats until we are black in the face and cherry-pick the “evidence” likewise.  I put evidence in quotes because the more research is done, the more likely it is that the facts will change, something that non-scientists often forget.

Lastly do lockdowns work, however you define each term, in economic terms?  That has a clear answer.  No.

So I remain a lockdown agnostic.  And I remain at home except for exercise.  And today I get my first vaccine dose.

There is more than a touch of the blind men and the elephant.  But more importantly I have had my first jab; I truly believe the end is in sight.  But it does seem that, in comparison to the acceptance of high death tolls in flu epidemics, we have gone quite mad over this one.  It looks as if almost no-one has died of “ordinary” influenza, so all we have done is replaced one potentially fatal disease with another, albeit one with nastier features.  I remain sad that there are so many reports of people being admitted to hospital and acquiring Covid while there; I would be very interested to know whether the numbers of norovirus cases has dropped. It’s another one often acquired in hospital, or on cruise ships which sometimes appear to be much the same thing).  Although I am reminded by myself that MRSA was often not hospital-acquired, merely hospital-identified.

In my book “Mad Medicine”, which I still urge you all to purchase, I wrote the following two essays way back about 2010:

New buildings, old problems

Talk to many doctors and you will hear them say that their crumbling Victorian buildings had a charm and ambience (feng shui if you will) that is unmatched by a modern glass tower. But is the new building actually better? It may be filled with labour-saving and energy efficient devices but if the glass windows face into the midday sun it will get unbearably hot. And as it is air-conditioned you cannot open the windows. And maybe the air-conditioning cannot be used because the water cooling tanks harbour legionella. So the wards are sealed, and all the miasma of stale breath, infected wounds and sweat is unable to dissipate. This may be why so many modern hospital wards stink – made worse because there are not enough nurses to wash the decrepit patients.

On a personal note I will exempt Torbay Hospital from this diatribe, because the personal care my mother received during her terminal illness was exemplary and gave me hope that if the NHS can return to standards like theirs, all could be well.

The Victorians knew a lot about cross-infection, which is why they built serried ranks of wards separated by open corridors to prevent transport of infectious agents across the whole hospital. Lots of nurses kept the patients clean. Any floating microbes would drift through the ward to the centre, where a coal fire burned constantly, so that air was sucked into the tall chimney and the bugs were incinerated as they followed the air flow. Of course there were side-wards for highly infectious folk and the windows were often left open (or more recently extractor fans maintained flow; one has of course to remember that if the sideroom contains the infection and the main ward holds the immunocompromised then the fan must suck out, not in[1], while if the patient with no white cells is in the sideroom for their own safety…).

I like the idea of burning bugs. So let’s redesign all hospitals to include a gas or coal heating system, complete with tall chimneys, so the methicillin-resistant Staphylococcus Aureus (MRSA), Clostridium Difficile (C. Diff) and other such can be massacred.

Except we can’t, because with all the hysteria over climate change we won’t be allowed to burn fossil fuel, and electric fires won’t work. Let’s hope for a supervolcano eruption, releasing so much dust that we will have a mini Ice Age and can stop worrying. Or stop third world countries from cutting down their rainforests. Or stop cotton production in Russia so the Aral Sea can re-fill.  Sorry.  Got distracted.

That’s not to say that old hospitals are perfect. At the Brook Hospital in Woolwich the doctors’ dining room was in a converted ward. A couple of consultants thought the water tasted odd and complained. On the third complaint an investigation began, and the work department were puzzled to find that the water pressure to the drinking water tap seemed rather low. They had a thought, and went up into the roof space, to find the tap was fed from an uncovered cold water tank which contained several dead pigeons.

Ward infections: acquired or identified?

My musings on the value of old-fashioned techniques for sterilisation reminded me that there is another myth, sadly believed by politicians, that there is an important problem called hospital-acquired infection. There is a problem with hospital infections, but is it rightly named and if we changed a word might it take some of the hysteria out of MRSA?

