Wednesday, 26 August 2020

Goodbye Public Health, England!

Yes commas are important. After cutting funding to  Public Health England (PHE) by 25% over the last 5 years, Matt "Handsfree" Hancock has now pushed it over the edge. Its role of improving health and wellbeing, reducing inequalities in health will be taken up by a new body which seems to be focused on pandemic preparation rather than the wider issue of Public Health.

Hence the comma; might it be goodbye to Public Health, England?

There have been mistakes of course, yet PHE is an executive agency of the Department of Health, so the buck should stop at 'Handsfree' himself, but no. He is passing the buck back down the line and more worrying for me, and changing the direction of Public Health

There has of course been problems.

The U-turn regarding the way Public Heath England (PHE) have been counting COVID19 related deaths is a good example of the chaos in central government. 

The counting fiasco

In those first few months of the pandemic it might have been reasonable to count everyone testing positive for COVID19 as dying directly of it. Testing was restricted to hospital admissions and undercounting in the community likely. Yet to leave that rule in place for six months thereafter, could at best be called careless, at worst, manipulative.

It also remains true that people with COVID19 can die directly as a consequence of the infection after 60 days and more, and it is important that these are included in the total, but with such small numbers, it should be possible to look at deaths case by case to increase accuracy and confidence. 

Indeed the latest figures show a total of 57,478 excess deaths since the pandemic hit our shores, and this figure has fallen by 1,660 as deaths have been below the 5 year average for the last 8 weeks in a row. With far smaller numbers of people dying, these errors make a bigger relative difference. 

The responsibility for this decision was with the Secretary of State for Health, Handsfree himself.

Testing tracing

This too is rightly seen as somewhat of a PHE failure. We were unable to test and trace at the time when we needed it most, and now in the summer and autumn, testing has been increased significantly despite the low number of people experiencing illness significant enough to attend hospital for help.

Yet this was not something to lay directly at PHE's door, it was due to years of disinvestment in preparedness for a pandemic, ignoring pandemic planning and reducing the number of public labs that could do the work. The decisions to use SERCO to do the work and its miserable failure to do the job properly were dogma driven and entirely political. 

We are now testing and tracing like never before for an illness which is not directly impacting on the health service. Perhaps it can be seen as a rehearsal for the winter wave, if it comes. 

The recent diversion of testing and tracing work to the far more effective local public health bodies is long overdue, but the funds, so generously showered on the private sector are yet to follow.

As to a "world beating App", it is our own fiasco with electronic testing and tracing that has led the way - providing the world with lessons on exactly how not to do it.  

End of the line

The upshot of this is that PHE is to be wound up and merged with the NHS Test and Trace service and the Joint Biosecurity Centre to form the National Institute for Health Protection. 

The lives of 5,500 staff are now thrown into uncertainty as the inevitable 'renegotiation' of contracts grinds on over the next six months, so lots of stress for the staff who need to be at their best during the winter, as well as their families.

This is despite this being the worst time to create turmoil in the public health sector by yet another big reorganisation but don't politicians like "Handsfree" just love big announcements and so he is charging ahead nonetheless. Let's hope the subsequent administrative chaos does not coincide with a winter wave.

"Handsfree" has said that the primary focus of this new organisation will be our response to pandemics and also of course, give us the impression that the problem has been with PHE rather than his own poor understanding of health, viruses and the potential of the public sector. 

At least there is, implicit in this statement, the recognition that more pandemics are on their way. But what of the many other threats to public health such as climate change, air pollution, food policy, social inequality and of course, our own governments many policies which, COVID19 has revealed have helped England become the unhealthiest nation in Europe?

Public health will not go away

The underlying reasons for our big hit from the pandemic are our underfunded and unprepared public services, our planet destroying travel hubs like Heathrow but also our terrible public heath. We live in a society riddled with worsening health inequalities, stressful lives for so many, terrible food, and a health system critically ill even before COVID19 came along. All driven by politicians who exist in their own little all powerful bubble of corporate chums.

Even the recent exam fiasco is due to policy which makes pupils academic future depend on exams rather that the more accurate coursework assessments. More stress for our kids - another public health issue.

Consistency where we need it least - cronyism:

The interim head of the new quango is to be the Baroness Harding of Winscombe, Dido Harding, whose post at the top of a mobile phone company makes her less than ideal for the post, particularly given the data breaches during her time there.

Like so many at the top of these organisations, she has no knowledge of the health sector or public health.

Her main qualifications seem to be simply being a member of the Conservative Party, being chums of David Cameron, and having a husband who is a Tory MP, who incidentally, advises the a neoliberal body called "1828" which calls for the NHS to be replaced by an insurance based system and er, Public Health England to be scrapped. 

I feel sure that we are heading for more dogma-driven confusion and chaos just when we need it least.  At least there we have consistency.



Friday, 21 August 2020

Lockdown - where have the premature babies gone??

It seems there has been a big drop in the number of very low birthweight babies being born in March and April this year. 

A huge decrease in the rate of very premature births has been reported in the first few months of lockdown in Ireland and Denmark; media reports of reductions in 50% from Canada too. They cannot be alone, and the findings are accurate as these births are easy (indeed mandatory) to count. 

