Miscellaneous Miscellany

I know that you are all going to tell me that I had decided to send out Rural Miscellany on a weekly basis, but I have so many links gathered together, that I felt I should send this out as an extra.
Thank you to those who send me their special poems and links. I thought that I would use this extra edition to share them with you all. Please keep them coming!


Dr David Campbell is a GP in Lakes Entrance, Victoria, Australia. As well as being a rural GP he has made an enormous contribution to Rural Health Care in Australia. He has served for many years on the Board of the Australian College of Rural and Remote Medicine (ACRRM), first as the Victorian Director, then Vice President, then President. He has practised as a rural doctor in Lakes Entrance, Victoria since 1983 and is a foundation member and Fellow of the College. He is currently Director of the East Gippsland Regional Clinical School and Associate Professor, Rural Community-Based Medical Education, with Monash University. He is a member of the Committee of Management of Rural Doctors’ Association of Victoria. David is a Director of Gippsland Education and Training for General Practice, and has recently joined the Board of “Southern GP Training” in Victoria. He has special interests in medical education and emergency medicine and is an instructor with Advanced Paediatric Life Support Australia, as well as principal author and instructor with the “Rural Emergency Skills Training” Course in Australia.
David sent me this poem which he wrote in the style of the poem by the Australian poet, Banjo Paterson’s famous poem “The Man from Snowy River” after attending a conference in the USA.
David writes:
“The Man from Snowy River” is a poem by Australian bush poet Banjo Paterson. It was first published in The Bulletin, an Australian news magazine, on 26 April 1890, and was published by Angus & Robertson in October 1895, with other poems by Paterson, in The Man from Snowy River and Other Verses.
The poem tells the story of a horseback pursuit to recapture the colt of a prizewinning racehorse that escaped from its paddock and is living with the Brumbies (wild horses) of the mountain ranges. Eventually, the Brumbies descend a seemingly impassably steep slope, at which point the assembled riders give up the pursuit, except the young protagonist, who spurs his “pony” (small horse) down the “terrible descent” and catches the mob.
Two characters mentioned in the early part of the poem are featured in previous Paterson poems; “Clancy of the Overflow” and Harrison from “Old Pardon, Son of Reprieve”.
The poem was already famous and well-known across Australia before the story was made into a film in 1982, directed by George Miller, and grossed $50 million AUD in the box office.
I wrote “The Man from Flathead River” in 2013 after the CLIC conference in Montana, where our visit to Yellowstone National Park was cancelled because of the Government Shutdown during the Obama Presidency when the Republicans had control of the Senate.
The CLIC conference was hosted by Jay Erickson, a family physician in Whitefish Montana, USA. Jay is also the Assistant Clinical Dean of the Montana WWAMI program assisting students and young doctors to undertake their training in rural Montana.
The Flathead River runs through Jay’s home town of Whitefish. When our tour was cancelled, Jay stepped up, rounded us up, and took us on a bus ride through the snow in “outback” Montana, visiting some famous historic sites and engaging us with the fascinating history of the region.
The poem was a tribute to Jay and his team and his organisational skills.

The Man form Flathead River

There was movement in Montana, for the word had passed around
That the government had shut down all the parks,
Yellowstone included; CLIC delegates excluded
By the Tea Party–they nearly broke our hearts.
All the well-known medical educators from the canyons and the plains
Had mustered at the Big Sky overnight,
For rural docs love a challenge when the cowpat hits the fan,
And with admin staff face a battle with delight.

There was Ellen from Seattle who hailed from Albuquerque way,
The woman with her hair as white as snow;
Few could go beside her when she jumped into the fray –
She would tread where few professors dared to go.
Ron Loge out from Dillon way came down to lend a hand,
No better teacher ever held the reins;
No disease could ever beat him while with students he did stand,
He liked to teach while skiing on the plains.

And Mike was there, with Masters to guide us in the bus,
With one hand on the wheel he liked to drive
With ponytail, moustache and endless tales for us-
such as are by mountain drivers prized.
He was hard and tough and wiry – just the sort that won’t say die –
There was courage in his quick impatient tread;
And he bore the badge of gameness in his bright and fiery eye,
And the proud and lofty carriage of his head.

But still we needed someone to find out where we all could stay,
And choose a route that Yellowstone could match.
What better team for this than Bernadette and Jay
To put a tour together right from scratch.
So we waited slightly anxious – Ron Loge stood his friend –
“I think we ought to let him lead” he said;
“I warrant he’ll be with us when he’s wanted at the end,
For both his team and he are mountain bred.

“He hails from Flathead River, up by Glacier National Park,
Where the hills are twice as steep and twice as rough,
Where a need to improvise is taken in their stride,
The docs from there are more than good enough.
And the Flathead River doctors on the mountains make their home,
Where the river runs those giant hills between;
I have seen some hardy preceptors since I first commenced to roam,
But nowhere yet such teachers have I seen.”

So he did – they chose a trip from Big Sky round to Butte –
With lots of little stops along the way
From Big Hole and to Bannock where the sheriff stole the loot
But soon hung from gallows which still stand until this day.
And Jay and Bernadette and Suzanne made sure that we were right
With water, food, coffee and great meals
And their biggest job of all was to keep the mob in sight,
If once they wandered off into those hills.

