Trust is crucial in lockdown—and beyond
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1721 (Published 30 April 2020) Cite this as: BMJ 2020;369:m1721Read our latest coverage of the coronavirus pandemic
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Dear Editor
How are we going to ensure transparency and independence in in the processes of vetting and recommendation of vaccine products, given notably the debacle of 2009 [1] and other issues which have arisen [2]?
[1] Fiona Godlee, 'A tale of two vaccines', BMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4152 (Published 04 October 2018)
[2] Noel Thomas, ‘ Re: MEPs devise strategy to tackle vaccine hesitancy among public’, 29 March 2018, https://www.bmj.com/content/360/bmj.k1378/rr-3
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
Dear Editor
Trust in high dose intravenous Vitamin C
Probably the greatest lack of trust, leading to a prolonged lockdown, has been the failure to use high dose intravenous Vitamin C to treat coronavirus disease in the UK.
Simmons and Smith report the now overwhelming evidence of the efficacy of an intravenous vitamin C protocol against coronavirus. They write that in spite of this accumulation of the evidence, the FDA, the CDC, and many respected members of the medical community inexplicably jeopardize their own credibility, apparently to save the irrelevant business model of the pharmaceutical industry. [1]
Shockingly, vitamin C has been known to be viricidal since 1948. [2] Diseased cells tend to accumulate iron. The ascorbate (vitamin C) ion contributes to the production of hydrogen peroxide. In a reaction called the Fenton Reaction, an iron ion reacts with a molecule of hydrogen peroxide to produce free radicals (reactive oxygen species, ROS) that can oxidize and damage any other molecules in their proximity. When this activity occurs inside the diseased cell, the inner workings of the cell are destroyed, and the diseased cell is rendered inoperative. Unlike vaccines, this anti-viral mechanism has nothing to do with the type of the target viral particle or its molecular antigens, which is the strategy upon which modern vaccines depend. If the invading organism mutates, the Fenton reaction process will destroy the cell all the same -- without any need of appropriate antibodies. The diseased cells self-select because they hoard the iron. An increased availability of ascorbate and hydrogen peroxide leaves the healthy cells untouched. [3]
In late January or early February, 2020, the Chinese government placed an order with Dutch State Mines (DSM) for 50 tons of vitamin C. Hospital trials started in Wuhan on February 12. Patients would be administered 24,000 milligrams of vitamin C each day for 7 days. The next day, on February 13, Dr Richard Cheng, director of the Medical and Scientific Advisory Board to the International Intravenous Vitamin C China Epidemic Medical Support Team, and U.S. board-certified specialist in anti-aging medicine, announced a second intravenous vitamin C study, in which 6,000 to 12,000 milligrams per day would be given to moderate and severe cases. These announcements were made on the hospital's website, and these protocols were being published all over Asia. [4] The next day, February 14, the clinical trial commenced at Zhongnan Hospital in Wuhan, China. In just two days, on February 16, Shanghai announced an "official" recommendation to use high-dose intravenous treatment of vitamin C to treat COVID-19. [5] The official recommendation called for doses ranging from 50-200 milligrams per kilogram of body weight per day, or up to as much as 16,000 milligrams per day. On April 8, approximately 100 days since the unexplained pneumonia appeared in Wuhan, the lockdown in China was being lifted.
The potential beneficial effects of high dose Vitamin C treatment is too important to ignore in the UK.
1 Simmons WF, Smith RG. Vitamin C and coronavirus: not a vaccine; just a humble cure. Orthomolecular Medicine News Service, May 4, 2020.
2 Klenner FR. (1948) Virus pneumonia and its treatment with vitamin C. South Med Surg. 110:36-38. https://www.ncbi.nlm.nih.gov/pubmed/18900646 http://www.whale.to/v/c/klenner2.html
3 Li J, Cao F, Yin HL, Huang ZJ, et al (2020) Ferroptosis: past, present and future. Cell Death Dis. 11:88. https://www.ncbi.nlm.nih.gov/pubmed/32015325
4 Cheng R. (2020) Can early and large dose vitamin C be used in the treatment and prevention of COVID-19? Medicine Drug Discov. In Press, Journal Pre-proof. https://www.sciencedirect.com/science/article/pii/S2590098620300154
5 Government of Shanghai now officially recommends high-dose vitamin C for COVID-19 Coronavirus.
https://www.reddit.com/r/CoronavirusFOS/comments/fczmu8/government_ of_shanghai_now_officially_recommends https://mp.weixin.qq.com/s/bF2YhJKiOfe1yimBc4XwOA
http://rs.yiigle.com/m/yufabiao/1183266.htm
Competing interests: No competing interests
Dear Editor
You correctly state:
"Much hope is invested in a vaccine, with 82 potential candidates and seven approved for human trials around the world (doi:10.1136/bmj.m1679). But even the most optimistic timeframe is 12-18 months, and the World Health Organization has repeatedly warned countries not to rely on a vaccine to end the pandemic."