The reductions are hugely significant - very low birthweight births were down by a staggering 3.8 fold in Ireland, a 90% reduction of babies born below 28 weeks in Denmark, a 50% reduction in Canada.

This is truly phenomenal and unexpected news, so why has this happened and what's it about?

A bit of background.

My interest in prematurity stems from my time as a junior doctor in Plymouth's Special Care Baby Unit, nestled on top of the old maternity unit at Freedom Fields. It was back in the mid 80's that I found myself spending every working day, and many nights looking after very small babies while Mums and Dads adjusted to the impact of their baby slowly growing, usually with respiratory and nutritional support, inside those bright perspex boxes. 

Freedom Fields Hospital Maternity Unit



Babies born under 28 weeks gestation are called Very Low Birthweight babies and not surprisingly need the most help and suffer the most problems while in hospital, in childhood and on into adult life. 

Of course, technology and techniques on what are now called Neonatal Intensive Care Units have improved apace; management is far more slick with less side effects, and outcomes improving all the time. Yet the rate of premature birth has resisted any medical intervention, with about 7% of babies born weighing less that 2.5Kg. (5.5lb). 

Anything that could reduce the rate and impact of premature birth would be welcome, but the holy grail of prevention has been elusive. 

Impact of social inequality - again....

Higher rates of premature birth are associated with poverty, smoking and stress, but the causes behind prematurity have not been established

1 in 13 births, that's about 60,000 babies a year in the UK continue to be born before 37 weeks. The rate of premature birth varies from 12% in Blackpool to 3.8% in leafy Morden. The overall rate in the US is 12% with its even more marked disparities across populations. 

The curse of social inequality starts early!

Yet the lockdown has increased social inequality here and around the world, so the reductions in premature births are certainly not due to any reduction in poverty.

It  might be imagined that lockdown would have increased stress at home; domestic abuse has increased and undoubtedly the lockdown made life difficult for some women. Perhaps for some there might have been more time at home with the family, we don't yet know. Yet the drop in rates of prematurity is real, so what else might be behind this welcome news?

Lockdown Blockbuster!

So, if these reports hold up, we have some big clues of how to keep babies in their mothers wombs until they are more ready for the outside world - the frustrating thing is that we don't know yet exactly what is was. However, if this was caused by a drug, the 'inventor' of this blockbuster would become a billionaire overnight! But is is not a drug, it is COVID19, or rather it is associated with the measures taken in response to the pandemic - the lockdown. 

The accuracy of the figures are beyond doubt, but what are the implications? It has to be that the lockdown has has a positive effect on expectant mothers health, but what might that be?

Smoking?

Is it that smoking, that potent cause of prematurity, has reduced? Smoking doubles the risk of premature birth before 32 weeks and 30% of adults have quit in the face of COVID19, but thereductions in smoking are less than the reductions in premature birth, so this might not be the full explanation.

Air pollution?

Air pollution is another likely culprit. It has been estimated that air pollution causes 3% of premature births in the US, a significant figure, but it is acknowledged that with air pollution now ubiquitous, it is difficult to study - there are no comparable control groups with which to compare exposed mothers. 

So the reduction in air pollution during the lockdown has potentially had a big effect on health due to less inhalation of tiny particles in air called particulate matter, as well as nitrogen oxides, nanoparticles loaded with metal, abrasives and a huge catalogue of other toxins. The clear air of the spring might have not only smelt and looked wonderful, but it might have made a difference to maternal and foetal health.

This means that 3% mentioned in the study is likely to be an underestimate. Further, the drop in air pollution experienced by mothers are unprecedented in my lifetime - heavily polluted residential areas in cities are the scandalous modern norm. 

Other viruses?

I wonder if the isolation of lockdown might have reduced the incidence other viral infections which might also play a part? We just don't know, but perhaps if we find out there might be big implications for anyone at particular risk of premature birth. Such restrictions as we have seen are not likely to become the norm for pregnant women, but the reduction in premature birth are real and are certainly worth thinking about. 

So, the exact causes will be hard to disentangle from the wonderful effect on these babies and mothers and perhaps the forthcoming publication of these papers in peer reviewed journals will create a drive to find out more. Im sure there will be more data on the way, and it will be interesting to see if these benefits persist, or even reverse as the economic effects of our reaction to COVID19 starts to impact.

Whatever the outcome, it seems inevitable to conclude that there are aspects of our modern lifestyle, put on hold by the response to the COVID19 pandemic which have been behind most of our premature births, the resultant deaths and health impacts on babies, their families and society. 

In other words, it seems that current 'normal' arrangements for pregnant women are well, how other can I put it - dangerous and damaging.

A COVID19 message....


Permit me to rant a little about the way we fail in this country to put proper emphasis on helping babies and children. The effect of lockdown on prematurity is a big message from the pandemic that we are getting things wrong and we need change. 

While take home message for those contemplating pregnancy is definitely to stop smoking and live the healthiest lifestyle possible, it goes beyond what the individual can do for themselves. A basic duty of a decent society is that we shoul look after the next generation. How?