And they planned a change in weather so the hills were white with snow.
The bus took utmost care to keep the track,
Till it halted still unbeaten, then Mike turned its head for home,
And to Butte and more good food they brought us back.
And on the way they even found some time for us to shop,
To take with us mementos of the trip;
And they found a local teacher–on Butte history he was hot,
At dinner with his stories and his wit.

And down by Whitefish Lake where the pine-clad ridges raise
Their torn and rugged battlements on high,
Where the air is clear as crystal, and the white stars fairly blaze
At midnight in the cold and frosty sky
And where around the clinics, preceptors led by Jay
the students they with wisdom do equip,
The man from Flathead River is a household word today,
And the CLIC-ers tell the story of his trip.

(With most sincere apologies to Banjo Patterson)

Banjo’s Poem The Man from Snowy River

Sorry but I don’t have a recording of David’s poem but look at this wonderful video of Flathead River


Special thanks to Professor Couper who sent me these links, including the second book from TS Eliot’s Four Quartets, East Cocker. We featured the first poem, Burnt Norton some time ago. Ian wrote:
Despite not having children or grandchildren of the appropriate age, I have recently re-discovered Dr Seuss (have you heard rap artists preforming Dr Seuss books? – it was as if he wrote for them; check it out on YouTube if you haven’t), because some of what he writes is profound (Read “Oh, the places you’ll go” if you don’t remember it/haven’t read it before, or listen to JZ rap it), and also AA Milne (Winne the Pooh). In terms of the latter, I landed up with him after re-reading some TS Elliot, who has always been a favourite of mine – his lines
in East Coker from the Four Quarters (quoted by our minister),

“In order to arrive at what you do not know
You must go by a way which is the way of ignorance”

are so challenging (even more so in the context of the stanza, which I looked up), and reminded me of Pooh:

“Rabbit’s clever,” said Pooh thoughtfully.
“Yes,” said Piglet, “Rabbit’s clever.”
“And he has Brain.”
“Yes,” said Piglet, “Rabbit has Brain.”
There was a long silence.
“I suppose,” said Pooh, “that that’s why he never understands anything.”

TS Eliot (1888-1965)
Thomas Stearns Eliot OM was an American-born British poet, essayist, publisher, playwright, literary critic and editor. Born in St. Louis, Missouri, to a prominent Boston Brahmin family, he moved to England in 1914 at the age of 25 and went on to settle, work and marry there.
He became a British subject in 1927 at the age of 39, subsequently renouncing his American citizenship. Considered one of the 20th century’s major poets, Eliot attracted widespread attention for his poem “The Love Song of J. Alfred Prufrock” in 1915, which was seen as a masterpiece of the Modernist movement. It was followed by some of the best-known poems in the English language, including “The Waste Land” (1922), “The Hollow Men” (1925), “Ash Wednesday” (1930), and Four Quartets (1943).[4] He was also known for his seven plays, particularly Murder in the Cathedral (1935) and The Cocktail Party (1949). He was awarded the Nobel Prize in Literature in 1948, “for his outstanding, pioneer contribution to present-day poetry”.
East Cocker is the 2nd part of his Four Quartets. He started writing it in 1939, and modelled the poem after Burnt Norton as a way to focus his thoughts. The poem focuses on life, death, and continuity between the two. Humans are seen as disorderly and science is viewed as unable to save mankind from its flaws. Instead, science and reason lead mankind to warfare, and humanity needs to become humble in order to escape the cycle of destruction.
I have included the first part

East Cocker

In my beginning is my end. In succession
Houses rise and fall, crumble, are extended,
Are removed, destroyed, restored, or in their place
Is an open field, or a factory, or a by-pass.
Old stone to new building, old timber to new fires,
Old fires to ashes, and ashes to the earth
Which is already flesh, fur and faeces,
Bone of man and beast, cornstalk and leaf.
Houses live and die: there is a time for building
And a time for living and for generation
And a time for the wind to break the loosened pane
And to shake the wainscot where the field-mouse trots
And to shake the tattered arras woven with a silent motto.

In my beginning is my end. Now the light falls
Across the open field, leaving the deep lane
Shuttered with branches, dark in the afternoon,
Where you lean against a bank while a van passes,
And the deep lane insists on the direction
Into the village, in the electric heat
Hypnotised. In a warm haze the sultry light
Is absorbed, not refracted, by grey stone.
The dahlias sleep in the empty silence.
Wait for the early owl.

In that open field
If you do not come too close, if you do not come too close,
On a summer midnight, you can hear the music
Of the weak pipe and the little drum
And see them dancing around the bonfire
The association of man and woman
In daunsinge, signifying matrimonie—
A dignified and commodiois sacrament.
Two and two, necessarye coniunction,
Holding eche other by the hand or the arm
Whiche betokeneth concorde. Round and round the fire
Leaping through the flames, or joined in circles,
Rustically solemn or in rustic laughter
Lifting heavy feet in clumsy shoes,
Earth feet, loam feet, lifted in country mirth
Mirth of those long since under earth
Nourishing the corn. Keeping time,
Keeping the rhythm in their dancing
As in their living in the living seasons
The time of the seasons and the constellations
The time of milking and the time of harvest
The time of the coupling of man and woman
And that of beasts. Feet rising and falling.
Eating and drinking. Dung and death.

Dawn points, and another day
Prepares for heat and silence. Out at sea the dawn wind
Wrinkles and slides. I am here
Or there, or elsewhere. In my beginning.

