Hot flushes make the news again.

Posted on April 28, 2022 by Elen Samuel

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

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

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

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

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

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

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

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

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

Posted in Health Delivery, HRT, Medicine, sexual relationships | Tagged , , | 2 Comments

Misogyny and contraception

Posted on January 15, 2022 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Vaccine Hesitancy and Anti-vaxxers.

Posted on January 1, 2022 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Covid-19, Immune systems and Neanderthals.

Posted on March 16, 2021 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Long life, Pandemics and Populations

Posted on February 1, 2021 by Elen Samuel

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Posted on November 2, 2020 by Elen Samuel


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

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

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


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

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

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

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

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

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

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

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

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

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


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

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


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

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

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

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

Posted in Coronavirus, Health Delivery, Health Management, Health Policy, hospital beds, old age | Tagged , , , | 4 Comments

Coronavirus – Covid-sars-19 – the long view.

Posted on June 17, 2020 by Elen Samuel

First the good news. The pandemic will end sometime, because they always do. There are three ways in which it could end. Firstly, with a vaccine or a really effective treatment for the severe cases. This is the best case scenario, and the only questions would be, in the meantime, who and how many would die of it, or be left permanently crippled by it; and whether the world economy can recover.

Secondly, it could go on for years, with countries managing it as best they can, containing it where possible, or if not, trying to protect those who would be most severely affected. This would involve a considerable number of deaths, before it mutates to something different, which could be to a milder form or (hopefully not) into something even worse. This is where we are at the moment.

Thirdly, it could end because everyone has either had it and died or got immunity. This is how the 1918 flu virus ended. Similar strains have frequently emerged since and caused quite a few deaths, but that virus is no longer around. This is the “herd immunity” strategy.

Of these the far most palatable is the first, and I have high hopes there will be such a breakthrough. Of the two possibilities, vaccine or treatment, I personally think the treatment option would be the more useful. The hallmark of this virus compared with all other respiratory tract viruses is that, as we know, it is a mild illness for most fit young people, and disproportionately attacks older people and those with “pre-existing conditions”, as the phrase goes. If the virus progresses to its second stage, where the immune system appears to go into overdrive, then perhaps only 50% will recover, and many of these will suffer long term sequelae. If this stage can be targeted by new drugs, then this would be the best way of protecting those elderly and vulnerable. As soon as they show signs of severe illness and need intensive care we might have drugs which might both prevent it getting worse and treating it quickly, stopping the severe damage caused by this second stage. Because of the unique way the virus enters body cells, I am confident that sooner or later we will get such a drug, or more likely, drugs, in combination. We did it for AIDS, which was again a deadly killer, worse than coronavirus. Indeed, as I was writing this, came the news that dexamethasone has been found to reduce death rates slightly in the most severely ill. This is excellent news, although not surprising. It is the obvious choice for severe inflammation of any sort. Possibly it has been used many times by doctors “off label”, since the pandemic began, with benefit to some patients already. Of course it was essential to have a proper clinical trial to prove it worked, and so it is great news that it has been proved to be successful so conclusively. More drugs will need to be developed though, especially to find something that will prevent this second stage of the disease entirely. It might take a while. The countries which have tackled it early, such as Taiwan, New Zealand and so on will have won out, because they will have saved tens of thousands of their citizens from an early death – if they can continue to keep the virus away in the meantime.

A vaccine, on the other hand, works far less well for the elderly than it does for the young and fit, because their immune systems are often so weak. So it would protect the young and fit, who don’t need protecting from the virus itself, and only when herd immunity has built up through the community will the elderly themselves be totally protected. This in turn means that the whole world would have to be immunised, and that would require organisation, cooperation and an absence of corruption. These traits are not obvious in the world as we know it.

