Friday, 12 August 2022

Monkeypox and medical ethics

You are not been alone if you’ve noticed that the public health establishment’s reaction to the monkeypox outbreak has been rather different from its reaction to COVID-19. In the latest episode of Last Orders, Tom Slater drew a parallel with the summer of 2020 when the public health establishment’s attitude towards large gatherings was firmly negative if it involved a loved one’s funeral or a child attending school, but strongly positive if it involved protesting for a fashionable cause.

An article in the current issue of the British Medical Journal criticises the medical response to monkeypox. Written by a New York physician, it highlights several shortcomings which require action: patients are waiting too long to get swabs and vaccines, and suspected cases are told to self-isolate “without being provided a place to isolate, a non-stigmatizing medical reason or note to provide to their employers, or financial protections for work missed.”

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These problems are relatively easy to solve with some money and effort. I have nothing to add to his recommendations, but my eye was drawn to the conclusion of the article in which he appeals to medical ethics:

And lastly, we must recognize that the least stigmatizing and least homophobic approach to this infectious disease is to provide individuals with information on how it spreads and what steps can mitigate their risk of disease. Our patients have the autonomy to figure out what’s best for them. As a healthcare community, it’s our job to help individuals make informed decisions about what they want to do with their bodies, and provide empathetic care regardless of what that decision is. As doctors, we must show the basic compassion that is missing in all of our policies for monkeypox.

This seems to me to be a reasonable and liberal approach. Indeed, since the author is talking about infectious disease, one might almost describe it as ultra-libertarian. No mandatory vaccines this time around.

Monkeypox is not COVID-19. It is much less deadly and far less transmissible. It is not going to bring any health service to its knees. 

And yet it is quite a nasty infectious disease which carries negative externalities, costs money and puts a burden on the healthcare system. If giving people the facts and letting them make their own decisions is the best approach with this contagious disease - and I agree that it is - it would be inconsistent and unethical to demand government coercion against individuals making “informed decisions about what they want to do with their bodies” when those decisions have little or no effect on other people and when the diseases involved are non-communicable.

I am not familiar with the author of the BMJ article. For all I know he could be a prominent campaigner against the nanny state in New York. If so, he has his work cut out. New York’s former mayor, Michael Bloomberg, tried to ban large servings of sugary drinks. Its last mayor, Bill de Blasio, successfully banned the sale of flavoured vapes. It is illegal to smoke in Central Park, a tract of land that is nearly twice the size of Monaco. 

I, for one, applaud the author’s call for a humane and liberal approach to risky lifestyle decisions and am heartened to see his views appear in a journal that has not always cherished such principles. I look forward to the public health establishment basing policy recommendations on free choice and individual autonomy in the future. 

Our patients have the autonomy to figure out what’s best for them. 

Thank you, brother.




Wednesday, 3 August 2022

Minimum pricing isn't working

Promises, promises

Minimum pricing of alcohol in Scotland is not going well. Self-styled public health advocates are baffled.

Now in its fifth year and facing a subset clause next year, the Scottish government’s own evaluation has made grim reading for those who claimed that setting a floor price of 50p on a unit of alcohol would be a game-changer in Scotland’s relationship with The Drink.  

 

.. no changes in the trend direction or statistically significant changes in the level of all alcohol-related crime and disorder

 
(Except in one local authority where alcohol-related crime went up.)
 
In the same month, a thorough evaluation of the impact of minimum pricing on alcohol-related A & E attendances was published. It found that the policy may have been associated with an increase in visits:
 

The odds ratio for an alcohol-related emergency department attendance following minimum unit pricing was 1.14 (95% confidence interval 0.90 to 1.44; p = 0.272). In absolute terms, we estimated that minimum unit pricing was associated with 258 more alcohol-related emergency department visits (95% confidence interval –191 to 707) across Scotland than would have been the case had minimum unit pricing not been implemented.

 
In June 2022, the evaluation looked at the heavy drinkers who were supposed to benefit most from minimum pricing. Its conclusions were unflinching: 
 

There is no clear evidence that MUP led to an overall reduction in alcohol consumption among people drinking at harmful levels or those with alcohol dependence, although some individuals did report reducing their consumption.

