MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Sorry, but this post is unrelated to so-called alternative medicine (SCAM), the usual topic of this blog

The deaths caused by the corona-virus differ from country to country. Germany’s fatalities have been widely acknowledged to be unusually low, while those of the UK seem worryingly high. On 9 April, Germany had just over 2600 deaths and about 118000 cases of infection. In the UK, these figures were around 8000 and 57000 (these data are from here).

This translates to hugely different rates of death per active case. But, as the Germans test many more people than the UK, this difference in rates can easily be explained. The more tests one does, the more likely it is that new cases will be identified. This obviously results in higher total case numbers. In turn, the proportion of fatal cases will be smaller.

But what about the absolute numbers of deaths?

What might they tell us?

Assuming that medical care is similarly competent in both countries (and knowing that a causal therapy does not exist), should there not be a lower fatality figure (proportional to the number of cases) in the UK compared to Germany? To me, it does not make sense that the opposite is true: in the UK, we have a total of 8000 fatalities, while Germany has 2600. Similarly, on 9 April [to just pick one day at random] there were 881 deaths in the UK and 337 in Germany.

Should it not be the other way round?

I know these figures are far from precise (and I am here only interested in estimates and trends), but the difference is clear enough and the trend has been consistent.

If that is so, what is the reason?

The only explanation that I can think of is that the UK numbers of active cases are wrong,  – not just slightly wrong, but very profoundly wrong.

As the UK did not test extensively, we know the UK case numbers are an underestimate. Some say they are higher by a factor of two or three.

Most people seem to think that the German case figures – because of the German programme of adequate testing – might be about right. Assuming that UK doctors are as good at saving the lives of corona patients as their German colleagues, and assuming that everything else is roughly equal, one might extrapolate from the UK fatality numbers the level of infection in the UK.

If 2600 death in Germany correspond to 118000 cases, 8000 deaths in the UK should, according to this logic, correspond to about 363000 cases. This is roughly 6 times the number I see in the official statistics!

I know this is a very simplistic calculation, but is it fundamentally wrong?

If not, should we not get some explanations or transparent data from our government?

I am truly puzzled.

Can someone PLEASE enlighten me?

 

64 Responses to Why are the corona-fatality numbers in the UK so high compared to Germany?

  • Indeed this is even more puzzeling since the % and true numbers of over 65 are significantly higher in Germany compared with the UK…

    https://www.prb.org/countries-with-the-oldest-populations/

  • This difference could be due to a combination of the increase in tests, differences healthcare provision and the proportion who are becoming severe.

    It could be as Germany is finding more cases which changes the numerator as you suggest.

    It could also be due to the healthcare service available, if you have more doctors and more ITU beds then you may be able to better treat more severe cases and more rapidly escalate care if they become unwell, which may increase survival chances.

    Or it could be due to the severity of the disease, for example the England obesity is ~31% compared to ~25% in Germany. So if obesity is a risk factor for severity then Germany may have a smaller proportion. There are many potential risk factors with varying degrees of evidence at this point, so it may not be possible to determine which factors may be having this much of an effect.

    One should always consider that this could be due to chance, although with such a large difference I would imagine this to be unlikely.

    • it’s not about the numerator – the mystery is about the absolute number of deaths.
      better healthcare service is a possibility that I also considered. but this would be a very damming judgement on the NHS, and I doubt that it could explain the huge difference. remember: there is no causal therapy!
      severity of disease/risk-factors might be part of an explanation; but Germans are on average older, so …

  • A possible explanation (no, not primarily the frequency of homeopathy use this time) is brought into the discussion here: consider the frequency of antibiotic doses or the antibiotic resistance rates in a European comparison, and you will find especially in relation to the Mediterranean countries, France and the UK a striking correlation to death rates.
    And then look at the same low death rates in Norway, which started a separate antibiotic saving program (strictly CRP-dependent use of an antibiotics to prevent non-guideline therapy for viral infections)…..

  • Edzard,

    I think you are right, it is about how the numbers are recorded, which is fundamentally about testing. It seems very plausible to me that the true number of people infected are many times more than the official statistics. If you think about how those statistics are collected this is almost inevitable. Mostly in the UK people are tested because they have symptoms and attend hospital. This excludes all the people with symptoms who remain at home (the majority) and all those with no symptoms at all (testing of the entire population of Iceland suggests that this could be between a third and a half of all cases).

    Coronavirus deaths in the UK are defined as anybody who dies who has tested positive for coronavirus during their final illness, regardless of what the true cause may be (e.g. a stroke, coronary heart disease or as a result of an accident). Deaths where there is no positive test are not counted. There is also a delay of a few days between the occurrence of death and the posting to the official record (this is why the number of deaths recorded on Mondays is always below the curve for the rest of the week). If that delay is different between countries that will also affect the apparent death rate.

    Dr Hummer,

    consider the frequency of antibiotic doses or the antibiotic resistance rates in a European comparison, and you will find especially in relation to the Mediterranean countries, France and the UK a striking correlation to death rates.

