The Wry Observer’s Covid-19 update (223)

The Heneghan/Jefferson dialogue on their “Trust the Evidence” blog underlines the disappearance of the Hallett Inquiry from the news now that the Big Beasts have given their evidence, which wasn’t worth much anyway. Having trawled through the module list again I looked at the core participants and was perhaps unsurprised to find that they were almost without exception people who could have had no insight into the pathological mechanisms of Covid-19. As for the module remits there is but one sentence in the Vaccines and Therapeutics module that gets to the heart of the matter – when people get very sick with Covid-19, how should they have been treated. I am somewhat concerned that they are going to spend time analysing trials, which I have stated many times were unnecessary.

When will the clinicians (hello, here I am!) get their chance to explain things? I am still waiting to be called… never mind that I am retired, medicine in many ways is like swimming or riding a bicycle, you never forget how to do it. A single case will, if significant enough, stick in the mind forever. Significance can take many shapes; amusing, challenging, upsetting, revelational, oxymoronic among others. There are many examples in my book “Mad Medicine” (https://www.amazon.co.uk/Mad-Medicine-maxims-National-Service/dp/1688011897) which any student of medicine or the NHS would do well to read, not least so they don’t fall into the traps that I did or underestimate the importance of institutional memory.

(Written 13th July)

The Wry Observer’s Covid-19 update (218): medical oxymorons and Settled Science

During the pandemic we became used to, and rather weary of the concept of following “The Science” but just as other terms take on unnecessary qualifiers “The Science” has now morphed into “Settled Science”. The term is of course absurd as any proper scientist will tell you, and I have added it to my list of oxymorons in medicine (read my book “Mad Medicine” for more). Settled Science is a useful term of approbation when trying to rubbish hypotheses, or proofs, that contradict it. It gives a spurious sense of finality in science but there are innumerable examples of how Settled Science is unsettled – and not only in medicine. Think Einstein and the theory of relativity, which was unsettled by the postulation and later discovery of the Higgs boson. Think Galileo and Copernicus, the fools on the hill (who saw the sun going down, but the eyes in their head saw the world spinning round – possibly the most profound Beatles song); William Harvey discovering the circulation; John Snow undermining the miasma theory of infection with his observations on the Broad Street pump; Semmelweis and puerperal fever; Pasteur and bacteria; the electron microscope and cellular pathology. And then there are the various examples of where it becomes apparent that the Settled Science is based on a falsehood; spinach and its iron content, forgetting the oxalic acid that chelates the iron, never mind the decimal point being in the wrong place in the initial calculations; discovering the real cause of peptic ulceration was a bacterium, Helicobacter pylori; thinking that rheumatoid arthritis had something to do with Epstein-Barr virus, when the results were due to a contaminated reagent; climate change statistics muddled by temperature measurements in conurbations, or most recently from a thermometer close to an air force runway where jets were taking off at full blast.

Science is never Settled. It takes but one contrary observation to knock down a long-held belief – the Black Swan principle. For example – coral bleaching as a sign of global warming. It can be a local phenomenon and nothing to do with fossil fuel burning but relating to the warming events of underwater volcanic eruptions, as last year in the Pacific. And a quick question: has the bleaching in the Great Barrier Reef continued inexorably to progress? Actually no; indeed it appears to have reversed. The Settled Scientists prefer to ignore such observations that contradict them, just as they have been downplaying the growing evidence that SARS-CoV-2 vaccines cause harm. This is not science, but dogma, back to the days of the Inquisition. It is not good. So I beg readers not to use the term Settled Science ever again.

The Wry Observer’s Covid-19 update (217)

Today “Trust the Evidence”, the blog of Drs Heneghan and Jefferson, asks whether the pandemic is over, to which I responded:

“The pandemic is over. No-one seems to worry about it except politicians and the WHO. Here in my small town people toss out the fact they have Covid as if it were no more than a cold – which of course it isn’t, whether because of vaccination (doubtful) or viral mutation to a milder form (highly likely). So yet again I ask the question: does a pandemic infection really matter if it doesn’t kill people? It’s rhetorical really, because the answer is no. Do you need to stop transmission of a mild non-fatal virus? No. Do you need to rapidly identify, and appropriately treat, people who get the virus and then, for reasons of genetics, obesity and other such, get very ill (aka Covid-19, cytokine storm, hyperimmune state)? Yes. And yet all the noise is about stopping transmission. As this is impossible let’s simply concentrate on the suddenly seriously sick, which is a relatively simple task. The same applies to future pandemics. And while we are about it let’s ban modelling because of the GIGO principle (garbage in, garbage out).

It irks me greatly that those in charge continue to rely on the wrong experts. If I needed a hip replacement I would not ask a neurosurgeon, so why, when confronted with a serious medical condition like Covid-19, normally treated by physicians and intensivists, are we relying on experts in statistics, virology, public health and epidemiology? Their solutions are unravelling faster than a roll of toilet paper by the Andrex puppy.”