Yet, politicians - notably Boris Johnson and Donald Trump - are absolutely hooked on the idea that vaccines will save us, as if just willing it and spending our money will bring it about. Their are three problems with this:
1) They are offering something they may not be able to deliver on at all - in effect stringing people along with false hope
2) Products may be brought to the market, even mandated, with reckless speed - even on an 18 month schedule we will have no means to judge long term effects
3) They may focus insufficiently on other measures to help break the lockdown: for instance the things that we all might do to boost general immunity, reducing polypharmacy, taking supplements such as Vitamin D, Vitamin C, zinc etc.
Offering something which is not there, may not be there for a long time or not at all is a demonstration of magical thinking and not a way to earn trust.
Finally, what happens with all our investment in vaccines in the United Kingdom if it turns out that more credible products emerge elsewhere?
Competing interests: AgeofAutism.com, an on-line daily journal, concerns itself with the potential environmental sources for the proliferation of autism, neurological impairment, immune dysfunction and chronic disease. I receive no payment as UK Editor
Dear Editor
Godlee mentions the “many things needing scrutiny in the aftermath of this pandemic.” The aftermath will have less to do with the pandemic, than with the consequences, now and in the future, of our response to the pandemic.
The concept to proportionality is frequently referred to in legal, diplomatic and military circles when assessing the level of response to an action or threat, whether real or perceived.
The global total of deaths due to covid-19 is currently about 240,000. For the UK, the figure is about 29,000
A recent estimate of the average number of deaths, globally, due to influenza, in twelve months is 389,000. (1)
The NHS suggests that about 10.000 people die each year from influenza in the UK. (2)
The International Labour Organisation has estimated that 1.6 billion people will lose their livelihoods as a result of the covid -19 lockdown. (3)
Douglas et al gave some indication of problems that may accrue in the UK due to lockdown.(4) That those problems are already occurring, is reported daily in the UK press.
There have been many expressions of concern about the effect of lockdown in developing countries. (5)
The oft repeated statement that ‘we are all in this together’ does not take account of the relative security of employment, salary and pension that most political leaders, decision makers, and most contributors to this website, enjoy.
The 1.6 billion people, and their families, who may lose their livelihood, will not be so fortunate.
Must we wait for the aftermath, before applying the concept of proportionality to the global response to covid-19?
1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815659/
2 https://www.greenwichccg.nhs.uk/News-Publications/news/Pages/Around-10,0...
3 https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_743036/lang-...
4 https://www.bmj.com/content/369/bmj.m1557
5 https://www.theguardian.com/commentisfree/2020/may/03/while-the-west-fix...
Competing interests: I have an NHS pension.
Dear Editor
The occurrence of a pandemic is never programmed therefore the circulation of a virus and its mortality remain unpredictable. It is certain that the spread of the virus unmasks the gaps in health systems.
Confining people has of course very serious health consequences. Loneliness and fear make them vulnerable. People lose logic when they are afraid; the concern about catching a virus whose consequences could be serious prevents them from consulting and going to the hospital when any symptom appears. When governments and scientists don't know how to deal with the virus people feel insecure and threatened. The recommendations of the rulers are open to discussion.
Containment blunts the spread curve of the virus, delays mass immunity, decreases hospitalizations and mortality but nevertheless it masks mortality related to other pathologies.
Allowing the virus to spread can lead to a faster occurrence of mass immunity, a faster shutdown of the epidemic but it's a risky bet: it involves a high mortality rate for a shorter period of time, an oversaturation of health facilities and a loss of the moment to smooth the curve.
Lifting the lockdown would be a step to be taken all over the world. Strategies are almost the same with a few nuances.
According to the Joint European Roadmap towards lifting COVID-19 containment measures, sufficient health care system capacity includes the availability of primary care structures and the access to care in particular for vulnerable groups. However, the UK government requires the confidence that the NHS has sufficient critical and specialist care across the whole of the country.
It is true that the management of hospitalized patients is provided by specialists but who will take care of the majority of patients with minimal symptoms that do not require hospitalization. Both primary care physicians and specialists must be involved in this crisis management.
“Test, trace and isolate” is a strategy that limits the spread of the virus. Social distancing reduces deaths but delays mass immunity. It should last at least 1 to 3 months, potentially longer. More sustained diagnostic tests could reduce the need for significant, long-term social distancing. The epidemic may stretch over time and more people will have the chance to become immune.
Can our society withstand these efforts for a long time to come? It is not easy to choose the right strategy in the absence of treatment and vaccine. Test, trace and treat will be the ideal strategy.