    Before you start looking for correlations, the first thing you have to do in epidemiology is to look at what the numbers represent and how they are collected. You should also be aware that you can find correlations between almost anything, particularly if you are choosy about what you leave out.

    • if my ‘back of an envelope’ calculation is correct and the UK has ~ 6 times the cases officially announced, should we not be told?

      • we ought to be told, if only because this would alleviate the fear that our healthcare is much worse than the German [an assumption that had kept me awake at night]

        • If it is any consolation, in all my dealings with the German healthcare system I have found it shocking how much worse they are in general than the NHS. Key weaknesses in Germany are:

          A widespread reluctance to share information with other practitioners, such as patient history and notes.

          Starting specialist training too early in a doctor’s career, so that they do not have enough general experience and experience in other fields to recognise that a problem is outside their area of expertise and they should refer.

          The presence of numerous private clinics offering unproven treatments whose rightful place is confined to clinical trials.

          The widespread popularity and acceptance of alternative medicine.

          Most importantly, in the UK all care has to involve the GP in order to be funded, which means that there is someone who is in a position to pull everything together, avoiding the situation where multiple specialists are treating the same patient with little idea of what the others are doing and nobody in charge.

          I must stress that at a time when our own health is being threatened, it is more important than ever to be rational in our choices, and not to allow fear to govern our decisions.

          As far as I can see, the main area in which Germany is ahead of us is in testing for coronavirus infection. Although isolation and social distancing are helping to reduce the transmission rate (R0), only a tiny proportion of the population have been infected so far (I have seen estimates of about 4%) so the main benefit of this approach is to reduce the risk of the NHS being overwhelmed. The way to deal with any outbreak of infection (in the absence of an effective vaccine) is to identify all cases, trace their contacts and quarantine them. This is what China and South Korea have done, and it is this targeted approach, rather than the lockdown of Wuhan, which is thought to have been the most effective measure.

          • I do agree with SOME OF your criticism of the German system.
            some of it is, however, not right. for instance, the info sharing is obligatory. hospital doctors MUST write to the GP when dismissing a patient; these letters are the bane of the junior doctors who have to re-do them until the boss agrees. when i worked as a clinician in the UK [ages ago] this just did not happen.

    • Quote: “Coronavirus deaths in the UK are defined as anybody who dies who has tested positive for coronavirus during their final illness, regardless of what the true cause may be (e.g. a stroke, coronary heart disease or as a result of an accident).”

      According to statements of Prof. Wieler, director of the RKI, this is also true for Germany. So this probably is not a huge factor for explaining the differences observed between the UK and Germany.

      • Another thing I wanted to point out:
        the idea that (many?) false positive cases are counted today, because we (in Germany) do not separate between the persons that died “solely” because of SARS-CoV2 is often used by the “COVID19-deniers”, who then claim that the virus is less dangerous as the leading experts think.

        For me, the question if the patients died “solely” because of COVID19 or if the virus was “only” one additional (but important) factor seems somewhat inappropriate and academic at best.

        1. It doesn´t make any difference regarding the recommendations about how we should act to avoid that people in risk of loosing their lives get infected.
        2. Let me compare COVID19 to the case of Niels Högel.
        Mr. Högel is a German serial killer who worked as a male nurse at several hospitals. He killed appr. 100 people by injecting life-threatening substances during his shifts, and then tried to be a “hero” by rescuing them.
        • Most of his victims were old and weakened.
        • Many were treated at ICU stations.
        • Some of the patients survived the Högel-attack, many did not.
        According to the logic that some people apply to COVID19, we should not hold N. Högel responsible for some of the cases, because they would have “died anyways”.
        I do not agree with this view.

        • Jashak,

          For me, the question if the patients died “solely” because of COVID19 or if the virus was “only” one additional (but important) factor seems somewhat inappropriate and academic at best.

          This sort of question has to be answered by any doctor completing a death certificate in the UK, where they are actually certifying the cause of death, not the fact of it. They have to put the main cause of death and up to two additional diagnoses leading up to it, as well as an optional diagnosis contributing to the death but not actually causing it. So a certificate might look like this:

          1.a Multi-organ failure
          1.b Adult respiratory distress syndrome
          1.c Covid-19 infection
          2. Type II diabetes

          Many doctors find this a bit confusing and aren’t very rigorous about how they complete the certificates, even though they are used for collecting national statistics used by epidemiologists.

          At the end of an epidemic, it is possible to count the number of additional deaths over and above those expected, and therefore to get an estimate of how many were killed by the disease in question without having to rely on any specific diagnostic method, but of course we can’t do that with coronavirus at this stage.

          • @ Dr. M.-K.,
            interesting. I can understand why many doctors find it confusing, especially if they have to assess cases where the concurrence of several factors lead to death, and every single factor alone would not have been lethal (as seems to be the case for most COVID19 cases).