Let me make it clear that I have no doubt that patients may acquire MRSA or C. Diff during a hospital admission. That’s why we had a policy on my rehabilitation unit that no patient could be admitted without being screened first – not that our bed managers cared, and we had frequent occasion to complain when unscreened patients were dumped on the unit so that A&E patients could be decanted within the four hour target time[2]. Indeed I got into trouble when our experience was reported in “BMA News Review” in 2004[3] and I was threatened with disciplinary action for breaching the hospital’s whistleblowing policy, which I hadn’t (and it was unedifying to see managers lying about the issue). But MRSA doesn’t spontaneously appear like magic on a hospital ward, does it? I was seized with schadenfreude when, in a letter of response to my resignation, our Chief Executive told me how wonderful the Trust’s success has been in reducing hospital infection – when all he had done was to introduce my seven-year-old plan which he had never read!

One of the good things to come from targets (and the target was to reduce MRSA septicaemia, not actual surface infection) was that our microbiologist had to develop a good data set both to look at numbers of MRSA infections on wards and where in each case it had come from. Analysis over several months in 2009 revealed an interesting but perhaps unsurprising conclusion; the vast majority of MRSA came in from the community. Patients did not acquire it after hospital admission. They came in with it. Of course we all know that out there in the community the district nurses carry it about and the care homes let it spread among their inmates – or that’s how it seemed to me when I compared the lazy, laissez-faire attitude to MRSA colonisation with the stringent curative and preventative measures on my rehab unit. But it underlined the truth – that most MRSA is not hospital-acquired, it is hospital identified. How then it is government writ that a hospital can be penalised for high MRSA rates is beyond me, when its only “fault” is in admitting unscreened patients who are ill, and then testing them! So let’s have a campaign to distinguish acquired from identified, realise the scale of the problem is not that great, and concentrate on dealing with the source – the place where everything is better – the community!

Politicians like to pretend that they have fixed things, and I was particularly amused by a report in the “Sunday Times” in mid-April 2010 in which the then Health Secretary, Andy Burnham, trumpeted the news that good ideas from the NHS were to be exported worldwide – including how to manage MRSA! I found this rich coming from a government that, when my experience on how to manage MRSA was reported, threatened my managers; it was this that resulted in the attempt to silence me with disciplinary threats when all I had done was describe my unit’s good practice.

We went to Venice for a long weekend. I was tempted to visit one of the many shops catering for Carnival and purchase a Venetian cloak and hat together with a plague doctor’s mask, and wear this into the hospital during the next norovirus outbreak…

Prophetic, or what?  Sadly I haven’t been able to get to Venice to buy my mask.

Paul Fürst, engraving, c. 1721, of a plague doctor of Marseilles (introduced as ‘Dr Beaky of Rome’). From Wikipedia, entry on Plague doctor costume

Finally a note about yet another new approach to treatment – Allocetra, which “resets” the immune system (see https://www.enlivex.com/, or for a more detailed slideshow of why macrophages are reprogrammed go to https://www.enlivex.com/wp-content/uploads/2021/01/enlivex-investor-presentation-jan-2021.pdf).  It appears to be unrelated to the song of the same name by GHIML, whoever they are.

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[1] This was brought home to me as an SHO at the Hammersmith Hospital, when the team visited a sick and septic patient in a sideroom on the haematology ward, which was full of aplastic and neutropenic patients. My boss, neurologist Nigel Legg, spotted the fan was going the wrong way so the bugs, instead of being sucked out of the window, were blowing under the door into the ward. As we shut the door to leave he looked down, stamped his foot carefully and grinned at us “Got one!” he said.

[2] Andrew Bamji, Tackling MRSA. Hospital Doctor, 22^nd April 2004

[3] Alex Wafer, A&E Targets damage MRSA safeguards. November 13^th 2004

The Wry Observer’s Covid-19 update (119)

Correction to the above.  The more you look at the graphs, the more you begin to wonder whether there was a small second wave in September, which started to subside before being overwhelmed by a third wave in November.  Anyway does it matter?  The lockdown sceptics are still doing battle with the zealots, to no-one’s great credit I think.  The truth about all of that is somewhere in the middle.

What else?  The BMJ has popped up another opinion piece suggesting that ethnic predisposition, and its recognition, means that Covid-19 has “brought into sharp focus the burning ethnic injustices in our society”.  Nothing about genetic predisposition; just socio-economic nonsense, although one cannot argue with the concept that some parts of healthcare may be compromised by racism.  I have raised the genetic flag before, but nobody seems to have seen it.

