I would like to thank and congratulate my colleague Chris Dowrick, for his contribution as guest editor for this extra edition of Rural Miscellany.

Chris is Professor of Primary Medical Care at Liverpool University. He describes himself as having: “a broad academic and clinical perspective, with particular interests in primary mental health care”
In addition to his university work he is a General Practitioner with Aintree Park Group Practice, Professorial Research Fellow with the Department of General Practice in the University of Melbourne, and Chair of the Wonca Working Party for Mental Health.
His recent books include:
‘Person-centred Primary Care: Searching for the Self’ Routledge 2018.
‘Global Primary Mental Health Care’ Routledge 2020
His contribution is on the English poet Gerard Manley Hopkins.

If you feel that you would like to host a special edition of Rural Miscellany, please let me know (john@johnwj.com). You will be very welcome.

Delight, despair and self-compassion:
The poetry of Gerard Manley Hopkins

Gerard Manley Hopkins was one of the most original poets writing in English during the 19th century. Throughout his life he experienced a range of intense emotions, from great joy to utter misery. And he has an astonishing ability to express his emotions in his poetry.
I’ve chosen six of Hopkins’ sonnets. The first, his own personal favourite, was composed in north Wales in 1877. The second was written in Liverpool in 1880, while he was working as a local priest. The next four are taken from his so-called ‘Terrible Sonnets’, written in Dublin in 1885 as he worked through a period of profound sadness.

First, share with me the pleasure of Hopkins’ own favourite poem, The Windhover:
I caught this morning morning’s minion, king-
dom of daylight’s dauphin, dapple-dawn-drawn Falcon, in his riding
Of the rolling level underneath him steady air, and striding
High there, how he rung upon the rein of a wimpling wing
In his ecstasy! then off, off forth on swing,
As a skate’s heel sweeps smooth on a bow-bend: the hurl and gliding
Rebuffed the big wind. My heart in hiding
Stirred for a bird, – the achieve of, the mastery of the thing!

Brute beauty and valour and act, oh, air, pride, plume, here
Buckle! AND the fire that breaks from thee then, a billion
Times told lovelier, more dangerous, O my chevalier!

No wonder of it: shéer plód makes plough down sillion
Shine, and blue-bleak embers, ah my dear,
Fall, gall themselves, and gash gold-vermilion.

This sonnet works best when you read it out loud. You’ll soon find you are flying with the falcon, up and down, barely taking a breath until the first full stop arrives, half way though line seven.
We can gain profound courage from this poem. The beauty and joy of the falcon, ecstatically riding the wind, infuses us with his energy. It prompts us to celebrate those moments in our own lives when we feel effortlessly magnificent and free.

Comfort of others
This poem is about the life and the death of a Liverpool blacksmith. He died
of pulmonary tuberculosis at the age of 31 – the average life expectancy in
Liverpool at that time.

Felix Randal the farrier, O is he dead then? my duty all ended,
Who have watched his mould of man, big-boned and hardy-handsome
Pining, pining, till time when reason rambled in it, and some
Fatal four disorders, fleshed there, all contended?
Sickness broke him. Impatient, he cursed at first, but mended
Being anointed and all; though a heavenlier heart began some
Months earlier, since I had our sweet reprieve and ransom
Tendered to him. Ah well, God rest him all road ever he offended!

This seeing the sick endears them to us, us too it endears.
My tongue had taught thee comfort, touch had quenched thy tears,
Thy tears that touched my heart, child, Felix, poor Felix Randal;
How far from then forethought of, all thy more boisterous years,
When thou at the random grim forge, powerful amidst peers,
Didst fettle for the great grey drayhorse his bright and battering sandal.

I find a very strong affinity with Hopkins throughout this poem. He wrote it just a few minutes’ walk from my University office. So it feels particularly real and tangible to me.
For me it resonates strongly with the real-world relationships I enjoy as a family doctor today, especially the mutual benefits that derive from his care of Felix as his death approaches: ‘This seeing the sick endears them to us, us too it endears’.

Here is Hopkins’ most desolate sonnet:

No worst, there is none. Pitched past pitch of grief,
More pangs will, schooled at forepangs, wilder ring.
Comforter, where, where is your comforting?
Mary, mother of us, where is your relief?
My cries heave, herds-long; huddle in a main, a chief-
Woe, wórld-sorrow; on an áge old anvil wince and sing –
Then lull, then leave off. Fury has shrieked ‘No ling-
ering! Let me be fell: force I must be brief’.

O the mind, mind has mountains; cliffs of fall
Frightful, sheer, no-man-fathomed. Hold them cheap
May who ne’er hung there. Nor does long our small
Durance deal with that steep or deep. Here! creep,
Wretch, under a comfort serves in a whirlwind: all
Life death does end and each day dies with sleep.
How could this dread-full poem ever be helpful to someone in the depths of despair?
First, it makes a connection for us. ‘It’s like finding a friend,’ a patient told me recently;’ I felt like he was sitting next to me, reading to me. It brings a closeness.’
Second, it can help us accept that it’s OK, it’s legitimate to feel so distressed – something we may often doubt or feel guilty about.

This next poem is also deeply troubling but does offer us a glimmer of light along the way.

I wake and feel the fell of dark, not day.
What hours, O what black hoürs we have spent
This night! what sights you, heart, saw; the ways you went!
And more must, in yet longer light’s delay.
With witness I speak this! But where I say
Hours I mean years, mean life. And my lament
Is cries countless, cried like dead letters sent
To dearest him that lives alas! away.

I am gall, I am heartburn. God’s most deep decree
Bitter would have me taste: my taste was me;
Bones built in me, flesh filled, blood brimmed the curse.
Selfyeast of spirit a dull dough sours. I see
The lost are like this, and their scourge to be
As I am mine, their sweating selves; but worse.

The main message Hopkins conveys to me in this poem is his dreadful sense of loss. And yet, there is an element of detachment. Despite his obvious distress, Hopkins is able to write perfectly formed classic sonnet lines. There is resonance again with mindfulness meditation – with the point at which we begin to create a space between ourselves and the pain and distress. Instead of being caught outside in the middle of a thunderstorm, we begin to watch the thunderstorm through a window.

The next poem is called Carrion Comfort.

Not, I’ll not, carrion comfort, Despair, not feast on thee;
Not untwist — slack they may be — these last strands of man
In me ór, most weary, cry I can no more. I can;
Can something, hope, wish day come, not choose not to be.
But ah, but O thou terrible, why wouldst thou rude on me
Thy wring-world right foot rock? lay a lionlimb against me? scan
With darksome devouring eyes my bruisèd bones? and fan,
O in turns of tempest, me heaped there; me frantic to avoid thee and flee?

Why? That my chaff might fly; my grain lie, sheer and clear.
Nay in all that toil, that coil, since (seems) I kissed the rod,
Hand rather, my heart lo! lapped strength, stole joy, would laugh, chéer.
Cheer whom though? the hero whose heaven-handling flung me, fóot tród
Me? or me that fought him? O which one? is it each one? That night, that year
Of now done darkness I wretch lay wrestling with (my God!) my God.