  • https://www.bbc.co.uk/news/health-52234061

    This article gives some useful statistics re UK and Germany testing.

    • but the difference in testing can only explain the difference in cases – not the one in deaths.

      • Edzard on Saturday 11 April 2020

        “…..but this would be a very damming judgement on the NHS, and I doubt that it could explain the huge difference. remember: there is no causal therapy!
        severity of disease/risk-factors might be part of an explanation; but Germans are on average older, so …”

        Because the NHS is providing medical contribution. Germans would only be providing care! Why not compare with Japan figures?

        You have yourself mentioned that in the past, the process of curing itself contributed to deaths. Why should it be different this time? It is always your next generations that, with the benefit of hindsight, define how stupid you are. Only this time your generation of doctors would be pronounced idiots. Until now you had the advantage to call your predecessors, names and tick them off.

        The deaths are coming from the extent of medication used: past and present. Run a statistical review of the medical history of the dead, and you will be able to find reasons. You can discuss co-morbidity for others but realize how many of the medications taken in the past are responsible for their death today.

        Remember the rationale behind Prince Charles to get well (your wishes not with standing) without much effort.

        In line with calculation, UK infected numbers will overtake that of China by 13.04.20. The final dead figure would be ahead of Italy’s. This should not worry you unless you are in the infected zone. But the second wave is still due! If the mutation is more malignant, not many would be around to read your writings.

        This would be a blip in the 100 years of “constantly evolving medical science”. NHS is responsible for a higher number of dead, every year on account of incorrect handling of diabetic patients alone and no one asks question.

        Did it ever occur to you that the present direction of medical science is completely erroneous? The whole world under lock down is a telling reminder of how little the “medical science” development is in the past 100 years. Don’t gloat about it.

        For a change look at suitable data sites on COVID 19:

        https://www.worldometers.info/coronavirus/#countries

  • I wrote about something similar 11 days earlier than your blog and got a multiplier of around 7 then.

    Now I am concerned about the anomalous recovery count. The death/recovery ratio is important. Why is not being reported properly in the UK?

    https://www.facebook.com/martin.3dman/posts/10163222259415246

    • thank you
      very interesting and relevant

    • Since we don’t know the infection rate it is not possible to estimate the recovery rate.

      Also for hospitalised patients the time from admission to death is shorter than the time from admission to recovery, so while the numbers are in a state of flux any ratio is also going to keep changing.

      Again, you can’t compare figures for hospitalisations vs. deaths unless you know that the criteria for admission are the same. In places where facilities are more stretched these will be stricter.

      Finally, you need to correct the figures for demographics, which do vary widely between countries.

  • ”but the difference in testing can only explain the difference in cases – not the one in deaths.“

    This is true. But I think the underreporting in UK cases because of lack of testing explains much of the difference in deaths and death rates.

    Do we know whether the German deaths include eg deaths at home/in care settings.

    I do feel that the lack of clarity in the UK is not good.

  • Many thanks for giving everyone a break from SCAM!
    At last, we are experiencing total silence from Big Pharma. They say they are working on a vaccine… really? This virus has already mutated into at least three different strains (A,B & C) – that’s what viruses do. So any vaccine released to the Public will be virtually useless. Great for the drug companies as they will make $billions of dollars out of it.
    More to point that Edzard made about comparisons between Germany and the UK. Just like many Government experts you are avoiding the ‘elephant in the room’. Just look at the reported deaths in Australia compared to the UK (per head of population). I wouldn’t dare even hint (ha ha) that while the UK has endured a dark, wet winter during the pandemic, the Ozzies have been making lots of Vitamin D from the rays of their summer sun. We know that Vitamin D is a recognised immunomodulator and could be partly responsible for such low fatalities in Australia.
    I am taking 5,000 IU’s (liposomal) together with 500 mcg’s of K2 (MK7) each day until I can get a Serum 25(OH)D test from my GP. No doubt some will say that any daily dose over the recommended 400 IU’s of Vitamin D could be toxic. If you reckon that, then show me the evidence that higher doses can be harmful.

    • thanks for not giving us a break from SCAM and your bizarre thinking and ill-informed arguments.

      • What a juvenile and unhelpful comment Edzard – I’m surprised and disappointed in you. If you disagree with someone’s opinion you rubbish it without offering an alternative opinion… shame on you!
        Which of my comments do you consider ill-informed? And remember, I want to see any counter-arguments supported with real evidence.

    • This virus has already mutated into at least three different strains (A,B & C) – that’s what viruses do. So any vaccine released to the Public will be virtually useless.

      I am afraid that I am not impressed by your knowledge of either virology or immunology. By that logic the same should apply for vaccines against any virus, which we know simply isn’t true.

      Vitamin D is a recognised immunomodulator and could be partly responsible for such low fatalities in Australia.

      What about Italy? Singapore?