Their article is worth reading, and can be found at https://trusttheevidence.substack.com/p/a-round-up-of-recent-tte-posts-and?utm_source=post-email-title&publication_id=1029183&post_id=116930775&isFreemail=false&utm_medium=email

At the same time I criticised a BMJ update “A living WHO guideline on drugs to prevent covid-19” (https://doi.org/10.1136/bmj.n526) which is, I think, a red herring, oxymoron or whatever, not least as it repeats the fallacy that SARS-CoV-2 infection and Covid-19 are synonymous, but particularly because its main purpose is the continuing discreditation of hydroxychloroquine. So I wrote:

“It is regrettable that this article will serve only to confuse both medical and lay readers.

I have made the point many times that confusion arises from the improper interchangeability of the terms “SARS-CoV-2” and “Covid-19”. They are not the same. Covid-19 is a specific syndrome of severe illness due to the induction of a hyperimmune state (cytokine storm, CSS) by infection with SARS-CoV-2. Thus preventing Covid-19 requires prevention of the development of that hyperimmune state. As the risk of such development depends on several factors (including genetic susceptibility) it is far from certain that SARS-CoV-2 infection will progress to Covid-19 and anyway the risk from more recent virus variants has clearly diminished substantially. But as one cannot predict in advance, the whole concept of preventing Covid-19 is an oxymoron and discussion of prophylaxis is a waste of time.

The vast majority of cases of SARS-CoV-2 infection develop little more than a bad cold or flu-like illness. So is the application of any antiviral drug actually necessary? I think not. What is necessary is a system for promptly identifying incipient Covid-19 (by measuring oxygen saturation in the first instance, and applying appropriate blood tests such as CRP, fibrinogen, D-dimer, platelet count etc) and then appropriately treating that developing cytokine storm with steroids and biologics. One could argue that hydroxychloroquine, a weak immune modulator, might have a role alongside these but none of the trials have employed it specifically in that capacity, and in any case if one was to extrapolate from its use in inflammatory joint disease one would use it in combination or not at all, as there are things that work better. So discussing the hydroxychloroquine evidence is also a waste of time.

SARS-CoV-2 infection is not the only thing that can precipitate a cytokine storm and I remain baffled by the apparent failure of almost every commentator to realise this. We need a hard reset based on longstanding management of the syndrome – which in my view requires everyone to read Cron and Behrens’ textbook [reference given, but omitted here as I have mentioned it ad nauseam et infinitum]. The reaction to the appearance of SARS-CoV-2 was, in retrospect, one of panic and hysteria. Most people need no treatment. Those that do should have the correct treatment applied promptly.”

The Wry Observer’s Covid-19 update (190)

Once again I have been holding off writing because the changes have been too frequent for any overall picture to be clear. But I now believe that the “demic” has slid with a whimper from “Pan” to “En”. Overall numbers of positive tests are falling consistently; hospital admissions are not rising; intensive care beds are under no more pressure that has been normal for the time of year. This is despite there being no lockdown, and despite schoolchildren mixing freely, both of which in the official narrative should have sent cases soaring. Meanwhile coronavirus news has slipped down the news items underneath No 10 Downing Street parties (note the plural), the situation in Ukraine and the Winter Olympics.

I watched another fascinating episode of “The Green Planet” with David Attenborough last night. It is hard to watch the time-lapse sequences of plants doing clever or violent things and not become convinced that they are sentient – which might be a problem for vegans. But last night Attenborough looked at monocultures – in particular the Lodgepole Pine, which is now seriously threatened by the Mountain Pine Beetle because the delicate balance that kept pine and beetle in equilibrium has been upset by overcrowding in single-species plantations. This is a paradigm for humanity; overcrowd human beings in cities and you have a monoculture; plagues and pandemics will spread like wildfire. I suppose this is self-evident, but it took an example from the plant world for me to see this clearly.

Perhaps it’s now time to wrap up my Pandemic diary if it’s no longer a pandemic. Where are we?

Let’s start with the origin. It came out of Wuhan, but the circumstantial evidence very strongly points to a laboratory leak. There is no good evidence to tie the outbreak to the Wuhan wet market or to pangolins. The closest anyone got to finding a similar virus was in bats from caves far to the south. Were those bats brought to the virus research facility in Wuhan? And were experiments done to enhance virulence? It is likely that the answer to both questions is yes. I am always highly suspicious of scenarios where there is missing data, especially when it appears that that data was available but has been removed. I am also wary of denials from people who have a conflict of interest, and believe that the Daszak letter in “The Lancet” was a deliberate attempt to lay a false trail. If the circumstantial evidence is overwhelming and defence rebuttals unconvincing then I think even a court of law would find it hard not to convict. But deceit and cover-ups breed anger and loss of trust. It would be so much simpler if people fessed up and told the truth.

That said, why was the death rate in Wuhan so much lower than that which engulfed Europe in early 2020? One might ask also why the death rate in many Asian countries failed to reach the levels seen in the West. Was it because Eastern peoples had some protection from previous exposure to other coronaviruses, so had cross-reacting antibodies? Or did the virus mutate on its way to Italy and become more virulent?

In any case, speculation now is medically unhelpful, though scientifically and politically necessary.