Let’s focus on the first four lines, which are all about thoughts of suicide. Hopkins is not just accepting his despair. Now has started to wrestle with it. He is not giving up, as we can see from his double negative ‘not choose not to be’. He can stay alive. He can hope.

Hopkins’ final poem is about comfort of the self.

My own heart let me more have pity on; let
Me live to my sad self hereafter kind,
Charitable; not live this tormented mind
With this tormented mind tormenting yet.
I cast for comfort I can no more get
By groping round my comfortless, than blind
Eyes in their dark can day or thirst can find
Thirst’s all-in-all in all a world of wet.

Soul, self; come, poor Jackself, I do advise
You, jaded, let be; call off thoughts awhile
Elsewhere; leave comfort root-room; let joy size
At God knows when to God knows what; whose smile
‘s not wrung, see you; unforeseen times rather — as skies
Betweenpie mountains — lights a lovely mile.

Hopkins is beginning to be gentler with his ‘sad self’, giving himself a break from his incessant internal critical chatter. It’s time to ‘call off thoughts awhile elsewhere’.
We can do the same. We can be compassionate to ourselves, have pity on our hearts. We can treat ourselves just as well as we treat our friends and the people we love. I love Hopkins’ phrase ‘leave comfort root-room’. It’s about giving ourselves permission and space for a sense of ease and well-being to set down roots and begin to grow.

Christopher Dowrick
Liverpool, October 2020


Sophie Redlin is a GP, expedition medic, mental health trainer and researcher currently based in London but actively looking for more rural opportunities! Her research interests lie in challenging the Western narrative around emotional distress and finding alternative and community-orientated approaches to supporting those suffering. In 2019 she was awarded a Winston Churchill fellowship to research indigenous attitudes towards mental health in the US and explore whether elements of traditional practices, such as talking circles, might be respectfully transferable to a Western population to serve as an alternative mental healthcare approach.

“Growing up with Schizophrenic twin uncles, I was aware from an early age that how an illness is viewed and managed directly influences both the patient’s and carer’s experience of it. My uncles were diagnosed at a time when both their condition and needs were poorly understood and initially little support was available other than their antipsychotic medication. However, with the progression of time and attitudes, their care became more holistic and carer-focused and as a consequence my family’s ability to cope increased exponentially. To this day my grandparents maintain that while they appreciate the 40 years of psychiatric care my uncles have received, the peer support they have experienced from a community group has been of equal if not higher value.

A number of years into my medical career while working as a GP Registrar in London, a distressed patient consulted with me three times in two weeks seeking advice around problems she was having with her housemates. Her story sat at the opposite end of the mental health spectrum to that of my uncles, her problems being more psychosocial perhaps than ‘medical’, but despite the differences I was struck by the thought that just like my uncles in the early years of their diagnosis, here was another person in distress who was about to be let down by the one-size-fits-all and largely ‘medicalised’ pathway of the Western mental healthcare model. As with so many patients presenting in this way, she fell somewhere between the approach of ‘doing nothing’ and the more ‘medicalised’ routes of pharmacological or psychological therapy and as her doctor working within a system that still largely neglects to address the underlying causes and contributors to distress, I had little to offer her other than myself.

Her story prompted me to take time out of training to explore the root causes and management of emotional distress worldwide. Time spent in the US, Norway, Japan and Orkney revealed the benefits of cohesive communities (often seen in more rural areas) in preventing and managing the escalation of distress and exposed me to practices such as talking circles, particularly within indigenous cultures, that helped to bridge the gap between healthcare and community by providing additional peer support and mentorship to those suffering.

After learning of the work of Dr Lewis Mehl-Madrona, a native Cherokee and Lakota physician and published author on the benefits of using talking circles within both native and non-native populations, I knew I needed to explore the practice of talking circles in more depth and explore whether elements of the indigenous talking circle might be respectfully transferred to a UK population to serve as an alternative and community-empowering approach to supporting those in distress.

With the support of a Winston Churchill fellowship, I was granted the incredible opportunity to do just that and in 2019 travelled to Maine, Alaska, Arizona and Hawaii to spend time with healers such as Lewis and participate in talking circles in a variety of settings.

My report, recently published, (https://www.wcmt.org.uk/fellows/reports/understanding-role-talking-circle-enhancing-well-being?fbclid=IwAR2MLJGu7fPnSrF7KDHtuyTAdR83JtZ1XlPe3Da6rLEHZxL_1B-h00P1i3Q) has been a labour of love and an attempt to put a truly transformative journey into words. I can’t thank the people I met along the way enough for what they have taught me, for the ways in which they have challenged my very core beliefs around healing and for the seeds they have planted which are now bearing the fruit of my own ideas going forwards.”

Today’s posts

1. International: The guardian: Hundreds of thousands with mental health conditions being chained, says charity
Adults and children are regularly shackled and locked up in 60 countries, report finds
Hundreds of thousands of people with mental health conditions in 60 countries are still being chained, according to a comprehensive and damning new study.
Human Rights Watch says that men, women and children – some as young as 10 – are regularly shackled or locked in confined spaces for weeks, months, and even years, across Asia, Africa, Europe, the Middle East, and the Americas.
The report, Living in Chains: Shackling of People with Psychosocial Disabilities Worldwide, examines how people with mental health conditions are often shackled against their will by families in their own homes or in overcrowded and unsanitary institutions because of widespread stigma and a lack of mental health services.
Many of those affected are forced to eat, sleep, urinate and defecate in the same tiny area. In state-run or private institutions, as well as traditional or religious healing centres, they are shackled for restraint or punishment and often forced to fast, take medications or herbal concoctions and face physical and sexual violence.

2. USA: NEJM: Editorial: The FDA and the Importance of Trust
As SARS-CoV-2 emerged, the global scientific community first studied the virus at the bench, then took what was learned to the bedside in the hope of helping patients, and later returned to the bench with observations from the bedside.1 Such a process has led to progress in the treatment and prevention of every important disease we have faced, including AIDS, cancer, and diabetes. In the case of SARS-CoV-2, the information we have gathered has increased our understanding of the biology of the virus, the diagnosis of the infection, the nature of the injury it causes, and potential therapies to treat it, but much is still unknown. In Covid-19, clinicians at the bedside continue to face an imperfectly understood disease that leads to tragic consequences for too many patients. Under enormous pressure to help patients while doing no harm, clinicians rely on the transparency of the scientific process and on the careful judgment of regulators who base their decisions on the best available scientific understanding of the disease.
Adequately sized and well-conducted randomized clinical trials are the foundation of evidence-based medicine, but they take time. As clinicians wait for trial data to emerge, they must often try available treatments without proof of their efficacy. This clinical urgency should not, however, be confused with knowledge of which treatment works and which has little value or may be harmful. Unbiased, transparent decisions by regulators are essential in times of uncertainty. Regulators ensure the essential steps of analyzing information from scientists and providing thoughtful guidance to clinicians and patients.