      I am taking 5,000 IU’s (liposomal) together with 500 mcg’s of K2 (MK7) each day until I can get a Serum 25(OH)D test from my GP. No doubt some will say that any daily dose over the recommended 400 IU’s of Vitamin D could be toxic. If you reckon that, then show me the evidence that higher doses can be harmful.

      I have no idea why you are taking vitamin K, as it is rather unusual to have a deficiency in this (though it is an effective antidote to warfarin overdose).

      You will able to read about the features of hypervitaminosis D in any standard undergraduate textbook in medicine.

      In my view, the evolution of pale skin in higher latitudes despite the increased risk of sunburn and skin cancer points to an important role for vitamin D over and above its function in calcium metabolism, in while case the recommended daily allowance may well be too low. However, too much can not only lead to ectopic calcification (such as kidney stones) but also hypercalcaemia, which has many ill-effects, including gastrointestinal upset, depression, acute confusion and even psychosis. While there are differences between the metabolisms of individuals, it is recommended that you should not take more than 4,000 IU’s a day in order to avoid the risk of toxicity.

      You may not personally have come to harm from this (yet), but if you are advising others to do the same, be aware that one of them may become poisoned as a result.

      • Dr Julian, it is generally agreed by many specialists in the field of virology that every virus mutates into a number of different strains over a period of time. You should read the current consensus of opinion being published by many experts in this field. I am surprised at your lack of knowledge.
        It seems that you are disagreeing with anyone that you don’t consider to be on your academic level. That is a sad indictment of some practitioners involved in mainstream medicine.
        Just for the record, Italy is not as far south as Australia when I last looked at the map! Like Spain, Italy is now just entering their summer period, don’t you know that?

      • Just spotted your recommendation that I should take NO MORE than 4,000IU’s of vitamin D per day. Was that a typo Dr Julian? Did you mean to say four-hundred IU’s that many Doctors recommend as a standard daily dose?
        If you hadn’t chosen to cherry-pick my words you would have acknowledged that I am only taking 5,000IU’s until I can obtain a serum 25(OH)D test from either my GP or a private clinic.
        And if you really believe that 5,000IU’s of Vitamin D is toxic, whereas your suggestion of 4,000IU’s is OK, then I can only hope you are not currently practicing and getting paid for your advice.
        If you have no idea why I am combining Vitamin D3 with Vitamin K2 (MK7) I’m not prepared to educate you.

        • Mr Grant,

          Just spotted your recommendation that I should take NO MORE than 4,000IU’s of vitamin D per day. Was that a typo Dr Julian? Did you mean to say four-hundred IU’s that many Doctors recommend as a standard daily dose?

          No, it wasn’t a typo. Perhaps you should read my post again, more carefully.

          The current recommended daily dose of vitamin D is 400 IU’s per day. That is based on a minimum requirement to maintain normal health.

          Doses greater than 4,000 IU’s daily are associated with a risk of vitamin D toxicity. Your post suggested that you were unaware of this, both because you were asking for evidence that higher doses can be toxic (which is so well-established that it is in standard medical textbooks) and also because you were taking a higher dose (5,000 IU’s) yourself. By denying the known toxicity and endorsing this practice you are encouraging others to do the same, apparently without regard to the possible consequences.

          If you hadn’t chosen to cherry-pick my words you would have acknowledged that I am only taking 5,000IU’s until I can obtain a serum 25(OH)D test from either my GP or a private clinic.

          I don’t think I was cherry-picking your words. You stated that you were taking 5,000 IU’s daily and I stated that doses over 4,000 IU’s were known to be toxic. The fact that you are treating yourself for vitamin D deficiency without even having established whether you are in fact deficient does not change the fact that it is a potentially dangerous dose to take.

          And if you really believe that 5,000IU’s of Vitamin D is toxic, whereas your suggestion of 4,000IU’s is OK, then I can only hope you are not currently practicing and getting paid for your advice.

          I am not currently practising. Nor is drawing attention to the dangers of overdosing on vitamins giving medical advice. I gave up my registration with the General Medical Council when I had to take early retirement due to ill-health, though they have recently reinstated me in case I decide to go back to the NHS during the current crisis (as I am significantly immunocompromised I have no plans to do this).

          Nor did I say that 5,000 IU’s is toxic and 4,000 IU’s is OK. What I said was:
          “it is recommended that you should not take more than 4,000 IU’s a day in order to avoid the risk of toxicity.” These are standard recommendations and not my own.

          The toxic effects of any overdose will depend on many factors, including the genetic make-up of the individual concerned, and even the time of day.

          Dr Julian, it is generally agreed by many specialists in the field of virology that every virus mutates into a number of different strains over a period of time.

          Agreed. So do bacteria, and indeed this is true of any clonal proliferation of living organisms.

          So any vaccine released to the Public will be virtually useless.

