25th July 2020

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Why the scaremongering about COVID?

This week we were told that, in the UK at least, anyone who had a positive COVID test who then died – of anything – would be recorded as dying of COVID. No matter when they die.

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Even more weird is the fact that there does not seem to be any time limit to this. So, you could test positive in March 2020, then die in March 2040, and still be recorded as dying of COVID. I doubt this will happen, but it could.

To be honest I have known something very strange has been going on with the UK data for some time. In that, the UK has not provided any figures on how many people have recovered from COVID. In almost all countries, figures are provided on the total number of cased, the total number of deaths, the number of active cases and the number who have recovered.

In the US for example, there have been just over three and a half million cases, a hundred and forty thousand deaths and one point seven million people have officially recovered. In the UK, there have been nearly three hundred thousand cases, forty-five thousand deaths – and no recorded recoveries.

In short, in the UK, you cannot ever recover from COVID. Once you’ve got it, that’s it, you’ve got it. This anomaly has been reported on before. Here for instance, from the Guardian in June.

‘Britain is an outlier internationally in not reporting the number of people who have recovered from Covid-19 alongside statistics on deaths and numbers of identified cases.’ ¹

Why would anyone want to do this? You would think the Government would be pulling out all the stops to decrease the number of recorded COVID deaths. Especially as the UK is sitting in a pretty dismal place on the international comparison charts. Why deliberately inflate your figures.

However, it is not just the UK that is hyping up COVID deaths. A reader of my blog sent me an analysis of the WHO advice on death certification, which seems accurate. In his analysis:

1. If you die of anything and they suspect you might have it, with no tests and perhaps just because everyone else is assumed to have it, then COVID-19 goes on the death certificate as primary cause of death. Broadly speaking… unless the patient dies of something that is sudden and cannot be a long-term comorbidity.
2. If you have the same symptoms as flu or pneumonia you must be put down as COVID19 and not due to an influenza type illness.
3. Any certificates that are in any way erroneous with regard to the above must be recoded to conform.
4. Any COVID-19 codes that are wrong should not be fixed in any circumstances

To me looks like a recipe for systematic over inflation of death counts, designed to disallow or circumvent clinical judgement ².

In the US Dr Scott Jensen, who is a physician, and a member of the Minnesota senate, has been notified by the board of medical practice in Minnesota that he is being investigated for public statements he has made.

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For pointing out the over-reporting of COVID-19 deaths and daring to claim that COVID-19 is no worse than a bad flu season, he could be struck off the medical register. You can see Dr Jensen discussing this YouTube ³.

So, it seems that, around the world the same things are being seen. A seemingly coordinated attempt to vastly over-inflate the number of deaths caused by COVID-19, and to drive home how deadly it is.

For example, a few days ago, a new story hit the headlines in the UK, warning of hundreds of thousands of deaths this winter.

‘The UK could see about 120,000 new coronavirus deaths in a second wave of infections this winter, scientists say.

Asked to model a “reasonable” worst-case scenario, they suggest a range between 24,500 and 251,000 of virus-related deaths in hospitals alone, peaking in January and February.’ ⁴

Where did this come from? It was a model, using exactly the same assumptions as that created by Prof Neil Ferguson from Imperial College London in March. The one that warned of five hundred thousand deaths in the UK. Only out by a factor of ten. Probably far more, because many of the deaths recorded as due to COVID have been, simply, wrong.

How certain was their prediction of 120,000 deaths? Professor Stephen Holgate, who chaired the report then said. ‘This is not a prediction – but it is a possibility.’ A possibility… Perhaps it should be published in the Journal of possibility-based medicine. A journal where you simply make up facts, then see how many people run around in sheer terror.

What is now happening is extremely disturbing. COVID has certainly been a serious disease, but the flu epidemics of 1957 and 1967 were just as bad, if not worse, with regard to total fatalities. They were both over a million, and COVID has a long way to go to match that ⁵

In addition, in those epidemics far more younger people died. With COVID, if you are under fifteen, the chance of dying of COVID is around one in two million, which is three times less than the chance of being struck by lightning ⁶.

Across Europe, the excess in deaths has simply disappeared ⁷. There is no increased mortality anywhere to be seen. Whilst we are told about outbreaks of COVID deaths in various cities, the rate of new infection in these ‘outbreaks’ is less than one in a thousand. Which is not really an outbreak at all.

Despite this, mask wearing is to be mandatory. When COVID-19 took off, no-one was wearing a mask in my unit, unless they were helping a patient, and there was no social distancing between staff. Now the trust has decreed masks must be worn at all time, and social distancing is being ruthlessly enforced. A bell now rings, and we must wipe of all surfaces in front of us…

The reality is that COVID-19 has all but gone in the UK and Europe. The slow, but inexorable rise in deaths in the UK is being driven by the fact that anyone who has ever had a positive COVID-19 test, who dies, is recorded as dying of COVID.

Yet, as COVID-19 disappears, mask wearing and social distancing is being enforced as never before, and the prospect of a deadly second wave is being waved like a black shroud, with warnings of hundreds of thousands of deaths to come.

A biomedical scientist in the UK sent me an e-mail two days ago, about the testing they had done.

‘In the week 9th – 16th July we carried out 2800 PCR tests (across three different platforms: mainly on the Hologic Panther, but some on the Cepheid GeneXpert and Biomerieux BioFire) and had only 4 positives. These 4 positives were all patients who had previously tested positive. We had NO new cases, and after checking back a few weeks, the only positives we have had have been from repeat swabs from these same 4 patients – they were almost acting like QC samples to ensure that our tests were actually working properly!’

Two thousand eight hundred tests and none positive. This scientist contacted other laboratories, and they were seeing the same things. ‘I have contacted a couple of nearby NHS Pathology Labs and they reported the same findings as us: zero or near zero new cases for several weeks.’

What on earth is going on?

1: http://www.theguardian.com/world/2020/jun/18/health-experts-criticise-uk-failure-track-recovered-covid-19-cases

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3: http://www.youtube.com/watch?v=KpGeRFK0tao

4: http://www.bbc.co.uk/news/health-53392148

5: http://www.webmd.com/cold-and-flu/what-are-epidemics-pandemics-outbreaks#3.

6: http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsinvolvingcovid19englandandwales/deathsoccurringinjune2020

7: http://www.euromomo.eu/graphs-and-maps#z-scores-by-country

9th July 2020

A guest article

I was sent this piece on Vitamin D and COVID by a reader of this blog. I thought it was very good and asked them if they minded me posting it. They said fine, but they wish to remain anonymous. Not everyone likes the glare of publicity – with all the attending Trolling and insults that inevitably follow [you should read my in-box sometime].

Season, Latitude, and COVID-19 Severity

Here is a coronavirus puzzle for you to ponder.  For context, let’s look at how many people have died of COVID-19 in the USA (as of mid-June).  Websites give different totals, but it’s around 120,000, or about 360 per million of population.  So how many died in Australia?  102.  How many died in New Zealand?  22.  In both countries, the death rate is 4 per million.  That is an extraordinary contrast!

Wouldn’t public health officials like to know the cause of this difference?  Are the Antipodeans that much better at hand-washing and social distancing than the people of New York, Italy or Great Britain?  Do they share a highly-effective cure kept secret from the rest of the world?  Or is there another reason for the disparity?

Unlike the USA and other countries where the disease has taken a huge toll, the coronavirus arrived in Australia and New Zealand in mid-summer.  Most of the inhabitants of these two countries are descendants of pale-skinned British settlers (and convicts in the case of Australia).  Yet at the same time the death rate in Great Britain, the homeland of their ancestors, is over 600 per million.

This suggests that sunshine, and, specifically, the sunshine vitamin, are responsible for the difference.  If you look at the death rates throughout the world, it becomes apparent that countries in the southern hemisphere fared much better than countries north of the equator.

Actually, the division between countries with high death rates and low death rates is about the 37^th parallel north.  According to Wikipedia, the 37^th parallel is the dividing line between greater than average and less than average sun exposure.

So it appears that people living south of the equator, and south of the 37^th parallel north, experienced, in general, higher levels of sun exposure and lower death rates from the coronavirus than those in the northern hemisphere north of the of the 37^th parallel.

This explains the very low death rates observed in Africa. Many experts have forecast that the coronavirus would take a heavy toll in Africa because of poor healthcare infrastructure in much of the continent.  Yet this has not happened.  For example, death rates in Ghana, Nigeria, Kenya, Ivory Coast, Togo, South Sudan, Niger and Burkina Faso are between 2 and 3 per million.

Virtually all of the continent is south of the 37^th parallel north and sub-Saharan Africa is close to the Equator.  It could be argued that the low death rate is an artifact of poor record keeping, but reasonably good data about another virus, Ebola, reached world attention, so high death rates from coronavirus would likely be evident.

The same is true in the Far East.  Indonesia, Malaysia, Singapore and Sri Lanka are near the equator and have coronavirus death rates per million of 8, 4, 4, and 0.5.  But this pattern breaks down when one looks at that most equatorial of nations, Ecuador.

Here the reported coronavirus death rate is about 223 per million.  Other major countries of the South American continent, Brazil, Peru, Chile and Bolivia, have per million death rates of 208, 208, 176, and 54, which is quite a contrast to those seen in Africa and Southeast Asia.  The disparity may arise from a greater susceptibility to the coronavirus among people with indigenous ancestry.

Support for this idea comes from the death rates in Argentina and Uruguay, which are 19 and 7, per million, respectively.  Unlike the rest of South America, the populations of these two countries are very largely of European ancestry, mostly Spanish and Italian.  Remember that while it was summer in Argentina and Uruguay, at the same time it was winter in Spain and Italy, where COVID-19 death tolls per million were 580 and 571, respectively.

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Vitamin D3 is created in the skin by the ultraviolet light in sunlight.  Before the advent of dietary supplements, sunlight was the only significant source of Vitamin D3.  Fatty fish is a natural dietary source. Vitamin D3 is transformed inside the body to calcidiol, 25(OH)D3, which is not a vitamin, but a hormone.

Calcidiol has a half-life in the body of 2 to 3 weeks, so serum levels decline if they are not continually replenished by sun exposure or dietary supplements.   Winters in the higher latitudes diminish sun exposure due to shorter days, lower sun angle (if the sun is lower than 45 degrees in the sky, little UV light makes it through the atmosphere), and the need to bundle up or stay indoors in cold weather.

About 15 years ago it was discovered that Vitamin D is critical to the proper function of the innate immune system.  Broadly, there are two kinds of immunity – innate and acquired.  The body acquires immunity when it creates antibodies in response to infection by a specific pathogen.  This is the principal behind vaccines – to trigger the creation of antibodies.

However, the body also has an innate immune system that responds to the wide range of pathogens to which it is exposed every day.  Recently it has been demonstrated that the innate immune system is the body’s principal defense against another viral disease – influenza.  The annual wintertime outbreaks of influenza are triggered by declining levels of serum vitamin D in the host population.  That is why influenza doesn’t occur in the summer and is very uncommon in the tropics.

For in-depth discussion of innate immunity, Vitamin D3 and influenza, read the paper in Virology Journal titled “On the Epidemiology of Influenza” by John Cannell, et. al., and his earlier paper “Epidemic Influenza and Vitamin D” published in the journal Epidemiology and Infection.  Open access full text of both articles can be found on the internet on PubMed.

