COVID-19
does discriminate. It is prejudiced against the elderly and infirm, against ethnic minorities and those who live in deprivation and with illness. This is not simply a pandemic of clinical infection but of social injustice.
Devolved Scotland is a public health pioneer: the first in the UK to insist on nutritional standards for school meals, ban smoking in public places and set a minimum unit price for alcohol. It has sought to level life's playing field with free personal care, prescriptions and university tuition and taken stout action to protect the marginalised in society. But COVID-19 respects none of it. In the teeth of this pandemic, the Scottish Government is ploughing ahead with a bill to extend hate crime legislation to cover discrimination against the elderly. Meanwhile, coronavirus is ripping through our care homes.
If ministers are serious about stamping out prejudice, they must confront it wherever it is found and no matter what guise it takes. And so Nicola Sturgeon and Health Secretary Jeane Freeman must surely be wondering what it is that similar-sized nations Norway, Finland and New Zealand have done to minimise the damage wreaked by COVID-19. Between them, these countries have seen a little over 550 deaths while Scotland has suffered more than 3,500. They do not all share the same latitudes or lockdowns, but there is one thing they do have in common: vitamin D.
Finland has fought aggressively to eradicate the scourge of vitamin D deficiency from its society with fortification of dairy products and public health campaigns to encourage the taking of supplements. Norway has done something similar alongside a traditional diet rich in oily fish. In March, when the pandemic hit, New Zealand was just emerging from its summer when – in common with Nordic countries – only 1% of the population is short of what it needs. Compare that figure to Scotland's as we emerged from our winter: 54%, at the last official count.
There is now a grim pattern across the Western world where those in care homes, in BAME communities and the poor are dying in greater numbers from COVID-19. And it's these parts of society that also have the worst levels of vitamin D deficiency.
There is a wood in front of us, but are the trees perhaps obscuring our view? In 1847, Ignaz Semmelweis – a Hungarian doctor on a maternity ward at Vienna General Hospital – thought the unthinkable. He wondered whether new mothers were dying there in great numbers from gruesome childbed fever because doctors delivering their babies were not washing their hands. His experiments in basic hygiene cut mortality by 90%, but he was frozen out by medical orthodoxy and died insane in an asylum. How ironic that we now employ Semmelweis' self-evident wisdom as the most basic cornerstone of our response to COVID-19.
At the same time, another epidemiological deviant was at work in London. Using nothing more than observation, John Snow worked out that the lethal cholera outbreak in his neighbourhood was not caused by foul vapours emanating from the earth – the mythical miasma propounded by eminent scientists – but a water pump on Broad Street dispensing filthy supplies. His deduction has virtually wiped out the disease in the developed world.
Meanwhile, here in Edinburgh, Henry Littlejohn was given the task of rooting out the misery caused by typhoid, smallpox and cholera amid the foul fug and filth of Auld Reekie's labyrinthine Old Town. He was an establishment medical man to his boots – but he refused to dwell upon the niceties of blind randomisation and placebo controls and instead set about tearing down the squalid slums and ripping out the open sewers that had become the cursed birthright of the poor.
His groundbreaking
Report on the Sanitary Condition of the City of Edinburgh of 1865, states: 'No drain could be remedied, no cesspool cleaned, no midden removed, had we to delay our operations until we could prove that the existence of the special nuisances was detrimental to health... I am convinced that, like all other means tending to improve the health of the people, the good results will be apparent in a diminished mortality'.
Sure enough, within 20 years, he had slashed Edinburgh's death rates by over 40% to the lowest level of any major Western city. Yet it's 3,000 miles away that we may find the most significant lesson for our times, in the musings of Henry Ingersoll Bowditch MD, who was grappling with the tuberculosis outbreaks that regularly cut swathes through 19th-century New England. Long before vitamin D was 'discovered' and antibiotics were born, he noticed that those deprived of natural light or living in damp conditions were more likely to catch the deadly lung disease – but that they often quickly recovered when exposed to sunshine.
Bowditch cited the case of two healthy brothers who married two healthy sisters and both raised large families in the same Massachusetts village. The younger sibling lived in a house 'bathed all day long in sunlight, and consumption [TB] did not touch any of the young lives under its roof'. However, the elder brother's home was on 'a grassy plain, covered all summer with the rankest verdure [and] enclosed by lofty hills. The life-giving sun rose later and set earlier'. All his children died.