          That does not follow. Vaccines are approved for use after they have been tested and shown to be effective. DNA analysis enables different strains of a virus to be distinguished even if their antigencity is identical. Whether a mutation affects immunity depends on where the mutation is. In any case, a vaccine does not need to be 100% effective to be useful. What it has to do (in combination with other measures) is to reduce the transmission rate (R0) to below 1.

          It seems that you are disagreeing with anyone that you don’t consider to be on your academic level

          It may seem that way to you. However, my intent is to reduce the spread of dangerous misinformation by educating, informing and drawing attention to factual errors and inconsistencies. I have never considered myself to be an academic, and I limit my comments to areas where I have some expertise.

          If you have no idea why I am combining Vitamin D3 with Vitamin K2 (MK7) I’m not prepared to educate you.

          I am aware that there has been some suggestion of synergy between these two fat-soluble vitamins and that it is an area of active research. However, I am not aware of any current evidence of a benefit from taking more than four times the recommended daily allowance of vitamin K in otherwise healthy individuals. If there is indeed a synergistic effect then I would also be concerned about potentiation of toxicity.

          I’m not prepared to educate you
          Well, that makes one of us, then.

          Just for the record, Italy is not as far south as Australia when I last looked at the map! Like Spain, Italy is now just entering their summer period, don’t you know that?

          I have had enough trips to Italy to be well aware of the climate there, which is usually warm and sunny at this time of year, and I certainly wouldn’t go there in March or April without protection against the sun. Italy is much closer to the equator than the UK or Germany, and even when the weather is bad the intensity of daylight is greater. The difference is particularly marked in winter, when the days are longer, too.

          On a factual point, the vernal equinox was only three weeks ago and summer does not start in Italy until the beginning of June.

  • There is no mystery. Yes the UK has 6 times more COVID-19 cases than reported, because of their testing regime and because
    – COVID arrived in the UK earlier than it arrived in Germany
    -the UK mishandled COVID-19, especially with the “herd immunity” folly.
    So the UK has a lot more disease than Germany which tested and isolated patients, and traced, tested and isolated contacts.

    • if that is so, would it not be fair and necessary to tell the public?

      • I don’t expect the UK conservatives to be fair or to be honest about their own failure.
        Most of the public are afraid of the coronavirus, only a rare few draw your (in my opinion incorrect) conclusion about the NHS.

    • Yes, I know; that would be an explanation, if the UK system had already been hopelessly over-stretched; as far as I know, this has not yet happened.

  • There’s no comparison. Germany is so superior she can even produce pencils whereas the UK produces… repeats of Pointless TV programmes by the once great BBC.

    Likewise the “envy of the world” NHS is repeating itself endlessly in conditions that forced e.g. Henry Marsh (Do No Harm):
    https://www.amazon.co.uk/Do-No-Harm-Stories-Surgery/dp/178022592X/ref=sr_1_1?dchild=1&keywords=henry+marsh+do+no+harm&qid=1586615099&sr=8-1

    and Adam Kay (This is Going to Hurt):
    https://www.amazon.co.uk/This-Going-Hurt-Secret-Diaries/dp/1509858636/ref=sr_1_1?crid=1SRHF2PW4AM6U&dchild=1&keywords=adam+kay+this+is+going+to+hurt&qid=1586615141&sprefix=adam+kay+%2Caps%2C176&sr=8-1

    to resign.

    If the NHS listened to either of these two gentlemen, i.e. to people, instead of to government-central-planning, neither Marsh nor Kay would have had to resign.

    • I hope you know what this comment is about – because I don’t

      • Edzard on Saturday 11 April 2020 at 16:34 said:
        “I hope you know what this comment is about – because I don’t”

        I believe you, hence your original question, the title of your blog post.

        It seems that academics don’t realise what actually goes on in British industry and from both Marsh’s and Kay’s books above, the NHS appears to be just as bad – they are not the only ones e.g. flashing up on the TV right now are figures that say 50% of nurses do not have the proper protective equipment (PPE) – my guess is that this does not apply in Germany – hence it is no surprise that Germany is just as superior medically, as she in in everything else, right down to making pencils.

        • only a moron can be told that his/her comment is not understandable and post a further comment that fails to explain it.
          seems like you do not understand even your own comments.

          • Edzard on Saturday 11 April 2020 at 19:55 said

            “only a moron can be told that his/her comment is not understandable and post a further comment that fails to explain it.
            seems like you do not understand even your own comments.”

            A superior thing works better than an inferior thing, that’s all there is to understand.

            What you do is to take an arbitrarily narrow view of comparison that creates a “mystery” where there was none, from the whole-view e.g. “Why (in late 20th century) are Japanese automobiles better than US? What’s wrong with the Edsel?”, when someone took a Japanese gearbox apart, it was discovered that the tolerances were an order of magnitude better than their published figures – that’s why they were quieter than US gearboxes.

            But the “problem” was much bigger than just tolerances, it was the whole culture, centuries old, of perfection, in everything, and respect in language and manners etc. The US is loud and overstated, the Japanese, quiet and understanded.

