“All war is a symptom of man’s failure as a thinking animal.”
“War is what happens when language fails.”
“When the rich wage war it’s the poor who die.”
“It is forbidden to kill; therefore, all murderers are punished unless they kill in large numbers and to the sound of trumpets.”
“Older men declare war. But it is youth that must fight and die.”
“I know not with what weapons World War III will be fought, but World War IV will be fought with sticks and stones.”
Lest we forget
Forgive me for this post but I felt morally obliged to send it, even in these difficult times. I understand that some of you might interpret it as being somewhat morbid. In the UK as in many other European countries and further afield, we mark the 11th November as a day of remembrance for those who gave their lives for their countries. This marks the day that the guns finally fell silent on the Western Front at the end of World War One. On the eleventh minute of the eleventh hour, of the eleventh day of the eleventh month in 1918. Most of those killed were young men and women whose lives were extinguished before they could live out their full lifespan.
War and conflict have created a whole genre of poetry and many would argue that poetry may be the fitting medium to describe the reality and futility of war. Wilfred Owen, arguably Britain’s greatest war poet wrote “My subject is War, and the pity of War. The Poetry is in the pity”.
I became acquainted with some of the poets that emerged during the 1st World War when I was at school. The literature of this conflict has remained on school curricula for many decades and I hope it remains so. I am still in awe of them and I felt that I needed to collect some together.
Poetry before that period, is patriotic and often glorifies war rather than telling it as it really is, a futile, inhuman, cruel and degrading experience.
I also want to remember the countless civilians who also died. They have no monuments and their names do not appear on war memorials and scrolls of honour.
Please take the opportunity to read these poems, you will find them moving and inspiring.
The first poems describing the glory and heroism of war, soon give way to the reality in later more modern works.
Incidentally, the end of World War One saw the start of the Spanish Flue Pandemic that killed many more people than did the conflict itself
Richard Lovelace (1617-1657)
Richard Lovelace was an English poet in the seventeenth century. He was a cavalier poet who fought on behalf of the king during the Civil War. His best-known works are “To Althea, from Prison”, and “To Lucasta, Going to the Warres”
In the poem “To Lucasta, Going to the Warres”, Lovelace defends his decision to take up his sword and head off to battle, arguing with his beloved that it is honour which calls him away from her.
Lovelace responds to his lover’s complaint that he is leaving her to go off to fight. “Don’t tell me I’m mean for leaving you like this”, he says, “because I go to war out of honour, and because I am an honourable man. If I were not honourable, I wouldn’t be a fit lover for you – so the very thing that takes me away from you, namely my sense of duty and honour, is the thing that makes it possible for me to be a good lover for you in the first place.”
To Lucasta, Going to the Warres
Tell me not (Sweet) I am unkinde.
That from the Nunnerie
Of thy chaste breast, and quiet minde,
To Warre and Armes I flie.
True; a new Mistresse now I chase,
The first Foe in the Field;
And with a stronger Faith imbrace
A Sword, a Horse, a Shield.
Yet this Inconsistency is such,
As thou too shalt adore;
I could not love thee (Deare) so much,
Lov’d I not Honour more.
“To Lucasta, Going To The Wars” Richard Lovelace poem (Lov’d I not Honour more)
Alfred Lord Tennyson 1809-1892
Alfred Tennyson, 1st Baron Tennyson FRS was a British poet. He was the Poet Laureate during much of Queen Victoria’s reign and remains one of the most popular British poets
Although decried by some critics as overly sentimental, his verse soon proved popular and brought Tennyson to the attention of well-known writers and poets of the day, such as Samuel Taylor Coleridge. Tennyson’s early poetry, with its medievalism and powerful visual imagery, was a major influence painters and fellow writers.
The Charge of the Light Brigade was extremely popular although vilified by many
Even the Tennyson seems to have found its popularity irritating but it is a poem that attracts a love or hate response. It recounts a military blunder when the Light Brigade Cavalry was sent into action against the Russian guns resulting in unnecessary slaughter at the Battle of Balaclava, during the Crimea War. It is a tribute to those that died and the glorification of war and empire. It is the highlighting of courage and at the same time a denouncing of military incompetence.
Tennyson wrote this poem on reading the account in the London Times. He is quoted as saying “The Charge of the Light Brigade may signal a new journalistic genre of poetry, where, if the news can’t be got from poems, poets can certainly get their poems from the news”
The Charge of the Light Brigade
Half a league, half a league,
Half a league onward,
All in the valley of Death
Rode the six hundred.
“Forward, the Light Brigade!
Charge for the guns!” he said:
Into the valley of Death
Rode the six hundred.
“Forward, the Light Brigade!”
Was there a man dismay’d?
Not tho’ the soldier knew
Some one had blunder’d:
Theirs not to make reply,
Theirs not to reason why,
Theirs but to do and die:
Into the valley of Death
Rode the six hundred.
Cannon to right of them,
Cannon to left of them,
Cannon in front of them
Volley’d and thunder’d;
Storm’d at with shot and shell,
Boldly they rode and well,
Into the jaws of Death,
Into the mouth of Hell
Rode the six hundred.
Flash’d all their sabres bare,
Flash’d as they turn’d in air
Sabring the gunners there,
Charging an army, while
All the world wonder’d:
Plunged in the battery-smoke
Right thro’ the line they broke;
Cossack and Russian
Reel’d from the sabre-stroke
Shatter’d and sunder’d.
Then they rode back, but not
Not the six hundred.
Cannon to right of them,
Cannon to left of them,
Cannon behind them
Volley’d and thunder’d;
Storm’d at with shot and shell,
While horse and hero fell,
They that had fought so well
Came thro’ the jaws of Death,
Back from the mouth of Hell,
All that was left of them,
Left of six hundred.
When can their glory fade?
O the wild charge they made!
All the world wonder’d.
Honor the charge they made!
Honor the Light Brigade,
Noble six hundred!
“The Charge of the Light Brigade” Alfred, Lord Tennyson (read by Tom O’Bedlam)
The Charge of the Light Brigade
Rupert Brooke (1887-1915)
Rupert Chawner Brooke was an English poet known for his idealistic war sonnets written during the First World War, especially The Soldier. He was also known for his boyish good looks, which were said to have prompted the Irish poet W. B. Yeats to describe him as “the handsomest young man in England”
He enlisted at the outbreak of war in August 1914 and came to public attention as a war poet early the following year, when The Times published two sonnets (The Dead” and The Soldier); the latter was then read from the pulpit of St Paul’s Cathedral on Easter Sunday. Brooke’s most famous collection of poetry, containing all five sonnets, 1914 & Other Poems, was first published in May 1915 and, in testament to his popularity, ran to 11 further impressions that year and by June 1918 had reached its 24th impression; a process undoubtedly fuelled through posthumous interest.
He is considered to be a war poet despite the fact that he died relatively soon after the start of the war. He died in April from pneumococcal sepsis following an infected mosquito bite in Greece. The poem is a patriotic statement glorifying the gallant pursuit of fighting for one’s country. This was early in the war and bears little resemblance to the gritty writings of poets such as Wilfred Owen and Siegfried Sassoon describing the realities and horrors of the war in the following years.
I think with our modern sensibilities, we find this type of poem uncomfortable, describing a world long gone away (Thank goodness!).
If I should die, think only this of me:
That there’s some corner of a foreign field
That is for ever England. There shall be
In that rich earth a richer dust concealed;
A dust whom England bore, shaped, made aware,
Gave, once, her flowers to love, her ways to roam;
A body of England’s, breathing English air,
Washed by the rivers, blest by suns of home.
And think, this heart, all evil shed away,
A pulse in the eternal mind, no less
Gives somewhere back the thoughts by England given;
Her sights and sounds; dreams happy as her day;
And laughter, learnt of friends; and gentleness,
In hearts at peace, under an English heaven.
The Soldier: Rupert Brooke
Vera Brittain (1893-1970)
Vera Mary Brittain was an English Voluntary Aid Detachment nurse, writer, feminist, socialist, and pacifist. Her best-selling 1933 memoir Testament of Youth recounted her experiences during the First World War and the beginning of her journey towards pacifism.
This is a poem from one that was left behind. One of thousands who lost sons, daughters, lovers and spouses. It reflects overwhelming loss felt at home and the hopelessness that they faced.
This poem was dedicated to her fiancé Roland Aubrey Leighton, who was killed at the age of 20 by a sniper in 1915, four months after she had accepted his marriage proposal.
Perhaps some day the sun will shine again,
And I shall see that still the skies are blue,
And feel once more I do not live in vain,
Although bereft of You.
Perhaps the golden meadows at my feet
Will make the sunny hours of spring seem gay,
And I shall find the white May-blossoms sweet,
Though You have passed away.
Perhaps the summer woods will shimmer bright,
And crimson roses once again be fair,
And autumn harvest fields a rich delight,
Although You are not there.
Perhaps some day I shall not shrink in pain
To see the passing of the dying year,
And listen to Christmas songs again,
Although You cannot hear.
But though kind Time may many joys renew,
There is one greatest joy I shall not know
Again, because my heart for loss of You
Was broken, long ago.
Perhaps – By Vera Brittain
Wilfred Owen (1893-1918)
Wilfred Owen is arguably the greatest War poet in the English Language. Wilfred Edward Salter Owen was born on March 18, 1893, in Oswestry, on the Welsh border of Shropshire. Both parents were of Welsh descent. After a move to Birkenhead, the family settled in Shrewsbury, where Owen attended Shrewsbury Technical School and graduated in 1911 at the age of 18.
