The Wry Observer’s Covid-19 update (203)

Back in July 2020 I suggested, apropos Richard Horton’s analysis of errors in the management of the SARS-CoV-2 pandemic, that one should not write a history of the war until the war is over. There is nothing so far that has made me change my mind on this. Part of the reason there has been a long gap between entries is that there has been growing uncertainty over The Truth (aka The Science) in a large number of areas. The other part is a family bereavement, which not only occupied much time of site but led to a large backlog of home, garden and allotment maintenance (still not caught up).

So –

Where did the virus come from? A “Commission” report published by “The Lancet” casts a large shadow (https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)01585-9/fulltext) because it examines the possibility not just that the virus leaked from a Chinese laboratory but that it may have originated in a US one. This would fit with the previous revelations of American support and funding for Chinese labs and the idea that the furin cleavage process, which appears to have rendered the original virus more dangerous, was first developed in the USA. Might it also explain the frantic initial attempts to cast the blame on the Wuhan wet market, where it is now clear the virus spread from but could not have originated? No evidence has ever emerged of an animal host in China. Peter Daszak’s work may be the key to this question, but there has been a reluctance of the key players (suspects?) to release full information.

Lockdowns: do they work? The official line still says yes, but the dissidents have nitpicked the statistics, and say that the infection peaks precede the lockdowns, which suggests that the waning of infection is part of the normal natural cycle of infectious diseases and that lockdowns were incidental. In any case it is now thought by many that the virus arrived much earlier than first thought, perhaps in late 2019 (which would not surprise me, as I thought I contracted it then). These arguments are of course independent of the issue of the economic damage done, where there is a growing consensus that it outweighed any benefit. And of course the death rates in places that did not lock down are not that different from those that did.

The Lancet report in my view undoes the whole concept of lockdown. I quote

“Public policies did not properly address the profoundly unequal effects of the pandemic. Heavily burdened groups include essential workers, who are already disproportionately concentrated in more vulnerable minority and low-income communities; children; women, who face employment, safety, and income losses, exacerbated by the adverse consequences of school closures; people living in congregate settings, such as prisons or care homes, especially for older populations; people living with chronic conditions and disability; Indigenous Peoples; migrants, refugees, and displaced populations; people without access to quality and affordable health care; and people who face the burdens of long COVID.”

The ”heavily burdened” groups include essential workers. Indeed they do, but these are just the people who could not and did not lock down, and of course the initial UK policy of emptying hospital beds by throwing out the untested elderly spread the infection into the vulnerable care homes. My point has always been that the so-called lockdowns had too many exceptions to be real lockdowns – and that “proper” lockdowns as we have seen in China have consequences far worse than the illness. As for whether travel restrictions would have worked my answer is no – because by the time anyone realised what was happening it was already too late. The virus had already spread worldwide. Its risks remained unappreciated until after it was everywhere.

Masks: do they work? There has been recent controversy over the initial conjecture that SARS-CoV-2 spread by droplets, and that in fact the major route was airborne transmission. This undermines all the efforts made to sterilise surfaces, wash hands and so on. None of the decent studies (and again, most have been dissected by critical statisticians as well as clinicians) confirm benefit, unless the masks were of a decent specification. This implies that all the home-made cloth masks, and most of the flimsy paper ones, were a waste of time. It was therefore ironic to see an article in the BMJ about schools and masks illustrated with a phot of children all wearing useless masks.

Schools: should they have closed? The effect on education and children’s social interaction has been catastrophic. Were children really such a major source of spread that the draconian restrictions were justified? Certainly the risk to children of severe illness was low.

Vaccines: did they really work? The current official line is yes, but quite how remains unclear because they do not seem to have stopped people getting infected (perhaps unsurprising, as they provide no surface protection – we learn a nasal spray vaccine is being tested) and the evidence that they reduce the risk of severe disease, Covid-19, is unclear. I have been unhappy at the rather strident tone of some of the vaccine opponents but their concerns over inadequate testing, and significant vaccine side-effects, is reasonable, not least over the issue of possible vaccine-induced myocarditis in younger people. Of course this has been an absolute projection in the absence of discussion on the natural rate of infection-induced, or indeed other causes of myocarditis. The conspiracy theorists are putting forward the view that Big Pharma has driven the vaccination programme to make money. I am undecided on this; it seems too glib.

PCR testing: was it a good way to assess infections? Almost certainly not, as the test was oversensitive, and remained positive for long after initial infection due to the detection of very small and non-significant viral fragments. Lateral flow tests were better, but PCR testing was relied on for too long, and distorted statistics.

Fatality rate: was it accurate? Even though full analysis now suggests that the rate was around 1% I still think that the recording of deaths as due to Covid-19 was so slapdash as to be not worth a lot. Certainly in the early stages Covid-19 became a useful excuse even when people were dying with it but not of it. In my book a Covid-19 death required the presence of a significant respiratory illness with a superimposed cytokine storm. Even now I suspect that proper testing is inadequate and so these criteria of mine remain unfulfilled. It is also clear that different countries had different rules, so making comparative data very difficult to analyse. The analysis of excess deaths has thrown up some curious anomalies not least within the home nations of the UK and these need explaining.

