Can the NHS survive?

While going about my normal life, fitting in appointments for dentists and  eye tests amongst shopping and hair appointments, I sometimes think about the changes in provision for these first two since I retired from clinical practice  over ten years ago.   I particularly think about how many patients I used to see for dental problems, despite the ruling from our college and health board that we should never see them.  It was usually for painful things like dental abscesses or gum disease  where patients knew that we could prescribe painkillers or antibiotics. It was a complete misuse of our time.  Dentists were trained to give preventative and  appropriate advice  in every consultation, which would lead to the patients taking better care of their teeth, and it was  a core part of their NHS contract.  At that time most dentists did some NHS work, and always saw children, but patients still appeared in our surgeries.  The problem for us was that the patient would make an appointment, and we wouldn’t know until they arrived that this was a dental problem.  We then had to  tell them that we couldn’t treat them, but these were our patients that we saw for medical conditions, and we didn’t want to  have a long argument about antibiotics in the middle of a busy surgery.  We used to put notices up telling patients to see their dentist, but as NHS dentists became scarce, (after implementation of contracts that didn’t pay them enough), the pressure didn’t go away.  Then, overnight, all that stopped in its tracks when the pandemic hit.  GP’s  closed their doors and had to implement a system whereby patients with covid could be triaged safely. 

So suddenly for the first time in the history of the NHS, GPs could do what they had always wanted to do, that is, implement a triage system, so that patients could be directed to the most appropriate professional – nurse, counsellor, physio, dentist and so on, and this immediately improved the flow through the system.  We had tried to do that in our practice years before I retired, but it had always caused controversy, with receptionists becoming a barrier and getting abuse. 

As everyone knows, once the pandemic was over, most practice continued this system, whereby the patients have to state their reason for needing an appointment, and whether they want a face to face appointment or a telephone consultation, before an appointment is given.  It must have completely revolutionised  doctors’ workload, but it doesn’t seem to have made it easier to see a doctor, mostly because of a severe shortage of doctors and other health care workers after the pandemic.

The shortages have led to some non-essential services being withdrawn from general practice.  Consider ENT and ear wax.  We GP’s used to give our nurses a day’s training, an old metal syringe, and they would remove the wax.  It was a tribute to the nurses that they mostly did an excellent job despite poor equipment.  The GP practice did not get any extra money from the NHS for providing  this service, but patients needed it done.  It is very debilitating and unpleasant to have one’s ears blocked by ear wax. But now quite rightly, it is mandatory to have better equipment, especially to visualise the ear drum, which is often obscured by the wax.  If a patient had ear pain, and the GP could only see ear wax, the GP would probably back both horses as it were, and treat with antibiotics in case it was an ear infection (otitis media), as well as ear drops to soften the wax. There was certainly potential for missing more serious infections and chronic external ear infections, caused by eczema, which would need steroid drops.  But GP practices would have to buy this extra kit, and probably do more of the work themselves, and were unwilling to make this investment when there were staff shortages, so the authorities decided that ear syringing was no longer to be done in general practice.  So now you go to SpecSavers, where they provide an excellent service with first class equipment.  But of course there is a fee; quite a reasonable one I would say. But we know that many patients really cannot afford to pay anything nowadays with the cost of living crisis. Where do they go?  I’m not sure but many will end up in overcrowded ENT emergency clinic seeing a hospital doctor, adding to waiting lists.

Nowadays in the UK most dentists have withdrawn from the NHS.  If you can’t pay the high fees  when you have a dental emergency, there are often local emergency services available, at a modest charge, but the treatment is usually quite basic.  It is definitely a two tier system as most dentists  have improved their surgeries with more and more expensive  kit, and can do more and more cutting edge  treatment and more cosmetic dentistry.  If you are well off you will get a first class service.

A similar situation now happens with eye problems. Most patients, even when I was practising, knew it was no use going to a GP for visual problems such as poor vision, floaters, and so on; the place to go is the optometrist, even though there was always a charge.  But I used to see patients in primary care with acute conjunctivitis, hay fever, and tear duct problems, and did the best I could armed with only an ophthalmoscope.  At that time optometrists could not prescribe antibiotic or steroid eye drops. But with contact lenses  becoming so popular, most optometrists went on courses to enable them to prescribe, whether privately or for NHS medications.  High street pharmacists can also prescribe antibiotics for simple conjunctivitis, if they have been specially trained to do so, but not many are.  In England, Pharmacists are about to be paid for seeing patients, but GPs are complaining that the former are going to be paid twice as much as they are.  GPs get about £164 per year per patient, with a bit more for the elderly. That shows exactly how efficient they are.

Recognising the difficulty, both Wales and Scotland  have set up NHS services in Optometrist practices, if they agree.  Under the Eye Health Examination Wales initiative, “you are entitled to have your eyes examined free of charge by a registered optometrist if you have an eye problem that occurred suddenly [acutely) which you think requires urgent attention”. ¹ This has been in existence for many years and can work quite well.  Optometrists can use their skills and equipment to examine the eyes in more detail, and so can diagnose serious illnesses such as glaucoma, diabetic eye problems and tumours.  But there are problems.  In my part of Scotland some GP practices won’t see eye problems at all and refer patients direct to Optometrists.  Optometrists triage the scheme vigorously and don’t advertise it in case they get overloaded,  and they also aren’t able to provide the full range of primary care eye care which requires liaison between hospital consultants.  Patients can be shunted from GP to Optometrist and back again and patients never know whether they are expected to pay for the services or not. Some Optometrists also want to recoup their expenditure on scans and other  tests and  will perform them, and charge, despite there being no relevant indication for their use at that time. 

Patients with painful eye conditions don’t expect to pay fo this service and Optometrists can put barriers in the way.  I suspect many patients will go to their local eye department in the hospital if there aren’t such schemes operating and they can’t pay. 

We always come back to the difficulty with private services sitting alongside “free at the point of use” services – how to manage demand.  When the workforce is depleted it becomes impossible.  Patients paying to see a consultant privately and hoping they can be pushed up the waiting list has been happening for years. 

There is no doubt in my mind that the NHS has been neglected since 2010, and pay has fallen considerably. Professional people will go where they can earn more money and have better conditions. Last year, my ophthalmic consultant moved to Saudi Arabia, to earn more money before he retired, causing havoc in his department. A Psychiatrist  I know moved to New Zealand for the same reason, citing poor conditions and low pay.Young doctors are leaving the NHS early in their careers citing overwork and poor conditions. 

Marketisation and privatisation in the NHS is happening more and more.  There are so many on-line  advice lines where patients can  get up to date information about what to do about their symptoms.  The old system of a doctor knowing their patients has gone; general practice is hard work and many GPs are leaving, and their practices then have to be taken over by the Health Authority. So attention is turning to establishing centres which will do the full range of treatment, including eyes and dental work, physios and psychologists.   If Labour win the next election plans include ‘GP hubs’ where patients can walk in at evenings and weekends, bringing together doctors, nurses, dentists pharmacists and treatment of minor injuries to take pressures off A&E. ²  Chronic disease management, the core of primary care these days, could be managed there, by nurses and GPs who are already trained to cover these responsibilities.  This sort of neighbourhood primary care might be a good way forward.  It could be cost effective and allow scarce support services to address the needs of several practices at a sustainable level, but It should  be locally led with  several practices co-operating in each neighbourhood;

They could only do this, though, if extra money was provided, in addition to what is already spent on GP services.  This is what happened in Australia which offers walk-in services seven days a week, for situations that are urgent, but not a major emergency.

There would  undoubtedly be battles with patient care organizations and health service unions for this to happen.  While such plans may work quite well in big cities, in rural areas  it is not so easy and patients would have to travel long distances.  Getting staff would be difficult too. It would be imperative to invest more in training staff. 

One of the big problems since the pandemic has been that there has been an increase in the number of people who are too ill to work, and it is likely that failure to treat illnesses or do operations early enough is exacerbating this.  That is a very good reason to invest in the health service to get them back to work.  In a similar vein, most large companies who value their workforce will set up some sort of service locally to save their workers having to spend time going to the doctor.  And going further, I would like to see occupational health services provided for people in smaller workplaces.   But should all care be free? For some people it must be, and in the UK benefits system this is true for people who qualify.  But it is unrealistic these days to say that everything should be free at the point of use.

We also must tackle the built in advantages of private medicine that is entrenched in the UK.  Private medicine in the UK is like a leech on the NHS.  All its practitioners are fully trained doctors, the costs of whose training are born entirely by the NHS, where young doctors learn by doing procedures under supervision.  This takes up time and needs the skills of senior doctors who teach them.  I have never seen this happen in private hospitals, and I would think that patients would not agree to it, as they want the consultant to perform the operations if they are paying a lot of money.  The private sector also picks and chooses what it does — usually the straightforward operations and treatments.  Complicated and expensive treatments are left to the NHS, as are almost all cancer services.  Also, If anything goes wrong in a private hospital in the UK, the patient is immediately transferred to the NHS, so the private sector does not bear any of the secondary costs of treating them.  It is well known that the private sector in the UK is hugely profitable because of this, but still the costs to the patients are higher than in lots of countries where these advantages do not apply.  No wonder the big US  companies are champing at the bit to get control over this licence to print money.  There is evidence that the quality of healthcare declines after private equity involvement.  In a recent  American study in JAMA, 1, an analysis of more than 600,000 Medicare patients found that private equity hospitals did fewer procedures among younger and less disadvantaged patients.  There was also a doubling of surgical site infections in the private equity hospitals compared  with those in the public sector, and there was a fall in the number of surgical site infections in private equity hospitals, a 27% increase in patient falls, and a 38% increase in central-line associated infections, despite fewer central lines being done.  These changes happened following  private equity buy out.  Explanations could include decreased staffing, changes in “operator technique” or poorer clinician experience, according to this study. ³

While I continue to hope that NHS service can survive and improve in the future if a government is elected that will continue to invest in the NHS, I wonder whether it will be possible.  There is a huge amount of pent up demand with long waiting times,  and  the workforce is not increasing. The experiences I and my family have had recently however have shown that the goodwill  and expertise is still there.  My brother had first class care in a Glasgow hospital recently for an admission after a fall just before Christmas, and I myself have had good emergency care recently although it has to be said that I knew to access the services through my  GP rather than go through emergency departments.  I do feel that the staff on both occasions gave care with skill, compassion and first class diagnostic services  despite being very busy indeed, and this gives me hope that things can improve.  We just need politicians who understand the need for a professional service unencumbered by the need to make a profit, with patients at its heart. 

reference. 

1. https://thepracticeofhealth.nhs.wales/clinics-services/referrals/self-referrals/welsh-eye-care-scheme/

2. https://www.pulsetoday.co.uk/news/politics/labour-planning-gp-shake-up-resembling-darzi-centre-model/

3. https://original.newsbreak.com/@healthsia-1608606/3277518604178-private-equity-takeovers-linked-to-declining-quality-of-care-in-hospitals-nationwide-analysis

Demographics as a tool in war in Gaza

Our world does seem to be unwinding. Climate breakdown, wars, mass killings, pestilence, poverty and malnutrition are all related. From a planetary perspective, this is nothing new; as David Attenborough points out, our planet has seen this, and much worse, before. But life survived. What is different this time?

The obvious difference is that humanity, the human race, is observing this breakdown and knows that it is man made. But most of us are not thinking about the fact of climate change, we are worrying about us. About other humans, our family, friends, our culture and society, even other people’s culture in Ukraine and the middle East, and we see everything through this lens.

But unfortunately, we are not an intelligent species. Yes, some of us might be intelligent and aware of the dangers. But our species, homo sapiens, is not at all intelligent – we act primarily as animals, particularly clever animals, but still with the urges, drives and biology that comes with that.

Isn’t it obvious that an intelligent species would not breed itself into oblivion, would take steps to conserve the planet, and would arrange our society to harmonise with our environment?

