Covid, not to exaggerate, has ravaged our nation. The lockdown was severe in every regard – social, financial, employment, commerce, education, childcare, transport, aviation, leisure, mental health, sport, hospitality, religious gatherings, weddings, funerals, civil liberties and more. Of course, at the outset we knew so little of this disease that was galloping through the world, killing so many. We had not been here before. And so I hope any retrospective analysis will judge that the lockdown was entirely justified by the massive uncertainty. We did not know Covid’s disease profile, nor did we have any viable means to treat it. No wonder we emptied the shelves of alcohol gel (why pasta?), feared the postman spreading it though the post, or our shopping though products touched by others. Picking up litter, once a British thing to do, became off limits in case we infected ourselves. Closing a park gate was left to those with gloves. And stroking a passing dog was possibly suicidal.
Let’s fast forward to where we are six months later. We know that Covid is highly infectious, more so than many seasonal diseases. In short, it is easy to transmit and become infected. So the hand washing, alcohol gel and social distancing make sense. And, as a result of the infectivity, and mixing in the young, right now positive tests are blooming, especially the 18-35 age group. Yet very few are sick. And 97% of school children being tested return negative results.
So, at risk of defying all collective wisdom, is catching Covid necessarily a problem? Isn’t it much more about if we catch it, how it might affect us? How it translates into admissions, ventilated patients and deaths? Can I call these three (ie admissions, ventilated patients and deaths) AVDs?
Is it better to consider the threat to be AVDs rather than positive cases a transition in thinking too far for us? Or is this the logical conclusion to what we are seeing? Do the numbers of positive tests actually translate into AVDs? Of course, the established wisdom says yes. University students with minimal symptoms will still see grandma, and she might become ill, or even die. Young adults may work in care homes, introducing lethal cross contamination. Positive cases clearly can result in AVDs. Yet, maybe there is more to it than that. As we enter month 7, and the prospect of another 6 months of severe social and financial disruption, what might alter the actions we feel we need to take?
If AVDs are the real worry, let’s look at what we know. We have now seen almost 42,000 deaths, representing a death rate per head of population being one of the highest in Europe, followed by Scotland. But it might have been worse. Remember, we were initially told it might be 500,000 in the UK.
But where did these deaths originate, and who is actually at risk? So far around 20,000, or nearly 50% of our deaths arose from care homes. Yes, that was a catastrophic failure of screening and protection. But it arose from one endemic problem within the NHS. For years social care has been underfunded, meaning that capacity was poor. As far back as I recall, I carried out ward rounds where I resigned myself to the fact that several elderly patients would spend another night in an acute bed, when they actually needed a care home bed. So when Covid struck, many of our hospitals beds were occupied by people that did not need to be there. At last the vector to get these cases out of acute beds had arrived! And they were moved. The NHS mood was to applaud that, at last, things were as they should have been for years. But sadly they were not tested, as testing was rudimentary, and we all know what resulted.
The disease profile of Covid initially looked to be age determined. And we heard black minorities were of greater risk. But drill down on that and it isn’t precisely true. The risk of death is determined by finer discriminators. It is actually associated pre-existing illnesses that determines the risk. The comorbidities of diabetes, obesity, hypertension, chronic obstructive airways disease and dementia load the mortality massively. For example, we now know that one third of our deaths were in type 2 diabetic patients.
The interesting fact that is not mentioned by our experts, is the very low death rates in people of all ages who have no comorbidities. If these are removed, adults have a surprisingly low risk of dying from Covid.
Look at this bar graph, arising from Italy at the end of March. Our TV screens showed us very large numbers in Italy being hospitalised and dying. But those with no comorbidities made up hardly any of the deaths. And those with over 3 made up almost half of the deaths. It was the same in the UK where 95% of our deaths had pre-existing medical conditions.
Looking at almost 9,000 cases, here is the age breakdown showing the rising death rate with age in patients with comorbidities. In the elderly over 75, the death rate was 4.35%.
But if we then exclude those with comorbidities, we get a very different table. Even in older adults the death rate is very low. Fit adults over 75 had a death rate of 0.31%.
And to get this in context, over this past summer in the UK, more people died of influenza and pneumonia than Covid. In an average year 5,000-10,000 die of influenza, with an age spread that does not always spare the young.