The next question is whether public health management of the pandemic was clinically appropriate. Certainly the lockdown concept was never a part of pandemic management planning until this pandemic – indeed, quite the opposite. But I think that Western governments were panicked into lockdowns by the pictures coming from China and by the siren calls of those who thought that something must be done. Of course, in theory a lockdown will stop an infectious disease in its tracks, by isolating virus carriers until they no longer have it. But in practice a full lockdown is unachievable. There are too many exceptions, such as the need to maintain essential services, hospitals and the like. The virus can be brought back into a country from outside despite a so-called lockdown – witness its reappearance in New Zealand with a single family – and lastly the presence of asymptomatic carriers who are infectious proved impossible to stop – at least until it became apparent that lateral flow tests were a good marker for infectivity. And it became clear from the statistics that infection peaks started to wane before lockdowns were actually implemented.

So while the retrospectoscope enables us to see this clearly I think it’s fair to suggest that the concept of lockdown was reasonable – until you factor in its impracticability. On that basis the second and third attempts at lockdown were a waste of time and effort. We should never try them again given the economic consequences.

While retrospectoscopes are infallible, prospectoscopes are not, and the epidemiological modelling was a catastrophe. I fail to understand why, when the official initial modelling was so clearly wrong, and contradicted by unofficial “others” which proved far more accurate, it was persisted with. There was some irredeemable flaw, which might have been predicted since previous modelling of potential pandemics done by the same group were also wildly inaccurate. A further problem was the concentration of politicians, media and advisers on only the worst-case scenario rather than taking a balanced approach on the range of possible outcomes.

This brings me to the next question. Not only the alarmist predictions, but also the real hospitalisation and death rates were weaponised to create fear, with their presentation by mongers of doom on a regular basis in the media. But were the “real” figures truly representative of reality? In fact they were not. Despite regular rubbishing by officialdom of those who claimed that many of the deaths were with Covid-19 and not from it, the critics’ narrative has in the end prevailed, to the extent that the BBC now qualifies its figures with that very proviso. And worse, it was apparent from a very early stage that in-hospital infection was not just occasional, but commonplace; it is now being suggested that over 30% of hospital-identified infections were nosocomial. And even worse  the decanting of untested elderly patients from hospital back to care homes fuelled the explosion of infections in the latter.

On that point, was it really necessary to imprison this group of elderly and frail folk, forbidding family contacts? Given that it was also clear early on that younger people were less at risk after infection from developing the Covid-19 syndrome, I think it was a brutal and inhumane policy which was almost certainly not necessary.

Next is the question of nomenclature. I have long maintained that infection with SARS-CoV-2 is not the same as Covid-19. The latter is a specific syndrome caused by SARS-CoV-2 but not in every case by a long chalk. So conflating the two is confusing and scientifically unjustified. What mattered from the outset was whether you could identify those at risk of developing Covid-19, whether you could identify at an early stage those who had developed Covid-19, and whether, once identified, you could treat it.

The answer to the first of these is yes. The elderly, obese and others with significant medical conditions were at high risk. So were those from certain ethnic groups who had a genetic susceptibility to the development of a cytokine storm syndrome. In particular reference to this last group, if ethnically susceptible hospital workers had been shielded as I believe (and said often) that they should have been then we might not have seen the tragic deaths of many of them.

The answer to the second of these is also yes. It was apparent that patients transitioning from SARS-CoV-2 infection to Covid-19 syndrome could be identified by the use of pulse oximetry and certain specific blood tests. Their introduction was slow because previous evidence was ignored. Covid-19 was treated as a new disease and thus required detailed analysis. I pointed out repeatedly that while SARS-CoV-2 was a new virus, what it caused (Covid-19) was not and the evidence already existed. Time was wasted; lives were lost.

The third of these is, sadly, also yes. Sadly because an insane insistence on trialling treatments led to unwarranted delays in initiation. The treatment of a cytokine storm syndrome was already set out. The definitive textbook listed what should be done. There was no need for trials; the evidence was there. In the end, but no thanks to that book, the wheel was reinvented and sanity was restored. But at a cost.

The development of vaccines and specific antiviral drugs was spectacularly rapid. Whether vaccines are as effective overall as is currently being touted is open to question. Certainly it is apparent (and one might, as a clinician, have predicted this) vaccination does not stop one from acquiring the virus, not is it likely to stop you completely from transmitting it if it is highly infectious, but it may stop the immune system from overreacting, so you are less likely to develop Covid-19 from SARS-CoV-2. That in itself is sufficient justification for me. But look at the difference between the fast-tracking of approval for vaccines and the full clinical trials done on Covid-19 treatment. One the one hand corners were cut, while on the other and arguably more important, corners were not cut. The disconnect jars horribly. It is made even more apparent by the rush to set up emergency hospitals which were almost never needed, the rush to bring in PPE which was often substandard and, indeed, the economic lack of rigour that led to the provision of emergency loans without proper checks. When one reads that one of these was used to finance criminal activity it is sickening. See https://www.dailymail.co.uk/news/article-10427189/Outraged-judge-calls-investigation-car-thieving-gang-got-145-000-Covid-bounce-loans.html .