Baby friendly economics


Prematurity costs. Even as far back as 2006, costs of prematurity were estimated to be nearly £3 billion a year with excess costs averaging £23,000 per baby till the age of 18 compared to a birth at full term. This rose to £60,000 for a very low birthweight baby and £90,000 for the smallest babies of all.  Allow for 4% annual inflation in medical costs and that means that in 2020 the care of very low birthweight babies adds up to about £100,000 and totals £5 billion annually. These estimates do not include the cost of adult care for anyone with disabilities, or the economic loss due to reduced employment opportunities, so are considerable underestimates of the total lifetime costs. 

So supporting women financially to live well early in pregnancy makes economic sense. Less stressful pregnancies would be likely to save money as well as hardship, suffering and disability.

Currently maternity pay is paid for a total of 39 weeks at 90% of average weekly earnings for the first 6 weeks and £151 or 90% of income (whichever is lower) for the next 33 weeks. That is equivalent to a measly £8,000 a year for the most important job on earth!

Mothers therefore often have a financial need to work through pregnancy and there is no specific support at all for mothers in the critical early months. Further, as in so many other areas of human welfare, we are nearly at the bottom (36th) of the 41 EU and OECD nations when it comes to economic support for pregnant mums.

With social inequality increasing as a effect of political ideology, financial stress of many families will increase for many of our poorest families at this time. The stress of worrying about money on a day by day basis takes a toll on mothers and babies health. 

More importantly in this context maternity leave should commence far earlier, and the amount paid to mothers enough to make a more relaxed, foetus-friendly life affordable for all. There would be huge savings of on the costs of prematurity by sensible investment in the lives of young mothers.

The fact that both parents in many families have to work to get by during pregnancy and then for much of parenthood is a sign of national economic failure which has taken place over my lifetime. In the optimistic past, it was hoped that moves towards more gender equality would lead to shared parenthood. 

Yet our economic 'development' has led to modern parents both having to work to provide am adequate income, and the consequent need to sub-contract out parenting to nurseries. This has been one gigantic leap backward for society in general and women in particular..

Baby friendly environment


betterstreets.com
Despite the air quality in the poorest areas now returning to their normal toxic levels, lockdown briefly focused the mind on the benefits of clearing this up. Perhaps instead of designing low emission areas to focus on city centres, they should focus on areas known to have higher rates of prematurity, in other words the highly polluted inner city residential areas

More research on this is not needed, we know enough to recognise the need to expand car free areas and to control traffic in pollution hot spots which would also reduce noise, danger, increase social contact, improve community life and reduce the social isolation which is one of the causes of premature birth.

Baby friendly education


It is known that 'lower" social class, poor education, relationship issues, mental health problems all help prevent prematurity. Better 'life education' at school would help. More emphasis on relationship and sexual education would have a positive impact on family life later on. 

It seems that 45% of pregnancies are unplanned in the UK. Our rate of teenage pregnancy, (usually unplanned), is again, only slightly better than the USA who sit at the bottom of the league table and worse that other OECD nations.  Better relationship skills and family planning education would encourage the transformative effect of more pregnancies being planned. 

Ante-natal classes might become more frequent and with a wider input from diverse teams of health professionals and educationalists. This could be along the lines of healthy living clinics I am helping the neurologists with in Torbay. These all-morning classes in improving health aim to help new patients with MS make the most out of lifestyle as they adjust to their diagnosis.

Better maternity services


Making midwives pay for their education is not moral or practical and can be reversed at the stroke of a pen. According to the Royal College of Midwives, we need 2,500 more midwives just to maintain standards and more to improve them. This is not happening and as a GP I was aware of the increased stress and frustration experienced by stretched midwives. 

It cannot be overstated that a nation without enough midwives has got its priorities all wrong.

Any reduction in ante natal care is false economy, however it can reasonably be presumed that ante natal classes during lockdown were reduced, so however good they might be, they are not the cause of the reduction in early births.

Sure start Centres

The destruction of Sure Start centres which supported young mothers on the back of Austerity
was little short of cruel. Despite that they had been shown to reduce health care costs, the axe fell on thousands of sure start centres and left many mothers without this amazing service.

For many mothers it was replaced with, er, nothing.

A less baby-damaging society?


While not doubting the adverse effect of the lockdown on many people, in particular the worsening of poverty as well as the unwelcome and immoral increase of wealth flowing up to undeserving rich, the isolation and the stress, it has given us unequivocal evidence of the damage the pre COVID19 'normal' modern world if inflicting on the developing child. 

If supporting mothers financially, reducing the need for work, reduction of exposure to air pollution, reducing levels of stress and perhaps reduction in the level of other viral infections makes such a huge difference then this must, on humanitarian as well as economic grounds, be translated into political policy to protect and support mothers improve the life of their babies, and thus the future of humanity.

I have a wonderful picture in my mind of quieter smaller Neonatal Intensive Care Units, happier mothers and more babies born nearer their time. Also less overworked doctors and nurses due to a huge drop in the number of premature babies being born. Happier healthier babies and mothers too lead to healthier adults and a better society. 

Perhaps we might now have clues we need to reduce our rates of premature birth, or are we happy to go back to the old normal of a society which is clearly toxic to the next generation, even before they are born? I will update as more information comes in.

Wednesday, 12 August 2020

How we eat and our health - time for your last supper??

