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Vaxxers and anti-vaxxers

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I wrote the bones of this a year ago. But then we knew nothing of Covid-19, and we would not have believed what was about to arrive. Now, with all we have suffered, and with a Covid-19 vaccine arriving, maybe this is much more relevant.

The cow might have saved more lives than any other animal. Probably tens of millions. Through the healthy benefits of milk? Nutritious protein? Keeping grass short to ward away snakes? No, none of the above. It has been through milkmaids.

In 1796 a physician working in Gloucestershire heard it rumoured that milkmaids did not contract smallpox, whereas in other individuals it was rife. His name was Edward Jenner, and he had an inspired thought. Cows contracted cowpox, a mildly eruptive viral disease of their udders caused by the vaccinia virus, part of the genus Orthopoxvirus. The virus is zoonotic, meaning that it is transferable between species, such as from cows to humans. The cowpox virus is closely related to variola, the causative virus of smallpox. Jenner noted that it was true that the milkmaids who had contracted cowpox, resulting in a mild illness, did not subsequently contract smallpox. Dr Jenner needed to test a theory.

At that time smallpox had an overall mortality rate of 30% and was naturally greatly feared by the population. It was therefore with ease that he persuaded a local mother to allow him to inject a small amount of cow serum into her 8 year old son. Not only did he survive this highly irregular onslaught, but he was then found to be resistant to the wave of smallpox sweeping the community. Others underwent the same injection, with identically protective effects. Dr Jenner used the Latin word for cow, vacca, to name his ingenious new technique. Thus ‘vaccination’ was born, and the humble cow was its genesis. Centuries later, vaccinations have saved tens of millions of lives.

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The Jenner Institute in Oxford has just developed it’s Covid-19 vaccine with characteristic determination and expertise.

Cowpox is now rare, with one case in the last 15 years on the Welsh – Cheshire border in June 2018. And smallpox is virtually extinct worldwide. But measles remains, and here lies a sorry tale that has relevance to Covid 19.

Measles is a contagious viral disease that can cause viral meningitis, blindness and permanent severe brain damage. A vaccine was introduced to the UK in 1968, but uptake was slow. In 1980, 2.6 million people died of measles throughout the world. According to the WHO, by 2014 global vaccination programs had reduced this number to 114,900 deaths, an amazing achievement.

This means that the measles vaccination prevents over two million deaths a year globally. The World Health Organisation estimates that many more lives could be saved globally if vaccination rates improved. In many poor countries parents queue with their infants for hours for vaccinations. In DRC last year there were 6,000 deaths due to measles, as a result of no national vaccination programme. Yet in the West, uptakes are dropping as confidence in the safety of vaccines falls.

That Western parents have become suspicious of vaccinations is of immense concern. Measles is a serious illness, and complications are more common in children under the age of 5. They include blindness, encephalitis, severe diarrhoea and related dehydration, ear infections and severe respiratory infections such as pneumonia. Severe complications can be fatal. So what lies behind this any-vat trend? Perhaps there are three main issues that have an influence over some parents’ minds.

The first is the persistence of concern that perhaps Andrew Wakefield really did know something, and the medical establishment has carried out a cover up. He was the former doctor who claimed in 1998 to have found a link between measles-mumps-rubella (MMR) vaccination and autism. But let’s look at his work. Wakefield drew the association between the MMR vaccine and autism based on a study involving only 12 children. And many children have autism and nearly all have been given the MMR vaccine. So forming an association between the two based on 12 cases is patently ludicrous. In discrediting the combination MMR vaccine he was suggesting parents should give their children single shots over a longer period of time, and that the load of all three was too much. Incidental to this was that more money would be made from three separate vaccines by certain companies within the vaccine producing industry. Furthermore, and most shockingly, he was paid £435,643 in fees, plus £3,910 in expenses by lawyers trying to prove that the MMR vaccine was unsafe. The payments were part of £3.4m distributed to doctors and scientists who had been recruited to support the change to three separate vaccines. A lawsuit was taken out against MMR manufacturers.