The ethnicity issue: was this properly handled? Genetic evidence (much of it preceding the arrival of SARS-CoV-2) was subjugated to a socio-political construct suggesting that the risk to ethnic minorities was something to do with racism and deprivation, which was scientific nonsense.

Treatment of Covid-19: was it adequate? In a word, no, and this despite my own and others’ desperate attempts to indicate the right investigations and therapy – the latter eventually introduced after an unnecessary trial proved what was already known.

Ivermectin: does it work? It certainly has some serious clinician support, and drug trials that rubbished it have in their turn been rubbished. So that’s a don’t know. The vitamin D and hydroxychloroquine fans are less well supported by some reasonable research.

The Lancet report has, like so many other commentaries, one enormous black hole. It concentrates on prevention and containment. However it does not address the undoubted truth that a pandemic illness is of no consequence if it only makes people a bit ill. So it is looking at Covid-19 through the wrong end of the telescope. What actually matters is not the start but the end; if there is adequate prediction of who will get very sick, and if there is thereafter successful treatment – so that people might either be prevented from becoming very sick, or properly treated if they do, then the infection is of no more consequence than any other viral infection. So in that light where is the section on the understanding of the physiological process of severe Covid-19 and its treatment? I word-searched for “cytokine storm” (and just cytokine) in the report. My search returned zero results. I had another look for “steroid” and “tocilizumab” Also a zero. I looked for “oxygen”, hoping to find something about monitoring of levels. Bingo! Four results, none of which related to monitoring and were mostly about the supply of oxygen to hospitals. As for “genetic”, there are eight occurrences, all of which relate to the genetics of the virus and none to the genetic susceptibility of specific ethnic groups.

This represents to me a total failure to understand what has been important in this pandemic. Spread is nigh on impossible to stop; lockdowns, masks etc may limit it a bit, but that’s as far as one can go. Treatment of severe disease prevents death.

The tragic case of Archie

The desperately sad story of Archie Battersbee has occupied the news for some weeks.  After what appeared to be a dare gone wrong, Archie ended up in hospital on a ventilator with his distraught family trying everything they could to stop the hospital from withdrawing ventilatory support.

The press reports implied that Archie was still alive until the moment the ventilator was switched off, but that they did so indicates that, like the grieving family, journalists have failed to understand what constitutes death.  When, finally, his heart stopped after the ventilator was turned off the press reported that he had “finally died”.  In reality he had been dead for some weeks.

I will try to explain.

I first became embroiled in discussions over death following a “Panorama” programme broadcast on the BBC in 1980.  The programme suggested that a number of people had been diagnosed as irrecoverably brain dead when they were not.  The programme caused a furore because it generated enormous fear in the public that medical staff might switch off life support when life was not extinct.

Unfortunately the programme was based on a series of misunderstandings and untruths.  As a result one of the Hammersmith Hospital neurologists, Christopher Pallis, and the Glasgow neurosurgeon Bryan Jennett instigated a debate on the programme to be broadcast by the BBC itself.  This was a first; a documentary had never before been subjected to such scrutiny.  It served to clarify that the original programme had made a large number of errors and had been poorly researched; its defence by a series of experts was demolished.  But it prompted Chris to write a short book “ABC of Brain Stem Death”, based on a series of articles in the British Medical Journal, to explain in simple terms what death actually was.  This was published in 1983.

Chris had enlisted my help, as one of his old trainees, in the run-up to the debate and in the writing of the book.  So I became thoroughly versed in the clinical and philosophical issues about death.

It appears that the lessons of the “Panorama” programme and Chris’s book have still to be learned, forty years on.

The ancients understood that death occurred when breathing stopped.  Harvey’s discovery of the circulation led to a new concept – that death did not occur until the heart stopped.  Thus it became a belief that if the heartbeat could be maintained, death had not occurred.  The introduction of artificial ventilation meant that oxygenation of the heart and other body organs could be maintained almost indefinitely.  But if the brain no longer functioned, then ventilation would not sustain life as we would understand it.  It would sustain a set of body organs only.

The brain defines self.  The lower part of the brain stem (that part between the cortex and the spinal cord) controls breathing.  The upper part determines the capacity for consciousness through the activity of a structure known as the ascending reticular formation, which “switches on” the cortical hemispheres.  If the brain stem is irreversibly damaged by trauma or anoxia (deprivation of oxygen) then the organism as a whole is dead.  Spontaneous respiration is no longer possible and the cortex cannot function.  All organs will eventually fail, even if the lungs are ventilated and a heartbeat is maintained. 

