Night’s candles are burnt out, and jocund day stands tiptoe on the misty mountain tops.
Spanish life is not always likeable but it is compellingly loveable.
- Christopher Howse: 'A Pilgrim in Spain'*
Today is what the Brits call Boxing Day. No one's really sure why.
Anyway, here's a Covid Special - Another good dose of information and common sense from Private Eye's MD. . UK biased, of course, but surely of wider interest and relevance:-
1. Celebrate science
Whatever your view on the profits of the pharmaceutical industry, the extraordinary achievement in producing Covid vaccines within a year deserves praise. Not only could vaccines save lives and prevent transmission, they could also return life to a semblance of normal. Even countries with far better control of the virus than us will embrace vaccination, though they have bought more time to ponder which of the vaccines they want to use.
The UK is not in that position. Having failed to act quickly at the start of the pandemic, and with widespread community transmission only partly curtailed by harmful restrictions, we are acting most quickly with vaccinations. If they work, and enough people choose to be vaccinated, it's the UK's best chance of ending the lockdowns, protecting the NHS and care homes, reopening society and boosting employment and the economy.
Indirectly, vaccination could make it easier for non-Covid conditions to be diagnosed and treated, improve mental and sexual health, end isolation, and allow people to die and grieve with support and dignity. But mass vaccination won't happen overnight. And it isn't harmless.
2. First do the least harm. Then do some good
"First do no harm" is my least favourite aphorism. It is widely quoted as a cornerstone of the Hippocratic Oath, notably by people who oppose vaccination. It comes from Latin ("primum non nocere") and is wrongly attributed to Hippocrates, who was Greek. In truth, every health intervention can do harm as well as good. Merely labelling someone with high blood pressure or high Covid risk can have profound psychological consequences.
This pandemic has taught us that "do no harm" is for the birds. Every public health intervention made in the name of containing Covid (isolation at the end of life; banning funerals; banning social gatherings; closing schools, businesses and sports, hospitality and cultural venues; protecting the NHS at the cost of care homes; national lockdown, regional lockdown; failures of testing, tracing and PPE; etc) has had significant costs and harms.
Because we were late to act at the outset and let the virus nm free, we have spent a staggering £280bn trying to slow it down. But we can never be sure how many lives have been saved by locking down or how many we would have saved by spending the money on other things, or more effectively. We may never know if we've done more good than harm, but we do know the harm we have inflicted on ourselves is so big you can see it from space. In such a festival of self-harm, not having a vaccine because no one can guarantee it is "I 00 percent safe" or "completely free from harm" seems odd, particularly when you consider the potential good it could do.
3. There is no 'zero risk'
Nothing in a pandemic has a better benefit:risk ratio than vaccines. When rare but serious side effects occur, such as severe allergy and anaphylaxis, they happen at the time of administration, which is why vaccines are given where there are resuscitation facilities. Of the thousands of Pfizer BioNTech vaccines given in the UK so far, two people have had severe allergic reactions and recovered with treatment. Both had a history of severe allergy to triggers other than vaccines, and anyone with such a history should not have the Pfizer vaccine.
When vaccines are given to billions of people, as they will be for Covid, thousands of adverse reactions will be reported. Most will be unrelated to the vaccines, but some will be. Which is why vaccination should be voluntary and all vaccines should be protected by the Vaccine Damage Payment Scheme.
4. Keep vaccines voluntary
In MD's view, forcing people to have vaccines against their will does more harm than good, and may increase side effects (if you think something is going to harm or help you, often it does). Some people may refuse inoculation because of the warnings of a TikTok celebrity who will happily snort cocaine imported in a mule's rectum but tells his millions of followers a rigorously tested vaccine is dangerously impure.
In the dark days of medical paternalism, patients were told their tests, jabs, treatment or screening were a 'Jolly good idea" by a doctor or nurse they had no choice but to trust. There was little nuanced discussion about pros and cons. Many patients are still happy to do whatever the doctor/nurse/NHS/Queen recommends, particularly in a crisis. But others want proper informed consent. The government and NHS need to give it to them.
5. Brains need BRAUNS
Informed choice for any medical intervention requires BRAUNS. You need to know and understand the Benefits, Risks, Alternatives, Unknowns, what if I did Nothing?, and Safety net if something goes wrong.
The NHS does not have a glorious history in giving fully informed consent for mass screening, mass vaccination or indeed any new products (eg the vaginal mesh), and regulators don't always protect people when shit happens (read First Do No Harm, the coruscating Independent Medicines and Medical Devices Safety Review chaired by Baroness Cumberlege).
The Pfizer Covid vaccine uses a new technology and the trial safety data and efficacy (available at www.gov.uk) are excellent. However, you never know how a new vaccine (or any therapy) will perform and how long protection will last until you try it in the real world. No severe allergic reactions were reported in the trials, but they happen in real life.
The chances of having short or long-term serious side effects for existing vaccines is roughly one in 25,000. The chances of having life-threatening side effects is roughly one in 1,000,000. This compares to one in 250 and one in I 0,000 for a course of antibiotics, making vaccines roughly I 00 times safer to take than, say, penicillin. And much less harmful than lockdown.