The campaign led by Wakefield, caused immunisation rates to slump immediately from 92% to 78.9%. His theory was subsequently found to have been based on fabricated data, and has been decisively and internationally debunked. The National Autistic Society says: “There is no link between autism and the MMR vaccine. We believe that no further attention or research funding should be unnecessarily directed towards examining a link that has already been comprehensively discredited.” And despite this resulting in Wakefield being struck off the General Medical Register, the fear that he sowed lingers on. So it’s totally understandable that the Health Secretary has refused to rule out the banning of unvaccinated children from schools, as countries such as France, Italy and the US do.

The second, more recent cause of MMR vaccine aversion is the proliferation of immunisation misinformation online. According to a recent study, half of parents of children aged under five in Britain have been exposed to negative messages about vaccines on social media. I searched FaceBook recently, and there is actually very little ‘anti-vaxxer’ material on public display, as it is mostly in private groups. This is probably because the majority of parents are positive about MMR, and would be critical of any parents they know who openly declare to be anti-vaxxers. But in Europe the number of measles cases rose to 82,000 in 2018, 15 times higher than in 2016. More than 70 people died of measles across Europe in 2018. In the UK we saw a rise from 91 cases in 2015 to almost a thousand in 2018.The number of children receiving the five-in-one jab, which protects against whooping cough and other illnesses, has reached a ten-year low among one-year-olds. And the number of children under two who were given the MMR vaccine, for measles, mumps and rubella, dropped from 91.2 per cent in 2017-18 to 90.3 per cent in 2018-19. The World Health Organisation (WHO) target for population immunity is 95 per cent.

The third reason is simply that many parents do not understand how potentially dangerous these illnesses are. Mumps in an adult male, for example, can result in infertility. And influenza is dangerous. There were over 50,000 excess winter deaths in England and Wales in the 2018-19 winter, the highest recorded since 1975/76, according to data released by the Office of National Statistics (ONS). The increase is thought to be a result of the prevalence of flu that season, alongside ineffectiveness of the flu vaccine and colder than usual temperatures, according to the ONS. They estimate 20,000 were directly due to influenza. While relatively rare, some children die from flu each year. Since 2004-2005, flu-related deaths in children reported to CDC during regular flu seasons have ranged from 37 to 188 deaths per annum.

And now Covid-19 has hit us so badly, with it’s own vaccination programme just around the corner. How will people respond? Initial surveys have shown a troubling percentage of people unwilling to have the vaccine. A survey by University College London of 70,000 people in late September 2020, found that only half (49%) considered themselves “very likely” to get vaccinated once there is a Covid vaccine and 10% said they were “very unlikely”. There were considerable anxieties about the side-effects of the vaccines we already have. More than half (53%) believed to varying degrees that vaccines can cause unforeseen effects. Nearly a third (30%) believed there could be future problems for adults or children that were as yet unknown. More than a third (38%) thought natural immunity – from having the infection and recovering – was better than immunity from vaccines. A small minority (4%) said they did not believe vaccines offered protection.

The reality is that any side effects are found in the very large scale Phase 3 trials, and that, once vaccinated without a significant side effect, long term side effects do not occur.

What untruths motivate people to avoid Covid vaccination? Big Pharma cynicism is one reason. Some companies are clearly aiming to profit, but isn’t it more important to ensure safety and health? In the UK, the MHRA (Medicines & Healthcare products Regulatory Agency) is extremely robust, and possibly one of the best in the world. People need to be encouraged to trust them. And let us shun some nonsense such as the vaccine will change your DNA. Sorry, cynics, this cannot happen.

A few are ethically troubled as vaccines are developed using human tissue grown from an aborted foetus from 1973. This is understandable, but the massive benefit of all our vaccines must far outweigh our ethical concerns. Millions of lives have been saved through vaccination since.

What can we conclude is to be done? Maybe the purging of FaceBook? Sadly their responsiveness to date, though better than it has been, is not inspiring. Maybe some solid public education might help, such as vaccine-supporting broadcasts on TV. Certainly we need greater health visitor and practice nurse contact with worried parents. There is evidence that poor access to advice is a factor in poor vaccine uptake. But eventually, if all else fails, we may need to move toward mandatory vaccination: no vaccination certification means no schooling or flying, for instance. Has it worked elsewhere? It is probably too early to tell. But let us understand: Covid-19, influenza and measles are all more contagious than Ebola, tuberculosis or flu. They have limited specific treatments and can be picked up from the air or from surfaces for many hours after an infected person has come and gone.