Rigorous clinical tests are undertaken to establish brain stem and brain death.  These are designed to ensure that there is no stem or cortical response measurable.  They must be performed by two experienced medical practitioners and include a careful test for apnoea (by stopping the ventilator and observing no spontaneous breathing, and a rise in blood carbon dioxide levels).  They are undertaken under a stringent set of preconditions that abolish the possibility of error; for example, a drugs overdose or hypothermia may suppress brain and brain stem function, and therefore it must be certain that the observations do not have a reversible cause.  Damage must be proved, and proved to be irreversible; all possible confounders must be accounted for, and backed up by other evidence of structural damage.

The brain stem thus defines life or death.  The concept that if the heart is still beating then a patient is alive is a false one.  If a mammal is guillotined its head is physically detached from its body but its heart will continue to beat.  If blood loss was prevented in such a circumstance, for example by anastomosis of the main arteries into the head with the veins out if it, the heart might continue to beat for some time – despite the unalterable fact that the head is no longer part of the body.  Can it reasonably be supposed that such an organism still lives?  No.  The organism as a whole is dead, even if there is not death of the whole organism.  Once the brain is dead, so is the organism as a whole, and if the brain stem is dead this is a sufficient component of brain death.  Analysis of all cases where brain stem death has been confirmed, and no preconditions were missed, finds not a single case of recovery.

Families are often sure that their relative is not dead because they appear to make spontaneous movements or react to stimuli.  Sadly these are inevitably reflex movements.  This needs to be carefully explained.  It also needs to be made clear how the tests, simple as they are, confirm that brain stem death has occurred.  These tests are clinical, not legal (although they are legally accepted).  So the only role of any court in the determination of what should be done when a clinical team decides to stop ventilation is to be certain that (a) the essential preconditions for making the diagnosis were met and (b) that the clinical tests were properly conducted.  It is wrong to state that a patient who is brain stem dead is being “kept alive”.  They are not.

Pallis also notes the negative effect of ventilating a dead patient on staff, writing “I would emphasise the damaging effect on morale of highly trained staff asked to clean the mouths or treat the pressure areas of patients who are already dead… Whereas the functions of the lungs and heart may be taken over by machines, those of the brain cannot”.

It is unfortunate that, in these circumstances, the media continue to state that the patient is on “life support”.  If they are brain stem dead, as judged by the medical criteria, they cannot be, because life is extinct.

What is needed is a nationwide network of experienced and well-informed counsellors who can spend time with relatives explaining the minutiae of death.  They need to explain clearly that, as Bryan Jennett puts it, in the act of disconnection [of the ventilator] “the doctor is not withdrawing treatment and allowing someone to die, but ceasing to do something useless to someone who is already dead”.  I find it very distressing that cases like Archie’s continue to occur, with desperate and futile appeals to higher and higher courts, and even the United Nations.  These are usually reported as implying that the patient is still alive.  Perhaps proper explanation by experts will mitigate the distress of families confronted with these terrible scenarios,and facilitate the sad process of letting go..

Reference: Christopher Pallis. ABC of brain stem death. British Medical Journal, London 1983

The Wry Observer’s Covid-19 update (202)

Another uptick in cases, and admissions, although it seems that most of these are with rather than from. What lessons have we learned since I last wrote? There has certainly been a great deal of re-analysis of previous research and the number of cases appearing now makes it quite clear that vaccination does not stop spread of infection. China embarked on a vicious lockdown, it would seem to no real benefit. Further evidence has emerged about the risks of vaccines and I certainly think now that these outweigh the benefits at least in the child and young adult population. There are also questions being asked about whether the trial data has been manipulated. I shan’t comment on that other than to say that there are some suspicions. Masks do not work and have contributed to social isolation in schools. But while there has been an increase in case numbers one gets the impression that severe Covid-19 has not increased substantially. Viral mutation? Vaccination protection? Both?

Meanwhile there has been an interesting analysis of the modelling methods of the famous Neil Ferguson, who has been pilloried for the huge inaccuracies of his projections but on the basis of the retrospective analysis of real data. This new assessment looks at the modelling software, and finds it seriously wanting. See https://dailysceptic.org/2022/07/10/its-difficult-to-see-how-anyone-could-be-more-wrong-new-code-review-of-neil-fergusons-amateurish-model/. Best read rather than have me try to summarise it, but it’s pretty devastating.

And, of course, there have been political convulsions in the UK. Boris Johnson’s terminological inexactitudes finally caught up with him, as he broke the one rule: if you are going to cover up, make sure the cover-up is watertight, or you will be exposed as a liar (with bad judgement too in all probability, as here). The Health Secretary resigned and we have yet another, Steve Barclay, who does have some experience in the department as a junior minister. So the Conservative Party has to choose a new leader, and the rather distasteful jockeying for position has begun. What this might do for the management of SARS-CoV-2 who knows, but there is talk in the press of further lockdowns. Noooo!.