So in the meantime, what can we do? I think we need to recognise why this virus is so novel and why it has arrived just now. If we think of the virus world as organisms trying to get a foothold in an ecological system so that they can multiply exponentially as soon as possible (which is what they do) then this virus has identified with terrifying accuracy the weak spots in humanity in the twenty first century. Firstly, there are far too many of us. We are probably nearing the end game of unrestrained growth on this planet, and the global system of feeding ourselves is beginning to fray. It’s no coincidence that this virus was born in a food market. Irrespective of coronavirus, we are approaching the horrors of overpopulation which can befall any species – famine, plague, war, or any combination of these. But we have technology on our side and we have an extremely effective system of health care across the whole world. Some people think that this will keep us safe forever. Good luck with that. So very cleverly, this virus has found a way of attacking our new weak points.

When I started in medical practice in 1970, the population looked very different from now. People in general were thinner, (there were very fat people, but far fewer of them), they ate very simple food, especially after the war; and there was very little processed food, except perhaps the ubiquitous Spam. High blood pressure was very rare, but also very severe as we didn’t recognise the milder forms as being a problem, and diabetes also quite rare. Heart attacks and strokes killed huge number of men at very young ages, as did peptic ulcers. Respiratory disease was rife because of smoking and pollution at work, especially in the mines; and in the atmosphere. Life expectancy was much shorter. Over my time in practice, most of these diseases were tackled spectacularly well, and life expectancy rose rapidly. But few diseases, usually infections, were completely beaten, and so from the 80’s upwards people began living longer with long term conditions, sometimes taking very expensive medication. Nowadays it is the exception rather than the rule for the over 60’s to not take any medication at all. This is the population that the virus has found a way to target, through the ACE receptor. We medics first heard of the ACE protein in the 80’s with the advent of a new drug to tackle high blood pressure, and these drugs, called ACE-inhibitors, were very effective in preventing the long term effects of high blood pressure on the cardiovascular system and heart. But just as we were learning to treat and prevent the epidemic of heart attacks, very successfully indeed (although we were never quite sure how we did it ) we human beings in the developed world, developed things further in order to feed the hordes of new people who were being born, and surviving. This involved energy- intensive factory farming, and in order to make it cheap, food companies added more and more sugar, low quality fats and excessive salt to our diets. It took a long time for scientists to realise that it was sugar not fat that was causing the obesity epidemic, and therefore the diabetes epidemic. And now what do we find? The people who are targeted by this virus for especial harm are the obese and people with diabetes and heart problems. It isn’t a coincidence. While we are not sure of the exact relationship between the way the virus gets in to the body and the people who suffer from it the most, there is no doubt that they are the victims. So the virus is finding the weakest leak in humanity – those who have suffered from the consumption of poor quality food, have become obese and often have diabetes, heart and circulation problems and are being kept alive by modern medication. Of course this is an oversimplification. But the link is clear.


There are other risk factors that the virus rather likes – male sex, poor immune systems due to disease, and, it seems, black and minority ethnic people. The excessive risk for men versus women seems to be because women have two x chromosomes which have more genes for coding healthy immune systems. Nothing we can do about that, I am afraid. And any one with a chronic disease, especially cancer or leukaemia, is very vulnerable. Transplant patients whose immune systems are deliberatively weakened to prevent their own cells attacking the transplant. are also at great risk. They must all be protected while we wait for salvation by technology. But the problems BAME people face are interesting. It is becoming very clear that it isn’t because the virus targets such people because of race. There is no racial gene here. If it were so, you might find that people of African descent might have the lowest death toll from coronavirus, not the highest, as the prevalence of diabetes in countries of SubSaharan Africa is the lowest in the world, between 4 and 6 %. But in Africa, as in the rest of the world, urbanization leads to a change in diet towards the highly processed food, full of sugar, refined carbohydrates and low quality fat that we eat in the west, so that urban dwellers have a higher incidence of obesity diabetes, hypertension and cardiac problems, than in rural areas. And the same thing happens when present day Africans, and previously their ancestors, migrated to higher income countries of the west. Unfortunately on average they did not partake of the higher incomes in their new homes and now often lIve in relative poverty. So their incidence of chronic disease such as diabetes and cardiovascular diseases rises, and that, together with their increased exposure through their low paid work to the virus as front line workers, explains the very high death toll amongst black workers in New York and other cities in America and in the NHS workforce in the NHS in Britain.