In the same way that people transmit viruses, they can also transit truth. It maybe time for these of us who believe in vaccines to speak out more persuasively and coax the doubters to see reason. Spread the good news!


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Empathy

Apparently empathy, the ability to understand and share the feelings of another, is the new interactive quality we should all be showing.  While it’s not clear exactly how humans experience empathy, there is a growing body of research on the topic.

While sympathy and compassion are related to empathy, there are important differences. Sympathy and compassion are often thought to involve more of a passive connection, while empathy generally involves a much more active attempt to understand and connect with another person.  If it could be measured, it would be part of our emotional intelligence, often called EQ.  This is distinct from our intellectual intelligence, or IQ.

My last two blogs have been based around the intelligent, accurate handling of information, ie Covid risks and vaccination.  But I wanted to also explore the immense value of being aware of others’ feelings, even if we disagree.  

Brexit was a prime example.  Certainly in late 2016 it was ‘show your hand and risk loosing a friend’.  Empathy was in short supply!  Few people felt they wanted to ask their friend for their thoughts and explore the reasons for them, showing understanding for those reasons.

How does IQ relate to EQ?  Clearly some high IQ people behave as if they can’t do EQ.  And others find EQ comes naturally.  My dog is lowish in IQ but tremendously high in EQ!  But the present debate is more about asking the question ‘Can you learn empathy?’ And there are other questions such as ‘What are its effects in relationships, families, neighbourhoods and workplaces?’

Can you learn it?  The simple (and surprising) answer is yes. And what are its effects?  Basically better relationships, better family life, enhanced enjoyment of life, and a greater appreciation of the workplace.

So while some people are emotionally and naturally empathic, there is also something known as cognitive empathy, which involves having more complete and accurate knowledge about the contents of another person’s mind, including how the person feels.  Cognitive empathy is more like a skill: humans learn to recognise and understand others’ emotions as a way to process their behaviour.  Cognitive empathy can be acquired.

At various stages of my medical career I was the lead consultant.  At first I did not feel the need to show much empathy.  But as life’s tragedies happened, such as a male nurse dying of HIV, or relationship breakdowns among staff, I realised the essential nature of empathy.  Workplace satisfaction is heavily dependant on it.  In fact some psychologists measure empathy by the effects it has in a community or workplace.  Are people feeling understood?  Are they feeling appreciated?  It is a strange observation that you can be quite a strict boss, but if empathetic, a loved boss.

So what are some of the steps to learn empathy?  There is no doubt that emotional connection begins to happen when we ask questions.  Especially ones that aren’t loaded with our opinions.  In fact, as we ask questions about how the other responded, felt or reacted, we often discover things in common.  We can put ourselves in the others’ shoes.

Another key step is simply to listen, and limit our comments to imagining a way forward.  And here we have a key skill which must be learned, which is to withhold our reaction once someone has disclosed their delicate emotions.  Those emotions must be held in tissue paper and respected.

You don’t need to say what you think. Don’t forget, people will get who you are by what they see and feel from you.  It was Maya Angelou (1928-2014) who famously said ‘I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel’.

As this difficult year ends and 2021 begins, let’s strive to make those around us feel good.

Happy new year!

The Doves and the Hawks of Covid

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.

Share if you agree.

Johnnie

A career’s reflection on the NHS part 2 – pre Covid 19

Political intervention is usually unhelpful and cross party working is needed

Over my 47 years, reorganisations, new systems, new contracts and new targets all came in different colours.  But during my life as an A&E Consultant, I have witnessed a lot of 2nd World care. If anyone believes A&E is in a sudden crisis they need to appreciate it has never been resourced adequately.  Through the 1980’s until recently, I have seen people neglected in corridors. Thirty years ago I recall a woman of 41, dying on a trolley in a corridor queue while completely unsupervised.  Throughout the years I witnessed inhumane stacking of elderly people waiting for beds in drafty holding areas and, more recently, people who could not leave an ambulance waiting outside A&E as there was no physical space for them in the department.  Meanwhile Chief Executives came and went on salaries that defied justification. 