3. BMJ Open: Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study
Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the
patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.
This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

4. UK: The Guardian: Covid: more than 80% of positive UK cases in study had no core symptoms
ONS survey said 86.1% of people between April and June had none of the main symptoms of coronavirus. More than 80% of people who tested positive in a national coronavirus survey had none of the core symptoms of the disease the day they took the test, scientists say. The finding has prompted fears that future Covid-19 outbreaks will be hard to control without more widespread testing in the community to pick up “silent transmission”, particularly in universities and high-risk workplaces such as meat processing facilities.Researchers at UCL said 86.1% of infected people picked up by the Office for National Statistics Covid-19 survey between April and June had none of the main symptoms of the illness, namely a cough, or a fever, or a loss of taste or smell the day they had the test.Three quarters who tested positive had no notable symptoms at all, the scientists found when they checked whether people reported other ailments such as fatigue and breathlessness on the day of testing.
Unlike coronavirus testing in the community which focuses on people with symptoms, the ONS infection survey routinely tests tens of thousands of households around the country whether the occupants have symptoms or not.

5. USA: Washington Post: Covid-19 death rates are lower worldwide, but no one is sure whether that’s a blip or a trend
Scientists warn against complacency in this ‘cliffhanger moment,’ saying even reduced lethality could mean millions more lives lost
After working for three months straight at Detroit Medical Center, Said El Zein noticed that the coronavirus patients who began arriving in May appeared less sick than those who came before. More than 4,000 miles away in northern Italy, researcher Chiara Piubelli was struck by the same thing. Rafael Cantón, an infectious-disease specialist in Madrid, also marveled at the change. “It’s totally different,” he said last month of the falling admissions at his medical center, noting that only 130 of 1,000 beds were full despite surging infections — a huge change from early spring when every bed was occupied. Death rates from the novel coronavirus are lower in hot spots around the world, even as new infections accelerate in what may be the pandemic’s next wave. Scientists are confident the change is real, but the reasons for it — and whether it will last — are a matter of intense debate.

6. WHO: Universal health coverage, oral health, equity and personal responsibility
Universal health coverage (UHC) is broadly defined as all individuals having access to needed health services without financial hardship.1 Over the last decade, the push for UHC has gained considerable momentum, having become a priority area in reaching the sustainable development goals (SDGs) by 2030. Initial evaluations indicate progress in important areas such as coverage of human immunodeficiency virus, tuberculosis and malaria services.1 Oral health, by contrast, has been largely absent from the UHC discussion, and limited progress has been made in addressing oral diseases around the world over the last twenty years.2
In many countries, oral health is deemed low priority and attributed to individual, rather than social responsibility. However, a few countries working towards UHC include dental services for some or all population groups, suggesting that the exclusion of oral health from UHC is no conceptual inevitability. Failing to broaden UHC to encompass oral health risks undermining systemic health outcomes and exacerbating health disparities. As countries plan and align strategies towards UHC, reviewing whether excluding oral health is compatible with the overall goals of UHC is necessary.
To monitor progress towards UHC, the World Health Organization (WHO) and the World Bank use 16 tracer indicators in four categories: (i) reproductive, maternal, and child health; (ii) infectious diseases; (iii) noncommunicable diseases; and (iv) service capacity and access.1 Though poor oral health is recognized as a noncommunicable disease, it was excluded from being an indicator for the health-related SDG, which aims to broadly improve health outcomes.

7. The Lancet: The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion
“As we embark on this great collective journey, we pledge that no one will be left behind. Recognizing that the dignity of the human person is fundamental, we wish to see the goals and targets met for all nations and peoples and for all segments of society. And we will endeavour to reach the furthest behind first.”
Transforming our world: the 2030 agenda for sustainable development
We live in an era of unprecedented global wealth. Nevertheless, about one billion people in low-income and lower-middle-income countries (LLMICs) still experience levels of poverty that have long been described as “beneath any reasonable definition of human decency”, in the words of former World Bank president, Robert McNamara.
This Commission was formed at the end of 2015 in the conviction that non-communicable diseases and injuries (NCDIs) are an important, yet an under-recognised and poorly-understood contributor to the death and suffering of this vulnerable population. The aims of the Commission were to rethink global policies, mend a great disparity in health, and broaden the global health agenda in the interest of equity.
8. UK: NICE: NICE & SIGN announce latest rapid Covid-19 guideline will address Long Covid
NICE and the Scottish Intercollegiate Guidelines Network (SIGN) have today (5 October 2020) announced they will work with the Royal College of General Practitioners (RCGP) to develop a guideline on persistent effects of Covid-19 (Long Covid) on patients.NICE and SIGN will develop the guideline jointly with the RCGP, alongside an independent cross-specialty clinical group.
People have reported persistent symptoms of Covid-19 regardless of how ill they were initially or whether they were hospitalised. Longer term impacts can include on-going shortness of breath, fatigue, heart, lung, kidney, neurological and musculoskeletal problems. It is estimated there could be as many as 60,000 people in the UK who probably have Long Covid.1
The guideline will address, among other things, a formal definition of the disease, how to identify on-going symptoms and a definition of best practice investigation and treatment options to support the management of the condition across diverse communities.
“There is growing evidence to suggest Covid-19 is a multi-system disease that for many people involves persistent symptoms with longer term impacts on their health. It is important, therefore, that people requiring ongoing support and treatment are identified quickly and are supported by the NHS throughout every stage of their journey. We also want to ensure that clinicians have clear guidance on how best to support patients struggling with this newly emerging disease.” “National guidance in this emerging field will help to align services with the needs of people who may be at risk of receiving inconsistent care. The guideline will support health and care services with recommendations on monitoring, testing, treatment options and the provision of advice and support for those who are experiencing these long-term effects.” “Treating or managing any new virus or condition is a challenge for healthcare professionals whose priority is always trying to deliver the best possible care for their patients. The College is delighted to be working with both NICE and SIGN to develop this guideline. It aims to support GPs and other healthcare professionals to ensure all patients with long term effects of Covid-19, including those diagnosed in the community irrespective of whether they received a positive test or not, can be cared for in the best possible way, based on the latest evidence.”

9. WHO: One stillbirth occurs every 16 seconds, according to first ever joint UN estimates
COVID-19-related health service disruptions could worsen the situation, potentially adding nearly 200 000 more stillbirths over a 12-month period
Almost 2 million babies are stillborn every year – or 1 every 16 seconds – according to the first ever joint stillbirth estimates released by UNICEF, WHO, the World Bank Group and the Population Division of the United Nations Department of Economic and Social Affairs.
The vast majority of stillbirths, 84 per cent, occur in low- and lower-middle-income countries, according to the new report, A Neglected Tragedy: The Global Burden of Stillbirths. In 2019, 3 in 4 stillbirths occurred in sub-Saharan Africa or Southern Asia. A stillbirth is defined in the report as a baby born with no signs of life at 28 weeks of pregancy or more.
“Losing a child at birth or during pregnancy is a devastating tragedy for a family, one that is often endured quietly, yet all too frequently, around the world,” said Henrietta Fore, UNICEF Executive Director. “Every 16 seconds, a mother somewhere will suffer the unspeakable tragedy of stillbirth. Beyond the loss of life, the psychological and financial costs for women, families and societies are severe and long lasting. For many of these mothers, it simply didn’t have to be this way. A majority of stillbirths could have been prevented with high quality monitoring, proper antenatal care and a skilled birth attendant.”