Having originally considered a career in the church, he became disillusioned with the inadequate response of the Church of England to the sufferings of the underprivileged. In his spare time, he read widely and began to write poetry.
He spent 2 years in France as a tutor and became an ardent Francophile. The horror of the war in France impacted on him and his decision to enlist. By October he had enlisted and by June 1916 he received a commission as lieutenant in the Manchester Regiment. On December 29, 1916 he left for France with the Lancashire Fusiliers.
On arriving in France, his romantic view of war soon disappeared as he saw the horrors around him and the impact of the conflict on his men.
For example, he described a poisoned gas attack that occurred during one of many marches. This became the basis of his famous poem “ Dulce et Decorum Est” They had marched three miles over a shelled road and three more along a flooded trench, where those who got stuck in the heavy mud had to leave some clothing and equipment, and move ahead on bleeding and freezing feet. They were under machine-gun fire, shelled by heavy explosives throughout the cold march, and were almost unconscious from fatigue when the poison-gas attack occurred.
Suffering from shell shock and “brain concussion” he was admitted Craiglockhart War Hospital in Edinburgh where he met his fellow to poet Siegfried Sassoon. They were to have a major impact on each other’s work
Owen re-joined his regiment in June 1918, and in August, he returned to France. In October he was awarded the Military Cross for bravery at Amiens. He was killed on November 4, 1918, while attempting to lead his men across the Sambre-Oise canal at Ors. He was 25 years old. The news reached his parents on November 11, Armistice Day.
Wilfred Owen wrote nearly all of his poems in slightly over a year, from August 1917 to September 1918. Only five poems were published in his lifetime. The rest were all published later as the public gradually became aware of the horrors of the Great War.
I include 3 poems. The first “Dulce et Decorum Est“ describes that gas attack mentioned above. It needs little in the way of description as it speaks for itself. For those who are not Latin Scholars, the title comes from the Roman poet Horace: “It is sweet and fitting to die for one’s country.”
The second poem is largely self-explanatory. Owen alludes to the futility of war by describing the death of a young rural solider and describes how the power of sun warmed up the earth and created life. He says at the end in desperation “O what made fatuous sunbeams toil To break earth’s sleep at all?”
Finally, “Strange Meeting” is a deep and profound poem about reconciliation. Two soldiers meet each other in an imagined landscape (perhaps in hell). One had killed the other in battle. It was written at a time when hate and loathing were at their height and when the unimaginable scale of the conflict took the lives of millions of young men and women.
I could have included many more great poems by Wilfred Owen and I implore you to read them.
Dulce et Decorum Est
Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge,
Till on the haunting flares we turned our backs,
And towards our distant rest began to trudge.
Men marched asleep. Many had lost their boots,
But limped on, blood-shod. All went lame; all blind;
Drunk with fatigue; deaf even to the hoots
Of gas-shells dropping softly behind.
Gas! GAS! Quick, boys!—An ecstasy of fumbling
Fitting the clumsy helmets just in time,
But someone still was yelling out and stumbling
And flound’ring like a man in fire or lime.—
Dim through the misty panes and thick green light,
As under a green sea, I saw him drowning.
In all my dreams before my helpless sight,
He plunges at me, guttering, choking, drowning.
If in some smothering dreams, you too could pace
Behind the wagon that we flung him in,
And watch the white eyes writhing in his face,
His hanging face, like a devil’s sick of sin;
If you could hear, at every jolt, the blood
Come gargling from the froth-corrupted lungs,
Obscene as cancer, bitter as the cud
Of vile, incurable sores on innocent tongues,—
My friend, you would not tell with such high zest
To children ardent for some desperate glory,
The old Lie: Dulce et decorum est
Pro patria mori.
Dulce Et Decorum Est read by Christopher Eccleston
Move him into the sun—
Gently its touch awoke him once,
At home, whispering of fields half-sown.
Always it woke him, even in France,
Until this morning and this snow.
If anything might rouse him now
The kind old sun will know.
Think how it wakes the seeds—
Woke once the clays of a cold star.
Are limbs, so dear-achieved, are sides
Full-nerved, still warm, too hard to stir?
Was it for this the clay grew tall?
—O what made fatuous sunbeams toil
To break earth’s sleep at all?
Futility read by Alex Jennings
It seemed that out of battle I escaped
Down some profound dull tunnel, long since scooped
Through granites which titanic wars had groined.
Yet also there encumbered sleepers groaned,
Too fast in thought or death to be bestirred.
Then, as I probed them, one sprang up, and stared
With piteous recognition in fixed eyes,
Lifting distressful hands, as if to bless.
And by his smile, I knew that sullen hall,—
By his dead smile I knew we stood in Hell.
With a thousand fears that vision’s face was grained;
Yet no blood reached there from the upper ground,
And no guns thumped, or down the flues made moan.
“Strange friend,” I said, “here is no cause to mourn.”
“None,” said that other, “save the undone years,
The hopelessness. Whatever hope is yours,
Was my life also; I went hunting wild
After the wildest beauty in the world,
Which lies not calm in eyes, or braided hair,
But mocks the steady running of the hour,
And if it grieves, grieves richlier than here.
For by my glee might many men have laughed,
And of my weeping something had been left,
Which must die now. I mean the truth untold,
The pity of war, the pity war distilled.
Now men will go content with what we spoiled.
Or, discontent, boil bloody, and be spilled.
They will be swift with swiftness of the tigress.
None will break ranks, though nations trek from progress.
Courage was mine, and I had mystery;
Wisdom was mine, and I had mastery:
To miss the march of this retreating world
Into vain citadels that are not walled.
Then, when much blood had clogged their chariot-wheels,
I would go up and wash them from sweet wells,
Even with truths that lie too deep for taint.
I would have poured my spirit without stint
But not through wounds; not on the cess of war.
Foreheads of men have bled where no wounds were.
“I am the enemy you killed, my friend.
I knew you in this dark: for so you frowned
Yesterday through me as you jabbed and killed.
I parried; but my hands were loath and cold.
Let us sleep now. . . .”
Strange Meeting read by Tom O’Bedlam
Siegfried Sassoon (1886-1967)
Siegfried Loraine Sassoon, CBE, MC was an English poet, writer, and soldier. Decorated for bravery on the Western Front, he became one of the leading poets of the First World War.
Siegfried Sassoon is best remembered for his angry and compassionate poems about World War I, which brought him public and critical acclaim. Avoiding the sentimentality and jingoism of many war poets such as Rupert Brooke, Sassoon wrote of the horror and brutality of trench warfare and contemptuously satirized generals, politicians, and churchmen for their incompetence and blind support of the war. He was also well known as a novelist and political commentator. In 1957 he was awarded the Queen’s Medal for Poetry.
The first poem, “The Poet as Hero” speaks for itself. The experience of war has changed him from a wealthy idealistic recruit to what he describes as “you’ve asked me why of my old, silly sweetness I’ve repented– my ecstasies changed to an ugly cry”.
Memory was written towards the end of the war. In it he harks back to his idyllic life before the conflict, but he admits that it is a world that no longer exists and all that has happened makes it impossible for him to return to it.
The last poem, The Hero returns to a cynical theme. Here he describes the gulf that exists between the front line and the home front. There is however humanity in the poem as the circumstances of the boy’s death are changed so to give comfort to his grieving mother.
The Poet as Hero
You’ve heard me, scornful, harsh, and discontented,
Mocking and loathing War: you’ve asked me why
Of my old, silly sweetness I’ve repented–
My ecstasies changed to an ugly cry.
You are aware that once I sought the Grail,
Riding in armour bright, serene and strong;
And it was told that through my infant wail
There rose immortal semblances of song.
But now I’ve said good-bye to Galahad,
And am no more the knight of dreams and show:
For lust and senseless hatred make me glad,
And my killed friends are with me where I go.
Wound for red wound I burn to smite their wrongs;
And there is absolution in my songs.
The Poet As Hero – Siegfried Sassoon – Read by William Gwynne
When I was young my heart and head were light,
And I was gay and feckless as a colt
Out in the fields, with morning in the may,
Wind on the grass, wings in the orchard bloom.
O thrilling sweet, my joy, when life was free
And all the paths led on from hawthorn-time
Across the carolling meadows into June.
But now my heart is heavy-laden. I sit
Burning my dreams away beside the fire:
For death has made me wise and bitter and strong;
And I am rich in all that I have lost.
O starshine on the fields of long-ago,
Bring me the darkness and the nightingale;
Dim wealds of vanished summer, peace of home,
And silence; and the faces of my friends.
Memory: Siegfried Sassoon
‘Jack fell as he’d have wished,’ the mother said,
And folded up the letter that she’d read.
‘The Colonel writes so nicely.’ Something broke
In the tired voice that quavered to a choke.
She half looked up. ‘We mothers are so proud
Of our dead soldiers.’ Then her face was bowed.
Quietly the Brother Officer went out.
He’d told the poor old dear some gallant lies
That she would nourish all her days, no doubt
For while he coughed and mumbled, her weak eyes
Had shone with gentle triumph, brimmed with joy,
Because he’d been so brave, her glorious boy.
He thought how ‘Jack’, cold-footed, useless swine,
Had panicked down the trench that night the mine
Went up at Wicked Corner; how he’d tried
To get sent home, and how, at last, he died,
Blown to small bits. And no one seemed to care
Except that lonely woman with white hair.
