Thoughts from Pontevedra, Galicia, Spain: 8.7.21  

 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’

Cosas de España/Galiza 

If I were asked I’d say the great majority of Spanish drivers are fine at the wheel. But I’m regularly surprised by the actions of a few. I don’t mean the ones who cut across my bows from an outside lane – 4 inside 10 minutes yesterday – as I’m inured to this and have developed a 6th sense. Rather, I mean – for example – the person who pulled out in front of me at a junction near my house last evening when I was 2-3m from him/her. And the guy who almost mowed me down 5 minutes later in the car park of BricoKing, when he drove across 2 empty bays to get to the one closest to the door. But at least I got the standard cursory wave of apology from him.

I’ve drafted a book about my first 15 months in Spain. That winter – 2000-2001 – was, my new friends insisted, the worst in 25 years. I remember it – and my 5 broken umbrellas – very well indeed. But I’d quite forgotten that July 2001 was ‘the wettest since records began’. The sun is shining brightly today but here’s a foto from yesterday’s local paper that speaks for itself about the rain of the previous few days:-

The UK

The latest MD review of Covid is below, following close on the heels of the previous one, thanks to the vagaries of the postal service. It was written before Mr Hancock departed.

Astonishing to read that a BBC newsreader is paid £429,000 a year, vastly more than the Prime Minister. Hard to argue with the comment that No newsreader could possibly be worth this.

The UK and the EU post Brexit

It’s said that the EU – having been given the opportunity on a plate – has failed in its (vengeful?) attempt to destroy the City of London and to transfer most of its business to the Continent. Says one observer: Brussels has failed in lots of ways over the last couple of decades, from mis-managing the single currency, to stifling industry in red tape. But this will go down as one of its most glaring failures.


María explained yesterday that Punto in my electricity bill meant Peak time. Ironically the RAE dictionary doesn’t give ‘peak’ among its 43 meanings of punto. Preferred words are cumbrecima and pico.

A sketch in English becomes un sketch in Spanish –  Escena breve, normalmente cómica, que con otras de las mismas características se integra en un conjunto teatral, cinematográfico o televisivo. Of course, it might be written sketch but is almost certainly pronounced esketch.

Finally  . . .

This is a reprise of yesterday’s Kiki Dee and Elton John duet, in 2000 when – astonishingly – she was 54. This was during a sell-out concert in New York’s Madison Square Garden. Hard to believe but the previous year – desperate for money – Elton John had performed in Pontevedra’s bullring!

And here’s Ms Dee in 1974 showing why many of us think she never got the fame she deserved.


Open and shut case 
The grand reopening of everything has been delayed, sensibly in MD’s view. Even before the avoidable calamity caused by the arrival and spread of the Delta variant from India,, the UK stood out for two things in the international league table of pandemic harm: high rates of excess death in the under 65s, and high rates of long Covid. 
This is largely because many of us are overweight and carry chronic diseases at a young age that make us more susceptible to early Covid death and long-term harm than, say, Scandinavian populations. Many people on UK intensive therapy units with Covid have been obese and in their 50s, some younger. So opening up before all those aged 5O and over had been offered both jabs, plus a fortnight to kick in, was always the least harmful option. The Delta variant has made it even more so – if we want to avoid even more avoidable Covid harm. However, it will cause other harms that have to be mitigated and compensated. 
How much physical and economic harm could have been avoided with better border controls will be a matter for the public inquiry in 10 years’ time. Hopefully by then a huge public health drive will have made us happier, healthier, lighter, fitter and more virus resistant. 

No one knows 
As to what happens next, no one knows. Hospitalisations are up by 50% in a week, and deaths by 8%. The numbers are small compared to January. But exponential growth has left us for dead three times before. Do we err on the side of caution or optimism? 
As ever, different scientific advisers have different predictions: from a third wave that is “considerably smaller” than January, to one that is “considerably larger”. Would lifting the remaining restrictions now overwhelm (some) hospitals? SAGE cannot say with confidence either way. But it does think even a short delay in full-fat freedom would lead to a significant drop in hospital admissions for Covid (and allow more people to get vaccinated). Eventually, individuals will be left alone to decide the risks they pose to themselves and others (as football supporters are already vividly demonstrating). 

