25 Mar 2021

However, I do not think that anyone could have anticipated the number and controversial nature of the news stories covering the rolling out of vaccines in the last few weeks.

Three issues have dominated the public and professional press – mainly concerning the Oxford University and AstraZeneca product. First, questions about its effectiveness in certain age groups (President Macron of France referring to its “quasi- ineffectiveness”); then, its safety profile was questioned in the context of very rare cranial thrombo-embolic events and; finally, the difficulties in delivering enough doses, mainly to EU countries, including the threat of export bans from the EU.

Perhaps the main story here is the differing responses to these events, particularly from the European Commission and some of its member states. Following the concerns over safety issues, 16 EU countries halted the use of the Oxford University and AstraZeneca vaccine citing the “precautionary principle”. Some of these countries have still not reinstated their rollout programmes, even after all the relevant regulatory bodies (the MHRA in the UK, the EMEA in Europe and the WHO) said that the vaccine was safe, a view reinforced by the recent large study undertaken in the USA.

Bizarrely, at the same time as the safety and effectiveness of the vaccine was being called into question, and millions of doses sat unused, the EU began a fracas with AstraZeneca because they were not delivering all the doses according to their contract.

The decision to “pause” many vaccination programmes and the resulting reduction in the vaccine rollout triggered considerable concerns among doctors, both in the UK and the affected countries. The arguments were well summarised by Stephen Griffin, associate professor in the School of Medicine at the University of Leeds, who said: 

“Although reports of a small number of blood clots should be investigated, the response of many countries to halt vaccinations was disproportionate. Since many European countries are currently experiencing another resurgence of SARS-CoV-2 infections and yet are lagging behind in terms of rollout, the importance of continuing the vaccination programmes cannot be overestimated, and the harm caused by depriving people of access to a vaccine will likely vastly outweigh even the worst case scenario if any link to the clotting disorders is eventually found. It should also be noted that nationwide gestures such as this are bound to fuel hesitancy, or more extreme anti-vaccine sentiment, further undermining the vaccination effort.”

It was put more colourfully by Professor Sir John Bell, Regius Professor of Medicine at Oxford, who said that the decision was “completely crackers”.

This clash between politicians and the medical profession reminded me of an aphorism related to medicine from Rudolf Virchow, a 19th century German physician and politician.

Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine [...] as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution

Rudolf Virchow, a 19th century German physician and politician

Rudolf Ludwig Carl Virchow (1821-1902) was a German physician, anthropologist, pathologist, prehistorian, biologist and politician. As a clinician he was the first to describe and name many diseases, including leukaemia, but importantly in the current vaccination debate, he discovered and explained thrombosis and embolism. As well as being known as “the father of modern pathology” Virchow actively worked for social change to fight poverty and diseases. His methods involved pathological observations and statistical analyses. He called this new field “social medicine”. And finally, as a politician he had the opportunity to influence national policy and triggered the famous “sausage duel” with Otto Von Bismark.

So as the current debate over the Oxford AstraZeneca vaccine spans all three of Virchow’s often radical ideas (clinical, public health and politics), I was curious to speculate what he might have made of the current tensions between politics and medicine. 

However, as I read more about Virchow in preparing this blog, I began to have significant doubts. I had not known that his societal approach also led him to some false conclusions. He believed that epidemics were social in origin, and the way to combat them was political, not medical. This led him to regard germ theory as advocated by Louis Pasteur and Robert Koch as a hindrance to prevention and cure of infections. Virchow also had an aversion to the theory of evolution resulting in him calling Charles Darwin an “ignoramus”. All this made me think that we would get little illumination on how to approach our current problems, even from such an illustrious polymath. Reflecting on my disappointment, I wondered if perhaps his life and career did provide some useful insights. Namely that even the best scientists can make mistakes, and politicians can make the wrong decision for what they might consider the right reasons – albeit, I hope, in the context of current vaccine decisions, on the basis of dubious understanding of epidemiological risk and that lack of evidence on effectiveness is not the same as evidence of lack of effectiveness, rather than peevish nationalist perspectives. 

So where does this get us? Well, back to my frequent call for openness and transparency in decision making, which I have emphasised in our Covid-related ARC work on health prioritisation (see my blog Covid-19: The reality of ‘opportunity costs’ will need to be debated openly). This is because even the best experts can be wrong sometimes and we must accept that evidence (and data) inform and do not determine policy. This debate – fuelled by Dominic Cummings referring to the “smoking ruin” of the Department of Health and Social Care in his recent attendance at the All Party Science and Technology Committee – has caused a resurgence of calls for a review of pandemic decision making.

This is something that Virchow would have approved of. He said:

Knowledge which is unable to support action is not genuine – and how unsure is activity without understanding... If medicine is to fulfil her great task, then she must enter the political and social life... The physicians are the natural attorneys of the poor, and the social problems should largely be solved by them

Rudolf Virchow, a 19th century German physician and politician

Too soon for such a review we hear the government say. This reminds me of the words of Martin Buxton, Professor of Health Economics at Brunel University when asked when is the best time to assess health interventions: “It is always too soon to evaluate until it is too late,” he said. Tuesday 23 March was the anniversary of the first lockdown and resulted in a national reflection on what the last year has meant to us all, including what could have been done differently. 

Why not have a series of defined, targeted, issue-specific reviews to inform our immediate future practice? You could, for example, examine the disruptive nature of politicians constantly creating new public health institutions (see my blog, The blame game has started: the downgrading of Public Health England). Ironically, the new Institute for Health Protection created in August 2020 by the government has already been disbanded and a new institution, the UK Health Security Agency has been announced this week

This careful scrutiny could help prepare us for the “bumps and twists on the road, possibly including the emergence of more new variants” that England's chief medical officer Professor Chris Whitty warned is facing us now. This would be better than the promise of an all-encompassing review that might take years, and which may never come to definite conclusions, and even if it did, might be too late for the next pandemic.