Hero: Siegfried Sassoon
WB Yates (1865-1939)
William Butler Yeats was an Irish poet and one of the foremost giants of 20th-century literature. A pillar of the Irish literary establishment, he helped to found the Abbey Theatre, and in his later years served two terms as a Senator of the Irish Free State. He was a Nobel Laureate, one of the many that Ireland has produced.
In this poem an Irish airman, fighting in World War I, foresees his death fighting among the clouds. He says that he does not hate those he fights, nor love those he guards. His country is “Kiltartan’s Cross,” his countrymen “Kiltartan’s poor.” He says that no outcome in the war will make their lives worse or better than before the war began. He did not need to fight but many Irish men volunteered to fight in both wars for the British Empire. He did not decide to fight because of a law or a sense of duty, nor because of “public men” or “cheering crowds.” He joined because he wanted to fly when he says, “a lonely impulse of delight” drove him to “this tumult in the clouds.” He says that he weighed his life in his mind and found that “The years to come seemed waste of breath, A waste of breath the years behind.”
An Irish Airman foresees his Death
I know that I shall meet my fate
Somewhere among the clouds above;
Those that I fight I do not hate,
Those that I guard I do not love;
My country is Kiltartan Cross,
My countrymen Kiltartan’s poor,
No likely end could bring them loss
Or leave them happier than before.
Nor law, nor duty bade me fight,
Nor public men, nor cheering crowds,
A lonely impulse of delight
Drove to this tumult in the clouds;
I balanced all, brought all to mind,
The years to come seemed waste of breath,
A waste of breath the years behind
In balance with this life, this death.
Adrian Dunbar recites W.B. Yeats’ An Irish Airman Foresees His Death
John Agard (1949)
John Agard is an Afro-Guyanese playwright, poet and children’s writer, now living in Britain. In 2012, he was selected for the Queen’s Gold Medal for Poetry. Agard grew up in Georgetown, British Guiana. He loved to listen to cricket commentary on the radio and began making up his own, which led to a love of language. He went on to study English, French and Latin at A-level, writing his first poetry when he was in sixth-form, and left school in 1967. He taught the languages he had studied and worked in a local library. He was also a sub-editor and feature writer for the Guiana Sunday Chronicle, publishing two books while he was still in Guyana.
His father settled in London and Agard moved to Britain with his partner the poet Grace Nichols in 1977, settling in Ironbridge, Shropshire. He worked for the Commonwealth Institute and the BBC in London.
This modern poem is a fitting way to finish this selection. How can those heroes adapt to a life in peacetime? Many of homeless in our towns & cities and significant proportion of the prison population are ex-servicemen, made up with those who have not been able to make that transition. Perhaps we should consider these also when we pursue “In Memoriam”
In Times of Peace
That finger – index to be exact –
so used to a trigger’s warmth
how will it begin to deal with skin
that threatens only to embrace?
Those feet, so at home in heavy boots
and stepping over bodies –
how will they cope with a bubble bath
when foam is all there is for ambush?
And what of hearts in times of peace?
Will war-worn hearts grow sluggish
like Valentine roses wilting
without the adrenalin of a bullet’s blood-rush?
When the dust of peace has settled on a nation,
how will human arms handle the death of weapons?
And what of ears, are ears so tuned to sirens
that the closing of wings causes a tremor?
As for eyes, are eyes ready for the soft dance
of a butterfly’s bootless invasion?
In Times of Peace: Read by Noel Clarke
I finish with a few links
First a recording of “The War Requiem” by the English Composer Benjamin Britten. This was composed in 1962 to commemorate the consecration of the new Coventry Cathedral, replacing the medieval building destroyed during the war. Britten incorporates the poetry of Wilfred Owen into the body of the work.
The Requiem is played by the NDR Radiophilharmonie and the Royal Liverpool Philharmonic Orchestra under the musical direction of Andrew Manze in the Kuppelsaal Hannover.
This is a recording of a concert to commemorate 100 years since the end of the Great War
“Oh! What a Lovely War” is a 1969 British musical satire directed by Richard Attenborough which explores the events of World War I, using popular songs of the time. Here is the closing sequence.
The television comedy series called Blackadder follows a fictional aristocratic scoundrel Edmund Blackadder through the ages with his dogsbody, Baldrick. The series finishes with the 1st World War. Blackadder is played by Rowan Atkinson, known around the world as Mr Bean. This is the final sequence when they finally “go over the top” and the laughter turns to pathos
1. International: BBC: Covid vaccine: First ‘milestone’ vaccine offers 90% protection
The first effective coronavirus vaccine can prevent more than 90% of people from getting Covid-19, a preliminary analysis shows.
The developers – Pfizer and BioNTech – described it as a “great day for science and humanity”. Their vaccine has been tested on 43,500 people in six countries and no safety concerns have been raised. The companies plan to apply for emergency approval to use the vaccine by the end of the month. No vaccine has gone from the drawing board to being proven highly effective in such a short period of time. There are still huge challenges ahead, but the announcement has been warmly welcomed with scientists describing themselves smiling “ear to ear” and some suggesting life could be back to normal by spring. “I am probably the first guy to say that, but I will say that with some confidence,” said Sir John Bell, regius professor of medicine at Oxford University.
2. Nature: Russia announces positive COVID-vaccine results from controversial trial
Developers of the Sputnik V vaccine announce phase III results, two days after Pfizer and BioNTech released the first compelling evidence that a vaccine can protect against coronavirus infection. For the second time this week, researchers have announced positive results for the final, human stages of a coronavirus vaccine trial. This time, the results are from the Russian vaccine trial, dubbed Sputnik V.
On 9 November, New York City-based drug company Pfizer put out a press release on positive interim results from a coronavirus vaccine phase III trial — the first to report on the final round of human testing. It was the first compelling evidence that a vaccine can prevent COVID-19. Today, the developers of a controversial Russian vaccine called Sputnik V have announced, also in a press release, that their candidate seems to be similarly effective at preventing the disease. The Gamaleya National Center of Epidemiology and Microbiology in Moscow and the Russian Direct Investment Fund said that an interim analysis of 20 COVID-19 cases identified among trial participants has found that the vaccine was 92% effective. The analysis looked at more than 16,000 volunteers — who received either the vaccine or a placebo — 3 weeks after they had taken the first dose. The trial has enrolled a total of 40,000 participants, the release said
3. UK: RCGP/BMA: Guidance on Workload Prioritisation during COVID-19 Pandemic level Rising
In response to the COVID-19 pandemic, the RCGP and the BMA’s GP committee has prepared joint guidance to help practices across the UK to prioritise the clinical and non- clinical workload in general practice. The current RCGP/BMA guidance on COVID-19 Response Levels can be found here:
The initial pandemic peak in the spring saw a reduction in the breadth of GP services offered as general practitioners and their teams, focused on infection prevention and control in order to keep staff and patients safe, and prioritised workload to focus on the clinical priority of responding to COVID-19 whilst keeping essential core services running. Patients were largely accepting of these changes, understanding the need for GP practices to operate in different ways and to only use face to face consultation methods where clinically necessary. Many patients learnt to self-care for minor self- limiting illnesses and the majority were tolerant of the postponement of more routine management of their long-term health conditions. Some were afraid to enter health facilities and others decided not to present to their GP worried they were overburdening a stretched NHS. During the summer months, as the pandemic level reduced, there was a restoration in most practices, of most GP services to pre-COVID-19 levels, with an accompanying marked rise in non-clinical workload. It also saw the widespread continuation of new consulting methods.
4. Nature: What Pfizer’s landmark COVID vaccine results mean for the pandemic
Scientists welcome the first compelling evidence that a vaccine can prevent COVID-19. But questions remain about how much protection it offers, to whom and for how long. It works! Scientists have greeted with cautious optimism a press release declaring positive interim results from a coronavirus vaccine phase III trial — the first to report on the final round of human testing. New York City-based drug company Pfizer made the announcement on 9 November. It offers the first compelling evidence that a vaccine can prevent COVID-19 — and bodes well for other COVID-19 vaccines in development. But the information released at this early stage does not answer key questions that will determine whether the Pfizer vaccine, and others like it, can prevent the most severe cases or quell the coronavirus pandemic.
“We need to see the data in the end, but that still doesn’t dampen my enthusiasm. This is fantastic,” says Florian Krammer, a virologist at Icahn School of Medicine at Mount Sinai in New York City, who is one of the trial’s more than 40,000 participants. “I hope I’m not in the placebo group.” The vaccine, which is being co-developed by BioNTech in Mainz, Germany, consists of molecular instructions — in the form of messenger RNA — for human cells to make the coronavirus spike protein, the immune system’s key target for this type of virus. The two-dose vaccine showed promise in animal studies and early-stage clinical trials. But the only way to know whether the vaccine works is to give it to a large number of people and then follow them over weeks or months to see whether they become infected and symptomatic. These results are compared with those for a group of participants who are given a placebo.
5. USA: Washington Post: As coronavirus soars, hospitals hope to avoid an agonizing choice: Who gets care and who goes home: New cases and hospitalizations break records
In Ohio, the rapid spread of the virus has pushed the state health-care system to the brink. Expressing deep concern, Gov. Mike DeWine ® vowed to enforce his statewide mask mandate and issued new restrictions on social gatherings. “We can’t surrender to this virus. We can’t let it run wild,” he said.
And in Iowa, where a record number of new infections in a day coincided with a record number of deaths, the White House coronavirus task force issued a dire warning about “the unyielding covid spread” throughout the state.