People drinking at harmful levels who struggled to afford the higher prices arising from MUP coped by using, and often intensifying, strategies they were familiar with from previous periods when alcohol was unaffordable for them. These strategies typically included obtaining extra money, while reducing alcohol consumption was a last resort.

MUP led to increased financial strain for a substantial minority of those with alcohol dependence as they obtained extra money via methods including reduced spending on food and utility bills, increased borrowing from family, friends or pawnbrokers, running down savings or other capital, and using foodbanks or other forms of charity.

Some people with alcohol dependence and their family members reported concerns about increased intoxication after they switched to consuming spirits rather than cider. In some of these cases, people also expressed concerns about increased violence. 

 

Alcohol-related hospital admissions refused to decline after the policy was introduced and alcohol-related deaths are at a nine-year high, although lockdowns doubtless had an affect on the latter. The policy cost Scottish drinkers £270 million in its first four years and all the SNP have to cling to is a modest drop in alcohol consumption, much of which is due to COVID-19.

Last month, a new piece of research was published in BMJ Open looking at alcohol consumption. It was not part of the official evaluation and was produced by academics who are very sympathetic to minimum pricing. They nevertheless struggled to make the policy look like a success.

Using Kantar survey data and comparing Scotland to northern England, they found that the introduction of minimum pricing was followed by a drop in consumption, as shown below.
 

It looks like an impressively steep decline until you realise that 5 grams of alcohol is barely half a unit. Per week. And the reduction in consumption from the off-trade, which is the only place minimum pricing makes any difference, was just 3 grams.

Moreover, the reduction in consumption was not evenly spread across the population. It was weighted towards women who tend to drink less anyway. 
 

The reductions in consumption are largely driven by women (a reduction of 8.6 g per week, 95% CI 2.9 to 14.3) rather than by men (a reduction of 3.3 g per week, 95% CI –3.6 to 10.4)

 
And among men who were the heaviest drinkers, consumption actually increased.
 

For the 95th percentile the introduction of MUP was associated with an increase in consumption for men of 13.8 g (95% CI 5.8 to 21.5), but not for women (4.8 g, 95% CI −4.0 to 13.7).

 
The study also contains bad news for the pub industry which, in classic Baptists and bootleggers fashion, supported minimum pricing for nakedly self-interested reasons.
 

For younger men there was an increase in off-trade consumption, which was offset by decreases in on-trade consumption in the same group.

 
I warned that this would happen five years ago. Leave people with less money in their pocket and they will have less to spend on the luxuries in life, like going to the pub.

None of these findings are terribly surprising to people who are more worldly than your average ‘public health’ academic. Raising the price of cheap booze was always more likely to change the behaviour of moderate tipplers than heavy drinkers. Hardcore drinkers were always going to find money to keep drinking and minimum pricing was never going to help the pub trade. It was only likely to make the poor poorer.

The authors of the study seem flabbergasted that a policy that had so much (naive and flawed) modelling behind it could turn out like it has.
 

When the Minister for Public Health, Sport and Wellbeing introduced the 2018 alcohol policy framework, he emphasised that the implementation of the MUP [minimum unit price] was strongly motivated by an interest in decreasing health inequalities through a reduction in alcohol consumption among the heaviest and most vulnerable drinkers. Our results indicate that this goal may not be fully realised…

 
You can say that again.
 

… first, we found that women, who are less heavy drinkers in our data and in almost all surveys worldwide to date, reduced their consumption more than men; second, the 5% of heaviest drinking men had an increase in consumption associated with MUP; and, third, younger men and men living in more deprived areas had no decrease in consumption associated with MUP. These results are surprising as modelling studies would have suggested otherwise.

 
It takes a heart of stone not to laugh at the best laid plans of philosopher kings falling apart at the seams.
 

We do not know why, for both younger men (those aged <32 years) and for those living in residential areas in the bottom two-fifths of deprivation, there was no decrease in consumption associated with MUP compared with older men and those living in less deprived areas.

 
One wonders if the authors have ever met any men aged under 32 or anyone in the bottom two-fifths of the income distribution. 
 

Several studies have found that overall, heavier drinkers— including people with alcohol use disorders—react less to price than the general population (ie, they react more price inelastic and their consumption is determined by other factors). However, while this may explain lower reductions, it cannot explain an increase in consumption.