On a background of chronic underfunding, political interference has tended to make certain problems worse not better and demand has risen over time.

Many have called for the NHS and Social Care to be taken out of the political arena, and overseen by a cross party commission, in order to avoid political point scoring, and simplistic solutions.  Let me describe one such example.  When A&E targets were introduced by Labour in 2004, they did not come with any new resources.  The backdrop was  a mix of relentless increased demand, reduced acute bed capacity and woefully inadequate elderly services.  But we identified all work that could be jettisoned to focus on achieving the goal, as failure involved penalties to already squeezed budgets.  That meant many rapid review clinics in A&E disappeared, and patients were merely loaded into specialist clinics thereby, in turn, reducing these clinic’s capacity to see GP referrals.  Or they were admitted to a bed, contributing to the burgeoning bed-block witnessed over the preceding years.  Worst of all, A&E specialist expertise was trimmed to what could be done in 4 hours, rather than what could be done to sort out a problem and get a patient safely home. And the final whammy has been that A&E attendance increased by a massive 22% over the last 10 years.

Combine this with the fact that between 1987/8 and 2016/17, the total number of NHS hospital beds fell by an eye-watering 52%, from 299,364 to 142,568.  The rise in day surgery, helped by key-hole surgery, and the change in mental health policy were the main drivers, but there were others.  Not surprisingly we have seen a growing shortage of beds as acute demand has increased. In 2016/17, overnight general and acute bed occupancy averaged 90.3 per cent, and regularly exceeded 95% in the winter, well above the level many consider safe.

While the system has been played with, it is not so fundamentally different to pre-1948 years. So GPs have a confused role, somewhere between gate-keepers, chronic disease managers, and (just hanging on to) being family doctors. Their numbers and their workload mean they are harder to access. Hospitals are still in a separate silo, with competing acute versus elective care.  The patients who can’t access their busy GPs tend to default to the creaking A&E service.  Meanwhile social care is still dislocated from secondary care, and massively unavailable.

In addition to ill judged political interference, there has been a lack of joined up thinking and working resulting in waste, lack of clarity about how the component parts work together and inefficiency. Failing parts of the system have tended to increase costs for all other areas

The crumbling care system in England has cost the NHS £669 million over the last five years with hospitals forced to care for elderly patients who could otherwise be discharged.  Analysis by Age UK concluded that over these five years the NHS lost 2.4 million bed days as a result of so-called “bed-blocking” because of a lack of care and support outside hospitals.  Over the course of a year more than 680,000 elderly people treated by the NHS languish on wards for weeks, even though they are well enough to be looked after in a care home or at home with social services support. At the same time, cancelled operations have rocketed by almost a third since last year as hospitals ran out of beds.

One good thing has been the standardisation of treatments by the rise in clinical governance.  Perhaps the best known example is the National Institute for Health and Care Excellence (NICE) which seeks the best outcomes for the best prices.  And our drug procurement process is robust.  We have resisted pressure from some EU suppliers and have imported alternatives from countries such as India.  This gives me confidence that the Trump medicine fear-mongering is just that:- fear-mongering.

Improved public health is crucial as ever increasing demand is not sustainable

But despite all I have written about threats to the NHS, there is more.  Lifestyle factors are a major determinant of health demand and the UK has a particular problem regarding our role as consumers.  We have a couple of national foibles.

The first is highlighted by a study of the 36 OECD nations which shows that the UK’s alcohol consumption is now among the highest in developed countries.  The research shows that adults in Britain are now consuming an average of 9.7 litres of pure alcohol a year, the equivalent of 108 bottles of wine annually.  The figure amounts to an extra nine bottles of wine, or 35 pints of beer annually.

Separate figures show the number of pensioners starting treatment for alcohol problems has doubled in the past decade.  Health campaigners said baby boomers who grew up in a “hedonistic culture” in the 60s and 70s were consuming far more than younger drinkers, and turning “a blind eye” to the potential health risks. 