India: Basic Healthcare Services: Of the glamour of primary health care, and clinical courage
Till 5 years ago, my work as a pediatrician and public health physician was quite far away from primary health care. Be it working in a tertiary care hospital, or a training institution, or being part of community-based research, there was a clear distinction between ‘us’ and ‘them’. My immersion in primary healthcare began 5 years ago, when I started working in deep rural, tribal areas in southern Rajasthan. The early days were so difficult- how do you manage a hypertensive emergency, rheumatic heart disease with failure, antepartum hemorrhage, and more, all at once? My training was in pediatrics, I had last seen adult patients over 20 years ago. I was nervous as anything! Fast forward 5 years, I understand the primary healthcare space much better. “What is it like to work in primary healthcare,” I’m often asked. Well, here goes. A normal day can bring an adolescent with diabetes and ketoacidosis, a severely malnourished child with severe pneumonia, many men with advanced tuberculosis, and a lot more. Many of the sick who actually need hospitalization in a tertiary care hospital, often 70-100 kms away will say- “We cannot go so far. Please do what you can”. And you do. There is little choice anyway. And most of the times, it works.
Many times I hear people say that primary healthcare is about ‘choti-moti bimari’ (minor illnesses). It is much more than that, I want to tell them.
6. Nature: Why do COVID death rates seem to be falling?
Hard-won experience, changing demographics and reduced strain on hospitals are all possibilities — but no one knows how long the change will last. Many regions of the world have experienced the pandemic in punishing waves, but Chennai in India endured a six-month flood, according to Bharath Kumar Tirupakuzhi Vijayaraghavan. The Apollo Main Hospital, where Vijayaraghavan works as an intensive-care specialist, was never overwhelmed, but it was relentlessly busy. And although the numbers of people with COVID-19 finally began to fall in mid-October, Vijayaraghavan worries about the possible impact of the festival season, which began on 20 October, and the public’s waning compliance with health measures. “Everybody is exhausted,” he says. “It’s become a never-ending health-care problem.” One shining light that he can point to is his intensive-care unit’s dwindling fatality rate. In April, up to 35% of those in the unit with COVID-19 perished, and about 70% of those on ventilators died. Now, the intensive-care mortality rate for people with the illness is down to 30%, and for those on ventilators it is around 45–50%. “This itself was a relief,” says Vijayaraghavan. Around the world, similar stories are emerging. Charlotte Summers, an intensive-care physician at the University of Cambridge, UK, says that data collected by the country’s National Health Service (NHS) show a decline in death rates1 (see ‘Mortality falls’). Critical-care physician Derek Angus at the University of Pittsburgh in Pennsylvania says that his hospital’s statistics team also saw reductions over time. “Without question, we’ve noticed a drop in mortality,” says Angus. “All things being equal, patients have a better chance of getting out alive.”
7. South Africa: African Journal of Primary Health Care & Family Medicine (PHCFM): Re-organising primary health care to respond to the Coronavirus epidemic in Cape Town, South Africa
continent. The Metropolitan Health Services have re-organised their primary health care (PHC) services to tackle the epidemic with a community-orientated primary care perspective. Two key goals have guided the re-organisation, the need to maintain social distancing and reduce risk to people using the services and the need to prepare for an influx of people with COVID-19. Facilities were re-organised to have ‘screening and streaming’ at the entrance and patients were separated into hot and cold streams. Both streams had ‘see and treat’ stations for the rapid treatment of minor ailments. Patients in separate streams were then managed further. If patients with chronic conditions were stable, they were provided with home delivery of medication by community health workers. Community health workers also engaged in community-based screening and testing. Initial evaluation of PHC preparedness was generally good. However, a number of key issues were identified. Additional infrastructure was required in some facilities to keep the streams separate with the onset of winter. Managers had to actively address the anxiety and fears of the primary care workforce. Attention also needed to be given to the prevention and treatment of non-COVID conditions as utilisation of these services decreased. The epidemic exposed intersectoral and intrasectoral fault lines, particularly access to social services at a time when they were most needed. Community screening and testing had to be refocused due to limited laboratory capacity and a lengthening turnaround time.
8. WHO: Nature: Where did COVID come from? WHO investigation begins but faces challenges
Identifying the source will be tricky, and investigators will need to grapple with the sensitive political situation. The World Health Organization (WHO) has released its plan to investigate the origins of the COVID pandemic. The search will start in Wuhan — the Chinese city where the new coronavirus SARS-CoV-2 was first identified — and expand across China and beyond. Tracing the virus’s path is important for preventing future viral spillovers, but scientists say the WHO team faces a daunting task. Most researchers think the virus originated in bats, but how it jumped to people is unknown. Other coronaviruses have passed from an intermediate animal host; for example, the virus that caused an outbreak of severe acute respiratory syndrome (SARS) in 2002–04 probably came to people from raccoon dogs (Nyctereutes procyonoides) or civets. “Finding an animal with a SARS-CoV-2 infection is like looking for a needle in the world’s largest haystack. They may never find a ‘smoking bat’” or other animal, says Angela Rasmussen, a virologist at Columbia University in New York City. “It will be key for the investigators to establish a collaborative relationship with scientists and government officials in China.” Nailing down the origins of a virus can take years, if it can be done at all, and the investigation will also have to navigate the highly sensitive political situation between China and the United States. US President Donald Trump has been “calling it a China virus and the Chinese government is trying to do everything to prove that it is not a China virus”, says Linfa Wang, a virologist at Duke–National University of Singapore Medical School. The political blame game has meant that crucial details about research under way in China have not been made public, says Wang, who was part of the WHO mission that looked for the origin of SARS in China in 2003.
9. The Lancet: Bidirectional associations between COVID-19 and psychiatric disorder: retrospective cohort studies of 62 354 COVID-19 cases in the USA
Adverse mental health consequences of COVID-19, including anxiety and depression, have been widely predicted but not yet accurately measured. There are a range of physical health risk factors for COVID-19, but it is not known if there are also psychiatric risk factors. In this electronic health record network cohort study using data from 69 million individuals, 62 354 of whom had a diagnosis of COVID-19, we assessed whether a diagnosis of COVID-19 (compared with other health events) was associated with increased rates of subsequent psychiatric diagnoses, and whether patients with a history of psychiatric illness are at a higher risk of being diagnosed with COVID-19.
Survivors of COVID-19 appear to be at increased risk of psychiatric sequelae, and a psychiatric diagnosis might be an independent risk factor for COVID-19. Although preliminary, our findings have implications for clinical services, and prospective cohort studies are warranted.
10. USA: NEJM Editorial: Dying in a Leadership Vacuum
Covid-19 has created a crisis throughout the world. This crisis has produced a test of leadership. With no good options to combat a novel pathogen, countries were forced to make hard choices about how to respond. Here in the United States, our leaders have failed that test. They have taken a crisis and turned it into a tragedy.
The magnitude of this failure is astonishing. According to the Johns Hopkins Center for Systems Science and Engineering,1 the United States leads the world in Covid-19 cases and in deaths due to the disease, far exceeding the numbers in much larger countries, such as China. The death rate in this country is more than double that of Canada, exceeds that of Japan, a country with a vulnerable and elderly population, by a factor of almost 50, and even dwarfs the rates in lower-middle-income countries, such as Vietnam, by a factor of almost 2000. Covid-19 is an overwhelming challenge, and many factors contribute to its severity. But the one we can control is how we behave. And in the United States we have consistently behaved poorly.
We know that we could have done better. China, faced with the first outbreak, chose strict quarantine and isolation after an initial delay. These measures were severe but effective, essentially eliminating transmission at the point where the outbreak began and reducing the death rate to a reported 3 per million, as compared with more than 500 per million in the United States. Countries that had far more exchange with China, such as Singapore and South Korea, began intensive testing early, along with aggressive contact tracing and appropriate isolation, and have had relatively small outbreaks. And New Zealand has used these same measures, together with its geographic advantages, to come close to eliminating the disease, something that has allowed that country to limit the time of closure and to largely reopen society to a prepandemic level. In general, not only have many democracies done better than the United States, but they have also outperformed us by orders of magnitude.
11. NEJM: Mild or Moderate Covid-19
Coronaviruses typically cause common cold symptoms, but two betacoronaviruses — SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV) — can cause pneumonia, respiratory failure, and death. In late 2019, infection with a novel betacoronavirus, subsequently named SARS-CoV-2, was reported in people who had been exposed to a market in Wuhan, China, where live animals were sold. Since then, there has been rapid spread of the virus, leading to a global pandemic of Covid-19. Here, we discuss the presentation and management of Covid-19 in patients with mild or moderate illness, as well as prevention and control of the infection. Discussion of Covid-19 that occurs in children and during pregnancy and of severe disease is beyond the scope of this article.
KEY CLINICAL POINTS: Mild or Moderate Covid-19
• Covid-19 has a range of clinical manifestations, including cough, fever, myalgias, gastrointestinal symptoms, and anosmia.
• Diagnosis of Covid-19 is commonly made through detection of SARS-CoV-2 RNA by PCR testing of a nasopharyngeal swab or other specimens, including saliva. Antigen tests are generally less sensitive than PCR tests but are less expensive and can be used at the point of care with rapid results.
• Evaluation and management of Covid-19 depend on the severity of the disease. Patients with mild disease usually recover at home, whereas patients with moderate disease should be monitored closely and sometimes hospitalized.
• Remdesivir and dexamethasone have demonstrated benefits in hospitalized patients with severe Covid-19, but in patients with moderate disease, dexamethasone is not efficacious (and may be harmful) and data are insufficient to recommend for or against routine use of remdesivir.