            The workers hated making the Edsel so much that they deliberately sabotaged it by putting loose nuts inside the panels to make it rattle etc. – the Japanese, the opposite.

    • Germany is so superior she can even produce pencils whereas the UK produces…

      Keswick in the Lake District is famous for its pencils.

      • Dr Julian Money-Kyrle on Sunday 12 April 2020 at 00:47 said

        “Keswick in the Lake District is famous for its pencils.”

        Well, I’ll be damned! It brings a lump to my throat, you are quite right!

    • Old Bob,

      Henry Marsh used to work in Atkinson Morley’s Hospital, a small hospital in Wimbledon dedicated to the treatment of neurological disorders and damage. This eventually closed and most of it was moved to St. George’s Hospital, a much larger general hospital in Tooting, a rather less salubrious area of London, which had been dysfunctional since the moment they moved there from their original site at Hyde Park Corner. This was not helped by St. George’s not noticing, when they put the (very desirable) Hyde Park Corner site on the market (to fund the new build at Tooting), that there was a legal clause that allowed the Duke of Westminster to buy it back from them at the original purchase price. Since his family had sold it to them in 1733, this was quite a bargain for him, and left the hospital badly out of pocket.

      My wife has worked as a Clinical Psychologist in both Atkinson Morley’s and St. George’s and found the same differences between them as did Henry Marsh, who always used to refer to it as St. Beastly’s whenever I spoke to him on the phone. As far as I can tell everything to do with neurology and mental health was particularly awful (my experience of working there as a Senior House Officer in Medicine in 1991/92 wasn’t much different from working as a junior doctor anywhere in the NHS – ref. Alan Kay). Having seen for myself over the course of my career the problems arising when departments are moved around between hospitals with quite different ethos and organisational systems, I don’t blame him for wanting to get out.

      Alan Kay’s experiences as recounted in “This is Going to Hurt” are very familiar to me and to any junior doctor working in the UK at that time, though he seems to have had his own issues, too. Things are a bit different now, thank goodness.

      The NHS is the one thing that the electorate in Britain has consistently cared about more than any other issue, so every new Government wants to be seen to be visibly improving it. Unfortunately what would really make a difference is a lot more money, which they have seldom been prepared to allocate, so instead each Government reorganises everything instead. This causes chaos for a few years before everyone adapts to the new regime and it all settles down again, until the next change of Government. We have had a Conservative Government for the past 10 years so the NHS is reasonably stable at the moment.

  • @ all qualified doctors with experience with ICU-pneumonia treatments:
    The rationale behind the current “social distancing” strategy is that we have to avoid overwhelming the available ICU capacity. Of course, it seems obvious that chances are greatly improving if ICUs are available, but I have not seen any concrete numbers (I assume these numbers have bot yet been determined for COVID19).
    Also, I have never heard anyone discussing the effect that ICU treatment has on improving the chance of survival of pneumonia.

    Can anyone here give an estimate (supported by evidence) on the efficacy of ICU treatment regarding pneumonia, specifically regarding the reduction of the risk of dying from it?
    I think this number is important when discussion the “herd immunity” strategy vs the “social distancing” strategy and would find it very interesting and it could also be part of the explanation for the vastly differing death tolls in different countries.

    • Jashak,

      According to the original report from Wuhan, which I think was published in The Lancet, 37 patients in the series were ventilated, of which 36 died. However, I have heard a more recent statistic (which I can’t verify as I can’t remember the source) that roughly 50% of patients ventilated with ARDS (the main indication for ITU in Covid-19) survive.

      • Dear Dr. Money-Kyrle,
        Thank you for your answer.
        I had heard about the Wuhan numbers, which was part of the reason I posed the question. I was very surprised and could hardly believe it.
        Even the 50% survival rate sounds terrifying (especially since the number of patients surviving without ventilation is not mentioned, so the “additional benefit” of ICUs is not clear to me).
        As a layperson, I would have thought that the ICU ventilation treatment would be far more effective in saving lives.

        If it is true that the benefit of the ICU ventilation treatment on prospects of survival really is so low as the Wuhan numbers suggest and the severely affected patients die at a similar rate no matter if they are treated in an ICU or not, then the official statements that we should do everything to avoid overwhelming the ICUs seems not logical to me.

        A more honest line of reasoning why we should follow social distancing rules would then be that we must gain time to find an effective treatment or even a vaccination.
        Would you agree with this assessment?

        • Most emergency admissions to ITU are because the patient is very sick and deemed to be at high risk of death without invasive treatment. I don’t have accurate figures, but I would have thought that 50% survival in a group that would otherwise have a mortality approaching 100% is quite a good outcome. But then, perhaps I am more used to the realities of treating serious disease.

          I am lucky enough to have survived a week’s ventilation in ITU myself, and I am under no illusions about what a narrow escape I had.