The Wry Observer’s Covid-19 update (201); Old news is new again

Yesterday was our wedding anniversary, else I would have posted the news that a Neandertal gene was responsible for Covid-19 susceptibility and thus “millions of deaths”, as reported in “The Times” and the “Daily Telegraph”. Of course regular readers of my blog will recall that I first reported the research pointing to a Chromosome 3 anomaly inherited from a Neandertal back 7th July 2020 (Blog 46). I quoted from one of the papers:

“The Neandertal haplotype occurs in South Asia at a frequency of 30%, in Europa at 8%, among admixed Americans at 4% and at lower frequencies in East Asia. The highest frequency occurs in Bangladesh, where more than half the population (63%) carries at least one copy of the Neandertal risk variant and 13% is homozygous for the variant. The Neandertal variant may thus be a substantial contributor to COVID-19 risk in certain populations.”

A couple of months earlier I had written to “The Times” with my concerns about the increased susceptibility of NHS staff from South Asia and Bangladesh in particular, suggesting they should be shielded from front-line NHS, so in a way it came as no surprise to find a scientific explanation rather than the ridiculous idea that it was somehow due to institutional racism. Quite why the research has resurfaced after two years I am not clear, but yet again I fume over the wall of silence that greeted my various attempts to bring the issue to the attention of the government. I have a reasonable pedigree in both clinical work, especially where immunological disease is concerned, and some analytical skills, but above all I have been unconstrained by having to work, so I have been able to research the Covid scene thoroughly. I wonder whether the fact that I retired from the NHS 11 years ago is being held against me.  Actually I don’t really, being a believer that cock-up is far commoner than conspiracy, but there is increasing evidence that decision-makers, like some politicians, are not prepared to change their opinion even when new evidence emerges that contradicts their long-held views. Maybe the Hallett Inquiry will agree. I will certainly try to put my experience forward.

The Wry Observer’s Covid-19 update (200)

I never expected to get the 200 up, but here we are, rather later than I had hoped.  It’s a bit like an end of life experience, where breathing becomes intermittent, stopping and restarting, with the intervals between the restarts getting longer.  The medical term is Cheyne-Stokes respiration.  What happens is that after a time of no breathing (apnoea) the carbon dioxide level in the blood builds up sufficiently to stimulate the respiratory centre, so breathing restarts.  The blog intervals are getting quite long now, and I suspect it will expire soon (famous last words).

Anyway… I have had the dreaded virus!  Picked up in a capital city where we went out for dinner in a very crowded restaurant.  In Wales.  Sore throat, streaming nose, just like a cold; then a bit of a cough, and loss of taste, so I tested.  You are supposed to wait 30 minutes before deciding that the T line on the lateral flow thing is negative.  Mine went bright red in 30 seconds.  Horrible worry that it would not go negative before we were due to fly to Menorca, but it did, so we had a great holiday, with lots of sun, many interesting sights and good food (even better because my taste came back quite quickly).  However we had to cancel several plans, including my year group’s reunion, which would have been the first time I had seen most of them for over 40 years.  Let’s hope there will be another soon.

What lessons from the biter bit?  First, that current SARS-CoV-2 infection is truly, in most cases (and I am over 70) not much worse than a bad cold or mild flu.  Second, that being triple vaccinated clearly does not stop you getting infected.  Thirdly, that the symptoms were identical to what I had in December 2019.  So was it coronavirus then?  And if not, what?  Another, cold-producing coronavirus?  That can go in the “Don’t know” basket.  And fourthly, a question.  If one has had it, do you need a fourth vaccine?

Meanwhile the controversies rage on, with leaks suggesting that the Pfizer vaccine research was unscientific, that lockdowns were a disaster, that Boris Johnson has slithered out of trouble with the Met (no more fines) and Sue Gray’s somewhat anodyne report.  Oh, and I finally had a definitive response to my Freedom of Information request.  It said that responsibility for the data had been moved to another department, so they could not answer it.  If all government departments are as inefficient as this (remember I made the first request at the end of 2021, so it’s taken nearly 18 months to get a “Don’t know”) we might as well make it all up as we go along.

As for the vaccine stuff that too goes in my “Don’t know” basket.  For lockdowns I think the situation is a bit more balanced.  As the outset I am sure it was the right thing to do, because we knew so little about SARS-CoV-2.  Once data started to accumulate, however, it became clear that continuing with lockdowns was a waste of time, not least – as I have said before – because if you cannot do a total lockdown, as per Shanghai, it’s not going to stop transmission.  And of course the virus mutated to a less virulent form, which is what was predicted.  Whether we live on a knife edge and continue to have coronaphobia, always expecting some worse variant will appear as some of the doom-mongers predict, seems ridiculous; we will never escape like that.

