Yay! The pandemic is over! It must be, because various fora are now discussing how to deal with the next one as if we can simply stop discussing this one. As if it’s possible. No lessons have ever been learned from any pandemic in the 20th Century (science was not good enough before then, what with miasma theory and the rubbishing of Semmelweis and others) and certainly not from pontificating non-clinicians. Even the plans devised following the swine flu pandemic, modified by the Ebola experience, were thrown out of the window with SARS-CoV-2 as a succession of governments panicked and did all the things (like lockdowns) that scientists and clinicians had said would not work.
We have been reassured repeatedly that the rule-makers have been following “The Science”, listening to and following “the experts” and that those questioning the official line are always wrong, and metaphorically thrown from a window on the 10th floor because they protest against the “settled science”. Such reassurances cut no ice, because they blindly believe the incredible, the impossible and false prophesy. And continue so to do in the face of evidence to the contrary. Let’s look at that in a little more detail.
First, “The Science”. Those in power – and, regrettably some of the soi-disant experts – have manifestly failed to understand that science is not immutable. The concept of settled science is an oxymoron. However it may happen, whether due to more detailed research, better conducted research, new understanding of disease mechanisms, genetics etc, science changes. As a simple example look at diabetes. Before the discovery of insulin in 1921 (incidentally a discovery made not by Banting and Best but by a Romanian doctor called Paulescu) no-one knew what diabetes was; it was a mystery. After discovery it became obvious in The Science that diabetes was due to insulin deficiency. Then it became apparent that that was not the whole story; some patients seemed not to produce enough or any, while others produced it, but the body receptors seemed resistant to it. As time went by the concept of Type 1 and Type 2 diabetes developed. Then it was found that some people had had an autoimmune reaction to their insulin-producing cells causing deficiency, while the resistance in others was related to obesity, and later to other hormones. Glucagon turned up. So the settled science that diabetes was just an underproduction of insulin was blown out of the water. Diabetes is almost as much of a mystery as it was in 1920. There are many such examples in medicine; the entire medical oeuvre for managing peptic ulcer was abandoned when a chance investigation by someone with a hypothesis they thought should be tested showed that the organism Helicobacter Pylori was implicated.
The same has happened with SARS-CoV-2. First it was thought to be seriously fatal. Then it was realised that it could be, but the risk of fatality was very low. Then variants came along which were variously less fatal and more infectious. Ventilators were the bee’s knees until they weren’t, as experience showed that they increased the risk of death – and there was a good scientific reason for why, just a pity it was post-hoc. Then a few people began to look carefully at why people could get really sick, found it was largely a hyperimmune phenomenon and began treating that. Meanwhile various side-tracks diverted attention, such as why some groups seemed more susceptible to severe illness than others, with attribution to institutional racism when it was in fact genetic predisposition. Then the experts pinned their colours to the mast of vaccination, believing that this would be the panacea required, although both the scientific and common-sense basis for vaccination being able to prevent transmission was absent, and growing evidence that the vaccine component could cause significant other medical conditions was dismissed.
But worse, far worse than a systemic failure to comprehend scientific method, was a total and abject failure to read the literature and an institutional memory vacuum. The evidence from every pandemic or plague was that lockdowns do not work; they never have for reasons I have discussed before, but basically because they can (a) never be complete for long enough and (b) because the bug can come back in from somewhere else. If you let some people out of lockdown (eg essential workers) and then put them back in their household with all their imprisoned relatives, but they acquired the infection while out, then the confined population will all get it. This again is simple common sense, and illustrated by the spread of SARS-CoV-2 in care homes introduced by care workers. This too is no new thing; during the panic in the early 2000s over MRSA, which was widely viewed as hospital-acquired, a study in my own hospital showed the majority of cases were imported. They were not hospital-acquired, merely hospital-identified.
So what of the experts? We were constantly told that they were top people. But as I have suggested several times in the last three years they were the wrong experts. If I want to treat a brain tumour I do not wish a climate scientist to direct the surgery. Likewise if I see a patient with a serious immune disease I don’t want an epidemiologist, public health doctor or statistician to advise on clinical management. I would have hoped that was simple common sense, but there has been an absence of that in the last three years. Nearly all the “experts” wheeled out time and again were the wrong people. Furthermore some of these had developed predictive models. These served to alarm the public, as they did not explain ranges, confidence intervals or caveats. Worse, their record when they used the models in the past was appalling. To rely on the wrong, unreliable experts whose prophesies were known to be suspect verged on the criminal. As for masks… well, I may wear one in a crowded space where transmission risk is very high, but only because the evidence to benefit or no benefit is not there, as the recent Cochrane review showed, and if someone was to cough in my face there’s a certain amount of direct protection. I think!
