Thoughts from Pontevedra, Galicia, Spain: 13.4.21

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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’

NOTE: If you want to know more about Galicia, click here. Detailed info on Pontevedra coming soon. 

Covid 

See below for the latest solid – but UK biased – Overview from Private Eye’s medical columnist.

I learned yesterday that: There are risks associated with both smoking and oral contraceptives, and mixing the two can be a deadly combination. Smoking is known to restrict one’s blood vessels, causing blood clots that lead to cardiovascular issues. If you are taking one of Bayer’s birth control pills (Yasmin, Yaz, Beyaz, Safyral) or a generic version, you will want to know these pills have higher risks of side effects than other types of oral contraceptives. Bayer’s oral contraceptive products and their generic versions contain drospirenone, a type of progestin hormone not found in most other oral contraceptives. Rather than taking the drugs off the market, the FDA decided to change the labels for Yaz, Yasmin, Beyaz and Safyral to warn patients and doctors about the increased risk for developing blood clots. One wonders how many young women are happy to takes this risk while rejecting the AZ vaccine.

Spain: Those 70-79 ‘soon’. With the J&J(Janssen) product. Which some say, like the rest, isn’t really a vaccine.

Cosas de España/Galiza 

In a country in which both consumer protection and corporate ethics are lower than elsewhere, one can run up against unexpected problems/issues. Unannounced new or increased bank charges are the most obvious. This morning I’ve been trying to change car insurance companies, having been advised last week that, even if the premium had been paid yesterday, I could get the bank to cancel it and get back my money. Not necessarily, it seems; if the payment was made against a credit card, this can’t be done. Now I know why offer a 5% discount for (automatic) annual renewal via a card.

More here on the government’s decision to open the Valley of the Fallen graves holding 30,000 bodies the from civil war.

During said war, a British brigade, composed largely of communists, advanced up a hill SE of Madrid during a hot day. Feeling the heat, the men decided to discard what they didn’t really need. So . . An extraordinary variety of objects was found later among the debris – hand grenades, ammunition, machine-gun spare parts and clothes and equipment of all kinds. But the personal items which had been jettisoned provided the strangest part of the collection. There were books of all kinds. The Marxist textbooks, which were large and heavy, lay fairly near the bottom of the hill. The rest were an amazing variety, ranging from third-rate pornography to the sort of books which normally fill the shelves of the more serious type of undergraduate. There were copies of the works of Nietzsche, and Spinoza, Spanish language textbooks, Rhys Davids’s Early Buddhism and every kind of taste in poetry. Some things hadn’t been discarded. One volunteer still carried with him his mandolin. Another was equipped with Shakespeare’s Tragedies.

María’s Level Ground: Day 9. Swab discomfort.

The UK

The National Scarecrow has had a haircut. Apparently done by his cat.

Which reminds me of a question which came to my my mind yesterday . . . Is 4 more years of Boris Johnson a hairy prospect?

The Way of the World/Social media

The ‘right-wing’ view? It isn’t oppression to ask for the right answer  It derives from the post-modern replacement of objective truth by subjective opinion.

Finally  . . . 

To my astonishment, Jerry Lee Lewis is still bashing the ivories aged 86. Here he is – uncharacteristically slow – when he was 70. Start at 0.58. 

If you click on nearby links, you can see him performing with other stars. Allegedly: On October 27, 2020, to celebrate Lewis’ 85th birthday, a livestream aired on YouTube, Facebook and his official website. The livestream special, Whole Lotta Celebratin’ Goin’ On, featured appearances and performances by Willie Nelson, Elton John, Mike Love, Priscilla Presley, Joe Walsh and others. 

COVID OVERVIEW: MD OF Private Eye

Remembrance day 

23 March, the anniversary of the first lockdown, was as good a day as any to remember those lost to and harmed by the pandemic. 

Research by the Health Foundation estimates the true figure for UK Covid deaths so far is 146,000 and that each life was cut short by up to 10 years (6.5 years for the over-75s). People in the most deprived parts of England were twice as likely to die from Covid-19, and they also died at younger ages. Many had pre-existing health conditions. 

This is sadly unsurprising. Before Covid, the richest in the UK lived a decade longer than the poorest, who suffer 20 more years of chronic disease. Covid has exacerbated existing inequalities. The rich have been able to stay safe at home thanks to the poor delivering to our doors. Instead of just focusing on Covid, we need to focus on preventing all premature death and disease, whatever the cause. Covid has also taught us that no amount of healthcare can reverse an unhealthy environment or self-destructive behaviour. 