6. Scepticism can be healthy and harmful
Those who do not wish to have a vaccine should have that choice respected. However, they should also be made aware of the potential dangers of not vaccinating, to others as much as themselves.
We have a long-established, safe and highly effective MMR vaccine. Unfortunately, too many parents still doubt it decades after the Andrew Wakefield autism scare, and the UK has now lost its measles-free status. The Eye got MMR wrong and was corrected by MD (see Eyes passim).
It is very hard to prove a drug or vaccine is safe and effective (trials have to be large and meticulously conducted). It is also very hard to disprove an allegation of harm, however implausible. Vaccines have done far more good than harm over centuries, but some - or some batches - have been harmful and needed to be called out. We shouldn't put a halo around any intervention, but neither should we smear it with bullshit. Transparency over data and safety reporting is key. The pharma industry has been too slow to put all data for all trials in the public domain, but Covid vaccines are likely to be the most scrutinised in history.
Herd immunity will require a majority of eligible Brits to be vaccinated. It will also need huge levels of public trust (undermined by the misinformation of the Brexit debate) and a strong sense of the importance of the collective over the individual (not a traditional selling point of the hard Tory right). It may take the Queen and David Attenborough to get it over the line.
MD's 202 I prediction is that as soon as all the over-50s and high-risk people have been offered a vaccine, and those who want it have had it, the government will cease all restrictions. And there will be benefits and harms.
7. Promote health for all
Vaccines save millions of lives, but not as many as giving everyone a decent standard of living. The most reliable indicator of health is wealth. Money buys freedom, space, nutritious food, care and escape from adversity, which translates in the UK to ten years more life expectancy and 20 more years of disease-free living compared to the poorest.
The pandemic, and our response to it, has magnified existing health inequalities. During the first wave it doubled your risk of death, and during the current wave it's adding 20 percent. So the more at risk you are by dint of age, disease, disability or deprivation, the more likely you are to die during the pandemic (and not necessarily of Covid).
Countries with the highest death tolls were not only poorly prepared and slow to react, but also had very high levels of health inequality, poverty, mental illness, obesity and chronic disease. For example, the "Northern Powerhouse" area has suffered 12 more Covid-related deaths per 100,000 than the rest of England and will also be hardest hit by lockdowns, recession and Brexit. Time to level up.
8. Health workers are human not heroes
Most NHS staff enjoyed the Thursday clapping and rainbows, but many (including MD) were uncomfortable with the "heroes" label. To do a very stressful job competently, in the most difficult circumstances, we need adequate training, supervision, sleep, nutritious food, regular breaks and freedom from fear and bullying. We also need adequate PPE to protect us. The idea that we have heroic stamina and invincibility is dangerous nonsense.
Hospital-acquired Covid infections are now at an all-time high (on 6 December they accounted for 24 percent of the total), and 36 trusts saw Covid admissions increase by more than 20 percent, with 19 days still to go before Christmas. True, winter is always tough in the NHS (four years ago the Red Cross described trolley queues in our emergency departments as a "humanitarian crisis") but 25 percent of the junior doctors in many hospitals (including my own) are currently off sick or isolating as Covid contacts. Some staff over 50 are very unwell with Covid, 650 health and care staff died from Covid this year and 2020 has also been a terrible year for mental health. More GP and consultant colleagues have been lost to suicide. Many doctors are innately self-critical workaholics who hate not being able to deliver a decent standard of care for all their patients. Please think of that when you're complaining how hard it is to see a consultant or GP. We have no heroic power to fix an overloaded system.
There is light at the end of the tunnel, but the tunnel is longer than you think and Christmas will be particularly treacherous. Think carefully before embracing the multi-household bubble-fest. My mum (84) has chosen to have the vaccine but not to have Christmas with her grandchildren.
9. How we die matters
The moment sperm meets egg, we join the queue for death. Humans are the one species who know our fate well in advance. Our mortality rate will always be 100 percent; it's how we die that matters. Some people were taken well before their time by Covid, but the median age of Covid death is 82.4 years.
The greatest trauma is that many people died quickly and unexpectedly, often on their own and with no chance to say goodbye. Funerals have been strictly spaced and limited, leading to even more isolation and grief. Most people would choose a quick death over weeks of wasting away, but for those left behind the loss is more profound if words are left unsaid.
Of the many cultural shifts of the pandemic (face-masks, elbow bumps, Jonathan Yan-Tam action dolls), the least understood is the extraordinary increase (more than 25,000) in people dying at home. Few had Covid tests, and postmortems have been limited, so we may never know why. Some may have lived if they'd sought help for, say, a heart attack or cancer. Many may have been fearful of catching Covid in hospital without realising they'd already caught it. Some may have wanted to "protect the NHS" when they most needed to use it. There may even be a link between "working from home" and "dying at home".
Hopefully, some people had decent deaths at home, surrounded by the love of their family, rather than saying goodbye in a mask and visor at two metres or via iPad. Vaccines could end this insanity too. I'll be having mine.
* A terrible book, by the way. Don't be tempted to buy it, unless you're a very religious Protestant.