• Infection control efforts center on personal protective equipment for health care workers, social distancing, and testing.
12. South Africa: PHCFM: Family medicine internship support during the COVID-19 pandemic in Cape Town, South Africa – A narrative report
The health-service redesign that came with the preparation for the surge of COVID-19 had a potential of disrupting the Family Medicine internship programme like it did to many other health and academic programmes. A team of Cape-Town based Community Health Centre (CHC) doctors mitigated this challenge by designing an innovative tool that facilitated ongoing supervision of the interns in order to achieve the outcomes of the Health Professions Council of South Africa (HPCSA).
13. Ghana: PHCFM: Exploring the illness experiences amongst families living with 2019 coronavirus disease in Ghana: Three case reports
The 2019 corona virus disease (COVID-19) has wreaked havoc on countries, communities and households. Its effect on individuals and their families, although enormous, has not been adequately explored. We thus present a report on the illness experiences of three families in Ghana who had at least one member diagnosed with COVID-19. We interviewed them and recorded their commonest fears, such as death, stigmatisation and collapse of family business. Respondents had a fair idea about symptoms of COVID-19, mode of transmission and safety precautions. Family separation and loss of income were some of the adverse effects expressed. Majority of them were hopeful that family members with COVID-19 would recover and be reunited. The biopsychosocial impact of COVID-19 is tremendous and family physicians and other primary care workers have an essential role to play in addressing this.
14. NEJM: Persistence and Evolution of SARS-CoV-2 in an Immunocompromised Host
A 45-year-old man with severe antiphospholipid syndrome complicated by diffuse alveolar hemorrhage,1 who was receiving anticoagulation therapy, glucocorticoids, cyclophosphamide, and intermittent rituximab and eculizumab, was admitted to the hospital with fever (Fig. S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). On day 0, Covid-19 was diagnosed by SARS-CoV-2 reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay of a nasopharyngeal swab specimen, and the patient received a 5-day course of remdesivir (Fig. S2). Glucocorticoid doses were increased because of suspected diffuse alveolar hemorrhage. He was discharged on day 5 without a need for supplemental oxygen.
From day 6 through day 68, the patient quarantined alone at home, but during the quarantine period, he was hospitalized three times for abdominal pain and once for fatigue and dyspnea. The admissions were complicated by hypoxemia that caused concern for recurrent diffuse alveolar hemorrhage and was treated with increased doses of glucocorticoids. SARS-CoV-2 RT-PCR cycle threshold (Ct) values increased to 37.8 on day 39, which suggested resolving infection (Table S1).2,3
On day 72 (4 days into another hospital admission for hypoxemia), RT-PCR assay of a nasopharyngeal swab was positive, with a Ct value of 27.6, causing concern for a recurrence of Covid-19. The patient again received remdesivir (a 10-day course), and subsequent RT-PCR assays were negative. On day 105, the patient was admitted for cellulitis. On day 111, hypoxemia developed, ultimately requiring treatment with high-flow oxygen. Given the concern for recurrent diffuse alveolar hemorrhage, the patient’s immunosuppression was escalated (Figs. S1 through S3). On day 128, the RT-PCR Ct value was 32.7, which caused concern for a second Covid-19 recurrence, and the patient was given another 5-day course of remdesivir. A subsequent RT-PCR assay was negative. Given continued respiratory decline and concern for ongoing diffuse alveolar hemorrhage, the patient was treated with intravenous immunoglobulin, intravenous cyclophosphamide, and daily ruxolitinib, in addition to glucocorticoids.
15. UK: NEJM: Trying to “Protect the NHS” in the United Kingdom
By July 1, 2020, the first wave of Covid-19 in Europe had ebbed, with death rates down to less than 5% of their April peaks. After locking down too late, the United Kingdom experienced one of the worst first waves and tied with Spain for cumulative Covid deaths per million population — lower than Belgium but about double the average for the European Union. The effective reproduction number (Re) was less than 1 in all U.K. regions, but many of us warned that there were still too many people infected and that more needed to be done to avoid a second wave in the late autumn.1 A report in mid-July from the U.K. Academy of Medical Sciences suggested that a winter wave could be worse than the first and argued that “intense preparation” was needed over the summer.2 The message from the government, however, was that the worst was over and the economy had to be reopened.
A centerpiece of the government’s response was to be a “world-beating” test, trace, and isolate (TTI) system. Although nearly all public health officers recommended that such a system should reinforce local “boots on the ground” capacity, contracts were given to private companies to build a highly centralized call center, in which minimally trained workers would contact people who had tested positive and attempt to reach their close contacts with the advice to self-isolate. The leaders of the laboratory process similarly ignored requests to strengthen local laboratories and instead built from scratch a network of seven “Lighthouse Laboratories” to which samples had to be sent long distances, with a consequent increase in test turnaround time. Not surprisingly, the TTI system has consistently underperformed, even when case numbers were much lower in July and August. It is now unable to keep up with the surge in infections, and the companies managing it have finally reached out to local public health authorities for help.
16. USA: STAT News: Covid-19 vaccine from Pfizer and BioNTech is strongly effective, early data from large trial indicate
Pfizer and partner BioNTech said Monday that their vaccine against Covid-19 was strongly effective, exceeding expectations with results that are likely to be met with cautious excitement — and relief — in the face of the global pandemic.
The vaccine is the first to be tested in the United States to generate late-stage data. The companies said an early analysis of the results showed that individuals who received two injections of the vaccine three weeks apart experienced more than 90% fewer cases of symptomatic Covid-19 than those who received a placebo. For months, researchers have cautioned that a vaccine that might only be 60% or 70% effective.
The Phase 3 study is ongoing and additional data could affect results.
In keeping with guidance from the Food and Drug Administration, the companies will not file for an emergency use authorization to distribute the vaccine until they reach another milestone: when half of the patients in their study have been observed for any safety issues for at least two months following their second dose. Pfizer expects to cross that threshold in the third week of November.
“I’ve been in vaccine development for 35 years,” William Gruber, Pfizer’s senior vice president of vaccine clinical research and development, told STAT. “I’ve seen some really good things. This is extraordinary.” He later added: “This really bodes well for us being able to get a handle on the epidemic and get us out of this situation.”
17. India: Nature: Scientists criticize use of unproven COVID drugs in India
Researchers say it is unclear on what basis the drugs were approved for ‘emergency use’. In India, which has the world’s second-largest COVID-19 outbreak, there is a desperate need for effective treatments. But researchers are concerned about how the country’s drug regulator is handling potential therapies. The Drugs Controller General of India (DCGI) has approved several repurposed drugs for ‘restricted emergency use’ for treating the disease, the first time it has used such powers. Yet scientists say it’s unclear on what basis the drugs were approved, and critics argue that the manufacturers’ data on their effectiveness is unconvincing so far.
“Transparency is even more important in the pandemic,” says Anant Bhan, a public-health researcher at Yenepoya University in Mangalore. “It’s a new virus where we don’t have definitive treatments available.” Scientists are also concerned that the emergency authorizations are influencing other countries’ decisions. One of the drugs approved for COVID-19 in India is itolizumab, which is used to treat the autoimmune condition psoriasis. This has now been approved for emergency use in Cuba, partly on the basis of Indian data and approval, according to Cuban media. And Equillium, a biotech company based in La Jolla, California, which has a licence to manufacturer itolizumab, received approval in the United States on 29 October to proceed with a large trial. Equillium’s filing to the US financial regulator notes that it was encouraged by India’s data and approval.
18. USA: Washington Post: In North Dakota, asymptomatic health-care workers with covid-19 can stay on duty
North Dakota will now allow health-care workers with asymptomatic cases of covid-19 to continue working in coronavirus wards of hospitals, Gov. Doug Burgum ® announced Monday. The change is meant to ease some of the burden on hospitals facing staffing shortages as doctors and nurses become infected or self-quarantine due to contact with an infected person, Burgum said at a news conference. Asymptomatic workers awaiting test results can also continue serving, which the governor said should free dozens of staff members at a time in each hospital. North Dakota has further tried to reduce the strain on hospitals by contracting with nurses from out of state, pausing elective surgeries at some locations and implementing surge plans, Burgum said. Still, he said the state’s hospitals “are under enormous pressure” as roughly 20 percent of patients have covid-19.
Coronavirus-related hospitalizations in North Dakota have been trending sharply upward since early October. That figure has more than tripled from 106 on Oct. 1 to 343 on Tuesday, according to data tracked by The Washington Post. Of those hospitalized patients, about a quarter are in intensive care units.
19. UK: BBC: Coronavirus: 5,000 ‘extra’ heart deaths since March
Almost 5,000 more people have died from heart problems in England than would be expected since the start of the pandemic, the British Heart Foundation has warned.
Analysis by the charity found excess deaths are 7% above predicted levels.
It is urging people not to delay checks or treatment during the second wave of the virus.
NHS England said hospitals are redesigning services so that care can go ahead safely.
The BHF analysed mortality data in England between the start of the first national lockdown on 20 March and 30 October.
It found 73,799 cases where heart or circulatory disease was named as the underlying cause of death. That is 4,785 higher than the number projected by Public Health England over the same time period.
In around a quarter of the additional or excess cases, Covid-19 was mentioned on the death certificate, suggesting that in the majority of cases other factors were to blame.