10. USA: Scientific American: Policy and Ethics: COVID Misinformation Is Killing People: This “infodemic” has to stop
The confluence of misinformation and infectious disease isn’t unique to COVID-19. Misinformation contributed to the spread of the Ebola epidemic in West Africa, and it plagues efforts to educate the public on the importance of vaccinating against measles. But when it comes to COVID-19, the pandemic has come to be defined by a tsunami of persistent misinformation to the public on everything from the utility of masks and the efficacy of school closures, to the wisdom behind social distancing, and even the promise of untested remedies. According to a study published by the National Bureau of Economic Research, areas of the country exposed to television programming that downplayed the severity of the pandemic saw greater numbers of cases and deaths—because people didn’t follow public health precautions.
10 Sec
In the United States, misinformation spread by elements of the media, by public leaders and by individuals with large social media platforms has contributed to a disproportionately large share of COVID-19 burden: we house 4 percent of the global population but account for 22 percent of global COVID-19 deaths. With winter around the corner and people spending more time indoors, it is more imperative than ever that we counter misinformation and clearly communicate risks to the public; in addition, as we await the arrival of a vaccine, it is equally important to arm the public with facts. We have work to do: a recent poll found that just half of the American public plans to get a COVID-19 vaccine.

11. International: Medical Update Online: Leading scientists propose a ‘more humane’ strategy for the management of the coronavirus pandemic.
A blueprint for a kinder and more effective strategy to manage the coronavirus pandemic has been published by a team of three scientists – Dr Martin Kulldorff, professor of medicine at Harvard University, Dr Sunetra Gupta, professor of theoretical epidemiology at Oxford University and Dr Jay Bhattacharya, professor at Stanford University Medical School – with the support of a further 35 leading scientists worldwide. (See the Great Barrington Declaration https://gbdeclaration.org )
Current strategies are not effective. In the UK the policy is to ‘control the virus’ through lockdowns and related measures whilst waiting for the arrival of an effective vaccine. They can only prolong the circulation of the virus rather than eliminate it. In the meantime, they result in extensive collateral damage including delays to cancer diagnoses and treatment, falling vaccination rates and mental health problems. Because they are unselective – and lock down both those at minimal risk and those at high risk – the burden falls disproportionately on the underprivileged. Lockdown can be weathered by those with financial buffers but many do not have these. In addition, lock-downs strangle commerce and lead to the collapse of businesses. These are all significant consequences – and part of the price for the current strategy.
The Great Barrington Declaration proposes an alternative approach bearing in mind that a strategy must take into account the totality of public health and not focus on one element without considering the wider consequences. Current strategies for covid management have failed to do this and have generated enormous collateral damage, says Professor Kulldorff.
The authors point out that we know great deal more about the virus than we did in March and they have formulated their proposal with this new knowledge in mind. The virus has one great weakness – its differential effects on the young and old. There is a 1000-fold difference in the risk of mortality between the youngest and oldest individuals – and this is something that we should be exploiting, argues Professor Kulldorff. The proposed strategy, in essence, is to protect (or shield) the vulnerable but allow the young to go about their daily lives unhindered – going to work, to school, to sports venues and to restaurants. Creative use of social security systems could ensure that this is done without undue hardship. Young people would contract the infection but be largely unaffected and it could reasonably be expected that the epidemic would peak and resolve in the space of three months, explains Professor Gupta. After this time there should be a sufficient level of herd immunity to ensure that older and vulnerable people could safely be released from lockdown/isolation. They would be protected because the virus would no longer be circulating.

12. Vietnam: BMJ Open: Contamination and washing of cloth masks and risk of infection among hospital health workers in Vietnam: a post hoc analysis of a randomised controlled trial
Background In a previous randomised controlled trial (RCT) in hospital healthcare workers (HCWs), cloth masks resulted in a higher risk of respiratory infections compared with medical masks. This was the only published RCT of cloth masks at the time of the COVID-19 pandemic. Objective To do a post hoc analysis of unpublished data on mask washing and mask contamination from the original RCT to further understand poor performance of the two-layered cotton cloth mask used by HCWs in that RCT. Setting 14 secondary-level/tertiary-level hospitals in Hanoi, Vietnam. Participants A subgroup of 607 HCWs aged ≥18 years working full time in selected high-risk wards, who used a two-layered cloth mask and were part of a randomised controlled clinical trial comparing medical masks and cloth masks. Intervention Washing method for cloth masks (self-washing or hospital laundry). A substudy of contamination of a sample of 15 cloth and medical masks was also conducted. Outcome measure Infection rate over 4 weeks of follow up and viral contamination of masks tested by multiplex PCR. Results Viral contamination with rhinovirus was identified on both used medical and cloth masks. Most HCW (77% of daily washing) self-washed their masks by hand. The risk of infection was more than double among HCW self-washing their masks compared with the hospital laundry (HR 2.04 (95% CI 1.03 to 4.00); p=0.04). There was no significant difference in infection between HCW who wore cloth masks washed in the hospital laundry compared with medical masks (p=0.5). Conclusions Using self-reported method of washing, we showed double the risk of infection with seasonal respiratory viruses if masks were self-washed by hand by HCWs. The majority of HCWs in the study reported hand-washing their mask themselves. This could explain the poor performance of two layered cloth masks, if the self-washing was inadequate. Cloth masks washed in the hospital laundry were as protective as medical masks. Both cloth and medical masks were contaminated, but only cloth masks were reused in the study, reiterating the importance of daily washing of reusable cloth masks using proper method. A well-washed cloth mask can be as protective as a medical mask.

13. Vietnam: BMJ Open: A cluster randomised trial of cloth masks compared with medical masks in healthcare workers
The aim of this study was to compare the efficacy of cloth masks to medical masks in hospital healthcare workers (HCWs). The null hypothesis is that there is no difference between medical masks and cloth masks. Setting 14 secondary-level/tertiary-level hospitals in Hanoi, Vietnam. Participants 1607 hospital HCWs aged ≥18 years working full-time in selected high-risk wards. Intervention Hospital wards were randomised to: medical masks, cloth masks or a control group (usual practice, which included mask wearing). Participants used the mask on every shift for 4 consecutive weeks. Main outcome measure Clinical respiratory illness (CRI), influenza-like illness (ILI) and laboratory-confirmed respiratory virus infection. Results The rates of all infection outcomes were highest in the cloth mask arm, with the rate of ILI statistically significantly higher in the cloth mask arm (relative risk (RR)=13.00, 95% CI 1.69 to 100.07) compared with the medical mask arm. Cloth masks also had significantly higher rates of ILI compared with the control arm. An analysis by mask use showed ILI (RR=6.64, 95% CI 1.45 to 28.65) and laboratory-confirmed virus (RR=1.72, 95% CI 1.01 to 2.94) were significantly higher in the cloth masks group compared with the medical masks group. Penetration of cloth masks by particles was almost 97% and medical masks 44%. Conclusions This study is the first RCT of cloth masks, and the results caution against the use of cloth masks. This is an important finding to inform occupational health and safety. Moisture retention, reuse of cloth masks and poor filtration may result in increased risk of infection. Further research is needed to inform the widespread use of cloth masks globally. However, as a precautionary measure, cloth masks should not be recommended for HCWs, particularly in high-risk situations, and guidelines need to be updated. Trial registration number Australian New Zealand Clinical Trials Registry