The second is that over the last decade obesity prevalence has doubled.  Some 67% of men are either overweight (40%) or obese (27%).   Meanwhile, 31% of women are overweight and a further 30% are obese.  Professor Stephen Powis, NHS National Medical Director, said: “Obesity is a dangerous public health threat that is already leading to 13 types of cancer, heart attacks and strokes, with these figures bringing another stark reminder of the scale of the obesity crisis”.  Research shows that 13 million adults are now classed as obese.  Obesity is the most significant driver for new cases of type 2 diabetes, accounting for up to 85% of risk.  As a result, record numbers are being treated for type 2 diabetes. It follows reports that the numbers being treated in hospital for obesity-related conditions have risen by nearly one quarter in a year.

Simon Stevens, the NHS chief executive, has warned that the “startling” trends could cut short thousands of lives.  The number of obese adults in England has risen from 6.9 million in 1997 to around 13 million in 2017.  The analysis, by Diabetes UK, warns that 29% of adults and 20% of children leaving primary school are obese.

 As I write, over 10% of all NHS drug spending is devoted to treating diabetes, and the overall bill for all types of medication and devices to treat diabetes has reached more than £1 billion, representing a 68% increase in 10 years.

While there is widespread concern among the general public about funding for the health service, there is perhaps a lack of awareness that reducing demand through improved public health is crucial for the sustainability of the health service in the long term.

Yet many people are reluctant to engage with the facts and the risks. Ed Southgate reported in the Telegraph this week “Parents branded a primary school “disgraceful” after it gave Slimming World leaflets to children”.  He went on to report ‘A mother-of-four emptied her five-year-old son’s homework bag last Friday to discover a booklet entitled Be Slim for Life showing before and after pictures of two weight-loss journeys.  The 42-year-old mother, from Staffordshire, said it was “appalling” to allow the “inappropriate” material to go out to impressionable youngsters and said her eight-year-old son had since asked about his weight.  She said: “There’s so much pressure on kids at the minute already. They are meant to conform to be stick-thin insects. Then they’re having this leaflet in their face saying ‘be slim for life’. If they’re not ‘slim for life’, does that mean they’re not accepted?”  Tackling obesity will obviously be an uphill climb.

Lifestyle and diet may well play a part, but how money is spent is also crucial to the impact.  System changes are necessary.  In fact, our ‘gatekeeping’ primary care philosophy in perhaps the single-most barrier to achieving falls in cancer mortality rates.  Cancer diagnoses used to be rare in A&E and are now common-place.

In conclusion, let’s not be simplistic in blaming the left or the right of our political spectrum for the present state of our NHS.  It really is a lot more complicated.  Those Facebook ditties and covert insults really don’t do the subject justice. Yes, we probably need to get to 8.5% of GDP as a minimum for Government NHS funding.  And we certainly would benefit massively from a cross-party commission to lead the NHS and Social Care.  But we need to decide where that money comes from, and how it is spent.  These are not left or right issues, but ones that need balance, wisdom and rational thinking. But I think we also need to take a lot more responsibility for our own health.

A career’s reflection on the NHS

It is early 2020.  We have missed the A&E target for 4 years.  A&E waits make headlines, and some predict being charged massively overpriced sums for drugs as Trump claims rights to the NHS as the price of a trade deal.  And privatisation is apparently the secret agenda anyway.  But what are the facts, the trends and the history?  Here is the first of three blogs based on my career which included being an A&E Consultant from 1989 until 2017, on the theme that the NHS is chronically underfunded courtesy of both parties.

I started as a medical student in 1973, and have watched the trials and tribulations of the NHS over these past 47 years.  And to remind you, that meant a patchwork of political paymasters, 18 years under Labour and 27 under the Conservatives +/- Alliance, namely:

1974 Labour, 1979 Conservative, 1997 Labour, 2010 Conservative / Liberal Democrat alliance, 2015 and 2019 Conservative.

The Organisation for Economic Co-operation and Development is an intergovernmental economic organisation with 36 member countries, founded in 1961 to stimulate economic progress and world trade.  A recent OECD report shows that right now, the UK has the second lowest number of beds and doctors in Europe (the lowest is Poland) compared with its population.  Britain has 2.8 doctors per 1,000 people, compared with an OECD average of 3.5 doctors.  Bed numbers are also among the lowest, with 2.5 per 100,000 people, compared with an OECD average of 4.7. Why?  Can we blame the any one party?  I think it is more nuanced than that. Maybe we need to understand our history.