But we can’t. We have the over-riding urge to maximise our own survival at the expense of everything else – all life in our environment ,and other human’s survival. Humans all over the world, but probably most of all in the successful societies of the developed West are totally
concerned only with our humanity. The Judaic religions, Jewish, Christian and Moslem, all preach the idea which has so dominated our world for so long, that humans are sacred in God’s view. Each human being is a blessing, and children are often the whole point of our existence. It permeates our thinking so that every child in the world, and every child yet to be born, is of fundamental importance to the world.

It is a wonderful idea, often so selfless, with people championing those worse off themselves, and working towards a better society. But, and it is a big but, how can you do this in a world where the population has long outgrown the resources of the world? We are now, in developed nations, consuming the resources of 2,3. even 4 planet earths in one year. Even if resources are spread equally, this is an unsustainable Ponzi scheme. Of course it isn’t spread equally,
and far too many men, (and few women) are getting richer and richer, at the expense of the rest of us.

I am arguing for the absolute need to remember other species, and other environments. They are just as important to the functioning of the planet as we humans are. . We are not the only species that matters, and we must stop prioritising ourselves and our children in this way.

The present Middle Eastern War is widely regarded as an impossible problem to solve, and it is. Take the two main combatant peoples and their religions; both want to dominant one area. If we were an intelligent species we would see that whatever the problems, they will be made worse by having more children. It is a stark choice – if you live in an area of 141 square miles with 2 million others, and you cannot move anywhere else because the world is too crowded and no-one else will have you, you should at the very least limit the growth of your population. But in Gaza, contraception and abortion are prohibited. Women are still expected to have 5, 6 or 7 children, never mind that the resources of the land have long been depleted, and the whole society is funded by the UN. The same ideas permeated orthodox Jewish communities – they are given the resources to have as many children as they want, as they are “God’s chosen people”.


It is worse than that of course. Both sides use demographics to achieve political aims. The more children, the more the rest of the world cannot help but support them. At present 47% of the populatiojn of Gaza are children – the highest proportion in the world. That isn’t a natural phenomenon in this day and age – it is engineered by Hamas for their own ends. The more populous a society the more importance they will have, Hamas does not care about the children – they are just pawns to get what they want, which is power, but they need women to have more of them. I am sure the women of Gaza are aware of this — but what can they do? And the more children they have, the more likely (they will reason) that at least some of them might survive.

The Israel government is almost as bad. For years ultra orthodox Jews have been pandered to, and subsidized so that the fathers of families can study instead of work, and have many children They have now influenced the government with the result that the current one is the most hard right it has ever been. It has been completely captured by the religious right, and behaving in a way which is even more ruthless than Hamas. This isn’t intelligent behaviour – this is madness. Religion is important and our societies have often been the better for it, and it certainly provided a central role for people’s understanding of the world and the meaning of life. But that religious bit of us is now the cause of so much human suffering.

The world is waking up to the overpopulation problem – or at least the half of the world that is female. Everywhere women who are beneficiaries of the means to have fewer children, are doing just that. The population of Europe, the Americas, even Bangladesh is now stabilising, despite the futile efforts of the men in charge of several countries to persuade women to have more babies, Women are taking advantage of contraception, making sure that they can give a better life for their 2 children and themselves than if they had 7. Africa will follow if there is time. But the lag due to historic high conception rates means that an actual reduction of the world population will not start before the ned of the century. And what will the world be like then?

Yes, in the current war, we will all grieve for the deaths of innocent children. But do we want the world to continue with humans on it living in harmony with our natural resources, or not? Surely all communitiues, including Gaza should be allowed contraception?

There are other flash-points with language and race being other trigger points for violence. All of these will worsen with climate change , which will make huge areas unliveable in. I have no idea whether our civilzation will survive it. The planet, and life on it will survive. Let’s at least make sure that our population reduces to a more sustainable level by contraception, not by mass annhliation.

Looking Back on Covid-19

As I write this, some scientists are urging us to start to wear masks again, because there is a new variant  and cases of covid are rising. Covid hasn’t gone away and we know that things may take a turn for the worse again. Yet it is remarkable how most of us have put the covid epidemic out of our minds, so soon. The success of scientists who managed to work out so quickly how this totally new disease worked, and develop effective vaccines, meant that the virus had to mutate to survive.  As has happened before  (after the 1918 “Spanish” flu epidemic),  it mutated in a way that made the infection much less dangerous, and now most of us can go back to our old way of life with little change.  Until the next surge of course. 

But now seems to me to be a good time to look back at the pandemic so far. As in many countries, in the UK there is an ongoing Inquiry into how the pandemic was managed, called “Every Story Matters – UK Covid-19 Inquiry”.     This inquiry looks at many aspects of the coronavirus epidemic and how prepared the country was, and how the NHS and other agencies responded. However, it is not going to be a quick look at the main important points but a long  exhaustive study with many aspects and discussions which could go on for years. 

Just now, I would like to consider just a few salient points even if it is very early to come to any definitive conclusions.These are personal observations and   recollections which may be helpful, but may eventually turn out to be not entirely accurate. We’ll see. I am not blaming any country or health system for what happened. Wrong choices are inevitable when politicians, health workers and  scientists are dealing with a completely new disease. A lot of people, scientists included, thought it was similar to flu, when it turned out not to be at all. But we do need to learn lessons. 

The first event to consider was the initial Chinese response. We may never know what part, if any, Chinese scientists in Wuhan had in the origin of the disease, but certainly the chaotic and sometimes entirely wrong choices they made indicate to me that they weren’t expecting it, or knew about it,  at least at that time and place. They tried to deny it, castigating health workers who tried to flag up this entirely new disease, even to the extent of silencing one brave front-line doctor, who then died of covid.  Then, to some extent they may have over-reacted, putting huge numbers of very elderly people through the trauma of intubation and artificial ventilation, and keeping them there for very long periods.  To do this they had to  build enormous new field hospitals, and train many more staff.  But  the survival rate for the frail elderly (over 80’s) was very low. — 3% in one study.* and the mental trauma these people had to undergo, and the effects on hospital care for everyone else and on the workers themselves  were horrific. When the disease spread rapidly to Europe, doctors assumed that the Chinese were doing something right, and copied them, ventilating all very sick patients for long periods of time. In Italy, the very sophisticated health system there was soon under immense strain and nearly collapsed  

During this time I remember discussing what was happening with a group of retired doctors, and we all felt that it was totally inappropriate. We were knowledgable enough about the effects and results of long term intubation on elderly people and we were all very sure  that we would not want that for ourselves.   We would take our chances without it. 

In Britain, huge field hospitals  were quickly  set up to enable long term ventilation in ICU conditions.  But hardly any of these beds were used for critical covid care. The problem was lack of staff. Extra hospital beds can’t be used if there aren’t available extra fully trained staff. (Who knew?, as they say.)  In a pandemic, difficult choices have to be made, but It took more than a year for the doctors to realise the futility of this well-meaning attempt, and soon they had to restrict ICU ventilation to younger fitter patients who had a better chance of survival. 

The “Spanish” flu epidemic after the first world war, (we had all learnt about this in medical school)  did not mainly affect the elderly but instead targeted and killed mostly young healthy people – in that case often men and their families who had survived the first world war. So I, as an elderly person, at least felt grateful that Covid was not affecting young people. 

The next completely new problem concerned  trying to stop the spread of the disease,  using Test and Trace. This is a well documented  historic method of stopping the spread of  any infectious disease,  which worked well with diseases like Ebola, TB and flu to some extent. But nobody knew at the start of the pandemic how the virus was transmitted.

Covid turned out to be spread by aerosols, not droplets like flu. Therefore you could not get it very easily from contaminated surfaces, but it could spread round rooms in aerosols in the air extremely quickly.  Also it was not realised at that time  that  Covid could spread to the next victim in the 24 hours after infection, during  the prodromal period, and before the infected persons even knew they had the disease. 

 This was completely new. We were all taught that with most infections you are most contagious in the 3 to 4 days after you start to feel sick, and you remain contagious as long as you have symptoms.  But with Covid it seems that people can spread the disease immediately after the virus gets into the body,  during the incubation period and early prodromal  period. At this time there are no symptoms because the body is only just gearing up to fight the infection, and the symptoms such as fever, pain, or inflammation come from activation of the immune system,,

So this fact, which is related to the novel way in which the virus gets in through the ACE receptor, puts a real spanner in the works. Historically in any community at risk from an infectious disease, public health workers would try to immediately isolate people with symptoms and prevent them mixing with any non-infected  people.  This  requires a very methodical approach and when done well it works even with very infectious diseases.  The initial Covid virus (SARS-CoV-2)  was not extremely infectious  – the “r” number of people each person infected was less than 2, while measles for instance is about 15. But if people can’t be  isolated because they don’t know they have  the disease then you have to do retrospective  tracing and isolation – looking back on the people who were in contact with an index case for many days before they presented,  and seeing where they had spread the disease. This is actually what Taiwan, which had had experience of a similar virus, Sars 1, did to great effect. On learning of the first case of SARS-CoV-2 in January 2020, the authorities immediately closed the border with China,  imposed universal mask wearing, hand hygiene, introduce of digital technology incorporating big data, and quarantine of COVID-19 cases. As a result in 2020 there were 823 recorded cases with 9 deaths in Taiwan, a tiny amount compared to other countries, which shows what can be done using strict methods. Ultimately however the virus escaped even Taiwan’s efforts, as an outbreak among Taiwanese crew members of the state-owned China Airlines in late April 2021 led to a sharp surge in cases, causing a total of 4,871 COVID-19 cases in June, 2021. There were ultinatelty a total of 17,172 deaths from Covid there, still a lot lower than in many other countries.   

But the half hearted contact tracing done in so many countries did not stand a chance, and in Britain where a privatised and fragmented system was used, it was very poor indeed. According to reports, too few people were getting tested, results were coming back too slowly and not enough people were sticking to the instructions to isolate. So test and trace in the UK was having a marginal impact on transmission, and infection rates were still rising exponentially. 

This is why, in retrospect, I think that the initial lockdown was essential to prevent the exponential spread of covid and complete breakdown of health services for everyone.  Nothing else would stop it. 

After that first long lockdown though, if a well thought out and comprehensive track and trace system had been in place then it might have been possible to avoid the draconian successive lockdowns that were so damaging to children, those in poor housing and those vulnerable to violence. 

There has been a lot of discussion about the fact that  nursing homes were not protected at the beginning and that so many vulnerable people died there despite the best efforts of staff. But even now I can’t see a really good method of doing this. A hospital has to be able to admit those really sick people with covid who need urgent treatment. Therefore they need to discharge those patients who don’t need active care. Of course they should always test those patients and ensure they are covid negative before they are transferred to nursing homes, and this didn’t happen for many weeks.  But what if they tested negative 2 hours before transfer but then became positive  during the transfer process? This must have happened many times.  If patients weren’t to go back to nursing homes,  where were they to go?  Staying in hospital with really good systems of decontamination  and PPE  would only lead to more pressure on beds and treatment facilities. If possible, patients could go home, but even there if they weren’t able to manage without  help, they would have care staff visiting them, who could get covid and spread it to people they visited.  The need to develop a rapid accurate test early on in the pandemic was paramount, and was done, but it took time. People in hospital without covid still needed to be treated at a less intensive level, and so they were transferred to other wards, but despite heroic anti-infection measures, the virus still got around.

Nosocomial infection is the name given to hospital-acquired infections, and these have been around as long as hospitals have existed.  They are devastating to patients and their relatives. You go to hospital to be treated, not to catch deadly diseases. But they have always occurred and always will, unless better methods of PPE  are found. In the more distant past ordinary people were only too aware that hospitals could be dangerous places, and often wouldn’t go there at all. Only in the most  wealthy countries  with the best precautions can the  risk of infection be safely ignored.  

