Over the last few weeks I have found it increasingly difficult to articulate what I believe and understand about Covid-19. It suddenly struck me that this is because I (unlike the government, the media and even SAGE it seems) do not see Covid-19 in isolation from the rest of life, health, illness, well-being and society. This blog is rather longer than my usual ones, and has actually taken me many, many hours to write, edit and think through. I will get back to my recipes, ponderings and thoughts on the climate in August, but for now I felt this was really important. I really hope you can make it through to the end, and I really hope if you are currently living with either fear or frustration, in this pandemic, it will help.
We live in a world with a multitude of beauty and a multitude of horrors. Our world is one of creation and destruction, one of rhythms and cycles, one where animals eat each other, wars break out (not just in the human species) and balance is always being forged and re-forged. Disease, illness, and infections are part of that, throughout the global species – animal and plant. As a GP I deal with disease in the human population. … I see and treat people holistically as much as possible. No man is an island as the saying goes. We live in families, in communities and in our society … then we live in the global society called humanity on top of that. Health is a broad term that sits in the middle of our lives. Health is the absence of illness. The absence of disease …. Or Dis-Ease. … Health is in fact our total being, being in balance. .. mentally, emotionally and physically. Most doctors agree that we cannot have true health without all three of these things being ‘in balance’ in us. Research (and in fact just being aware of your own self) shows us that physical health is influenced hugely by mental and emotional health. A couple of basic examples are below.
There is good evidence at multiple levels within the body’s physiology that psychology, the nervous system functioning and our immune systems are all linked (termed “psychoneuroimmunology” or PNI) https://en.wikipedia.org/wiki/Psychoneuroimmunology#:~:text=Psychoneuroimmunology%20(PNI)%2C%20also%20referred,systems%20of%20the%20human%20body.
If we ignore this we will never treat people, only ever diseases … and that is something that as doctors we learn is not ok. It is something that doctors of old had to learn by trial and error, and we have to learn from their mistakes. Unfortunately, it is exactly what our current and recent government guidelines seem to be doing. Initially it felt like they were trying to strike a balance (treat the person), now it does not.
It is because of this (and the surrounding knowledge that comes from all of this) that I cannot condone lock-down and I cannot agree with ‘the science’ as it is currently being presented.
In its pure form, science is the systematic intellectual and physical study of the structure and behaviour of the natural world, one thing at a time. It uses initial observations to come up with a simple 1 stranded question that can in time be answered. It turns that question into a hypothesis that through repeated experiment and observation can yield an answer. … An answer that will be the same every time you repeat the experiment. Any decent GCSE science student will tell you that a good experiment should only have one changing variable; that confounding factors must be accounted for; and that results can only be trusted to the extent to which the experiment was done well. An A-Level student should be expected to also add in that a hypothesis can only ever be disproved (not proved) and that results can be extrapolated to some degree in some circumstances, but that increasing extrapolation results in increasing margin of error. This is basic science: observation and experimentation, yielding results that can then be interpreted to give conclusions.
The basic science around Covid-19 therefore must adhere to these principles. It therefore mainly comes from a lab. In the labs they isolate Sars-CoV-2 (the virus name – Covid-19 is the disease presentation name) they culture it, they experiment with it to answer questions such as: What does it do on this medium? Does light effect it? Does heat effect it? Will it replicate in all types of human tissue cells or only skin / mucosa / red blood cells? They might go on to drop different human immune compounds on it: Does this stop it? What about this one? What about this combination? Basically they observe it in the lab under different conditions (repeating each one many times to verify it) to see what it actually does. What it does in the here and now. These are the results. This is the basic science. The results are then interpreted, and maybe extrapolated and some predictions and suggestions are made… These interpretations and predictions are not the science: it is the scientists trying to give advice and suggestions about what might happen, given what they have observed happening. It is of course why they did all the basic science in the first place, but as we know, the greater the extrapolation, the greater the risk of being wrong. … However it is these thoughts and further hypotheses that are fed out to us by the media and the government as “The Science”, rather than telling us clearly what the basic science shows, and what we can then interpret from it. It might seem a pedantic point, but I think it is an important one. Without it we don’t know how much weight to give each piece of information. We lose the nuances. For example, the basic lab science tells us that the virus can survive on hard surfaces in a laboratory. It also tells us we can pick it up on our skin from a surface, and that we can transfer it from our hands to our mouths. It also tells us that we can become infected when we have virus in our mouth and observation shows us that a few people with this virus can become very ill and even die. However the media rhetoric is that us “The Science” tells us it is on all surfaces, if we touch a surface we will get the virus and we will die. … In fact this is not even what the scientists concluded. It is a sensationalised version, and is untrue. It is fear-mongering.