'We see the evil influence on man caused by absence of the sun's rays,' wrote Bowditch in 1869, 'in the pallid and emaciated forms of many of the children of the poor, particularly of those living where the direct sunlight cannot enter... The unfortunate invalid quietly stays within doors day after day… Nothing is more pernicious, no behaviour more unwise.
Whenever in doubt, we say to our patients about going out,
always go out. Sunlight has a potent influence in raising the human body from various weaknesses that sometimes are the precursors of fatal phthisis [TB]'.
Here, then, is a doctor 150 years ago, troubled at how the authorities are seemingly missing the obvious when it comes to eradicating an epidemic of a voracious lung disease. The parallels are spine-tingling. Yes, Bowditch also railed against sloth and poor diet, damp cellars and sedentary occupations, but, time and again, he returned to a familiar theme. Urging new planning regulations, he implored: 'Build your houses in the country… choose a slope where the sun can have full access to it, if possible, all the day… Nothing but evil comes from too much shade'. Science has finally caught up with him.
In the 21st century, we now understand how sun on the skin – or, in its absence, regular portions of oily fish, egg yolk or supplements – replenishes the body's stocks of vitamin D. We also know that severe cases of TB are often linked to deficiency of this crucial hormone. Just as with COVID-19, death often follows 'cytokine storm', a frenzied immune response in weakened patients that damages lungs and other major organs as they struggle to breathe. Healthy levels of vitamin D have been shown to calm the 'storm' and there is evidence that they help prevent respiratory infections in the first place too. Incredibly stark data is now emerging from southern Asian hospitals in which 96% of COVID-19 patients with sufficiency live and 99% of those deficient die.
We know that obesity is a significant risk factor – and that obesity steals away vitamin D and locks it up in fat tissue. We know that COVID-19 selects by ethnicity – and that darker skin types do not synthesise this nutrient from sunlight at the same rate as lighter types. And we also know that, paradoxically, deficiency is rife in sunny Italy and Spain, where complacent governments failed to promote vitamin D, even as their populations became increasingly elderly and housebound.
A second wave of COVID-19 may arrive in the UK this winter. There are those who say that health strategies must wait until we have the results of randomised trials that could take years to complete – but where is this 'gold standard' proof for social distancing or the wearing of face masks? Semmelweis and Snow, Littlejohn and Bowditch, they are lionised today because they did not wait to act on the truth they observed with their own eyes.
An effective vaccination may be many months away yet – if one arrives at all – and there is no guarantee of a 'silver bullet' of any kind to defeat this disease. But, even without a clinical cure or inoculation, the data and the impending summer season are screaming at us to be bold.
There is a public health intervention available to us that – in the finest Scottish traditions – is about attacking inequality in society and, in doing so, perhaps preventing the worst ravages of COVID-19. A simple but urgent manifesto could save countless lives across Scotland and – if a beacon for others – the rest of the UK and further afield too.
• Free vitamin D supplements for high-risk groups and frontline NHS and care staff.
• Public health campaigns around daily sunshine requirements, supplements and vitamin D-rich meals.
• Collaboration with the food industry to provide increased demand for and supply of price-discounted vitamin D-fortified products including bread and milk.
• Research to track vitamin D levels and COVID-19 infection and death rates, especially among high-risk groups.
The logistical networks currently being built by government and the NHS provide a now-or-never opportunity to implement these measures swiftly and at minimal cost.
What have we to lose? If all these data and all these established biological pathways prove to be wrong and it transpires that vitamin D actually has no positive impact on COVID-19, the worst-case scenario is that Scotland emerges with a slightly healthier general population. However, if they are correct, the prize is beyond worth.
Astonishingly prescient, the words of Bowditch echo down the ages for those willing to listen: 'It is the duty of our law-makers to take some action in regard to the health of the people of the Commonwealth... It is better, and, moreover, in the end it is much cheaper, to prepare for and prevent evils, than to wait till they have grown to huge dimensions which by their very bulk may present almost inseparable obstacles to a radical cure of them'.
On so many levels, we need the sunshine back in our lives. It's time for Scotland to throw open the windows.
