Covid-19, Vitamin D, and UK Government policy - I had a dream
A work of fiction by Dr David Grimes 8 MAY 2020
Consultant physician and gastroenterologist
Day 0 (early May 2020)
The scene:
10 Downing Street, London W1
The Press Room
The reporters are waiting, now on-line.
Enter three men, and stand behind their lecterns.
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| Professor Chris Whitty, Prime Minister Boris Johnson, Sir Patrick Vallance |
Prime Minister, Boris Johnson (it is he, recovered)
This morning we have, er, some very good news for you all, in fact spectacular news, the very best that we have had for a long time. I will ask Chris Whitty to give more details.
Professor Chris Whitty, Chief Medical Officer
Thank you Prime Minister. The good news today is that we now have a new way to reduce dramatically serious illness and deaths from Covid-19. The way to do this is remarkably simple. We have heard a great deal about the development of vaccines to provide immunity, but it is unlikely that they will be available and tested for safety until the end of the year. In the meantime we have a great opportunity at hand today. It is vitamin D. It will boost our immunity and reduce deaths at a stroke.
Prime Minister
So there we are. I told you that we had really good news today, great news. Really great news. I will turn to Patrick to explain further.
Sir Patrick Vallance, Chief Scientist
Thank you Prime Minister. Vitamin D is not new. In fact it first appeared on the evolutionary scale 1.2 billion years ago, but its importance in immunity has been a feature for only the past 500 million years. The next bit is slightly technical. Vitamin D is created by the action of the sun on 7-dehydro-cholesterol and this is manufactured in our skin. It enters the blood stream and becomes activated in the liver and kidneys. It combines with what are called vitamin D receptors (VDRs) on the surface of target cells, like putting a plug in electrical socket. It then activates several genes, like switching on an electrical appliance once it is plugged in. The activated genes include those that enable the proliferation of the defensive immunity cells, such as T-lymphocytes and macrophages. This is an essential response to infection.
Prime Minister
I think I can just about understand that. Would you like to add anything Chris?
Chris Whitty
It was realised only recently, early in the 20th century, just before World War One, that vitamin D is actually important for immunity. At that time rickets was common in our industrial cities and this was shown to be due to shortage of vitamin D, the result of air pollution preventing the penetration of full intensity sunlight to ground level. It was noted that rickets and tuberculosis frequently co-existed within families. It is now clear from the experience of the AIDS epidemic in particular that tuberculosis becomes activated when immunity is suppressed. Vitamin D deficiency is another but much milder form of immunodeficiency.
Prime Minister
Do you mean that air pollution causes suppression of immunity and that is why it is bad for us?
Patrick Vallance
Yes, and we have seen that the pandemic of Covid-19 took hold in northern Italy, which has the greatest air pollution in Europe. I believe that vitamin D levels have been very low in Northern Italy and also in many parts of Spain, but the reason for this is not yet clear. Air pollution will also explain why the pandemic is causing more deaths in our inner cities than in rural areas.
Prime Minister
I think there is more evidence concerning the value of vitamin D in Covid-19.
Patrick Vallance
Yes. It is possible to measure the amount of vitamin D in the body by a simple blood test that has been available in all NHS hospitals for several years, and it is available in many countries in the world. It is important for the blood level of vitamin D to be greater than 30ng/ml, or 75nmol/L. Less than 10 is regarded as serious deficiency. An imaginative study has been reported from the Philippines by Professor Mark Alipiorrt, who unfortunately has been very ill with pneumonia, but I have the good news that he is now recovering. Vitamin D testing was undertaken in 212 patients with proven Covid-19 in three hospitals in south-east Asia.
Prime Minister
Chris, can you tell us the results?
Chris Whitty
The results are dramatic. Of the 55 patients with ideal blood levels of vitamin D, 47 had just mild disease. In 4 the disease was moderate, in 2 severe, and in 2 critical. But on the other hand, only 2 patients with low blood levels of vitamin D had mild disease, and in the other 155 patients the disease was moderate, severe or critical.
Prime Minister
Gosh! So there was a clear benefit form having a good blood level of vitamin D. I think there has been another study. Patrick.
Patrick Vallance
Yes Prime Minister. This was in Indonesia. As the pandemic started in the far East, there have been more opportunities for research. 780 patients with Covid-19 were tested for blood levels of vitamin D, and they were followed up to observe clinical outcome. Chris.