On top of this issue above, mixed into the scientific enquiry and experimentation, and the ensuing conclusions drawn, is the mathematical modelling of epidemiology. Epidemiology is not basic science, although it uses scientific thought processes. It (hopefully) uses scientific data that is collected, but then pulls this into a mathematical model along with statistical data. It is a systematic study (like science)… but (unlike basic science) not of one simple controlled variable. It uses population data, scientific data and statistical tests to come up with predictions about the future. It can give us an idea of the ‘likely best case scenario and likely worst case scenario’. It is a bit like the conclusion drawing and extrapolation of the scientists, but unfortunately it is a more complex process and so can’t ‘repeat and verify’ in the same way. The way Epidemiology verifies and modifies its hypotheses is to add more data over time and ask does this still fit the model? Over time this means that it can become incredibly helpful and accurate – significant amounts of data, from all over the world, and over a significant period of time, looking at how temperature, climate, population density, demographics, and a multitude of other factors can influence whichever disease it is looking it. We rely on it for a lot of our understanding of disease and therefore also for finding things that might work in treatment. … However in the early stages of a new disease it is known to be crude in its estimates and at best to give only moderately accurate predictions. So in a few years, when this is behind us and there is a lot more data, and a lot more time, it is likely that a model will be created that is able to accurately predict the next Covid-19 flash. But currently that is not the case, and we must remember it is not pure basic science that gives us quick and simple answers. However the current crude (early) models also are fed to us via the media along with the scientists’ conclusions and thoughts, as “The Science”.
With regards to the Covid-19 pandemic, there is even more of an issue. The original mathematical model used for Covid-19 has now been widely discredited. … more information was fed into the model and it did not fit. In a basic science field we would describe the equivalent as ‘disproving the hypothesis’ but epidemiology is not able to be so concrete … so it can only be discredited, which although in reality the same, sounds much more opinion based …. and the policy makers are therefore free to still use it to inform our policy.
Businesss insider article
Statistical modelling discussion forum, Columbia University, NY.
In any pandemic there will be an ‘excess’ of deaths – more than the norm for that time of year, or that population or that country. Not overwhelming our ventilator capacity was a very reasonable aim in the early part of the crisis – particularly with the mathematical models we were working with. However, rather subtly and without overt statement or explanation the mantra seems to have changed to suggest that no-one should get Covid-19.
So we need to stop and ask: What are the true objectives of our national response?
I suggest that the questions we need to ask are below:
Set A – Public health objectives
- What is the public health (PH) objective regarding Covid-19 as an isolated single issue?
- What response best meets that Covid-19 PH objective?
- Is the PH objective regarding Covid-19 reasonable when looked at in a total health context?
- Is the policy response to the Covid-19 issue reasonable when looked at in a total health context?
Within these PH questions lie these questions:
- Are we saving lives:
- Are we as a species going to gain long term immunity (full or partial) to Covid-19?
- If so, is that something we should aim for?
- If so, then by exposure or vaccine or both?
Alongside these we must ask: Is the response to Covid-19 allowed to increase the risks of other health issues?
- Which health issues? – Physical health issues, mental health issues?
- By how much?
- For how long?
There are other questions about Track and Trace, asymptomatic patients / carriers, long term lung effects of severe disease, the inaccurate measuring of lethality (CFR vs IFR) but I think maybe I’ll leave that for another time or for someone else.
And then there are the broad ethical and moral questions:
- How much might we gain from re-evaluating our priorities and creating a greener economy?
- How much are we prepared to sacrifice our nation’s children and their future – from our economic collapse and from the psychological effects of the lockdown response?
- How much are we prepared to sacrifice our mental health for our physical lack of symptoms?
- How much we are willing to lose our freedom – to have a life, but not to live.
ALL of the above questions and their complex, (sometimes non-binary, sometimes individual specific) answers play in to the much more complex CLINICAL picture of how Covid-19 is affecting us as individuals and as a Nation / world.