  • @Dr. JMK

    Perhaps medical science is slow to realize that ventilators is not the preferred remedy. Yes, some lives have been saved with ventilators, while many have been lost relying on a failed solution.

    Rather than focusing on attempting to force oxygen into blood cells that will not carry the blood, perhaps SBM should be focusing on how to get the blood cells carrying oxygen to the body again.

    “As patients go downhill, protocols developed for other respiratory conditions call for increasing the force with which a ventilator delivers oxygen, the amount of oxygen, or the rate of delivery, she explained. But if oxygen can’t cross into the blood from the lungs in the first place, those measures, especially greater force, may prove harmful. High levels of oxygen impair the lung’s air sacs, while high pressure to force in more oxygen damages the lungs.”

    The virus itself is to blame for the hypoxemia, and beyond a result of decreased lung function due to virus related lung damage.

    • RG

      I don’t know who you are quoting here.

      Your understanding of the pathogy and treatment of adult respiratory distress syndrome is so wrong I don’t know where to begin in answering you, so I will leave it there.

      • @ Dr. JMK

        Doc, I know that your medical and health related knowledge is far superior to mine. That said, you don’t need me to tell you that this virus is different. So in the end, it will be revealed how this virus does not follow historical conventional pathology.
        I don’t pretend to be more educated, but perhaps more informed.
        Time will tell.

        • RG@

          I don’t pretend to be more educated, but perhaps more informed.
          Time will tell.

          I am struggling not to laugh.

          • @Bjorn

            Don’t fight the laughter…. it’s quite a healthy thing for you, probably better for you than seeing an MD.

    • RG

      The Dunning-Krugerism you display at times is quite breathtaking. Thankfully, you and your foolish notions are of no consequence, other than as a vague irritation to those who are actually involved in caring for patients.

      • @Lenny

        Save it for yourself…. Lenny.

        I wouldn’t see a hack dentist like you that is still depositing mercury in human orifices if my life depended on it.

        • RG

          And which dental school did you attend to be able to pass informed comment on clinical practice?

          Your Dunning-Krugerism yet again..

          And I haven’t used amalgam in my practice for many years. You really should stop listening to those voices in your head. They aren’t good for you.

          • @Lenny

            “And I haven’t used amalgam in my practice for many years.”

            hmmmm, I don’t recall that being your position about a year ago.

          • Sorry that should have read “used amalgam routinely”. I place a couple of amalgams a year.

            And, once again, what makes you think you are in a position to pass comment on clinical dentistry?

            But amalgam has not been shown to be harmful, RG. Unless you have conclusive data to show otherwise. Have you “done your research”?

            Remember that the father of the anti-amalgam movement, Sandra’s best friend Hal Huggins, was a proven fraud, liar and quack who had his license revoked as a result. Have you ever read his charge sheet? I have. It is chilling. And yet this is who you side with. A man happy to do actual, proven harm in order to line his pockets. And Sandra, a deluded, predatory zealot for the nonsense which is homeopathy, a witch who stalks people online and taunts the recently-bereaved. Nice company you keep.

          • @Lenny

            So, why did you all but stop using amalgam ? Something must have influenced you to make the change …. no ?

          • @RG

            I’ve answered this previously. Composite resins are better restorative materials.

  • I think it does look like absolute numbers of deaths in Germany are lower than in the U.K.

    https://www.worldometers.info/coronavirus/#countries

    Are the Germans doing anything with all their testing that uses it to reduce transmission? I see no reporting to indicate that they are contact-tracing to break transmission chains.

  • For hypothesis generation, we see no end at all, currently. The first port of call is of course a spectacularly huge amount of fantastically bad data. From everywhere. Complete hysteria to publish ‘studies’ with ginormously frivolous statistics when the n is below 10? Yeah. Everyone working from pre-prints?

    There are nonetheless some questions popping through my head:

    Different populations. Different genetics. Different behaviours.

    Different testing strategies, different tests? Which country uses which?

    Different treatment guidelines, different medications used. Lots of experimentation done?

    And that poses a big one: the side-effects and interactions are apparently huge.

    The recent endorsement by – among others Trump and Raoult, what a combo – of (Hydro-)Chloroquin/Azithromycin is by itself a real killer if combined with diabetic medications.

    Trying to read as much case reports as I could find. Which is for sure not all of them. But I found it very interesting to see that anamnestic questions seem to not be that high on the agenda for most published material.

    We see a group defined as ‘at elevated risk’ that is old, often high blood pressure, cardio-vascularly challenged and diabetic? All of those conditions are usually in the “we must treat that” bracket of the elderly population.

    Yet, while some reports do ask for eg smoking status, prior medication is mysteriously absent. That ‘includes’ both chronic medications and self-treatment of acute symptoms, whether by aspirin or the now infamous ibuprofen, or various herbs and the like. Given the now examined link between aspirin and its deleterious effects when given in excess like in the Spanish flu…

    Similarly we see still growing concerns for using ACE inhibitors or statins. Are they detrimental or increasing risk – or at the opposite end, saving lives even with Corona active? Some theories to that end do not look good, evidence is mostly absent either way.