However, the COVID-19 coronavirus is not influenza, so the role of innate immunity and Vitamin D in the incidence and virulence of this disease must be established.  Given the very recent emergence of COVID-19, it is understandable that not very much research on the role of Vitamin D has been published.

However, one key paper has come out, which has been summarized in the website Grassroothealth.net/blog/first-data-published-covid-19-severity-vitamin-d-levels/.  The data are observational and the population of patients was 212, but the results are statistically significant.  People with adequate levels of serum Vitamin D in their blood experienced mild bouts of COVID-19, while those with inadequate levels suffered ordinary, severe or critical cases.  The chart in the article illustrates these data.

The results of this study are exactly consistent with the idea that sun exposure is inversely correlated with the virulence of COVID-19.  When serum levels of Vitamin D are high, the disease is mild.  When they are low, the disease is severe.   Which then leads one to ask what are the specific effects of Vitamin D that reduce the severity of COVID-19 infection?

There are at least two.  Severe cases can be complicated by what is called a “cytokine storm.”  This is a severe over-reaction of the immune system that can be fatal.  Vitamin D is known to prevent this condition (see the above-referenced articles by John Cannell).  A second effect is related to the recent discovery that COVID-19 attacks blood vessels, in particular, the endothelium, which is the internal lining of vessels, causing widespread clotting¹.

Research published in 2015 showed that Vitamin D3,  in the form that is created in the skin by UV light or taken as a dietary supplement, has a direct, protective effect on the endothelium ² Because Vitamin D3 lasts in the body only a day or so before it is processed into calcidiol, one needs a daily dose of sunshine or supplement to maintain the protective effect on blood vessels.  It should be underscored that sunscreen blocks UV rays from reaching the skin and therefore diminishes the formation of Vitamin D.  The skin pigment melanin is a natural sun screen and has a similar effect.

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With enough sun, one’s body makes all that is necessary to counteract the virus.  But modern lifestyles can make it impossible for many people to get sufficient daily sun exposure in the summer, and during Minnesota winters it is physically impossible because the sun is too low in the sky, not to mention that it is too cold to take off your clothes.

Therefore, one needs a program of supplementation with Vitamin D3, which is readily available over the counter.  The question, of course, is how much.  Grassrootshealth has devoted considerable study to finding the answer, a good discussion of which can be found here ³ The coronavirus statistics I used are from the site Worldometers ⁴

1: http://www.sciencetimes.com/articles/25872/20200529/coronavirus-respiratory-disease-change-everything.ht.

2: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140370.

3: http://www.grassrootshealth.net/blog/current-recommendations-low/

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26th June 2020

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This is so weird and inexplicable I can’t fathom it: why did deaths in people aged 15-44 spike during lockdown, & only in England?

As a doctor, I occasionally get confronted with difficult, unexplainable things, but this is a mystery I cannot solve. What lies behind this unusual rise in deaths in an age group that isn’t vulnerable to COVID-19?

It has been almost impossible to make any sense of the figures on COVID -19 deaths from around the world. They do say that the first casualty of war is truth. However, the enemy, in this case, does not much care what anyone says, so there is no point in lying to it.

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However, if you do try to compare lock down vs. no lock down, the COVID mortality figures appear incomprehensible. Belgium, for example, entered lockdown on the 18^th of March, whilst Belarus did not lock down at all. Belgium has a population of 11.5 million, while Belarus has 9.5 million.

Belgium, as of the 22^nd of June, had suffered 9,696 COVID related deaths.

Belarus, as of the 22^nd of June, had suffered 346 COVID related deaths.

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The death rate in Belarus, per million of population, is 36.

Which means that the death rate in Belgium is over twenty-three times as high as in Belarus. Yes, two European countries sitting at approximately the same latitude, both starting with the letter ‘B’, and they have a vastly different rate of death. What can we make of such statistics? The simple answer would be to say that I don’t believe the figures from Belarus.

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In fact, the death rate in Japan is very nearly the same rate as the rate in New Zealand, which has had only twenty-two deaths, and has been lauded for its aggressive lockdown policy and low rate of deaths. The NZ death rate is 4.9 per million.

In short, if you look around the world, there are no patterns to be seen, and the death rates between countries vary by more than hundred-fold. However, nowhere in the world have they been weirder, or more difficult to interpret, than in England, and – even more curiously – in younger people.

Around ten days ago, someone pointed out to me an anomaly so strange, so unexpected, that I have since spent a considerable amount of time speaking to other doctors, and statisticians, to find an explanation. With no luck so far.

First, to provide some context. The most accurate figures to use, in studying the COVID epidemic, are excess deaths. That is deaths from all causes, over and above the average from the last few years. If, say, 10,000 people normally die in the first week in April, a figure of 15,000 deaths, in the same week this year, would represent 5,000 “excess” deaths.

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If an elderly person goes downhill rapidly and dies in a care home, and they did not have a test, did they die of COVID, yes or no? Probably, possibly? Doctors in the UK have been advised to write yes, while in other countries they are more likely to write no. On the other hand, there are tales of doctors in the US being coached to write COVID on almost all death certificates, because the hospital is paid more money if they do so.

Which means that relying purely on the statistics for COVID recorded deaths may be highly misleading. However, you can absolutely rely on the diagnosis of death. It is a tricky clinical condition to miss.

So, if you want the outcome that is the most reliable indicator that something truly significant is going on, you need to look at excess mortality rates. If they stay the same, you can be reassured nothing serious is happening. This is true however much the diagnosis of a single condition rises.

To provide this data, as close to real-time as possible, EuroMOMO (European mortality monitoring activity) was established. Currently, it monitors changes in overall mortality in 24 different European countries. England, Wales, Scotland and Northern Ireland are treated as separate countries. This becomes important.

EuroMOMO showed absolutely no change in mortality across all 25 countries until week eleven, the second week in March. It then rose rapidly, topping-out in week fourteen. By the end of May, everything had fallen back to normal. Which means the COVID mortality spike lasted ten weeks, from start to finish. Overall mortality rates are now lower than normal

It is fascinating that some countries showed a sharp rise in mortality, and some showed nothing. For example, Austria, Denmark, Finland and Germany – nothing. France, Belgium, Spain, the Netherlands, England – major spikes. Thirteen countries spiked, twelve did not.

Then, and here we get to the really weird part, is the data that was tucked away in a sub-section. A massive rise in mortality that was seen in only one country out of the twenty-five, and nowhere else. And a spike in the age group 15 to 44… one of age groups least vulnerable to COVID -19… and in England alone. Not in Scotland, Northern Ireland or Wales. It lasted five weeks and then disappeared.

Frustratingly, the figures on causes of death are not available – some types of death can take a long time to be recorded e.g. deaths from accidents, or suicides. So, were all the excess deaths from COVID, it seems unlikely as the total number of recorded deaths in this age group has been less than five hundred since the start of the epidemic and that is not going to create such a spike.

Might lockdown have, in some way, have caused it? Might the loneliness of it have caused a rise in suicides? Or a surge in drug overdoses? Or other reckless behaviour?

I don’t know… but if we are to truly understand what happened during the pandemic, we need to find out.

11th June 2020

[   This article was published in Russia Today I feel I should mention that I have taken some criticism for writing articles for Russia Today, I have remained silent on the matter up to now.

However, I would like to point out that I tried to contact the BBC with regard to many of the issues I have been highlighting e.g. the COVID care home disaster in the UK – no interest. I tried to contact UK newspapers – no interest. And I have a good relationship with a lot of journalists.

In addition to this lack of interest in matters that I felt were extremely important, it concerns me that YouTube has a current policy of censoring content critical of COVID orthodoxy. Toby Young, who can be a divisive figure, wrote about this in the Spectator magazine, pointing out that Google and YouTube are using a form of censorship knowns as ‘shadow banning’, which makes content they disapprove of extremely difficult to find.

As Toby Young made clear, they shadow banned an interview with Peter Hitchens entitled ‘Lockdown is a catastrophe.’ They also removed an interview with Nobel laureate Michael Levitt called ‘the case against lockdown.’

When I criticised the modelling of Imperial College, a huge number of replies came flooding in. They attacked me, but were highly supportive of the modelling, and the Government actions. These posts were from people who have never posted before, or since. Hired guns? I watched an interview where a representative of Facebook explained that they were shutting down any posts on Vitamin C and COVID-19. Calling it fake news. As if they had any idea of the science behind it.

Currently, if people wish to point an accusatory finger at news outlets for manipulating and censoring the news, the facts, the information flow, they need to turn their attention a little closer to home. The mainstream media seem to have become what they should never, ever, be. Cheerleaders for their Governments.

And no, no-one has paid a single rouble to write this little rant. I have never written anything that I do not believe to be true. More fool me, probably. So, I would like to say thank you to Russia Today for being willing to publish my, completely unedited, thoughts.  ]

COVID – will lockdown lead to a major health disaster

I fear we may be heading for a post-lockdown health catastrophe that could mirror the disaster of the post-Soviet era.

The self-inflicted damage we’ve done to our economies in the name of combating COVID-19 may end up killing far more people than the virus itself. The economic collapse that followed the communist bloc’s break-up caused millions of deaths.

There has never been a situation to compare with what we have been living through these past weeks and months. Never in the history of the world have entire countries been locked down. Never have entire countries inflicted such enormous damage to their own economies and distorted their health systems away from all other activities, to deal with a virus.

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Perhaps they were unaware that we do this all the time. It is why NICE – the UK’s National Institute for Health and Care Excellence – was established in 2000. It is what all healthcare systems are forced to do. No country can afford to throw unlimited resources at healthcare. We all must decide what we can, and cannot, afford to do. Tough decisions to make, but essential.

Perhaps I came at the lockdown from a different viewpoint from most other people. When the pandemic took off, I was analysing the impact of economic and social upheaval on mortality. I was looking specifically at the breakup of the Soviet Union, as I knew that there had been a massive health impact from the rapid and uncontrolled “transformation” from a socialist to a market-based system.

An exhaustive study by three Austrian academics of the fallout from the dissolution of the communist bloc demonstrates the economic devastation it wrought:

“The immediate economic consequences of transformation were significant falls in gross national product. For example, between 1990 and 1993, real GDP had declined in Lithuania -18 per cent, Ukraine -10 per cent, Russia -10.1 per cent and Tajikistan -12.2 per cent. The first ten years of transformation was a period of great social disruption and chaos. The introduction of a market system of exchange led to a severe decline in gross domestic product, contraction of the labour market, and unemployment leading to social malaise including a rising death and suicide rate.”

What was the true impact on health? My main research interest is in cardiovascular medicine, and I was focussed on deaths from coronary heart disease (CHD). In lay terms, this means deaths from heart attacks. I had just put together the graph below, using Lithuania data.

As you can see, there was a dramatic increase in CHD deaths in 1989, the year that the Berlin wall fell. Lithuanians commenced their singing revolution, and there were mass demonstrations for independence, along with significant social upheaval.

The Soviet tanks rolled in, stayed for a bit, then rolled back out again, without doing much. Meanwhile, the Lithuanian GDP fell through the floor, and the rate of CHD virtually doubled over the next three years. A great mountain of increased mortality which makes anything from COVID look like a speed bump.

Of course, there were things over and above economic woes going on in Lithuania. However, I know that economic worries, by themselves, can be deadly. Perhaps the single deadliest thing of all. For instance, a study in South Africa found that people with significant financial worries were thirteen times more likely to have a heart attack:

“People who reported significant financial stress were 13 times more likely to have a heart attack than those who had minimal or no stress. Among those who experienced moderate work-related stress levels, the chances of having a heart attack were 5.6 times higher.”

