The elephant and the blind men, and Black Lives Matter.

Warning: this blog may (and should) leave you both angry and disturbed.

It’ also different one from any other in that it focuses on a specific health issue in an industrialised country (the UK) rather in any developing ones. Given that some of our team are currently locked down in the UK in the midst of a mishandled crisis, however, this is unavoidable – but in any case we hope what is exposed in what follows can easily be usefully interpreted in any country with the potential for important things to be learnt.

The parable of the blind men and the elephant

There is a very old Indian fable that tells the story of how a group of blind men encountered an elephant for the first time. Completely unfamiliar with the beast, they set about experiencing it the only way they could – by touch. The problem was that each one touched a separate part of the animal – one the trunk, another an ear, another a tusk, another a leg etc. – and as a result each one perceived it quite differently. The story then explains how (because of this) they ended up fundamentally disagreeing on what this strange elephant basically might be and (in some versions) even came to blows about it as a result.

The moral of the story is fairly obvious: that one person’s subjective experience may well be quite real and true, but that this experience can be severely limited and totally misleading if it fails to account for other truths or otherwise acknowledge the possibility of a wider totality of truth. At various times in the last two and a half millennia this parable has provided insights into the behaviour of those judged to be experts in fields of contradictory theories, so shining light on the importance of deeper understanding and respect for different perspectives on the same object of observation.

With this in mind, we now set about describing a different tentative exploration of another allegorical elephant (including our own exploration). And in this instance the elephant is the unquantifiable but anticipated risk of resurgence of lethal COVID-19 disease this coming winter in the northern hemisphere.

Next winter

The reality of this elephant is not any sort of ‘elephant in the room’ (i.e. one that no-one wants to talk about). This particular elephant is already well recognised as a risk of disease resurgence when the days shorten as winter draws in, when we spend more time indoors with windows closed, and when our immune systems weaken naturally. The only real uncertainty is just how big this risk is – but the billion dollar question behind it is this: what can we do about it given we have some months before it materialises?

Dr Robert Redfield, Director of the American CDC, warned in April that a resurgence of COVID-19 next winter could leave American resources even more overburdened than they have been already, not least because of a possible syndemic with seasonal flu.

(Dr Redfield’s own specific answer to this: keep up to date with flu vaccines).

Dr Hans Kluge, director for the WHO European region, has similarly said that he is "very concerned" that the disease could peak again as health services battle with winter flu, adding that seeing lockdowns eased should not be a time for celebration but should rather used for preparation for what’s probably coming.

(Dr Kluge’s answer: to bolster local hospital systems in the next four months).

Nelson Michael, the director for infectious disease research at Walter Reed Army Institute of Research, said much the same thing two months ago at a Pentagon briefing.

(Dr Michael’s answer: develop vaccines and an effective treatment plan, though admitting that this might not be done fast enough, which is pretty much the same position taken by Bill and Melinda Gates and by most other vaccine experts).

Dr Chris Whitty, the UK’s Chief Medical officer, has only today made a similar warning adding that in the winter the virus will have certain ‘advantages’ (not the least of which is that we are far more prone to infectious pathogens during winter months).

(Dr Whitty’s answer: vaguely to “learn lessons” from what has happened in the current outbreak that is still unravelling while at the same time navigating an “extremely difficult balancing act” trying to keep economies afloat).

We, in Moxafrica, are taking careful note of each of these warnings while our concerns are growing because we don’t believe that any of them actually get to the heart of the matter.

(Our own answer, meanwhile: strengthen our immune systems using moxa, Vitamin D and Vitamin K).

So we have five different attempts at interpreting the same elephant. The first recommends vaccination against a discrete different seasonal disease; the second endorses bolstering hospital systems that have already suffered massively from the first wave of disease and almost certainly won’t have recovered by next winter; the third resorts to investing in vaccine research on the pathogen itself despite acknowledging that one won’t be ready in time; the fourth endorses ‘learning lessons’ (a blindingly obvious idea but it would be helpful if that were being seen to actually happen - see more below on the PHE review which does the opposite).

And we must ask you to make your own mind up about the fifth.