Early deaths happen not just from environmental exposure to SARS-Cov-2, but cigarettes, drugs, air pollution, alcohol, junk food, sedentary lifestyles, accidents, abuse and despair. Globally, nearly 3m people have died from Covid, but 57m have died from causes that didn’t get a daily death update. Millions of these lives could have been saved with decent public health measures and universal healthcare. Far from being a drain on the economy, investing in and protecting health are fundamental to it. Another key lesson of Covid. 

Bug’s Law 

The International Health Regulations 2005 (IHR 2005) were agreed by 194 member states of the World Health Organization after the SARS outbreak of2002/3, placing a legal obligation on them to urgently report to the WHO any event “which may constitute a public health emergency of international concern”. Outbreaks of 4 named critical diseases have to be reported in all circumstances. Smallpox, poliomyelitis due to wild type poliovirus, human influenza caused by a new subtype, and severe acute respiratory syndrome (SARS). 

Many legal experts believe the Chinese government violated this law by delaying reporting of the initial SARS-CoY-2 outbreak in December 2019, perhaps by a month. China argues that it took a while to confirm the virus type, and it provided the entire genomic sequence on 12 January 2020, allowing vaccine development to start immediately, and a polymerase chain reaction (PCR) virus test to be developed on 16 January which should have allowed all countries to stop the outbreak, as China did. The UK, US and many others were simply not prepared. 

Sanctioning China and keeping it on board to stop the next outbreak is problematic. And IHR 2005 also applies to any SARS-CoV-2 variants of concern. 

Border control 

Now that vaccines and lockdowns have got infection rates right down, the government must decide if it wants to keep UK borders as virus-tight as it can without inviting economic ruin. This might mean compensating the travel industry but cautiously opening up domestic sports stadia, entertainment venues, shops, pubs, restaurants and holiday venues. 

Worryingly, a large South African trial has found that two doses of the Oxford/ AZ vaccine “did not show protection against mild-to-moderate Covid-19 due to the B.1.351 [South African] variant”. There were no cases of serious disease or death among trial participants, who were largely young. South Africa needs to keep using the vaccine in the elderly to see how much it reduces death. 

Clearly vaccine tweaks and boosters will be needed, and we may not now be holidaying abroad this summer. Evidence suggests all the variants travel by plane. But how much border control will UK citizens tolerate? 

Scotland has touted a zero-Covid policy, and almost got there last summer. It has done better than England on excess deaths but hasn’t been able to maintain zero. The virus has spread so widely as to become firmly embedded. It has so many global feeding and breeding stations to develop and select new variants. Vaccination will reduce deaths, but the virus is likely to remain one step ahead. 

Vaccinating to the max 

The UK is “vaccinating to the max” to minimise the harm of the virus, but that won’t reverse health inequalities. Some of those at highest risk are still declining a vaccine by arguing: “The state has screwed me over many times before, so why should I trust it now?” Public health works best in an environment of public trust and consent. Vaccines should remain voluntary except in jobs or situations where the risk of transmission is very high. 

UK uptake overall has been impressive. Uncontrolled spread of the Kent variant earned us the moniker of”Plague Island” in December and January. Now it is the rest of Europe that has become “plague continent”, thanks to their poorly executed vaccine plan and super-spread of the, er Kent variant. 

We are all in this together. We have now given more than half our adult population half the scheduled dose, with a few million having both doses, and none yet to children. So there is still plenty of potential for UK spread and variation. But once we have vaccinated our most vulnerable citizens twice, it’s entirely right that the rest of Europe, and the world, should be allowed to catch up. If not, we may soon re-import a Kent-meets-Bruges variant. 

The EU claims the UK “has given it nothing”, but we helped install bioreactors at the Halix vaccine factory in Leyden, Holland; we supply a crucial component of the Pfizer vaccine; and we invested heavily in developing the Oxford/AZ vaccine using UK taxes, expertise and trial volunteers, made available to the world at cost price and easy to store in a fridge. Alas, even if the EU had enough AZ vaccine for all its citizens, many would now refuse to have it. 

Vaccine safety 

In the midst of a third wave, thousands of EU citizens will die and be harmed by refusing a life-saving vaccine which may, but probably doesn’t, harm a tiny fraction of them. The balance of benefit and risk is greatly in favour of urgent vaccination, yet millions of doses are unused. Why? 