Now I return to my oft-repeated belief that while the SAGE committee was composed of experts, they were the wrong experts. I would not expect a theoretical mathematician to be planning the response to an infectious disease any more than I would imagine that an entomologist would sit on a committee setting the bank base rate. The whole official response was misdirected because the wrong people were in charge. SAGE should have contained intensivists and rheumatologists (these latter because of all physicians they have the most experience with immunomodulatory drugs). I offered my services more than once. I am faintly amused to see only yesterday reference to the JAK inhibitor, baricitinib, which is yet another antirheumatic agent alongside tocilizumab (it works in a different way immunologically and may also have direct antiviral activity) but rheumatologists are well-versed in its administration. The development of all these treatments underpins my assertion that much of the anti-SARS-CoV-2 activity has been directed at the wrong end of the stick. Preventing spread has major limitations, but if the disease it produces, Covid-19, can be eliminated then does that really matter? Indeed it is even being suggested in the media that the Omicron version is not, mostly, much more than a bad cold.

To me, however, the most egregious failure of officialdom was that it failed to listen to those who found reasonable fault with the official narrative. Time has proved many of them right. The targeted protection of vulnerable individuals as laid out in the Great Barrington Declaration was almost certainly right. Belatedly the presentation of data has been amended to address points made by critics, but even now it is inadequate. Even now, despite occasional asides that SARS-CoV-2 is not Covid-19, the use of the terms remains interchangeable. In my own case I sent several communications to the Department of Health outlining a strategy for diagnosing and treating Covid-19; I explained the ethic susceptibility issue; I drew parallels with existing data and research which clearly showed the way forward; I referred to the classic textbook. Most of this was nearly two years ago. I even sent copies of my submissions to the media.

For my pains I had – nothing. No acknowledgement, no response either thanking me for my input or indicating errors in my thinking (not that there were any). Only the rather odd coincidence of finding that my main email address was on a spam list shortly after reading that most emails to the Department of Health were consigned, unread, to spam folders.

Long term readers of my Covid-19 blog will see only too clearly that have made mistakes, wrong deductions and incorrect predictions. But I remain perfused with a sense of disappointment and frustration that I was not taken seriously. I have a track record of contributions to clinical medicine that is not weak; I was President of my specialist society, the British Society for Rheumatology; I have written submissions to government; for five years I wrote a critical review column examining published research in rheumatology for our specialist journal; I co-edited a textbook and wrote a well-received book on surgical history as well as my (self-published, not ashamed to admit it) NHS critique, “Mad Medicine”. So being ignored has been hard to accept. Not least because mostly I was right.

Time for a reprise of my poem “Pandemic Polemic”? Well, you can find it in blog No 2, from March 2020. Perhaps to lighten the mood you should have another, which has not been in print before. Some names have changed as reshuffles have supervened. You can sing it if you know the tune.

The Pandemic cometh

(with apologies to Flanders and Swann)

It was on the Monday morning that the government took fright
There was a new pandemic; it kept them up all night
They held a big press briefing to explain the plans they had;
It was going to be a lockdown, which would be pretty bad.

Oh it all makes work for the government to do…

On Tuesday morn the CMO was sensibly wheeled out;
Explaining virus R numbers, and what they were about,
He said intensive care bed numbers needed to inflate
To take the sickest patients we would need to ventilate.

Oh it all makes work for the government to do…

On Wednesday Matt Hancock said new hospitals would come,
He’d called the army engineers, and soon the job was done;
The Nightingale facilities were splendid don’t you know,
But ICU’s weren’t overwhelmed, so soon they had to go…

Oh it all makes work for the government to do…

On Thursday Rishi Sunak furloughed all the locked-down staff,
Told bosses not to sack them, for the nation would pay half,
Production hit rock bottom, but he was pleased he could announce
That the problem would not last long, the economy would bounce…

Oh it all makes work for the government to do…

On Friday Gavin Williamson played down the teachers’ fuss,
(He sounds just like Frank Spencer, but what is that to us);
All schools would shut, and parents anyway were all off work
So they could do the teaching! That drove them quite berserk.

Oh it all makes work for the government to do…

On Saturday it seemed quite clear the crisis was to end,
So people started partying with family and a friend
But then a spike of cases came, In Leicester and near Crewe
The government took fright again, so guess what they might do…

On Sunday ‘twas decided that relaxing was insane,
So come the Monday morning… lockdowns started up again!

The Wry Observer’s Covid-19 update (173): The Joint Select Committee Report: Coronavirus – the lessons learned to date

The joint Select Committee report emerged while we were travelling back from Burgundy, where there has been a calm acceptance of inside masks and vaccination proof, but as it was too late for yesterday’s newspapers to comment its dissection in the press really only began today.  The Daily Sceptics site has produced a digest; its author has read the report, so says there is no need for Daily Sceptics readers to read it, as it is very long. You can find it at https://committees.parliament.uk/publications/7496/documents/78687/default/

I disagree.  The devil is in the detail.  I am particularly annoyed that my own evidence, submitted fairly early last year, has been either lost or ignored.  I have looked carefully at the list of submissions and can see only one that comes from a clinician who is, or was (to allow for retirees like me) involved in acute patient care.  This is a gross oversight.  Management of very sick patients is not a matter for politicians, epidemiologists or public health doctors.  Without a clinical perspective the report is frankly worthless.  It’s all very well discussing what should or could have been done to prevent infection if there’s nothing much about how either to stop infection progressing to severe illness or how to treat that illness.