Lithuania was not the only ex-Soviet country to see a massive increase in death. Not just from CHD, but in all-cause mortality. Here is a section of a report on the break-up:

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“There were also significant drops in life expectancy in Armenia, Belarus, Bulgaria, Latvia, Lithuania, and Romania. The immediate cause of the rising mortality is the ‘rise in self-destructive behaviour, especially among men.’ Old problems such as alcoholism have increased; drug misuse, a relatively new problem in the former communist bloc, has risen dramatically in recent years.” The report, Transition 1999, stated that suicide rates climbed steeply too, by 60% in Russia, 80% in Lithuania, and 95% in Latvia since 1989.

Behind the self-destructive behaviour, the authors say, were economic factors, including rising poverty rates, unemployment, financial insecurity, and corruption. Whereas only 4% of the population in the region had incomes equivalent to $4 (£2.50) a day or less in 1988, that figure had climbed to 32% by 1994.

“What we are arguing,” said Omar Noman, an economist for the development fund and one of the report’s contributors, “is that the transition to market economies [in the region] is the biggest … killer we have seen in the 20th century, if you take out famines and wars. The sudden shock and what it did to the system … has effectively meant that five million [Russian men’s] lives have been lost in the 1990s.”

Five million lives lost in Russia… alone. As I write this, we have reached a worldwide figure of slightly under four hundred thousand deaths from COVID, in total. COVID now seems to be on the way out, and we may never reach half a million deaths in total. The economic impact, however, is only just beginning.

Moving back to CHD again, what were the Russian figures for CHD deaths following transition? As with Lithuania, they are quite fascinating, and highly disturbing.

You may ask why there was a two-year time lag between CHD deaths between Lithuania and Russia. I think the answer is that when the Berlin wall came down in 1989, it triggered an immediate crisis in Lithuania. On the other hand, the rest of the Soviet Union limped on for a couple of years. In 1991 there was an attempted coup, which failed. However, this did signal the end, and the Soviet Union then rapidly broke up.

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I think this can be explained by the fact that, in August 1998, there was a massive banking collapse. It virtually wiped out the stock market and destroyed the value of the rouble. At the same time, unemployment skyrocketed and the savings of the common man were further obliterated. The recovery took years, as this report makes clear:

“The enormity of Russia’s financial collapse on Aug. 17, 1998 only really hit home with me the next day. “We are so f-cked,” George Kogan, one of Moscow’s most famous and longest serving equity salesmen, explained to me standing in the apartment of Simon Dunlop, one of Moscow’s most famous entrepreneurs. “The whole system has just crashed. It will take years for Russia to recover.” ⁵

Having seen the health impact of economic crashes, I hope you can now see why I was deeply concerned about lockdown. It was clear to me that this could mean massive financial hardship, and I feared that the deaths that followed could be catastrophic.

When our pandemic “experts” were putting together their models on death rate, did they take any of this into consideration? They did not. But what is the point of any model that does not even bother to consider the potential negative impact of what they are recommending?

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We were persuaded into lockdown with the promise that hundreds of thousands of lives could be saved in the UK – and millions worldwide. We were never warned about the many millions of lives that could – and, I fear, will – be lost as a consequence of lockdown. I consider that to be negligent. Especially as, in this case, the patient in question was the entire population of the Earth.

2 June 2020

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The hypothesis here is that, the way the COVID kills people is, primarily, by damaging the endothelial cells that line all blood vessels, and also the lung endothelium facing the atmosphere.

This endothelial damage then triggers a widespread ‘inflammatory’ response that triggers the development of blood clots – not just in the lungs – but also everywhere else in the body. The endothelial damage is, in effect, the body attacking itself, through an immune response – the so-called ‘cytokine storm’. Some of the resulting clots that result are small, some big. This overall process is known as Disseminated Intravascular Coagulation (DIC).

DIC, by blocking and damaging a high percentage of small blood vessels in the lungs, hampers gas exchange, driving down oxygen levels, and can lead to death through oxygen desaturation.

Other organs can also become seriously damaged, because DIC can block up blood vessels anywhere in the body.  Larger blood clots can cause strokes, heart attacks, kidney failure and suchlike. Clots forming in veins, in the legs, can break off and travel into the lungs where they create pulmonary embolism. Venous Thromboembolism (VTE) is a common cause of death.

Essentially, people die as a result of blood clots.

Diabetes and COVID

The probable reason why diabetes has been found to be an important risk factor for dying from COVID is that, in diabetes, hyperglycaemia (excessively high blood sugar level) specifically damages the glycocalyx (a protective glycoprotein layer covering all endothelial cells). This exposes the endothelial cells to greater damage and will lead to a greater and more widespread level of DIC¹.

An additional problem with diabetes is that the glycocalyx layer is primarily where nitric oxide (NO) is synthesized. Nitric oxide is a potent anticoagulant factor and helps to protect endothelium from damage by Reactive Oxide Species (ROS) a.k.a. super-oxides.

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COVID-19 does nothing unique – it just does more of it

The idea of a virus causing and inflammatory response, followed by DIC is not new. Influenza A has also been shown to do this. As highlighted in the article ‘Aberrant coagulation causes a hyper-inflammatory response in severe influenza pneumonia.’

‘Influenza A virus (IAV) infects the respiratory tract in humans and causes significant morbidity and mortality worldwide each year. Aggressive inflammation, known as a cytokine storm, is thought to cause most of the damage in the lungs during IAV infection. Dysfunctional coagulation is a common complication in pathogenic influenza, manifested by lung endothelial activation, vascular leak, disseminated intravascular coagulation and pulmonary microembolism. Importantly, emerging evidence shows that an uncontrolled coagulation system, including both the cellular (endothelial cells and platelets) and protein (coagulation factors, anticoagulants and fibrinolysis proteases) components, contributes to the pathogenesis of influenza by augmenting viral replication and immune pathogenesis.’ ²

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This, in turn, blocks a key pathway pathway to NO synthesis. Instead of NO being synthesized, a ‘super-oxide’ is created, which causes more endothelial damage. In this way COVID has a dual damaging effect. There is less NO being made, with additional ‘super-oxide’ production. This effect was also seen with SARS ³.

Kawasaki’s and COVID

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Although the agent, or agents, that can cause Kawasaki’s have never been identified, Kawasaki’s disease is essentially a widespread vasculitis (damage/inflammation in blood vessels). It seems that an infective agent may alter endothelial cells in such a way that the body feels they are ‘alien’ and then decides to attack. A delayed immune response.

‘A new hyper-inflammatory disease seen in children is now thought to be a delayed immune reaction to COVID-19, as experts say there could have been up to 100 cases in the UK so far.

Last week, the president of the Royal College of Paediatrics and Child Health, Professor Russell Viner, said the number of cases across the country stood between ’75 and 100?, and said the evidence pointed to the syndrome being the body’s delayed overreaction to the virus.’⁴

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In support of this concept, in Kawasaki’s Anti-Endothelial Cell Antibodies (AECA) can be detected ⁵. These almost certainly coordinate the immune attack on the endothelium, causing the secondary cytokine storm, and the other forms of organ damage that have also been seen in COVID.

In essence, the parallels between COVID and Kawasaki’s are very close, and both can be related directly to endothelial damage. So, I think it can probably be said that COVID does cause Kawasaki’s.

COVID as a form of viral sepsis?

Another way to look at this is as COVID as a form of viral sepsis. Sepsis is due to a bacterial infection, not viral infection. In sepsis, bacteria get into the bloodstream and multiply.

As they multiply, they secrete (waste product) ‘exotoxins’. These exotoxins strip off the glycocalyx and seriously damage the underlying endothelial cells. This, in turn leads to widespread clotting (DIC). As with COVID you end up with organ failure and death. There can also be loss of fingers, toes, entire limbs, due to the blockage of smaller blood vessels.

‘Deviations from normal endothelial barrier function can lead to or be caused by various internal or external stresses and pathologic conditions. Sepsis and septic shock, as recently redefined, are associated with pulmonary edema caused by increased permeability to proteins across pulmonary endothelial and epithelial barriers, and recovery from septic shock is associated with a reduction in edema, consistent with restoration of vascular function.’⁶

The treatment regime

Looked at in this way, the treatment regime for COVID (support treatment) should consists of three prongs

1: Anticoagulants – e.g. low molecular weight heparin (to prevent DIC)

2’: Immunosuppression to reduce the assault on the endothelium by the immune system. The most powerful immunosuppressants are corticosteroids (to stop the immune attack on the endothelial cells)

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COVID kills the endothelium

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‘In April, blood clots emerged as one of the many mysterious symptoms attributed to COVID-19, a disease that had initially been thought to largely affect the lungs in the form of pneumonia. Quickly after came reports of young people dying due to coronavirus-related strokes. Next it was COVID toes — painful red or purple digits.

What do all of these symptoms have in common? An impairment in blood circulation. Add in the fact that 40% of deaths from COVID-19 are related to cardiovascular complications, and the disease starts to look like a vascular infection instead of a purely respiratory one.’ ⁷

In fact, COVID is both a respiratory and cardiovascular disease. However, I believe that its many manifestations, and the way that it kills people can be explained by the unifying observation that it damages endothelial cells.

Can Vitamin C be beneficial?

There have been many studies demonstrating the vitamin C can help to support nitric oxide synthesis and reduce super-oxide damage. As described below:

‘Circulating levels of vitamin C (ascorbate) are low in patients with sepsis. Parenteral administration of ascorbate raises plasma and tissue concentrations of the vitamin and may decrease morbidity. In animal models of sepsis, intravenous ascorbate injection increases survival and protects several microvascular functions, namely, capillary blood flow, microvascular permeability barrier, and arteriolar responsiveness to vasoconstrictors and vasodilators. The effects of parenteral ascorbate on microvascular function are both rapid and persistent. Ascorbate quickly accumulates in microvascular endothelial cells, scavenges reactive oxygen species, and acts through tetrahydrobiopterin to stimulate nitric oxide production by endothelial nitric oxide synthase. A major reason for the long duration of the improvement in microvascular function is that cells retain high levels of ascorbate, which alter redox-sensitive signalling pathways to diminish septic induction of NADPH oxidase and inducible nitric oxide synthase. These observations are consistent with the hypothesis that microvascular function in sepsis may be improved by parenteral administration of ascorbate as an adjuvant therapy.’⁸

I am aware there have been many attacks on the use of Vitamin C in COVID with various experts stating that it does not protect against becoming infected with COVID, nor does it boost the immune system. However, that is completely beside the point, we are looking at endothelial damage here.

If it is true that COVID attacks and damages the endothelium – and the evidence seems strong that it does – we must protect it. Nitric oxide can do this, as can Vitamin C. Even if it does no good, vitamin C certainly does no harm. I would strongly support its use in COVID, even if the mainstream view is to dismiss it as nonsense.

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COVID is a virus that, because it forces entry to cells through the ACE2 receptors, which are found in high concentration in both lung and circulatory endothelium, causes specific damage to these cells. Due to the addition, specific action of knocking out ACE2 receptors, NO synthesis is greatly reduced, and ROS/super/oxide compounds are formed. This greatly amplifies the endothelial damage.

This damage, and the resultant ‘cytokine storm’, leads on to DIC. This in turn causes deaths through organ failure and/or large blood clot formation which can block blood supply to the lungs, the heart, the brain, the kidneys etc.

