This week we talk about the liver, viral infections, and the NHS.
We also discuss blood scandals, needle usage, and Nobel Prizes.
Recommended Book: A World Appears by Michael Pollan
Transcript
The term “hepatitis” refers to the inflammation of the liver, which can result from all kinds of things, including environmental toxins, the consumption of alcohol, or autoimmune diseases. It can also result from viral infections, and the most prominent liver-inflaming viruses are called viral hepatitis.
There are five types of viral hepatitis, A, B, C, D, and E, and each of these viruses are distinct, not part of the same viral family, they’re just similarly named because they impact the same organ.
Hepatitis A and E are primarily spread through contaminated food and water, and generally resolve on their own, untreated, and cause relatively mild symptoms. Hepatitis B and C are spread through blood and other bodily fluids, and can linger in a host’s body for decades before even showing symptoms. Hepatitis D is a parasite of Hepatitis B, and thus only infects people who carry Hepatitis B.
Now again, these are all different conditions that just happen to inflame the liver, so impact and treatment also vary quite a lot. As I mentioned, A and E generally present with mild symptoms and tend to go away on their own, while B and C can stick around a long time. There’s a vaccine for B, but no cure; you can treat it, but that treatment involves suppressing it, and keeping it suppressed, forever. Hep C, in contrast, is curable, and has been since 2014 using what are called direct-acting antiviral pills, but these pills, which are taken for 8 to 12 weeks, are expensive—ranging from $22-95k without insurance, though that price is often reduced substantially for those with insurance, down to as low as $5. This category of drug coverage is often rejected by insurance companies, though, in part because they’re so expensive, that expense the result of little competition in this space; few companies make this type of drug, so those that do can charge more or less whatever they like.
Some people with Hepatitis C clear it on their own; about 30% of people who contract it, in fact, clear it within a few months, medication-free. Which is good, because our understanding of this virus is relatively new. Up until 1989, Hep C didn’t even have its own name: it was established as its own thing, not Hep A and not Hep B, back in the 1970s, and doctors knew that something that wasn’t those two viruses, that was being spread by transfusions, was causing hepatitis symptoms, but they didn’t know any real specifics, so they just called it “non-A, non-B hepatitis,” and that name stuck for more than a decade.
In 1989 the virus was cloned using molecular techniques (as opposed to simply growing the virus, which wasn’t proving fruitful in trying to isolate and identify the thing), and the folks who managed that cloning, and the person who later proved that the genome they cloned, alone, caused the disease, received a Nobel Prize in Medicine for their efforts in 2020.
By 1991, antibody tests were available for Hep C, and many countries began screening donated blood for this virus, to ensure it wasn’t working its way into their blood supply.
And one instance of that screening process, or I suppose, an event that led up to mass screening, and the consequences that followed, are what I’d like to talk about today. The UK’s efforts in trying to eliminate Hep C, and England’s recently announced near-success in that pursuit.
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Hepatitis C is an RNA virus with high genetic variability that makes developing a reliable vaccine difficult. And though somewhere between a quarter and a third of all cases clear on their own, those that don’t clear on their own become chronic, lying in wait for twenty to thirty years, slowly accumulating fibrosis—thick scar tissue in the liver—which eventually results in cirrhosis, which means a liver that’s so heavily scarred that the organ is no longer fully functional and the damage is permanent. From there, infected people often experience liver failure or hepatocellular (huh-pah-toe) carcinoma, liver cancer.
So this virus is a sleeper, and unless it’s caught by accident somewhere along the way, it slowly causes damage over time until the damage is too severe to reverse. About 80% of people who have it don’t know they have it, and in some parts of the world medical injections are the most common transmitter, but in higher-income areas, it’s usually transmitted by injectable drugs.
Pre-2014 treatments for Hep C were pretty horrible, involving a combination antiviral therapy called pegylated interferon plus ribavirin that was injected weekly for six months to a year, and this was terribly tolerated by pretty much everyone, causing anemia, depression, and flu-like symptoms for the duration. It also only cured about 50% of people who received the full treatment, and a lot of people had to stop because it caused such ridiculous side effects.
Another antiviral called Sofosbuvir (so-FAS-buh-vir), which kept Hep C from replicating in its host, hit the market in late-2013, and that led to a series of direct-acting antivirals that reduced the treatment period dramatically, allowing most people, 95%, to cure their Hep C entirely by taking generally well-tolerated pills for 8 to 12 weeks.
These pills were staggeringly expensive from the get-go, with an entire treatment course initially costing about $84,000, or $1,000 a pill. This led to rationing, and saving these pills for the worst-impacted people who already had severe liver damage. There were also pretty stringent requirements attached to their distribution, including that people who received them could no longer drink alcohol, because it was considered a waste to give these crazy expensive, liver-saving drugs to people who would just go and hurt their liver more, anyway.
In the UK, the demand for this treatment type was different than in most other countries, in large part because of something that happened back in the 1970s and 80s.
The UK’s publicly funded healthcare system, the NHS, was in the midst of a shortage of clotting factor, which are plasma proteins and ions that help blood clot and which are used for medical purposes. So they imported a bunch of plasma products from the US, and those products were sourced from the blood of paid donors—and that donor pool included prisoners and people who used injectable drugs. Just one Hep C contaminated blood donation could contaminate an entire batch of blood, and remember, they only started screening the blood supply for Hep C in 1991, and they didn’t start treating their blood supply for Hep C until a little before that, 1985, so this was well before they had any idea what was in those blood products they were importing and administering.