 
Yes, that is a particularly awkward finding. Even I didn’t see that coming.
 

The results may also imply a diminished impact on alcohol-attributable hospitalisations and mortality, which have been shown to be strongly associated with heavy drinking in men and in those of lower socioeconomic status. Indeed, a large controlled study on emergency department visits following the introduction of MUP did not show any reduction in alcohol-related emergency department visits.

 
It’s fair to say that minimum pricing hasn’t gone the way that the likes of Dr Nick Sheron, a blowhard anti-alcohol campaigner, expected. In 2014, he insisted that minimum pricing was an ‘almost perfect alcohol policy because it targets cheap booze bought by very heavy drinkers and leaves moderate drinkers completely unaffected’. In the same year, Sir Ian Gilmore, chair of the Alcohol Health Alliance, described minimum pricing as an ‘evidence-based policy exquisitely targeted at those, and those around them, who are currently suffering harm’.

In a sensational act of hubris, three activist-academics published an article in 2017 claiming that the evidence-base for minimum pricing, a policy that had never been tried anywhere, fulfilled the great epidemiologist Austin Bradford Hill’s criteria for causality. It seemed absurd at the time and it seems almost grotesque now.

Still, this being ‘public health’, the answer to the medicine failing is to demand more of the same medicine.
 

If indeed the findings of our study are corroborated, then additional and/or different pricing mechanisms may need to be considered to reduce alcohol-attributable hospitalisations and mortality.

‘Tis but a flesh wound!

 

Postscript

While I was writing this post, I came across this new study which finds evidence of another unintended consequence which seems obvious to the man on the Clapham omnibus but never occurred to those who have qualifications in public health.
 

Following the introduction of MUP, total household food expenditure in Scotland declined by 1.0%, 95%CI [-1.9%, − 0.0%], and total food volume declined by 0.8%, 95%CI [-1.7%, 0.2%] compared to the north of England.

 
That might not necessarily be a bad thing. Scotland has an obesity problem, after all.
 

There is variation in response between product categories, with less spending on fruit and vegetables and increased spending on crisps and snacks.

 
Oh.


Tuesday, 2 August 2022

The fantasy world of public health modellers

Remember the study claiming that the Transport for London ban on 'junk food' advertising had let to London households consuming 1,000 fewer calories per week? It was execrable rubbish and now a study based on it is claiming that nearly 100,000 cases of obesity have been prevented by the ban.

It's all pure fantasy, as I say at Cap-X...
 

Regardless of what you think of this particular policy, it is worrying that public health policy-making has become so divorced from observable reality. Policies are proposed on the basis of modelling, evaluated on the basis of modelling, and the modelling is carried out by advocates of the policy. At no point are facts allowed to intrude. A rise in chocolate consumption becomes a fall in chocolate consumption. A rise in obesity becomes a fall in obesity. Activist-academics have created a world of pure imagination and are exploiting the broken peer-review process to drag us all into their land of make believe.

 
Do have a read. The 'public health' racket is so far down the rabbit hole it beggars belief.


Monday, 1 August 2022

Nicotine use, past and present

Earlier today I mentioned a study that is a go-to resource for e-cigarette evidence. I now present you with the definitive short-read about the future of nicotine written by Clive Bates.
 

So, here is the interesting question. What if nicotine use is no longer all that harmful? What if the real problem was always the inhalation of toxic smoke while trying to consume nicotine for its benefits? As early as 1991, the leading medical journal The Lancet reflected on how the nicotine landscape might look after the year 2000: “There is no compelling objection to the recreational and even addictive use of nicotine provided it is not shown to be physically, psychologically or socially harmful to the user or to others.”

In my view, we have reached the position where smoke-free nicotine products, such as e-cigarettes, heated tobacco, smokeless tobacco or nicotine pouches, can provide nicotine at acceptably low risk. By acceptably low risk, I don’t mean perfect safety, but within society’s normal risk appetites for consumption and other recreational activities. If continuing innovation in the design of the products ultimately leads to smoking cigarettes becoming obsolete, then the vast burden of smoking-related disease will decline and fade away.

 
Clive discusses five objections to safe nicotine use and shows why these arguments don't stack up. Do read it all.