Just before the NHS started in July 1948 NHS, its author, Aneurin Bevan spoke of the medical profession’s worries about the service, and said if there were problems they could easily be put right.  That month, the Editor of the British Medical Journal, while seeing the logic of spreading the high cost of illness over the whole of the community, also saw dangers in a state medical service, with lack of incentive, massive administrative costs, stereotyped procedure and lack of intellectual freedom.  Additional resources were negligible, and the appointed day brought no extra doctors or nurses.  Within weeks Bevan was reputed to have become worried about the burgeoning costs, fearing its un-affordability.

NHS funding has been a problem from its inception. Funding as a % of GDP languished between 3 and 4% from 1948 to 1976, ensuring all building and equipment stock slowly deteriorated, and guaranteeing large renovation and repair bills for the future.  Around the year 2000, under Tony Blair funding as a % of GDP had reached 5%.  At that time the government introduced out-sourcing, meaning that for the first time contracts could go to non-NHS providers.  This has since been pejoratively referred to as ‘NHS-privatisation’. But it may have eased funding pressures as costs could be reduced.  Funding reached 6% by 2005.  Meanwhile, other nations had outstripped the UK.  The last few years have seen an increase, and we now register 7.5%.  The interesting fact is that if the % of GDP spending on the NHS is plotted by year, it is very difficult to identify which political party was in power at any given time. The fact is that no political party has a record to be proud of, though none admit to that.

So where are we now?  By all key metrics, the UK is the second worst in the 10 major world economies shown in this table.  I have omitted the USA which has the highest spending and the lowest life expectancy as it is (and always has been) a very inefficient system. 

CountrySpending per person ($)Gov spend as %GDPTotal spend as %GDPLife expect at birth
Switzerland70007.8%12.5%83.0
Norway60007.5%10%82.4
Germany60009.5%11%80.7
Austria55007.7%10%81.3
Sweden55009.3%11%82.2
Japan50009.2%11%84.0
Netherlands50007.7%10%81.6
France50009.3%11%82.4
UK40007.5%9%81.0
Italy35006.5%9%84.9
https://data.oecd.org/healthres/health-spending.htm

Government spending as a % of GDP is an honest measure of affordability, and a good measure of how we value healthcare, a bit like defence or education spending.  But each country adds to this with private healthcare funding.  In the case of the UK, this adds 1.5%, Norway adds 2.5% and Switzerland over 4.5%.   As UK spending, governmental or total, is below average, it follows that more spending or private healthcare may be needed.

But here are some interesting things: healthcare spending does not correlate with life expectancy, and people in Italy live the longest, despite being bottom of the league!  And pressure on emergency care is widespread across Europe, with long waits in the Republic of Ireland and France, our two closest neighbours. So what should we do? Follow Johnnies Blog for the next installment!

Back on line!

There has been a Johnnies blog silence for a number of weeks. It was partly that I was sorting out the ‘Johnnies Blog’ domain, and partly that with the election, I did not want to post anything that could be construed as political. Especially as I had been researching the last few decades of medical funding and outcomes in the UK! But I’m back!

Chlorine washed chicken

This is a strange topic for a blog, I hear you say. But I am so aware that many people automatically think chlorine washed chicken must be bad. After all, Donald Trump wants it, so it has to be. But as a medic I want to speak to fact, and challenge views. And, at the outset, let me be clear that I am not a Trump supporter.

It has long been realised that poultry is a potent source of pathogens such as E coli, Salmonella and Campylobacter. As a doctor I have treated many patients following their barbecues, chicken sandwiches and curries. Campylobacter is the most common, resulting in severe abdominal cramps, sometimes bloody diarrhoea, and occasionally death.