14. France: EPI-PHAFE: Drug use in France during the Covid-19 pandemic
EPI-PHARE publishes the results of a pharmaco-epidemiological study on the dispensation of reimbursed prescription drugs in pharmacies during the lockdown and post-lockdown periods, from March 16 to September 13, 2020.
Based on the data from the French National Health Data System (SNDS), this study aims to characterize the consumption behavior of the population towards drugs prescribed in town, whether or not linked to Covid -19, in the particular context of the Covid-19 epidemic and confinement. Based on the analysis of 3 billion prescriptions, it compares, for 58 therapeutic classes, the number of people who have had a dispensation of reimbursed prescription drugs in pharmacies every week since March 2020 with the “expected” number estimated on the basis of the same period in 2018 and 2019.

This report, which covers the period of national lockdown (weeks 12 to 19 from March 16, 2020 to May 10, 2020) and post-lockdown until September 13, 2020, shows that the Covid-19 pandemic with all its organizational consequences structures in the healthcare sector and on the population in general has profoundly destabilized the consumption of drugs in France.

15. Germany: Zeit Online: “It’s Up To Us”: Quarantine before family gatherings, take sore throats seriously and don’t overestimate the immediate effect of a vaccine: Virologist Christian Drosten’s advice for the corona winter.
The number of new infections is rising, but Germany can still make it through the winter without things getting too bad, says virologist Christian Drosten of Berlin’s prestigious Charité University Hospital. Is it OK to sit inside a restaurant when the weather gets cold? Or go ahead with the party you’ve planned? Things now hinge on the small, everyday decisions we make. And on whether everyone plays along.
Looking at the course of the pandemic puts me in a state of anxious attentiveness. We are in a period where there are no major problems on the medical side – and by that, I mean overcrowded hospitals and intensive care units – but also one in which we need to make sure that it doesn’t get that far. With this virus, you have to react early. You can see this by comparing Germany and Britain, two countries that are structured similarly. Germany simply implemented measures earlier in the spring. That has resulted in fewer infections and fewer deaths in this country so far.

16. Nature: Initiative pushes to make journal abstracts free to read in one place
Publishers agree to make journal summaries open and searchable in single repository.
In a bid to boost the reach and reuse of scientific results, a group of scholarly publishers has pledged to make abstracts of research papers free to read in a cross-disciplinary repository.
Most abstracts are already available on journal websites or on scholarly databases such as PubMed, even if the papers themselves are behind paywalls. But this patchwork limits the reach and visibility of global research, says Ludo Waltman, deputy director of the Centre for Science and Technology Studies at Leiden University in the Netherlands, and coordinator of the initiative for open abstracts, called I4OA.
Publishers involved in I4OA have agreed to submit their article summaries to Crossref, an agency that registers scholarly papers’ unique digital object identifiers (DOIs). Crossref will make the abstracts available in a common format. So far, 52 publishers have signed up to the initiative, including the American Association for the Advancement of Science and the US National Academy of Sciences.

17. New Zealand: RNZ: Near extinction’ of influenza in NZ as numbers drop due to lockdown
Mask wearing and social distancing for Covid-19 has all but cut influenza cases in New Zealand this year, with only six flu isolates detected in this country from April to August.
As we move into the spring/summer period where flu is always uncommon in New Zealand, Professor Michael Baker offers his analysis on the flu season numbers and why masks continue to be so important.
He said there has been “near extinction of influenza in New Zealand following our very effective Covid-19 response”, as numbers vanished from the two standard systems for surveillance – resulting in a 99.8 percent reduction in flu cases.
According to Baker, there were usually 1600 more deaths in winter, compared to other seasons, and around a third of those were caused by influenza, mostly in older people with long-term health conditions.
“What the Covid-19 response has done has largely eliminated those excess winter deaths and mortality as a whole is down around 5 percent,” he said. “So that means an extra 1500 people will survive this year who wouldn’t have.”

18. WHO: Occupational health and safety for health workers in the context of COVID-19
All health workers require knowledge and skills to protect themselves and others from the occupational risks they encounter, so that they can work safely and effectively. This course consists of five sections in response to these needs:
Module 1: Infectious risks to health and safety
Module 2: Physical risks to health and safety
Module 3: Psychosocial risks to health and safety
Module 4: Basic occupational health and safety in health services.

19. World Bank: Beyond COVID-19 (coronavirus): What will be the new normal for health systems and universal health coverage?
The COVID-19 (coronavirus) pandemic has substantial health, social, and economic impacts in all countries, rich and poor. It is a sharp reminder that everyone, everywhere should have access to quality and affordable health services. We will be living with COVID-19 and its consequences for a long time to come.
Health systems now face the dual challenge of responding to the outbreak and maintaining essential services. COVID-19 has reignited a debate from previous health emergencies: how to make health systems sufficiently resilient to manage shocks in ways that protect everyone, especially the most vulnerable? Where do we need to start thinking differently, and what can we do differently, to be better prepared for emergencies and make progress towards univeral health coverage (UHC)? What is the new normal for health systems and UHC?
The UHC movement has focused on ensuring that health services are accessible and affordable for all. However, achieving UHC also depends on disease prevention, health promotion and emergency preparedness. The measurement of health service coverage, which is the focus of the Sustainable Development Goals indicator 3.8.1, includes International Health Regulations core capacities to detect, assess and report public health events. COVID-19 demands that we think about UHC as protecting everyone. It calls for a renewed and urgent focus on specific public health actions as the first step towards UHC. This includes special attention to common goods for health – things like disease surveillance, laboratories and diagnosis, health information systems, communications about changing behaviors, engagement of communities and building public trust in the health system. These will largely not be provided by markets, hence they require public financing and collective action. Relative neglect of these areas has left communities more vulnerable to epidemics and other shocks.

20. Sierra Leone: WHO: Sierra Leone reversing immunization decline in wake of COVID-19
Although the first case of COVID-19 didn’t emerge until late in March in Sierra Leone, by late April, immunization rates and the use of child health care services had worryingly declined by about 19%. Mothers like Hawa Dumbuya feared making visits to a health facility, because they were concerned that with COVID-19 circulating by doing so they would put themselves and their children in harm’s way.
“I was afraid that going to the health facility would expose us to coronavirus,” Dumbuya admits. The Ministry of Health and Sanitation moved quickly to stem the growing anxieties and reverse the avoidance of critical child health care services.
Working with district communications unit staff and in collaboration with UNICEF and the World Health Organization (WHO), the Ministry ramped up public health messaging through radio stations. The informative announcements, played nationwide, urged mothers and caregivers to continue taking their children to health centres for the routine immunizations.These messages gave parents like Dambuya reassurance to take her baby, born in May, to her local health facility and to check on her own health. “Coming for delivery was a difficult decision because of the fear of COVID-19, but it was good that I was brought here,” says Dambuya.
“As we learned more about the disease and how to stay safe, it gave me courage to continue to seek health services while using a mask and other preventive measures,” she says. “I came for vaccine for my child, and she was vaccinated. We mothers were reminded to sit apart and to use our mask properly. And the nurses were also fully masked up. So that was reassuring.”