I think that the inquiry should come to the conclusion that a better test and trace system and better PPE  would have prevented the need for so many harmful lockdowns.There is no doubt that lockdowns were extremely damaging  to the fabric of society, and especially to children and the young people. They damaged children’s mental health and especially their education, and this damage is continuing. However the ill effects were very much worse for the poorest. Lack of equipment, lack of space and lack of help made online learning impossible for many children in poor households.The government did not give targeted help to such areas – in fact they seemed to give targeted help to private schools instead.   And the effect on the work of social services was disastrous.  Social workers could not visit households which needed help. Bullies and control freaks within families got away literally with murder. As a result, many children have died at the hands of abusive parents behind locked doors, using covid as an excuse not to admit social workers. 

The saddest case I read about was  the child disabled by spina bifida, who, unable to go to school during lockdown,  was confined to one room, unable to move from  her bed and fed solely on takeaways. She became morbidly obese and eventually died from infected bedsores. Her parents, who both worked, the mother as a carer, totally neglected her, and made excuse after excuse to refuse entry to social workers and others who wanted to check on what was happening.  We can have no idea what was going on in the minds of those parents, but the whole family obviously needed specialised help. It must be very hard for working parents to continue to look after a child as disabled as this for years. Undoubtedly the child should have been moved to a safe environment. But all normal checks and balances were prevented by the lockdown system, and the child got no help.The parents were both jailed for many years for the dreadful neglect and maltreatment. 

One other thing, on a separate health issue, this story shows is that it is what happens if a child eats nothing but fast food, and can get no exercise. The speed of progression of her obesity  where she went from 10 stone to 24 stone over the months of lockdown is mind boggling. Such fast food in this case was addictive, in that fast food was all this child had, and no doubt was the only thing that she enjoyed. But she would not have got so obese  if she was eating a balanced diet.   That fact is a lesson for everyone who thinks it is OK to eat a lot of junk food, and should be a lesson for the food industry which is providing such a lethal diet. But it would need government  direction for that to happen, 

Another big legacy of the pandemic is long covid. It may be that eventually long covid will prove to be the worst part of the pandemic worse even than the number of deaths and the effects on children and the poor.  This is because of the huge number of cases, and the severity of its effects on individuals. It is estimated that up to 10% of people contracting the Delta virus  developed long covid while less than 5% got it after Omicron. Vaccination also reduces the percentage of people getting long covid, so that if the virus does not mutate further there may eventually be a diminution of the number of new cases. But even so it is a huge number, at least 65 million cases world wide.

The severity of long covid varies a lot – some people have had extremely severe symptoms that have been likened to having had a stroke or a life changing accident, and which do not appear to be getting any better. Some are bed-bound and totally unable to care for themselves. Others have had less severe symptoms which nevertheless have a big effect on quality of life and ability to work. And the range of symptoms is huge, Neurological symptoms such as brain fog and poor concentration and memory can be very severe, resulting in their brains functioning at a level equivalent to being 10 years older. Long covid can lead to poor function of the autonomic system, giving rise to problems with low blood pressure and fainting; extreme fatigue,  especially after exercise, and also cardiac arrhythmias, chronic liver disease, cough and shortness of breath. The worst effects were seen in the 41 to 60 year age subgroup, and in those with more severe initial covid symptoms.  

To me,  it seemed very like the  disability caused by myalgic encephalitis, which I saw so often when I was in medical practice. Latest estimates are that around half of individuals with long COVID are estimated to meet the criteria for ME/CFS.   I hope that this might spur scientists on to find out exactly what is causing such disability. People with ME used to be told it was “all in the mind”, or at the very least, strongly influenced by mental factors such a depressions and anxiety, but  now iboth conditions are finally being taken very seriously. 

But the cause of Long Covid is still unknown. There is a wealth of evidence that  these symptoms could be caused by long term damage to various bodily systems, and can be measured by tests on blood cells and biochemical markers. It is likely that there are multiple, potentially overlapping, causes, such as  persistence of the virus in some tissues, immune dysregulation and mitochondrial dysfunction. Mitochondria are power house of the cells, and supply energy to the whole body, so damage to these organelles could well cause fatigue. What the exact mechanism is and why cold or flu viruses don’t cause such long term problems, is a mystery, but it is very obvious that the prevalence of these deleterious effects is  a game changer for health systems throughout the world. In  many individual cases of long covid there has been no improvement for months or years, and so far there is no treatment. 

So we can see that the personal and economic costs of long covid are very severe, and not many countries have really been able to come to terms with the amount of unmet medical need that exists. It is certainly true that ijn the UK, the well known reduction in participation in the labour market in the over 50’s is at least partly due to long covid, although there are other causes as well. 

The current inquiry is working to answer these questions, and many others, by examining  the UK’s response to and impact of the Covid-19 pandemic, and  to learn lessons for the future. I look forward to reading the report in due course, and hope the next pandemic is prepared for in a more thorough and scientific manner.   That said though, the next  pandemic will undoubtedly be very different again and may pose questions which are just as difficult. We just have to be quicker on the uptake next time.   

Apps for Women’s Health

The news that safe abortion is likely to be illegal in the USA, in vast swathes of the Midwest and south, is chilling.  The right to control what happens in one’s own body is a basic human right.   

In this blog I would like to move the conversation on to how to continue empowering women to make  choices over their bodies,  through using great advancements in the science of women’s health, both in contraception and in abortion. 

Abortion is never a first choice. It inevitably means that a woman (or teenager  or even a child)  has to make a choice to stop a bodily process which would lead to a new life, which if circumstances were right, might give great joy to the mother and her family and friends. Great advances in contraception have made it possible to prevent women and girls having to make that choice, because they can control their fertility more easily.  I remember the old days when girls would get pregnant out of complete ignorance, and had no choice but to have the baby. Sometimes they wanted to keep that baby, yet the “morals” of the day  dictated by religious institutions so that  they would be punished for getting pregnant and had to give their children up for adoption. Some of those women are  now telling of the awful effect on their lives.   That was another form of misogyny practiced by old men in positions of power in the big Christian  establishments, which was quite happy with young boys having sex but punished the girls who then got pregnant. 

These days we accept that young people will have sex when they feel ready for it, and where there is consent and no coercion. So why not make sure that girls are protected at the start? In my view it should be completely acceptable for all girls at the onset of puberty to be fitted with a long term contraceptive in their arm.   At the moment they can take the pill when they feel at risk of a pregnancy, but  a long lasting hormonal  implant would protect girls from the word go, and prevent the disastrous curtailing of their opportunities.  The implant is over 99% effective, and lasts for 3 years, and can be taken out sooner if desired. It can help reduce heavy periods and is completely safe. So the question is  “how can it be made more acceptable?”. In developed countries it would need education programs to advertise the benefits, which include preventing early marriage and economic benefits not only to the young girl, but also to the country as a whole.  The cost, as now, would be born mostly by international charities. It will be hard in countries such as in Africa, as I have written about in a previous blog. Access to education for girls may be severely limited, and many are married before they reach their eighteenth birthday. It will be a long hard road, but activists are continuing their work. 

As a result of the likelihood that Roe v Wade will be overturned in the USA,  women are getting together to fight, not only in the USA but all over the world where abortion  and contraception is restricted or prohibited.

The International Planned Parenthood Federation (IPPF) has published information about “safe at home” medical abortion services, which is being circulated world wide.  It is not well known that a high proportion of very early abortions are now being organised on-line in many countries;  the consultation  with a doctor is done online and the drugs posted to the woman in her own home. The method is recommended by the World Health Organization and the FDA ,and is perfectly safe, with a protocol that involves taking two drugs, Mifepristone  and Misoprostol, in tandem. The woman then has an early miscarriage at home. It was done legally during lockdown in the UK, up to 10 weeks  gestation without attending a clinic. It is also done extensively in Northern Ireland, which refuses to organise abortion services.  Of course sometimes it has to be done off the radar as anti-abortion activists will try to prevent it. But the situation in the USA and in many other part of the world is getting worse, with the rise in misogyny and sexual abuse, and we have to use such medical advances to fight the terrible  consequences of making abortion impossible to get.  So organizations such as  “Liberate Abortion”* which gives information  about abortion services and  “Aid Access”*  which gives practical help, are gearing up to expand even more for the USA. For the rest of the world, there is “Women on Web”* . There is a “Safe Abortion” app too. 

Aid Access is run by Dutch physician Rebecca Gomperts  and has provided a  cheap and readily accessible telemedicine service to people in the USA  since 2017, using a pharmacist in India who ships it to the patient in the US. India is the world leader in production of  generic medication, and the drugs are  of high quality, yet very cheap, so many more women can afford it.

Dr Gomperts says, “It is a medicine that should be available over the counter. It’s safer than many of the painkillers that you can buy in any pharmacy. The reason why it’s not possible has to do with politics and not medical science.” In richer countries girls are using apps to track their menstruation, so they know very early that they are probably pregnant. If there is a positive pregnancy test, then they can take abortion pills really early.  Clinically it is indistinguishable from delayed menstruation, or slightly later, a miscarriage. The   World Health Organization recently submitted  advice that women can safely self-manage medical abortion until 13 weeks of pregnancy, so it  really does empower more women and girls. Without the availability of such methods, women will turn to old fashioned methods of procuring an abortion  which cause  severe complications  such as  incomplete abortion with excessive blood loss and infection which often leads to death.  And why should any politicians seek to control the intimate details of a women’s menstrual cycle? Often people with such views are the very ones who say that they are against the state having any control over people’s lives.  What hypocrites they are!

So modern technology is definitely a force for good in allowing women to keep control of their own bodies, and fight off the challenges from groups that are anything but pro-life — they do not care about babies born into needless poverty once they are born, nor women who die because they are not allowed a timely abortion. The big challenge now is to spread these techniques to those who need them the most, women living in poverty in third world countries who are condemned to bear children that won’t have a future, especially if overpopulation and overconsumption mean that their homelands are disproportionately affected by climate change and they can no longer make a living.  It will need more organizations like the ones above to distribute  long term family planning to these areas, but education is key. Men and women need to know that these methods can guarantee a better life for all. A tall order of course, but  the alternative is horrendous. A world with many Afghanistans with no rights at all for half the population, more fighting, more poverty. Not a future for anyone to look forward to. 

https://aidaccess.org/en/

https://www.womenonweb.org/en/

Hot flushes make the news again.

  Reading articles in the press recently about the shortage of Hormone Replacement Therapy (HRT) gave me a sense of déjà vu. Yes, I’ve seen this all before.  Apparently some oestrogen  patches have been in short supply since some manufacturers had to stop producing them following supply issues in China.  So the popular news sites have been running articles on how women are suffering-

“Thousands of women are struggling to sleep or work as a result of a nationwide shortage of hormone replacement therapy (HRT) that has left some feeling suicidal,” campaigners have warned.(The Week.) “Women risking their health to source HRT amid shortages”, UK GP chief warns; (the Guardian), and “The Week” also asked  “is medical sexism causing the  menopause drugs crisis?”  

Now, as a woman and previously a GP, I am very aware and sympathetic to women complaining of menopausal symptoms. But what is happening now is basically a re-run of the rush to push HRT onto women that happened in the early 90’s.  When I was working then, I must have prescribed tons of the stuff,  at the behest of scientists writing articles about the benefits of HRT, doctors  (often paid by the pharmaceutical companies) recommending its use, and direct marketing from medical representatives who beat a trail to all women GPs to try to increase their sales.  The fact is that the ingredients, oestrogen and progesterone, are very cheap, and the profits that can be made by Big Pharma by developing new formulations and methods of delivery, from tablet regimes to patches, are huge. 