This post is not COVID19 related. Or is it? Having been interested in what we eat for decades, the subject of how we eat is now under the microscope. In other words, let's have a look at what is happening in the world of fasting and time restricted eating, and discover what the implications for your health are.

How we eat and how it affects our health.

You might wonder why the hell anyone would want to fast, and if its just another foodie fashion? Yet by the end of the article, I hope that you might think again about fasting as a useful way to improve health and longevity. 

As it happens, I have a personal interest in this. 

I recently decided that it might be a good idea to try Time Restricted Eating (TRE). Even in a thin person like me it has some theoretical benefits for brain health. For anyone overweight it helps shed the kilos, and for all of us all it helps get some control over eating patterns which over the time of my lifetime have become chaotic and harmful.

I wondered if it might therefore contribute to the Disease Modifying Lifestyle which I hope will keep my MS as quiet as possible.

So, about three months ago I started by eating my last meal by 6 and delaying breakfast till 11 or 12. The "16 to 18 hours of fasting and 8 to 6 of eating. This turns our engrained western habits upside down. 

It was easier than I thought. I have coffee instead of breakfast and find finishing the evening meal by 6 or 7 quite simple. The results for me have been interesting. 

I now experience less hunger, enjoy my late breakfast far more, and I lost a little weight. This was not really needed but find myself able to eat as much as I like with my three meals a day. My weight has now stabilised a few kilos lighter that before. 

Another thing I have really noticed is that I no longer feel the need for any snacks, nibbles or munchies. I never crave food! The guys in food marketing departments will be horrified!  This is a blessing in more ways than one. 

So let's have a look at where we are right now in terms of eating patterns; how we eat. As with so much of our food culture, it's a shocking picture. Onto the crazy world of snacking.....

Creating the snacking mindset


Anyone my age (64) has experienced a life of being blitzed by advertisements for snacks. Usually ones that hint you can "eat between meals without ruining your appetite" (see - those advertising jingles really do stick!). American children, during their 45 hours of TV viewing a week, watch about 120 fast food adverts, that's about 6,000 a year!

Over here in the UK, Cancer research, in a survey of 3,400 children found that children who use the internet more pester their parents more for snacks. These kids watched, on average an astonishing 22 hours of TV and spent 16 hours online each week. They watch 18 junk food adverts an hour, and I'm sure the advertisers will find ways of subverting the recent 9pm watershed for junk food adverts on TV.

Simultaneously, rates of obesity have doubled in children aged 2-5 (now 12.4%) and ages 6 to 11 (17.0%). In teens ages 12 to 19, obesity has tripled to 17.6% in the US and we are catching up fast.

So, have many of us have now been convinced that we cannot go for more that a couple of hours without a snack? Have we have got used to forever imagining ourselves being hungry, craving food within hours of eating even while we are paradoxically putting on weight? Indeed, have our eating habits been designed to maximise profits instead of providing healthy nutrition?

Some good science explores this. I hope it will help you understand how we have got into this mess and how we might help change the way we eat and live longer, healthier lives. 

Industrial eating patterns


Over recent time, eating patterns have been transformed. We are now eating far more often, again with the US leading the way. 

From eating an average of three times a day in 1977, this 2006 study shows we now eat 5 or six times a day, and probably more since then. In between meals there are increasing numbers of snacks with most people now eating more that 6 times a day.



This is likely to relate to the use of fridges and microwaves, but also the the availability of packaged food available at a whim as opposed to the end of more traditional kitchen tasks.

Another more recent study sheds more light on the day to day reality of this phenomenon:

24 hour eating


A clever survey of 47 individuals in the USA used an App to record every eating or drinking event over the space of 16 weeks and gives a further insight into what is going on. This eliminated the bias that plagues dietary studies based on self completed questionnaires. What they found, in short, represents culinary chaos:
Every dot represents calories!
  • Eating patterns varied from day to day.
  • Despite reporting eating three meals a day, this patten was largely absent when food intake was analysed.
  • Only half of calories were taken in the form of meals
  • The average duration between eating was just 3 hours
  • 28% of food items were pre-packaged meals
  • More that half of adults were eating over more than 15 hours a day.
They describe this beautifully in the clock (right) in which every dot represented calories being eaten and shows eating from dawn to dusk.

Regular patterns of eating seem to have gone out the window. I also can't help but notice the number of times people are eating at night. These are not night shift workers, they were healthy people (that is without diagnosed disease - yet). They are waking in the night feeling the need for a snack! 

Eating times
The slight peaks, shown in the graph representing the same data in a different way. Peaks at 12 and 7pm, representing the main meals, but with lots of grazing in between.

The average duration of eating was spread over 15 hours a day, a 9:15 fasting/eating pattern which takes a toll on health as I will describe below.  

They also found that when people reduced their total eating from over 15 hours daily to just 12, they lost an average of 3.3Kg, had more energy, and slept better. This weight loss persisted for the year of follow up, and tells us that that even a 12:12 pattern has health benefits.

So the reality is that many of us are eating most of the day, from an early breakfast to a late supper and sometimes waking for a nocturnal snack.

Given this, it is understandable that we take in more calories than we burn, but it goes beyond that simple paradigm. 



Why does this matter?


