Thursday 29 April 2021

Covid-19 & Vitamin D: There is no African Paradox

There is no African Paradox

A paradox is an observation that does not fit into the world as we understand it. It is the departure from a paradigm, the accepted wisdom of the way in which the world works.

But a paradox is the stimulus for change. If the paradox is true then it means that the paradigm must change: our understanding of the way the world works must also change. This is the way that science progresses, in big leaps but not very often.

The example of combustion

The memorable example from the wonderful Age of Enlightenment concerns the understanding of combustion. The paradigm of the time was that the process of combustion involved the release of Phlogiston from the burning substance as heat and light. Phlogiston was regard as a natural component of all substances. This paradigm had worked well and everyone was happy, until Joseph Priestley in Yorkshire, UK, and independently Antoine Lavoisier in Paris, investigated combustion from the scientific viewpoint. Science means measurement, and they studied the weights of solids and the volumes of gases. They demonstrated that the products of combustion of a metallic element had a greater mass that the original. If combustion was the loss of phlogiston, how could mass increase? It was suggested that phlogiston might have negative weight, but stretched credibility too far even at that time. 

They also noted that when combustion occurred and the weight of the solid increased, the volume of the enclosed air decreased. This was logically the result of consumption of a component of the air, what became known as oxygen (initially called "dephlogisticated air"). Priestley was reluctant to abandon the phlogiston hypothesis but Lavoisier was much more open-minded: the paradigm of combustion changed from phlogiston to oxygenation.

Joseph Priestley 1733–1804

Antoine Lavoisier 1743–1794

It was the careful and measurable observation of weight gain (and loss of volume of air) during combustion that was the paradox that changed the paradigm. This was a very big leap in understanding.

I emphasise "observation", because it is an important process that has been denigrated during the course of the Covid-19 pandemic in respect of the importance of vitamin D.

The "African Paradox"

I recently came across and read a paper entitled "Covid-19 pandemic: the African paradox", in what appeared at first sight to be a reputable journal, the Journal of Global Health.

This paper noted the very low levels of deaths from Covid-19 in Equatorial Africa compared to the temperate zone countries. It tried to explain this phenomenon in a number of unconvincing ways.

The obvious factor of geography was discussed, in relationship to temperature and humidity. However there was no consideration of sun exposure and vitamin D production. It was noted that the risk of Covid-19 death was less at higher altitudes, but no mention was made of greater sun intensity with altitude. I assume that the investigators were completely ignorant of the fundamental importance of the Sun and vitamin D in defensive immunity.

Covid-19 deaths per million population in equatorial African countries,
and also UK, USA, and India for comparison.

The logic is this. A man of ethnic black African origin, perhaps from Uganda but living in the UK has a risk of death from Covid-19 even higher than ethnic white people, with the national average 1,870 per million population. But a man ethnically and presumably genetically the same, perhaps his brother, but living in Uganda would face a risk of Covid-19 death of only 7 per million. This is dramatic and requires an explanation. It is not skin colour that determines the so-called African paradox.

It has been stated in a UK Biobank study, see previous Blog post, that ethnic black African people living in the UK have a high death rate from Covid-19 because they are black. And so the very low level of deaths in Uganda and other equatorial African nations compared to the very high levels in the UK, cannot be explained on the basis of skin colour. On this basis they should have the same death rates.

Another recent paper has investigated the same pattern. It identifies that the incidence of Covid-19 is greater between latitudes 30 and 50 degrees north of the Equator that in the tropics. Air temperature and humidity are discussed but as usual there is no mention of the Sun and vitamin D.

Why are Covid-19 death rates so low in equatorial Africa? This is the alleged paradox: is the understanding wrong?  Of course it is. There is a failure to understand some fundamental aspects of geography and human biology. The obvious difference is the country of residence with major differences in sunlight intensity. 

The difference could be the result of much greater socio-economic deprivation in the UK and USA compared to all Equatorial African countries, but like the phlogiston theory, it stretches comprehension too far. The difference is most obviously the result of vitamin D deficiency in the UK as the result of geography and the position of the UK closer to the North Pole than to the Equator..

The tilt of the Earth on its axis determines that in the UK, the vitamin D production season is of only six months duration, but at the equator the season is the full twelve months. However in early August 2020 the Covid-19 deaths in the UK were in single figures, about the same as in equatorial African countries all the year round.

The vitamin D production season in the UK

It is not just the comparison between deaths in equatorial Africa compared to temperate zone countries that require explanation, but also why there has been such a dramatic seasonal variation in the temperate countries only. Surely something to do with the sun.

Why is the importance of the Sun and vitamin D continually ignored when it is so obvious? Could correction of widespread vitamin D deficiency lead to UK health patterns in the winter to be the sam as the summer? Here is a huge opportunity for research, but apart from in the virus and vaccine laboratories, clinical research in the UK seems to be asleep.