 



E-cigarette facts and evidence

Colin Mendelsohn and colleagues have written a very nice response to a barking mad report commissioned by the Australian government about e-cigarettes. As you might expect from the Aussies, the report was a hatchet job on vaping. It made such claims as...

There is conclusive evidence that the use of e-cigarettes can cause respiratory disease 

(Based on the EVALI outbreak which had nothing to do with e-cigarettes.)

And...

There is strong evidence that never smokers who use e-cigarettes are on average around three times as likely than those who do not use e-cigarettes to initiate cigarette smoking.

(A claim that ignores the large decline in smoking rates among young people since vaping went mainstream and ignores common liability.)
 
Mendelsohn et al. conclude that:
 
Contrary to the conclusions of the Banks review, the evidence suggests that vaping nicotine is an effective smoking cessation aid; that vaping is substantially less harmful than smoking tobacco; that vaping is diverting young people away from smoking; and that vaping by smokers is likely to have a major net public health benefit if widely available to adult Australian smokers.

I doubt that this will come as a surprise to readers of this blog. The main reason I recommend the article is not for its conclusion but because it is a succinct summary of the evidence. 
 
It is difficult to keep up with e-cigarette research. More than 50 studies are published every week and a lot of it is junk science from the USA. Mendelsohn et al. is a handy, up-to-date reference point for anyone who wants to find the key studies on the main issues of risk, smoking cessation, the 'gateway' effect, the EVALI nonsense, etc.

It's one to keep in your back pocket if faced with spurious arguments against vaping. It's paywalled but I daresay the authors will give you access if you ask them on ResearchGate


UPDATE

Within minutes of posted this, I saw on Twitter that the lead author of the Aussie report has been given an award. Because of course she did.



Saturday, 30 July 2022

A reasonable question and a sensible answer about the Covid vaccines

This graph has been doing the rounds recently…
 
 
It is based on an Office for National Statistics (ONS) dataset which the vaccine hesitant have been getting excited about. Toby Young, editor of the Vaccine Sceptic Daily Sceptic mentioned it a few days ago…
 

 

And the rapper Zuby has been tweeting images like this…
 
 
Zuby seems to think that the vaccines are useless at best and dangerous at worst. This is, he reckons, a ‘scandal’.
 

In his defence, he posted a link to the relevant ONS spreadsheet and asked people to put him straight if he had misunderstood. He doesn’t want to spread fake news, you see?

It is a pretty hollow defence because numerous people have explained why he is wrong and yet, at the time of writing, he still hasn’t deleted his tweet.

Throughout the pandemic, smileys and anti-vaxxers have been blissfully ignorant of the base rate fallacy. Insofar as a few of them are aware of it, they don’t think they have fallen into it on this occasion. They note that 93% of the British population have been vaccinated and, since a similar proportion of Covid-related deaths are among the vaccinated, this strikes them as the final proof that the jabs don’t work.

Their raw figures are broadly correct. If you go to Table 1 of the spreadsheet, you can see all the Covid-related deaths each month by vaccination status. And if you go to the effort of tallying them all up, in April 2022 there were 3,571 deaths of which 206 were among unvaccinated people. In May 2022, there were 1,364 deaths, of which 82 were among the unvaccinated (NB. the numbers are based on death certificates so the figure for May will rise once all the deaths have been registered).

The overwhelming number of deaths were indeed among people who had had at least one vaccine: 94% in April and 94% in May. (Zuby’s chart has slightly different figures for some reason, but the general picture is similar.)

Add these figures together and you get 4,935 deaths for April and May combined, of which 288 were among the unvaccinated. These are exactly the figures shown in the red graph above. 94% again.

As the ONS’s Sarah Caul and others have pointed out, none of this tells you very much unless you adjust for the age and characteristics of the people who died. If you look at the age-standardised mortality rates, the picture is rather different.

In April, the age-standardised rate for Covid-related mortality was 204.7 per 100,000 person-years among the unvaccinated and 96.5 per 100,000 among the ever-vaccinated.

In May, the age-standardised mortality rate for Covid-related death was 77.6 per 100,000 among the unvaccinated and 35.5 per 100,000 among the ever-vaccinated.

In other words, people who have been vaccinated are half as likely to die a Covid-related death as those who ‘trust their immune system’.