It doesn’t help that the report continues to conflate SARS-CoV-2 and Covid-19.

To be fair, summary conclusion 18 does refer to treatment:

“Treatments for covid are another area where the UK’s response was genuinely worldleading. The RECOVERY Trial had, by mid-August 2021, recruited just over 42,000 volunteers worldwide to mount randomised trials of covid-19 treatments. Establishing the effectiveness of dexamethasone and the ineffectiveness of hydrochloroquine were vital contributions to the worldwide battle against covid-19 and estimated to have saved over a million lives globally.”

I will return to this.

Although the report acknowledges that foresight is not available in pandemic planning it excoriates the UK’s initial approach to the pandemic, based on the assumption that SARS-CoV-2 was likely to behave like “ordinary” flu.  There’s an oxymoron if ever there was.  Many clinicians and commentators, including myself, thought that SARS-CoV-2 was just another flu to start with.  It was not until April that the characteristics of Covid-19 and possible causes of the serious syndrome became clear. So I think it is unfair to criticise government, or the scientists, when the criticism is based on a retrospective analysis. It’s very easy to see your mistakes when you have the benefit of hindsight.  Yes, the government got it wrong, but no-one in the free world got it right until there were enough cases to make a judgement. That apart, the evidence that lockdowns made a major difference to transmission is minimal. Taking into account the multiple entry points (in the UK, the seed cases were not from China but from Italy, France and Spain), the discharge of hospital patients to care homes without screening and the reality of intra-hospital transmission) I do not believe that the prevarication over lockdown played a major part.  Furthermore as I have argued previously it was not a lockdown, only a partial one, given the numerous exceptions for key workers and healthcare staff. The evidence from the Antipodes shows that while you may reduce overall numbers by lockdowns you cannot make a watertight defence.  Cases will sneak in, and when lockdown comes off, unless you have a ruthless exclusion policy so that no-one with SARS-CoV-2 can get past, you will simply relight the smouldering embers.

Paragraph 46 says:

“The NHS went to extraordinary lengths to ensure that there was enough critical care capacity for people hospitalised with covid-19.”

Indeed it did, but it failed totally to introduce any strategy for early diagnosis, such as the community use of pulse oximetry to track deterioration.  It simply assumed that people would get infected, develop Covid-19 and become very sick.  As it happened the extra beds turned out to be unnecessary, developed as they were on wildly pessimistic projections – which was just as well as they could never have been staffed.  While ventilator capacity was dramatically increased, it took time to understand the lung pathology and realise that better results were obtained by continuous positive airway pressure (CPAP) and that ventilation might increase lung damage.

Para 55 states:

“Ventilation, spacing and isolation facilities in most areas of hospitals were not compliant with recommendations in Health Building Notes (HBN) and Health Technical Memoranda (HTM). No practical solutions were available to address this.”

I have raised the question of hospital airflow (or lack of it) before. Unquestionably this was the major cause of nosocomial infection.  It is an indictment of hospital design and dates back decades.

This section notes the NHS runs close to capacity all the time, so a major event like Covid-19 will inevitably cause a major problem.  Certainly true – but the cause of this goes back years, and is the result of successive governments trying to balance safety with expenditure required to maintain reserve capacity for emergencies, ie keeping large numbers of beds empty “just in case”.  In case of what?  That’s an argument that will go on forever.

The report refers to the instigation of a “full lockdown” Heading for para 96).  But as I have said, what happened was no such thing.

There has been a great deal of discussion about the failure to consider suggestions from outside sources, but as para 127 makes clear, such consideration was undertaken, and influenced decision-making:

“Dominic Cummings told our inquiry that Downing Street held a meeting on 20 September 2020 for the Prime Minister to hear both sides of the argument. He explained that Professor John Edmunds put forward the view that the Government should impose another lockdown while Professors Gupta and Heneghan put forward an opposing view. Professor Gupta and Professor Heneghan have subsequently written to us to highlight their view regarding that meeting, including, in their view, that a number of claims that Dominic Cummings made about their presentation to the Prime Minister were incorrect. Following that meeting, Mr Cummings explained that the Prime Minister was not persuaded about the need to impose another national lockdown.”

So the government did weigh the arguments.

There follows an account of the appearance of the more infectious alpha variant.  Here the report acknowledged the problem of trying to know the unknown:

“But these decisions were taken before the existence of the Alpha variant was known. So the justification for an earlier lockdown is greatly influenced by information that was not available at the time. It serves to illustrate that, in a pandemic whose course is unknown, some decisions will be taken which turn out to have been wrong, but which it was not possible to know at the time.” (para 138).

Reading the conclusions in this section of the report it is apparent that there is an understanding that government found it difficult to challenge the advice of its own scientists.  This chimes with my contention that they were consulting the wrong people. But para 160 actually underlines my sentiment:

“In bringing together many of the UK’s most accomplished scientists, SAGE became

a very UK body. In future, it should include more representation and a wider range

of disciplines, from other countries.”

Accomplished they may be, but in the wrong fields.