21. Africa: Africa Renewal: Could this be a turning point for Africa’s health systems?
PATH suggests five ways to place people at the centre of health systems and build back better. With close to 1.4 million confirmed COVID-19 cases and over 32,000 recorded deaths in Africa as of mid-September the pandemic has exerted significant strain on already overstretched health systems across the region, further affecting the delivery of other essential health services – such as immunization and those for sexual and reproductive health. These critical services are vital to protecting the most vulnerable and marginalized populations yet are some of the most impacted by the pandemic. Since the first case of COVID-19 was confirmed on the continent in February 2020, Africa’s response, led by the Africa Centres for Disease Control and Prevention (Africa CDC) has been commendable. Governments moved quickly to institute public health measures to curb its spread.
However, more is needed to ensure that Africa harnesses the urgency of the moment to shape more resilient and equitable systems equipped to withstand future threats and protect populations, especially the most vulnerable and marginalized.
Africa’s joint concerted response has brought together frontline health workers, policymakers, health system leaders and civil society from across the continent to share experiences, perspectives and best practices. Among the questions is how does Africa seize this opportunity to re-invent the health system and build better? Here are five possible quick wins:

22. UK: HSJ: Covid cases caught in hospital more than double in a week
The number of covid-19 cases likely to have been caught by patients already in hospital for other conditions has more than doubled in a week — rising more quickly than coronavirus admissions from the community.
It may raise concerns that the spread of Covid in hospitals is impossible to control even with new measures in place and has prompted new calls for routine testing of asymptomatic NHS staff, in case they spread the virus to patients.
Tens of thousands of people are in hospitals for other conditions – so the chance of any given patient catching covid remains very small.
But the rise in positive cases which are diagnosed eight or more days after admission (and therefore were probably caught in hospital, according to NHS England definitions), means it is still accounting for around one in 10 of the new covid cases in hospital.

23. Peru: Salud Conlupa: Todos deberíamos contar con un médico de familia
We should all have a family doctor
Más que una costumbre que se ha perdido, la medicina familiar y comunitaria es una especialidad que podría transformar la manera de entender nuestra salud y protegerla. Se ha demostrado que un sistema sanitario que prioriza este modelo de atención descongestiona los hospitales y reduce el gasto público. Sin embargo, sólo tenemos 832 doctores con esta especialidad en el Perú y su trabajo todavía es poco valorado.
More than a custom that has been lost, family and community medicine is a specialty that could transform the way we understand our health and protect it. A health system that prioritizes this model of care has been shown to decongest hospitals and reduce public spending. However, we only have 832 doctors with this specialty in Peru and their work is still undervalued.
24. Australia: University of Melbourne: JOINING THE DOTS ON DIABETES AND COVID-19
There is increasing concern for people living with diabetes whether it be ensuring continued access to medications, glucose management or the implications of infection with COVID-19 itself Most people who have lived with diabetes for some time have likely experienced struggles with sticking to strict treatment regimens or changes to their diet, as well as managing social and occupational life.
During the COVID-19 pandemic, there is added concern for people living with diabetes in relation to ensuring continued access to medications, glucose management or the implications of infection with COVID-19 itself.
The evidence around COVID-19 and diabetes shows that people with diabetes are not more likely to catch the infection, but once infected, are twice as likely than others to develop serious infection and are more likely to be admitted to an Intensive Care Unit (ICU).
Australian data has shown that diabetes was prevalent in 45 per cent of patients who died in hospital having tested positive for COVID-19. While data from China indicates 10 per cent of people with diabetes and COVID-19 infection died, compared with 2.5 per cent of people without diabetes.

25. UK: The Guardian: Whitehall told to release secret 2016 files on UK pandemic risks
Government accused of suppressing ‘terrifying’ findings of three-day simulation exercise
The government is on a collision course with the information commissioner over its refusal to publish a confidential report warning that the UK’s health system could not cope in a pandemic.
In a dramatic move, the Information Commissioner’s Office has ordered the Department of Health and Social Care (DHSC) to hand over the report into Exercise Cygnus, or explain its decision for refusing, by 23 October.
Cygnus, a three-day simulation exercise in 2016, assessed the UK’s ability to cope with an influenza pandemic, but its findings are pertinent to the current coronavirus crisis. Lawyers for an NHS doctor, Moosa Qureshi, who made a freedom of information request six months ago demanding to see the Cygnus report, have accused the government of deliberately delaying its response to his request. There is speculation that this is because the report’s contents would confirm that the government had failed to learn the lessons from its own exercise.

26. India: Jama: SARS-CoV-2 Infection Among Community Health Workers in India Before and After Use of Face Shields
The transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is believed to be predominantly through respiratory droplets from infected persons in close proximity to uninfected persons, although airborne transmission may also play a role. Face shields have been proposed to prevent transmission in the community, but data are lacking. We describe transmission in a community setting before and after the use of face shields.
This study found no SARS-CoV-2 infections among community health workers after the addition of face shields to their personal protective equipment. Because the first worker became symptomatic 13 days after beginning home visits and workers had no contact with family, coworkers, or the public, there is no known alternative source of infection for the workers except the asymptomatic contacts of SARS-CoV-2 patients. The face shields may have reduced ocular exposure or contamination of masks or hands or may have diverted movement of air around the face.

27. WHO Europe: How to enhance the integration of primary care and public health?
Approaches, facilitating factors and policy options
There are many calls for improved integration between public health and primary care, but it is less clear how this can be achieved. This policy brief describes the types of initiatives that have been undertaken; provides examples of such initiatives in Europe and beyond; and summarizes the factors that can help to enhance or hinder the integration of primary care and public health.
The relationship between primary care and public health is complex. In most European countries primary care performs some public health functions, while public health can help to make the provision of primary care more effective. Screening and immunization, for example, as well as interventions to support healthy lifestyles, are public health functions that are nowadays commonly provided in primary care, although with wide variations between countries. Importantly, there is a large overlap of activities between public health and primary care, and various settings come into consideration depending on the national context.

28. International: UBS: Future of Humans
Humanity is facing two important trends. Over the next 30 years, our numbers will grow and our average age will increase. These demographic trends are taking place alongside huge structural shifts. The Fourth Industrial Revolution— powered by automation and connectivity—and the environmental credit crunch will dramatically alter the way the global economy works. All these issues are entwined, but what do they mean for investors?
In this report, we consider some of the biggest areas of change for humankind—driven primarily by demographic shifts and enabled mainly by technology—and the associated investment implications. We expect changes to be largest in three key areas: education, healthcare, and happiness and consumer preferences.
We invite you to explore below the key takeaways and select investment opportunities from our Future of Humans report.