And the vaccine spat… how pathetic is the EU’s petulant response to the fact that it failed miserably to organise contracts for vaccine delivery.  It’s like a small child lying down in a supermarket aisle and screaming until its mother buys it the sweets it wanted.  What ever happened to “business is business”?  EU, you got caught on the hop.  Don’t cry over spilt milk.  Deal with your problem in an adult way.  Otherwise… if we can’t have your vaccine, you can’t have ours.  So there.  It is not particularly edifying to see President Macron on France in the van of this charge, especially when he was hanging on to launch the French vaccine – which doesn’t, it seems, work.  Bad luck, Mister.

Meanwhile I am sad to see that an anti-lockdown sceptics website has appeared, which is launching personal attacks of the scientists and clinicians who have been sceptical not only of lockdowns but of many other things official.  So far I appear to have stayed beneath their radar, though I was moved to respond to some of their claims.  I sent the following, which as it is a bit anti I am sure they will not publish (see www.covidfaq.co – not that there’s much there and it doesn’t appear to have been update for a week).  But still, I suppose it encourages debate.  I wrote:

I was interested to find your site.  For some facts (and opinions) you might like to look at my blog, which you will find at https://bamjiinrye.wordpress.com.

Lockdowns do not work, at least not in the way that they are supposed to work, in other words by eliminating the virus.  That is an impossibility unless you impose a complete lockdown, stop anyone going out, stop anyone coming in to the country and isolate all hospital and care home staff from the outside world until all the current cases have been discharged.  So the only thing that a lockdown will achieve is a reduction in spread.  But, here and there, it will pop up again, as apparently has just happened in China.  That reduction will reduce hospital admissions, of course, but are there really more “cases”?  In absolute numbers there are.  However in relative numbers there are not, apart from a small blip at the turn of the year.  You determine the relative number by the percentage of tests that are positive.  50,000 cases sounds dreadful.  However, if you have done 500,000 tests then the picture is no different from finding 10,000 positives from 100,000 tests.  In fact the latest gov.uk figures are 30,004 positives from 665,330 tests.  The percentage is little different from other European nations.  It just looks worse in terms of “cases” because we have done more tests.  And in any event it is false to claim that a positive test represents a case, false positives notwithstanding, because of the way PCR tests are being done.  You should be aware that the PCR test was not designed for use in the way it is currently being used.

Two other points.  Firstly the ethnic differences in outcome are almost certainly genetic.  See my blog for more details.  Secondly, because “The Science” has been hidebound in defining SARS-CoV-2 as a new virus, and thus believing that Covid-19 is a new disease, it has ignored all the evidence that severe disease is identical to the cytokine storm provoked by a large number of triggers – including old coronaviruses.  The insistence of doing trials on things like dexamethasone has in my view caused many unnecessary deaths because appropriate treatment, though available, was not given – and indeed I cannot find out whether people are being correctly tested for deterioration, or treated correctly once they get sick.

I have tried to engage with the government and DoH – from a position of substantial clinical knowledge – with total lack of success.  My position is that Covid-19 is a serious condition regardless of nitpicking over IFR and CFR but it is being diagnosed late and undertreated.  So far my recommendations have been partly adopted but only nine months after I made them and almost certainly in spite of them rather than because of them.  Again, see my blog for April and May 2020.  You do your pro-government stance no favours by attacking sceptics for errors in prediction while ignoring the errors of officialdom.  Motes and beams.  Yes, we all make mistakes.  Yes, the science changes.  There is a duty of all to admit mistakes and respond to changes in the science.  Can you truly argue that Ferguson’s initial predictions of numbers was accurate?  Can you argue in favour of clinical trials with drugs whose efficacy has already been long-established?  Given the uncertainty over whether reported deaths are from Covid or with Covid can you justify the daily toll of deaths to five significant figures?

News just out; REGEN-COV, which is a monoclonal antibody (given experimentally to our old friend Trump) appears to be highly effective.  Only an early analysis of 400 patients, but at least the UK is on the curve this time with a trial of 2000 or so patients.  If it proves to be true we now have three lines of defence – vaccines (which provoke antibody formation and may prime T-cells for longer immunity), this cocktail of two antibodies which may stop the virus in its track before it provokes a cytokine storm, and then steroids and interleukin blockade (plus or minus ivermectin) for the storm itself (and for ivermectin possibly for both those last bits).

Are we getting there at last?