Natural evolution

It does not take a high level of education to observe the difference between a December day in the UK at 53 degrees north of the equator, and the same day in Uganda which is on the equator. The difference is the light and heat, the results of intensity of the Sun determined by the elevation of the Sun above the horizon. 

In the tropics it is summer all the year round, and the elevation of the Sun means that vitamin D can be produced in the skin on every day of the year. This is where evolution led to the appearance Homo sapiens. The great apes have mainly white skin, but extensive body hair protects the skin from the damaging effects of UV from the Sun. Homo sapiens evolved with very little body hair but with a melanin pigment-rich skin to protect against solar UV. It was still possible for vitamin D to be produced from 7-dehydro-cholesterol in the skin in adequate amounts. 

Studies of the Maasai tribesmen in East Africa have shown them to have an average blood vitamin D level of about 40ng/ml, 100nmol/L. This can be regarded as the ideal as determined by natural evolution. Experience during the Covid-19 pandemic has confirmed that this is ideal, with critical illness and death being extremely rare at and above this blood level. 

Migration and Latitude

When living in tropical or semi-tropical countries there is an evolutionary advantage of a protective melanin-rich skin. UV from the sun can be very damaging and protection by nature's sunscreen is essential. Although melanin blocks most UV penetration into the skin, adequate blood levels of vitamin D will be produced unless there is extensive covering with clothes. Most of the time spent indoors during the hours of daylight is characteristic of a significant part of the populations, mainly as a result of a move from an agricultural to an office working environment. This can also lead to vitamin D deficiency, There is also the influence of modesty of dress, amplified by religious rules.

Migration of humankind from Africa into northern Europe created an environment in which the summer is short and the sun is relatively low in the sky, with reduced intensity. For people with melanin-rich skin, vitamin D deficiency became very likely with health consequences. Evolution in Europe during thousands of years selected a white skin to have a biological and survival advantage because of better production of vitamin D.

The sub-optimal immunity caused by vitamin D deficiency is a survival disadvantage, but mainly in the older population, and this would not have an influence on the extinction of dark-skinned humans who might have migrated to Northern Europe. However during recent years childhood rickets due to severe vitamin D deficiency (previously a characteristic of the industrial revolution) has been seen in children of parents who had moved to the UK from tropical Africa and the West Indies, and also from South Asia. Rickets is characterised by soft bones, and a result is compression of the pelvic outlet. This can have a devastating effect on young adult females as it will result in obstructed labour, with death of both mother and child in the absence of the advanced maternity care (especially Caesarian section) that we have today. The end of successful reproduction would indeed lead to extinction of those with a high incidence of serious vitamin D deficiency in childhood.

Migration in the 20th and 21st centuries

The rapid transmigration of many people from tropical Africa, the West Indies, and South Asia during the years since 1950 has brought to attention the health disadvantage of a melanin-rich skin when living closer to the North Pole than to the Equator.

This has been well-established during these years, but I am both amazed and saddened that the knowledge of it is not wide-spread, even among doctors and other health workers. A higher than average death rate from Covid-19 was completely predictable at the onset of the pandemic and was obvious during its first few weeks. But the importance of vitamin D deficiency in their deaths has been consistently denied.

The UK Standing Advisory Group on Emergencies (SAGE) is supposed to be composed of the best brains in the nation, but that might not be the case. A comment by SAGE appeared in the national press.

It is beyond belief that SAGE could have come to such a conclusion.  I have mentioned in previous posts that 24 out of 25 (96%) of working doctors in the UK who died from Covid-19 between March 23rd and May 2nd 2020 were of Black African or South Asian ethnicity. How has this escaped the attention of national bodies composed of allegedly clever people? If there is a paradox, this is it. To regard vitamin D deficiency as just a "rumour" for excess deaths from Covid-19 among BAME people is an insult, in particular to the 24 ethnic Black African and South Asian doctors who died while working during the pandemic (an additional one was ethnic white). The attitude of SAGE is a disgrace, and I hope that an apology will be forthcoming.

Three UK national committees reported on the high Covid-19 death rate among the ethnic Black African and South Asian groups but failed to mention the deaths of doctors or to consider vitamin D. This failure has led to the deaths of many people. I hope for even more apologies in the near future.

These reports did not mention the African non-paradox. When trying to reach an important conclusion, it is essential to to use all possible evidence, but this sound advice was not followed. This process is clear from a court of law where evidence must not be with-held, and it should be the same in health issues. However a report, or even alleged "proof", is never a final judgment. As the great economist John Maynard Keynes stated: "When the evidence changes, I change my mind. What do you do, Sir?" 