Supportive treatment requires the use of agents that can increase NO/reduce ROS, slow or stop the cytokine storm, and anti-coagulants. Oxygen is required when there is significant lung damage.

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1: http://diabetes.diabetesjournals.org/content/55/2/480#:~:text=First%2C%20hyperglycemia%20per%20se%20is,on%20the%20synthesis%20of%20glycosaminoglycans.

2: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947825/

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5: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1906533/

6: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5812759/

7: http://elemental.medium.com/coronavirus-may-be-a-blood-vessel-disease-which-explains-everything-2c4032481ab2

8: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2767105/#:~:text=Vitamin%20C%20and%20increase%20in%20endothelial%20permeability%20in%20sepsis,disease%20progression%20to%20septic%20shock.

31st May 2020

[This article was first published on RT.com, and can be seen there at http://www.rt.com/op-ed/490006-death-certificates-COVID-19-do-not-trust/]

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I suppose most people would be somewhat surprised to know that the cause of death, as written on death certificates, is often little more than an educated guess. Most people die when they are old, often over eighty. A post-mortem is very rarely carried out.

Which means that, as a doctor, you have a think about the patient’s symptoms in the last two weeks of life or so. You go back over the notes to look for existing medical conditions. Previous stroke, diabetes, chronic obstructive pulmonary disease, angina, dementia and suchlike. Then you talk to the relatives and carers and try to find out what they saw. Did they struggle for breath, were they gradually going downhill, not eating or drinking?

If I saw them in the last two weeks of life, what do I think was the most likely cause of death? There are, of course, other factors. Did they fall, did they break a leg and have an operation – in which case a post-mortem would more likely be carried out to find out if the operation was a cause.

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What were we now supposed to do? If an elderly person died in a care home, or at home, did they die of COVID? Well, frankly, who knows? Especially if they didn’t have a test for COVID – which for several weeks was not even allowed. Only patients entering hospital were deemed worthy of a test. No-one else.

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Where I work, things were left more open. I discussed things with colleagues and there was very little consensus. I put COVID on a couple of certificates, and not on a couple of others. Based on how the person seemed to die.

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It matters greatly for two main reasons. First, if we vastly overestimate deaths from COVID, we will greatly underestimate the harm caused by the lockdown. This issue was looked at in a recent article published in the BMJ, The British Medical Journal.  It stated: “Only a third of the excess deaths seen in the community in England and Wales can be explained by COVID-19.

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“At a briefing hosted by the Science Media Centre on 12 May he explained that, over the past five weeks, care homes and other community settings had had to deal with a “staggering burden” of 30 000 more deaths than would normally be expected, as patients were moved out of hospitals that were anticipating high demand for beds.

“Of those 30 000, only 10 000 have had COVID-19 specified on the death certificate. While Spiegelhalter acknowledged that some of these ‘excess deaths’ might be the result of underdiagnosis, ‘the huge number of unexplained extra deaths in homes and care homes is extraordinary. When we look back . . . this rise in non-COVID extra deaths outside the hospital is something I hope will be given really severe attention.’

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From my own perspective, I have certainly found it extremely difficult to get elderly patients admitted to hospital. I recently managed with one old chap who was found to have sepsis, not COVID. Had he died in the Care Home; he would almost certainly have been diagnosed as “dying of COVID”.

The bottom line here is that, if we do not diagnose deaths accurately, we will never know how many died “of” COVID, or ‘because of’ the COVID lockdown. Those supporting lockdown, and advising Governments, can point to how deadly COVID was, and say we were right to do what we did. When it may have been that lockdown itself was just as deadly. Directing care away from everything else, to deal with a single condition. Keeping sick, ill, vulnerable people away from hospitals.

The other reason why having accurate statistics is vitally important is in planning for the future. We have to accurately know what happened this time, in order to plan for the next pandemic, which seems almost inevitable as the world grows more crowded. What are the benefits of lockdown, what are the harms? What should we do next time a deadly virus strikes?

If COVID killed 30,000, and lockdown killed the other 30,000, then the lockdown was a complete and utter waste of time. and should never happen again. The great fear is that this would be a message this Government does not want to hear – so they will do everything possible not to hear it.

It will be decreed that all the excess deaths we have seen this year were due to COVID. That escape route will be made far easier if no-one has any real idea who actually died of COVID, and who did not. Yes, the data on COVID deaths really matters.

19th May 2020

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His prediction shaped the response of many countries around the world, definitely in the UK and the US. So, where did this half a million-figure come from? On a related note, the two million figure for the US is something which makes no sense at all.

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Getting back to Ferguson, and his model. So far, he has refused to release the data underpinning his model. Which, considering the impact it has had, is completely unacceptable. I think I would have given him a Chinese burn, at the very least, to get him to show me how he worked things out.

In truth, it is not exactly difficult to establish where this number came from. You can simply work backwards. There are sixty-six million six hundred thousand people living in the UK. If five hundred thousand die, that represents an infection fatality rate (IFR) of 0.75%. In other words, for every thousand people getting infected with COVID, seven and a half will die – on average.

Of course, there is an assumption built into the model that not everyone will get infected. Which is reasonable. There has been no pandemic in the history of the world where a bug managed to infect everyone – although it might be interesting to know why some people do not get infected, ever, when everyone around them is… This, I find, is the sort of question that never gets much looked at. Oh well.

Anyway, the Ferguson model predicts that eighty per cent of people could end up infected with COVID (which seems extraordinarily high and is simply a guess). That eighty per cent would happen if we all mingle and go to the pub, football matches, and suchlike. This increases the infection fatality rate (IFR) to 0.937% (0.75 ÷ 0.8). An IFR of 0.937% means that for every thousand people who get infected, nine and a half will die – on average.

The Ferguson team came up with an IFR of 0.9% (range 0.4 – 1.4), but I have no idea why it is not 0.937%. They talked about ‘mitigation’, but that didn’t seem to mean anything – it was just a fudge factor. Maybe they thought giving such a precise figure would look ridiculous when there are so many unknown variables flying about. True, but then again, I think the figures of 80% and 0.9 are simply wild guesses and look equally ridiculous.

The entire model can be seen in the original Ferguson model ¹. By the way, I think I should mention that this paper was published on the 16^th of March. Bear that date in mind.

So, that’s the model. Not very difficult really. Even though it is presented as some hugely complex mathematical monster, requiring the use of several super-computers running day and night to deal with the vast swathes of equations and data. Not so. You just need to do this:

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“Difficulty is a coin which the learned conjure with so as not to reveal the vanity of their studies and which human stupidity is keen to accept in payment.” Michel de Montaigne

You may wonder what the difference is between Case Fatality Rate (CFR), which is often mentioned, and the Infection Fatality Rate (IFR) – which is rarely mentioned. At the moment the case fatality rate (CFR) in the UK is well over 10%. This is clearly much higher than any predicted IFR.

The reason for this massive difference is because, if you only test people who are very ill, who have arrived in hospital (the bad cases of COVID), you are only testing those who are most ill, and most likely to die. Which gives you this very high CFR.

During any epidemic the CFR will always be high at the start, then start to fall, as more and more people with milder and milder symptoms are tested. Or, you later find out how many were actually infected.

However, unless you test everyone in the community, even those with no symptoms, the CFR will always be larger than the IFR. I hope this is clear.

This is a long-winded way of saying that no-one had much of a clue what the COVID-19 IFR may be. In the UK this is still the case, because no-one has a clue as to how many people have actually been infected.

All is not lost though, you can try to make a best guess, and you can do this by looking at the population, or country, where the greatest percentage of the population has been tested. At present that country is Iceland, total population 366,130.

With regard to the CFR in Iceland, as of the 10th of May, fifty-four thousand tests had been done. There were 1,800 positive cases, and the total number of deaths was ten, with no deaths for the previous three weeks. This represents a case fatality rate of 0.55%.²

This figure is the absolute maximum CFR, because it has not changed since the 19^th of April, and there were another twelve thousand tests during that time, with only twenty-two more positive cases.

What does this tell us about the IFR? Well, we know that IFR will always be lower than the CFR. However, even if we assume that the CFR and IFR in Iceland are the same (which is next to impossible) the maximum death rate, in the UK, based on those figures, would be

66,600,000 x 0.0055 x 0.8 = 293,600

As an aside in Iceland they randomly tested 848 children and found that the number infected was 0.00%. Some of those children must have been exposed to the virus, so viral exposure clearly does not even, always, lead to asymptomatic disease…

The 0.8 figure (80% of the population getting infected) still seems extraordinarily high to me, but I am willing to let it go. Even though it looks that the total number of people who may become infected is almost certainly far, far, less than 80%.

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66,600,000 x 0.0055 x 0.8 x 0.5 = 146,800

Anyway, as of today, that figure is a pretty reasonable estimate of the absolute maximum deaths we could have seen, in the UK, had we done nothing. One quarter of the Ferguson number.

Has the Ferguson number changed? Well, it has certainly wobbled about all over the place. On the 5^th of April, Neil Ferguson made this prediction

‘LONDON (Reuters) – UK deaths from the coronavirus could rise to between about 7,000 and 20,000 under measures taken to slow the spread of the virus, Neil Ferguson, a professor at Imperial College in London who has helped shape the government’s response, said on Sunday.’ ⁴

As I write this, we have had just over 34,000 deaths under lockdown. So, not quite seven to twenty thousand. Undaunted, on the 28^th of April Professor Ferguson changed his mind again, and then gave this warning:

‘100,000 could die of coronavirus this year if a gradual lockdown lift is implemented to just shield the elderly, warns epidemiologist Prof Neil Ferguson – as new analysis warns 60,000 are predicted to die by start of August.’ ³

“Five hundred thousand” changes to “seven to twenty thousand”, then becomes a “hundred thousand” or maybe “sixty thousand”. One two, miss a few, ninety-nine a hundred.

Yes, of course, we all know that Professor Ferguson was recently found to have been, repeatedly, visited by a young married lady. Thus, flouting the very lockdown rules that he had done so much to create. The words delicious, and irony, spring to mind. That, however enjoyable it may be as a Shakespearean tale, of a man laid low by hubris, is not the main point.

The main point is why the bloody hell, how the bloody hell, did this man – and his group – come to hold so much sway. His figures underpinning the original model could not be verified, because he would not release the source data. Even if the figures had been available for scrutiny they kept swinging wildly about the place and have already been proven to be blindingly inaccurate.

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‘Paul the Octopus (26 January 2008 – 26 October 2010) was a common octopus used to predict the results of association football matches. Accurate predictions in the 2010 World Cup brought him worldwide attention as an animal oracle.’⁵

Instead, our Government just kept repeating the mantra. ‘We are being led by The Science.’ As if Science required a definite article. Here is ‘the science’, let me show it to you. Crikey, and here’s me, I thought science was a bunch of ideas, conjectures and hypotheses used to try and explain the physical world around us. Constantly under debate, always changing. Never certain.

But no, it turns out it is an actual thing. ‘The science’. Boris keeps it in number ten Downing Street, and they share a cup of tea in the afternoon, along with a few jammy dodgers. Luckily ‘The Science’ is immune to COVID, so social distancing is not required. The Science also, probably, moves in mysterious ways.

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Its wonders to perform

It plants its footsteps in the sea

And rides upon the storm”

To be a little more serious, what is the science that is leading them. Mathematical models? Models that change and swirl and have little basis in reality. Models used to create predictions. As a friend has remarked to me many times: “there are two types of prediction – lucky and lousy”.