As I continued to prescribe HRT, I slowly realised what was happening. More and more, the menopause was made into an illness, and many everyday problems such as lack of libido, lack of sleep, and tiredness were put down to the menopause, to be cured by HRT of course (although mostly it didn’t). Women’s magazines were full of the benefits, the evidence was skewed, and the known side effects were downplayed. It got to the point where women were told that the health benefits were such that  every menopausal and post-menopausal woman  should go on HRT to prevent heart attacks.  I took HRT myself for several years, with marginal symptomatic benefit. By the early 2000s it was being noted that only 37% of post menopausal women were actually taking it and shouldn’t we doctors be doing more to persuade the rest? 

Then in 2002 came the results of the Women’s Health Initiative study. * This was a randomized placebo-controlled clinical trial of therapeutic and dietary interventions influencing postmenopausal women’s health.  It comprehensively debunked all the false claims that were being made. In detail, 8,506 women participants received standard HRT in 1 tablet, and 8,102 women received a placebo (an inactive tablet which looked the same). The results were that in the group that took HRT there were 7 more heart attacks (a 29 per cent increase), 8 more strokes (a 41 per cent increase),
8 more pulmonary embolisms (blood clot which went to the lungs), and 8 more invasive breast cancers. There were some benefits  – 6 fewer colorectal cancers and 5 fewer hip fractures (due to the beneficial effect on osteoporosis).  The effects were all small as you can see, but if you were one of the unlucky ones  who got breast cancer or a stroke, it was tragic. Menopausal symptoms are not life-threatening. 

So there was overall harm from HRT, and as a result of that study and several others like it, we GPs were told only to prescribe HRT for short term treatment for menopausal symptoms and we should not prescribe it at all for women past the menopause. There was then a dramatic worldwide decrease in its use. While I drastically reduced the amount of HRT I prescribed, I don’t remember any difficult conversations with women who ought to stop it. They accepted the evidence and gradually the symptoms went away, as they do. In cases when symptoms were severe and the health risks had been discussed, of course  I did prescribe it,  but I didn’t see lots of rebound effects due to the lack of HRT, and there were no headlines about this. 

In 2012 some scientists reworked the results of the trial and indicated that HRT may actually be safe in younger women. However, the article’s authors, from South Africa, Germany and the UK, admitted that they had all acted, or continue to act, as consultants for pharmaceutical companies that make HRT, and presumably this is the result they would like to see.  Since then it has become clear that HRT is indeed making a comeback. Demand has certainly risen.  About 512,000 scripts were written in England in February, compared to 265,000 in March 2017, data shows. According to the Daily Mail – “Prescriptions of HRT have doubled in just five years as women and GPs become increasingly aware of the excruciating and wide-ranging symptoms of the menopause”.  Campaigners have also blamed “medical sexism and a lack of training” for women being left to suffer debilitating menopause symptoms, which also include depression and brain fog”,  (The Guardian). Research suggests that “14m working days a year are being lost to the UK economy as a result of menopausal symptoms,” the paper reported. However the Mail on Sunday was much nearer the truth when it said the cause was  “Celebrity campaigns, political action and greater media coverage of the menopause,” and pointed to “waning concerns about HRT’s possible side-effects.” So the bandwagon is back. Yes, HRT is an invaluable help to some women suffering hot flushes and  other symptoms, but it is not life-saving and it is not without risks.  Labour MP Carolyn Harris, co-chair of the UK menopause task force, has been appointed hormone replacement therapy (HRT) tsar to address the problem. According to her, “Women have not been listened to, women have been ignored, they’ve been prescribed and diagnosed with other conditions and the menopause wasn’t even considered”. She added, “For a menopausal woman this HRT is as important as insulin is to a diabetic,” she added. That is certainly not the case.  Insulin is a life-saver, HRT is for symptom relief only. And I found that some women were so convinced by the hype that they wrongly put all their symptoms down to HRT.  In one case the woman actually had a brain tumour and the diagnosis was delayed as she insisted on trying HRT first. So Carolyn Harris should not be so partisan.  Of course, with the current “Me-Too” campaign, anything relating to women and their health is good copy, but you can also see how the media is manipulating the situation to get women to ask for it. There is not much doubt columnists and reporters are being paid to do this by drug companies, who are hoping to make lots more money if HRT can be rehabilitated. 

This increase in use of HRT is undoubtedly one of the reasons for the shortage. There are long-standing structural problems in the medicines supply chain which have been exacerbated by the pandemic and in Britain possibly by Brexit, which are also found in many other industries. Drug shortages will continue to be an issue in healthcare.  It is extremely important that essential drugs are available at all times and it is not sensible to drum up support for non-essential drugs and so stress the situation even further.  I do hope that reporting the subject is more balanced than it was when I was working and so many women were misled.

* Ref https://doi.org/10.1001/jama.288.3.321

Misogyny and contraception

Misogyny is defined as “hatred or contempt for women and girls” and is, and probably always was, widespread. In 1275 a tract was written by one Jean Le Fevre, all about the wickedness of women. And  it seems his belief  was widespread in societies from Europe to the Highlands of New Guinea, when they were first encountered by Europeans.  Women were not only inferior but also dangerous, and contact with them could cause death by “withering away”.  There is evidence that in the fifteenth century large proportions of the youths in Dijon had participated in gang rape of women at least once in their lives.  Belief in witchcraft was common, when women were always blamed and usually killed.  We may not be quite as violent these days but our culture too suffers from a big streak of misogyny.  

It is also evident in the Bible.  In the Genesis fable, Eve succumbed to the serpent’s temptation. She ate from the tree, and made sure that Adam did as well.  She was the main guilty party.  So all three Abrahamic religions began with misogyny.  In modern western society, most people do not think that they are misogynist.  But sexism is widespread and is undoubtedly used to keep women at a lower social status than men, thus maintaining the societal rules of patriarchy.  Misogyny has been widely practiced for thousands of years and is reflected in art, literature, philosophy and historical events.  The UN Development Program studied 75 countries representing 80 percent of the world’s population and found that nine in 10 people – including women – hold  prejudiced views that include: men are better politicians and business leaders than women; that going to university is more important for men than women; and that men should get preferential treatment in competitive job markets.  There was considerable variation among nations in measured misogynist views ranging from those in Andorra and Sweden to those in Pakistan and Nigeria.  Many of these societies are deeply patriarchal and hold dear the ideas of virility, power and the cult of fertility. Men in power in patriarchal societies see an increase in population as a source of power and a bulwark against  other countries’ encroachment.

As a girl, I was brought up with views that the ideal was one of equality between the sexes.  I was well aware that this was not entirely true in practice, and by the time I applied to medical school it was clearly not true.  In 1963 there was a quota of 1 girl being allowed in to London medical schools for every 9 boys, and Oxford and Cambridge had a ratio of 9 lads for every lass.  Outrageous as it now may seem, many local educational authorities set a higher pass rate for girls than for boys in the 11-plus exams – they wanted to reduce the proportion of girls reaching grammar school.

I thought victory had come when the equality law was passed in 1985 outlawing such practices, but there still isn’t true equality.  However, I never remember suffering from any extreme disadvantage, and certainly was not aware of the high level of sexual abuse that modern women and girls face, still less the idea of “incels” who believe that women are at fault for not giving them access to sex, and should therefore be punished.

Was it always thus? Perhaps not. Anthropologists have studied modern day hunter-gatherer societies, and found that generally, men and women have equal influence on who they live with and where they hunt, and this may well have been the case for prehistoric hunter-gatherer societies.  The reason for this may be that such societies could be more successful than those where men make all the decisions, because  the hunting way of life depended on division of day to day tasks, not a male provider and dependent women and children.  Many scientists believe that it was only with the development of farming, and  ability to store food and resources, that men could acquire power at the expense of women without detriment to the functioning of  the society as a whole.  Incidentally, we also  know also that the advent of farming let to the beginning of total exploitation of the planet’s resources for humankind, which has led directly to our current problems of global warming, instability of climate, and extinction of other species which could ultimately threaten human existence.

Modern African rural societies are not fair societies.  Women do most of the agricultural work, and child rearing, yet men and boys have more prestige and may even get the lion’s share of food.  Women bear the brunt of poverty and each additional child makes things worse.  Such societies are now very patriarchal, with men making most of the decisions.  Yet in traditional pre-colonial societies women often held important political positions, with some societies being matrilineal.  There were queens as well as kings.  Elder women had important voices on how to run communities.  Some scholars put the blame on colonialism for the diminishing power of women, because male chiefs negotiated with European colonisers, and the land tenure system that benefitted women was replaced by a European model which prioritised men. Education of boys was also favoured by European administrators.  The result is that Africa has some of the most gender unequal societies in the world, and despite money being spent to improve women’s lot, change comes very slowly. 

The countries with highest birthrate at the present time  are all in sub-Saharan Africa, where the fertility rate between 2015 to 2020 was 4.5.  In Africa as a whole it was 4.3. Yet Africa is not overpopulated.  It is huge, and historically late in increasing its population, due to disease, lack of industrialisation and the ravages of slavery.  The population even today makes very little contribution to global warming, with low CO2 production and low use of earth’s resource, apart from destruction of the rainforest.  But African countries are suffering from their high birth rates, rather than reaping a demographic dividend, as happened with Asian and European countries in the recent past.  While African countries have not caused global warming, they are suffering most  from its  effects such as drought, desertification, rising sea levels, storms, heat waves, and floods. As food supply is affected by failure of agricultural systems more land is put to use, and pressure on conservation areas is intense, threatening whole ecosystems and therefore the planet. Very many young people have no prospects and with drought, water shortages, soil erosion and all the other woes with a warming climate there is a huge risk of war, breakdown of societies, mass starvation and out-migration. 

These problems link with misogyny in that in these areas it affects girls’ access to education; time after time it is found that just one thing  educating girls up to and beyond the level of boys’ education, produces an immediate  benefit.  But misogyny denies them this. Allowing access to contraception  will allow women to choose fewer children, and with that, they can make the most of their education to lift themselves out of poverty and give the next generation of children a much better chance to contribute to their country’s development.  And a fall in their birthrate will lead eventually to a falling world population, which should eventually  reduce, and eventually halt the world’s rapid descent into planetary destabilisation and decline not only for humanity but the whole of the plants and animals that we share it with. 

But organisations which promote contraception and availability of abortion face extreme hatred and opposition from right wing groups in America and religious groups all over the world, especially Catholicism and Islam.  At the moment such groups are trying to prevent girls and women having these rights and so far are succeeding.

It seems very perverse for countries, organisations and religions to oppose contraception  and other benefits to women and families as they do.  I’m interested in why exactly these right wing groups hold such strong positions on things that affect women so much.  Economically it makes no sense. Societies that treat women badly are poorer and less stable. Just look at Afghanistan now. Gender equality has been conclusively shown to stimulate economic growth, which is important, especially in countries with higher unemployment rates and less economic opportunity.  If a country only uses half its workforce, it will not produce as much.  Simple.  But it seems the answer is that even small advances in women’s rights to education threaten men’s ability to have as many children as they want, and prevent them keeping power, both in the family and in politics.  So there is a battle of the sexes with women wanting more autonomy in order to be freed from the tyranny of more and more children, as against men who want more power, and are less likely to do much to help in the arduous task of rearing these children. 

A few years ago, John Magufuli, the late former president of Tanzania, exhorted women to “throw their contraceptives away” and “keep reproducing” to make their country strong.  Magufuli, a Covid denier, is now dead – of Covid.  But his views live on.  The idea of limiting population growth in Africa is controversial, often for good reason.  It is hard to disentangle telling people not to have babies from a tawdry history of forced sterilisation, racism and eugenics.  Many African leaders – 53 out of 54 of whom are men – believe it is none of other people’s business how many children their people choose to have, although in fact “choice” may not be the word for the womenfolk.  So it is difficult for organisations which work to promote contraception to make progress, especially since the Republican party in America  continues to oppose charitable funds which do this worldwide. 