I broadly agree with the section on testing (chapter 4).  Neither would I dispute the report’s comments on the issue of care homes in the following chapter.  It is interesting to read that Dominic Cummings thought that the Secretary of State’s announcement of a 100,000 target for testing was “incredibly stupid”.  The report clearly indicates its disagreement:

“… we consider that the impact of the Secretary of State’s target to have been an appropriate one to galvanise the rapid change the system needed. However, as such a personal and unilateral approach was needed—and appears not to have been supported by other parts of Government—it is concerning to contemplate what would have happened without this unorthodox initiative.” (para 184)

As for the ethnic minority issue (chapter 6), I have discussed this at length in previous posts.  I have no doubt that transmission of SARS-CoV-2 was influenced by social circumstances (large families living together, cultural contacts etc) but that the development of Covid-19 was a genetic issue.  Ant reader of Cron and Behrens’ textbook would be hard-pressed to disagree despite the very firm conclusions of the SAGE ethnicity subgroup (which did not include any clinicians with an understanding of cytokine storms) that genetic factors could not explain the high numbers..  The evidence for cytokine storms from other causes being related to chromosomal abnormalities is very strong.  But I suppose that if you haven’t read the textbook you might not know – though I did try repeatedly to get government advisors to go through it. How many did?  A number?  As one manager once told me with a grin, zero is a number.  One does have to wonder, though, whether the disproportionate mortality in those with learning disabilities was at least in part the result of an attitude that such people were less worthy of being saved.

The vaccination programme is praised, and in my view rightly so.  It was almost incredible that a vaccine should be developed so fast, although the technology to do this was already developed, and therefore merely needed tweaking.  The way in which this was done is a model for any future need.  Could it have been done any more quickly?  I doubt it.

The trials of treatments section is where I struggle hardest.  Para 387 says:

“One of the strongest, and most easily overlooked, components of the UK’s response to covid-19 has been in its forward position in trialling treatments against the disease. The RECOVERY Trial had, by mid-August 2021, recruited just over 42,000 volunteers worldwide to mount randomised trials of covid-19 treatments.587 Professor Peter Horby told our inquiry, “It is probably true to say that the UK has, of any country, been the most successful in running clinical trials for the treatment of Covid-19[…] we are, by far, the biggest trial in the world.”588 As a result of these mass-participation randomised clinical trials, treatments like dexamethasone were found to make a major contribution to reducing the severity and duration of covid-19 among patients receiving respiratory support. Professor Chris Whitty, Chief Medical officer for England, for example, told the Science and Technology Committee in November 2020, that “On dexamethasone, the UK can feel proud that this is something we did for the whole world very fast. That will reduce mortality”.589 Establishing the effectiveness of dexamethasone was a vital contribution to the worldwide battle against covid-19 and is estimated to have saved over a million lives globally.”

In late April and early May 2020 I proposed the use of high-dose steroids (and interleukin antagonists such as tocilizumab) for the treatment of severe Covid-19.  This was on the basis that such treatments were already established for the management of a cytokine storm; and that I had had personal experience of treating one such.  Any trial would merely confirm what was already known, and indeed was in use in some units in the United States – and the outcome of the RECOVERY trial was exactly what one would have expected.  It was completely unnecessary.  The delay occasioned by waiting for the result was of several months.  Dexamethasone (or an equivalent high-dose steroid) if deployed when I has suggested, would have saved many more lives (I estimated that over 20,000 might have been lost to the delay in the UK alone).

As I have said several times in previous blogs my attempts to get this point across to the decision-makers met with a black hole.

The section is unbelievably brief.  It fails even to mention tocilizumab, which supports my contention that no-one on the committees had heard of, let alone read, Cron and Behrens, in which tocilizumab is mentioned no less than 12 times.  I might add that Kawasaki disease, a children’s inflammatory condition well-known to rheumatologists and which resembles one of the types of Covid-19 seen in children, is treated with steroids and another interleukin antagonist, anakinra, which so far does not appear to have been trialled.  Given that tocilizumab is belatedly being used widely for Covid-19, and that anakinra is much cheaper, this seems to be a major omission, especially as its use for Covid-19 is causing problems for rheumatology patients whose supplies are being compromised. I repeat, yet again – we may or may not be able to stop SARS-CoV-2 infections, but what matters is whether we can diagnose them early, whether we can predict progression to Covid-19 and if they do (and importantly such patients are the ones that die) that they get prompt treatment.

So I think the report has missed a trick, or several.  There are many holes in it, and some of these are because, like the government, the Select Committees have failed to call evidence from the right people.  My own was lost.  I know of several rheumatologists whose experience of immune diseases is practical as well as theoretical, and have referenced them in previous blogs.  I have suggested to government, its advisors and the Health Select Committee, that if they don’t want to take well-meant (but soundly based) advice from a retired consultant with a good track record of research analysis that they could at least take it from highly intelligent and well-informed consultants still in clinical practice.  Well, they haven’t, and this report is the worse for it.  Roll on the independent inquiry!