Compulsory or not? 
Should vaccination of care-home workers be mandatory? Would any gains from reducing the risk of a Covid outbreak be lost by the dangers of a worsening staff crisis? There are 112,000 staff vacancies in social care, and if mandatory vaccination were accompanied by improvements in pay, training and working conditions, it might help fill the gap. 
In London, vacancies are high but only 23% of homes have at least 80%of their staff vaccinated, and only 40% in the South-east. Multicultural education programmes are inching up the vaccine uptake but not as fast as the Delta variant is spreading. Health and care staff have risked their lives during the pandemic, and 1,500 have died alongside more than 42,000 residents. Health secretary Matt Hancock is being eviscerated for the holes in his supposed “protective ring” around care homes. You can understand why he wants to act. 
There are alternatives. Those who decline a vaccine could have daily lateral flow tests – and we’ve spent more than £1bn on those – but they are prone to false negatives (ie you think you’re not infected when you are) and the US regulator has branded them useless. Care homes could be left to decide their own policies, so people could choose a home where the policy was compulsory or voluntary, but choice is in short supply in a sector with so many going bankrupt and having to close. Care homes could also make vaccination of residents mandatory. Staff moving around are more likely to be super-spreaders; but residents with chronic, poor immunity are more likely to harbour a virus for longer and create variant strains. 
The unions are against mandatory vaccinations but MD personally would not object to being told to have vaccinations as a condition of being a doctor (as with Hepatitis B). The UK, as ever, is divided, so we will have comparators: England will experiment first, with Scotland, Wales and Northern Ireland currently keeping it voluntary and seeing if gentle persuasion, peer pressure and, for some, a £500 gratitude bonus does the trick. 
Ultimately, this may end up in the courts. 
Care workers may sue for an infringement of human rights; relatives may sue for Covid needlessly contracted in a care home. It could go on for years. Meanwhile, the Delta variant keeps spreading, but those who are double-vaccinated are much less likely to die from Covid (though they may still die from dementia). 

Care home deaths 
Have more people died from Covid or dementia in care homes during the pandemic? It depends on your sex. The Office for National Statistics has published its analysis of care home deaths in England and Wales registered between the week ending 20 March 2020 and week ending 2 April 2021 – so covering both waves of the pandemic. 
• 173,974 care home residents have died since the pandemic began, an increase of 19.5% compared with the five-year average (145,560 deaths); of these, 42,341 involved Covid-19, accounting for 24.3%of all deaths of care home residents. 
• Deaths of care home residents involving Covid-19 increased sharply in wave one; but a higher proportion of deaths involved Covid-19 in wave two (25.7 percent) than in wave one (23.1%). 
• The higher proportion in wave two could be due to undiagnosed Covid-19 cases in the first wave. 
• There were more total deaths of care home residents above the five-year average in wave one (27,079 excess deaths) than in wave two (1,335 excess deaths). 
• During the first and second wave, Covid-19 was the leading cause of death in male care home residents, while dementia and Alzheimer’s disease was the leading cause for female residents. 
• Dementia and Alzheimer’s disease was the most common pre-existing condition found among deaths due to Covid-19 in both male and female care home residents in wave one and wave two. 
So, more women died from dementia and Alzheimer’s disease in care homes than from Covid, and more men died from Covid, but many will also have had Alzheimer’s disease or other forms of dementia as well. Many of the deaths have been quick and gentle, but sadly also in isolation. It’s impossible to know how you will feel at the time, but thinking ahead, if I was in my 80s or 90s with dementia in a care home, I would not mind a Covid death, and might even prefer it to watching Cash in the Attic. Not all Covid deaths are tragedies. However, al 59 I have done everything reasonable to avoid Covid because it can be a horrible way to die young, and I witness in my work the long-term damage that viruses can do. I have the influenza vaccine every year, even though it is less effective than the Covid jabs. I want to reduce my risk of any unpleasant virus, and of passing it on.