The graph below shows what happens to glucose and insulin levels during the traditional three meals a day. We eat food containing starch, it is slowly absorbed by the gut, and the pancreas produces insulin to keep the level of glucose in the blood within certain limits.


Metabolic response to meals



I cannot find a similar graph to illustrate the metabolic chaos that eating many times over most of the day will bring, but you can imaging the multiple peaks of insulin and the yo-yoing of blood glucose levels throughout the day. 

This is not what our digestive or endocrine systems are designed for at all and will lead to problems with glucose tolerance, insulin insensitivity and progress to diabetes in so many together with feelings of fatigue, lack of energy and poor sleep. It too is associated with greater risk of the biggest killer, heart disease.

A metabolic metaphor


Imagine that lots of calories arriving at mealtimes and snacks. There is no let up in between with continual snacking and nibbles from breakfast to that last supper and nocturnal nibble. A full day of eating. How and where does our body store those calories? 

Imagine calories are like cars driving into town. The town centre has short and long term car parks filling as more cars arrive than they can cope with. The short term car parks, akin to the livers stores of glycogen soon fill up and the overspill has to go somewhere - the long stay car parks which are located in the belly, which soon expand with stores of energy from the flood of unneeded calories for ever arriving with no time to empty the short term stores.

The stored fat is not consumed as the short term storage in the liver is always full and so more and more yet more fat is stored in the belly, around the liver and organs like the heart. Like a town centre surrounded, and indeed being consumed by ever expanding long term car parks. This leads to what we term central obesity. (As well as city centre blight)

Metaphors only go so far, remember though, there are a few overweight people who eat too much good food, who stay healthy, and thin people who don't eat too many calories, but exist on a diet made of junk snacks and whose health, though lean, is a ticking time bomb.

Simple steps to create your own eating culture


One of the many disadvantages of Brexit is their capture of the concept of "Taking Back Control", yet this is precisely what we need to do when it comes to our food and our health. So many of my patients felt so much better when they realised that they were able to do this, to control their weight by knowing what to do with food and eating. 
These simple daily steps represent giant leaps forward in terms of how we eat:
  • It helps to eat meals - three times a day.
  • Snacking is not needed, so keep eating in between meals to a minimum.
  • Restricting eating to a 12 hour window is a good start
  • Extending the daily time without food is beneficial for anyone trying to lose weight.


Fasting - The last supper


5:2 diet
The most common way of fasting is to restrict eating on one or two days a week to a decent 500Kcal breakfast and nothing for the rest of the day. 
To follow the car park metaphor, the city centre parks empty, and the cars from the over-expanded long stay parks have space to be moved in and then leave. The fat in your belly and around your organs is mobilised and converted to energy in the form of ketones which are said to be particularly good for the brain. Empty spaces appear and are removed; we lose weight, feel better, sleep better, live longer. 
You need to build up to this slowly over a month or two as the metabolic changes from forever trying to store calories to using them up can tale a little getting used to. You develop what is called "ketosis" as the body burns up the unwanted fat, but this can leave you feeling tired if done too quickly. 
Yet is is so well worth the effort and time getting there. If you want to lose weight, its a great way to  achieve it, its wonderful not to be craving food all day - it helps us get back in control of our diet and our health.
Time Restricted Feeding

This for me was simple. Delay breakfast until 11 or 12, eat at lunch time, and dinner about 6. No snacks, indeed, little desire for them. Insulin peaks with meals and does its job properly, you have much more stable blood glucose, a bit of ketosis every day. The system is back to normal, the pancreas which produces Insulin at the right times and doesn't get exhausted.

Again, this can be done gradually. Some people have breakfast and end the eating day in the afternoon. Whatever fits in with your routine. 

Whatever you choose to do, those suppers taken at exactly the time the body least needs them, come to a welcome end. The last supper indeed!

Exceptions to the rule:


In population terms, fasting is most beneficial for the two thirds of us who are overweight, that is where this advice is most helpful. It has potentially has benefits for people with type 2 diabetes, or those multitudes with pre-diabetes who need to take action to control metabolic damage. Also for those with MS, there are potential benefits which have been described as beneficial "biohacking"

There are exceptions to every rule. Occasionally people need to keep weight up in the face of illness, or surgery - and of course, pregnancy with its increased need for calories and extra nutrition. In these situations, eating will need to be spread over a longer period of time to take in all the extra nutrition required for maternal and foetal health. Nevertheless, it is important to eat real food and resist the temptation to snack on ultra-processed junk food. 

Children too may be rather different as skipping meals and breakfast for youngsters is more often a marker of a poverty and want than conscious choice, and regular meals are of benefit given the extra calories needed for (hopefully) extra activity and the nutrition needed for brain and body growth. 

Reduction in snacking on the usual culprits of biscuits, buns, cakes and confectionary, with their high content of sugar, industrial fats and salt, is however beneficial for anyone.

The bottom line:


This goes way beyond personal choice. People don't choose to be overweight or develop diabetes, it is a mirror held up against the way we create, transport, subsidise, advertise and sell food.

We don't choose to watch tens of thousands of health damaging adverts in our young lives, and we don't choose the resultant culture.