20. Argentina: ARTE: Video: The Homeless of the Pandemic
Living in Guernica, Argentina, is nobody’s dream but everybody’s last resort. The pandemic left these families no longer able to pay rent, and so instead the shanty town of Guernica sprang up in July in a matter of days. But even this last refuge is under threat, as the land the shacks are built on is private property, earmarked for a luxury development.
S ED Video
21. Nature: COVID mink analysis shows mutations are not dangerous — yet
The analysis found the mutations probably won’t jeopardize vaccines, but scientists say the rampant spread means the animals still need to be killed.
Health officials in Denmark have released genetic and experimental data on a cluster of SARS-CoV-2 mutations circulating in farmed mink and people, days after they announced the mutations could jeopardize the effectiveness of potential COVID-19 vaccines. News of the mutations prompted the Danish Prime Minister Mette Frederiksen to announce on 4 November plans to end mink farming for the foreseeable future — and cull some 17 million animals — sparking a fierce debate about whether such action was legal. But scientists were careful not to raise the alarm until they saw the data. Now, scientists who have reviewed the data say the mutations themselves aren’t particularly concerning because there is little evidence that they allow the virus to spread more easily among people, make it more deadly or will jeopardize therapeutics and vaccines. “The mink-associated mutations we know of are not associated with rapid spread, nor with any changes in morbidity and mortality,” says Astrid Iversen, a virologist at the University of Oxford, UK.
22. India: Bloomberg: How the World’s biggest Slump Stopped the Virus
Normally, Khwaja Qureshi’s recycling facility in Dharavi, the slum in Mumbai, would be no place for three newborn tabby kittens. Before efforts to contain the novel coronavirus idled much of the Indian economy, the 350-square-foot concrete room was a hive of nonstop industry. Five workers were there 12 hours a day, seven days a week, dumping crushed water bottles, broken television casings, and discarded lunchboxes into a roaring iron shredder, then loading the resulting mix of plastic into jute sacks for sale to manufacturers. But during a recent visit, the shredder was silent and the workers gone, decamped to their villages in India’s north. That left the kittens plenty of space to gambol across the bare floor, nap on a comfortable cardboard box, or be amused by the neighborhood kids who came to visit.
Qureshi, a stout, thick-fingered man of 43 whose father founded the operation, mostly ignored his feline workplace companions. He’d been spending his days sitting on a plastic chair, drinking cup after cup of milk tea and chatting with other Dharavi entrepreneurs, all of them part of Mumbai’s fearsomely efficient but completely informal recycling industry, who stopped by to talk business. The consensus was pessimistic. India’s economy is in an historic slump, and less economic activity means fewer things being thrown away—and also less demand to make new products from the old. No one had much hope that things would pick up soon.
The irony is that Dharavi, which has a population of about 1 million and is probably the most densely packed human settlement on Earth, has largely contained the coronavirus. Thanks to an aggressive response by local officials and the active participation of residents, the slum has gone from what looked like an out-of-control outbreak in April and May to a late-September average of 1.3 cases per day for every 100,000 residents, compared with about 7 per 100,000 in Portugal. That success has made Dharavi an unlikely role model, its methods copied by epidemiologists elsewhere and singled out for praise by the World Health Organization. It’s also a remarkable contrast to the disaster unfolding in the rest of India. The country has recorded more than 6.5 million confirmed cases—putting it on track to soon overtake the U.S.—and over 103,000 deaths.
23. Australia: University of Melbourne: ADOLESCENCE – A CRITICAL TIME TO ADDRESS GENDER INEQUALITY
A major study across 40 countries in Asia and the Pacific reveals the stark gender inequalities faced by adolescents, providing a roadmap for effective action
Adolescence should be a time of opportunities. But for millions of adolescents around the world, early and later adolescence is blighted by emerging gender inequalities.
Most often it is girls who are disadvantaged, but there are aspects of life where gender norms mean boys are more likely to experience harms.
Published in Lancet Global Health, our major study of the state of children and adolescents across 40 low-and middle-income countries in Asia and the Pacific – home to half the world’s population aged 18 and under – has highlighted that gender inequality accelerates from early adolescence. The data show that, in the region, preference for sons remains – in places like India, Vietnam and China, more boys are born compared to girls than is naturally expected, and more girls die in infancy and very early childhood in some countries in South Asia and the Pacific.
But in the majority of countries, there are few gender differences for health, education and other outcomes during childhood. It is during early adolescence that disparities become evident. Compared to boys, adolescent girls spend more time on household chores, are less likely to have access to the internet and information media, and are more likely to be married and to become a parent. Over 25 per cent of girls in Afghanistan, Bangladesh, Bhutan, India, Nepal and Laos are already married by the time they are 18.
24. Nature: Exclusive: Behind the front lines of the Ebola wars: How the World Health Organization is battling bullets, politics and a deadly virus in the Democratic Republic of the Congo.
Tedros Adhanom Ghebreyesus concentrates on a map of a long-forsaken war zone in the northeastern provinces of the Democratic Republic of the Congo (DRC). Ebola is gaining ground here, and Tedros, the director-general of the World Health Organization (WHO), needs to stop it. He huddles in a dim corner of a mess hall with his officers on the front lines. Their fingers dance across the map as they point to areas occupied by militia and explain how their teams struggle to circulate through these parts with vaccines and thermometers, key tools for limiting Ebola’s transmission. As darkness falls, more WHO staff file into the hall at the United Nations compound in Butembo, a volatile city in North Kivu province. The din of their conversations rises as a buffet of stewed meat, fried fish and plantains gets cold and some boxed wine grows warm. Eventually, Tedros, as he prefers to be called, ends the meeting with his top aides and announces that it’s time to eat.
He settles into a chair at a table of young Ebola responders — mainly Congolese public-health specialists and physicians — and falls silent. It was June, and Tedros was facing pressure from all directions. The outbreak had already grown to be the second largest in history. And despite having a new Ebola vaccine and drugs to treat the disease, the death rate was soaring at 67% because the therapies weren’t reaching everyone in need. Armed groups weren’t the WHO’s only challenge. Many residents just didn’t accept that Ebola responders were there to help. A deep-seated scepticism of outsiders comes from more than a century of conflict, exploitation and political corruption in the region. And wars over the past 25 years have destroyed any semblance of a reliable, regulated health system. “The outbreak of Ebola is a symptom,” Tedros explains. “The root cause is political instability.”
25. USA: University of Pittsburgh: Modern-Day Hippocrates: Incoming School of Medicine Students Write Their Own Oath
In addition to reciting the traditional Hippocratic Oath during the White Coat Ceremony on Aug. 16, the members of the University of Pittsburgh School of Medicine’s Class of 2024 started a new tradition by writing their own class oath to acknowledge their ever-evolving responsibilities as physicians.
On the Friday before the ceremony, students officially presented the new oath to Anantha Shekhar, senior vice chancellor for the health sciences and John and Gertrude Petersen Dean of the School of Medicine.
“At Pitt, we challenge our students to change the world—and the future of medicine—for the better. This class didn’t wait,” said Shekhar. “Their class oath, the first of its kind in our program’s history, speaks to the power and importance of clinical care and research in creating a more inclusive and just society, and I am excited to watch them put this promise into practice.”
Working with advisors and student affairs leadership, the oath-writing committee dedicated 80 hours to writing the Oath of Professionalism during orientation week. The oath—which highlights issues such as COVID-19, health care disparities and racial injustice—is not merely about current events, said first-year medical student Tito Onyekweli. “We believe that our oath acknowledges the context of U.S. history and medicine, and uses it to explain our current state,” Onyekweli said. “We used the past and present to clarify our future goals as physicians.” The students did acknowledge that they are beginning their careers in medicine at an unforgettable time. The oath addresses championing diversity in medicine and society, being an ally to those of low socioeconomic status and restoring trust in the health care community.
“We start our medical journey amidst the COVID-19 pandemic and a national civil rights movement reinvigorated by the killings of Breonna Taylor, George Floyd and Ahmaud Arbery,” the oath begins. “We honor the 700,000+ lives lost to COVID-19, despite the sacrifices of health care workers.” Moving forward, each incoming Pitt Med class will be invited to write its own unique oath during orientation week in an effort to help establish their professional identities as physicians.
26. USA: NEJM: An Outbreak of Covid-19 on an Aircraft Carrier
The U.S.S. Theodore Roosevelt was conducting operations in the western Pacific Ocean when an outbreak of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) occurred on board. On identification of the outbreak, the ship was diverted to U.S. Naval Base Guam. The base hospital, a 42-bed inpatient facility, provides medical care for U.S. military beneficiaries and others in the region. Although the initial response was handled by the medical staffs of the ship and Naval Hospital Guam, it was quickly augmented by a joint medical task force.
This report provides key findings from the U.S. Navy response and epidemiologic investigation of the outbreak. Over the course of the response, every member of the crew of the U.S.S. Theodore Roosevelt was evaluated, tested, placed in isolation or quarantine, and monitored on a daily basis to ensure their well-being. Our findings offer insights into the epidemiology and outcomes of SARS-CoV-2 infection in healthy, fit, military-aged adults who are housed in close quarters.
27. UK: RCGP: Recruitment and implementation of medical students in response to COVID-19
This resource acts as a guide to practices considering supplementing their workforce (e.g. use of medical students) in response to COVID-19. This document offers guidance, examples and best practice to suit the needs of your local circumstances.
“Our practice is looking to gain the support of medical students in response to COVID-19.”