Chris Whitty
Almost half of the patients had low levels of vitamin D, and almost half of the patients died. Of the 380 with good levels of vitamin D, that is above 30, only 16 died. Of the 400 with low levels of vitamin D, almost all died.
Prime Minister
This is really amazing. Are there any other studies?
Chris Whitty
Yes. I have just received this morning a report from an imaginative Dr Gerry Schwalfenberg in Edmonton, Alberta, in Canada. He realised a little while ago that low blood vitamin D level is a bad thing and it is especially common in elderly people living in care homes. He looks after residents in a nursing home and so he gave them all vitamin D 2,000units each day by mouth and later he tested the blood levels. In 94% of the residents, the levels were above 32ng/ml (80nmol/L). Those whose blood levels remained low were given a higher dose of vitamin D
Prime Minister
Has that been of benefit to them?
Chris Whitty
Yes it has. Not a single resident of this nursing home has been ill with Covid-19, whereas there have been many cases in all the other neighbouring nursing homes
Prime Minister
That is even more really good news. Are there any more examples, Chris?
Chris Whitty
Yes. With exception of San Marino, Belgium has in Europe the highest number of Covid-19 deaths relative to population size. We have just this morning read a report from Belgium that vitamin D levels were much lower in the patients who died from Covid-19
Prime Minister
So we have a great opportunity to protect the wonderful and proud people of our great country, and defeat the most dangerous enemy that we have faced since the second world war. Patrick, what is the next step?
Patrick Vallance
We have these clinical studies and we have the basic science of the vital role of vitamin D in the process of immunity. We need to protect people by issuing them with vitamin D. There are two dosage regimes. The first is to use capsules or tablets of vitamin D. A dose of 2,000 units a day is usually adequate, but at this time of national emergency I would recommend 4,000 units a day. An alternative is to give a single dose of 100,000 units, in an oil which can be given by injection or by mouth. Its effect will last for about two months.
Prime Minister
Will this be expensive? Do we need to ask the permission of the Chancellor of the Exchequer?
Patrick Vallance
It is cheap. The single dose will cost about £1, and the 4,000 unit capsules will cost about £10 for a year’s supply. We obviously must multiply these numbers by the number of the UK population.
Prime Minister
That is even more good news. I am sure that our Chancellor of the Exchequer Rashi Sunak will be very pleased. Chris, do you have any comments?
Chris Whitty
It will take a little time for the public health departments in the UK to organise the distribution of vitamin D.
Prime Minister
But surely this is very urgent. People are still dying of Covid-19, about 500 each day.
Chris Whitty
Yes, but we need to prioritise distribution of vitamin D to those most at risk. This will obviously be health service workers, and then care workers, and then the residents of care homes.
Prime Minister
I think that I might have heard a suggestion that people of black African and Asian ethnicity might be at risk from Covid-19. Patrick, do you know if this might be true?
Patrick Vallance
I might have also have heard the suggestion that people of black African and Asian ethnicity might be at special risk. There is a view that they must all be rehoused as a matter of urgency, but that is a challenge that we cannot meet today. I am also given to understand from the newspapers, but I have not seen any official figures, that 26 doctors in the UK have died from Covid-19, and that 25 of them were of black African and Asian ethnicity. That is quite a coincidence. However it has been known for a long time that such people are almost all deficient in vitamin D as the result of dark skin and sun-avoiding behaviour.
Prime Minister
And so must they also have a priority for receiving vitamin D?
Sir Patrick Vallance
Yes, Prime Minister. But the more people who have priority, the more difficult the task of distribution.
Prime Minister
But if vitamin D is so urgent and so cheap might people want to buy their own supplies?
Chris Whitty
Yes Prime Minister, that is what I have done.
Sir Patrick Vallance
And so have I.
Prime Minister
I think I was given a vitamin D injection when I was in hospital.
Chris Whitty
That is probably why you recovered so well and so quickly when you were so close to death.
Prime Minister
Yes, and once again I would like to thank all the brave staff for the wonderful treatment and care that I was given. So, the vitamin D story seems to be straightforward. Are there any dissenting voices?
Patrick Vallance
There are a few. Notably the Oxford group, who are busy developing and testing a vaccine. They feel that vitamin D is an untested diversion from what they are doing.