I have just received my copy of “Zero: Eliminating preventable harm and tragedy in the NHS” by Jeremy Hunt, an ex-Secretary of State for Health and currently Chair of the Health Select Committee.  The Guardian’s review, by Rachel Clarke who has written her own book, asks quite reasonably (as I did to myself) why he didn’t try to impose his radical solutions while in Secretarial office.  You can read her review at https://www.theguardian.com/books/2022/may/22/zero-by-jeremy-hunt-review-this-is-going-to-hurt. The strike of junior doctors which he caused with the proposal of a new contract might help to explain why he could not; previously a plan to reorganise the hospitals of South-East London was scuppered by a medical pressure group, and the two events would have made me, had I been in his shoes, pause.  Even if events proved him right, at least so far as the South-East London hospitals issue goes; you can read my thoughts on this in “Mad Medicine”.  Anyway I have a reading backlog of various things, as well as a Covid book to review for an award competition, so my own review of Hunt will appear mañana.  I have to say he was very complimentary about “Mad Medicine”.

Today’s “The Times” carries an article about an NHS report that suggests hospital consultants should be redeployed into the community (where, of course, they already are unless you make the incorrect assumption that hospitals are separated from the community by some sort of impermeable barrier).  I outlined my own experience of running clinics in health centres in a letter of response, which says basically “Been there, doesn’t work”.

The Wry Observer’s Covid-19 update (199)

It’s been a long time since the last contribution, during which quite a lot has not happened on the Covid-19 front, viz. no repeat of previous hysteria as the infection rate rocketed. I suspect part of this is because even the most hawkish advisers expected a peak and subsequent fall, which is what happened, without the need to return to lockdowns etc. Mind you this is not the case in China, where a repeat of internment has caused havoc. The enforcement scenes are grim. Is this new lockdown worth it? I doubt it very much.

It’s also true that although UK infections have gone up, there has not been a major rise in the serious consequences, presumably because Omicron is “milder”. There is also increasing evidence that vaccines are not that effective. Certainly it seems that one can acquire SARS-CoV-2 despite having had two jabs and a booster, and even acquire it more than once. But mask-wearing remains voluntary and certainly life in Cardiff (where we went for a reunion over the weekend) appears to be entirely normal, judging by the numbers on the street on a Friday night (partygoers, bouncers and police alike). And I would add that covid susceptibility might be higher than elsewhere judging by the size of many revellers.

On the other hand quite a lot has been happening in terms of the slow process of unravelling or debunking government and department of Health policies and management. There’s an interesting piece by Carl Heneghan and Tom Jefferson at https://brownstone.org/articles/the-uk-covid-response-a-stool-with-three-legs/. Their three legs are PCR testing (and its misuse), attribution of death (which brings us back to what so many people have questioned – whether deaths are with or from) and the recording of hospital episodes. The article is yet another example of how following “The Science” is all very well, but the principle falls down when the science is critically evaluated and found to be wanting, more especially when those in charge refuse to listen.

A court case has determined that the UK government’s initial policy of decanting elderly people from hospitals to care homes was unlawful and on that basis it made a mockery of the then Health Secretary’s claim that a defensive ring was being placed around those care homes. I suppose one could argue that many people have said this for quite a while. Whether anyone will be fined, or go to prison, is a moot point. Matt Hancock claims that he was not given the right information, which is a reasonable way to try and avoid being blamed, although the buck stopped with him. Someone should fall on their sword. Hancock? An expert? This actually mirrors my longstanding contention that the government was relying on the wrong experts, as I have again pointed out in a BMJ Rapid Response to an article titled “An untrustworthy government during a pandemic—a lethal combination” (BMJ 2022; 377 doi: https://doi.org/10.1136/bmj.o1011, published 20 April 2022):

Dear Editor,

Perhaps the real issue is not that the government got everything wrong with its management of the SARS-CoV-2 pandemic, but why it got it wrong. In my opinion it was because much of the expert decision-making was made by the wrong experts. It is clear now, and indeed was evident from early on, that not everyone who became infected with the virus went on to develop the severe and often fatal complications that were Covid-19, and why that should be was not a question that could be answered by epidemiologists and public health people but by clinicians who began to understand the underlying pathogenesis of severe disease – a major disturbance of immunological reactivity. These “wrong” experts failed to see the parallels with previous, similar trigger factors for a cytokine storm syndrome. They failed also to understand rapidly enough the investigation results that would confirm its development. They failed to realise that, just because the SARS-CoV-2 virus was novel, what it resulted in was not. Thus they failed to institute a system of rapid and appropriate diagnostic tests, relied on clinical signs that did not identify risk early enough, and failed to recommend treatments that already existed, deciding instead to embark on unnecessary trials.

Over the last two years I have conducted what seems like a one-man crusade to get the government and its advisers to include appropriate clinicians. My efforts were completely fruitless. I had no response to any of my submissions on testing and treatment (accurate as most of them turned out to be) – not even any acknowledgement of those submissions. Indeed I was later to learn that the inputs of so-called armchair commentators were immediately consigned to the waste paper basket or its electronic equivalent, the email junk folder.