Listen to TS Elliot read East Cocker

Listen to Dr Seuss Rap “Oh, the places you’ll go”


My friend and colleague Jean Pierre Jacquet, who is a rural GP in the French Alps, sent me this poem
Jean Pierre said “I need to remember what I learned in school. You will find a poem by Ronsard, it is written in old French. The poet explains to a young woman that she must enjoy life before old age. like the rose whose life is short. The first sentence, ‘ mignonne allons voir si la rose’ is well known by the French ‘Have a nice evening’,”

Pierre de Ronsard (1524 -1585)
Pierre de Ronsard was a French poet. His own generation in France called him, a “prince of poets”. Pierre de Ronsard was born at the Manoir de la Possonnière, in the village of Couture-sur-Loir, Vendômois (in present-day Loir-et-Cher).
He was initially educated at home and later sent to the Collège de Navarre in Paris at the age of nine. When Madeleine of France was married to James V of Scotland, Ronsard was attached as a page in the Scottish court. His apparently promising diplomatic career was, however, cut short by an attack of deafness following a 1540 visit, as part of legation to Alsace, that no physician could cure; he would subsequently determine to devote himself to study.

Ode À Cassandre

Mignonne, allons voir si la rose
Qui ce matin avoit déclose
Sa robe de pourpre au Soleil,
A point perdu cette vesprée (old spelling for vêprée)
Les plis de sa robe pourprée,
Et son teint au vôtre pareil.

Las ! voyez comme en peu d’espace,
Mignonne, elle a dessus la place
Las ! las ses beautés laissé choir !
Ô vraiment marâtre Nature,
Puis qu’une telle fleur ne dure
Que du matin jusques au soir ! (old way for jusqu’au)

Donc, si vous me croyez, mignonne,
Tandis que votre âge fleuronne
En sa plus verte nouveauté,
Cueillez, cueillez vôtre jeunesse :
Comme à cette fleur la vieillesse
Fera ternir votre beauté.

Ode À Cassandre

Ode to Cassandre

Sweetheart, let’s see if the rose
That this morning had open
Her crimson dress to the Sun,
This evening hasn’t lost
The folds of her crimson dress,
And her complexion similar to yours.
Ah! See how in such short space
My sweetheart, she has on this very spot
All her beauties lost!
O, so un-motherly Nature,
Since such a beautiful flower
Only last from dawn to dusk!

So if you believe me, my sweetheart,
While time still flowers for you,
In its freshest novelty,
Do take advantage of your youthful bloom:
As it did to this flower, the doom
Of age will blight your beauty.

My old friend, Victor Inem from Nigeria sent me this poem/song from a popular Nigerian folklore singer, Bongos Ikwue about living in rural Nigeria

Bongos Ikwue (1942-)
Bongos Ikwue is a Nigerian music legend, who was born in Otukpo, Benue State, Nigeria, on the 6th of June 1942. At school his friends called him “Forge” because he was always making up (forging) and singing his own songs. In 1962. After school he headed off to the Ahmadu Bello University. While at university, a chemistry lecturer, Mrs. Harmony taught him some Irish songs. In 1967 he founded and headed the Groovies band, which became extremely popular in the 1970’s through to the 80’s.
He is loved him for his soulful, folksy songs, the most popular of which includes: Cockcrow At Dawn, Still Searching, Amen, Otachikpokpo and a host of others. Apart from the raw beauty of his voice, another thing that sets the musical genius apart is his dedication to the promotion of Africa and African values, by his continuous use of his native Idoma language in his songs. He is well loved by a vast majority of Nigerians with a fan base that cuts across language barriers and ethnic tension; he also has an international fan base. The Bongos’ music genre is not easily deciphered. He is also a master of the African ideals he chooses to express.
Great stuff!

Cockcrow at dawn

You can hear the bird sing in the morning,
You can hear the water splashing down the hill kind of roaring.
You can see the sun going down
And the people as they go by
Without a frown
Here the traffic never jam
Don’t cost much to buy some yams
And the neighbours say hello
And will strife to pull you up from down be low
You can even hear the sound of the cock crow at dawn.
Will he ever get there?
Will he ever make it?
Will he ever hear the sound of the cock crow at dawn?
1, 2 3 4 5 6 buses everyday
With nothing left at the end of each day
And the rattle he must pay
With much to think, he often has no say.
Will he ever get there?
Will he ever make it?
Will he ever hear the sound of the cock crow at dawn?
Here the traffic never jam
Don’t cost much to buy some yams
And the neighbours say hello
And will strife to pull you up from down be low
You can even hear the sound of the cock crow at dawn.
You can even hear the sound of the cock crow at dawn.
You can even hear the sound of the cock crow at dawn.

Official Cock Crow At Dawn video by the iconic Bongos Ikwue

Dr Aleksandar Lazic sent me some more Bosnian poetry. You will remember that with his help we did a full feature in June. Here are some poems by Aleksa Šantić with translations

Aleksa Šantić (1868-1924)
Aleksa Šantić was a poet from Bosnia and Herzegovina. A Herzegovinian Serb, his poetry reflecting both the urban culture of the region and the growing national awareness. The most common themes of his poems are social injustice, nostalgic love, suffering of the Serb people, and the unity of the South Slavs. He was the editor-in-chief of the magazine Zora (1896–1901). Šantić was one of the leading persons of Serbian literary and national movement in Mostar. In 1914 Šantić became a member of the Serbian Royal Academy.