All this is seen in the present struggle, Roe v. Wade in America, where Republican states are trying  to make abortion impossible for any woman. They aren’t pro-life – they show no interest at all in helping women bring up children once they are born.  Republicans weren’t even anti-abortion at all until the 80’s when it was adopted as a political ploy.  It isn’t even directly about religion. There are widely different rules on contraception within Christianity.  The Qur’an does not make any explicit statements about the morality of contraception, but contains statements encouraging procreation. Until Saudi Arabia  started using its oil wealth to spread its extreme kind of wahhabism,  Islamic  communities could be very tolerant.  Since then the expression of misogyny has been rising very rapidly in the last 20 or so  years. This may also be a direct result of the push for better treatment of women and the feminist movement, that threatens a small subsection of men. 

Also, amongst  the right wingers in America  who are most against contraception and abortion, there  is also a huge racist component.  The underlying belief of many evangelicals is that Europeans are the most developed human beings in the world but they are being swamped by other races and are in danger of losing their power.  The picture of a (white) man at the head of the family, the breadwinner, with subservient wife and many children is the picture that such groups want to perpetuate, and see in the rise in populations of non-white groups as an existential threat.  Mind you, these twin beliefs of anti-abortion and anti-contraception and extreme racism are very illogical, as the biggest losers from easily available contraception and abortion are poor women of colour, so their activities could advance the day in which the whites in America become the minority. Although they might think that, as lack of contraception and abortion also keeps them poor, it may not threaten their power too much.  

We should  try to work out the causes of misogyny amongst men in order to see how it could be tackled from this perspective. One author,  David D. Gilmore, has written a book “Misogyny: The Male Malady” which tries to show that from a social anthropological view misogygny arises from “the shared psychic course of the male of the species” – an inner conflict of the fact that men both need women desperately, but try to deny  this as they think women are dangerous to their life prospects.  This certainly comes some way to explain the thinking of Incels, who “try to relieve their inner turmoil by demolishing its source”.  He also states that though psychogenic in origin, under special conditions misogyny can become a full blown epidemic.  Examples arise where there is a feeling of victimhood, in patrilineal societies, war or religious puritanism.  It is clear that women cannot change this – it must be something that men should recognise and boys should be taught.  Misogyny should be tackled at a scientific, psychological, and societal levels, and governments should legislate to prevent these ideas feeding on themselves with amplification in  the present interconnected world. 

So it is clear that the world is at a crossroads.  If misogyny in America, Islamic countries and elsewhere results in a refusal of contraception to women, it risks humanity itself.  The planet will be degraded and there will be less room on it for both men and women. I think it is very important to recognise misopgyny in our midst, and for both men and women to fight it at every opportunity. 

Vaccine Hesitancy and Anti-vaxxers.

As a doctor, I can’t understand anti-vaxxers, certainly not the vociferous sort who campaign aganist vaccination outside schools, or just refuse without giving a reason. Vaccinations have always been an incredible scientific advance. In the 1960’s, I was so relieved myself to get the polio vaccine when it came, because people and especially children were terrified of it. Every school had at least one child who died, or came back in a wheelchair. Then smallpox, measles, whooping cough, and a host of others greatly reduced the threat of illness at all ages. Vaccination was a miracle. Only cranks refused it.

But now the world’s recovery from Covid-19 is being threatened because many people are refusing the vaccine. Despite the undoubted fact that vaccines work, and that most people dying from covid in rich countries are unvaccinated, people are still refusing.  Only a minority  are anti-science or staunch anti-vaxxers with bizarre theories. The majority are just not convinced. So why?  

Firstly, trust, in the government’s policy makers; the health service and in the vaccine itself.  In some countries (Russia, USA, Albania, many African countries), people just don’t trust the vaccines, and think they do more harm than good. They may particularly distrust Big Pharma, often for good reason, especially in the USA after the Oxycontin debacle, and in Africa where there have been many clinical trials which have harmed patients.  They may distrust doctors who they may perceive as only in it for money, or when they or a close relative have been damaged by medical treatment or a procedure. Or they just distrust their governments for political reasons as in Russia. They therefore gravitate to treatments which are seen as more natural and therefore safer. They tend to discard scientific  research, preferring to do their own “research” through Google. 

Other reasons centre on whether or not the person thinks the disease to be a serious risk to their health, and in the case of Covid it is well known that younger fit people are unlikely to get seriously ill. Some such people don’t think it is very important, even though people in this category do get very ill and can die.  Whether the vaccine is easily available as well is an important determinant, especially in poorer environments.  

But a very important determinant is the willingness to protect others from infection, through getting the vaccine oneself, and this varies greatly with a person’s world-view. It requires an understanding of how good health can be a lottery, and that you can get seriously ill  very suddenly despite having taken every precaution, and being basically fit. Illness can strike anyone at anytime.

People who distrust healthcare and the science associated with it, often want to be in control, rather than consult professionals,  and can be  reluctant to use it.  They  prefer to go for over-the-counter  treatment, or advertised procedures without scientific rigour, and other home or traditional remedies. They assume that if they treat their bodies properly – healthy diet, plenty of exercise, knowledge of how the body works – they will never get ill. I admire these people in a way. But  such people can fail to get medical care soon enough, if they are unlucky enough to get a sudden severe illness.  In contrast, a few people (who are have access to free scientific medical care  and good education) can tend to rely entirely on the medical system for all their needs and can overuse it, not realising that the body is indeed very good at healing itself. They may therefore demand medical care early without being prepared to wait and see. This takes away their “agency” and they can become very dependent and passive. When they become ill they say “you can’t be too careful”, and are very risk-averse, which itseff may have negative consequences for their health. So it is important to strike a balance between consuming every kind of recomended medical care, and treating oneself with no regard for science.

Fortunately, in the UK  not so many people are as sceptical of vaccination as in the USA. This is because in general people really do trust their NHS, and o think that there is bound to be  a pill for every ill, or that there is a treatment that will magically make you better regardless, and that you have a right to every treatment at very little personal financial cost. I saw this a lot when I was working in general  practice in the UK. 

 This dichotomy between different world views of healthcare was manageable in a less interconnected world, when there was a spectrum of beliefs but the extreme ends being held by a small proportion of people. But now, with social media amplifying such world views, and applying  algorithms which are geared  towards making  money for themselves, more and more people are being pushed into the category that distrusts medical care and emphasises their own ability to keep themselves fit, such as the “wellness” movement.  Refusing vaccination, which has very little to do with personal autonomy and everything to do with health of populations is a very dangerous strategy, both for themselves and the communitioes they are part of. 

Personally, I have a lot of common ground with people who want to use mainstream medical services as little as possible.   I spent 35 years in general practice, and I found it was essential to treat each person as an individual, and find out what  each person really wanted out of the consultation, as people varied so much in their ideas.  If they follow quack theories and  mad gurus, so long as they keep it in perspective, so what?  I am very aware from my medical work that the body is indeed very good indeed at healing itself.  95% of symptoms get better entirely on their own.  And it is refreshing to find people  who are determined to maximize their health  and are convinced that they will succeed. It contrasts with the people who thronged into my surgery with every cough and cold, who were chronically anxious and never took responsibilty for their own health, prefering to rely on the doctor’s prescriptions every time. They could be  utterly dependant on their doctor, sometimes because they were lonely, and were underconfident.  Some  even wanted to be diagnosed with an illness as that would either  get them out of work they didn’t like,  or get them more money; some who were disorganised and  lacking in drive.  Some had very high expectations and could be very demanding. 

But mostly I saw many who were just  very unlucky in the  lottery of health, and suffered a lifetime of bad health, yet tried their best to conform to medical advice in order to make  their health as good as possible. There were people who drew the short straw and developed type I diabetes in childhood, or had rheumatoid arthritis, in other words diseases they could not possibly have caused themselves. Then there were the many people who were poor, weren’t able to afford a good healthy food, having to buy ultra processed poor quality food because it was cheap, had jobs which were hard on their backs and joints. Their bodies tended it wear out more quickly because  of the stresses and strains of their lifestyles. These people could be helped by modern medicine and it was my job to do just that.

Of course, in the modern “wellness” culture, where bloggers, health gurus, and health influencers thrive,  it isn’t only well-trained dieticians, or physios from whom that people get their information, it is also websites that promise immediate cures and therapy which have no validity in scientific terms at all. “Dieticians” and “Physios” with no qualifications can treat patients  and charge a lot of money with no oversight.  It is all about control and money. It is often relatively young people, usually basically fit, with jobs and a reasonable amount of money,  who are starting to think about “wellness”, and looking up on-line to find how they can stay fit. More often women than men, they are willing to learn about the human body and how it works, and want to follow a lifestyle that suits them.  All very good,but many do not want to involve medical professionals at all, especially where there is a high cost in doing so such as in USA.  If the internet provided a balanced view of scientifically accurate information then that would not be a problem. But the algorithms that govern the websites they see quickly pull them towards more extreme  content, and misinfornmation is rife, and soon they may be reading  stuff that tends towards QAnon,and very right wing ideas. One trope that gets traction is that you can control your health by following these arcane rules, and if you do you will never get ill. They look at Covid, and see that the worst effects of the virus are on those who are already ill, and feel that they won’t get ill because they are following the right rules. 

More than that, people can  come to believe that those who do get ill are in some way at fault – they eat unhealthily and take harmful medications  or foods, and  they  may regard the lives of those less fortunate than themselves as having scant value. One writer says “Some of the most strikingly nasty stuff I’ve seen with Covid misinformation has come from wellness influencers.” All this works against the fundamentals to do with vaccination – that you don’t only do it to protect yourself, but you do it to protect everybody else, including those you love who may be unluckier than you in their health. This outlook is a world apart from the disdainfulness that I refer to above in which they don’t see why they should take any risk at all for the common good.  Modern vaccines are extremely safe, but bad events can happen to the detriment of a very few individuals. But when, as in this case, the virus is so infectious that you are very likely indeed to get it, and  can get seriously ill with it, then the risk is very much worth taking on an individual level, aside from helping the whole community. 

It is likely that some anti-vaxxers cannot now be persuaded to get vaccinated – their views are too entrenched.  But htere are many who are vaccine-hesitant who might be persuaded. So what can health professionals and governments do to help these people come forward? There are reasons such as needle phobia  for instance where the underlying anxiety can be treated, and there are now vaccines that can be given viaskin  patches. Vaccines should be readily available – vaccines can be given in drop in clinics, people shouldn’t have to wait in long queues,  there should be an unhurried atmosphere to calm nerves and so on. Huge vaccination camaigns can help. In some difficult neighborhoods, rewards could be offered. 

Then there is the question of sanctions for those who won’t get vaccinated. These have to be carefully titrated against people’s freedoms. Vaccine passorts for certain venues or travel, can work well, as in France,   On the whole I am against compulsion, and against forcing people out of a job unless it is really dangerous for an unvaccinated person to be in that situation – hospital ward or care homes for instance. In the end it will be a decision made by the individual, and although it is heartrending to see people dying of covid pleading to be vaccinated when it is too late. 

More importantly online platforms should be held accountable forn the harmful and incorrect information they publish, as any other publishingt company would have to be. It is a scandal that they can get away with it. 

Covid-19, Immune systems and Neanderthals.

Why are some groups of people, in families, in localities, from specific geographical areas, or races, more susceptible to Covid-19?  This is a huge questions for health services to answer, as they see the disease concentrating in certain areas and amongst specific groups of people.   If we can understand why, then surely we may be able to develop strategies to prevent this happening.  

In June last year, in this blog, I wrote about how, as well as all older people, the virus has managed to target exactly the groups of people who already suffer from long term diseases such as obesity, diabetes, cardiovascular disease such as heart problems and strokes.  These people are killed disproportionately by the virus, as we now know, and in western societies the people who have a much higher incidence of these diseases are older people, and some who have  a BAME background.   It has become  abundantly clear that the reasons these people are getting the virus in the first place is because of inequality, low pay, poor eating habits because of poverty, working in unsafe environments, such as meat processing plants, garment factories, and more than anything else, working in front-facing jobs in health and social care.  So they are at risk regardless of their genetic background or susceptibility. 