Yet, given the weakness of political leadership, the ascendance of global agri-business and ongoing aggressive junk food marketing, the way out of this trap does involve making decisions to release ourselves from our habits and make create our own food future.

The governments drive to reduce obesity will, Im afraid, not be enough to tackle this. Exercise for example, is a good for health and wellbeing in so many ways, but on its own is not and effective way to lose weight. You can run a marathon and lose just 1 pound!

Further, the food, and sugar lobbies are not going away and still have far more power and influence than the health lobby, such as it is.

These cultural habits play a significant part in that epidemic of unwanted stored calories appearing so clearly in the COVID19 death statistics. 

Make no mistake, losing those excess calories, stored away as inflammation-generating fat in the belly and around vital organs, brings big health benefits and in the current situation, reduces your risk of a whole host of illnesses, excess deaths from COVID19 being just the latest. 

I wish you happy eating, and contented healthy fasting in between!



Thursday, 6 August 2020

July COVID19 update - what is going on?

In March and April this year, as the toll from COVID19 climbed, it soon became clear that we  did too little too late; delayed lockdown, terrible procurement and general over-centralised dogma driven chaos as our politicians grappled with science they had little understanding of or experience with.

Now, as we are heading for Autumn, things are very different. Mortality across Europe has returned to normal levels, that is; there are no excess deaths in Europe. In Devon, there were 10 cases in the last week in a population of about 1,000,000, and no deaths.

In England (unlike Scotland and Northern Ireland) there is a general agreement that COVID19 is not going away. In other words, that eradication is not possible and that we have to get used to it - that it will become an endemic disease like flu or colds. But what does that mean on the ground?

Perhaps we have to live with a certain element of personal risk - but right now that level of risk seems very low as I will show below. So how does that square with attempts to snuff out outbreaks which are not causing serious harm in terms of hospital admissions or deaths? As we no longer need to "protect the NHS" what are we now trying to achieve?
 

Numbers.....


PHE are not publishing the daily deaths on their dashboard since mid July while a review takes place of what they are actually counting. (No, this is not a Monty Python sketch!) This  has been prompted by potential over-counting due to people with positive tests dying of unrelated causes and still counting as a COVID19 "associated" death months later. 

In some cases this may well have been relevant as recovery can be prolonged and death delayed after severe COVID19. The numbers are not huge and the main trends the same, yet potential errors are now becoming important as the numbers of deaths continue to fall and small errors play a relatively bigger part. It hardly inspires confidence.

As ever, trends can tell us more than actual numbers, and according to the ONS, total deaths over the last week (8823) are now less than the five year average (9093) with 295 deaths having "COVID19" mentioned on the death certificate. 

What about its prevalence in the general population? The ONS explore community (outside hospitals or care homes) prevalence with random nasal swabs taken over the last six weeks in England and found that 116,026 swabs revealed 56 positive tests. On the basis of this, they modelled that 37,000 people in the UK had the infection in the last week, giving a prevalence of 0.07%, that is 1 in 1,500 people. Daily admissions are down to 183 people (July 22nd) with 83 in ventilator beds. 

On the basis of the ONS study there might be a 3% chance of hospital admission if you get the infection, so it remains a significant illness, though highly stratified of course, according to age and risk factors. 

What is happening with testing?


The number of tests done is increasing all the time as this graph shows:

COVID TESTS

The more tests you do, the more positive results you will get, so is the increase in 'cases' an artefact of this? The graph interestingly also shows the difference between testing capacity (grey area) and tests done (blue area). That represents public funds going to the private companies contracted to do this work, much of which is for doing very little. 

Testing and tracing, sadly, is in the doldrums. The Government in England have made a mess of the system. I could hardly believe the contortions of a minister trying to gloss over the cracks in the system yesterday morning. Not enough people with infections are coming forward, likely due to inability to lose pay due to isolation after a positive test, or skepticism, or ignorance. Then they are not able to list all their close contacts, and then not all the contacts are able to be traced. Each step moves away from the target needed for the system to work.

Local public health teams continue to do the majority of the graft with 'complex' cases being the bulk of the work, and must be very frustrated indeed. Local government, public health bodies and primary care are intentionally being kept out of the loop.

The government have effectively used the pandemic to outsource Public sector work. As Boris stated in a speech in February, there are opportunities in a pandemic for business. More on this later. 

Anyway, to the results.....

So, the total daily cases look like this
COVID 19 "CASES"

It is to be expected that the number of positive "cases" are increasing as lockdown is released, and as the number of people tested increases. That is exactly what would be expected of an endemic infection in the summer.

Now when I was a practicing doctor, a 'case' meant someone with an illness, someone who came in my door with a problem. With COVID19  I'm reading everywhere about the number of 'cases' but this increasingly means people who are not unwell, and often being tested because of minor symptoms or if they have been in contact with cases, not, in the clinical sense, 'cases' at all.

We shall have to wait a few weeks to see if the increase in positive tests impacts on mortality or admissions, but I doubt it. Given its the summer, perhaps it is worth the wait before plunging into more restrictions? 

What really matters are hospital admissions and deaths:


The data for these are reassuring as they continue to testify to the reduced impact of the virus in the UK.