Who then was responsible for this shameful and persistent exclusion of experts (I would argue the right experts)? Was it the government? Or was it the overblown SAGE committee that trusted in its own expertise? If the latter, then perhaps the government should not take the blame, not least if it did not know that there were other experts knocking on the door.

If SARS-CoV-2 infection never caused the severe sequel of Covid-19 the pandemic would indeed have had little more impact than a flu pandemic. So the only thing that mattered was to stop infection from progressing to Covid-19, thus reducing hospitalisation and intensive care requirements and reducing fatalities. This required the right tests and the right treatments, none of which were in the purview of the “experts”. Whether or not any community could contain or eradicate the virus (which time has shown to be impossible) is thereafter an irrelevance.

It has been very disappointing over the last two years to observe the blind and largely uncritical obedience of health workers to what had been proved to be flawed diktat. The one rule of research is that initial findings can be overturned later, so no-one can afford to be dogmatic. There is egg of faces when such dogmatism comes back to haunt you. I am pleased to see that some of my arguments are now being echoed by other non-governmental experts. How long will it be before the government’s “experts” are held to account? I imagine that first of all Lady Hallett has to set her Inquiry’s terms of reference.

The Wry Observer’s Covid-19 update (198)

After the total hysteria of previous rises in case numbers there has been almost complete silence from the UK government over the most recent. I suspect this partly reflects the distraction of the war in Ukraine (where, I might say, the denials from Russia remind me of the way in which small children continue to lie in the face of all the evidence). It may also be because (a) it is now abundantly clear to everyone (in the face of all the evidence) that vaccination does not stop acquisition (b) despite acquisition, people don’t seem to be getting so ill – which is probably a benefit of vaccination and (c) government has been taken severely to task over its so-called “Nudge Unit” which has previously been ramping up hysteria.

I have sent in my suggestions for lines of enquiry for the Hallett inquiry. Mainly to do with the absence of any analysis of the failure to implement timely treatment of Covid-19.

I have just finished the epidemiologist Mark Woolhouse’s book “The Year the World Went Mad: A Scientific Memoir”. I recommend it. He has been on the inside. His exposition is clear and easy to follow, and it is clear he does not think that lockdowns work – but targeted shielding does. Obviously the Chinese government, which has just locked down Shanghai, hasn’t read the book. It should. He is particularly scathing about the schools lockout which he concludes had no scientific validity. And while on about China it is amusing, or sad depending which way you look at it, that a traditional Chinese medicine of no proven benefit (but the usual slew of nonspecific reasons for efficacy) has been distributed to residents of Hong Kong. See Will Jones’ piece in the “Daily Sceptic” at https://dailysceptic.org/2022/04/04/hong-kong-sends-traditional-chinese-medicine-to-three-million-citizens/.

One thing though is glaringly missing from Woolhouse’s book – if something missing can glare. Treatment! It just confirms my prejudice or observation, made previously ad nauseam, that the people involved in managing the pandemic have been in many respects the wrong ones. I cannot believe that the delays in managing serious disease would have been anything like as bad had the right clinicians been involved (also, ad nauseam, not for want of my trying). I may not be hot on R numbers and models but I (and any competent rheumatologists) can manage immune-mediated diseases. OK, so what I suggested originally is now more or less in place, though I suspect not uniformly implemented.

It’s interesting that aspects of Long Covid are being attributed to the development of autoantibodies, which might provide an interesting line of research to look at standard autoimmune disease again for viral triggers. It’s been done before and failed, but maybe we weren’t quite looking at the right bits, a bit like the blind men and the elephant. That said, the list of Long Covid symptoms is pretty protean, and I have had then all since December 2019. Does that mean that I must have had Covid, all negative tests notwithstanding? Or is this a Jerome K Jerome moment; you may recall that in “Three Men in a Boat” he describes reading the household medical compendium and concludes that he has everything in it except housemaid’s knee. I think there’s a lot of research that needs doing on that.

I note also that it’s being suggested, much as the original SARS-CoV-2 has been labelled as an artificially created virus that leaked (and the tide goes in and out on that hypothesis) that Omicron, by virtue of the number and site of its mutations, is also a lab-engineered variant. It’s known that South African laboratories were working on SARS-CoV-2. Conspiracy? Cock-up?

Meanwhile the Ivermectin controversy rumbles on. The research debunking it is being debunked in its turn. Conspiracy theories swirl about (it’s so cheap that drug companies would lose billions if it was authorised etc). We shall see. I have discovered, though, when I went into our local farm store for some fleece to wrap our pear tree against the frost, that they have huge tubs of the stuff for the sheep, of which we have thousands down here, with more thousands on the way, because lambing has begun. It’s lovely to walk through the fields and see all these cute little things wobbling around, and watching them grow.