29. UK: HSJ: Exclusive: Covid-hit trust scales back electives and prepares staff for redeployment
• Liverpool’s hospitals have begun scaling back their elective activity in response to rising covid admissions
• Cancer and urgent procedures to be protected “where possible”
• Comes as NHSE triggers testing of asymptomatic staff in the north and puts Nightingales on standby
• Non-specialist staff to be prepared for redeployment to critical care teams
Liverpool’s hospitals have begun scaling back their elective activity and preparing non-specialist staff to be redeployed to critical care teams, according to a memo seen by HSJ.

30. Nature Editorial: Long COVID: let patients help define long-lasting COVID symptoms
The terminology for long-lasting COVID symptoms — and the definition of recovery — must incorporate patients’ perspectives.
Breathlessness and fatigue are among the continuing and debilitating symptoms being reported by people with COVID-19 — often months after the onset of the disease, and often long after they have been declared recovered.
Researchers and clinicians have yet to agree on a name for these ongoing symptoms. The literature includes “post-COVID syndrome” and “chronic COVID-19”. Now, researchers, patient groups and those affected by the condition are urging that “long COVID” be used.
They are also calling for the definition of recovery from COVID-19 to be based on criteria that extend beyond just testing negative for COVID. People’s symptoms should be considered, too, such as chest heaviness, breathlessness, muscle pains, palpitations and fatigue, as Nisreen Alwan, a public-health researcher at the University of Southampton, UK, wrote in a World View article in August (N. A. Alwan Nature 584, 170; 2020).

31. Africa: WHO: COVID-19 halting crucial mental health services in Africa, WHO survey
Critical funding gaps are halting and disrupting crucial mental health services in Africa, as demand for these services rise amid the COVID-19 pandemic, a new World Health Organization (WHO) survey shows.

The survey of 28 African countries was undertaken as part of the first global examination of the devastating impact of COVID-19 on access to mental health services. It underscores the urgent need for increased funding. Of the countries responding in the African region, 37% reported that their COVID-19 mental health response plans are partially funded and a further 37% reported having no funds at all.
This comes as the COVID-19 pandemic increases demand for mental health services.
“Isolation, loss of income, the deaths of loved ones and a barrage of information on the dangers of this new virus can stir up stress levels and trigger mental health conditions or exacerbate existing ones,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “The COVID-19 pandemic has shown, more than ever, how mental health is integral to health and well-being and must be an essential part of health services during outbreaks and emergencies.”

32. Africa: Mendeley: Challenges toward achieving universal health coverage in Ghana, Kenya, Nigeria, and Tanzania
Although many sub-Saharan African countries have made efforts to provide universal health coverage (UHC) for their citizens, several of these initiatives have achieved little success. This study aims to review the challenges facing UHC in Ghana, Kenya, Nigeria, and Tanzania, and to suggest program or policy changes that might bolster UHC. Routine data reported by the World Bank and World Health Organization, as well as annual reports of the national health insurance schemes of Ghana, Kenya, Nigeria, and Tanzania, were analyzed. The data were supplemented by a review of published and gray literature on health insurance coverage in these four countries. The analysis showed that some of the challenges facing UHC in these countries include (1) large proportion of the population living in extreme poverty and unable to pay premiums, (2) large informal sector whose members are mostly uninsured, (3) high dropout rate from insurance schemes, (4) poorly funded primary health care system, and 卌 segmented health insurance fund pool. In order to achieve UHC by 2030, it will be important for these countries to (1) raise sufficient revenue to finance their health systems, (2) improve the efficiency of revenue utilization, (3) identify and provide coverage for the very poor, (4) reduce the proportion of the population that is underinsured, and 卌 improve access to quality health care in rural areas.

33. International: Oxford Academic: Health Policy and Planning: Factors influencing the scale-up of public health interventions in low- and middle-income countries: a qualitative systematic literature review
To achieve universal health coverage, the scale-up of high impact public health interventions is essential. However, scale-up is challenging and often not successful. Therefore, a systematic review was conducted to provide insights into the factors influencing the scale-up of public health interventions in low- and middle-income countries (LMICs). Two databases were searched for studies with a qualitative research component. The GRADE-CERQual approach was applied to assess the confidence in the evidence for each key review finding. A multi-level perspective on transition was applied to ensure a focus on vertical scale-up for sustainability. According to this theory, changes in the way of organizing (structure), doing (practice) and thinking (culture) need to take place to ensure the scale-up of an intervention. Among the most prominent factors influencing scale-up through changes in structure was the availability of financial, human and material resources. Inadequate supply chains were often barriers to scale-up. Advocacy activities positively influenced scale-up, and changes in the policy environment hindered or facilitated scale-up. The most outstanding factors influencing scale-up through changes in practice were the availability of a strategic plan for scale-up and the way in which training and supervision was conducted. Furthermore, collaborations such as community participation and partnerships facilitated scale-up, as well as the availability of research and monitoring and evaluation data. Factors influencing scale-up through a change in culture were less prominent in the literature. While some studies articulated the acceptability of the intervention in a given sociocultural environment, more emphasis was placed on the importance of stakeholders feeling a need for a specific intervention to facilitate its scale-up. All identified factors should be taken into account when scaling up public health interventions in LMICs. The different factors are strongly interlinked, and most of them are related to one crucial first step: the development of a scale-up strategy before scaling up.

34. USA: AP News: ‘So frustrating’: Doctors and nurses battle virus skeptics
Treating the sick and dying isn’t even the toughest part for nurse Amelia Montgomery as the coronavirus surges in her corner of red America.
It’s dealing with patients and relatives who don’t believe the virus is real, refuse to wear masks and demand treatments like hydroxychloroquine, which President Donald Trump has championed even though experts say it is not effective against the scourge that has killed over 210,000 in the U.S.
Montgomery finds herself, like so many other doctors and nurses, in a world where the politics of the crisis are complicating treatment efforts, with some people even resisting getting tested.

It’s unclear how Trump’s bout with the virus will affect the situation, but some doctors aren’t optimistic. After a few days of treatment at a military hospital, the president tweeted Monday, “Don’t be afraid of Covid. Don’t let it dominate your life. … I feel better than I did 20 years ago!”
35. USA: The Guardian: I volunteered to be a human guinea pig for a Covid vaccine. Now I’m having second thoughts
I am willing to risk my life so that vulnerable populations across the globe can be protected, but not to make pharma shareholders rich or to produce a vaccine only available to US citizens. The US decision to not join Covax, a multilateral effort to ensure that the vaccine is fairly distributed worldwide, places corporate greed and vaccine nationalism over the needs of people.
I cannot speak for other volunteers, but I suspect they might feel the same: I would refuse to participate in a human challenge trial if the eventual vaccine wasn’t made available to everyone, everywhere. And because vaccines are impossible without potential trial participants, we can demand a better vaccine process for everyone, not just for Covid-19, but for the future. We can refuse to risk our health unless a vaccine is accessible to everyone.
As it stands, Covax is deeply flawed. The plan currently provides universal vaccine access only to wealthy countries, lines the pockets of pharma executives, and dictates terms to poorer nations while falling short of providing the number of vaccines they need. Despite this, it is clear that we need international cooperation to prevent nationalism from raising the cost of a vaccine for everyone. Covax may be a flawed solution, but Trump’s go-it-alone approach will isolate the United States and jeopardize the health of billions.