    What is the status of medications in those taking the “severe course”? I don’t know, not many seem interested. In Germany the Robert-Koch-Institut advised pathologists to abstain from looking into bodies of the deceased. So much so, that the Union of German Pathologists now protests publicly about that lack of curiosity and effective prevention getting at the data needed.

    Are previous vaccination strategies – for example BCG – beneficial? There is also a East/West discrepancy *within* Germany that some tried to explain by previous differences between FRG and GDR policy on that. But the best comment on that line of reasoning is indeed “a word of caution”

    > In this work we emphasize caution amidst the publication surge on COVID-19, and highlight the political/economical-, arbitrary selection-, and fear/anxiety related biases, which may obscure scientific rigor. (https://www.medrxiv.org/content/10.1101/2020.04.09.20056903v1)

    It looks like those groups urging patients to under no circumstance to discontinue their respective meds have currently as much hard evidence on their hands as those thinking them to be the devil’s handmaiden. A very recent preprint only told me that ‘the first systematic review’ basically rests on very small number of equally bad quality papers and only concluded that corticoids may be of some value once the stage is at ‘severe’. That is a very slim base.

    Since Hendrik Streeck, I think, postulated that initial viral load may be one determining factor for severity of developing illness, explaining perhaps why localised catastrophic outbreaks may happen, density of infection clusters need to be looked at? For sure his first representative study for Gangelt/Heinsberg seems to confirm that also for Germany the number of reported positve test cases is quite a hefty underestimation of infections. (Well: If those tests he used are indeed as reliaböle as the manufacturer claimed and Streeck believes…) But his results aren’t final yet, despite publish or perish press conference on a half-finished study.

    So despite my biggest interest: what did people swallow before and during illness, there is a n non-iatrogenic factor emerging:

    The proposed interventions now apparently studied do include such strange ideas like Vitamin B3 and silicon. A combination that seems a bit ‘strange to me’. But it got university funding, so they may know much better than me?

    Then we see a at the least two-phase disease progression, with very probably different therapy targets? A mild course for which you want your immune system ramped up. And the severe one where the cytokine storm does so much damage that you want the immune system dampened?

    For that we see indeed a suggestion to look at vitamin D. Which is at the nutritional uptake level found to be low in Southern European countries, less than ideal in the UK, goodish in Germany and high in Nordic countries. (https://doi.org/10.1530/EJE-18-0736 / https://doi.org/10.1101/2020.04.08.20058578) It may even account somewhat for the higher proportion of melanin-expressing patients dying in the US, on top of all the racism and broken health care system prevalent there. Yet: that alone for sure can’t be ‘it’.

    Very probably I am even much more confused than you are. The amount of not-up-to-par publications is staggering.

  • The number of cases being reported in the UK is a significant under-estimate of the actual number of cases. This makes sense because (as Dr Julian Money-Kyrle said) the UK is mostly testing those people who are ill enough to attend hospital. Some community testing is happening which, although increasing, is currently at a low level. Whilst it’s not possible to establish actual numbers (or even a good estimate of them) it seems likely that there are more cases in the UK than in Germany. It’s just that Germarny are finding far more of those cases. Also, simply dividing deaths to date by cases does not take account of delays from a positive test to death. The following paper gives some estimates of the reporting rate of cases for different countries. Note that at one point Germany was probably testing 100% of cases and the UK was never anywhere near that: https://cmmid.github.io/topics/covid19/severity/global_cfr_estimates.html (Please note: As stated at the top of the paper, this is a pre-print that has not yet been peer-reviewed.)

    The difference in testing is one of a number of reasons that comparison between countries is probably of little value at such an early stage of this pandemic.

  • Dr. Edzard,

    I appreciate your comment on coronavirus.
    Inconsistency between Germany and UK Covid-19 figures are shown in this chart:
    Cases Death Tests Tests/M pop
    Germany 125,452 2,871 1,317,887 15,731
    UK 78,991 9,875 334,974 4,934
    Germany tests have been four times as in UK.
    You can get this information in https://www.worldometers.info/coronavirus/#countries

    • Victor Buenda,

      I, too, have found that to be a very informative Web site, allowing you to drill down into the data to some extent, and also with the option of showing many of the graphs on a logarithmic scale, which is much more informative than a linear scale when dealing with numbers that are changing exponentially with time, since it transforms an exponential curve into a straight line, with changes in slope representing changes in growth rate. This enables you to see the effects of control measures much earlier than by simply looking at the numbers.

    • If testing is the only answer, then why countries which have done more testing then Germany (15,730 per 1M pop), such as Italy (17,315 per 1 M pop) and Switzerland (22,393 per 1M pop) have far more reported deaths per 1M, 338 and 131 respectively vs only 38 per 1M pop in Germany? (using the same source worldometers, 14/April)

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