Što te nema?
Kad na mlado poljsko cv’jeće
Biser niže ponoć nijema,
Kroz grudi mi želja l’jeće:
“Štote nema, što te nema?”

Kad mi sanak pokoj dade
I duša se miru sprema,
Kroz srce se glasak krade:
“Što te nema, što te nema?”

Vedri istok kad zarudi
U trepetu od alema,
I tad duša pjesmu budi:
“Što te nema, što te nema?”

I u času bujne sreće
I kad tuga uzdah sprema,
Moja ljubav pjesmu kreće:
“Što te nema, što te nema”..

Where are you

When pearls of dew at night are strewn
On meadow flowers in early bloom,
My bosom starts a longing tune:
“Where are you, where are you?”

When, relaxed, I fall asleep,
When my soul calm is deep,
In my heart whispers creep:
“Where are you, where are you?”

When the dawn glows red
In the shimmer of jewels clad,
My soul stirs a song in bed:
“Where are you, where are you?”

When great rejoicing is on high
And gloom prepares a heavy sigh,
My love begins to sing the rhyme:
”Where are you, where are you?”

(Translated by Milomir Ilic)

Performed by late Jadranka Stojaković


Sinoć kad se vraćah iz topla hamama,
Prođoh pokraj bašče staroga imama.
Kad tamo u bašči, u hladu jasmina
S ibrikom u ruci stajaše Emina.

Ja kakva je pusta! Tako mi imana,
Stid je ne bi bilo da je kod sultana.
Pa još kada šeće i plećima kreće,
Ni hodžin mi zapis više pomoć’ neće!

Ja joj nazvah selam. Al’ moga mi dina,
Ne šće ni da čuje lijepa Emina,
Već u srebrn ibrik zahvatila vode,
Pa niz bašču đule zaljevati ode.

S grana vjetar puhnu, pa niz pleći puste
Rasplete joj njene pletenice guste.
Zamirisa kosa, k’o zumbuli plavi,
A meni se krenu bururet u glavi!

Malo ne posrnuh, mojega mi dina,
Al’ meni ne dođe lijepa Emina.
Samo me je jednom pogledala mrko,
Niti haje, alčak, što za njome crko’!


Last night, returning from the warm hamam,
I passed by the garden of the old imam,
And lo, in the garden, in the shade of a jasmine,
There with a pitcher in her hand stood Emina.

What beauty! By my Muslim faith I could swear,
She wouldn’t be ashamed if she were at the sultan’s!
And the way she walks and her shoulders move…
-Not even a hodja’s amulet could help me!

I offered her salaam, but by my faith,
Beautiful Emina wouldn’t even hear it.
Instead, scooping water in her silver pitcher,
Around the garden she went to water the roses.

A wind blew from the branches down her lovely shoulders
Unravelling those thick braids of hers.
Her hair gave off a scent of blue hyacinths,
Making me giddy and confused!

I nearly stumbled, I swear by my faith,
But beautiful Emina didn’t come to me.
She only gave me a frowning look,
Not caring, the naughty one, that I’m crazy for her!


I would like to thank my friends Roger and Angela Hughes for this poem. They are not medical but know that I have been posting poems and sent me this poem by a late friend of theirs.

O Cynric Mytton-Davies (1924-1992)
Cynric Mytton-Davies was a Welsh poet, journalist and author who was born in 1924. I can’t find out much about him and his poetry is difficult to come by. This poem is certainly worth posting out to you. Spring song was written in 1976

Spring Song

Never neglect to look
Or anything miss
Of beauty,
For this may be
Your final opportunity.

These bluebells,
This pink flowering cherry,
Hurry to see them;
Gather the bell-hung stems
In blue carpeted woods,
Primroses yellow
In the Hedgerows,
Royal purple violets.
See the Laburnum
Flash its golden pendants,
Jewellery of Spring;
Woods starred with celandines
And white anemones
Like milk drops scattered
On the brown ground.

You could not buy these things
Though you owned all
The gold of Africa
And vast Arabia’s oil,
For these are gifts
Strewn on your sight
An evanescent minute.
Savour them while you may

Some four score times
If you are fortunate
You may behold them:
Or sadly, a year of youth
Could be the last.

So, go.
Let not so brief a gift
Slip through your fingers.
Never neglect to look.

Today’s Posts

1. 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.

2. International: Financial Times: Covid-19: The global crisis — in data: Charts and maps show paradoxes of a pandemic that has claimed a million lives
The emergence of a new Sars-like coronavirus could not have come at a worse time for China. The country was already 10 days into Chunyun — the Lunar New Year travel season that is also the largest annual human migration on the planet — when government officials finally confirmed human-to-human transmission of the as-yet-unnamed virus on January 20.
The city at the centre of the outbreak, Wuhan in Hubei province, went into lockdown three days later. By then, much of the city’s populace was already on the move across the country to enjoy the festivities with their families, an enormous outflow of people by road, rail and air estimated to total 5m — almost half of Wuhan’s official population — by the city’s mayor.
Given the scale of human movement, further spread of the virus across China seemed inevitable. And yet, nine months after the outbreak, province-level cases data reveal China’s remarkable success in containing it to the province of origin.
Although there are valid concerns about the reliability of China’s official figures, its success in containing the virus is largely explained by another factor — intensive contact tracing. But this, too, was subject to a curious paradox of its own: for a nation with a reputation for using cutting-edge technology to spy on its citizens, much of it was achieved with old-school methods such as questionnaires.
While China curbed the outbreak, the transmission of the virus overseas — and the differing responses of other nations to its arrival — meant that the real story of Covid-19 was only just beginning.

