The Name and Blame Game

Why Bill Maher is wrong about the naming of medical conditions and why it matters.

A Temporary Pause

Due to problems with my internet service provider I will not be able to post here on a regular basis for the next 5 or 6 days.  Please do not worry.  I am in relatively good health and am safe.  Normal posting will be resumed next week.

Blog Signposting

This blog is a collection of my writing and insights on the on-going Covid-19 pandemic from the UK.

My brain blog (about neurology /loved experience of brain injury / chronic pain) is here - https://neuronaljunction.blogspot.com/?m=1

My work blog (about my ongoing research, the history medicine, the archaeology of disease, historical epidemics, magic, and my field more generally is here - https://judeseal.blogspot.com/?m=1

Wash your hands regularly.

Follow the guidelines.

Stay home.

Save lives. 

We Need To Talk About DNR (DNACR)

TL:DR – A Do Not Resuscitate note (DNACR - Do Not Attempt Cardiopulmonary Resuscitation)  is not a Death Warrant.  It’s a clinical decision, only taken when all evidence suggests that a complex, last resort procedure with approximately only a 1 in 4 survival rate, is unlikely to succeed.  DNRs are a clinical decision, which is always taken within the guidelines set out by the law. and medical ethics.  The law in the UK has not changed.

Content Warning - Discussion of death, resuscitation, injury - below the read more tag.  

.

.

.

.

.

.

.

Herd Immunity - A Quick Explanation

There has been a lot of discussion in the last few weeks of the UK Government’s original strategy towards Covid-19 – which was in summary to allow the infection to spread to create herd immunity given the fact that, based on the data being shared at the time, only around 15% of cases required hospital treatment.  Obviously, this did not correctly factor in the exponential spread of the infection.  (It is worth noting that some factors potentially skew the statistics – the general under-reporting of Covid-19 infections being one – if the infection rate is, as predicted, higher than currently shown in the statistics the death rate as a percentage may in fact fall).  This strategy has become known by the general short hand of Herd Immunity.  However this had led to some problematic reporting and some frankly dangerous statements being made - such as in this tweet from Emma Kennedy (who is a writer, actress, and television presenter, whose academic training is in corporate law, human rights law, and intellectual property law, not epidemiology, virology, immunology, or medicine).

Anyone seriously advocating for Herd Immunity is happy for the vulnerable in this country to die unnecessarily.

That’s it.

There is no more discussion.

— Emma Kennedy (@EmmaKennedy) April 4, 2020

The concept of herd immunity is not unique to Covid-19 or the coronaviruses.  In fact building herd immunity is one of the clinical purposes of vaccination programmes.  There will, in any human population, be those who cannot be vaccinated for a number of reasons – the most common being immunosuppression – either naturally or through immunosuppressant medication to treat autoimmune disorders.  These individuals cannot be vaccinated safely – however they can be protected.  Mass vaccination of those who can be vaccinated breaks the chains of transmission – allowing the unvaccinated to move freely within the population surrounded by the generally immune ‘herd’.  Thus the mass vaccinated act as a screen for those who cannot be.  This has been the strategy behind the treatment of dozens of conditions – including measles.  Herd immunity is therefore a vital method of protecting the vulnerable from dangerous, potentially fatal infections.  The use of Herd Immunity as a convenient label for the UK government’s initial strategy is causing some to equate the entire concept with this strategy and its potential impact on vulnerable populations.  In reality the clinical concept is the exact reverse of this – it is a method of protecting vulnerable populations.  Such rhetoric is not only inaccurate, but plays into the hands of one of the most dangerous ideas to have spread into society in the last two decades – the anti-vaccination movement.  This mistaken use of a label with a  clear clinical meaning plays into the hands of those who argue vaccination is in fact designed to damage society’s most vulnerable.  Herd immunity may not be appropriate for rapid spreading infections with Covid-19 with severe clinical impacts – but in other cases, it literally saves lives. 

"No test is better than a bad test."

A hastily written summary of why the effectiveness of tests needs to be established before it can be rolled out.  

There has been a lot of criticism over the statement by the Government that when it comes to the virus which causes Covid-19 that “No test is better than a bad test.”

Comment threads on videos where the statement is made including numerous statements arguing that such a statement cannot be true, is impossible, etc.  And on the surface it sounds impossible.  The problem is that a badly designed test could be ineffective in any number of ways.  Assuming only two answers – yes or no – to be a good test it would have to be better than a random match probability (i.e. it would have to be right more than 50% of the time).  A badly designed test could either over or under count the number of cases.  In the case of over counting – yes there are potentially fewer bad outcomes – but when there are limited resources false negatives can burn up resources quickly leaving less available from confirmed positive cases.  False negatives could be catastrophic, not only for the patient, who won’t get the treatment and could die, but because of the false sense of security created by being told that the results were negative – the person could return into society and spread the virus to family, friends, etc without knowing.  It is safer to assume people are exposed, and limit testing to confirmatory, rather than investigatory testing (which may have to repeated again and again after exposure) to keep hold of some resources for testing cases where clinical decisions depend on the results.  This is in effect similar to the idea of treating every wire as if is a live electrical wire unless absolutely and safely confirmed otherwise.  This is why the tests that have been purchased by the UK government need to be validated – we need to see how sensitive they are, how reliable they are, and how quickly and efficiently they can be performed in practice versus  in theory.  Yes, front-line workers in the NHS should have priority for testing, but we owe it to them to make sure we get it right when it happens.  It is easy to criticise decision makers for inaction – and no doubt mistakes have been made in every country dealing with this crisis – but we have to remember that to a certain degree there is no perfect outcome – especially when taking clinical decisions which for some people will be the difference between life and death.