Having already (wrongly) judged the AZ vaccine to be ineffective in the elderly, some EU countries temporarily suspended its use because of an alleged increase in clotting risk. The European Medicines Agency (EMA) found no increase in clots overall. Indeed, there are more clots in those unvaccinated. The EMA did find the vaccine may be associated with a very rare type of blood clot, but the risk of clots overall, long-term harm and death is far higher if you get Covid. In the UK, 20m AZ doses have been safely given and it has already led to a 60-70% risk reduction in symptomatic Covid and more than 80%decrease in severe cases. 

Alas, once you damage a vaccine’s reputation, it rarely recovers. Angela Merkel knows this. She will also know that lifting the suspension and belatedly agreeing to have the AZ vaccine herself, having decried it on two counts previously, won’t change many minds. “The British vaccine” has been declared second-rate in Europe. AstraZeneca’s shares have tumbled. 

Risk communication 

It’s clearly important to monitor any new vaccines that use new technologies and will be given to billions of people. The UK Medicines and Healthcare products Regulatory Agency and the EMA should give regular public briefings on vaccine benefits and risks as they unfold: how many vaccines have been given; our best estimate of their contribution in reducing death, disease and spread; recorded adverse events; and the adverse events we would expect in a population that hadn’t received the vaccine. 

They should do this for every one of the Covid vaccines, not just pick on the British one, whenever important new data emerge. Far better for people who understand the science to communicate the science, rather than protective EU leaders bitter about Brexit. 

Greed not so good? 

The UK wasn’t prepared for a pandemic and so splashed £12.5bn on PPE in 2020 that would have cost £2.5bn at 20I9 prices, and was largely imported from, well, China. The government will not disclose the contracts or profits made by deal brokers, despite a legal obligation to do so. For all this hugely expensive “personal protection”, 900 health and care staff have died after contracting Covid (though not all at work}, more than 450 people a day caught Covid while in hospital in January 2021, and more than 40,000 in total. Clearly, we need to rethink healthcare-acquired Covid. Better ventilation and barriers may be needed. Meanwhile, Boris Johnson’s paltry 1% pay rise for NHS nurses (4% in Scotland) will drive more into agency working, where they can earn 3 times as much per hour, doing the same job. The NHS also has to pay a large slice to the agency, with a total cost of up to 6 times that of a salaried nurse. 

Long Covid 

MD works in an NHS service for young people with ME/chronic fatigue syndrome and knows how they can struggle to be believed. Long Covid could repeat this prejudice or be a golden opportunity to research the long-term damage a viral infection can inflict on the body, and to develop new treatments. It will be a very heterogeneous condition, with some sufferers having end organ damage after intensive care, and others with extreme fatigue but normal routine investigations. 

No one can say how long any individual’s long Covid will last, but we need to learn from those who are fortunate enough to recover fully. A professor at the Liverpool School of Tropical Medicine, caught Covid and blogged about it for the British Medical Journal: “I felt so unwell I thought I was dying. The rollercoaster that followed lasted for months However, he has since made a full recovery by increasing his activities when he felt ready, and not suffering severe payback. Yet others in his situation are finding any such increase leaves them with profound post-exertional malaise. This is also true of the ME/ CFS patients I see. Some make a full recovery, some reach a plateau and stay there, and others appear to recover and then get relapses. 

ME/CFS diagnosis, research and treatment are hampered because we don’t yet have a diagnostic blood test. The same is true for long Covid. It needs a definition agreed by patients and doctors, and national guidance body NICE needs to develop guidelines for treatment. 

Bugs and us 

Infectious diseases have altered the course of history far more than war, but they are not all bad. Their evolutionary challenge has helped us evolve, and many technological advances will follow the Covid challenge. 

Our bodies contain trillions of microbes living harmoniously in huge communities in our gut and respiratory tract, and on our skin. Our relationship with them is both essential to our existence and highly complex. Environment, as ever, is the key. Microbes thrive and help us thrive in one part of our body, but kill us if they end up in another. Gut bugs in the gut, good. Gut bugs in the blood or brain, dead. 

Over the centuries, our struggle with microbes has delivered some haymaker blows but as yet no knockout, apart from smallpox. We should be in awe of the evolutionary ingenuity that has allowed microbes to adapt, survive and flourish in the face of all we’ve thrown at them. SARS-CoV-2 doesn’t have enough genetic material to be “evil” or “malign”. It exists only to spread, and we have given it the opportunity. 

Yes, it can kill us, but largely because our fickleness, selfishness and short memories have allowed it to. We didn’t learn the lessons of SARS-CoV-1 in 2003. Nearly all our health is determined by our environment, and 7.8bn hungry humans determine that environment more than any other species. We habitually destroy habitats that bring bugs and their animal hosts closer to us. In a sense, we get the bugs we deserve. And they usually win. 

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