This coronavirus pandemic has exposed the failings of health systems around the world, disrupted institutional functioning and revealed the fragility of human beings who until then considered themselves all-powerful with the technologies at their disposal.
Health systems that neglect optimal medical care for the elderly, people of minority ethnic origin and those without medical coverage need to be reassessed.
It is essential to reconsider health systems and at-risk populations and address long-hidden and sidelined gaps.
Grace Abi Rizk MD MH EPID
Associate professor in family medicine
Saint Joseph University
Competing interests: No competing interests
Dear Editor
COVID-19 was declared a global pandemic by the World Health Organization in early March of 2020 and, as of the end of April, has been the silent killer to over 200,000 people worldwide. It has caused grave physical, economical, and emotional turmoil to the human race and the world is left wondering what normal may be like in the future. It has caused the world to pause and, in the United Kingdom (UK), people may only leave their homes for essential reasons. This impacts an individual’s productivity, economic gain and mental health, to say the least, but has been proven by countries before us to be the only present answer. As medical students in the UK, our vision can be partially tunnelled to impacts on self, via medical education, and how it has impacted the National Health Service (NHS). COVID-19 is painted in a well-deserved negative light, but it should also be noted the possible positives it could have in these previously mentioned areas.
Receiving lectures in large lecture halls has been the norm for most medical students for decades. Introduction of alternative teaching methods, such as problem-based learning, has allowed for versatile teaching with active student engagement- a component of learning students enjoy. The use of technology in the medical curricula seems to vary in medical schools across the country. Whilst some have little use of technology, others have introduced apps for electronic sign-off competencies and have even offered all their students’ devices, such as iPads. A consequence of COVID-19 has been the transition from face-to-face teaching to virtual online platforms such as Microsoft Teams and Zoom. Some educators who have previously struggled with simple computer-based tasks are now pushed out of their comfort zones. Whilst the future of medical education remains uncertain, there is a great chance that virtual teaching may continue until all social distancing measures have been halted. Furthermore, if these teaching methods are deemed to be successful and efficient, the use of technology in teaching may continue and be incorporated in the core medical curriculum across medical schools. This may be the driving force some medical schools needed in order to gain confidence in using these methods.
The hospital environment is where most learning occurs for the average medical student; being able to bring textbooks to life, learn and perform practical skills, amongst many other things. Whilst observing the medical professionals, the workings of the NHS and the relationships it has within it and with others can be easily recognized. The NHS provides public healthcare, free at the point of delivery, and before COVID-19 had not been viewed by some of the public as a well-run service. This may be due to long-waiting times for appointments and patients being “lost in the system”, only to list a couple. However, this global pandemic has turned the thoughts of many of the public to positive ones. NHS healthcare workers are deemed the “real heroes” and the UK population demonstrates this in so many ways, ranging from special considerations and discounts for food shopping to the entire nation clapping outside their homes weekly.
The private healthcare system in the UK is viewed to be available to those of higher societal classes and there is a known gap in communication between this institution and the NHS. However, an unprecedented increase in collaboration between the two has become apparent since COVID-19 began. Private hospitals have opened their beds and equipment to the public, along with their staff joining the NHS workforce, in order to cope with the large demand this virus is putting on healthcare in the UK. Not only has this relationship developed, but relationships within the NHS have also grown. Medical students have stepped up to help where they can, for example final years have started as junior doctors within days of getting their results. Each staff member at the hospital has had to come together to battle this pandemic – doctors, nurses, porters, cleaners – no role more important than the other.
Whilst COVID-19 has undoubtedly caused ruin globally, it has enabled some barriers to be broken. This can be seen in the vast transformations in medical curricula to enable continuation of training for tomorrow’s doctors and positive changes in relationships within and between the NHS and other public institutions. The course of these changes may be temporary but have potential to have lasting impact.
Competing interests: No competing interests
Dear Editor
Current Global Scenario of COVID-19
As of today the coronavirus COVID-19 is affecting 212 countries and territories around the world and 2 international conveyances.
The total global number of COVID-19 confirmed cases are over 3.3 Million (3,326,005). The number of deaths are recorded as 234,505 with a 18% death rate which is less than 3% from the previous week. The recovered number of cases are over 1 Million (1,052,180) at rate of 82% which shows improvement from the previous week.
As of now among infected people over 1,989,150 (98%) have a mild clinical condition and about 50,823 (2%) are critically ill and which is also lower than the previous week report. The global scenario of COVID-19 in this week shows some signs of improvement from tprevious weeks. The current trends of the COVID-19 Pandemic is less than many projections and predictions.
Many countries have slowly started relaxation of the imposed lockdown.