Hospital admissions continue to fall:

HOSPITAL ADMISSIONS WITH COVID19

Unfortunately, we (unusually) don't publish figures for recovered cases which would be useful to know and indeed, exclude from any further mortality figures. It would also be helpful to know how people are recovering as there are concerns that for a significant number, the illness lingers on for some time and symptoms of ongoing listlessness and fatigue can be very frustrating for those trying to rehabilitate. 

Yet any discussion of a "Second Wave" is clearly off the mark right now, it there is going to be a second wave, it will arrive in the winter. Worryingly, it is only a few weeks now until children return to school and I cant help but feel the summer has been a lost opportunity to get the pandemic infrastructure of testing, tracing, isolating and supporting right. 


Deaths too are now running at low levels as this graph shows


Bear in mind also that small errors in counting now make a bigger difference.  Deaths with COVID mentioned on the certificate continue, but there are issues with the counting which need to be resolved soon, but the more solid data on total death, as I said above, are reassuringly normal.

COVID 19 DEATHS

As ever, we seem to be one step behind. The initial lockdown was too-little-too-late, and now reversing relaxation of restrictions might be too-much-too-early? I wonder if they are needed at all during the summer and autumn. Winter might be another matter - I really hope it might not.

There are other encouraging factors at play.....

Vitamin D is more important than we think


Like its more benign cousins the betacoronaviruses and influenza, COVID19 dies out in the summer. For me the most compelling driver of this are higher levels of Vitamin D, and their positive effect on what is called our innate immunity - our own, inbuilt immune defences. It goes beyond common sense that this vital vitamin, so low in the winter makes a big difference, one recent paper stating:

"Population-wide vitamin D sufficiency could also prevent seasonal respiratory epidemics, decrease our dependence on pharmaceutical solutions, reduce hospitalisations, and thus greatly lower healthcare costs while significantly increasing quality of life"

This is displayed in this graphic from Dr David Grimes, a longstanding campaigner on the value of vitamin D supplementation. 
Thanks to David Grimes for the image

Lots of lobbying seems to have dragged out the recognition from the Chief Scientific Officer, Sir David Vallance, that millions more should be taking Vitamin D. I will post on this again later, before the winter, but am perplexed at the lack of interest shown by government to what has the potential to be a true game changer. Lobbying is continuing, but in the meantime, make sure you get adequate Vitamin D by getting lots of sun (most people are unable to) or supplementation with 4-5000iu Vitamin D3 daily. I will post again on this soon.

Immunity might be more widespread that we think


In another post, I wrote of the T Cells and how they target invaders like COVID19, how exposure to SARS and other coronaviruses might offer cross reactivity against COVID19, and
T Cells (big green cell)
COVID19 (small yellow objects)
(Science)
 how we might be building up herd immunity way ahead of the levels of antibodies circulating in the community. 

Another recent study shows that cross reactivity of T cells against COVID19 is present in the blood of 50% of pre-pandemic blood samples which might explain why some people cope so well when infected.

I hope there may be ways of testing this sort of immunity more widely, but it does also seems to explain why so many younger people are spared the worst of the illness, while us older ones tend to have run out of effective T cell immunity. (Immunosenescence)

Herd immunity might be nearer than we think


Classic ways of looking at herd immunity are changing with COVID19 and the estimate of how many people need to be infected falling according to some scientists. 

The usual levels of herd immunity (80-90%) cited are for unexposed populations with no immunity to an infection, but this will be reduced by whatever protection is derived from previous infections with milder coronaviruses.

This means that is has differing impacts on different groups of people with differing exposures. The young immune do alot of 'hoovering up' of the virus it seems. Meanwhile, some of those those susceptible tend to get the virus early and thus are not available for re-infection. Both these effects reduce the proportion of the population needed for herd immunity. So there are suggestions that the level we need for herd immunity as measured by a positive antibody test might be as low as 20%. 

"Nerd Immunity" may help


Also contact tracing through digital means may reduce spread, and thus the likelihood of coming across the virus, and therefore the level of infection needed for herd immunity. With so many of us having mobile phones we are all in this sense, 'nerds', and so with the right technology this might might also reduce the opportunity for the virus to spread.

There is hope this will make a difference in India and has been a significant part of the strategy in South Korean containment of the virus, as, backed up by effective epidemiological footwork it changes herd behaviour and again reduces the number of hosts for available for COVID19.

All these factors mean the virus is less likely to find a susceptible host and find itself up more and more cul-de-sacs.

Air pollution is more of a killer than we think


What about air pollution? Some of the decline, and the subsequent increase in cases be due to that wonderful decrease in air pollution we experienced in lockdown being reversed as we return to our poisonous levels of emissions from traffic and travel.
Civilisation??

American research suggests that relaxation of restrictions and increased air pollution takes a heavy toll on COVID19 related illness. 

They conclude: 

"Our results show that increased pollution nearly doubles the conditional daily COVID-19 death rate and case rate.These results are stronger for counties with higher fractions of Black individuals, lower income individuals and unemployed individuals, suggesting that the burden of pollution exposure is unequal. Pollution might have the largest impacts on the most vulnerable members of society, causing higher death rates and more severe cases of COVID-19."

