I was lucky enough to sign up for a lecture at Kellogg College, home of Oxford University’s Centre of Evidence-Based Medicine, given by Professor Carl Heneghan, and Dr. Tom Jefferson. They promised to enlighten us on the subject of “Evidence-Based Medicine (EBM): Why it’s important and Why It’s Controversial”.
I was nearly tempted by a concurrent lecture with the far more poetic title “Dance of the Chromosomes” – however, I spotted that Carl Heneghan, the epidemiologist, was speaking, and I was excited to get the chance to see him in person. I had noted him as being one of the more common-sense and independent-minded voices in the media during the pandemic, with a firm and coolheaded grasp of the statistics and a willingness to speak up for science. He is the Director of the Centre for Evidence Based Medicine at Oxford University, and is still practising as an urgent care NHS GP amongst other things. Alongside him was Tom Jefferson, fellow scientist and the holder of numerous impressive appointments and achievements. With important regard to the recent pandemic, he is a – if not the – world leading expert on stopping the spread of respiratory viruses. They collaborate together on the excellent Trust The Evidence Substack, currently looking at where the money actually goes in the NHS.
What is EBM again?
They began with a short explanation of what EBM is. I expect we all know this, but a brief refresher: it appeared solidly in the mid-1990s, as medicine shifted from a paternalistic to a patient-centred, informed approach. David Sackett is given much of the credit for the development of EBM, and it was he who set up the Centre for EBM at Oxford which Heneghan now directs. It is considered to have three aspects:
- the best available research/evidence (systematic reviews, etc) – integrated with
- clinical expertise, and in accordance with
- patient values
What the patient wants and values is a crucial part of the equation.
Were Covid models evidence-based?
Well, it didn’t take them long to get onto covid, thank goodness. That’s what I was there for. They are such sticklers for not assuming anything, that they even said they first had to ask the question – was it really a novel virus? They pointed out that coronaviruses were first isolated in the UK in 1966, (although called something else), that they are ubiquitous, and that their ecology and how they mutate is still somewhat unknown.
The models that were produced, though, were based on influenza, which is a totally different RNA virus. Sounds like a problem from the off. MODELS are NOT EVIDENCE, said Tom. He is highly critical of their role in driving policy. I would say, from his tone, that Tom is not the modellers’ greatest fan.
Social butchery caused by the models
Part of his antipathy was the fact that they justified “social butchery“, a phrase he used more than once. He thought that their catastrophic predictions cause people to “flip” overnight, turning our tolerant and benign land into a snitcher’s paradise. Flashback to the scene straight out of Carry on Covid when an image of the Mayor of Leicester mounting a ladder to gain entry to his girlfriend’s top window was widely circulated. (He was actually up there doing DIY… (sounds even worse – ed.))
The problem is that mathematical models and no clinical experience would suggest that you can control the spread of an infection without any downsides. Incorrect! – according to these two – who say that the downsides were immense, and, in any case, the unexpected always happens with respiratory viruses.
Hindsight for others, foresight for Tom and Carl
April 2020 was the tipping point, for them. This was approximately 2 weeks into the lockdown (...to slow the spread….), when they advised publicly that the lockdown would bankrupt us and our descendants. However they consider it was too late to change things by then. The genie was already out of the bottle…
How did they have this foresight, when most of us were refusing to touch our mail till it had been on the mat for 2 hours, and were begging the government for faster, harder, deeper lockdown? Well, Tom happens to live in Italy and had a contact on the Lombardy Crisis Unit in the North of the country – do we all remember the frightening pictures, the crowded wards, the people gasping for air? It was terrifying. However he was reliably informed that the epidemic had actually peaked at ten days. The numbers were already coming down a week before Italy imposed lockdown. Three weeks later, we repeated exactly the same pattern in the UK.
Farr’s Law of Epidemics
At this point Carl and Tom explained to us William Farr’s Law of Epidemics. Farr’s Law is apparently very important, but not considered, or maybe not even known, by the modellers. It basically points out that – and I paraphrase – what goes up must come down. The life cycle of an epidemic can usually be explained by a symmetrical bell curve. Ten days was the peak with covid, then it began to fall.
The care home crisis
In the UK, many old people were being hastily deposited in care homes at this time – dropped off by teams in hazmat suits into a building full of frail and vulnerable elderly people with weak immune systems – and those homes then began to have mini-epidemics. This meant that it looked as if the numbers were not falling; i.e. the number of infections had not peaked.
Carl pointed out that, just as elderly people often do not express typical symptoms during a urinary tract infection (high fever, aches, etc.), they also do not express typical symptoms when they have covid. Why? This is due to the failure to mount an immune response. (It’s coming to us all one day…) So some people with covid were exposed to others because they were not diagnosed. 40% of deaths in the first wave happened in care homes, Carl said, and 80% of care homes in Oxford had covid outbreaks during this wave. The one place which needed protection was the one place which seemed to have none.