Our lives, our economy, our health service, all those people no longer getting treatment for other conditions, the heart attack patients not turning up at hospital, the cancelled cancer treatments, thousands of small businesses sacrificed at the altar of a mathematical model created by the mad modellers of the lockdown. Our lives, in their hands.

K’inell. As they say.

1: http://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf

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3: http://www.reuters.com/article/us-health-coronavirus-britain-ferguson/uk-coronavirus-deaths-could-reach-7000-to-20000-ferguson-idUSKBN21N0BN

4: http://www.dailymail.co.uk/news/article-8258043/Professor-Neil-Ferguson-warns-100-000-UK-coronavirus-deaths-lockdown-lifted-soon.html

5: http://www.google.com/search?q=octopus+predicting+football+results&oq=Octopus+predi&aqs=chrome.4.0j69i57j0l6.5812j0j7&sourceid=chrome&ie=UTF-8

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I am doing my last Food Bank Show on Sunday 17th May, (tomorrow). Unless, the lockdown tightens up again – so who knows for sure.

I am hoping to talk about what I have learned about COVID.  A tricky task as information floods in from all sides. What may work to protect people, what definitely doesn’t. Why the official responses are so slow. Anosmia (for example) is a very clear sign of infection with COVID, and is such an unusual sign that it can virtually be used to diagnose the disease. Yet, in the UK, the authorities are still refusing to add it to their ‘official’ signs and symptoms of COVID infection. They are so slow, and so conservative, that the entire pandemic may well be finished, and written about in history books, before they dare move from their laboriously constructed models. Ventilate very ill people. It turns out that ventilation may have made many people far worse. What drugs work? Let’s go back to the very same, very useless, antivirals and promote their use. Even if the trials have been equivocal at best, and completely useless, or damaging at worst. What about vitamins. The medical profession dismisses and decries vitamins as the work of the devil. The very idea that vitamin D and vitamin C may be beneficial…. This is utter nonsense. What about zinc, or magnesium… Again, dismissed.

They say of army generals that when a new war starts, they always fall back on the tactics of the last war fought. In a pandemic the experts fall back on the things they learned in the past. Our ‘experts’ are, essentially, a significant barrier to getting anything done. Especially looking at anything new, or different, that might work.

Experts getting in the way of new ideas was something noted many years ago by Professor David Sackett (one of the main founders of Evidence Based Medicine). As he wrote in 2000 in the BMJ in the article.

‘The sins of expertness and a proposal for redemption.’ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118019/

‘But there are still far more experts around than is healthy for the advancement of science. Because their voluntary retirement does not seem to be any more frequent in 2000 than it was in 1980, I repeat my proposal that the retirement of experts be made compulsory at the point of their academic promotion and tenure.’

I have nothing against knowledge and expertise, but the COVID pandemic has highlighted a significant issue. Namely that experts, are experts from the past, and about the past. When confronted with something new, they drag us back into what they know. A cavalry charge in a world armed with machine-guns. An outflanking manoeuvre when the enemy has spotter planes and bombers. Social isolation when we have no real idea how this virus spreads. Anyway, I hope it will be interesting.

Here is the link to the show

11th May 2020

I was asked by Russia Today to write an op-ed on what had been happening to me in my work over the last couple of months. It has appeared on their website http://www.rt.com/op-ed/488075-nhs-made-covid-19-crisis-worse/ This is what I wrote:

‘A slow and botched response’: how my eight weeks on the COVID-19 frontline taught me how the NHS made this crisis worse.

No PPE, no tests, no support. I work as a GP in care homes and a hospital setting, and watched in horror over the past few weeks at how the approach we took to tackling the virus caused my elderly patients to die.

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All was calm at the start of the year. Yes, China was going into lock down, a few people had become trapped on cruise liners, posting interminable on-line videos. Would COVID come here, to the UK? The NHS was untroubled, slumbering.

I went skiing in France, in the Grand Massif, in the first week in March, when COVID still seemed a distant thing, unlikely to change my work, or my life. I suppose it was like sitting on a mountain, being told that a bank of snow was forming that might eventually form an avalanche and head my way. But when I looked out of the window, the sun was shining, the sky was blue. Nothing to see.

I knew no-one who had COVID, nothing much was going on. I had seen no patients with the disease, but in early March the avalanche was striking Italy, and the sky above was darkening. Was it really coming here? I watched Liverpool getting knocked out of the Champions League by Atletico Madrid. Then Spain locked down. Then…

Then the cases in the UK started to rise. Suddenly, this was getting serious. What exactly was this disease? Was it like the flu, was it something else? As the avalanche began to rumble, hospital managers began charging about at high speed, bumping into each other and bellowing instructions – often directly contradictory. We had bronze meetings, then silver and gold meetings. The clipboards were all out.

Almost instantly things had gone from placid to panic, panic, panic. On the TV news, we could see hospitals were getting overwhelmed in Italy. The elderly were lying, dying, in corridors. Ventilators, we need ventilators. We need more capacity in the hospitals, we need beds. Like a slumbering beast, the NHS had awoken. More than a bit late.

Money started to get thrown around – as if money could suddenly make more beds in the hospital, or more staff, or create new nursing homes – or open those that had been shut. The bullying began. Of course, it wasn’t called bullying, but hospitals needed to be cleared out and nothing and no-one was going to get in the way. Edicts were handed down, orders barked.

In our little world, we were commanded to discharge our hospital patients as quickly as possible, to send them back to their families or their care homes.  The two nursing homes where I look after patients, started to fill up with new patients from hospital, often COVID positive. Staff had no PPE; barrier nursing was impossible. Early warning signs. I made my concerns about this clear.

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However, if a member of staff developed symptoms – everyone else had to stay at work. Because… a virus at home was obviously completely different to a virus at work. At this time there was no swabbing, no testing, so no-one knew who was infected, and who was not.

This was when we all became aware that expediency, and targets, were clearly overwhelming any safety concerns. Staff had little, or no, protection. The PPE that was deemed to be necessary – was whatever PPE was actually available. The guidance could change three times a day.

All of a sudden, in early April, the elderly patients I was looking after started to die. One day, there were no cases, then, 24-hours later, we had many. The deaths were strange, quick. One nurse watched four patients develop exactly the same symptoms. A fall, then strange absences (short-term loss of consciousness), then their breathing rate going up and their oxygen levels falling. The patients were remarkably calm, not distressed. Then they died. Two before ambulances could even get to them.

More staff started to get symptoms, patients were getting symptoms, still no-one could get a test. The only people being tested were those, very ill, arriving at hospital. Why? What did it matter if they Covid, or not? They were ill, they needed the correct treatment for their symptoms.

What difference would it make if they had a diagnosis of COVID?. It was the managers that needed to know. It seemed that research statistics were more important than protecting the staff. We really needed to know.

Early April and the local hospital was now, virtually empty, wards lying silent, elective surgery halted, cancer treatment stopped. By mid-April, the emergency Nightingale hospitals were also empty. Well, the primary objective had certainly been met. The hospitals were clear.

All this time, our care home beds were being filled up with COVID positive patients (many having been discharged or turned away from hospitals), and patients who had not been tested, but could be infected. Here we were, with the elderly vulnerable, in our care. The absolutely most at-risk population. Piling them in. Every time I coughed, I wondered, have I got it? I started popping an oxygen monitor onto my finger on a regular basis. Was it dropping? What’s my temperature? What’s my pulse rate… luckily, nothing changed.

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But yes, this was all that was required, according to Public Health England. Until better PPE arrived, then suddenly that was what we required instead. Then it ran out, and we didn’t need better PPE anymore. Back to the disintegrating pinnies.

In the nursing homes and Intermediate Care, my objections to filling up beds with COVID positive patients was beginning to have some effect. Rather too late. Our rehab unit has beds for thirty patients; ten were COVID positive. Eight died, and seven staff were tested positive. On the positive side, moves were being made to clear the unit, to turn it green, free from COVID.

Then came the problem of death certification. What should I write? COVID, or not COVID? Who knew, because still no-one was being tested in nursing homes. Not patients, not staff. Pure guesswork. By this point, even the national news was recognising that Care Homes were the new front line of COVID. Further edicts rained down, four or five new protocols a day.

Where are we now. Things are calming down, becoming clearer. The world of panic is rotating more slowly. What went wrong? We all know that, in a crisis, things can go haywire. Things that, in retrospect, look idiotic. Idiotic decisions.

The main thing that went wrong, I believe, was a failure to understand that hospitals would become the vectors for COVID, the epicentres for the infection. We – the hospitals, the decisions taken by the NHS managers with their clipboards – spread the disease, especially among the elderly vulnerable in care homes. A disease that we were trying to stop… killing the elderly and vulnerable.

I believe it a terrible indictment of our system that it become obsessed by a target. One that ran roughshod over our duty of care for those in our care. The primary rule of medicine is Primum non nocere. Not primum nocere.

灯蓝专业版免费 安卓: Since I wrote this article a few days ago, the Swedish Government has apologised for not protecting the elderly. Yes, the UK was not the only place where stupid things were done.

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“We failed to protect our elderly. That’s really serious, and a failure for society as a whole.” Sweden’s government has apologised for not protecting older people, with 90% of the country’s COVID-19 deaths occurring in the over-70s.” http://www.theguardian.com/world/2020/may/10/coronavirus-latest-at-a-glance-may-10

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I will be appearing on a podcast tomorrow morning at 10am (Saturday, 2nd May 2020) UK time, talking about Covid and suchlike – and probably getting dragged off into other interesting areas, as usual. It is with Steve Bennett, a friend, and a man who is trying to promote the high fat low carb (primal) way of life. I fully support him in doing this. He is also putting a considerable amount of money into foodbanks in the UK, to help out those in need during the lockdown. I hope you may be able to watch at http://thefoodbankshow.com

28th April 2020

I have found, I suspect like almost everyone else, that it is almost impossible to keep track of what is going on with COVID. Stories swirl and multiply, and almost everyone seems to be trying to get something out of it. People are claiming miracle cures and success – but it is difficult to verify any such claims.

The normal rules of research (flawed though they often are) have completely flown out of the window. It is like the wild west, with snake oil salesmen announcing wonderful products that not only cure COVID, but every other disease… I mean every other disease, known to man.

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‘A vaccine you say sir, of course, I shall have one ready and done in four months, start to finish … safety sir, did you mention safety? No need for such things, vaccines are always safe, never caused anyone any harm. Never a single case of any problems.’

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‘The WHO sir… what’s that you say? It may be that you can get infected twice. So how is any vaccine going to work. Well, I must say sir that vaccines are far more effective at creating immunity than getting the actual infection. Everyone knows that sir… what do you mean utter bollocks. I can tell you that a vaccine will always work, every time, guaranteed one hundred per cent effective, or your money back.’

‘Bill Gates is behind it all sir you say, pushing for mandatory vaccines for all diseases. You think it’s like something out of 1984. Well, Mr Gates is an expert in viruses sir, is he not…His operating system did allow a massive attack on IT systems in the NHS in 2017 sir. Now, if you will excuse me, I have more snake oil to sell… tatty bye sir, and good luck to you.’

‘Roll up, roll up.’

Which takes me to vitamin D. Which is my miracle cure for COVID.

I know that, in the West, the medical profession, hates vitamins with a passion. Those who promote vitamins are the very personification of woo, woo medicine. They have no proven beneficial effects they rant and on, and on. Insult and attack.