The Wry Observer’s Covid-19 update (197)

Still here. Much going on; ghastly war in Ukraine, P&O sacked 800 workers by e-video, and we have a new shed on the allotment, so we have spent quite a time repatriating the refugee garden equipment which had been kindly rescued by a number of our fellow allotment holders and safely stored. SARS-CoV-2 has slipped down the news columns, which is not surprising in the context of the appalling sights and sounds from Ukraine. Who would have thought, even three months ago, that we would become so familiar with the geography; I could draw a rough map, with major towns and cities, from memory. But the numbers of SARS-CoV-2 infections has been rising substantially to a level where previously we would be faced with the Prime Minister flanked by his advisors, telling us to lock down, wear masks, keep our distance etc.

So what has changed on the SARS-CoV-2 front? Firstly the increasing, indeed large numbers of infections are not translating to hospital admissions and deaths in the way that was true a year ago. Secondly the public has become blasé, not least as they encounter those who have acquired the virus but have not had much more than a rather bad dose of flu. Thirdly the effect on transmission from vaccination has been very limited; this contributes, I think, to the public’s rather dismissive attitude. Sadly vaccination has not proved to be the hoped-for magic bullet, though it may be responsible at least in part for the reduced severity. And lastly the ongoing analysis of case numbers placed against lockdown restrictions shows ever more clearly that lockdowns do not work (because, I believe, they can never be complete enough to work).

The Covid-19 Inquiry has set up its consultation on terms of reference, and I have submitted my additional suggestions to those already included – requesting that the effective exclusion of clinicians with knowledge be considered, and that the delays in instituting proper management protocols for severe disease requires examination. My other concerns will go into my evidence. The ever-rolling stream of time will fit them in at some point. I will make sure of it.

Meanwhile in the statin business the proverbial has hit the fan, with two statin sceptics, Malcolm Kendrick and Zoe Harcombe, bringing a libel action for defamation against the “Daily Mail” for accusing them of being statin deniers and being thereby responsible for the deaths of those warned off statins. This has echoes of the measles vaccine case, with the difference being that (at least from what I have seen and read) that Kendrick and Harcombe’s views are evidence based while Wakefield’s measles vaccine research was fraudulent. That they chime with mine is neither here nor there. The BMJ has covered the story briefly at https://www.bmj.com/content/376/bmj.o741 (BMJ 2022;376:o741). I have written a Rapid Response:

“The “Daily Mail” is quoted in your article as saying that two so-called statin deniers have placed people “at a greater risk of a deadly or debilitating heart attack or stroke by misleading them into the false belief that statins do not work and/or have debilitating side effects, and thereby leading them to refuse or to abandon the treatment that has been definitively proven by medical science to benefit health in critical ways including by saving lives while causing insignificant side effects in the process.”

On 27th January 2009 the same paper published a piece by me entitled “The hidden (and painful) cost of statins”

( https://www.dailymail.co.uk/health/article-1128333/Viewpoint-The-hidden-painful-cost-statins.html) in which I detailed my personal experience of side-effects – noting that symptoms recurred on rechallenge and that my creatine kinase levels rose significantly. The effect was far from “insignificant” and took over two years to abate completely. In my clinical practice I saw several patients with significant rheumatic symptoms that were also unquestionably caused by statins.

As far as I know the “Daily Mail” has not retracted my opinion piece.

I would add that my experience pre-dated the wide discussion on whether statins could produce muscle problems and long before the concept of a nocebo effect was articulated. In any case, to develop a nocebo effect requires one to know what side-effect might be likely, and in 2009 I did not.

Both before and after this publication I and many other researchers pointed out that (1) benefit was expressed in relative risk but adverse events in absolute risk, thus exaggerating the former while playing down the latter (2) that the original research linking heart disease and cholesterol was biased and scientifically flawed (3) that the substantial reduction of LDL cholesterol by PCSK inhibitors failed to produce an equivalent benefit in preventing heart disease (4) that blood cholesterol is affected, if not controlled by carbohydrate and not fat intake and (5) that proper understanding of the development of arterial plaque concludes that its development is a consequence of inflammation and not of a high cholesterol level.

It is interesting to read that the form of words is being examined. There is certainly a difference between a sceptic and a denier, and I am not aware of any commentator who states that statins do not have any clinical benefit. They do. But the effect is small (absolute risk reduction around 2-3%) and is anyway in all probability due to their anti-inflammatory effect. Whether this small effect is worth the vast expenditure on them matters more in relation to their mode of action – and I have written several times that their effect on cholesterol is merely an interesting, but irrelevant one – than it does to the generation of side-effects. If they are clinically ineffective then why use them?

Many scientists and clinicians are convinced that the major villain in heart disease is carbohydrate, as John Yudkin first outlined decades ago. I would venture to suggest that those who deny this are the ones putting patients at risk. The upcoming court case brings to mind the appearance of Galileo before the Inquisition, and who was right then?”