In the UK we don’t manage the risk very well. Campylobacter is still number one when it comes to bacterial food poisoning in the UK. It is reported by Public Health England that in 2016 there were just short of 60,000 laboratory confirmed cases. More troubling is that the milder cases don’t get reported, and the Food Standards Agency estimates that the true caseload may be over 250,000.

Worse still, on average there are 110 deaths annually – which works out at about one death every three days. And these numbers have only dropped slightly over the last 10 years.

Public Health England, which issues annual audits on the problem, reported that in 2016-17 54% of chicken meat on sale was infected by Campylobacter. The Food Standards Agency believed the figure to be much higher, stating 73% of raw retail chickens were contaminated with Campylobacter. In real terms that means somewhere between 320 million to 460 million infected chickens a year are handled in our homes.

More worrying, according to the British Poultry Association, Campylobacter is still found on the outer packaging of 7% of raw chicken. This means that almost 9 million contaminated packages of chicken are sold in the UK every year, and these packages sit in our fridges alongside other foods.

It is a fact that washing with chlorine solution reduces the risk. It is widely accepted to be effective in limiting pathogens. That is why chlorine is in all swimming pools from which we do not ban our children. It is not a harmful product. So why not use it to wash chicken?

The issue is that the EU does not allow producers to wash meat with any substance other than water unless the substance is explicitly approved by the European Commission (EC Regulation 853/2004). And chlorine solution is not approved. I am guessing the reason is that the EU wants to have high standards of food production, and not to rely on any chemical treatments which might cause producers to lower their standards. And on that count it does better than the USA.

The problem of Campylobacter is driven by the mass production and mass transportation of chickens. And this happens in every country. Many factory-grown chickens gain more than 50g in weight every day. However, their immune systems, organs and legs cannot keep up, so they suffer a range of physical problems as a result.

And here, the maximum amount of time live birds can be transported is 12 hours. In the US, it is double that time. Cramped, hot, and maltreated, the chickens become susceptible both to contracting and spreading infection.

Quite apart from the Campylobacter risk to humans, there are clearly significant animal welfare issues. But given the scale of the problem, maybe the industry needs a comprehensive review.

But personally, post Brexit, if given the choice, I am more than happy to have my chicken chlorine washed.

Peace

Humans apparently have several basic needs. Food, security, shelter and warmth feature among them. The Bible tells us that peace is one of them also. The Aaronic blessing (Num 6:24-26) promises peace, (The LORD bless you and keep you; the LORD make his face shine upon you and be gracious to you; the LORD turn his face toward you and give you peace). And I Corinthians 7:15 tells us “God has called us to live in peace”.

Peace is the most basic commodity for our society to own, for our politicians to forge, and for all of us to host in our hearts. Not least the believer. It arrives as guilt departs. It leaves immediately sin enters our lives. Now, since we all do wrong (I John 1:10) we need to keep short accounts with God. I love the sense of cleansing that comes as I confess sin daily. And it is worth saying that the longer I am a Christian, the more sensitive to sin I become.

Has your peace gone? If it has, you can’t function in the kingdom. Let me ask you when you last confessed your sin in detail to your Father? Maybe you don’t want to confess because you are holding on to a secret, cherished sin. In which case Psalm 66:18 tells us that while you cherish this sin, God will not hear you.

Now Jesus is the King of peace (that’s what King of Salem means – Hebrews 7:2) and His speciality is to give us kingdom rights to swap all sorts of weights for peace (eg anxiety – Philippians 4:6&7). He tells us to be at peace with all men (Hebrews 12:14) but I am sure this can only happen when it starts on the inside.

God’s order is that we lay hold of peace. After that we gain joy as we overcome, then we love as we persevere. Only after that will the power flow. So how is it with you? Is the peace there? Because if not, you can lay hold of it today.

Shalom!

The money affair

When we say we want to follow Christ, make Him Lord and experience all He has for us, we have one very real test of our devotion. Money. Jesus never seemed to be satisfied with a slice of the pie of our obedience. He did not rejoice in the tithe or a big offering as much as He did in the sacrificial, complete giving of a widow.
The New Testament concept of stewardship arises from our total commitment to Jesus Christ. When He becomes our Lord, He becomes Lord of our time, talents, finances, and everything else.