Have you been contacted by your local medical school? Each medical school is responsible for their own medical students. Each school is therefore responsible for developing their own process for which medical students will be able to 1) express their interest/support; 2) seek approval from their parent medical school; 3) be matched with a local trust and/or practice. In the first instance, medical schools are likely to contact their network of practices to assess local demand, many of which are teaching practices that already have strong links with the medical school and their primary care department. If you have received contact with your medical school, you’re in the strongest position and we’d advise you to follow the guidance and instruction provided by your local school. If you haven’t been contacted, it is likely that your local medical school is taking a different approach and we’d recommend that you contact one of the following organisations if you wish to take on medical students at your practice during this time:
• Local medical school(s)
• Relevant Primary Care Network, Health Board, Cluster or equivalent
• Relevant Training Hub.
If your geographical location means that you don’t have a medical school within a reasonable distance of your practice, we’d recommend you contacting your local PCN, Health Board, Cluster, Training Hub or equivalent in the first instance. Though medical students are advised to seek opportunities local to their medical school, there are opportunities for them to offer support local to their home address.
28. How to stop restaurants from driving COVID infections: US mobile data suggests restaurants, gyms and cafes can be COVID hotspots — and reveals strategies for limiting spread.
In cities worldwide, coronavirus outbreaks have been linked to restaurants, cafes and gyms. Now, a new model using mobile-phone data to map people’s movements suggests that these venues could account for most COVID-19 infections in US cities.
The model, published in Nature today, also reveals how reducing occupancy in venues can significantly cut the number of infections.
The model “has concrete pointers as to what may be cost-effective measures to contain the spread of the disease, while at the same time, limiting the damage to the economy”, says Thiemo Fetzer, an economist at the University of Warwick in Coventry. “This is the policy sweet spot.”
To predict how people’s movements might affect viral transmission, the research team input anonymized location data from mobile-phone apps into a simple epidemiological model that estimated how quickly the disease spreads. The location data, collected by SafeGraph, a company based in Denver, Colorado, came from 10 of the largest US cities, including Chicago, Illinois; New York; and Philadelphia, Pennsylvania. It mapped how people moved in and out of 57,000 neighbourhoods to points of interest, such as restaurants, churches, gyms, hotels, car dealers and sporting-goods stores for 2 months starting in March.
29. USA: Wired: The Strange and Twisted Tale of Hydroxychloroquine
The much-hyped drug sparked a battle between power and knowledge. Let’s not repeat it.
IN THE MID-1600S, a Jesuit priest serving in Peru got a useful tip. The indigenous people there, he learned, were using the bark of a particular kind of tree to treat fevers. The priest, who’d probably gone a few rounds himself with the local diseases, got ahold of some of the reddish-brown bark from this “fever-tree” and shipped it back to Europe. In the 1670s, what came to be called Jesuit bark had made its way into a popular patent medicine, along with rose leaves, lemon juice, and wine.
That was the beginning of the impressively effective bark’s role in pharmacology (and its side career in mixology). In the mid-1700s the prolific Swedish taxonomist Carl Linnaeus gave the tree’s genus its name—having heard a fanciful (and untrue) tale about the bark’s success treating the Spanish Countess of Chinchón, he dubbed it Cinchona. In 1820, French chemists isolated the active ingredient, a plant alkaloid they named quinine. Its bitter flavor became not only a hallmark of the prevention and treatment of malaria but also the basis for a medicinal fizzy water—a “tonic”—that mixed well with the gin that Europeans brought with them to their equatorial conquests. Today quinine can be found in bitters, vermouth, and absinthe; next time you order a Manhattan or a Sazerac, give a little l’chaim to the Peruvians.
Medicine that treats a deadly disease but grows only on certain finicky trees is the kind of thing chemists live for. A failed attempt to synthesize quinine in the 1800s had accidentally produced the first synthetic pigment (a lovely shade of mauve); after World War I, when endemic malaria arguably did almost as much as Allied soldiers to limit Germany’s expansionist ambitions, that country set its scientists to solving a problem. A dye company called Bayer took up the quinine challenge, synthesized some reasonably useful replacements, and became a pharmaceutical powerhouse with a global market. When World War II denied the US access to both German drugs and the quinine-producing cinchona trees of Java, the Americans basically stole a recipe from German prisoners of war and turned that into a successful treatment.
That drug was called chloroquine. It has a slightly better-tolerated cousin, hydroxychloroquine. You may have heard of them.
30. Nature: Memo for President Biden: Five steps to getting more from science: Going back to normal is not enough. A revamp is required.
As things look now, the US presidency of Donald Trump will soon be in the rear-view mirror, but the damage his administration leaves behind will require a sustained effort to repair. That’s especially true when it comes to restoring competency and trust in federal research agencies. President-elect Joe Biden needs to do this as soon as possible, not least to quell a pandemic that is setting records for the numbers of new cases and is on track to kill more Americans than died in the Second World War. The country cannot continue to bear the ad hoc, ineffective and incoherent pandemic response it has endured under Trump. The list of needed actions is long, but here we highlight five that the Biden administration should take swiftly. We call not for a return to business as usual but for fundamental, sometimes counter-intuitive changes that will strengthen the use of science in US policy and by the research community more broadly.
31. UK: BMA/RCGP: COVID-19 Response Levels Workload prioritisation for primary care
This document outlines types of work that should be undertaken in primary care, depending on COVID-19 prevalence. As COVID-19 becomes more prevalent, it may be appropriate to move to higher response level and de-prioritise some clinical and non-clinical work and focus on continued delivery of a reduced range of general practice services. Decisions to move between levels should be taken at a local level, with due consideration of national conditions and guidance.
Maintaining public confidence that ‘general practice is open’ and that where clinically appropriate, face to face access to GP’s is possible, must be a clear communication priority at all levels of response. When deciding on service prioritisation the RCGP and BMA RAG rated guide, RCGP Guidance on workload prioritisation during COVID-19 (April 2020), may help frame conversations with local partners. This guide can be found here: https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP- guidance/202003233RCGPGuidanceprioritisationroutineworkduringCovidFINAL.ashx?la =en.
32. USA: Washington Post: Trump rails against ‘medical deep state’ after Pfizer vaccine news comes after Election Day
But company insists the election didn’t affect timing of the promising data.
President Trump is lashing out at the Food and Drug Administration following a disclosure Monday that an experimental coronavirus vaccine from pharmaceutical giant Pfizer is more than 90 percent effective,convinced the timing — six days after Election Day — proves the “medical deep state” deliberately tried to sabotage his electoral prospects by delaying the results. Shortly after Trump heard the news Monday, he demanded Health and Human Services Secretary Alex Azar “get to the bottom” of what happened with Pfizer, according to a senior White House official who spoke on the condition of anonymity to describe the president’s actions. A few hours later, the issue was front and center at a meeting of the White House coronavirus task force when FDA Commissioner Stephen Hahn briefed members about the vaccine data.
33. UK: Royal College of Physicians: Ethical guidance published for frontline staff dealing with pandemic
The Royal College of Physicians has published ethical guidance for frontline staff dealing with the COVID-19 pandemic, supported by more than a dozen other health organisations. Members of the RCP’s Committee on Ethical Issues in Medicine, chaired by Dr Alexis Paton, developed the guidance, which is supported by nine other Royal Colleges and five medical faculties. It takes into consideration recent joint statements from the General Medical Council (GMC), the NHS and the UK’s four Chief Medical Officers. The guidance reminds frontline staff that while so much has changed during the pandemic, they still need to ensure that care is provided in a fair and equitable way.
34. USA: Washington Post: President-elect Biden announces coronavirus task force made up of physicians and health experts
President-elect Joe Biden on Monday announced the members of his coronavirus task force, a group made up entirely of doctors and health experts, signaling his intent to seek a science-based approach to bring the raging pandemic under control.
Biden’s task force will have three co-chairs: Vivek H. Murthy, surgeon general during the Obama administration; David Kessler, Food and Drug Administration commissioner under Presidents George H.W. Bush and Bill Clinton; and Marcella Nunez-Smith, associate dean for health equity research at the Yale School of Medicine. Murthy and Kessler have briefed Biden for months on the pandemic.
Biden will inherit the worst crisis since the Great Depression, made more difficult by President Trump’s refusal to concede the election and commit to a peaceful transition of power. The Trump administration has not put forward national plans for testing, contact tracing and resolving shortages in personal protective equipment that hospitals and health-care facilities are experiencing again as the nation enters its third surge of the virus.
35. NEJM: Perspective: The Stress of Bayesian Medicine — Uncomfortable Uncertainty in the Face of Covid-19
“Have you heard about Covid toes?” My wife, while working through her clinical notes from her pediatrics practice that day, asked the question with a tone of resignation. I hadn’t, but I quickly searched the Web and found a number of reports of rashes on the toes of children infected with SARS-CoV-2. I remembered from medical school that rashes were a relatively common symptom in children with viral infections, but the fact that kids were showing any signs of SARS-CoV-2 infection was worrisome.“Yikes. Did you see that today?” I asked. “No, I just read about it,” she sighed. “I’m sure we’ll be getting calls.” A statistic commonly cited by medical educators is that the corpus of medical knowledge doubles approximately every 2 years. But though that may very well be true in the aggregate, the day-to-day practice of medicine does not change at a breakneck pace. The treatment of the vast majority of human ailments is based on decades of knowledge and is built on a foundation of research into normal human body functioning and the origin and nature of disease states and the ways in which the field of medicine can detect and treat them.