But there is another, rather sensitive question.  Do some people have an inherently worse genetic risk than others, a risk that is encoded in their DNA?   There is considerable scientific interest in this, and it seems that there is considerable variation among people’s immunity to viruses like Sars-CoV-2, and some of it even dates back to our cousins, the Neanderthals, more than 40,000 years ago, and how their genes affect our immunity today. 

To go into more detail, we need to know how our immune system works to protect people from disease, before we can understand how our genes affects it.  I am not sure that many people actually know what the “immune system” is; where in the body it resides, and how it works. 

The system works through many different sorts of cells, located in various organs in the body, (liver, spleen, lymph nodes, etc)  all of which have their specific jobs to do and way of working. There are two sorts of immune system — the “innate” and the “adaptive”  The innate ones will tackle all infections in a general way, through blood cells like neutrophils and monocytes, and  require no specific training.  The adaptive ones consist of T-cells and B-cells, which need “training” through contact with antigens in the virus, or through vaccination, to do their jobs, and proteins in the blood called “complement”, which facilitate that.  Infants have only innate  response and have to learn how to cope with infections as they encounter them. 

 If you would like to know, this is a link:

https://primaryimmune.org/immune-system-and-primary-immunodeficiency

In general it has been known for a long time that old age, gender and nutrition affect the immune system.  Nowadays, the number of words written about how to boost your immune system is extreme.  Health and fitness are the most popular subjects for blogs, partly due to their capacity for making money, though some of them give sensible advice on lifestyle factors.  There are innumerable blogs on how zinc, or vitamins C and  D,  and many others, can improve the immune response, but the science behind them is complex and disputed.  Vitamin deficiencies are rare, and the number of people nowadays who suffer disease because of them is even rarer.  A healthy diet and lifestyle is enough for most people to stay healthy.  But it is good that people are concerned about their health and most “remedies” do no harm, and definitely make money for some people!

This blog does not make money.  I don’t have anything to sell.  But I am interested in how the immune system works and like to share my thoughts. 

It is a fact that some people’s immune systems do work better than other people’s, and this can be due to both social factors as above, and genetic factors.  Certainly with infections, there is a lot of evidence that the genetic code, the DNA, of people in areas of high levels of infections can alter over time, through natural selection, to obviate some of the worse effects of severe infections.  It happens in the animal kingdom, and it happened in our distant past.  It doesn’t always work very well, and sometimes acquiring a resistance to one disease, usually an overwhelming long term infection, predisposes you to another quite separate one.  

The ones I heard of when I was  a young medic, were the diseases of the  red blood cells, the haemoglobinopathies, that existed because one copy of the gene protected against malaria, which was (and still is) a real killer, especially of children.  The flip side of that was that two copies of that gene would cause a separate, extremely severe disease, sickle cell disease.  The gene survived because most people had only one copy of the gene and survived longer than those without it.  The few people with two copies were collateral damage as it were, in a genetic sense.  Sickle cell disease is a very unpleasant disease which can also kill, but fewer people, because far fewer people had two copies.  Other such pairings were diseases such as cholera and cystic fibrosis, tuberculosis and Tay-Sachs disease, and many others.  Sometimes we discover some lucky people who have developed a resistance to specific diseases that other people don’t have, and we are always looking out for such people so that we can possibly learn to tweak or target biochemical changes in order to  protect more people. Some mutations also can cause an increase in susceptibility to illness, immunodeficiency, and cause a lot of ill health.  In all these cases it is worth doing research to start looking for cures for difficult infections such as HIV rabies and Ebola, as well as Covid-19. 

The interesting areas for me are those concerning targeted treatment of certain cancers, which is underpinned by carefully controlled clinical trials, and has had a lot of success in improving survival rates in ovarian cancers and many other diseases.  Your DNA can be explored and doctors can work out which treatment is likely to work best for you. 

And of course finally to Covid-19.  What do we know about the genetic reasons for susceptibility to Covid-19?  It is obvious there are some; we have all heard of families which have been struck down with Covid, with brothers dying side by side, and several members of the same family in intensive care as the virus rips through communities.  Many of these families have been from BAME communities.  But it is complicated. Recently, scientists have discovered genes that can affect Covid-19, which came originally from Neanderthals – those hominids closely related to us who died out 40,000 years ago.  We now know that their genes did not die out completely because some of them  interacted with modern humans, had sex with them, and had children.  Their descendants lived all over Europe and Asia and so the people there now have an average of 2% of their genes which originally came from Neanderthals, and overall, over half the Neanderthal  genome still survives.  This immediately introduces a disparity in modern human DNA, as Neanderthal ancestors left Africa long before modern humans came into existence and they were isolated outside Africa for thousands of years.  They never made it back to Africa, and so any genes that changed through mutations to help them survive the challenges of a cold northern environment are not going to appear in modern Africans, apart from the ones who have an admixture of non-African genes. 

We know that changes to the Neanderthal genome that survive have disproportionally affected the immune system, and  this may be related to the fact that the Neanderthals came from a small population, often interbreeding with close relatives. This is known to cause  susceptibility to infection in infants, and genes to protect themselves against these infections had an advantage.  It is extremely likely that they passed some of these on to modern humans.  One of these may be a Neanderthal haplotype (sequence of genes), found on chromosome 12.  Its effect is protective, as having a single copy is associated with a 22% lower chance of critical illness in covid-19. Between 25% and 35% of the population of Eurasia carry at least one copy. In Vietnam and eastern China more than half the population are carriers.  It is not found in sub-Saharan Africa. However, Americans of mostly African descent can carry the genes if they have some Eurasian ancestry as well.  It seems to reduce the spread of viruses such as Sars-CoV-2 by causing infected cells to self-destruct more easily, and has been around for a while as it also provides some protection against viruses such as West Nile virus.

But there is also a genetic variation which can cause more severe disease. This sequence is found on chromosome 3, and also came from Neanderthals originally.  A person with it has double the chance of needing intensive care.  If such a person has 2 copies – one on each chromosome –  the risk of severe disease is even greater.  The gene-sequence is most common among people of South Asian descent, with 63% of the population of Bangladesh carrying at least one copy; and among Europeans, where the prevalence is around 16%.  As expected, it is virtually absent from Africa.  More strikingly, it is also very rare in large swathes of eastern Asia.  It appears to make the disease worse  by increasing the production of cytokines, the defensive system that  can go into overdrive and cause severe disease.  An overly aggressive immune response is one mechanism by which covid-19 kills.  This may not be the whole story though, as in Bangladesh despite the prevalence of the harmful haplotype, the official covid-19 death rate in Bangladesh is just 5.1 per 100,000, lower than in many countries without the gene sequence.  And in sub-Saharan Africa, despite not getting the protective genes from Neanderthals, the population has not suffered to the same extent as Europeans and south Asians, and this shows that environmental factors must still be very important indeed.

Pulling everything together, therefore we can explain why some Bangladeshi and other South Asian men  and women in Britain have been so badly affected.  They are not only more likely to work in public-facing jobs, to be obese, suffer from diabetes and hypertension, but they may also be more likely to carry this deleterious gene sequence.  They may live in poorer neighbourhoods, but I remember being shocked at the beginning of the pandemic when several accounts in the medical press told of Asian doctors in their late 60’s and early 70’s, who had worked all their lives for the NHS, and given great service, but then died quickly with Covid after returning to the front line. They were motivated by a desire to help, but they and their families cannot have imagined  that they would have been at such great risk, as they were well off and lived healthy lives.  If only we could have known then what we know now. 

Long life, Pandemics and Populations

Do you want to live a longer life in good health?  I have  myself written quite a few articles on ageing (such as “Age doesn’t come by itself”) in this blog, so when I read about this on a popular website recently, my interest was piqued by such a question.  Who doesn’t want to live longer in good health (or even otherwise)?  Only those who are so ill that they see no future, or people with incurable depression, perhaps.  But anyone enjoying good health and a satisfying life usually wants to live a longer life in good health, if it is possible.

In fact the item in question was, as you might expect, a fulsome exposition of wondrous scientific advances just around the corner that are going to lead to breakthroughs which will extend people’s lifespans considerably with no downsides. On looking at the detail of these, you can see that they are all tiny steps forward in understanding the ageing process, such as in gene therapy, plasmid delivery, faecal microbiota transplantation, regrowing the thymus gland  and many others.They may all be genuine attempts to prolong life but the main emphasis seemed to be on getting private finance to support these initiatives, and it is unlikely that the true timescales of doing this will be communicated to those willing to part with their cash. 

A better way of trying to improve the way we age would be to use drugs which have been in use for some time, and so don’t need large amounts of money to develop, and see if they will work. There are two examples which are being looked at. The first is a very old drug; one so old that GPs like myself  were using it back in the 70’s.  It is called metformin, and is still in use today as a very important treatment for type 2 diabetes as well as several other conditions.  Researchers found that diabetic people who had been using it for decades had lower death rates overall (all-cause  mortality)  than their counterparts who had never used it, (1) despite their diabetes which usually increases death rates from various causes.  They had fewer cancer diagnoses, and a lower rate of cardiovascular diseases than diabetics who did not take metformin.  So the authors of this article considered that metformin could be extending lifespans and healths by acting as a geroprotective agent, suppressing the inflammation caused by senescent cells which are dying.

Another newer drug, rapamycin, an immunosuppressant, can increase lifespan in mice by about 10%,  and this is thought to be because it inhibits a pathway called mTOR which is known to be involved with the ageing process, and has an effect on things like liver and heart degeneration(2). It has been shown to  slow the progression of Alzheimer’s and Huntingdon’s disease, and in older people can dramatically improve immune function and vaccination responses – something which might be very useful right now, in the middle of a pandemic which is actively going to reduce human life expectancy by at least a year, it is said. 

So perhaps we shouldn’t be looking at extending life just now, and our priority has to be to deal with the very pressing needs of this most serious health to human health in a century. 

Fortunately the full extent of science to tackle these challenges has been exceptional, with the rapid development of several successful vaccines, some very helpful treatments, and an enhanced understanding of the importance of good public health systems all over the world.  What has been amazing is how much scientists have discovered about this novel illness in such a short time.  It now appears that that it is possible to work out who is most likely to suffer badly from this disease, and in what way, separating out the many who are not going to have anything more than a minor self-limiting illness.  Firstly, looking the initial few days of the illness, it is found that the more distinct symptoms you have, the more likely you are to go on to get serious disease, and so should seek medical help early.  The details are on the ZOE website (3), which Prof Tim Specter is running with great success.  Some  of the most distressing stories of early deaths from covid-19 have been how so many, often younger people, were admitted too late in their illness to be saved.  This appeared sometimes to be the result of the algorithms used by the emergency 111 service, which told people to stay at home even though they were actually suffering from lung failure, because it was not realised that people could be suffering from very low oxygen levels without becoming breathless.  (The symptom of breathlessness is actually more dependent on carbon dioxide levels being high than oxygen levels being low.)  The use of pulse oximeters, which measure your oxygen saturation levels, at home  would have allowed these people to survive  by  encouraging early admission to hospital.  So if a patient early in the illness  develops multiple symptoms they should contact a doctor and request a pulse oximeter so that they can  check on their oxygen levels at home.

Algorithms and  prediction models such as ISARIC4C (4) are also being developed from huge amounts of data collected by health systems which will predict the risk of a person already in hospital with Covid going on to develop serious disease.  This would also help hospitals cope with the surge of patients.  In addition, scientists are now able to tell from blood tests at the beginning of the illness whether a person’s immune system is likely to go into overdrive and so cause serious disease. (5) So, again, early medical intervention might be able to stop the process happening.  The death toll in the near future might come down quite markedly. 