What then of the future? We have no way of knowing whether the next bug, an imaginary organism causing Disease X as it’s being called, will be mild, moderate or severe; we don’t know how it might be transmitted, or what organ systems it will affect. So why plan for the unknown and unknowable, except to keep the doom-mongers busy with their worst case scenarios, which so far have never happened? This is futility medicine at its worst. And why use the same discredited “experts”? Wait for Disease X to arrive, and then work out why people die from it, and then institute the treatment to stop that. A paradigm – norovirus is endemic, but has major outbreaks like on cruise ships where transmission is inevitable. No-one really cares, because it makes you ill briefly and nastily and is then gone again. With HIV there was total panic just as with SARS-CoV-2 at the outset. Is there now? No – because it can be treated (whether it actually is treated in some parts of the world is a different matter).
A long article about the world’s potential planning for Disease X by Tom Whipple appeared in “The Times” a couple of days ago. It praised the idea of future planning, but in view of previous failures of plans to meet the actuality I wrote a slightly acid response, which was not printed, so here it is:
Tom Whipple’s article (Saturday 18th March) sums up the future management of a pandemic in his first sentence: “Nothing that was decided… mattered much”. For if a highly infectious organism spreads rapidly it is of no consequence if it does not make people seriously ill or kill people. And if it has the potential to do so, the priority is to find treatments that mitigate or abolish that risk. HIV is a paradigm.
The coronavirus pandemic has shown us that prevention of spread was an impossibility. The virus was already widespread before containment measures were taken. It also showed that “rigorous” science trumped clinical acumen and intuition. Well before Horby and Landray’s steroid trial was set up to “do something different” some perceptive physicians had already deduced what was causing people to become very sick (a cytokine storm) and introduced both a diagnostic and treatment protocol which included high dose steroids and immune modulators such as tocilizumab. In the face of overwhelming clinical clarity the dexamethasone trial was unnecessary and served only to prove what was already known.
I outlined most of the above in a written letter to the Secretary of State on 5th June 2020, having failed to get any response from either the Chief Medical Officer or the Chief Scientific Officer at the end of April. No action was taken; waiting for the result of the trial caused a delay of several months in implementing the right therapy and resulted, in my view, of many thousands of unnecessary deaths.
Too long, of course; a common problem of my writing. The HIV reference might be a little obscure, but when it appeared the world panicked just as it has done with SARS-CoV-2, and now there are treatments which suppress or even eliminate it the world has forgotten about it.
Meanwhile… where did the SARS-CoV-2 virus come from? Back in March three years ago I wondered if the illness I had had in December 2019 was due to it, and some evidence suggests it was indeed about before the Wuhan outbreak. Did it come from the States, with a virus there being shipped to China where gain-of-function experiments were conducted and from where it leaked? Or, as a recent set of articles has suggested based around the “coincidental” visit of the German Chancellor Angela Merkel to Wuhan at the appropriate time, did it come from Germany? Will we ever know? What we should know is who covered up what. Some of the involved players have been remarkably devious when responding to questions.
And also the conspiracy theories are again rampant, not just over the viral origin, but over whether vaccines work/ make people sick (a suggestion that Long Covid may be the result of an excess immune reaction if the vaccine gets straight into the bloodstream because the giver has not aspirated to check the needle is only in muscle before injecting); more conspiracy over whether the manufacturers have rubbished cheap treatments because they are protecting their vaccine-related profits; more concern over the apparent excess deaths – are they vaccine-related; and suggestions that the World Health Organisation is trying to establish a new world order where it sets the rules for pandemics and thus controls the world. Doing so by relying on the wrong experts, by failing to understand history and the changing nature of scientific facts, by remaining heavily influenced by others with a major conflict of interest is both scientifically and morally wrong.
It occurs to me that my blog has never included my letter to Matt Hancock, way back three years ago in June 2020. I did put in the protocol. Here is the letter that went with it:
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.
Note those last five words.
The Wry Observer 