The past year has seen an enormous amount of evidence to support the correction of vitamin D deficiency in our defence against Covid-19, but government advisors have shown no sign of absorbing this evidence. If only they would listen to the wisdom of Keynes.

The African experience is not a paradox. It shows the importance of the Sun and vitamin D, and it amplifies the serious disadvantage of ethnic African people living in the UK without taking vitamin D to correct an inevitable deficiency. 

Ethnic minorities from Africa, the West Indies, and South Asia living in the UK and other temperate zone countries have been failed very seriously by public health authorities by their ignoring of critically important evidence. These ethnic minorities should all be taking vitamin D, and the ideal time to check for deficiency is during pregnancy.

No child should be born vitamin D deficient. 

No-one should die from Covid-19 when vitamin D deficient. 



Wednesday 14 April 2021

Covid-19 & Vitamin D: One year after the onset

We have experienced a year of the Covid-19 pandemic. and now in the UK it is looking very different.

Figure 1. UK: Covid-19 deaths each day, from March 20th 2020

On March 10th 2020 the WHO declared a pandemic of Covid-19. It was on March 20th that the pandemic became real in the UK. Deaths had risen to about 50 per day. On March 23rd there had been a total of 258 deaths, and something had to be done. That something was "lockdown", intended to reduce spread of the respiratory virus. Face masks must be worn in public places, and there was to be social distancing with a minimum of two metres between individuals. People could not visit each other's houses. The residents of homes for the elderly or seriously disabled could not be visited by their families. Public events such as concerts and worship were stopped. Universities were closed and then schools. Holidays were cancelled. Elective admissions to hospital for surgery were cancelled. Many workplaces were closed and air travel virtually came to an end. Public transport was  strongly discouraged and the roads were very quiet.

These were physical methods to try to reduce transmission, but respiratory viruses are notoriously difficult to control. Deaths increased to almost 1,000 per day during the following month. We had no natural immunity and our vitamin D reserves were at the lowest part of the annual cycle. It is much easier to control micro-organisms that are transmitted in contaminated water or food, or contagious diseases that are transmitted by direct contact (touch). Air transmission is not visible and not easily controlled. 

The introduction of lockdown was not based on evidence as it had never been attempted previously, at least not on a large scale. It seemed to be sensible, given the very limited understanding by the government of the nature of the pandemic. We subsequently entered the summer recess of Covid-19 illness and death during the "vitamin D immunity season". Later in the year when we moved into the "vitamin D deficiency season", further lockdown measures were introduced. 

It is easy to say that the deaths would have been even higher without lockdown, but we must remember that the UK had about the highest death rate from Covid-19 at that time. Since then the UK has been overtaken by nine European nations with higher numbers of deaths per million.

Figure 2. Covid-19 deaths per million, in European and American nations

Figure 2 illustrates the 38 nations of the world with more that 1,000 Covid-19 deaths per million. Most are in Europe, with 9 in the Americas. Some of the nations in Europe are very small, Gibraltar, San Marino, and Andorra in particular.

From late April the daily deaths declined in the UK and other northern hemisphere nations, and this coincided with increasing sun energy each day at sea level, and therefore increasing vitamin D production. It can be said that the weather was warmer but humankind is isothermal. We maintain constant body temperature but the average blood level of vitamin D is much greater in the summer than in the winter. The winter–summer pattern of illness is the same in all temperate zone countries, no matter what the ambient temperature. Vitamin D activates defensive immunity and so it is to be expected that the number of deaths from respiratory infections will reduce during the summer, as happens every year. There are in practice two seasons to the year: the vitamin D immunity season, and the vitamin D deficiency season. This is very obvious in Figure 3, which illustrates the effect of the sun and vitamin D production. 

Figure 3. UK: Covid-19 deaths each day, from March 20th 2020

The decline in case and death numbers continued into the summer as vitamin D production increased, and blood levels of 25(OH)D, calcifediol, the reserve supply also increased. And then of course, as reserves fell when we entered the vitamin D deficiency season, deaths form Covid-19 increased again.

It is interesting to note that we were warned early in 2020 that it would become so much worse in the autumn as there would be an additive effect of the influenza virus. This showed a fundamental lack of medical education, a phenomenon that I learned when I was at Manchester University in 1964. Observation (that important scientific process that in 2020 was rejected in respect of vitamin D) demonstrated that simultaneous virus infections generally do not occur. A virus is greedy: it does not want to share the infection with a competitor. Covid-19 had an advantage in 2020 in that the human host had not encountered it previously and therefore humankind had no immunity. Covid-19 rapidly established respiratory infection, and in the usual way it programmed its infected cells to produce Interferon. This prevented infection by other viruses. 

And that is what happened: during the autumn of 2020 the usual  winter viruses failed to appear. There was just Covid-19. 