Deaths due to isolation and abandonment
In a high percentage of cases, they have discovered that deaths were tragically due to abandonment. Care home staff were off sick themselves, or too scared to go to work, or venture too near the sickly residents. Sometimes one carer was in charge of 20 people. Visitors were not allowed in to help care for elderly relatives due to the risk of infection. It seems that there were problems with feeding, hydrating or monitoring some of those who were ill. In France it was found that many elderly people essentially died due to dehydration. This increased the mortality rate.
Christine’s Law
As a result of what happened, Tom and Carl believe there should be a law that stipulates that every person can choose an advocate/champion, and that person must be allowed access to them COME WHAT MAY. (Christine was a grandmother who had a catastrophic stroke in April 2020. I don’t know the full story but I’m guessing she suffered through having nobody able to visit.)
How reliable were the numbers?
There were 14 definitions of what constituted a “covid death”, and one, which was recommended by the CQC, was that a nursing home provider “considered it a covid death”. There were no post-mortems due to the risk of infection, muddying the waters further.
Further problems with the estimated numbers came from the Zoe App, in which people were diagnosed on the basis of symptoms. Any kind of pathogenic syndrome, stressy sore throat, allergic reaction or “a bit of rundownness”, could therefore be counted as covid.
They have found that in Scotland, Wales and Northern Ireland, up to 40% of hospital cases appeared after 8 days from admission. So 2/5 of those in hospital who were covid cases had been admitted for another reason and caught it whilst in there.
The Covid Inquiry
Sadly it seems we can’t all breathe a sigh of relief that there is now an inquiry to make sense of all this and prevent the madness from recurring. The covid inquiry is costing £190 000 a day. By the time it finishes it will probably have cost in excess of a quarter of a billion pounds (yes that’s right – 250 million pounds of OUR MONEY) and Tom and Carl (who did give evidence) think that the basic purpose it serves is to try to cover up the fact that everyone in charge absolutely lost their heads. They think there is zero chance that it will be admitted that the response was based on zero evidence.
One of the inquiry’s conclusions is that the response was very complex, with over 200 different bodies involved, and so it is necessary to create a new body, to oversee the other bodies. Hmmm… Tom and Carl reckon that the inquiry is unlikely to come up with good directives, and think that they could probably come up with some better recommendations sitting round a kitchen table for an afternoon, and I for one don’t doubt that. It would certainly be more cost effective.
Was the response even based on any proper scientific evidence?
We have discussed the fact that the models are not evidence. So was there actually any real evidence for the response? Masks, isolating, shutting schools, mass testing etc. Tom Jefferson is, as Carl pointed out, the most knowledgeable person on the planet regarding the evidence for physical interventions in these situations. This is by virtue of the fact that he is the long-time lead author of the Cochrane Review on Physical Interventions to Interrupt or Reduce the Spread of Respiratory Viruses. It is ~300 pages long, has now been updated 5 times, and was previously uncontroversial to the point that even Tom said that most people likely fell asleep before they had got to the end. Their conclusion was that the only thing likely to interrupt the spread of a respiratory virus was handwashing, especially in children. I think this means very regular handwashing, i.e. sending the children to wash their hands at the end of every lesson. Even then it only works a little bit. Surgical masks don’t seem to work. Tom is not even convinced that the more heavy duty N95 masks work. Being very precise they will not be drawn into definitive statements on anything they don’t have sufficient evidence for, but they can draw some conclusions. This is a direct quote from the most recent edition of the Cochrane Review (2023):
The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection. Hand hygiene is likely to modestly reduce the burden of respiratory illness
This study became somewhat political in February 2020, just prior to the lockdown. To Tom’s amazement, his own editors who had previously approved it, more than once, decided to undermine it because ‘they’ didn’t like the conclusions. In late Summer 2020 another randomized controlled trial in Denmark (DANMASK) showed that masks made no difference to viral spread. Tom then found himself in the odd situation of being an expert considered so knowledgeable that he had been invited to give advice in person to Boris Johnson and members of the cabinet, yet when he posted the results of a published, peer-reviewed RCT on mask wearing, he was censored on Facebook. He believes that this was the result of a coordinated strategy to manage the message, monitored by government. We are really being governed by a tiny cabal, he said.
The risks of interventions
Tom and Carl think that the downsides of the covid lockdowns are so severe that they likened it to maxing out our collective credit card. They consider it will take a very long time to pay back. They point out that the non-pharmaceutical interventions are NOT RISK FREE.
There have been apparently over 150 reports now looking at the environmental catastrophe of discarded masks.
Testing – was it a huge waste of money?