3. Africa: The Lancet: COVID-19 and health care inaccessibility in sub-Saharan Africa
The first case of COVID-19, the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), in sub-Saharan Africa was confirmed in Nigeria on Feb 27, 2020, followed by the first regional death in Burkina Faso on March 18, 2020. Since these initial events, more than 1 million cases and 20 000 deaths have been confirmed in the region. Despite initial fears of catastrophic spread and high mortality of COVID-19 in Africa, mainly because of high frequencies of HIV and tuberculosis co-infections in combination with weak health systems, the toll of the pandemic has remained lower than expected. However, based on previous research showing gaps in health facility accessibility in sub-Saharan Africa, populations without access to health care are probably not receiving COVID-19 testing, resulting in under-reporting of the true toll of the pandemic in this region.
In an Article in The Lancet Healthy Longevity, Pascal Geldsetzer and colleagues mapped health facility (in)accessibility among people aged 60 years or older across sub-Saharan Africa.
Older people and those with comorbidities are most at risk for negative sequelae and death from COVID-19. Therefore, Geldsetzer and colleagues focused their analyses on this vulnerable population, filling an existing gap in health facility accessibility research in sub-Saharan Africa. 15·9% (95% CI 10·1–24·4) of people aged 60 years or older had travel times longer than 2 h to access any health facility, suggesting minimal linkage to the health system, including COVID-19 testing and diagnosis. Moreover, access to hospitals (locations at which patients with COVID-19 with moderate-to-severe presentations would need treatment) ranged from a median travel time of 41 min (IQR 34–54) in Burundi to 1655 min (1065–2440; more than 24 h) in Gabon. For all adults aged 60 years or older, 9·6% (95% CI 5·2–16·9) had travel times to the nearest hospital of 6 h or longer. These analyses and resulting maps are invaluable for identifying locations where populations might be currently underserved by health-care facilities and where linkage to care could be scant. Moreover, the maps provide a foundation for addressing vaccine delivery challenges for future COVID-19 vaccination efforts. These analyses, paired with investigations of other high-risk groups and insights into facility capacity and readiness, will be instrumental in mitigating the effect of COVID-19 across sub-Saharan Africa.

4. India: The Print: Bring back the family doctor. India has too many specialists
Every town and city in India has a multi-speciality clinic or hospital. But where are our family physicians who can tell us ‘go to the doctor’?
If you live in a medium-sized or larger town in India, chances are that you have a private medical clinic or hospital not too far from your home. Chances are that it will describe itself as a “multi-speciality clinic” and the reception area will have a long list of specialists who you could consult. Even the smallest clinics in my neighbourhood in Bengaluru have around a dozen specialists on their roster. Every conceivable specialisation — from neurosurgery to psychiatry, interventional cardiology to maxillofacial surgery — is available within a 5-kilometre radius from my home.
The only problem is that if a person has, say a bad headache, he or she would not know where to start and which of these specialists to consult. In the best case, it is quite possible that they would see one of the specialists, do the lab investigations or scans she recommends, only to find out that the ailment belongs in the domain of another specialist. This, at once, is inefficient, stressful for the patient, undermines trust in the system, affects health-seeking behaviour and impacts overall health outcomes.

5. Lancet: Global health: time for radical change?
What strategies should governments adopt to improve the health of their citizens? Amid the COVID-19 syndemic it would be easy to focus attention on global health security—at a minimum, strong public health and health-care systems. WHO has based its global health strategy on three pillars: universal health coverage, health emergencies, and better health and wellbeing. The indispensable elements of robust public health and health care are well known and endlessly rehearsed—a capable health workforce; effective, safe, and high-quality service delivery; health information systems; access to essential medicines; sufficient financing; and good governance. But has the gaze of global health been too narrow? Have health leaders and advocates been missing the most important determinants of human health?
The latest report of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 raises uncomfortable questions about the direction global health has taken in the 21st century. On the one hand, the news seems good. The health of the world’s population is steadily improving. Global life expectancy at birth increased from 67·2 years in 2000 to 73·5 years in 2019. Healthy life expectancy has increased in 202 of 204 countries and territories. In 21 countries, healthy life expectancy at birth increased by more than 10 years between 1990 and 2019, with gains of up to 19·1 years. The estimated number of deaths in children under 5 years decreased from 9·6 million in 2000 to 5 million in 2019. Indeed, the falls in rates of age-standardised disability-adjusted life-years since 1990 have been the largest for communicable, maternal, neonatal, and nutritional diseases—and progress has been fastest in the past decade.

6. The Lancet: Global Burden of Disease
Global health data to drive change and improve lives
The Global Burden of Disease (GBD) study is the most comprehensive worldwide observational epidemiological study to date. Led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, Seattle (USA) the GBD study offers a powerful resource to understand the changing health challenges facing people across the world in the 21st century.
Examining trends from 1990 to the present, the latest GBD study includes data on mortality and morbidity in 204 countries and territories, 369 diseases and injuries, and 87 risk factors. By tracking progress within and between countries, it provides an important tool to inform clinicians, researchers, and policy makers, promote accountability, and improve lives worldwide.
In partnership with IHME, The Lancet has published global health estimates from the GBD study since 2010. In December 2018, the World Health Organisation and the IHME announced a formal partnership to collaborate to produce a single set of global health estimates to strengthen the validity of the GBD and improve its policy relevance and use. Every year, these capstone papers are published in a special issue of The Lancet.