So, to recap, I have seen in my lifetime a cohort of people come into existence who have been damaged by human progress, in that their food choices have been constrained by the need to supply ever more people as cheaply as possible. They then become dependant on the ability of modern medicine to keep them alive. Up to now we have tolerated this situation – even congratulated ourselves on our long lives, those of us now in retirement anyway. But the virus has evolved to hit these people hardest. However optimistic we can be that we will develop treatments and vaccines to beat it, I think it is inevitable that the increase in longevity that we have all taken for granted will stall (actually it had already stalled due to austerity), and then fall quite substantially, but probably most rapidly amongst the poor. And for those who are rich, and also very risk averse, there will be a considerable reduction in enjoyment of living.

Up to now, feeding the world has been a success story in that we have greatly reduced starvation and malnutrition all over the world, even though the population has been rising very fast. Our methods of farming have developed using copious supplies of energy from fossil fuels, 30% of all ice-free land, and 70% of available freshwater. But livestock is the world’s largest user of land resources, representing almost 80% of the total agricultural land. One-third of global arable land is used to grow feed, while 26% of the Earth’s ice-free terrestrial surface is used for grazing. And there are likely to be 2.3 billion more people in the next four decades. So we need to take a hard look at ourselves. Maybe it is inevitable that feeding large populations cheaply will have side effects, such that they can be exploited by ever new viruses. But changes will have to be made, to reduce the amount of meat we eat, change to other sources of protein, and reduce waste. Can this be done in the present Ponzi scheme system of more and more people consuming more and more of everything? On a finite planet? Of course not. We also really have to address the problem of overpopulation as well as of overconsumption. Big time. But will we do it? Not with insufficiently regulated market forces for sure, which are poisoning our world in so many places. I do hope that eventually after some years of living with this virus we will have the courage to change our ways, because otherwise our lives are likely to be changed in even worse ways. We are running out of time, and this virus is the first of so many challenges we will have to face. Let’s hope we rise to this one at least.

Posted in Coronavirus, Food, Health Delivery, healthy food, Medicine, pandemic | Tagged , , , , , , , | 2 Comments

So who really gets really sick with Coronavirus?

Posted on April 4, 2020 by Elen Samuel

It is still very early days of this new life for all of us. There are such a lot of changes – home working, loads of leisure time to fill, catching up with friends we have neglected due to busy schedules. There really are lots of positives for those of us wealthy enough not to have to worry about finances, feeding ourselves or looking after other family members., Quieter shopping, more outdoor exercise rather than the gym, and perhaps a re-evaluation of life in general. Pollution of the envirnoment is plummeting all over the world. In the end it could lead to real benefits for many people.

But for those who are not fit, reasonableIy well off or have difficult family problems, it is a different matter. People who lose their jobs suddenly are being helped by the government’s schemes but some are not covered and those already in debt are in an even worse predicament. Economies seem to be at a loss – what will be the result of an almost complete shut down of the economy and the sudden appearance of a magic money tree, being shaken now very vigorously to all sections of the population. I have even heard talk of a Debt Jubilee, which is a grand out-of-court settlement between bond investors, banks and consumer groups – “great haircut” – to fix the underlying problem of excessive debt ,and jump-start the economy. Apparently this is what was done in 2,400 BC, when the Sumerian king Enmetena declared a general debt cancellation in his kingdom. A debt jubilee is a recognition that economic life must be socially rooted if it is to be sustainable. If debts can’t be paid off, they won’t be – and it might be better for everyone if that can be addressed peacefully. Compare and contrast the treatment of Germany by the victors in the two world wars. After WW1 Germany was punished and its economy ruined, with dreadful inflation, leading to the rise of fascism; after WW2 in 1948, the Allied Powers replaced the reichsmark with the Deutsche mark, wiped out 90% of government and private debt and paved the way for West Germany’s economic miracle. In the present day case, without debt relief, especially for households at the lower end of the income and wealth spectrum, the world faces a prolonged spiral of depression driven by corporate collapses and rapidly falling demand for goods and service. Which way shall we go? A great levelling off, or a slump lasting for years which would kill far more people than co-vid 19? We shall soon see.