Testing cost us £37 billion apparently. On average we each took 22 tests. (If that includes lateral flows, I am surprised it is so low!! The children were being told to do them almost constantly). To put this in perspective, this is two and a half years of the entire General Practice budget. Tom illustrates the effect of this diversion of resources. One day he turned up to work (in his role as urgent care GP) to find that there were four staff on duty looking after 170 000 people. Across the road was a covid testing centre, staffed by 14, which was empty.
They are not totally against testing. A useful test would have been to look at who was infectious and who was not, and apparently there was a method by which this could be tested, however it was not used.
There is a focus now on more and more testing for things, they say. There is lots of money to made in testing; they are just concerned at the crippling costs for the NHS.
Catastrophising and social media
They feel that social media is causing societal catastrophising, and that young people are particularly susceptible. By the time you have reached middle age you have been through quite a few scares, and realised that they tend not to materialize: East Anglia is not underwater, we’re not trying to survive a nuclear Winter, and the world didn’t run out of oil in 2020. At 16, I considered these threats to be entirely credible, and I even worried about them. It’s far more difficult to scare me now. However, the youth have not developed antibodies to the latest political/media drama. Tom and Carl report that the number of mental health cases in the 18-24 group has tripled in recent years.
What do we need now?
They are concerned that, even though another lockdown would probably be resisted right now, give it 5 years, we might have forgotten our current mindsight and another scare could send us back there. They respect Sweden who have a Public Health Act which somehow prevents them locking down. (I believe Japan has one too.) We had something in the UK, but it was overridden by the Coronavirus Act. They think we need a better Public Health Act.
They also believe that we need a separation of advisors from government. At the moment, advisers have to toe the line. If they don’t, they get sacked. Remember David Nutt – the former drugs Tsar? He advocated decriminalisation and is big on research into the medicinal benefits of psychedelics. He lost his job.
Tom has serious doubts about those who wield power. He and Carl, in their dealings with senior politicians, have come to the conclusion that they get much of their information from the newspapers. They also have serious doubts about politicians’ integrity, intelligence and wish for democracy. No words minced; no punches pulled by Tom. He speaks his mind.
What should have happened? What should happen in the future?
They believe there is no point trying to manage an endemic respiratory virus.
What they would like to see is the preservation of free speech. They think people should be empowered to speak up and speak out more. They believe that the reason it took China so long to abandon pointless anti-Covid policies, well after everyone else had decided that more lockdown was futile, was due to the control of information.
They also, as I said earlier, would like Christine’s Law passed, so that no patient is ever left alone, whatever the circumstances. Not only is this an expression of basic humanity, it might also prevent suffering and death.
17 out of the last 20 Winters has been declared a crisis by the NHS – let’s make use of the next one to improve our knowledge! Tom and Carl would like to see the Winter virus season used to try large RCTs, to test interventions such as masking in schools, or even gargling (which only has two tiny RCTs but is at least cheap and easy). Does clapping on the doorstep really provide a protective effect against the virus – through demonstrating our goodness? (OK, I’m being facetious now – I was a clapper!).
Should another pandemic occur, they think we need oven-ready protocols for trials to roll out DURING the pandemic. Introduce masks in half the schools, surgical masks vs N95s for hospital staff, or get half the country gargling, or isolating, or testing, or whatever intervention is considered, and get some strong and reliable data.
Afterwords
I would really like someone to invent a machine that simply transmits the vast knowledge of these two impressive men into my brain to assimilate into my own mind. However, for the moment I have to do it the slow and tortuous way – by reading and listening and trying to understand . And so I gathered round the 2 star speakers at the end, with the other conference groupies, to catch any stray words of wisdom. They fell left, right and centre like magical mind grenades but I didn’t manage to write them down till later and I can’t vouch for their accuracy. For what it’s worth:
- they are studying the Pfizer vaccine – they think it had too small and short a trial so far. They are amazed it was recommended to pregnant women and small children, Tom is most concerned about the lipid nanoparticle aspect; in rats this seems to concentrate in the ovaries, they don’t know why
- they are currently working on looking at where the money actually goes in the NHS
- if you blow virus particles up someone’s nose 50% will not catch the virus
- it is better to have a cold in Winter, otherwise you will get a really bad one in Summer (surely someone should make some kind of folksy saying out of this)
- they think the UK was very late in banning the AstraZeneca vaccine compared to other countries
- sometimes people think they have a cold but the symptoms are stress-related
- old people might be better off being exposed to children, immunity wise
- we still don’t know how covid spread. Clare Craig says aerosol but they are not in total agreement with her, and think also it stuck to things like superglue. They have also found some evidence of faecal-oral transmission
Thanks very much for getting to the end of this quite long read – I hope you found it interesting
Disclaimer: this is compiled from hastily written notes during the lecture combined with my memory, and has not been checked by Carl or Tom so mistakes are possible! apologies in advance
Coming soon: Jo Wildy’s recent book: Mind and membrain