7. USA: CBS: Video:Rural hospitals become latest coronavirus hot spots
Rural states are now leading the country in per capita coronavirus hospitalizations. Adriana Diaz takes a closer look.
N Video

8. Africa: The Conversation: Training can improve patient and health worker safety in sub-Saharan Africa
Medical technology has made great advances. Yet, patients are often harmed while receiving medical care. Globally four out of 10 patients are harmed in primary and outpatient care. Furthermore, 15% of total hospital activity and expenditure is a direct result of adverse events or irregularities in healthcare delivery. Worldwide, there are more than five avoidable deaths every minute as a result of mistakes made by healthcare providers. These mistakes include incorrect diagnosis, wrong medication, and unsafe surgical procedures. The most sustainable and cost-effective way to protect patients’ lives is to reduce the causes of human error. Therefore, health providers must strive to practise in a ‘error-free’ environment. In order to achieve this goal, health workers need to be properly trained to reduce adverse outcomes.
When health systems are under pressure, so too are the professionals working within them. The safety of patients is intricately linked to the safety of health workers. Health professionals working under conditions that compromise their own health and safety will have difficulties delivering the highest standards of safety and quality care to their patients.

9. International: New York Times: Covid-19 Live Updates: 7 Countries Report at Least 100,000 New Cases in the Past Week
Argentina, Brazil, Britain, France, India, Russia and the United States have helped push the global total of coronavirus cases to more than 40.7 million.
In the past seven days, seven countries — Argentina, Brazil, Britain, France, India, Russia and the United States — have reported at least 100,000 new cases of the coronavirus, helping to push total cases worldwide to more than 40.7 million, according to a New York Times database. In many cases, these countries are seeing numbers that are much higher than they were during the height of the pandemic in the spring. At that point most countries locked down, stopping movement and much interpersonal contact. Strategies have changed, and today local lockdowns are the way forward for most. There is more testing, giving a clearer picture of the pandemic. But the numbers continue to grow. Over the past week in the United States, there have been 421,114 new cases, illustrating that the long-predicted fall wave of the virus is well underway. Midwestern and Rocky Mountain states are struggling to control major outbreaks. And the national trajectory is worsening by the day, as the cooler weather drives more people to stay indoors where the virus spreads easily. In some states, hospitals are almost full. India reported 411,718 over the past seven days, but numbers have been falling since mid-September. On Monday, the country recorded fewer than 50,000 cases, the lowest number since July, the government said. But the lower numbers, which would seem at first glance to be good news, have raised questions. The government recently approved the use of rapid coronavirus testing based on gene-editing technology, hoping to increase its testing capabilities. But experts question the reliability of rapid tests. In France, which has added 174,273 cases in the past seven days, a curfew has been implemented in Paris and eight other regions. Still, more than 11,000 virus patients are hospitalized, and 2,000 are in intensive care, a threshold that had not been reached since May. (The country currently has 5,800 intensive care beds.) Brazil, which has reported 160,326 cases in the past seven days, is among the countries with the lowest testing rates and still lacks a clear contact tracing policy. Despite being the country with the second-highest death toll, about eight million Brazilians had received laboratory tests by mid-October according to the Ministry of Health, less than a tenth of the number of people tested in the United States. But, as in India, the disease has been trending downward in Brazil since early August. The country is now reporting an average of 500 deaths a day, half of the daily toll it reported two months ago. Most big cities have eased most social-distancing measures and opened some schools, restaurants, and beaches. The number of daily recorded infections in Britain, which includes England, Northern Ireland, Scotland and Wales, has nearly tripled since the beginning of October. In the past seven days, Britain has reported 127,622 new cases. Hospitalizations and deaths are also rising, and in some parts of the country, intensive care units are being stretched to their limits. The countries that make up Britain are each forging their own paths: England has implemented a tiered alert system; Northern Ireland is ramping up restrictions for pubs and restaurants, and closing schools; Scotland implemented a two-week tightening of restrictions; and Wales was preparing to enter a two-week national lockdown. Russia has added 103,992 new cases in the past seven days.. The government, however, has resisted imposing even local lockdowns, although it has started to enforce mask-wearing requirements. The capital, Moscow, is recording about one-third of the country’s daily new cases. Health authorities there have opened temporary hospitals in a city park and in a large car-dealership center. But Mayor Sergei Sobyanin said curfews and business closings are “absolutely unacceptable and impossible for us.” Argentina has reported 101,964 cases in the past seven days. It is the fifth country to surpass one million total cases. The country received praise early in the pandemic by imposing a strict quarantine in mid-March, and although certain restrictions have been relaxed, much of the country is still under some type of lockdown order. Still, the virus which was once concentrated in the Buenos Aires area, has since expanded to much of the country, including remote areas with scarce medical resources.