However, as I have been known to point out, the ‘vit’ in vitamin, stands for vital. As in, if you don’t take them, you die. So, they do kind of have important beneficial effects on the human body. Of course, I know the counter argument, which is not that vitamins are not necessary, of course they are, even doctors agree with that. The battle is about the optimal level for health.

We are told that almost everyone has sufficient vitamin intake from the food they eat, and that anything above that intake just creates expensive urine. In addition, some vitamins can be dangerous in excess. We have seen up to one death a year, in some cases.

Leaving the battles about vitamins to one side, what are the optimal levels of various vitamins? The answer is no-one really knows … for sure. The central problem here is that, when vitamins were first isolated, their deficiencies were creating major and obvious health problems. A lack of vitamin C caused scurvy – leading to death.

A lack of vitamin B1 a.k.a. thiamine led to Beriberi, with nerve and muscle damage and wasting and death. A severe lack of vitamin B12 lead to nerve damage, anaemia, weakness and death.

So, the focus was very much on finding the dose of vitamins required to prevent these serious health problems. However, no-one was particularly interested in looking beyond this bare minimum, to try and establish what level of a vitamin is associated with optimal health. For example, what are long term effects on cancer and heart disease – for example. Or prevention of infections.

Looking specifically at vitamin D, the major and immediate health problem caused by a lack of vitamin D is on bones. Without vitamin D, calcium is not absorbed properly and the bones become thin and brittle. Children with low vitamin D develop rickets, bent bones that do not grow properly.

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More importantly right now, does a higher level of vitamin D enable you to fight off infections such as influenza and COVID? Of course, as I stated at the beginning, in the middle of the COVID maelstrom, people are claiming everything about everything.

So, I am going to take you back to 2008 to look at Virology Journal – yes, this is about as mainstream as you can possibly get in the world of virus research. The article was called ‘On the epidemiology of influenza.’ If you want to get your mind blown, read it ¹.

It set out to answer seven questions:

1. 1. Why is influenza both seasonal and ubiquitous and where is the virus between epidemics?
   2. Why are the epidemics so explosive?
   3. Why do epidemics end so abruptly?
   4. What explains the frequent coincidental timing of epidemics in countries of similar latitudes?
   5. Why is the serial interval obscure?
   6. Why is the secondary attack rate so low?
   7. Why did epidemics in previous ages spread so rapidly, despite the lack of modern transport?

Yes, I realise COVID is not Influenza, but past research on influenza is about as close as you can get. Cutting to the chase, of a very long article, the authors concluded the reason why flu was far more common in winter, is because people have much lower levels of Vitamin D.

Below is their graph of vitamin D levels in the UK, at different times of the year.

These researchers then looked at what happened to people who took vitamin D supplements all year round. One group took placebo, one group took 800 international units (IU) a day – and one group took 800 IU per day but 2000 IU a day in the final year of the trial. Below is a graph of what they found.

To put this another way, of those 104 subjects who took 2,000 IU of vitamin D 下载灯蓝专业版免费 day, only one got a cold or influenza in the entire year.

Perhaps more importantly, if you do get infected with influenza, vitamin D (especially D3) has a potent effect on protecting endothelial cells. And damage to endothelial cells appears to be a key mechanism by which COVID creates the most severe, and potentially fatal, symptoms. Here is a section from the paper ‘Dietary Vitamin D and Its Metabolites Non-Genomically Stabilize the Endothelium.’

‘Vitamin D is a known modulator of inflammation. Native dietary vitamin D3 is thought to be bio-inactive, and beneficial vitamin D3 effects are thought to be largely mediated by the metabolite 1,25(OH)2D3…

Our data suggests the presence of an alternative signaling modality by which D3 acts directly on endothelial cells to prevent vascular leak. The finding that D3 and its metabolites modulate endothelial stability may help explain the clinical correlations between low serum vitamin D levels and the many human diseases with well-described vascular dysfunction phenotypes.’ ²

In short, it seems Vitamin D stops you getting infected with viruses and, even if you do get infected, it helps to mitigate the worst effects. This could explain results from a, not yet published study, looking at the severity of COVID infections vs. the level of Vitamin D in the blood ³.

On the face of it, remarkable benefits. However, they fit with what is already known about the benefits of vitamin D on influenza.

Further supporting the role of vitamin D in COVID, it has been recognised in many countries that those with dark skin are more likely to get infected, and die, from COVID. Here from the Guardian (UK newspaper).

I am not alone in being alarmed at the preponderance of deaths from COVID-19 among those with dark skin (UK government urged to investigate coronavirus deaths of BAME doctors, 10 April). While COVID-19 is likely to magnify the effect of social deprivation, I don’t think this is the whole story.

Vitamin D is needed for many reasons, including correct functioning of the immune system. It is converted to its active form by the action of sunlight on the skin. This is impeded by having dark skin and leads to low levels of vitamin D. Supplementing with vitamin D3 at 5000iu daily corrects this deficiency, and it is now an urgent need for all people with dark skin (and most with white). There is a reasonable chance that vitamin D replacement could help reduce the risk we are seeing playing out so tragically in the BAME community ⁴.

So, what do we know?

1. Dark skinned people are more likely to die from COVID
2. Dark skinned people are more likely to have low vitamin D levels ⁵
3. Vitamin D supplements protect against colds and flu – and hopefully COVID
4. Higher levels of Vitamin D should be able to mitigate the damage caused by COVID

The increased risks of low vitamin D levels on COVID seem dramatic, and the benefits of supplementation with vitamin D could be just as dramatic. I have been going out into the sun wherever possible in the last month. I take Vitamin D3 supplements 4,000 units a day. I strongly advise everyone else to do the same.  It is snake oil, and it is free (if provided by the sun).

The only problem I see is that I cannot make any money out of this at all. Oh well. Perhaps I should claim to be making a vaccine, that could earn me billions.

1: http://virologyj.biomedcentral.com/articles/10.1186/1743-422X-5-29

2: http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0140370

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4: http://www.theguardian.com/society/2020/apr/10/uk-coronavirus-deaths-bame-doctors-bma

5: http://academic.oup.com/jn/article/136/4/1126/4664238

21st April 2020

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This, believe it or not, is NHS policy. Still.

Yes, you did just read that. COVID-19 patients, even those with symptoms, are 灯蓝专业版免费 安卓 to be discharged back home, or into care homes – unless unwell enough to require hospital care e.g. oxygen, fluids and suchlike. If this is not national policy, then the managers are telling me lies.

In fact, it does seem to be policy, although the guidance from the UK Government is virtually incomprehensible¹. I have read it a few times and I fail to fully understand it – or partially understand it. I tried reading it upside down, and it made just about as much sense.

I wrote about this situation in my last blog, as the impact of COVID of care homes was becoming apparent – even to politicians. I thought that someone, somewhere, might have realised the policy of flinging COVID positive patients – or patients who may have COVID – out of hospital, and into care homes, might prove a complete and utter disaster.

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Equally, sending people home is further complete madness. Sending them home to somewhere that, very often, contains another elderly and frail person. Normally a husband or a wife. Did anyone think through the consequences of this? Clearly not. Do you think the other person in the house may be at risk? Really, you think. Surely not, knock me down with a feather…

If there is not another elderly partner in the house, there will usually be carers who come in to look after the freshly discharged COVID positive patients. These carers will have almost no protective equipment. Even if they do, they will be lifting and moving the patient around, washing them, taking them to the toilet… in very close proximity. The chances of getting infected are very, very, high.

These carers will then go and visit other elderly, vulnerable patients scattered around the community. They become the perfect vectors to spread the virus far and wide, amongst the exact group of people that we are trying to protect.

I have been doing a lot of jumping up and down about this over the last few days. The hospital trusts appear incapable of understanding the argument. ‘Clear the hospital, clear the hospital’… are the only words they seem capable of uttering.

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‘Because it is national policy’. Squawk. ‘Because it is national policy’. Squawk. ‘Pieces of eight, pieces of eight.’

The entire nation has been locked down. Do not travel, stay two meters apart, do not go outside blah, blah. Meanwhile we have the perfect anti-lockdown policy in place for the very people we are mostly supposed to be protecting. There are two parallel universes here.

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As Albert Einstein said. ‘Two things are infinite, the universe and human stupidity… and I’m not so sure about the universe.’

Thud… the noise of my head hitting the desk in utter frustration.

1: http://www.gov.uk/government/publications/COVID-19-guidance-for-stepdown-of-infection-control-precautions-within-hospitals-and-discharging-COVID-19-patients-from-hospital-to-home-settings/guidance-for-stepdown-of-infection-control-precautions-and-discharging-COVID-19-patients

17th April 2020

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As a GP, I regularly visit care homes. At one I visit, they recently had eight residents who died in a week, probably from coronavirus. But there’s no testing, so who could possibly know…

When COVID struck, many things were not known, and could not possibly have been predicted. The transmission rate, the case fatality rate, the best way to treat those infected.

However, it was very clear, very early on, that COVID was killing the elderly in far greater numbers than anyone else. In Italy, the early figures released revealed that the average age of death was seventy-nine. The figures were slightly higher in Germany, and around eighty years old in pretty much every other country.

Equally, it was known that amongst the elderly who were dying, almost all of them had other serious medical conditions. Heart disease, high blood pressure, diabetes, chronic pulmonary disease and suchlike. This is often known in my line of work as “multimorbidity.”

In a world of uncertainty, one thing stood out. Which is that the unwell elderly were the ones who were most likely to die. Equally, they were the ones most likely to end up in hospital, potentially overwhelming the health services. As happened in Italy and Spain.

Ergo, you would think that someone, somewhere in the UK government, would have asked the obvious question. Where do we have the greatest concentrations of elderly, frail, people with multimorbidity? Could it possibly be that they are being looked after in care homes around the country?

Nursing homes, residential homes, care homes. They are all pretty much the same thing nowadays. Nursing homes tend to look after those with greater health needs, and they must have registered nurses looking after patients, but the distinctions have become blurred.

Many care homes are also specialised in looking after the elderly with dementia. In the UK, they are called EMI units [elderly mentally infirm]. These represent a particular problem in that residents tend to wander about from room to room.

So, in care homes we potentially had the perfect storm for the pandemic. They are full of elderly and infirm and highly vulnerable people. Environments where it is often impossible to isolate residents, and staff who have never been adequately trained in isolation measures. Equally, whilst relatives cannot visit hospitals, care homes have been continuing to allow them in.

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What was the government’s strategy for dealing with nursing homes?  It has been, up until the last couple of days, to make things even worse. The instructions from the Dept of Health have been to send patients diagnosed with COVID out of hospital, and back into care homes, with instructions to “barrier nurse” them, a term for a set of stringent infection control techniques.  Care homes were informed that they could not refuse to take the residents back.

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The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Cheshire, the local hospitals have never been so empty.

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Now, of course, the disaster is unfolding. The entirely predictable disaster. Here, from The Guardian:

‘Care home leaders have accused the government of vastly underestimating the deaths of elderly people from coronavirus, as they warned the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures.

Operators of several large care providers accused the government of not paying enough attention to the tragedy unfolding in residential settings across England, as figures from three of the largest chains show 620 deaths from COVID-19 in recent weeks.’

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It seems clear that many, many, COVID deaths in care homes will not even be registered as COVID deaths, so the figures are almost certainly worse here than are being reported.

I think we all recognise that the COVID pandemic has hit the country with great force, and that the Government has had to react at great speed. You can agree or disagree with some of the actions. However, one thing that stands out is that complete and utter abject failure to grasp the impact of COVID on care homes.