Public Health England’s 'Disparities in the risks and outcomes of COVID-19' Review, and what they are (not) doing about addressing these risks

Last week (on 2nd June) Public Health England (PHE) published its anticipated analytical review of the 'Disparities in the risks and outcomes of COVID-19' and we took a good look through all 81 pages of it. We noted that it formally identifies a set of major causes of disparities (some of which have only emerged since the disease exploded in Europe) among them being male, BAME, obese, having diabetes, being of an older age group etc).

Because of our own angles on protection against severe COVID-19 disease, we immediately noted that there was not one single reference to Vitamin D levels in this review despite four out of five of these groups being known to be have generally lower levels of this prohormone and thus these lower levels potentially contributing to a significant proportion of more severe disease (as proposed by a paper published in early April).

There could be a reasonable explanation for this omission, of course. Vitamin D levels may actually not contribute to any of these disparities at all! There certainly is a deficiency of evidence that this is the case, but there is also not an absence of such evidence, and anyway, as the saying goes, ‘absence of evidence does not mean evidence of absence’. We can equally invoke argument that reductions in vitamin D levels unquestionably contribute to the seasonal fluctuations in infectious diseases generally which experts are already identifying as being a contributory risk factor for COVID resurgence. In other words, we do think that this is a serious omission.

But even more seriously, we also realised that the review didn’t actually include a single recommendation as to what the next steps should be to reduce the risks that it did identify for any of these groups before the anticipated next wave might strike. This may sound unbelievable, but is quite true.

This is even more unbelievable given that PHE (in its own words) 'exists to protect and improve the nation’s health and wellbeing and reduce health inequalities'. As such we find that this omission - even if it were included but very carefully qualified - is telling evidence of negligence given the risks that exist. In any case, if no recommendations are made, what exactly was the point of the review anyway? Because right now, here in the UK some of its more vulnerable citizens appear to be being guided blindly into a public health crisis this coming winter by the very people entrusted to protect their health and nothing seems to be being done to protect them.

(Thankfully) only a small proportion of all the vulnerable groups identified by the PHE review have so far succumbed in this significant first wave of disease here in the UK, but this means of course that there tens of thousands more are still lined up to get infected and develop severe symptoms that may take them to hospitals next winter if they do so. Of course, a significant second wave may not materialise (we certainly hope so) but it should surely be expected unless the virus significantly weakens (which is unlikely unfortunately) or unless a safe and effective vaccine is properly tested and rolled out by next winter (which won’t happen).

Black, Asian and Minority Ethic (BAME) Groups and risks from COVID-19

In April (nearly two months ago) Yvonne Doyle, the medical director of PHE, had already identified that that there was “emerging evidence to suggest that covid-19 may be having a disproportionate impact on ethnic minority groups”. She added that “this is a really important issue, and detailed and careful work needs to be done before we draw any conclusions.” At the same time Chris Whitty (the UK’s Chief Medical Officer already quoted above) said that it was “critical that we find out which groups are most at risk so we can help to protect them” – and the PHE’s report was plainly intended to exactly that: identify those most at risk and then help protect them

The evidence contained in the report however belies this promise of protection and this significance of an absence of help for protection is made more acute for two reasons. The first is that, while only 20% of front line health workers in the UK are BAME, a shocking 65% of health workers who have died from COVID-19 are from this same group. (In other words this is a group employed by the UK government to help protect the British public who are thus facing the full frontal assault of this pathogen but who in the process are succumbing to it most frequently). The second reason is that the timing of this publication coincided with the sequelae to the death of George Floyd in the U.S. while in police custody on 25th May – which was by coincidence just before the anticipated publication of the PHE review which had been scheduled to appear before the end of May. In fact, this is reckoned by some to have caused the publication of the review to have been held back.

But it’s actually worse than this: the UK government has not just been accused of holding back the publication of the PHE report, but also of not publishing important parts of it exactly because of the movement that has arisen on UK soil as a result of this American murder.

Labour’s (UK’s opposition party's) shadow health secretary John Ashworth is explicit about this, accusing the UK government of "covering up vital recommendations" that could help protect black, Asian and minority ethnic (BAME) people from COVID-19. He did so after Sky News revealed that ‘government sources’ had told the news agency that vital recommendations from the review had been "held back" by the government, these sources adding that "ministers have had this element of the report" (i.e. this was an unofficial leak).