In India, the number of infected cases are 35365 with the recovered cases of 9068 and death in 1154.
For appropriate management of the COVID-19 outbreak in India, Government has classified its districts into 733 zones which includes 130 red zones, 284 orange zones and 319 green zones (without any COVID-19 cases) according to the certain COVID-19 related parameters.
This classification is multi-factorial and takes into consideration the incidence of COVID-19 cases, its doubling rate, extent of testing and surveillance feedback.
In the state of Tamilnadu there are 12 districts in red zone, 24 in orange zone and 1 district in green zone. As of today there are 2526 confirmed cases in Tamilnadu. Today India has extended its Pan-India lockdown which includes Air and Rail services for two more weeks till 17.5.2020 to break the chain of the COVID-19 spread
At present Remdesivir shows promising signs as treatment for COVID-19 infection. WHO says that dozens of vaccines are under development, including in Oxford, United Kingdom.
Competing interests: No competing interests
Dear Editor
Richard Horton in today's Lancet thinks the pandemic is existential. Its all about life and what life means - or words to that effect. So be it.
"COVID, I HATE EVERY INCH OF YOU!” HOW TO BEAT A PANDEMIC.
The first response to the pandemic and the media hype, is to normalise the situation, in so far as possible given one's circumstances. This is the “new normal” and it is not going away any time soon. What applies to health professionals is not necessarily the same as what applies to Covid patients and their families or to the general public. For the public in general and most health professionals the idea is to refuse to be shocked/stressed/overwhelmed by events. Try to keep the entire pandemic at arms length (in so far as possible depending on one's circumstances). This will mean a distancing from media, news and constant conversation about it. An average of one reliable news programme a day should suffice to keep up to date and then immediately switch off, or go to a completely different media content. Normalising the situation allows one to go about one's life and do what has to be done, without becoming paralysed by constant shocking news. Try to carry on life as best you can without focusing or dwelling on media and news. You don’t ignore what is happening but you minimise it so that you can function optimally in the normal areas of your life.
Forecasts predict the pandemic will last many months and maybe years, and long term psychological preparation and defences are needed. Daily routine, self-discipline and having a flexible but robust time table are necessary. The five pillars of good mental health can then rest on a solid basis. They are:
1. A good night sleep
2. A healthy nourishing diet
3. Regular exercise
4. A suitable job or occupation – work or something like work to do every day
5. Friends and a social network
The “DO NOTS” also apply. They are:
1. Do not binge on anything – food, alcohol, cigarettes, Netflix, TV, social media, pessimistic news or attitudes.
2. Do not underestimate the challenge. This pandemic can overwhelm anyone. One needs to know one's limits and look for help or a break when necessary.
3. Do not allow yourself to get burnt-out or unwell. Prudent planning and help seeking, and understanding the demands of the situation help one to step back and take time out, to get advice and support, and possibly to change roles for a while and recover.
4. Do not allow yourself to decompensate. Tensions are high, people are under stress and the work place and home life urgently need a calming presence. The self-restraint based on experience of one's breaking point, will help one to step back and walk away, go into a dark room, put on music headphones or whatever works, to side step an anger or frustration outburst.
5. Do not medicate the situation with prescribed drugs or street drugs. Sometimes prescribed and medically supervised medication is necessary, but self-management and management of work or stress inducing situations is preferable.
A best case scenario could be to have a compelling and almost totally absorbing interest, which distracts you so that you are almost oblivious to the furore happening all around you. This strategy could be compared to the experience you have when you either sleep through a long haul flight, or get so immersed in a book, that you are sorry when you touch down! You never felt the journey. This way of coping could be part of a suitable coping strategy. For a student it could be an interesting PhD project, for a mother it could be educating the children in a new and better way, for a taxi driver it could be books on tape or getting to know a new type of music.
Survivors of long periods of confinement and adversity like the Chilean miners all had discipline, a daily schedule and order imposed on the lives. Even without any natural light in the mine they divided the 24 hours into day and night. Another example is Viktor Frankl’s account of survival in a concentration camp “Man’s Search for Meaning”. The concepts of post traumatic growth and Maslow’s “Theory Z” describe the cathartic and transforming growth that often occur through and after severe adversity. There is a silver lining to the Covid cloud and each one has to find what works for them.
Competing interests: I am a psychiatrist trying to flatten the psychiatric curve!
Re: Trust is crucial in lockdown—and beyond
Dear Editor
An appeal to the Prime Minister:
Dear Prime Minister
I am ignorant.
I do not know How Many Died, because the Govt was so slow in acting to stop the spread.
I do want to trust you.
If you could just tell us:
On what date did your Chief Medical Officer advise you to lockdown?
Did you act on the advice immediately?
Thank you
Competing interests: No competing interests