The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. On Thursdays, while others have been clapping the NHS, I have been clapping for the unsung heroes of this epidemic. The care home staff.

12th April 2020

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And there are only four possible strategies:

To eradicate the virus from the entire population by enforcing lockdown. Or to enforce lockdown until there is an effective treatment. Or to enforce lockdown until there is a vaccine. Or to enforce lockdown to slow the spread of the virus, so as to prevent the NHS from being overwhelmed.

Eradication is virtually impossible with such a highly infectious disease. Even if the UK was successful, if other countries were not, keeping Covid-19 out would require border closures for years, maybe decades. Endless checks on planes, boats, lorries, cars. Constant testing and restrictions. It is almost certain that the virus would still slip through. This does not seem a viable option.

What about finding an effective treatment? The chances are vanishingly small. Influenza, a very similar virus, has been around for decades, and no game changing medications have yet been found.

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Ergo, there is only one overall strategy that can be followed. Control the spread to avoid overwhelming the NHS. This has never been made explicit, but the Government has, albeit indirectly, told us that this is exactly what they are doing.

In the last few days, a letter was sent to all households, signed by Prime Minister Boris Johnson, before he too succumbed to the disease. It was entitled “Coronavirus – stay at home; protect the NHS, save lives.” It contained this key passage:

“If too many people become seriously unwell at one time, the NHS will be unable to cope. This will cost lives. We must slow the spread of the disease, and reduce the number of people needing hospital treatment in order to save as many lives as possible.”

The key sentence is the first. If too many people become seriously unwell at one time.

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However, delay and mitigate doesn’t mean that people will not become infected and die. It just means that the NHS will not be overwhelmed by a massive wave of people getting ill at the same time. We are simply, it should be made clear, trying to control the “peak”, which now may likely be a series of “peaks”.

At present, ministers are not admitting this. They are presenting lock-down as a way of “beating this virus.” In order to enforce lockdown, they are haranguing and scaring the population into compliance.

Covid-19 is being presented as a deadly killer that does not discriminate. Young, old, we are all at risk of contracting this dreadful disease. Every night, the television news has story after story of young people who have been infected, and who have died. In fact, very, very few people under 20 have died so far. I believe it was five, at the end of last week.

There is hardly anything said about the fact that the average age of death is around eighty, that the vast, vast, majority of those dying are old (92% are aged over sixty) The great majority of them have several other serious medical conditions.

The reality is that for anyone younger than about sixty, Covid-19 is only slightly more dangerous than suffering from influenza. The infection fatality rate (IFR) currently stands at around 0.2% in those countries doing the most testing. This figure will inevitably fall, once we can identify those who were infected but had no symptoms.

By avoiding this more reassuring message, by frightening everyone into compliance, the Government has painted itself into a corner. How can they say to people that, last week you couldn’t drive two miles to walk in the countryside, or go to the beach, or go to a restaurant, or lie in a park sunbathing, in order to prevent the spread of this deadly killer disease …but this week you can?

Worse than that, when cases begin to rise again, about a month after lockdown is relaxed, we will all have to lock down again, to prevent the next surge? How will the public respond to this? I don’t know, but I expect that it is going to be extremely difficult, if not impossible, to force everyone back into lockdown again.

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That great harm is being done by it was made clear in an article last week in the Health Service Journal:

“NHS England analysts have been tasked with the challenging task of identifying patients who may not have the virus but may be at risk of significant harm or death because they are missing vital appointments or not attending emergency departments, with both the service and public so focused on covid-19.

“A senior NHS source familiar with the programme told HSJ: “There could be some very serious unintended consequences [to all the resources going into fighting coronavirus]. While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications.”

It may well seem that all this suffering was…well, for what, exactly? To simply prevent a surge of cases. This government, all governments, must be honest about this and admit that in the longer term we cannot prevent almost everybody getting infected and acknowledge that a proportion of those infected will die.

When lockdown restrictions are lifted this does not mean that the virus has gone. It does not mean that people cannot infect each other.  It does not mean we can simply carry on as before. It means that we have kept the first surge under control.

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6th April 2020

Here is a section from the Health Service Journal (HSJ) in the UK, discussing the current fears of NHSE (NHS England). The article is behind a paywall.

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Exclusive: NHSE to act over fears covid-19 focus could ‘do more harm than virus’

‘NHS England analysts have been tasked with the challenging task of identifying patients who may not have the virus but may be at risk of significant harm or death because they are missing vital appointments or not attending emergency departments, with both the service and public so focused on covid-19.

A senior NHS source familiar with the programme told HSJ: “There could be some very serious unintended consequences [to all the resource going into fighting coronavirus]. While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications.

“What we don’t want to do is take our eye off the ball in terms of all the core business and all the other healthcare issues the NHS normally attends to.

“People will be developing symptoms of serious but treatable diseases, babies will be born which need immunising, and people will be developing breast lumps and need mammograms.”…

Nuffield Trust deputy director of research Sarah Scobie said it was “a considerable worry that people are keeping away from routine and urgent health services, and also from emergency departments”.

She added: “The PHE (public health England) data suggests there could be significant problems already developing for heart disease related conditions patients, for example. Attendances relating to myocardial infarction at emergency departments have dropped right down, whereas ambulance calls in relation to chest pain have gone right [up].’

I suppose my first response would not be one of great surprise. In fact, it confirms what I have been saying for some time. When the great Swine Flu epidemic (that killed hardly anyone) created the last pandemic crisis in the UK, exactly the same thing happened. If, whatever you were suffering from, wasn’t Swine Flu, it didn’t seem to matter.

In my small part of the world a small but significant number of people were diagnosed with Swine Flu. This was done over the phone, by poorly trained operatives. These people were then prescribed the (almost entirely useless Tamiflu), they then died. It turned out that they had other conditions that could, and would, have been properly treated had we not been overcome by a massive over-reaction to Swine Flu. They died because of swine flu.

Last week, in Intermediate Care, we sent two patients into the local hospital who were seriously ill. They were both sent back almost immediately. They both died. Yes, they were ill, and may have died anyway. But I believe they should both have been admitted, and treated, and they could both still be alive. They died because of COVID.

Ambulance crews are under very heavy pressure not to admit anyone unless absolutely necessary. Some of those, not admitted, will die.

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Our local hospital now has more empty beds than at any time in history. Elective surgery has stopped, to free up resources. There is enormous managerial pressure to clear more and more people out of hospital, out of Intermediate Care beds, back home with little support available. Some of them will die because of this.

My last blog focussed on the economic costs of the reaction to COVID. My argument was that economics, and health, do not exist in isolate bubbles. Harm to the economy will result in harm to health and vice-versa.

Equally, if you spend all your healthcare resources trying to treat one thing, everything else will suffer, because resources are not infinite. At present we have virtually shut down the NHS to deal with COVID.

I saw several patients yesterday while I was working in “out of hours”, who were not critically ill, but they were ill. Two of them, I felt, really needed to be followed up. A girl with weight loss over the last three months, a man with clear signs in his chest that could have been malignant.

They will not be followed up any time soon. If at all.

At present there is a lot of discussion about how we are categorising deaths from COVID. Anyone who dies, having been diagnosed with COVID, is considered to have died of COVID. Even if they died of something else. The died with COVID, not of COVID.

There is, I believe, an even greater immediate problem here. Which is those who are dying because of COVID. This is not just me saying this, this is NHS England:

“While there will be a lot of covid-19 fatalities, we could end up losing more ‘years of life’ because of fatalities relating to non-covid-19 health complications.”

For many years, there has been an old medical joke. It will not make you laugh out loud, but it goes like this.

‘The operation was a success, unfortunately the patient died.’

29th March 2020

The current COVID pandemic has brought a very thorny and difficult issue to the forefront. How much money should we, as a society, spend on keeping people healthy/alive? No-one has ever fully got to grips with this question, but it has never been more important than now.

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I know that some people will instantly dismiss such a question as being cold-hearted, and simply stupid. ‘You cannot put a value on a human life.’ Is an argument that I have heard many times, almost whenever health economics is discussed.

The counter argument is that – if funds are not limitless – then we should focus on doing things whereby we can do the most good (save the most lives) for the least possible amount of money. Or use the money we have, to save the most lives. In fact, this is why the National Institute for Health and Care Excellence (NICE) was established.

NICE reviews interventions and decides whether they provide value for money. The economic term for this is cost-effectiveness. This work is complex and often relies on assumptions that can be difficult to verify.

However, keeping this as simple as possible, NICE tries to compare healthcare interventions against each other by using a form of ‘currency’ called the cost per QALY.  A QALY is a Quality Adjusted Life Year. One added year of the highest quality life would be one QALY.

People with conditions such as cancer, or severe heart disease, or who are suffering from chronic pain can be considered to have a quality of life less than one. For the sake of argument, we can say that their quality of life is 50%. Thus, one year of additional life gained for them, would have a value of 0.5 of a QALY.

It also needs to be borne in mind that not everything that is measured using a QALY, relates to saving, or extending, lifespan. For example, someone could have chronic hip pain, and a quality of life of 0.5. Then they have a hip replacement, and their pain goes away, their quality of life can improve from 0.5 to 1. If they live another twenty years, they will have gained 20 x 0.5 QALYs = 10 QALYs.

Obviously, things can get significantly more complicated than this, and the validity of the measured quality of life is a matter of considerable debate.

However, the fundamental question as always, comes down to the following. How much are we willing to pay for one QALY? [How much can you afford to pay for one QALY?] Not just the NHS, but the country as a whole? The current answer, in the UK, is that NICE will recommend funding medical interventions if they cost less than £30,000/QALY. Anything more than this is considered too expensive.

This figure is not set in stone and can vary depending on circumstances. Interventions for young children tend to get more spent per QALY, and powerful lobbying groups can bring pressure to bear on that figure.

However, the figure of £30,000 is generally accepted – if not widely publicised.

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To put it in more stark terms. In order to spend three hundred and fifty billion pounds, we require a return on investment of eleven point six million QALYs. If not, NICE would reject it.

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Are we likely to achieve this level of benefit? Of course, any attempt to model this requires several assumptions to be made. However, the model we can use in this case only has four variables, two of which are (pretty much) known. The variables are:

• How many people will die?
• What is the average age of death?
• What is the average reduction in life expectancy in those who die?
• What is the average quality of life of those who die?

[In truth, average age of death is only needed to calculate the average reduction in life expectancy.]

So, for example

• 500,000 die
• Average age at death 78.5
• Average reduction in life expectancy 3 years
• Average quality of life of those who die 0.7

QALYs lost: 500,000 x 3 x 0.7 = 1,050,000

Using these figures, if we spend three hundred and fifty billion pounds – in the hope of reducing the ‘QALYs lost’ figure to zero, then each QALY will have cost £333,000. Which is more than eleven times the maximum cost that NICE will approve.

Of course, people will immediately object to this model, and for valid reasons. How do we know how many will die, how do we know the average quality of life of those who die, how do we know the average reduction in life expectancy?

In fact, we do know two things with reasonable accuracy. First, we can be pretty certain about the average age of death, and we can also be fairly clear on the average quality of life of those who have died.

What is less certain is how many will die, and the average life expectancy of those who have died. At this point we need to look at the ‘variables’ in the model in a little more detail. This is UK only.