Furthermore, right now in late September the Covid death rate is remarkably low. This is probably in large measure because of another, little discussed fact. And that is that the viral load appears to determine the severity of illness. Very large doses of virons (ie complete virus particles) were inhaled by some of the medics who sadly died early in the course of this pandemic. ENT surgeons, dentists and ophthalmologists faired badly. We were frightened into thinking that one viron would kill us. But the reality is that many of us have probably been exposed to some virons without illness resulting. And now, with mask-wearing and social distancing, people are not being exposed to large viral loads.
So here is the question. If fit and healthy adults with no comorbidities have a low risk of death, and viral loads are low, why are most of us not allowed to get on with life? Why are we continuing with the massive disruption to our society, economy, employment, commerce, education, childcare, transport, aviation, leisure, mental health, sport, hospitality, religious gatherings, weddings, funerals and, in short, all our civil liberties?
The answer, we are told, is that it is for the greater good, to protect the vulnerable. The author of the phrase ‘the greatness of a nation can be judged by how it treats its weakest member’ is disputed, but its truth is not. But are we interpreting this responsibility properly?
Our draconian measures are having dreadful consequences. For the week ending 4th September, home deaths from non Covid causes eg stroke, heart attack, sepsis etc were over and above all Covid deaths. So in the last 8 weeks we saw 1,117 Covid deaths while excess home deaths were 5,556. It seems that the response to the virus is far more deadly than the virus itself. Which of the experts talks about that?
Why not open everything normally but insist that those with comorbidities to shield until a vaccine emerges? Sweden have modelled this approach. To date they have seen slightly more deaths than comparable neighbours, but let’s wait for the final analysis of all causes of death, mental health, family breakdown, economic impact etc.
Looking at the risk when co-morbidities exist, it is clear that any adult with any comorbidity should consider shielding. If we are unclear, our GP surgeries should able to advise us of our risk. Then as informed adults we know where we stand and whether we need to shield.
Herd immunity got itself a bad name early in the pandemic, as it was associated with the view that the price would be many elderly deaths, a reasonable and responsible view. However, in all my medical years, herd immunity is the epidemiologists way out of infectious diseases, be it through vaccination or infection. By allowing the virus to spread in the healthy, herd immunity surely will develop without the feared high mortality.
Some have made the point that the antibody response is short lived. Of course it is limited. If we kept a protective volume of antibodies to all pathogens we have encountered, our blood would be a gelatinous gloop! Antibodies are part of a wider immune response which also involves living cells with a memory, ie M cell lymphocytes. Those exposed to SARS almost two decades ago, show some protection against Covid-19 by virtue of their cellular immunity. I am unsure why Professor Mark Whitty is so unwilling to accept this immunological fact. If untrue, the whole point of a vaccine is nul and void.
That is why 32 scientists, academics and medics wrote to Boris Johnson last week to ask why, with 95% of deaths occurring in those with pre-existing medical conditions, we are attempting to suppress the virus until a vaccine is found, leading to significant harm across all age groups. Our present approach is not evidence-based. It is the result of a high profile chief medical officer being a dove, and a government unwilling to ignore his advice.
If you need any more convincing, read the writings of Professor Mark Woolhouse, chair of infectious disease epidemiology in Edinburgh, member of the UK SPI -M advisory group and of Scotland’s Covid-19 Advisory Group. He says simply that this season is not mid-March, and we need a risk-based strategy of living with Covid to avoid the massive damage that variants of lockdown result in.
So how does Johnnie’s blog propose we should tackle this? If Johnnie were PM, perish the though, what would the UK now do? Simply this: stop the strategy of suppressing the virus as the means to stop deaths. Rather, understand who dies and why. Cases, per se, are not the problem. Right now my grandson, who is 6, is forced to be at home for 2 weeks because one child in his year group of 120 tested positive for Covid. So now, the entire year group of 120 children are at home, with all that means for child-care, education and parental work duties. He can’t even come out with me on a dog walk. And this will inevitably be a repeating cycle. To say this is massive over-kill is an understatement.
Of course cases are going up. Universities, schools and cooler weather guarantee that. But can’t we ride the wave and be intelligent in what draconian measures we impose on society?
Right now, all the evidence I have presented is steadfastly passed over by the experts, as the political and scientific doves have the day. The hawks are ignored. At massive cost to our economy, society, health and civil liberties. Our children, teenagers and university students will pay twice over. Now, in wasted university fees, lost education and opportunity, then later in taxes to sort out the massive financial debt incurred.
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