The increased case and death rate up to the end of 2020 was as expected, but in January there was a sudden peak that has not really been explained. It is shown in Figure 3. Although mutations appear, we were not told of a mutation that would create up to 2,000 deaths per day in January 2021. Many mutations have been described but this is inevitable and there does not seem to have been a rogue mutation. Of course natural immunity optimised by vitamin D would provide defence against all mutations. The reason for the January peak, "the third wave", remains unexplained. 

This phenemenon was seen in some other European countries, but not in all. It was obvious in Ireland and Spain. This peak, or wave, settled rapidly at the end of January in the UK and these other countries. 

Figure 4. Ireland: Covid -19 deaths 2021, showing the January peak (data incomplete).

Figure 5. Spain: Covid -19 deaths 2021, showing the January peak (data incomplete).

Andalucía in Spain is particular interesting. When the second wave of Covid-19 was very active in October and November, the regional government introduced in November a policy of providing vitamin D in the activated form calcifediol, 25(OH)D, to elderly people. This policy was followed by a dramatic reduction of deaths during December, which I referred to as the "Andalucía miracle" whether the result of intervention by vitamin D or by God. At the end of December vaccine provision was added to the vitamin D initiative. 

Figure 6. Andalucía: Covid -19 deaths 2020-21, showing the three peaks.

But as we can seen in Figure 6, in January the decrease in deaths was suddenly reversed. There was a rapid increase in cases, hospital admission, and deaths from Covid-19. A third peak was reached and then a rapid decline, that is very obvious from daily numbers.

After one of the highest Covid-19 death rates in the world, the UK now finds itself in an excellent position.  The UK now appears to be close to the end of the pandemic. 

Figure 7. UK: Covid -19 cases per day March-April 2020 & 2021

The very low number of death each day now, in early April 2021, is very different what was happening this time a year ago. The trajectory is downwards in 2021.

Figure 8. UK: Covid -19 deaths each day March-April, 2020 & 2021

The difference from 2020 to 2021 is the result of a high level of herd immunity within the nation. It is not that the virus has "gone away", as viruses do not go away. The clinical effects of the virus might "go away" but this is because of herd immunity. It has always been the same.

A recent report (March 30th 2021) from the Office of National Statistics (ONS) informs us that more than half the population have antibodies to Covid-19. How many of these had an illness and how many had received the vaccine were not disclosed. About half the population had received a vaccine during the very extensive vaccination programme, and the number taking vitamin D had increased greatly, but without any national counting. It is suggested that vitamin D consumption has increased by a factor of perhaps 13. On the day of the ONS report Morrison's Supermarket had sold out and further supplies were only on order.

There continues with no official mention of vitamin D. There has been the accumulation of a great deal of knowledge concerning the extent of vitamin D deficiency and the great disadvantage of this when ill with Covid-19, with high risk of critical illness or death. But clinical medicine in the UK remains silent. An as yet unpublished study from Tameside, UK, indicates that 70% of individual doctors would take, prescribe, and advise vitamin D, but this was part of a large grass-roots movement, not officially sanctioned and not measured.

There has been a reduction on the number of Covid-19 cases and deaths in many European countries, but none as dramatic as the UK. The UK has a higher rate of vaccinations than other countries. I display in the figures the deaths per day, but the "cases" (less easily defined) show the same patterns but with larger numbers. The nations are not complete but those that have interested me during the past year.

Figure 9. Switzerland: Covid -19 deaths 2021, showing the January peak 
and subsequent decline

Figure 10. Austria: Covid -19 deaths 2021, showing the January peak 
and subsequent but incomplete decline

Figure 11. Germany: Covid -19 deaths 2021, showing the January peak 
and subsequent decline

Figure 12. Netherlands: Covid -19 deaths 2021, showing the January peak 
and subsequent decline

However the decline is not yet apparent in some other European countries. 

Figure 13. France: Covid -19 deaths 2021 (data incomplete)

Figure 14. Belgium: Covid -19 deaths 2021 

Figure 15. Italy: Covid -19 deaths 2021 

Figure 16. Sweden: Covid -19 deaths 2021 (data incomplete, numbers are very low)

Figure 17. Poland: Covid -19 deaths 2021 

These are examples of the experience of several European countries but not all. Some are approaching the end of the pandemic, and it is hoped that the others will follow shortly. 

It can be anticipated that during May 2021, as in May 2020, cases and death numbers will fall thought the vitamin D production season. If there is widespread immunity, the increase in the winter will be minimal.

Deaths have also been falling in North America.

Figure 18, Canada: Covid -19 deaths 2021 

Figure 19. USA: Covid -19 deaths 2021 

What has been happening in tropical countries will be the subject of  future post.