Chris Whitty
And there are many who feel that social justice for the ethnic and socio-economically disadvantaged should have priority over vitamin D supplements.
Prime Minister
That is tricky. So I think we must go ahead with vitamin D immediately. Today at the latest. Are there any questions? Laura.
Laura Keuensberg (BBC)
Thank you all for this welcome news.
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| Laura Keuensberg |
Could I please ask where vitamin D supplements come from and is there an adequate supply?
Prime Minister
Patrick, this is one for you.
Patrick Vallance
Thank you Laura. Most of the vitamin D supplements come from sheep’s wool, and some from fish oil. The oil from sheep’s wool must be processed to isolate 7-dehydro-cholesterol, and then this must be irradiated with UV light to convert it into vitamin D. A possible problem is that the great majority of this production takes place in China. The world annual production is uncertain, perhaps 7 tons, perhaps 97 metric tons. Most of it goes into animal feed, very important now that so many animals are kept indoors. The UK might require about 1 million tons or more, but I am told that Donald Trump has bought it all.
Prime Minister
Thank you Laura. Beth, you have a question.
Beth Rigby (Sky News)
You have mentioned the Oxford group who are inventing a
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| Beth Rigby |
vaccine at this moment. I am told that they demand a randomised control trial to see if there is any truth in the idea that vitamin D might be helpful in Covid-19. Is such a trial underway in the UK?
Prime Minister
Patrick should be able to answer this one.
Patrick Vallance
I do not have a full picture of any research that is going on at present. Perhaps Chris would know more.
Chris Whitty
I do not know of any, but research that individual hospitals undertake is up to themselves. The information about vitamin D that I have is that common sense tells us how good it is, and that is why I take it. If we have a controlled trial, half the subjects will take vitamin D and half will take a placebo, a dummy tablet. I would not be happy for me or any of my family or friends (with an occasional exception) to take the placebo as it might put me or others at a high risk of death. Unless we keep the subjects in the dark (perhaps literally) I do not see any controlled trial taking place. In other words at this stage, to conduct a placebo controlled trial of vitamin D would not be ethical, and with informed consent it would not be possible. The weight of evidence indicating that vitamin D is helpful in preventing serious illness and death from Covid-19 is well beyond reasonable doubt, to use a legal expression. We know that vitamin D is safe, but we do not yet have this information about the Oxford Vaccine, which is not yet available.
Prime Minister
Thanks you Chris. That is very clear. Heather, you have a question.
Heather Stewart (Guardian)
We hear great deal about testing. How many people in the UK have had their blood vitamin D levels tested?
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| Heather Stewart |
Prime Minister
Chris, can you answer this?
Chris Whitty
The short answer is that I have no idea. Hospitals do not inform the centre about the blood tests that they do.
Prime Minister
Thank you Heather. I think you have another question
Heather Stewart
Yes Prime Minister. Thank you. At the Guardian I am told that during the past month we have had a lot of letters about the value of vitamin D in the pandemic, mainly written by doctors. We published just one letter but we thought that the others must be from food-fad enthusiasts. Do you mean to say that they were all right in what they had written to us?
Prime Minister
Patrick, you might answer this.
Patrick Vallance
Well, Heather, it looks as though they were right.
Prime Minister
Tim, you have question.
Tim Shipman (Times & Sunday Times)
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| Tim Shipman |
It sounds as though there might be a long and widespread knowledge of the value of vitamin D in immunity and defence against infection. We have just heard about it for the first time this morning, and so may I ask when you first heard about it?
Prime Minister
Speaking for myself, it was just after breakfast this morning. What about you Patrick?
Patrick Vallance
I heard about it yesterday evening. I was alerted by a member of my staff who had just seen some interesting Blog posts and Tweets.
Prime Minister
And you Chris ? When did you first hear about it?
Chris Whitty
When Patrick phoned me yesterday evening.
Tim Shipman
Why did you as Chief Medical Officer not know about the value of vitamin D in defensive immunity?
Chris Whitty
Well, I can’t be expected to know everything. I thought vitamin D was all about bones and children with rickets.
Prime Minister
Let’s move on. Bob, you have a question.
Robert Peston (ITV News)
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| Robert Peston |
Prime Minister, what can people do if supplies of vitamin D are not sufficient for our needs?