So, looking ahead to a period when most people either have been immunised, or have had the disease with few ill effects, what can we say about how life will have been changed?   Will it be enough to get us back to the position when we can genuinely look forward to living longer and more productive lives  far into the future? Well, no. This pandemic has changed our lives forever…

Firstly it is plain that covid-19 will not have gone away.  It will still be there, mutating regularly, but perhaps not so frequently because there will be less of it, circulating at a low level in the background, but still capable of causing severe spikes at times, especially in the winter.  The particular problem with this virus is that it manages to infect other people while the infecting person is still going about his business, unaware that he is infected.  This is unusual, and means it is no disadvantage to the survival of the virus if its hosts are ultimately killed, as the virus has already spread.  So it is less likely that the virus will mutate to cause less serious illness, as other coronaviruses have done. 

And how much will the at-risk elderly change their lifestyles?  The latest guidance is that those who are very vulnerable will still have to self-isolate, even when immunised, far into the future.  Only when it is clear that immunization totally prevents severe illness and death can we really say the risk is small enough to go out in freedom.  Most older people will probably decide to get slowly back to normal  and accept the extra risk.  But I know many people in their seventies  and older who will have effectively stayed in their homes  for over a year when this is all over, and they may  find it hard to go out without worry.  They have often been able to occupy their time with solitary pastimes such as gardening, and reading, and to socialize

only on Zoom and the telephone, and some may no longer want to go back to the old times of mindless socialising and materialism (they think).

Likewise, younger people working from home may prefer this if the alternative is to go back to those dreadful long commutes, although for many women this has resulted in far more work and responsibilities within the home.  It would be nice to think that workplaces will be flexible in making the better use of the change in work patterns for a better outcome for the worker. 

The best news would be if working age people could get back to powering the economy so that some of the poverty and stress that the disadvantaged have suffered can be alleviated.  We look forward to people mixing again with our social and cultural activities like music, drama, and hospitality getting back to normal. 

We can be sure that all societies will be changed for ever by this pandemic.   What is now clear is that we are not all in this together. The inequality that has developed in the last 30 or so years of the current models of socioeconomic development has ensured that much of the older generation – the wealthy property-owning retired – are enabled to better survive and thrive as they have the means to self-protect, while the people they depend on for their everyday needs – the key workers in power supply industries, water, food production, sanitation as well as healthcare – are the ones who are more at risk of death.  Often there is a racial element, in that these workers are disproportionately from immigrant BAME or other disadvantaged backgrounds.  One can envisage a situation that will exacerbate the generation divide, so that the overall standard of living of the young will decline quite rapidly, while the older cohorts will continue to be sustained by their arguably unfair economic advantages. 

On the wider conclusions that may be drawn, health systems and social care need to be re-designed.  Transport systems hopefully can be largely renovated and re-designed to fit our new patterns, and similarly hospitality, catering, and hotels, will change location to where people have moved to, out of city centres, and open spaces will be developed further now that we have come to understand the need for them.  

These are changes we could easily make if the will is there.  But what about the bigger ecological questions of sustainable living, which haven’t gone away?  Are we better able to understand that the way of life we had is quickly going to lead to a severe breakdown in our climate and alter our way of life for ever? 

This  pandemic is actually well overdue.  Scientists have been warning of serious pandemics for over twenty years, and the successful overcoming of the MERS and SARS-1 threats was only a taster.  There are other diseases too that are being watched.  One, called NIPAH, has a death rate above 40%, and that would really put everything in jeopardy.(6)  Fruit bats are the natural host of this coronavirus and there is no treatment. 

The number of humans on this planet now, compared with two centuries ago, shows exponential growth, and this is something that we are perhaps better able to understand, thanks to our being confronted with the exponential growth of this virus.  Exponential growth is the hallmark of plagues, and we can now see that humanity is getting to the peak of its growth.  We are likely to encounter more plagues after this one, because we are destabilising the ecology, the life support we need from other plants and animals, and the very fabric of our planet.  There will undoubtedly be more pandemics.  Scientists  are particularly concerned with those that arise from bats, as did SARS-CoV-2  which causes Covid-19.  Bats are known to harbour many coronaviruses, and in tropical regions such as in Asia the viruses flourish.  Further population growth and encroachment of people into these previously secluded places increases the risk that viruses will cross over into people.  It isn’t the fault of the bats; left alone, everything would be fine.  We need to curb the population growth and accompanying indefinite (and impossible) consumption increases that are causing this problem. 

It was interesting to see in the lecture that prompted this article (on prolonging life) that overpopulation was dismissed out of hand.  They pointed to the fact that the world’s population is correcting itself as the birth rate falls in most developed countries.  While this is of course something to be welcomed, it does not solve the problem as these people are already on the  planet and enjoying a long lifespan, which could result in the ecology going over the tipping point, with extinctions of plants and animals continuing inexorably; and we shall pollute the land, the oceans and our atmospheres; a terrible legacy for our children and grandchildren.

The effects of a pandemic on overall population will depend on what age group the pandemic targets. The well known Black Death pandemics in the 14th century killed so many young workers (up to 60% of the population died) that eventually the remaining ones were enabled to put an end to feudalism.  This  ultimately led to a much improved life for generations to come, but that was very unusual.  During pandemics, availability of contraception is often reduced so that, especially with this one where young childbearing people are not affected very much, there may be a considerable rise in population even as life expectancy falls.  And after pandemics, the birth rate often rises, as optimism returns and people feel safe enough to reproduce, so the net result is that  the exponential rise continues unchecked after a brief blip. 

So the idea that humanity can look forward to living a longer life in good health is a pipe dream.   Once the worst of this pandemic is over, we ought not to try to get back to where we were.  That was a path that threatened destruction.  And it would be even more destructive if we thought that science could engineer yet more years of healthy living for the few extremely wealthy elderly who could afford to finance it.  This may not happen this time if the downsides of overpopulation come upon us quickly, but even so we need to be on our guard.  The economic system we have now is similar to a giant Ponzi scheme, in which a growing population consumes more and more at the expense of future ecologies to the eventual point of collapse. There may be authoritarian leaders who do not want the population to fall, as that would reduce their power in their terms and leave them with a lowered capacity for wealth generation to the benefit of their small class of collaborators.  I hope more people will understand the risks we are taking with our world, and  finally act to ensure everyone’s chance of a longer life is taken into account. 

1. https://pubmed.ncbi.nlm.nih.gov/28802803/  

2. https://pubmed.ncbi.nlm.nih.gov/19587680/

3. ZOE website https://covid.joinzoe.com-19

4. ISARIC4C *https://www.doctors.net.uk/blog/opinions/2021/01/25/big-data-can-help-doctors-predict-which-covid-patients-will-become-seriously-ill/

6. IPAH,https://www.bbc.com/future/article/20210106-nipah-virus-how-bats-could-cause-the-next-pandemic?fbclid=IwAR0NXW6G9M0ROeHjId8Je46qOS9oLFVVwrFc9EAjbzq_Uh6DXPMmW9F4ws4

5. Blood tests high CRP and ferritin levels may be correlated with more severe illness;https://www.bbc.com/future/article/20200505-cytokine-storms-when-the-body-attacks-itself

Covid-19 – lockdowns go on and on. What should we do?

The decision to impose a second lockdown in England is polarising people to a much greater extent than it did in March, as it seems obvious that this virus is not going away and we are going to have to live with it for a very long time.
There are now two main opposing camps; those who are for saving as many lives as possible, at all costs to the economy; and those who think the best way of increasing overall well-being is to keep the economy running, even if more people die. The second group think that politicians are prioritising saving lives (especially of elderly very sick people) at the cost of ruining the economy and blighting the lives of the young, especially the poor. Both are intrinsically worthy standpoints. How are we to be informed by science as to which is the better way forward?

To answer that, we have to assume that the longer the pandemic goes on, then the more likely we are to come up with both a good vaccine and good treatment to minimize the dreadful effects the virus can have on a minority of people. There is good reason to be hopeful here. As I have written before, I think good treatments are more important than a vaccine because that would attack the main problem – people becoming very ill, needing very high tech expensive medicine which overloads any health service – directly. Whereas a vaccine would depend on how well it protected people and what proportion would actually accept it. Treatments such as steroids, monoclonal antibodies and antivirals are coming on stream very quickly and they are all very hopeful. In fact a paper pre-published recently (12 4C) indicated that there has been at least a 10% mortality improvement in people admitted to critical care with COVID-19 in England, from 1st March until 30th May,

I have summarised my arguments on the question which is the best way forward in the next few pages. The references and further explanations following in an appendix so that people can look up further details as they see fit.


Covid-19 is a novel virus with unusual features. It mostly causes a mild illness, and can even be asymptomatic so that people don’t know they have it. But it also has the capacity to cause damaging and fatal illness in a minority of people who have underlying vulnerabilities; they are very elderly or suffer from certain illnesses which the virus has evolved to target -(1 7F) obesity, diabetes, hypertension, severe respiratory disease, and any condition where the immune system is compromised, such as cancer, and blood diseases. The illness that the virus causes is a multi-system disorder that takes a huge effort by healthcare staff to treat, and a sizeable proportion (now reducing) will not survive. This is a big problem because the load on any health service is impossible to sustain with existing human and other resources.* It would be the same as if meningococcal meningitis were ripping through the community, rather than occurring in its usual sporadic way.

The tried and trusted methods of managing any pandemic are test and trace for each individual case and restrictions of movement and even lockdown. But this will always entail huge downsides on the ability of people to earn their living and trade and distribute goods.

So I wanted to find a measure of comparing the benefits of saving as many lives as possible against the downsides (losses) of each individual person in a given community – a country, a large province, or similar. To do that I found a measure, WELLBYs, 2 which works out the average wellbeing of the total population in that community (involving economic and personal factors such as the effect of sudden unemployment, poverty, depression, loneliness; and other by-products of the situation or its management such as losses due to people not being treated with Covid using up all the medical manpower, or benefits such as reduced pollution under lockdown.

I found two studies using this measure, both done in late Spring 2020. The first 5 was done in Victoria in Australia, which showed that lockdown (at the time when it was being considered) would be three times as economically damaging as letting the virus take its course. The other was a forecast of when to relax the lockdown, using the same methodology. It too indicated that the sooner the better.

These two studies relied on a theory which was popular at the time, that letting the virus spread would soon induce “herd immunity”* 7 as more and more people became immune, while the the vulnerable could be isolated and protected. It has been promoted especially by those who value liberty and who point to the fact that the economic hardships tend to be concentrated in poorer communities.*

However this theory, though earlier supported by many governments, was soon found to have serious consequences. The first was the fact that in practice the the vulnerable could not be shielded, and died in large numbers.6. Secondly, even though many of these had never received any medical care during their illness in their care homes, or in their own homes, the medical services were still overwhelmed or at the point of being overwhelmed. 9 7F Staff were very hard hit, and without PPE many of them died. This was very different from flu where medical staff are confident of being able to continue despite a huge increase in workload. Thirdly,8 8G there was (and remains) the problem that the virus is far more infectious than originally thought, and spreads through droplets and fine particles (aerosols), often in living rooms at home as well as in large gatherings, and also is often spread without the person who has it knowing they are infected, so that they cannot take precautions.

So looking back on the original calculations in Australia and the UK, and recalculating, you would find that the inability to shield would increase the number of deaths excessively. Even though many of these deaths are given a low rating in WELLBY terms because there are fewer life years lost (the average age of Covid-19 death is about 80, close to general life expectancy), this still bumps up the loss side of the equation to high levels. Also the effects of health services collapse, with staff leaving, demoralised and ill, and behavioural changes in people fearful of getting the virus, would have a huge impact on the wellbeing of the population at large, and aggravate unemployment and poverty considerably. The ability of any state or government to cushion these effects would soon run out. I don’t think anybody has countenanced , nor should countenance the idea that we should choose not to treat people who wish to live.