Consequently, between 1970 and the early 1990s, more than 30,000 NHS patients received transfusions or other blood product treatments contaminated with Hep B, Hep C, or HIV, and about a tenth of those people, around 3,000 patients, have since died of those conditions.
The UK government leaned on denial and a refusal to look into the details of this for years, but in 2017 it announced an independent public inquiry into the matter, and in May of 2024, that inquiry concluded that this whole scandal was avoidable, that patients were knowingly exposed to “unacceptable risks,” and that there was a big cover up by government officials, doctors, and other people working with the NHS.
As of mid-2026, only a little over 3,200 people of the more than 18,500 who registered claims, demanding compensation from the government because they were impacted by this scandal, have been paid out. The expected total expense for the UK government is on the order of 12.8 billion pounds, but a lot of people who are probably due a payout, and who are in poor and deteriorating health as a consequence of all this, don’t yet have a sense of when they’ll receive their payment.
Back in 2016, before all that came to a head, the UK set itself an aggressive goal: to eliminate Hep C by the WHO’s 2030 target, or before. It then ran a competitive tender for antivirals, inviting medical suppliers to submit competing bids, resulting in the largest single medicine procurement program in the NHS’ history. The pharmaceutical companies that won their bids were also obliged, as part of the agreement, to help fund efforts to identify undiagnosed but infected patients, in addition to supplying antiviral pills, and this combination of investment and application led to the deployment of new tests and scanning machines, free postal test kits, the hiring of specialists, and services that focused on prisons and drug users.
The impact of all this has been significant: a more than 61% decline in infections from 2015 to 2024, nearly half of all drug users with Hep C had cleared the virus in that time, and deaths from Hep C are down 36% over the past decade.
The WHO treatment-coverage target—the percentage of people who are diagnosed getting treatment—was 80%, and England has hit 81.5%, which was recently announced to much fanfare. It hasn’t yet hit the diagnosis target, however, which is to diagnose 90% of people who are estimated to have Hep C; they’ve hit 84.6%, which is still quite a lot of progress, even if they’re not yet where they’d like to be. That’s all based on models, of course, as are the assumed number of infections among people who use injectable drugs, which is also a spot where England is currently flagging; there’s no centralized system in England to monitor needle and syringe provisions, and reinfection rates are around 8.8 per 100 person-years among people who had injected within three years of receiving treatment, and that rate is even higher for people who have ever been to prison, around 9.4 per 100.
What that means in practice is that the English government overall has done a pretty astounding and effective job at negotiating their relationships with pharma companies and getting detection on track at that scale, but on more ground-level issues that are, interestingly, a lot cheaper to implement, but at times more politically complicated because of public sentiment about drug use and drug users, they’re doing a lot less well—and important to note here is that these outcomes vary a bit across the four programs being run across the UK. Scotland and Wales are doing relatively better and worse in some regards compared to England, for instance.
Also worth noting here that while England is broadly doing a great job with Hep C diagnosis and treatment, they aren’t the first to achieve those WHO-set goals: Egypt reached Gold tier status according to the WHO’s Hep C guidelines in October of 2023, at that point having diagnosed 87% of people who have the virus, and treating 93% of those who were diagnosed. They managed to cut incidence of the virus by 97% in just 8 years, leaning on a system of high-yield testing—they tested more than 60 million people during those 8 years—alongside a production scheme that included local manufacturing of antivirals, making them more available and affordable.
All of which are generally good signs about where Hep C testing and treatment is going, at least in these regions. And it paints a optimistic picture for other countries that might want to replicate some of what’s working within their own borders.
Show Notes
https://www.bbc.com/news/articles/c75gk620r22o
https://en.wikipedia.org/wiki/Infected_blood_scandal_in_the_United_Kingdom
https://en.wikipedia.org/wiki/Hepatitis_C
https://en.wikipedia.org/wiki/Viral_hepatitis
https://en.wikipedia.org/wiki/Hepatitis_B
https://www.healthline.com/health/hepatitis-c/treatment-costs
https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
https://publichealthscotland.scot/publications/surveillance-of-hepatitis-c-in-scotland/surveillance-of-hepatitis-c-in-scotland-progress-on-elimination-of-hepatitis-c-as-a-major-public-health-concern-2025-update/
https://www.emro.who.int/media/news/egypt-becomes-the-first-country-to-achieve-who-validation-on-the-path-to-elimination-of-hepatitis-c.html
https://www.gov.uk/government/publications/hepatitis-c-in-england-and-the-uk/hepatitis-c-in-england-2025
https://www.england.nhs.uk/2026/08/100000-people-receive-treatment-to-cure-deadly-hep-c-virus-on-nhs-in-just-ten-years/
https://www.hepctrust.org.uk/blog/2019/04/hepatitis-c-trust-welcomes-elimination-deal-hepatitis-c-and-calls-government-backed/
https://commonslibrary.parliament.uk/research-briefings/cbp-10099/
https://www.who.int/teams/global-hiv-hepatitis-and-stis-programmes/hepatitis/reports/global-hepatitis-report-2026