36. International: Past Medical History: EDWARD JENNER AND THE SMALLPOX VACCINE
Every year, approximately 85% of the world’s children receive vaccines protecting them against deadly diseases such as polio, diphtheria, tetanus and tuberculosis. It has been estimated that vaccines save 9 million lives globally per year, and they have the potential to save an additional 16 million lives every year if effective vaccines are deployed against all potentially vaccine-preventable diseases. Although the story of vaccines did not begin with Edward Jenner, he is considered the founder of vaccinology in the west, and his work is said to have ‘saved more lives than the work of any other human’. For this reason, Jenner is often referred to as the ‘father of immunology’.
The story of vaccines did not begin with Jenner though, and the practice of immunisation in its earliest form predates him by hundreds of years. The story began in 429 BCE when the Greek historian Thucydides observed that people who had survived a smallpox epidemic in Athens did not subsequently become re-infected with the disease. He astutely noted that the initial infection somehow conferred immunity to these individuals.
It is thought that a primitive form of vaccination called variolation, which is the process of inoculating a susceptible person with material taken from a vesicle of a person with smallpox, was being employed in China and India as early as 1000 CE. Variolation gradually spread around the world, initially to Turkey and was then brought to England in 1721 by Lady Mary Wortley Montagu after she had observed it being performed in Constantinople. At this time, smallpox was one of the most deadly infectious diseases in Europe, and the practice of variolation became increasingly popular because of the fear surrounding the disease. Variolation was far from perfect, however, and those who undertook it usually suffered from a milder form of smallpox, some still dying. Fewer people died from variolation than those who had acquired smallpox naturally though.
S ED Humanities

37. UK: Learna; Study prn: Myalgic Encephalomyelitis / Chronic Fatigue Syndrome CPD (in the time of Covid-19)
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a common and severe complex multisystem disease with many sufferers waiting years for a diagnosis. The narrative and education to date has neither aligned with the patient experience of this illness, nor communicated the emerging biomedical evidence.
Following the coronavirus pandemic thousands of people will know how severe and debilitating the symptoms of fatigue can be. Millions will understand the experience of being housebound, but for most these experiences will have lasted days, weeks or months.
Imagine feeling viral, exhausted, unwell and in pain, confined to your bed or house, lying in a dark room for years or even decades. The world has been shocked by the damage that viruses can do, and soon we will need to examine the consequences of chronic post-viral illness including ME/CFS.
In writing this module I have started from scratch. I have drawn on the international peer reviewed literature and emerging international ME/CFS educational resources and have been fortunate to receive significant contributions from medical experts, scientists and patients.
I am humbled by the contributions of those who are severely ill and the effort and energy they have devoted to this collaboration. I recommend that you read the four pre-course peer reviewed papers before embarking on the learning module. It would be of great help if you could take a minute to click through the pre-and post-course questionnaire so that more accurate information can be gathered to help develop and update future ME/CFS learning materials.
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38. UK: British Business bank: Mental health in the workplace: what can employers do to help during Covid-19?
The pandemic has taken its toll on the wellbeing of people across the country. As businesses adapt to these unprecedented circumstances, an expert says that a preventative approach to mental health is key
Over the past few months, many of us have found our working environments and schedules changing drastically. Working from home, following new guidelines in the workplace or juggling childcare with an overflowing list of tasks and targets all bring challenges and can understandably leave people feeling unsettled. Now more than ever, it’s vital that both employees and employers are aware of their mental health and wellbeing needs, to keep the workforce happy and productive.
According to the Mental Health Foundation (MHF), addressing wellbeing in the workplace can increase productivity by as much as 12%, while the estimated value added to the economy by working people who have or have had mental health problems is £226bn a year.

39. Canada: The British Academy: All Our Relations by Tanya Talaga
The tragedy of suicide is that it is preventable. Each life gone is a lost opportunity for someone to have received help. The scope of the suicide problem is immense. From 1986 through December 2017, there were more than 558 suicides across NAN territory, a community comprising only 49,000 people. Last year, 2017, was the worst in recent memory, with 37 suicides. Most of the suicides are by hanging, and the majority are by young men. The number of attempts – those who try to take their lives but fail – is even greater. Since 1986, an almost incomprehensible 88 children between the ages of 10 and 14 have killed themselves.
The high youth-suicide numbers are not just found in NAN territory. According to the Centre for Suicide Prevention, in Canada suicide and self-inflicted injuries are the leading causes of death for First Nations youth and adults up to the age of 44. The centre also reports that the suicide rate for young First Nations men between the ages of 15 and 24 is 126 per 100,000, compared to 24 per 100,000 for non-Indigenous young men. First Nations women have a suicide rate of 35 per 100,000, compared to 5 per 100,000 for non-Indigenous women.
Suicide among Inuit is even more pronounced. Jack Hicks is an adjunct professor at the University of Saskatchewan in community health and epidemiology and a former suicide prevention advisor for the Government of Nunavut and Inuit Tapiriit Kanatami, a national organisation protecting and advancing the rights of Inuit in Canada. He says that for the past 15 years, the Inuit suicide rate has been 10 times the national average.
Indigenous youth suicide is not just a Canadian problem. Across the globe, Indigenous people living in colonised countries share a crushing commonality: their children are dying by their own hands. While there is no global data on how many Indigenous children and youth are taking their own lives, the statistics gathered from colonised nations point to similarities. The first is that suicide is a modern phenomenon within Indigenous Nations. In Canada, before the forced resettlement of Inuit people off the land and into towns, and before the Indian Residential Schools, suicide was uncommon. This also holds true for the Sami population in Scandinavia and the Indigenous people in Brazil and in Australia. And in each of these colonised countries, Indigenous young men have among the highest suicide rates globally
S ED Humanities

40. USA: Care: CARE Condemns Proposed Refugee Cap
In response to the Administration’s decision to lower refugee admissions to a historic low of 15,000, David Ray, CARE’s vice president of policy and advocacy, released the following statement:“The administration’s proposal to lower the number of refugees admitted into the United States to an historically low 15,000 people is disgraceful. Immigration was foundational to the birth of America and to close our doors to the world’s most vulnerable at a time of historic displacement is frankly un-American. Today, there are 26M refugees around the world, more than at any time since the Second World War. Countries with significantly less resources than United States like Bangladesh, Jordan, and Kenya have all opened their arms to vulnerable people escaping conflict. The United States must stand beside them and fulfill our duty as a humanitarian leader. Our American values demand that we help those in need. This decision is an affront to the dignity of vulnerable people fleeing conflict and persecution around the world—particularly women and children. CARE calls on the United States to restore its legacy as a global leader in resettling the most vulnerable and to redouble assistance, policy support, and diplomatic engagement to protect and assist the millions of displaced people around the world.”

Best wishes to you all and stay safe
Special thanks to Chris and Sophie for their great contributions

John Wynn-Jones