Those are the calculations that spurred on nearly all governments in Europe, and partly in the Americas, to impose lockdowns and restrictions in various ways. They were acknowledged even by many economists.* However it was recognised that this could only be a stopgap measure as the costs in monetary terms would climb relentlessly. Governments are hoping for better treatments and the introduction of vaccines soon as there will come a time when insufficient economic activity will become financially insupportable for the population. Many people think that this time has already come, but economic analysis 3 Bis still on the side of trying to “flatten the curve”, as they say.

Do lockdowns make a difference? 2 7F Of course they do, but they can only be temporary. Their success depends on compliance in a population – if it is very good as it has been in Sweden, and also in the UK just before the March lockdown when most people saw the need for it, then the is very little need for coercion from governments. That is why Sweden 11 6E did well early on although it is now taking a hit as big as any. The objections to lockdowns comes mainly from the libertarian wing of human thinking. If you are philosophically of the opinion that people should not be compelled to do things against their will, even for the greater public benefit, then these arguments will not convince you. I am writing really for those who think lockdowns should be considered as part of the armamentarium of people concerned with overall public health.

Nobody living now has ever been in this situation before. It follows fifty or more years of medical progress, so that many people are in “medicated survival” – living good productive lives but dependent on medication (often promoted by drug firms, and sometimes caused by poor quality food and lack of exercise.) So one might think this crisis was bound to come soon or later, apart from the increase in the risk of pandemics through encroachment on ecological systems the world over. And it begs the question – should we all expect to live so long? We have imbibed the religious “sanctity of life” belief, which means we deny death if we possibly can. Will this pandemic lead to a feeling that perhaps in an overpopulated world we should be allowed to make our own decisions of how we would wish our lives to end, rather than let our deaths be dictated by pandemics? One more thought – over 20% of deaths have occurred in people with Alzheimers disease. Given that this cruel disease strips people of their personalities and causes great distress when they are deprived of familiar human contact, is it wise to prolong the agony? Is there a negative QALY – when living is worse than dying? If there were, the position of some of those with Alzheimers today might qualify.
Personally, if I were in a care home with Alzheimers I would rather see my family even though I might get Covid and die from it. In fact I would actively prefer to go that way than to let Alzheimers take its course.


Appendix.
1. 7*Countries worse affected by Covid were found to be characterised by higher obesity, high median population age, and longer time before border closures from the first reported case. Lancet study.
2. 7*Rapid border closures, full lockdowns, and wide-spread testing were not associated with COVID-19 mortality per million people.* Full lockdowns and high scores on the global health security scale for risk environment were significantly associated with increased patient recovery rates. So it is clear that countries vary considerably in their predisposition to having a lot of people suffering from Covid, and lockdowns do not necessarily help much overall (it all depends on at what stage lockdowns are put enacted). But that doesn’t tell you how to weigh up the benefits and harms of restrictions and lockdowns in specific circumstances.
3.7 Reduced income spread was found to reduce mortality and the number of critical cases.
4. WELLBYs 2 are a way of quantifying the good and bad effects of policy choices on all aspects of total human wellbeing, not only death but health, wealth, and satisfaction due to reasonable employment and social life, and project forward the effects of the two main competing viewpoints in the change in “years of human wellbeing” resulting from the policy. It begins with a question – “Overall, how satisfied are you with your life these days?” It is a measure of subjective wellbeing, how people feel about their lives, measured on a 10 point scale, with 0 being very dissatisfied and 10 being totally satisfied. It has been refined over the last 25 years so that it is now well-correlated with other measures and has strong predictive powers—it is, for example, one of the best predictors of life-expectancy. It is also reliable—people give consistent answers when retested. It is used extensively in many countries such as New Zealand and Australia to inform politicians and government officials on what course to take.
5. WELLBYs 5 cover a wide range of scenarios, so that for instance, a 10% change in income alters wellbeing by around 0.02 points (on the 0-10 scale). Sudden unemployment causes a drop in the well being score of 0.7 points. Depression causes a drop of There are tables that can give results for a whole range of outcomes. You then add a time dimension such as how long this event lasts, or a set endpoint, in this case a year, to give the change in wellbeing-years (or WELLBY’s).  This is similar to the concept of QALY’s (Quality-Adjusted Life-Years) and Disability-Adjusted Life-Years (DALYs) which are used by NICE to work out whether a new expensive drug treatment should be licensed in this country or not. The WELLBY’s concept widens this considerably, and 6 WELLBY’s = 1 Daly. At the moment average life satisfaction in UK is 7.5 (0-10 scale). If a person dies one year earlier the loss is 7.5. If they die 10 years earlier that is a loss of 75 WELLBYs.
6. Shielding. In March 2020 vulnerable people were told to “shield” or cocoon themselves, and unfortunately this proved disastrous, as cases ravaged care homes and households.The result was that the UK now has one of the highest death rates in the world. The fact is, it can’t be done. People already disabled enough to need care have to have actual people doing the caring, either in their own homes or in care homes. Those carers are low paid, and are often freelance for various companies so that they are in and out of people’s homes and care homes all the time. They frequently themselves had to isolate. The very expensive care homes were able to hold on to their staff by getting them to live in and not mix outside the home. But carers have families, and most cannot do that. Multigenerational homes in poor neighbourhoods cannot shield their vulnerable. At the beginning of the epidemic patients already in hospital who could be discharged were sent to nursing homes, but they weren’t tested to exclude covid infection. So they passed Covid on in a closed environment, and over 22,000 died. And where else could they be sent? If back home (often not possible medically) then they might spread the virus in the community; if another public step-down facility, the same would apply. Add the huge numbers of younger, working people with diabetes, hypertension, COPD, and asthma, who really can’t shield, you can see that this isn’t a strategy at all.
7. Herd Immunity. It was thought that there would be herd immunity if the disease was allowed to spread in the community willy-nilly. But as time has gone on it has become clear that herd immunity will never be reached with covid, primarily because immunity only lasts a matter of months, and then you can get it again. No country has got even near 60% immunity yet. Immunity in the elderly is always very weak because their immune systems are weaker. Herd immunity is never going to work for this. It has never been achieved for any disease without vaccination and you also need lifelong immunity (as you can get with measles). Vaccination is also quite problematic because immunity with coronaviruses tends to be weak and not to last long, and we know that some people will be reluctant to accept it.
8. Spread of virus. 8 We now understand that Covid spreads mainly by aerosols, very tiny particles emitted during talking and singing, as well as coughing and sneezing. These stay in the air for many hours unless the ventilation is good. Unfortunately, people can be infectious some days before they know they have symptoms, so they can spread the virus easily amongst family and friends, where social distancing is not possible. Mask wearing helps a lot, but people find it difficult to tolerate for long periods. So, transmission happens in people’s homes, in workplaces, everywhere where people congregate. Restrictions are well tolerated mainly by those who consider themselves at risk, but young healthy people have very little incentive to follow them, and lots of disincentives, such as the need to earn a living. Most people are gregarious and really enjoy other people’s company. It is a big ask if you aren’t likely to suffer from the consequences.
9. Health Service But the real killer for the idea that you can let the pandemic spread freely when cases rise, is that health services can be overwhelmed. We have to have a health service which will be able to treat everybody during and after the worst of the pandemic. I think that people who don’t have a link to the acute healthcare sector have no idea of the strain on the medical workforce in the last six months. Health workers are dreading the winter with intense anxiety as though something bad is going to happen, and they will have to risk their and their family’s lives again. The problem seems to be that, unlike some other infections, the severity of the covid illness is often dose dependent. If you are sitting in a room for several hours with an infected person, but do not get very close and there is no loud talking or shouting, then you may well get infected, but it may be a mild case of the disease. But if you are exposed to high levels of the virus day in day out in a hospital, you may well get very severely ill and risk death. Many of my friends towards the end of their careers are retiring early and others are looking to change to something safer. It is absolutely nothing like the flu. I worked through many flu epidemics, and got it through work, and it never bothered me or anyone else. Maybe some older doctors felt they had had enough, but generally speaking it wasn’t anything we thought about. When people really consider whether they would risk overloading the health services so that so many staff leave or get ill that you cannot guarantee that you can get timely treatment for anything, most people do think twice.
10 3 B Economists. “A comprehensive policy response to the coronavirus will involve tolerating a very large contraction in economic activity until the spread of infections has dropped significantly.
52% agree strongly 36% agree 5% uncertain
Abandoning severe lockdowns at a time when the likelihood of a resurgence in infections remains high will lead to greater total economic damage than sustaining the lockdowns to eliminate the resurgence risk.
41% agree strongly 39% agree 14% uncertain
Optimally, the government would invest more than it is currently doing in expanding treatment capacity through steps such as building temporary hospitals, accelerating testing, making more masks and ventilators, and providing financial incentives for the production of a successful vaccine.
66% agree strongly 27% agree 0% uncertain.”
11. 6E Sweden. If you look at excess mortality, considered to be a very good pointer to actual covid deaths (there are so many systems of counting deaths from covid that you can’t compare one country’s performance on their own figures), Sweden is faring well when compared to England and Spain, and only doing slightly worse than Switzerland, but much worse than neighbouring Norway or Denmark. And on the economy, Swedes’ decision to avoid going outside or spending – regardless of government mandate – meant that the expected advantage was not that great. Sweden is indeed a special case, but the picture does not lead to a conclusion that lockdowns are not a sensible thing to do;
12. 4C. On future treatments; there is better news. This is a fluid ever changing situation, and the equations in the studies above can be more hopeful in the near future. The first is that the longer the pandemic goes on, then the more likely we are to come up with both a good vaccine and good treatment to minimise the severe effects the virus can have on a minority of people. As I have written before, I think good treatments are more important than a vaccine (which would depend on how well it protected people and what proportion would actually accept it) because treatments would attack the main problem directly – people becoming very ill, needing very high tech, expensive medicine which overloads any health service. There is news now that the death rate and average length of stay in hospital with Covid has improved by 10% or more over people admitted to critical care with COVID-19 in England, from 1st March until 30th May, and this is continuing to improve, because of a much better understanding of how to treat patients. with oxygen and CPAP rather than ventilation, and also better drugs. Treatments such as steroids, monoclonal antibodies and antivirals are coming on stream very quickly and they are all very hopeful.

So let us assume that in six months time treatment will be much better. It seems reasonable to try to save as many lives as possible by restricting people’s activities but keeping in mind and quantifying the adverse effects, so that as soon as possible, when the two side are more equally balanced the restrictions can be easily removed.


References
2A https://blogs.bmj.com/bmj/2020/09/24/taking-a-wellbeing-years-approach-to-policy-3
choice BMJ
3B/https://www.igmchicago.org/economic-outlook-survey/ Chicago Booth
2Ahttps://www.bmj.com/content/369/bmj.m1874

4C https://www.nytimes.com/2020/10/29/health/Covid-survival-rates.html?action=click&campaign_id=154&emc=edit_cb_20201029&instance_id=23621&module=RelatedLinks&nl=coronavirus-briefing&pgtype=Article&regi_id=137171699&segment_id=42812&te=1&user_id=8889c0932a8d117d281ebd203a6a5cdf
4Chttps://www.medrxiv.org/content/10.1101/2020.07.30.20165134v2

https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers Australia

5Dhttps://parliament.vic.gov.au/images/stories/committees/paec/COVID-19_Inquiry/Tabled_Documents_Round_2/CBA_Covid_Gigi_Foster.pdf
6Ehttps://www1.racgp.org.au/newsgp/gp-opinion/was-the-swedish-approach-to-covid-19-really-a-mist
8Ghttps://english.elpais.com/society/2020-10-28/a-room-a-bar-and-a-class-how-the-coronavirus-is-spread-through-the-air.html?ssm=TW_CC&emailType=Newsletter
7Fhttps://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30208-X/fulltext
6E https://reason.com/2020/09/16/how-much-difference-do-covid-19-lockdowns-make/ Sweden
6E https://www1.racgp.org.au/newsgp/gp-opinion/was-the-swedish-approach-to-covid-19-really-a-mist