This disproportionally affects the BAME and deprived communities who have always suffered more from the significant impacts of traffic, much from the exhausts of the more financially well endowed commuters. Horribly interesting. Sadly unsurprising. 

What are we doing to reduce dangerous levels of traffic - not enough. Restrictions on traffic in cities would help reduce spread, and much change is needed.  Cycling is getting a much needed boost, but roads are packed again everywhere as we fail to face up to our obligations to those who are effectively, passive smoking exhaust fumes due to transport policy designed to enhance the freedom of drivers, trapped themselves in cities designed for the car.

So what is going on?


Infections are not causing problems in terms of hospital admissions and there are now no excess deaths, despite ONS estimating 37,000 infections a week in England alone. 

So we have to be clear about why we are taking difficult steps to prevent its spread. The strategy is to suppress the virus to prevent a second wave, fine. 

Yet as we release lockdown more cases are inevitable, fuelled, for example, by poor working conditions in meat packing plants and sweat shops and the inability of big chunks of our cash strapped population to survive on sick pay.

This will make local outbreaks inevitable unless we are ready with an effective testing and tracing system, and full sick pay for those isolating. In England we are clearly are some way from this and with current policies will not get there any time soon. With schools soon to return, 'anytime soon' might well be too late.

Another possibility is to aim for  ZERO COVID19. Yet again, this would need much better testing and tracing, and more aggressive restrictions in regional and international travel, and is just not happening in England. In Scotland and Northern Ireland, perhaps.

As all outbreaks are local, surely we need more powerful local councils (as in most of the world) and locally rooted services to deal effectively with them. In England have sadly and intentionally all but destroyed this local infrastructure and continue to marginalise what is left of them  - in favour of lucrative private sector contracts which are failing to deliver.

Coupled with that is the lack of openness about decisions. The most recent restrictions in northern England have been announced without the data which underpins them being available to local government or the public. Again, these lockdowns are sledgehammers applies to the nut of small local outbreaks which need the micromanagement that only local services can apply.

Further secrecy shrouds the development of rapid tests for viral RNA with results reported to be available in 90 minutes. Sounds good, but we have a track record of expensive cock-ups. Have the tests been scrutinised and validated? The incidence of false positive and false negative rates are essential to understand the usefulness, or otherwise of the tests quality. Errors can have big impacts on the individual and communities, but no one outside government has any idea at the time of writing as to the quality of these tests.  

The only other option other than effective local management was to aim complete elimination of COVID19. In England that would require another complete lockdown until it disappears altogether, as well as isolation from other nations are who are struggling at the moment with more COVID19 infections. This is clearly not going to happen. So we need to understand that in the absence of effective eradication policies, infections will continue and inevitably increase as restrictions are removed. 

So there is remains considerable uncertainly as to what awaits us this winter. I hope that immunity is more widespread than we think, that the Vitamin D message is getting across, that we are far nearer to herd immunity that we might have thought, and that a vaccine will be available for the vulnerable. If this is the case, then the winter will be manageable without destroying jobs and rendering the NHS ineffective. 

It may also be possible that given some of the biology, severe restrictions now, before a real second wave comes along, will leave us weakened as the kids go back to school, as they must, and tired mentally, socially and economically.

So readers might well want to make sure they are up to date with the Vitamin D, get as much exercise and sun as possible, and get as fit as possible as the autumn approaches. Say goodbye to garbage food and say hello to better health and a higher likelihood of a mild illness if you do get infected.

While there is much to fear, there is also much to be optimistic about and it's so important to look after ourselves, our loved ones and those around us.

Final thoughts.


We are thinking about sending a human being to Mars. We can deliver pin point bombs to any square meter of space on the planet at the touch of a few buttons. We can deliver packages to anyone ordering them within 24 hours, and do all sorts of other, incredible, totally needless and so often, destructive things.

Yet, with COVID19 we have shown new levels of collective ineptitude, particularly in the world of politics and particularly in so called leading nations boasting about "greatness"; England and the USA in particular. So many other nations are also led by some dreadful individuals. 

Dealing with what by comparison in terms of effort, should have been a difficult by achievable  challenge (we were warned) has shown the gulf between the emerging realities of the world and out-dated political decision making. We have had breathtaking errors and cock-ups. Dogma manufactures mistakes, incompetence and corruption. 

Might a Citizens Assembly provide a better way of dealing with difficult decisions? I think so.

The real and much bigger threats of climate change and ecological destruction are increasing and the world is changing frighteningly fast; we will have to adapt more in our lifetimes that ever before in our history. Change is inevitable. Horizons are drawing in.


Bo-Jo on LBC
I reflect on Boris Johnson briefly wearing glasses to back up Dominic Cummings schoolboy excuse for his now infamous "see if I drive my car into a wall" eyesight test and wonder if we will ever get this right. 

Yet, can anyone ever be as idiotic as Trump; one day calling for less testing (and so less cases) and the next heralding the US as world leaders as they have a low ratio of deaths to positive tests (thanks to more cases). Please don't re-elect him!!

We have the ability, but not the political will to 'follow the science' that is, test your best ideas, and if they don't work, learn from them and explore new ones. We need more flexible thinking and action, better acknowledgement of the biology of this living planet and our place on it. 

We desperately need better politics.