The Wry Observer’s Covid-19 update (146)

I had to write something today, it being the anniversary of my ignored suggestion that steroids and tocilizumab should be employed in the acute management of Covid-19, no need for trials, same old arguments.  Meanwhile there is much fake outrage at the suggestion, whether it is true or not, that Boris Johnson was prepared to let Covid rip, bodies pile up etc.  We now know all sorts of things that we didn’t really know a year ago or even in October.  Lockdowns have a little effect, but cannot work unless they are total, which they never can be.  Lockdowns by confining families to closed spaces will increase spread.  Lockdowns in care homes that seal people up with carers who may be spreading it from one home to the next (because they work in a peripatetic way) will make things worse.  The major places of transmission are care homes and hospitals, as well as crowded households and indoor social venues.  Other than those you can be pretty sure that the risk of infection is low, and if you are under 75 your risk of death is extremely low.  Compare lockdown countries with no-lockdown countries and any differences in incidence can be explained by factors other than lockdown.  Modelling by computer has been ludicrously inaccurate, but the models made by theoretical physicists have been taken as gospel.  Test and Trace does not work for all sorts of reasons.  The population has its own limits on how far it is prepared to be oppressed, so it will start ignoring the rules.

So the proponents of the Great Barrington Declaration (I signed) are being slowly proved right. Lockdowns are a failure.  Targeted lockdowns are not. Had hospital transmission been avoided, and care homes better protected (which might well have involved simply opening some windows) the death rate would have been dramatically reduced, even without the steroids and anti-interleukin agents. So while BJ is being criticised for not locking down he was, in fact, interpreting the evidence quite correctly.  In the end he was listening to some of the counter-arguments put by Carl Heneghan and Sunetra Gupta.  The boffins were wrong, just as the Spanish Inquisition was wrong over whether the earth was flat.

Forget this nonsense and let’s move on.  Vaccination is knocking down the infection rate and sparing people from developing severe disease.  Compare those countries that have high vaccination levels against those that don’t and you do find a difference in incidence.  Meanwhile, having established that mechanical ventilation is not in the main a Good Thing, we are helping India by sending – ventilators!  The EU is threatening to sue AstraZeneca for not supplying the vaccine it promised on the one hand, while deciding it’s unsafe on the other, and piling up unused stocks.  God in Heaven, as Hastings might say in “Line of Duty”, or more circumspectly I might remind people of the concept of oxymoronic medicine, outlined in my book “Mad Medicine” (any excuse for a puff).  Send all that unused vaccine to India; send them steroids (cheap) and CPAP machines with oxygen concentrators if you must, but send them something that is proven to work, now.  No delay, forget any cost, in the context of what has been spent already it’s nothing.

A year on, and there is still no national protocol for treating severe Covid-19. There is still puzzlement over clinical features – Covid toes, long Covid, systemic disease, Kawasaki-like illness in children, etc etc.  Every time another such issue arises I have explained it, to no avail.  Advisors are not listening, or if they are they don’t understand because they are the wrong advisors.  Make the narrative fit the facts, not the other way about.  Learn about statistics and black swans. Use some common sense and listen to people who know what they are talking about. I am now, in between trying to read a book for review, starting on another Covid book – Jamie Walden’s book “The Cult of Covid: how lockdowns destroyed Britain”.  I’ll let you know how I get one, although I doubt the narrative will be much different from the other “lockdowns are useless” contributions.  But the more there are that say the same thing the more convincing the argument becomes…

The Wry Observer’s Covid-19 update (133)

Two main strands today.  Following the tragic murder of Sarah Everard, apparently by a serving police officer, a vigil on Clapham Common turned nasty when police intervened to break it up.  Watching the footage I have a few questions.  On the one hand did the police need to be so heavy-handed?  Was there any reason in coronavirus lockdown law necessitating such action?  On the other how many of those attending were in breach of lockdown travel restrictions, which are still in force?  And (more a statement than a question) why were those attending not socially distancing?  Also one clip certainly seemed to show a deliberate attempt to provoke the police.  If that was so then it is a shame that innocent and reasonable demonstrations can be subverted by those whose sole intent is to cause mischief.  But it proves a point I have been trying to make for a while; this sort of thing shows that what has been called a lockdown is nothing of the sort. Put any group in close proximity and they are at risk.  Intern everyone in their homes, but allow people to go out to work, shop or whatever and then bring it back to a closed environment, and you have a recipe for spread – and it’s not a lockdown.  Apart from which the people at the vigil were all shouting, many of them maskless.  Whether therefore any of them will spread or catch the coronavirus remains to be seen, though I would not be surprised.  The police are in a bind; if they do nothing they will be accused of letting people break the law (however worthy the cause) and if they do something they are pilloried for going over the top.

Also today the government is facing criticism for not locking down soon enough.  But as I have tried patiently to explain more than once, a lockdown can never be a lockdown; while the imposition of what was called a lockdown, but wasn’t, might have lessened the wave a bit it would never have suppressed it altogether.  And yet again the crowds gathering at last year’s Cheltenham races are being blamed for the first wave.  But the evidence suggests that had nothing to do with it, as cases came in all over the country from all over Europe.  If you plot backwards I doubt many secondary cases arose in Cheltenham. Nor from the football match in Liverpool, which seems to have avoided criticism this time, perhaps as – it’s Cheltenham time again.