10. Latin America: Nature: Latin America’s embrace of an unproven COVID treatment is hindering drug trials
Unchecked ivermectin use in the region is making it difficult to test the anti-parasite drug’s effectiveness against the coronavirus. As much of the world waits for an effective vaccine to curb the COVID-19 pandemic, some in Latin America are turning to an unproven treatment. There isn’t enough evidence that the drug, ivermectin, is safe or effective as a coronavirus therapy, however. So researchers are cautioning against using it outside clinical trials. Still, people in the region have rushed to take it, making it hard for researchers to properly test it. Ivermectin, an inexpensive, over-the-counter medicine, has been used for decades to treat livestock and people infested with parasitic worms — and in the past few months, its popularity as a preventative against COVID-19 has surged in Peru, Bolivia, Guatemala and other Latin American countries. The drug has been so in demand that in May, health-care workers passed out some 350,000 doses to residents in northern Bolivia. That same month, the Peruvian police seized around 20,000 bottles of animal-grade ivermectin that was sold on the black market as a treatment for human coronavirus infections. And in July, a university in Peru announced that it would produce 30,000 doses to bolster the country’s supply.

11. USA: CNN: US is nearing ‘rapid acceleration’ of Covid-19 cases, expert warns, as daily infections top 60,000
A leading health expert says US Covid-19 cases will begin to rapidly accelerate in a week as the country topped 60,000 new infections Tuesday — triple what the daily average was back in June, when restrictions had begun to ease.
The prediction comes after several state leaders reimposed some measures to help curb the spread of the virus, fueled by small gatherings increasingly moving indoors with the colder weather, as well as other factors such as college and school reopenings. The national seven-day case average has increased at least 18% since the previous week and is now a staggering 61% higher than what it was five weeks ago. And as multiple experts have warned, things will likely get worse before they get better. “It’s going to be a difficult fall and winter,” Dr. Scott Gottlieb, former commissioner of the US Food and Drug Administration, told CNBC Monday. “I think we’re about two or three weeks behind Europe — so we’re about a week away from starting to enter a period where we’re going to see a rapid acceleration in cases.”
The difference is many European countries were able to suppress their numbers of new cases over the summer, but the US entered the fall season with a relatively high baseline average of new infections — something experts warned wouldn’t help in containing another surge of cases. Dr. Anthony Fauci said earlier this week European Union countries were able to bring their baseline down because of strict and stringent lockdowns, adding the US did not “shut down nearly as much as our colleagues in Italy and Spain.”

12. Korea: Rueters: Deaths after flu shots in S.Korea fan fears, but authorities find no link
Nine people have died after getting flu shots in South Korea in the past week, raising concerns over the vaccine’s safety just as the seasonal inoculation programme is expanded to head off potential COVID-19 complications. Five new deaths were reported on Wednesday alone, but authorities had no plans to suspend the vaccination programme, unless investigations, including postmortems, revealed a link, which preliminary findings had not. “We have reviewed whether it is appropriate to continue the vaccination or better to suspend and wait for the results,” health official Kim Joong-gon told a briefing. “We came to the conclusion that the deaths had no direct relations with the vaccination given the limited data we have now and without detailed post mortem reports.” Kim said a preliminary investigation into six victims revealed five had underlying conditions. Health officials also said no toxic substances had been found in the same vaccine administered to other people. Coming just weeks after the roll out of the national vaccine programme was temporarily suspended over safety worries, the deaths, which include a 17-year-old boy and a man in his 70s, have dominated news headlines in South Korea.

13. UK: MedRxiv: Persistent symptoms after Covid-19: qualitative study of 114 “long Covid” patients and draft quality criteria for services
Background Approximately 10% of patients with Covid-19 experience symptoms beyond 3-4 weeks. Patients call this long Covid. We sought to document the lived experience of such patients, their accounts of accessing and receiving healthcare, and their ideas for improving services. Method We held 55 individual interviews and 8 focus groups (n = 59) with people recruited from UK-based long Covid patient support groups, social media and snowballing. We restricted some focus groups to health professionals since they had already self-organised into online communities. Participants were invited to tell their personal stories and comment on other stories. Data were audiotaped, transcribed, anonymised and coded using NVIVO. Analysis incorporated sociological theories of illness, healing, peer support, the clinical relationship, access to care, and service redesign. Results The sample was 70% female, aged 27-73 years, and comprised White British (74%), Asian (11%), White Other (7%), Black (4%), and Mixed (4%). 27 were doctors and 23 other health professionals. Approximately 10% had been hospitalised. Analysis revealed a confusing illness with many, varied and often relapsing-remitting symptoms and uncertain prognosis; a heavy sense of loss and stigma; difficulty accessing and navigating services; difficulty being taken seriously and achieving a diagnosis; disjointed and siloed care (including inability to access specialist services); variation in standards (e.g. inconsistent criteria for seeing, investigating and referring patients); variable quality of the therapeutic relationship (some participants felt well supported while others described feeling fobbed off); and possible critical events (e.g. deterioration after being unable to access services). Emotional touch points in participant experiences informed ideas for improving services. Conclusion Quality principles for a long Covid service should include ensuring access to care, reducing burden of illness, taking clinical responsibility and providing continuity of care, multi-disciplinary rehabilitation, evidence-based investigation and management, and further development of the knowledge base and clinical services.