It is important to recognise that the present push for lockdown of populations in most countries worldwide, is to prevent health services becoming overloaded and so to enable as many people to be treated as possible. Most people with the virus have a mild illness or no symptoms at all. Only a small proportion need hospital admission., and even fewer intensive care. Yet so far the mortality in those who have been ill enough to need ventilation is about 50%, and in some cases even lockdown down does not prevent the epidemic becoming so huge that many people cannot be treated because of lack of staff and equipment. The virus will run its course, and those people who are going to die will do so when the restrictions are finally lifted, as they would have to be in the end. It will be important to discover in more detail exactly which patients are more likely to die.

While we know that age and underlying chronic illnesses predispose to an increased incidence of severe illness needing treatment, it seems that many younger people without previous illnesses are now dying. A report from the Intensive Care National Audit and Research Centre found that of the 196 patients admitted to participating hospitals (England Wales and Northern Ireland) up to 19th  March, 16 died, 17 were discharged and 163 remained in critical care. This shows how long people stay in critical care and why so many staff and so much equipment is required. Almost three quarters (139) were male and the median age of those included in the audit, which is the first to outline in detail the case mix of UK patients in intensive care, was 64 years. This means that a lot of the patients were much younger than those reported in China. But something new was also noted. Only 20% of those patients had a BMI under 25 ie. were of normal weight. 33% had a BMI of between 25 and 30 (mild obesity, 33% between 30-40 and 13% were severely obese. (BMI >40). While the `British population is getting more obese, this is definitely skewed towards obese people needing intensive care more often.

So is the virus mutating? In Wuhan in China nearly all the people who died had either an underlying problem, were over 65 or both. It doesn’t seem like that now.

The only good way out of this situation is more research, with the ultimate aim a specific vaccine, or a new treatment. Once we have that we may be able to prevent so many people getting so ill. The work is already well under way, usuing a new technology – a “recombinant” vaccine*. About 35 companies and academic institutions are racing to create such a vaccine, at least four of which already have candidates they have been testing in animals. The first of these – produced by Boston-based biotech firm Moderna – will enter human trials imminently. This has been facilitated by the fact that many firms were already working on flu vaccines, because of the SARS and MERS epidemics, and because Chinese scientists were very quick to sequence the DNA of Sars-CoV-2, which shares between 80% and 90% of its genetic material with the virus that caused Sars – hence its name. A series of clinical and human trials are about to get underway, with the first, involving a few dozen healthy volunteers, testing the vaccine for safety and monitoring for adverse effects. The second, involving several hundred people, usually in a part of the world affected by the disease, looks at how effective the vaccine is, and the third does the same in several thousand people. But many vaccines fall by the wayside because they are unsafe, or they’re ineffective, or both, and the process must be safe and can’t be hurried. That’s why they say an effective vaccine may be many months away.

However, we must hope that science will win this battle. We must also hope that politicians now realise that it is vitally important to plan for epidemics and pandemics, and embrace policies that put the health of the population very high on their lists of priorities. Now that some countries, notably USA, UK and Australia have now realised that free market dogmas only work when times are good, let’s hope that there is a sea change in recognition of the importance of scientific rigour in future decisions. This might even lead to an understanding that climate change too needs to be treated very seriously before we all succumb to even more threats.

Posted in Health Delivery, Health Policy, hospital beds, Medicine, science | Leave a comment

Why did I become a doctor?

Posted on March 26, 2020 by Elen Samuel

As the coronavirus rages about us,  for many of us it is a time of contemplation.  For one thing, we all have time to think, and the fact that some of us may shortly be facing the fight of our life, concentrates the mind wonderfully.

So rather than continue this blog on things in medicine to be sceptical about, when this is definitely not a time to be sceptical about anything that might help the science of medicine, I have decided to write about myself, and why I decided to become a doctor.

I think many others of my age will also be doing this.  It is a time for reflection; about how we got here, and how future generations might do things differently, to the greater benefit of the planet and ourselves. So exploring the past seems a good place to start.