Prime Minister
That is difficult one Bob. Over to you Patrick.
Patrick Vallance
We can eat oily fish, such as mackerel in particular. Do you remember the days when as children we were given disgusting Cod Liver Oil? It turns out that our mothers were right. We can also obtain vitamin D from the sun, and in fact we usually obtain most of our vitamin D from the sun. We need to expose our skin, not quite all of it, to the sun, at this time of the year in the UK for up to one hour between 10:00am and 4:00pm. We can do this in our gardens, in the parks, and on the beach, or anywhere that is isn’t too cold, and of course when it is not raining.
Prime Minister
That might be bit tricky with social distancing, but we must act very quickly. I suppose we might do what I believe is happening in supermarkets and other places. People would apply for and be given a ticket to lie semi-naked in a park (not in a supermarket) or on a beach. We do not want too many people in one place at one time, and so the ticket would be valid for one hour only. And we would need to have police on patrol. We should be able to create a web-site for this later today and have it up and running by tomorrow morning. Are there any more questions?
Goes on for another half hour with the usual questions and the usual evasive answers.
Day 1.
The daily Covid-19 briefing becomes chaotic as Matt Hancock (Secretary of State for Health), Angel McLean (Deputy Chief Scientific Advisor), and Jenny Harries (Deputy Chief Medical Officer) are inundated with questions about vitamin D that they are unable to answer.
The briefing is brought to a rapid close.
Newspaper headlines:
Crowds outside pharmacies
Vitamin D is in short supply
Demand for permits is overwhelming
Web-site for permits to sunbathe in public places crashes.
Public parks crowded with semi-naked people
Queues of cars at approaches to beaches
Asian groups complain that sunbathing advice is against their religious practices
Day 2 Newspaper headlines:
Government suspends daily Covid-19 announcements
Vitamin D supplies to the public are exhausted
Black market develops for vitamin D
People fighting for entry into parks
Sunbathers refuse to leave after one hour
Police cannot control crowds
Day 3 Newspaper headlines:
Public Health agencies are struggling to prioritise the vitamin D supplies that they have been able to obtain.
China refuses to release more vitamin D
It is not yet warm enough to shear sheep
Fish shops noting a big demand for mackerel
Day 4 Newspaper headlines:
Vitamin D : Civil disobedience.
Family doctors are struggling with demand for
vitamin D blood tests
Crowds outside hospitals demanding vitamin D
Heavy rain diminishes crowds in parks
Day 5 Newspaper headlines:
Why was vitamin D not stockpiled?
If vitamin D has been known for a long time to help immunity,
why was it not recommended two months ago?
Large protests in Trafalgar Square
Chief Medical Officer and Chief Scientist resign
Calls on Prime Minister to resign
Day 6 Newspaper headlines:
Rapid decrease of deaths from Covid-19
Lockdown ended to enable people resume normal lives
Day 7 Newspaper headlines:
In anticipation of future epidemics, Government sets up
Scientific Advisory Committee for Immune Defence
And then I woke up, listened to the radio news and I realised that it had all been a dream, but a pleasant dream. It would have been nice to remain asleep but now I was awake I had to continue with the daily nightmare of Covid-19 with no action taken to stop deaths.
How many more will die today? Will there be any more deaths of black African and Asian doctors? Or more nurses and care workers? When will someone listen to what many doctors are saying and writing about the potential value of vitamin D? When will "vitamin D" appear in the newspapers, on the radio, on the television, or at the government daily Covid-19 briefing? When will we have a televised debate on the value of vitamin D, with full display of the large evidence?
I often hear and read vitamin D sceptics saying: "Vitamin D in Covid-19 is unproven". If commentators knew the meaning of "proof" they would not make such a ridiculous statement. Absolute proof rarely exists in the real world, and so, as in law, we must look at all the evidence, and then we must make a judgement on the basis of "Beyond reasonable doubt".
My Blog posts during the past six week have had more than 20,000 readers. Although the message does not appear to be reaching those in political power, it seems to be contributing to a much larger "grass-roots" movement. There has been an increasing demand for vitamin D, and supplies from some sources have been exhausted.
But perhaps the dream of government endorsement of the proven importance of vitamin D in maximising immunity will become a reality. Hopefully very soon.
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