Sadly, this may not be so surprising (though it has been officially denied) because this missing second half of the report is said to have contained work which looked at "social inequality" and "structural racism" within the UK. In other words, it may have been considered politically unwise to publish it because of the timing and what was happening on the streets . But apparently this review had previously considered submission from 4,000 stakeholders and organisations many of whom are now asking where their contributions have been considered in the final text.

Facing criticisms in parliament, Health Secretary Matt Hancock (on the 2nd June) assured those present that in his opinion 'Black lives [do] matter'. Existing evidence relating to the contents of this review, however, must challenge his narrative.

So why this lack of recommendations?

We can come up with no reasonable or justifiable explanation for there being no recommendations, but we can come up with three possibilities that do exist but are quite unjustifiable in our opinion.

The simplest one is that the government judged that publishing these parts of this review might incite unrest because it explicitly identified structural racism in the UK. Under different circumstances publishing this would have been quite justifiable, but people were out on the streets so perhaps hasty decisions were made by a government that already feels under siege. But we are already amid a public health crisis that disproportionately threatens this same group so if this is the reason it cannot be deemed reasonable because black lives (and others) will be lost because of it.

A second explanation might be that there’s literally nothing that can be reasonably done to better defend any of these groups next winter. Apart from this being implicitly defeatist as an answer, this isn’t true, of course. The NHS, for instance, has a duty of care to its employees so, having formally identified that its BAME staff are at risk, it has a duty of care to minimise their exposure to this risk any way they reasonably can do. What’s more, the government itself has a similar duty of care to protect its citizens, so has a corresponding duty to direct all government-controlled services accordingly. And (as already identified) PHE itself has a statutory obligation to protect the health of the nation and reduce health inequalities.

So this takes us to a third explanation. This is that, while all three organisations seem to be unavoidably vulnerable to accusations of criminal neglect by not making any recommendations available, the government’s legal advice may have suggested that (if recommendations were specifically made and then not met) this liability would be more significantly exposed and compounded.

The truth is that (just like how the blind man didn’t know what the other blind men were doing with the elephant) we don’t know, but from any conceivable perspective this appears overall to be an appalling story that is being shamefully under-reported in the public domain.

And, given that no-one is making any recommendations regarding reducing the risks to these vulnerable groups (beyond simple isolation), we cannot see why we ourselves cannot in the meantime suggest a cheap and safe way of reducing individual risks. Not doing so would seem to us to offer evidence of our own negligence as well in fact.

So can we do anything about this risk?

We would argue that we can, although we certainly don’t claim to have a picture of the whole elephant, we do have a rough idea of its enormous size and (given what we know about other ‘animals’) of its general rhythms of movement as well.

For all of those groups identified in the PHE review (and indeed for any others that may have been missed) we are convinced that relative risks can be safely reduced on three fronts: by increasing vitamin D levels by safe sunshine exposure during the summer and by supplementation which should significantly reduce risk of severe COVID-19 disease; by doing the same by increasing levels of vitamin K by supplementation; and furthermore by improving cellular immunity by daily self-administration of small cone direct moxa.

so finally – back to that elephant and those hapless blind men

Given we started out with the blind men and the elephant, it seems right to end with them if only to shine light on the need for deeper understanding and respect for different perspectives on the same object of observation. So we recognise that we must, of course, take note of this ourselves and act accordingly.

We can suggest that one way that those blind men could have usefully avoided those violent altercations with each other that occurred in some versions of the tale would have been, not just by having respect for alternative perspectives arising from palpating a different aspect of the beast, but most of all by actually listening to what these alternative observations were and allowing them to organically integrate into a collective appreciation of what all of the blind men were subjectively experiencing.

In the same way as covering up any noteworthy aspects of a clumsy palpatory exploration of an elephant (because it doesn’t suit a perspective informed by ignorance or prejudice) only leads to subsequent misunderstandings and potential strife, so does the withholding of any of the results of a review of a novel coronavirus at a volatile moment in a public health crisis. And nor will it save lives that really do matter next winter.

Failing to make those promised recommendations that might help protect these groups next winter has done no favours at all to the waning credibility of the UK government and its agencies. But nor has its done any favours to any of the groups that have been identified as being particularly vulnerable to this pathogen. In fact, quite appallingly it may contribute significantly to an existing death toll that is already tragically inflated by political misjudgements.