As I mentioned in my latest blog, on coronavirus, I am 75, which means that I was born in 1945, on a very cold day in January to be exact.  During that month the war in Europe was coming to an end with the Soviets advancing quickly from the East. The Auschwitz concentration camp, with its last 7,500 inmates still present, was liberated by Soviet forces that month, to the horror of the liberating forces.  It was clear that things were finally going our way, although the war in the far East went on until August when the Japanese surrendered after the Nagasaki bomb. 

Another baby born that month was the famous cellist, Jaqueline du Pre. 

I was brought up in Ebbw Vale, a town in the higher reaches of the Welsh valleys, which is famous for having as its MP for many years one Aneurin Bevan, who was the impetus behind the British NHS.  But I wasn’t born there, although that was where we lived, because my mother, aged 39, was expecting twins in her first pregnancy. The doctors thought that it was too dangerous for her to give birth in the Rookery, the local maternity hospital which had no doctors, but should travel 20 miles to the Lydia Beynon Nursing Home in Caerleon, where there were supposed to be doctors available. (This site has now been redeveloped into the Celtic Manor Resort).  In the event there may have been, but my mother did not see any as the birth was entirely straightforward. I was the second twin, my brother coming into the world 10 minutes before me. We were both small but a reasonable size for twins and we had no problems.  My mother took us home  (I have no idea how) after three days. 

Ebbw Vale at that time, like every other town in Britain, was in a state of heartfelt relief that the war, which had been going on for 5 years, was finally coming to an end. It was a time of hope and the town was beginning to think of what  would happen once peace was finally declared. Although most people think of the South Wales valleys as steep sided valleys with rows of houses along the bottom, Ebbw Vale was right at the top of the massive chain of valleys, and was therefore quite exposed. The bottom of the valley floor was 1000 feet up, and the mountains on either side reached over 1,800 feet, merging into open moorland, known as the Llangynidr moors.  Many houses had been built at the very top of the valley – in Spain it would have been known as a cirque, but we called it the cwm –  where the winds were pretty fierce.  It was always at least 2 degrees colder  there than down in the luscious Usk valley below. 

But it  was a very good place to grow up in. It had suffered dreadfully in the years after the great depression and my mother used to tell me of how people often used to go hungry, and  how poor some people were. She was the youngest of six, all of whom lived locally while we were growing up, and they weren’t nearly as poor as some – her father was a railwayman. Although the predominant employment at the time was coal mining, in the mid-thirties a steelworks, later known as Richard Thomas and Baldwins, had been built, and the town had begun to thrive. It was a close community with a strong culture, based on Eisteddfodau, literature, music, and regard for education. The steelworks were  the biggest in Europe and so quite important during the war, and so the town had set up a “Report Centre”, where people were organised to go out looking for any evidence that Hitler might have dropped a bomb locally on the mountains, or if there were any suspicious happenings.  As it happened, my father and mother both were volunteers there. My father was a teacher in the local grammar school, and at 40 was considered a confirmed bachelor, as he had never shown any inclination to get a girlfriend. My mother was also a teacher, also unmarried. She was a supply teacher, unqualified, but did the same work as a qualified teacher, for roughly half the pay. They lived on adjacent streets; my mother  with her brother’s family in Eureka Place and my father in “digs” in Brynheulog street, and they already knew each other socially, of course. And at the report centre they found that they had one important mutual interest – classical music.  My father had a primitive gramophone which played 78rpm  records. You needed 6 or so records to play a whole symphony so there was a complicated device where you could pile the records on one another so that they would automatically drop down at the end of each one, so that the next record could start playing. It must have been very exciting to hear a whole symphony in this report centre. Needless to say there wasn’t a lot to do there – Hitler never seemed to think that RTB’s steelworks, which we all thought was the ultimate in importance, worth bombing. In any case he would indeed have been very lucky to hit it – the mountains on either side were vast and planes weren’t that good at hitting long thin targets.  So our parents’ romance blossomed, and in February 1944, they decided they would get married, despite all the difficulties of the war, which was still in full swing at the time.  And eleven months later, we twins were born. I always say that it took Hitler and a world war to bring together these teachers living almost next door to each other in a small town. But obviously I am very glad it happened!