Number who may die

The 500,000 figure for possible deaths, that I used in the calculation above, is the absolute upper range of the numbers that have been proposed, and it comes from modelling that was developed by the Imperial College in London. Their modelling has been since used around the world to guide Government responses. ¹

On the other hand, the UK Government has used an estimated 250,000, for the upper limit of deaths – if nothing is done to prevent spread. Other figures have been much lower, but I am going to use 500,000 as the maximum, and 250,000 as the ‘most likely number’ in this model.

My minimum figure will be 20,000, as this has recently been suggested by the same Imperial research group. It seems low.

Average age of death

In Italy – which has had the greatest number of deaths – the average age at death is 78.5. This is comparable with age of death in other countries. I am going to use this as a non-variable ².

Average reduction in life expectancy

This is more complicated. Using Italy, again, the average life expectancy is 82.5 years (both men and women). However, if people die aged 78.5, this does not mean you have reduced life expectancy by 3 years.

The average life expectancy in Italy, at birth, is 82.5 years. However, once you reach 78.5, you can expect another eight or nine years of additional life. [You will have avoided car crashes, early cancer, suicide and suchlike which reduce the ‘average’ life expectancy of the entire population].

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Which means that these 78.5-year olds do not have a life expectancy of eight or nine years. It will be far less. How much less? This is virtually impossible to calculate. I am going to estimate a half – or 4.5 years (an average).

Which means that, in this model, my lower figure of years of life lost will be three years. My upper figure is nine years and my ‘most likely’ figure 4.5 years.

Average quality of life of those who die

Again, this is difficult to establish. However, studies have been done to work out the ’reported’ quality of life in those with multimorbidity. Perhaps the most accurate figure I could find with that elderly people with three underlying serious health problems have a quality of life of 0.8.³

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Having put figures to the likely range of the variables, we can look at the cost per QALY in various scenarios. I am only going to look at three. ‘Best case’ ‘Most likely’ and ‘Least benefit.’

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The calculation is:

500,000 x 9 x 0.8 = 3,600,000 QALYs

Which gives a cost per QALY of £97,200 [£3,5Bn ÷ 3.6m]

Most likely

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250,000 x 4.5 x 0.8 = 900.000 QALYs

Which gives a cost per QALY of £388,888 [£3.5Bn ÷ 900K]

Least benefit

Finally, we can tun the ‘least benefit’ scenario, which is 20,000 deaths prevented, with an average gain in life expectancy of 3 years.

20,000 x 3 x 0.8 = 48,000 QALYs

Which give a cost per QALY of 下载灯蓝专业版免费[£3.5Bn ÷ 48K]

As you can see, none of these models achieves a cost per QALY that would be approved by NICE.

Disability Adjusted Life Years

I fully recognise that looking at human life in from this purely economic perspective can seem harsh, almost inhumane. Can we really stand back and watch an elderly person ‘drown’ as their lungs fill up with fluid ‘Sorry, we are not spending money on more ventilators, because it is not cost-effective.’ Or suchlike.

However, there is also a health downside associated with our current approach. Many people are also going to suffer and die, because of the actions we are currently taking. On the BBC, a man with cancer was being interviewed. Due to the shutdown, his operation is being put back by several months – at least. Others with cancer will not be getting treatment. The level of worry and anxiety will be massive.

Hip replacements are also being postponed and other, hugely beneficial interventions are not being done. Those with heart disease and diabetes will not be treated. Elderly people, with no support, may simply die of starvation in their own homes. Jobs will be lost, companies are going bust, suicides will go up. Psychosocial stress will be immense.

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Which means that we are certainly not looking at a zero-sum game here, where every case of COVID prevented, or treated, is one less death. There is a health cost.

There is also the impact of economic damage, which can be immense. I studied what happened in Russia, following the breakup of the Soviet Union, and the economic and social chaos that ensued. There was a massive spike in premature deaths.

In men, life expectancy fell by almost seven years, over a two to three-year period. A seven-year loss of life expectancy in seventy million men, is forty-nine million QALYs worth. It is certainly a far greater health disaster than COVID can possibly create.⁴

In Lithuania, the impact of the break-up of the Soviet Union was also dramatic, and damaging. Below is a graph, looking purely at deaths from cardiovascular disease. As you can see, starting in 1989 (when the Berlin wall fell) there was an enormous spike, representing hundreds of thousands of premature deaths. These same spikes, in death and disease, were seen across most countries in the former Soviet Union. ⁵

These, the downsides, can be calculated, using the figure that is the opposite of the QALY, which is the DALY. The Disability Adjusted Life Year. Or, to put it another way, how much harm are you causing with your interventions? I am not doing this calculation here, because it would have about ten thousand variables and would take far too long.

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This was highlighted in a review by Michael Marmot, who studied two areas of Glasgow. Lenzie, which was rich, whilst the other area, Calton, was poor (socially deprived). The findings were stark:

…we can see this in Glasgow. When we published the report of the WHO Commission on Social Determinants of Health (CSDH) in 2008, I drew attention to stark inequalities in mortality between local areas of Glasgow: life expectancy of 54 for men in Calton, compared with 82 in Lenzie.’ ⁶

A twenty-eight-year difference in life expectancy between people living approximately five miles apart. The difference? Money.

This, I hope, puts into some perspective the discussion on cost per QALY. I framed it, to start with, as a discussion about money, but it is not really about money. Health does not exist in some bubble, sitting apart from the rest of society. Health and wealth are closely interrelated.

Which means that I fear that we are taking actions that could, in the longer term, if we are not very careful, result in significantly more deaths than we are trying to prevent.

Even if we restrict the analysis purely to the cost per QALY and narrow the ‘health’ analysis purely to COVID, and deaths from COVID, it remains difficult to justify spending £350 billion pounds to control a single disease.

I know that many people will violently disagree with this analysis and will think I am some cold-hearted fiend. ‘People are dying, we must do absolutely everything we can. No matter how much it costs.’ ‘What would you say if it was your mother…’ and suchlike.

Well, I have spoking to my mother, who is 92. Her view is that she has lived long enough. She thinks the Government actions are a ridiculous over-reaction. She is going out shopping and chatting to friends… she will take no advice on the matter.

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1: http://www.imperial.ac.uk/news/196234/covid19-imperial-researchers-model-likely-impact/

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4: http://en.wikipedia.org/wiki/Health_in_Russia

5: http://www.bhf.org.uk/informationsupport/publications/statistics/european-cardiovascular-disease-statistics-2012

6: http://journals.sagepub.com/doi/full/10.1177/1403494817717433

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I thought I should do a quick update on COVID-19, as some interesting and important information has been published in Italy. Looking at deaths in various age groups, underlying conditions etc.

It can be seen here http://www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdf

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• Mean age at death is 78.5 years (women slightly older than men)
• 2% of those dying had no comorbidities (other diseases e.g. heart disease, diabetes, cancer)
• ~50% had three or more comorbidities.

Symptoms

• 1% were coughing up blood (haemoptysis)
• 8% had diarrhoea
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[5.7% were admitted with no symptoms at all – not clear what they came in with. Presumably admitted with something else, then developed the symptoms later]

What did they die of?

96.5% died of acute respiratory distress syndrome.

‘Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function.

ARDS typically occurs in people who are already critically ill or who have significant injuries. Severe shortness of breath — the main symptom of ARDS — usually develops within a few hours to a few days after the precipitating injury or infection.

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Treatment is with oxygen and ventilation but has a low success rate in the very elderly.

Deaths under 50 years of age

To date (March the 20th), 36 of 3200 (1.1%) COVID-19 positive patients under the age of 50 have died. In particular, 9 of these were younger than 40 years, 8 men and 1 woman (age range between 31 and 39 years). For 2 patients under the age of 40 years, no clinical information is available; the remaining 7 had serious pre-existing pathologies (cardiovascular, renal, psychiatric pathologies, diabetes, obesity).

There do not seem to have been any deaths below the age of thirty.

ACE-inhibitors and Angiotensin Receptor Blockers (ARBs)

There has been much debate as to whether or not ACE-inhibitors (angiotensin converting enzyme inhibitors) and ARBs may increase the risk of death [these drugs are widely used to lower blood pressure]. This is because COVID-19 appears to enter the body through ACE2 receptors – found in high concentrations in the lungs and can cause upset to the neurohormonal system where ACE, and ACE receptors, play an important role.

The data from Italy is that:

‘Before hospitalization, 36% of COVID-19 positive deceased patients followed ACE-inhibitor therapy and 16% angiotensin receptor blockers-ARBs therapy. This information can be underestimated because data on drug treatment before admission were not always described in the chart.’

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Knowing this, it is important to know how many (elderly people) take either of these drugs, to see if there is a correlation between taking them and dying from COVID-19. The figures from Italy are not clear at all. However, the latest data on prevalence of high blood pressure in the adult Italian population was, around 52% (This is an absolute maximum).²

However, the number of people known to have had their high blood pressure recorded by their general practitioner is around 20% ³ . Which means that most people with high blood pressure are not treated with anything.

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So, we can say that 10% of the adult population is treated for hypertension, and that this may be around 20% in those aged around 80. Taking the figures one step further, it is estimated that about 67% of those who take antihypertensive in Italy use ACE-inhibitors, or ARB. ⁴

Bringing all of these figures together, it is likely the average percentage of eighty-year olds taking an ACE, or ARB is

67% of 20% of 52%x 2 = 14.0%

Which means that amongst 80-year olds ~14% are taking one, or other, of these drugs.

I cannot say either of these figures in carved in stone and I believe 14% is probably a overestimate. I wish there were more fully accurate figures to be had. So, what does this mean?

It means that:

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Which suggests you are four times as likely to die from COVID-19 if you are taking one of these drugs, prior to contracting the virus. This, of course, does not take into account confounding variables – many of which are currently unknown. By a confounder I mean that people taking these drugs may have more comorbidities, such as heart disease, diabetes etc.

However, it remains a very strong signal, and I do not think it can be ignored, particularly in the light of the knowledge that the COVID-19 virus has a significant impact on the ‘ACE system’.

On this basis I would strongly recommend that elderly people, with any comorbidity, who is taking an ACE-inhibitor/ARB should look to change their antihypertensive treatment to something else – whilst the threat from COVID-19 is high.

I should point out this runs contrary to the advice from the authors of a study in the European Heart Journal 20^th March:

SARS-CoV2: should inhibitors of the renin–angiotensin system be withdrawn in patients with COVID-19?

‘In conclusion, based on currently available data and in view of the overwhelming evidence of mortality reduction in cardiovascular disease, ACE-I and ARB therapy should be maintained or initiated in patients with heart failure, hypertension, or myocardial infarction according to current guidelines as tolerated, irrespective of SARS-CoV2. Withdrawal of RAAS inhibition or preemptive switch to alternate drugs at this point seems not advisable, since it might even increase cardiovascular mortality in critically ill COVID-19 patients.’ http://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa235/5810479

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Of course, no-one can be certain about what exactly is happening. I cannot be certain, but the signal from Italy on ACE-inhibitors and ARBs, seems very strong, and concerning. Based on it, I think my advice would be to change medication, if possible.

Stating this, I am aware that most GPs will not change anything, unless they get instruction from the acknowledged experts. Unfortunately, this is likely to take far more time than many people actually have.

1: http://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576

2: http://www.escardio.org/static_file/Escardio/Subspecialty/EACPR/Country%20of%20the%20month/Documents/italy-country-of-the-month-full-report.pdf

3: http://www.nature.com/articles/jhh200914

4: http://academic.oup.com/ajh/article/25/11/1182/115788