The Covid-19 whole picture is a Clinical Medicine picture and Clinical Medicine is not a pure basic science.
Clinical Medicine uses basic science to inform as a start point and then uses observation, case studies, clinical experience, understanding of the patient in front of us, understanding of the social situation in which that patient lives, intuition, partnering with a patient in decision making, risk balancing and even an understanding of health economics to make a CLINICAL Judgement on what is the right course of action.
We are being led by a group of people (our government) who have no clinical understanding, and by a scientific (not clinical) Advisory Group (SAGE) that labours under the same problem. Science can only answer simple questions. Science cannot answer whether we should have lock-down and whether lock-down will be good for us and save lives. Science can answer questions like: Does this virus spread between people? How is this virus spread between people? Can this virus float around freely in the air to infect anyone? And therefore the scientists can interpret and extrapolate to give us answers to whether lock-down will reduce the risk of contracting Covid-19 … and therefore reduce the number of people from dying of Covid-19. I think we can clearly see the answer to that will be YES. Any illness that can transmit between people will of course have less people contracting it if people keep away from each other. You don’t need to be a scientist to come to that conclusion, if you have the scientific data from the questions science can answer.
The problem is that “Will lock down and social distancing decrease the transmission of this virus?” is not the right question to ask. If we simply ask that question we should ask it of all illnesses…. And the answer would be the same for any person-to-person-spread pathogen. The question that needs to be asked is “Should we have lock-down and social distancing?” This is not a science question. This is a philosophical question, a moral question, an ethical question…. And maybe a Clinical Medicine question.
Covid-19 does not exist in a background of zero other illness; nor does it exist in a vacuum of zero other things than can negatively affect health; nor do people exist in an easily controlled science experiment. We MUST look at the bigger picture. And the bigger picture is this:
Worldwide disease context:
- Air Pollution kills ~7 Million people worldwide per year … every year. These are preventable deaths by changing behaviours – but we don’t change our behaviours / legislate to prevent them and they are not in the news. (https://www.who.int/health-topics/air-pollution#tab=tab_1)
- Malaria kills ~0.5 Million people per year …. every year. These are preventable deaths by providing mosquito nets to all in risky areas – but we don’t provide enough mosquito nets to help and they are not in the news. (https://www.who.int/gho/malaria/epidemic/deaths/en/)
- Measles kills 100,000 plus per year … every year (140,000 in 2019). These are preventable deaths by providing a simple, cheap vaccine to all – but we don’t provide that vaccine and they are not in the news. https://www.who.int/news-room/detail/05-12-2019-more-than-140-000-die-from-measles-as-cases-surge-worldwide
- Cancer kills ~9 Million people per year …. Every year. Approx 3 Million of these deaths are from ‘easily preventable cancers’ … diet, smoking and lack of exercise / obesity. … but people don’t change their diet or their habits – and it’s not in the news. (https://www.who.int/news-room/fact-sheets/detail/cancer)
- Influenza kills ~650,000 people per year (worldwide) from direct respiratory causes, plus all the flu-related non-respiratory deaths we know we see every year. (https://www.who.int/news-room/detail/14-12-2017-up-to-650-000-people-die-of-respiratory-diseases-linked-to-seasonal-flu-each-year)
- Covid-19 has killed 580,000 people worldwide so far, obviously that death rate will still go up, but it is at least beginning to peter out in most countries as far as we can see. … Not because of lockdowns (although some public health measures can play a part to help decrease it faster), but because of how pandemics and epidemics behave. (https://www.youtube.com/watch?v=7SM4PN7Yg1s)
UK Holistic Health context:
- The usual death rate in the UK is ~9,000 per week. The highest death rate in the peak of the covid-19 pandemic was ~16,000.
- The usual death toll from seasonal flu in the UK is ~17,000 per year. This year it was only 1,692 (I have no idea why it was so incredibly low) and we don’t yet know what the 2020-21 season will bring. … So Excess Deaths from Covid-19 cannot yet be counted. … as they are counted as ‘excess for year x’
- The estimated extra deaths from late treatment of cancers is predicted to be ~7,000 up to ~35,000 (https://www.bbc.co.uk/news/health-53300784). This relies on mathematical modelling, but it is it modelling with a lot of data over a long time, so is likely to be reasonably accurate. (The lower figure relies on everyone waiting for their treatment to have slow cancer progression and for it not to have increased in cancer stage, the higher figure I think uses a model where all cancer stages have gone up by 1)
- The Covid-19 lockdown has cost the UK government an estimated £298 Billion for this financial year…. And the long terms costs of a shrunken economy have not yet been predicted.