In my experience, the medical profession tends to select for individuals who crave a particular kind of mastery. Over many years, we immerse ourselves in the science and practice of healing, memorizing information from books and articles that give us the most accurate picture of myriad illnesses and their treatment. Though sometimes a single paper might break through and reach the front lines of medicine in a matter of months, the truth is that these changes usually occur slowly, allowing physicians to carefully update their knowledge and retain their claim on expertise.
Covid has blown a hole in that version of medicine.
36. Nature: ‘I’ve never worked harder’: the race to develop a COVID-19 vaccine
Teresa Lambe is working with AstraZeneca to give the world a shot against the SARS-CoV-2 coronavirus.
Since mid-January, my laboratory at the Jenner Institute at the University of Oxford, UK, has had a clear focus: developing a vaccine against the SARS-CoV-2 coronavirus. The −80 °C freezers in the background contain blood and serum samples from volunteers who have received a trial vaccine. The grey machine on my right reads the level of antibodies in those samples, a key measure of the vaccine’s effectiveness. We started our quest as soon as the genetic information for SARS-CoV-2 was published in January, when the virus was still largely confined to China. My brother was there at the time, so, over-protective big sister that I am, I was paying extra attention to what was going on. By mid-February, after working nights and weekends, my team had developed a vaccine that produced an antibody response in a small preclinical trial. We were well prepared to act quickly. The lab had been working on vaccines for other pathogens, including a type of coronavirus that causes Middle East respiratory syndrome (MERS). We already had viral vector, a modified cold virus that could safely and reliably deliver pieces of coronavirus to host cells, thereby triggering a response from the immune system. People ask why and how we moved so fast, but this is what we do. We develop and test vaccines.
Our vaccine is now undergoing phase III clinical trials. To ensure that it could be produced at industrial levels and delivered globally, if approved, we partnered with the pharmaceutical firm AstraZeneca.
37. USA: The Hill: Trump administration testing czar: Rise in cases is ‘real,’ not just from more testing
The Trump administration’s testing czar, Brett Giroir, said Tuesday that the country’s increase in coronavirus cases is not just because of more testing but also a surge in the disease across the country. His comments offer a stark contrast with those of President Trump. “Testing may be identifying some more cases, I think that’s clearly true, but what we’re seeing is a real increase in the numbers,” Giroir, an assistant secretary of Health and Human Services, said at a Washington Post Live event. “Compared to the post-Memorial Day surge, even though testing is up, this is a real increase in cases,” he added. “We know that not only because the case numbers are up and we can calculate that, but we know that hospitalizations are going up.”
The rise in hospitalizations is widely used as an indicator to show that the spread of the virus really is worsening in the United States.
Trump, however, has continued to blame testing for the increase in cases.
“Cases up because we TEST, TEST, TEST,” he tweeted Monday. “A Fake News Media Conspiracy. Many young people who heal very fast. 99.9%. Corrupt Media conspiracy at all time high. On November 4th., topic will totally change. VOTE!”
Experts have widely said the increase is not just because of more testing.
There are about 43,000 people in the hospital with coronavirus, according to the COVID Tracking Project, up from about 30,000 at the beginning of the month.
38. USA: STAT News: It may be time to reset expectations on when we’ll get a Covid-19 vaccine
he ambitious drive to produce Covid-19 vaccine at warp speed seems to be running up against reality. We all probably need to reset our expectations about how quickly we’re going to be able to be vaccinated.
Pauses in clinical trials to investigate potential safety issues, a slower-than-expected rate of infections among participants in at least one of the trials, and signals that an expert panel advising the Food and Drug Administration may not be comfortable recommending use of vaccines on very limited safety and efficacy data appear to be adding up to a slippage in the estimates of when vaccine will be ready to be deployed.
Asked Wednesday about when he expects the FDA will greenlight use of the first vaccines, Anthony Fauci moved the administration’s stated goalpost.
39. UK: University of Edinburgh: Covid-19 drug trial raises prospect of home treatment
A drug first developed more than 30 years ago is to have its effectiveness at reducing the progression of Covid-19 trialed in people who are self-isolating after testing positive for the disease. Researchers hope the treatment, which has been used for many years in Japan to reduce inflammation of the pancreas, if effective will reduce hospital admissions and ease pressure on the NHS. Scientists say the drug, called Camostat, can work by suppressing the ability of COVID-19 virus to infect human cells.
Home focus: This trial, called SPIKE-1, is one of the first to focus on people at home who have Covid-19. Most others until now have looked at patients in hospital.
The team believe that Camostat could be a potential treatment due to the data already gathered showing that it impairs the entry of coronaviruses into cells and may help stop the disease in humans.
40. UK: RCGP Learning: Shielding vulnerable patients from COVID-19
Shielding is a public health measure announced at the start of the COVID-19 pandemic. Those at the highest risk were advised not to leave the house at all for 12 weeks. That first phase of shielding has now ended and shielding is paused. In this short module we discuss the possible future of shielding, why it is important to keep the shielding list up to date, and what to do if the parent of a vulnerable child asks you about shielding or an adult previously in the shielding group asks for a fit note because they feel uncomfortable about returning to work. The previous module, with much more detail on the original shielding system, is archived and can be downloaded for reference. This module will be updated if there are new announcements on shielding and should be read in conjunction with any local information about added restrictions in your area.
41. UK: HSJ: NHS staff to get twice-weekly home covid tests with immediate effect
The NHS will roll out twice-weekly asymptomatic testing for all patient-facing hospital staff by the end of next week, according to a letter from NHS medical director Stephen Powis. Government said only last week that universal asymptomatic staff testing would start in December, but government has now agreed it will bring this forward to this week for a first tranche of 34 trusts; and all others next week.
HSJ has asked if primary care is covered.
The tests at 34 trusts this week will cover “over 250,000 staff,” Professor Powis said. He set out plans for the new testing regime in a letter to Commons health and social care committee chair Jeremy Hunt who has been pressing the government for routine staff testing since the summer. “Staff will be asked to test themselves at home twice a week with results available before coming into work,” Professor Powis said. The new testing regime can start following “further scientific validation of the lateral flow testing modality last week, and confirmation over the weekend from Test and Trace that they can now supply the NHS with sufficient test kits”.As of last week, the government and NHSE’s plan was to use a different method — Loop-Mediated Isothermal Amplification or LAMP saliva tests — for staff routine testing; but this will not be on stream until December. The lateral flow tests will be used, in staff’s homes, in the meantime. Lateral flow tests are less accurate than the PCR swab tests, having lower specificity and lower sensitivity. A test’s specificity relates to the proportion of samples it can correctly identify as negative for the coronavirus. Its sensitivity relates to the proportion of samples it can correctly identify as positive for the virus.
42. USA: Washington Post: More than 130 Secret Service officers are said to be infected with coronavirus or quarantining in wake of Trump’s campaign travel
More than 130 Secret Service officers who help protect the White House and the president when he travels have recently been ordered to isolate or quarantine because they tested positive for the coronavirus or had close contact with infected co-workers, according to three people familiar with agency staffing.
The spread of the coronavirus — which has sidelined roughly 10 percent of the agency’s core security team — is believed to be partly linked to campaign rallies that President Trump held in the weeks before the Nov. 3 election, according to the people who, like others interviewed for this report, spoke on the condition of anonymity to describe the situation.
In all, roughly 300 Secret Service officers and agents have had to isolate or quarantine since March because they were infected or exposed to infected colleagues, according to two people with knowledge of the figures.
43. USA: Washington Post: Democrats allege GOP refusal to accept election results is imperiling U.S. coronavirus response
Biden joins congressional Democrats to call for an economic relief package
Congressional Democratic leaders accused Republicans on Thursday of refusing to confront the dramatically worsening coronavirus pandemic and instead acquiescing to President Trump’s false insistence that he won last week’s presidential election.
Republicans dismissed the attacks and Trump didn’t weigh in at all, with his only public comments coming through a series of Twitter posts that included false claims of electoral success. As Washington has become paralyzed over the past 10 days, 1 million new people have tested positive for the virus as death numbers are climbing rapidly.
President-elect Joe Biden joined congressional Democratic leaders on Thursday and demanded a new economic relief package to address the dramatically worsening coronavirus pandemic before the end of the year.
Senate Majority Leader Mitch McConnell (R-Ky.) flatly rejected such a proposal, while Sen. Susan Collins (R-Maine) implored both sides to begin negotiating as the virus appeared to be sending a new shudder through the U.S. economy.
44. CDC: Indicators for Dynamic School Decision-Making
It is critical for schools to open as safely and as quickly as possible for in-person learning. To enable schools to open and remain open, it is important to adopt and correctly and consistently implement actions to slow the spread of SARS-CoV-2, the virus that causes COVID-19, not only inside the school, but also in the community. This means that students, families, teachers, school staff, and all community members should take actions to protect themselves and others where they live, work, learn, and play. In short, success in preventing the introduction and subsequent transmission of SARS-CoV-2 in schools is connected to and dependent upon preventing transmission in communities.
45. USA: Harvard Medical School: COVID-19 Costs Primary Care Billions
Declines in patient visits during pandemic projected to cost U.S. primary care practices $15 billion in revenue
Primary care practices are projected to lose more than $65,000 in revenue per full-time physician in 2020, following drastic declines in office visits and fees for services from March to May during the COVID-19 pandemic, according to a study led by researchers in the Blavatnik Institute at Harvard Medical School.
The lost revenue adds up to a shortfall of $15 billion to primary care practices across the United States, according to the analysis, published Jun 25 in Health Affairs.
Best wishes to you all and stay safe