Meanwhile (sic) in the history of plastic surgery business I am delighted to report that my book “Faces from the Front: Harold Gillies, The Queen’s Hospital, Sidcup and the Origins of Modern Plastic Surgery”, first published in 2017, has been reprinted and is available in paperback.

The Wry Observer’s Covid-19 update (196): not done yet…

Yesterday’s “Daily Sceptic” was very disappointing in that it appeared to condemn the Pfizer vaccine for failing to deliver on its aim. But it had not read the small print. The quotation made it clear that vaccination was not designed to stop infection with SARS-CoV-2 (because that isn’t actually medically possible) but was designed to reduce the risk of infection turning into Covid-19. The Sceptic’s piece fell into the trap of assuming that SARS-CoV-2 and Covid-19 are the same. I don’t know how many times I have to say this before the message gets through – but Covid-19 is the immunological consequence of infection, and in its clinical manifestation is little difference from the cytokine storm syndrome provoked by other triggers, viral or not. And vaccination does seem to reduce that risk. Apropos risk it looks as if the case numbers are rising once more, but there has been a deafening silence from the lockdown proponents this time. Perhaps the hospital admission and death rates remain steady. Certainly people appear to think that the infection fatality rate is now much the same as flu.

In my eyes all of this simply reinforces my longstanding message that combating infection requires concentration on identifying and then treating Covid-19 when it follows infection. Which should have been the focus all along. Only two years later and some people are coming round to my point of view.

Another canard pursued by the Daily Sceptic site is that of vaccine risk. The Yellow Card risk reporting system may be all we have, but it should not be reviewed without a large pinch of salt. Many so-called side-effects of treatments are quite incidental, indeed impossible to attribute to the treatment. Likewise there seems to be great unease about vaccine doses spreading round the body. Where on earth do you expect them to go? Food does not remain in the gut; it is digested and passes through the liver. Inject something into a muscle and the bloodstream will carry it all over the place. I cannot understand why this is surprising. It is a physiological fact; indeed, if it were not found in the liver I would wonder whether it had ever been injected. Now if it were a microchip one would expect it to stay where it was first put. But have these fearmongers actually had a dose of vaccine? If so, did they not realise that it is a liquid suspension? Have they never had a bruise and wondered why it has not persisted in situ indefinitely? Regrettably the purveying of such ignorant pseudoscience undermines the credibility of the Sceptics site, sad as I am to say it.

Of course the disappearance of SARS-CoV-2 and Covid-19 from the media may reflect the appearance of another invading organism, which is ravaging Ukraine. I have been reading an account of D-Day 1944: (“D-Day through German Eyes: How the Wehrmacht Lost France” by Jonathan Trigg). What is remarkable, and salutary, is that the major problems encountered by the German army were much the same as those met by the Russian army in Ukraine – lack of appropriate transport, inadequate provision for re-supply, employment of substandard infantry (regiments often made up of non-German soldiers, even Russians), failure to control the air and underestimation of the opposition. Not a lot different from Ukraine today, though the air power disparity is reversed and the war is not entirely between two armies. But the fact that very similar circumstances pertained in 1944 makes one wonder why lessons were not learned nearly 80 years later. But then one could say the same about the lessons learned from pandemics. Are they learned? If so, then they get forgotten.

Stop press: yet another reason to concentrate on the immune system; see https://www.cell.com/immunity/fulltext/S1074-7613(22)00046-2 for an exposition on whether continuing post Covid-19 breathlessness is caused by persisting immune hyperactivity in the lung. I find this completely unsurprising. But I suppose someone had to prove it.

The Wry Observer’s Covid-19 update (195): Aftershock

The UK government has stood down the SAGE committee, a clear sign that it also thinks the pandemic is over.  I said it first.  However yesterday there was an “exciting” piece in “The Times” by Tom Whipple (again) puffing the RECOVERY trial, which had just come out in favour of baricitinib – a JAK inhibitor I mentioned on 8th February.  He also pointed out that the serious nature of Covid-19 was because it provokes an immune overactivity.  Glory be – I have lost count of my attempts to explain this to the high-ups.  Have they really got it at last?

I felt compelled to write as follows:

“It is heartening to read that scientists finally agree that damping down immune activity is the way to treat severe Covid-19.  In a letter to “The Times” on 27th April 2020 I wrote “Therapeutic options should target CSS (cytokine storm syndrome) 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 had been used in CSS for years. There was never any need for trials. Baracitinib is just another drug which interferes with the immune cascade, thus targeting CSS. Had my suggestion been heeded (likewise my pleas for a rheumatologist to join SAGE, as we are experienced in managing immune mediated diseases) I believe that many, possibly thousands, of deaths would have been avoided.”

But then, dear readers, you know that, because I told you once before; it’s no secret any more (song reference: Whispering Grass by the Ink Spots, a name to conjure with in today’s world of wokeness).