- Socioeconomics significantly effects health outcomes … this is a complex correlation, but includes poorer diet, increased levels of smoking, decreased mental health, decreased education, increased domestic violence and many other things. (http://cfoaservices.co.uk/pdf/ProfessorSirMichaelMarmot.pdf)
- Unemployment is set to soar … This leads to worse socioeconomics and therefore worse long term health outcomes.(https://www.theguardian.com/business/2020/jun/16/uk-unemployment-furlough-scheme)
- Domestic violence (the effects of which can last a lifetime) cases and reports have increased significantly and in the first 3 weeks of lockdown 14 women and 2 children were murdered by domestic household members. (https://www.un.org/en/coronavirus/un-supporting-%E2%80%98trapped%E2%80%99-domestic-violence-victims-during-covid-19-pandemic)
- Child abuse cases (lifelong psychological harm) have gone up as has the demand for online obscene material. (https://www.bbc.co.uk/news/uk-52876226, https://www.bbc.co.uk/news/world-52773344)
- There have been an excess of deaths from Non-Covid causes throughout lockdown. As a GP I and many of my colleagues feel that these have been both directly due to lockdown, and due to the advice not to bother the doctors. These are the tragedies. The covid-19 deaths are part of the pandemic of covid-19. These others are due to the pandemic of fear. (https://www.imperial.ac.uk/news/198444/report-estimates-9000-non-covid-excess-deaths/, https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/analysisofdeathregistrationsnotinvolvingcoronaviruscovid19englandandwales28december2019to1may2020/technicalannex#:~:text=1.,coronavirus%20(COVID%2D19).
So, Covid-19 is a pandemic. It will kill people.
The experimental science tells us
- it is passed person to person
- It is probably transmitted in droplets
- It seems to need access to our wet mucosa to actually infect us.
The observational science tells us:
- It seems to infect the elderly, those with poor metabolic health (e.g. males over 60 with diabetes and obesity) and / or low vitamin D levels more severely and therefore a greater proportion of those groups die. (the elderly tend to have lower vitamin d and poorer metabolic health)
- Fever, cough and or loss of smell/taste in are thought to be the commonest symptoms, but recent UK testing data indicates that 78% of people testing positive have no symptoms at all
- It creates breathlessness in some people – this seems to be a marker of worse infection or worse immune reaction
- A very small number of people have an unexpected and severe immune reaction to it (a cytokine storm) and this can unfortunately kill them (SARS like reactions)
The Epidemiology tells us that pandemics have graph plots that go up and come down again. At this point in time the epidemiology of this particular new virus is not fully understood as the maths modelling hasn’t had the time it needs to become accurate.
The wider picture tells us that stopping social interactions, stopping other health care, stopping education, closing businesses may help to ‘flatten the curve’, but have a huge overall detrimental effect. We have to weigh up what we think the right balance is.
For me the current balance is definitely wrong.
Pandemics are part of the natural rhythm of the world we live in, but they are made worse by human failings and the ‘successes’ of our species – overpopulation / overcrowding, pollution from industrial economies, pollution from consumerist economies, human-caused climate change. On this occasion we have also made the recovery worse, and lost a lot of the successes we hold dear.
We should move out of lock down and social distancing, but ideally into a calmer, more nature based, culture. A culture where we appreciate our friends and family. A culture that maybe doesn’t need so many huge mass gatherings and long fossil fuelled journeys. A culture that promotes recovery for all … all people, all species. This would maybe make the losses we have created and endured in lockdown more worthwhile. It would maybe start to give us some tangible gains and even lessen the chances of future pandemics.
As an A-Level student I had to write a 3000 word essay arguing that “Man’s continued success will be his ultimate downfall”. I looked at the rise and fall of cultures, at the increased prevalence of diseases in built up areas, in the mental health of those living with lack of access to nature. I also looked at the climate effects that were known in the 1990’s of our ‘success’ … logging the rainforest, acid rain, rising sea levels, holes in the ozone layer. …. Man’s success is clearly going to be our ultimate downfall if we continue to measure success in the same way. If we don’t change our ways through this opportunity, it may end up a downfall by pandemic.