We were healthy twins on the whole, and put on weight rapidly. But health was a much more risky thing then, and my brother developed diphtheria at the age of 14 months.  It was a very serious disease, affecting the throat and sometimes causing fatal breathing obstruction. He was very ill in hospital for a month. It must have been a dreadfully worrying time for my parents, but he pulled through. Apparently I was badly affected by it, and missed him dreadfully.   But that was not the only time my brother was in hospital  I remember clearly what happened just after our third birthday. We decided to carry some books we had been playing with, upstairs. The stairs were steep and we decided to put the books on to a tablecloth, and we were carrying them upstairs with some difficulty. But just as we got to the top of the stairs Roger, who was below me, lost his footing and fell to the bottom, and broke his femur. I remember how upset I was, and I think now that perhaps I thought I had caused the accident – could I have pushed him? No-one would know of course, as no-one  witnessed it, and I don’t remember. But I was very distressed. I remembered visiting him in hospital with his leg pulled up on a pulley for weeks, and I was inconsolable.  And when he came home I fussed over him and was determined to look after him, to the point when I really got in the way. That was when I told everybody that I wanted to be a nurse when I grew up.  Then when I was a little bit older I was told that there were such things as lady doctors and I decided that I would be one of those. 

That conviction never left me, and when I passed the eleven plus and went to the grammar school, I took all the options for medicine, and eventually qualified and became a family doctor. 

So even without having Aneurin Bevan as my MP, medicine was in my blood, so to speak.  But he was a big influence on me and I went to hear him several times.  Roger was very interested in politics, and he took me to labour party meetings when we were in our teens. Aneurin Bevan used to speak at the “Stute” – the Miner’s and Working Man’s Institute, and he was a very fine speaker.  His stammer, which was still there even though he had worked hard at overcoming it, was actually  something which endeared you to him, and he could really get us very emotional about what needed to happen. It is not surprising that I have never got rid my strong social conscience.  I worked for the NHS the whole  of my life and I totally believe in a strong health service available to everyone.  Diphtheria is now no more because of the development of vaccines, and I can never understand the anti-vaxxers point of view.  I just wonder how many of them will refuse the anti-SARS-CoV-2 vaccine when it comes?  The one thing that consoles most of us in Britain who are in lockdown just now is that we know our NHS will do its very best for us, at no cost, and the staff will give their all. It is tragic when  politicians  deny them  the protection they need. 

I would like to think that this new pandemic will change the way public health is approached, and I would like to write more on this later as things develop.  So look out for my next blog!

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The real meaning of Coronavirus

Posted on March 20, 2020 by Elen Samuel

Well, we are in a mess. We have an ordinary sort of virus (whose closest relative is the common cold), which mostly causes a severe flu, from which most people recover without any complications. Admittedly it has a death rate probably more than twice than the usual flu we have every year, but compared with the plagues of yore (bubonic plague, (Black Death), typhoid, and the 1918 flu epidemic), this is a mild illness. It doesn’t come near AIDS, SARS, MERS, or Ebola,, the most recent really nasty communicable diseases to have threatened us, although they were quickly seen off with new treatments or vaccines. But nothing has caused the amount of fear, economic disruption and devastation of our day to day living, so quickly, as this has.

What is the difference? It seems to be that our civilisation has a moral code – that of wanting to look after the most vulnerable in our society; the elderly, the ill, and the poor, that is extremely admirable. Even countries with hard-wired policies of prioritising the needs of the fittest (the USA, the current British government, and China), have realised that a death rate of up to 18% of our oldest and frailest citizens is going to cause disruption on an immense scale, and that politically it would be unacceptable. The death rate of gay people from AIDS at the beginning of the 90’s, though huge, did not cause this economic upheaval even though many of the victims were economical active and successful, possibly because the target of the virus was a small minority and not as valued by the ordinary (straight) folk of the time. Happily both AIDS and the discrimination has since diminished greatly.