I won’t go over the base rate fallacy again. Plenty of people have explained it before and those who don’t want to hear it - or can’t understand it - will never be persuaded by me. But it is worth noting that you really have to go out of your way to arrange the figures in the manner shown in the graphs above. You have to add up a whole bunch of numbers, work out the percentages and plot them on a graph. Why go to such trouble when the age-standardised figures are right there in Table 1 next to numbers you’re adding together?

However, in the spirit of genuine sceptical enquiry, it is reasonable to ask why the vaccines only seem to be halving the risk of death when the original trials showed that they reduced the risk by over 90%. Funnily enough, the reasons involve issues with which smileys are very familiar. They just choose to ignore them on this occasion because they don’t fit their narrative.

The first is that the deaths listed in the ONS spreadsheet are what the ONS call ‘deaths involving COVID-19’ (which I call ‘Covid-related deaths’ above). These are deaths for which Covid is mentioned on the death certificate but for which Covid may not have been the primary cause. You may recall the whole ‘with Covid’’ versus ‘of Covid’ conversation in 2020-21. It was a virtual irrelevance back then because around 90% of deaths involving Covid had Covid listed as the primary cause on the death certificate.

But it is a much more significant issue now because the proportion of Covid-related deaths that are primarily caused by Covid has fallen. Since February 2022, the proportion of Covid-related deaths that the ONS classifies as ‘due to Covid’ has only been around 60-65%.

This means that at least a third of the deaths in the graphs above were mainly due to heart disease, cancer, dementia, etc. and Covid played little or no part. Since Covid vaccines do not prevent heart disease, cancer, dementia, etc., you wouldn’t expect a markedly higher survival rate among the vaccinated. Around a third of the deaths could not have been prevented with a Covid vaccine and they cannot therefore be used to gauge the efficacy of the vaccines. They only muddy the water.

It is extremely likely that if the ONS spreadsheet Zuby linked to confined itself to deaths due to Covid, rather than involving Covid, the age-standardised Covid mortality rate would be even lower among the vaccinated and higher among the unvaccinated.

Secondly, there is the issue of another smiley favourite: natural immunity. We were more than two years into the pandemic by April 2022 and the vast majority of people had already had Covid. The ONS estimates that between 27 April 2020 and 11 February 2022, 71% of people in England caught Covid at least once. Something in the region of 5% of the population caught it before 27 April 2020 and a very large number of people have had it since 11 February 2022.

A reasonable guess is that around 90% of the population have been infected at some point and the figure for unvaccinated people may be even higher.

Infection obviously produces a good deal of immunity and makes it likely that your next infection will be milder. If you survived Covid the first time, you’re very unlikely to die from it the second time.

By April 2022, virtually everybody in hospital with Covid had antibodies from vaccination or prior infection. That is why so few people are dying of Covid these days despite high rates of infection in the community.

There is also the small matter of lots of unvaccinated people already being dead by April 2022. They can only die once.

The clinical trials studied vaccinated people versus people who had not yet been infected - and they worked very well indeed. They work less well, relatively speaking, when you compare people who have antibodies from vaccination with people who have antibodies from prior infection. A combination of vaccines plus prior infection works best of all - that is why we still see better outcomes among vaccinated people relative to unvaccinated people - but the pool of unvaccinated people who have yet to be infected and die from it is inevitably running dry.

If Zuby, Toby, et al. want (further) proof the vaccine’s efficacy among people who have not been infected before, they need look no further than Table 1 again. If we check the figures for last April, the age-standardised Covid-related mortality rate was 146 per 100,000 among the unvaccinated but just 16 per 100,000 among the vaccinated.

In May 2021, the rate was 45.5 per 100,000 among the unvaccinated and a mere 6.2 per 100,000. Among those who had received a second dose, it was just 2.8 per 100,000.

All this stuff is right there on the same page of the same spreadsheet that the ‘sceptics’ have pored over to make their cute little graphs. How strange that they didn’t notice it.



Friday, 29 July 2022

Trussonomics and Sunakonomics

I was on the Sky News podcast this week with Miatta Fahnbulleh from the New Economics Foundation discussing the economic policies of Liz Truss and Rishi Sunak. You can listen here.