On the science (or lack of it) front several countries have halted the use of the AstraZeneca vaccine because of a handful of reports of clotting problems.  40 possible cases out of 5 million doses?  Hardly an issue, especially as it appears that the numbers of similar clotting problems recorded among non-vaccinated folk, as well a s those who received the Pfizer vaccine, were pretty well identical.  Nothing to see here!?  Of course it is rather amusing from one standpoint to ponder the oxymoronic behaviour of some member states of the EU; first they whine that the UK is not exporting the AstraZeneca vaccine to them (which wasn’t true anyway) and then they whine that it may be causing horrid side-effects (which it isn’t) so they don’t want it anyway.  Perhaps they need some scientists to co-ordinate their response by reviewing the evidence before jumping in with a knee-jerk reaction.  We don’t cancel all the trains because of forty leaves on the line.  A sense of proportion, and understanding of relative risk, is sorely needed among politicians.

The Wry Observer’s Covid-19 update (71)

Today it was announced that a trial of two monoclonal antibodies against SARS-CoV-2 are to be tested in 2000 patients “to boost the body’s immune system”.

This is a trial in which I would not wish to participate. You would have to get the timing right and catch the virus before it boosts the immune system itself (like, by causing a cytokine storm, which is what Covid-19 is, which I keep saying but no-one is listening). The BBC news bulletin announcing this also pointed out that the RECOVERY trial, of which this new antibody treatment will apparently be part, has so far found the one successful “new” treatment, viz. dexamethasone. Which if course suppresses the immune system. So something of an oxymoron here, apart from the fact that it’s not a new treatment for cytokine storms anyway; steroids are the mainstay, and this has been known for years.

This is one for a WWS approach. That stands for “watch, wait and see”. Anyone remember TG-1412? Go back to chapter 15. I am not happy about this one. But then when tumour necrosis factor antagonists were trialled in rheumatoid arthritis my first concern was that if they interfered with the body’s response to cancer cells they might provoke the development of cancer. But they haven’t. So I could be wrong again. I hope so.

Meanwhile the new rule of six is so confusing, being different in the four constituent parts of the UK, that I suspect the police will have their work cut out catching burglars and drug dealers, especially if neighbours start shopping each other and they have to investigate each apparent breach. WWS!

The Wry Observer’s Covid-19 update (8)

Here we go!  Spain and Italy are lifting their lockdowns, at least in part, and there’s an immediate clamour in the British media to do the same. But (1) we are a few weeks behind them on the curve – though ours does seem to be flattening and we have only used 19 beds in the giant Nightingale Hospital in London – and (2) has it occurred to the clamourers that it might be worth waiting to see what happens rather than rush in prematurely and get a horrible rebound?

It seems that the highly imaginative reconfiguration of our existing hospitals, albeit at the expense of closing some services, has kept the lid on ICU capacity.  If indeed that is so, how long, I wonder, will it be before the mediafolk start screaming about the ridiculous overprovision, what a waste, all those unused and therefore useless ventilators, why didn’t you start making these wonderful CPAP machines sooner, they are much cheaper, money could have been spent better elsewhere etc?  Not long, I suspect.

Come on, mediafolk.  At least try to understand that hindsight makes everything clear when it isn’t at the time.  What we medics call the retrospectoscope is a highly dangerous instrument.

Perhaps there is one mistake that was made.  Perhaps testing in care homes should have begun earlier. The point was made by one of the medical advisors that the management of serious infections such as MRSA has improved dramatically, but even they seem to believe that most of it was hospital acquired.  I don’t.  Most of that was hospital identified, not acquired. It actually came in from the community (the bacteriologist in my hospital did a study proving this). Likewise in care homes the original introduction must have been from somewhere else in the community.  It cannot just have appeared by magic.  The numbers of Covid-19 deaths are sad, but pneumonia has always been the old person’s friend; flu epidemics carry off the elderly and infirm; while each case must be taken on its individual merits I believe it may be morally unjustifiable to subject an elderly and infirm person to ICU management when the overall outcome is likely to be an inevitable death anyway.  But that applies to all old people who get very sick.  As I have written in my book “Mad Medicine” when my 94 year old mother was admitted to hospital with a broken arm following a fall, the surgeons wanted to fix that and also replace her arthritic hip.  Part blind, mostly deaf, suffering from a chronic and untreatable urinary infection, doubly incontinent, wishing to die (and having signed an advance directive) one’s only response could be “You cannot be serious”. Not least because she was a retired doctor and knew all the ins and outs.

What has been awful if that old and unsaveable folk have died without their relatives being there.  That has now been relaxed; one might say that is the first easing of lockdown, and very humane it is.  It would be nice if funeral services could resume, but only as long as those attending understand that there remains a risk.  But as I have said repeatedly, just because we can treat something does not inevitably mean that we should.

Mad Medicine

Delighted to announce that my new book “Mad Medicine: Myths, Maxims and Mayhem in the National Health Service” is not available through Amazon.  It contains some of the essays on my blog but a lot more besides!

 

https://www.amazon.co.uk/Mad-Medicine-maxims-National-Service/dp/1688011897/ref=sr_1_2?qid=1569056695&refinements=p_27%3AAndrew+Bamji&s=books&sr=1-2