It shows that the elderly, our parents, grandparents, and other older relatives, are really valued, and younger people get really upset when they become ill and die before their time. Doesn’t it?

Yes in part, of course it does. But we also have to take into account that in the last 30 years our society has acquired a very large pool of elderly frail people, with many chronic conditions. This virus is, very cleverly, taking huge advantage of this new susceptible group of hosts.. The Coronavirus, proper name SARS-CoV-2, has mutated to target a particular protein – the ACE2 protein on the surface of cells, in order to get into the cell. This ACE2 protein is one which is found in the cardiovascular and respiratory systems, and when people already have problems in these systems, the virus can kill very easily. It is very clear that once people have severe pneumonia or sepsis with this virus and need ventilation and life support, they can be critically ill for 3 or more weeks and 50% of them may die. This will overwhelm even the most advanced health system such as that in Lombardy, as well as China. We don’t even know what the long term effects are in these people – they may be very debilitating. And It spreads very quickly because there are so many such people in such high concentrations alive today.

We also need to take note of the fact that some of these people, the over 60’s, are amongst the most powerful people on earth. This virus strikes at the heart of economic privilege. OK, we can be sure that the richest in society will be able to jet off to safe havens, and if they do get ill, will have the very best of treatment; but most well-off elderly aren’t able to do this and are facing a situation when health systems, especially those which have grown up to cater almost specifically for this age group, cannot cope. Understandably they are very frightened and upset,

The systems we have for dealing with this situation aren’t working. Testing and quarantine do work – China, Singapore and South Korea have shown this, but even China does not have an exit strategy. When the restrictions are relaxed it is highly likely that the virus will reappear. We need to develop new treatments and most of all a really good vaccine, very quickly, Yet one characteristic of coronaviruses and other upper respiratory tract viruses is that they mutate very quickly (this is why the current flu vaccine has to change every year) and so it will be a real challenge to develop a vaccine which will last more than about six months.

So, is there an answer? Not that I can see. But as a doctor, who practiced over a period of 40 years, I can see that the way society has changed has, very gradually, made this sort of problem inevitable. For instance, In the medical literature and the popular press it is clear that some of the deaths have been in people who were in hospital anyway, being treated for severe illnesses, and after death were found to have tested positive for the coronavirus. Almost any agent could have caused this death. In the old days when I started practising as a doctor, pneumonia was considered to be the “old man’s friend” – a release from suffering after a life lived to the full. Nowadays death is not allowed, it appears, under any circumstances. Ordinary flu kills about eight thousand people a year, again usually people in very poor health. This year these people will die because of coronavirus instead, because it is a more aggressive disease. There will be many excess deaths due entirely to this new virus, but the number of years taken away will not be huge.

I don’t doubt that we will beat this virus, but it has already done a huge amount of damage to the world as a whole. I think it should be a wake up call for health systems throughout the world. Thinking of the 17 old people who died of the virus in one nursing home over a period of 10 days – this terrible toll isn’t likely to be due entirely to bad practices in the home. It is a risk when you have so many frail people, who are on the trajectory which is bound to lead to death in the near future, all together in one place.

I think the answer must lie with us elderly ourselves. I am seventy five, fit and healthy (as far as I know) and enjoying life to the full. But I know I won’t be fit for ever. I have no wish to stay in the anteroom to death in a nursing home for years. There must come a time when we are able to say to our loved ones “I have lived a fulfilling and enjoyable life. I now wish to have the ability to have a big, or small party, or no party at all, and quietly slip off without suffering”. If I became severly ill with Covid-19, I am not sure I would want invasive ventilation and life support for five weeks, with no guarantee I would live or be able to enjoy life afterwards.
And I would wish for the power that now resides with us elderly – the baby-boomers, the ones that have taken most of the resources to ourselves, to be transferred as soon as possible to the younger generations, who should not have to feel they have to prolong the lives of their parents beyond what is reasonable.

Posted in Coronavirus, Health Delivery, Health Management, hospital beds, Medicine, old age | Tagged , , , , , , , | 1 Comment