Jesus warned about the insidious effect of money, saying “Your heart will always be where your riches are” (Luke 12:34). And we don’t need to have much to be controlled by it. It’s a bit like an affair. Suddenly we can find that we are in too deep to pull away.


So here are some affair-proofing things we can do:
1 Give more than a trivial amount of money away. Look at the Master’s example, “For you know the grace of our Lord Jesus Christ, that though he was rich, yet for your sakes he became poor, so that you through his poverty might become rich” (2 Cor 8:9 NIV).
2 Give until it takes faith to do so. Then we might discover what Jesus had in mind when he said this, “Give, and it will be given to you. A good measure, pressed down, shaken together and running over, will be poured into your lap. For with the measure you use, it will be measured to you” (Luke 6:38 NIV).
3 Give to “kingdom” work. By that I mean to those who labour to extend God’s rule and influence on earth. Typically this may be to our church, and to those working with the poor and needy.
4 Give in secret. If we want to take the credit for our giving here on earth, there is no commendation later in heaven. So Jesus said “when you give to the needy, do not let your left hand know what your right hand is doing, so that your giving may be in secret. Then your Father, who sees what is done in secret, will reward you” (Mat 6:3&4).

Psychologists tell us that most people do not plan on being in an affair, it just happens. Maybe decide today that it will not happen between us and money.

Moral intuitions

There is a lot of evidence that we form our judgements emotionally. And then our moral reasoning simply serves as a rationalisation of already formed prejudices.

That’s quite an observation. But is it true? Are we really essentially emotional beings who seek to justify our emotionally reactive positions? And might this explain why so few adults alter their moral, ethical, religious or political positions during their lives, despite lots of persuasive information?

This was first demonstrated in 1979 in a study at Stanford by Charles Lord and colleagues. They presented undergraduates with two fictional studies, both with convincing statistics. One study claimed to prove capital punishment works as a deterrent, while the other concluded it had no effect on crime rates.

Before and after seeing the studies, participants were asked to give their views. Those who believed capital punishment is an effective deterrent rated the study supporting their views as credible, while rating the one that challenged their opinion as unconvincing. Those who were opposed to capital punishment reached the opposite conclusions. This phenomenon has become known as ‘confirmation bias’.

Further studies went on to demonstrate that our beliefs are rarely based on a deep understanding of a particular issue. When it comes to belief, it seems we remember facts that support our world view, but ignore or reject information that runs counter to our opinions – and the more passionately we feel about an issue, the more this is so.

The social psychologist Jonathan Haidt explored this further, and wrote in The Righteous Mind that in his view ‘moral judgement is caused by quick moral intuitions’. We react, then we justify that reaction intellectually. And then we don’t shift, despite evidence.

Haidt began developing his thoughts that there are six main moral intuitions, namely;
1 Justice and care: cherishing and protecting others; opposite of harm.
2 Fairness or proportionality: rendering justice according to shared rules; opposite of cheating.
3 Loyalty to a group: standing with your group, family, nation; opposite of betrayal.
4 Authority or respect: submitting to tradition and legitimate authority; opposite of subversion.
5 Sanctity or purity: abhorrence for disgusting things, foods, actions; opposite of degradation.
6 Liberty: to behave as I might choose; opposite of oppression.

Some people judge almost everything by two or three – and don’t really realise that there are moral intuitions other than their own. This apparently fuels in them a sense of anger towards others who see things differently. Meanwhile others judge the world by a broader number, which makes them more puzzled by their opponents, rather than angry.

Researchers have found that people’s sensitivities to the six moral foundations correlate with their political ideologies. Does this surprise you?

This all leads to this challenge: to what degree is our world view, opinion-base and general political orientation an emotional reaction to the world we see around us? And are we actually biased, choosing an emotive path that suits our hearts, which we then justify in our heads with a supportive, seemingly rational argument?

For the Christian, does this all raise issues of integrity? Is our selfish opinion used to justify some facts we know? Or can we be truly honest about what we see and perceive around us, forming our views on the facts, not our prejudice?

I imagine the answer tells us a lot about who we are.