Hancock in the dock 
The hunting of Hancock is now a national sport, but no one in the NHS expected competence from a newish health secretary with no experience in health, a penchant for untested tech interventions and an ability to bend in whatever way was likely to keep him in Boris Johnson’s cabinet. 
It hasn’t helped that his boss in this complex health emergency is a classics scholar. Scientists tend not to be attracted to politics because they hate the bluff, bluster, lies and deceit. Science is about sensible guessing with uncertain data, making errors, owning errors and learning from them in real time. It is the antithesis of politics. 
Politics is also obsessed with blame, and Hancock will likely be kept in place until he can soak up every last drop of it ahead of the public inquiry. Former chief aide Dominic Cummings’ mission to destroy Hancock with immediate effect is unlikely to succeed, even with screenshots of Boris Johnson referring to him as “totally fucking hopeless”. Cummings provided no hard evidence that Hancock had lied, rather that he was guilty of the same over-promises as Johnson. 
Just as the prime minister kept assuring anyone who would listen that it would all be over in 12 weeks/by Christmas, 
Hancock mimicked his boss’s supreme over-confidence. PPE and ventilator supplies were “all sorted”, there was the infamous ring around care homes, no one who needed NHS care would be denied it, everyone who needed a test would get one. All he was doing was telling his boss what he wanted to hear. 
Even now Hancock can’t stop himself spinning. He claims only 1.6% of care home outbreaks were seeded from hospitals where residents were discharged without testing, citing Public Health England (PHE) research. But he knows the research is biased by the fact that to detect an outbreak you need testing, and tests were rarely done during the first wave. As MD wrote at the time, you can’t beat a virus if you don’t know where it is. Absence of evidence is not the same as evidence of absence. 
It’s likely that even more people in care homes had Covid than was recognised because they simply weren’t tested. The PHE research Hancock quoted states that “the majority of these potentially hospital-seeded care home outbreaks were identified in March to mid-April 2020, with none identified from the end of July until September where a few recent cases have emerged”. So, once testing was finally mandated for discharge from hospitals to care homes in mid-April, it appears to have helped prevent outbreaks. 
If Johnson thought Hancock was hopeless, he had a very experienced former health secretary (Jeremy Hunt) waiting in the wings and desperate to be selected. There was enough work for two health secretaries – one to tackle Covid, the other to ensure non-Covid patients weren’t thrown under the bus. Hunt was responsible for our pre-pandemic preparation and should be interviewing himself on the current joint select committee inquiry into “what went wrong”. He was one of the first politicians to point out how badly prepared we were for mass testing at the outset. If he’d been recalled, we might know if it could have been done better with a different health secretary. 
Instead, Johnson stuck with lap-dog Hancock despite spotting serious failings and can hardly sack him now. Promoting Baroness (Dido) Harding to lead NHS England (she has applied for the job) after the mixed performance of Test and Trace might divert some heat from Hancock, but he remains the most useful long-term fall guy. However, Hancock has nothing to do with border controls, our repeated weak link. It may tum out that we undermined our good work on vaccines to help Johnson secure a trade deal with India by delaying the decision to put India on the UK’s travel red list. If so, Hancock’s failings may yet be overtaken by events. You can’t level up if you keep shutting down. 

Children last? 
The welfare of children is supposed to be our paramount political, legal and health concern, but it clearly isn’t. The shocking inequalities present before the pandemic have widened, and although there has been no increase in adult suicides, the same cannot be said of children. 
Bristol hospitals are now on their highest alert for childhood eating disorders and self-harm, a pattern repeated across the UK. Before the pandemic, agencies to safeguard children and improve their mental health had been stripped bare by austerity cuts, and so help is often now only available at crisis point, and sometimes too late. 
A report in July 2014 conservatively estimated the UK cost of child sexual abuse at £3.2bn, with the majority coming from lost productivity as victims of abuse are less likely to work and more likely to work in lower paid jobs and have serious health issues over a lifetime. If Johnson really wants to level up, he has to invest in children’s health and protecting them from harm, self-harm and exploitation. lf we keep fouling our nests, we will never fully recover. 

Levelling up vaccines
Vaccine nationalism was always likely to be an issue for poorer countries but even democracies like Taiwan are struggling. It did brilliantly to manage the pandemic initially, but relaxed too soon and cases are on the rise. Now China is blocking Taiwan’s attempts to buy Covid vaccines from anywhere other than China. The US has donated 750,000 vaccine doses but as cases increase, less than 5% of the population has been vaccinated. For its part, Taiwan donated 51m masks to other countries at the start of the pandemic. The world needs to return the favour.