14. International: CNBC: ‘Long Covid’: These 5 factors make it more likely you’ll suffer long-term from coronavirus
A new study has identified the main factors that make it more likely that patients will suffer long term from the coronavirus. “Long Covid” is the term given to people who had a confirmed (or suspected) coronavirus case and who recover from the initial infection but continue to suffer from a wide range of symptoms, from shortness of breath and migraines to chronic fatigue. A new analysis by researchers at King’s College London, using data from the COVID Symptom Study app, shows “that one in 20 people with Covid-19 are likely to suffer symptoms for 8 weeks or more.” The study, published on Wednesday, looked at data from 4,182 users of the COVID Symptom Study app who had tested positive for the virus, and had been consistently logging their health. The team found that older or overweight people, women, those with asthma and those with a greater number of different symptoms in the first week of their illness were more likely to develop “long Covid.”

15. UK: Kings College London: New study identifies those most at risk from ‘long COVID’
A new analysis by researchers at King’s, using data from the COVID Symptom Study app, shows that one in 20 people with COVID-19 are likely to suffer symptoms for 8 weeks or more (so-called ‘long COVID’), potentially adding up to many hundreds of thousands in the UK and millions worldwide. Led by Dr Claire Steves and Professor Tim Spector at King’s, this study focused on data from 4,182 COVID Symptom Study app users who had been consistently logging their health and tested positive for COVID-19 through swab PCR testing. The team found that older people, women and those with a greater number of different symptoms in the first week of their illness were more likely to develop long COVID.
The researchers have used this information to develop a model that can predict who is most at risk of long COVID based on their age, gender, and count of early symptoms. Statistical tests showed that this simple prediction was able to detect more than two thirds (69%) of people who went on to get Long-Covid (sensitivity), and 73% effective at avoiding false alarms (specificity). The team then tested this model against an independent dataset of 2,472 people who reported a positive coronavirus antibody test result with a range of symptoms and found that it gave similar predictions of risk. The research could be used to help target early interventions and research aimed at preventing and treating this condition. The research also provides insight into this poorly understood phenomenon and the experiences of people living with long COVID, and identifies two main symptom groupings. One was dominated by respiratory symptoms such as cough and shortness of breath, as well as fatigue and headaches, and the second form was clearly multi-system, affecting many parts of the body, including the brain, gut and heart. Long COVID sufferers more commonly reported heart symptoms such as palpitations or fast heartbeat, as well as pins and needles or numbness, and problems concentrating (‘brain fog’). People with long COVID were also twice as likely to report that their symptoms had come back again after recovering (relapse) compared with those having short COVID (16% vs 8.4%). Insights learned so far are being used to make the COVID Symptom Study app better for studying long-COVID.

16. UK: BBC: Coronavirus: Delirium ‘key symptom’ in frail older people
Doctors and carers should look out for signs of confusion or strange behaviour in frail older people because it could be an early warning sign of Covid-19, research suggests. Even if they have no cough or fever, delirium is more common in vulnerable over-65s than other, fitter people of the same age. But it’s not yet clear why this extreme confusion or delirium happens. The study calls for more awareness of it in hospitals and care homes. The three main symptoms of a Covid infection are a new and continuous cough, a temperature above 37.8C and a change in smell or taste. About 85% of people will have at least one of those symptoms. However, research suggests certain age groups may also have other symptoms, such as diarrhoea and vomiting in children. In this King’s College London study, data from more than 800 people over the age of 65 was analysed. They included 322 patients in hospital with Covid-19, and 535 people using the Covid Symptom Study app to record their symptoms or log health reports on behalf of friends and family. All had received a positive test result. The researchers found that older adults admitted to hospital who were classified as frail were more likely to have had delirium as one of their symptoms, compared with people of the same age who weren’t frail. Frailty is used by doctors to describe older people who find it difficult to recover from everyday illness, strains and accidents. They are also more likely to have falls and end up in hospital when ill. For one in five patients in hospital with Covid, delirium was their only symptom.

17. Oxford Academic: Age and Ageing: Probable delirium is a presenting symptom of COVID-19 in frail, older adults: a cohort study of 322 hospitalised and 535 community-based older adults
Frailty, increased vulnerability to physiological stressors, is associated with adverse outcomes. COVID-19 exhibits a more severe disease course in older, co-morbid adults. Awareness of atypical presentations is critical to facilitate early identification.
To assess how frailty affects presenting COVID-19 symptoms in older adults. Observational cohort study of hospitalised older patients and self-report data for community-based older adults. Admissions to St Thomas’ Hospital, London with laboratory-confirmed COVID-19. Community-based data for older adults using the COVID Symptom Study mobile application. Hospital cohort: patients aged 65 and over (n = 322); unscheduled hospital admission between March 1st, 2020-May 5th, 2020; COVID-19 confirmed by RT-PCR of nasopharyngeal swab. Community-based cohort: participants aged 65 and over enrolled in the COVID Symptom Study (n = 535); reported test-positive for COVID-19 from March 24th (application launch)-May 8th, 2020. Multivariable logistic regression analysis performed on age-matched samples from hospital and community-based cohorts to ascertain association of frailty with symptoms of confirmed COVID-19. Hospital cohort: significantly higher prevalence of probable delirium in the frail sample, with no difference in fever or cough. Community-based cohort: significantly higher prevalence of possible delirium in frailer, older adults, and fatigue and shortness of breath. This is the first study demonstrating higher prevalence of probable delirium as a COVID-19 symptom in older adults with frailty compared to other older adults. This emphasises need for systematic frailty assessment and screening for delirium in acutely ill older patients in hospital and community settings. Clinicians should suspect COVID-19 in frail adults with delirium.

18. UK: Reuters: UK plans COVID-19 ‘challenge’ trials that deliberately infect volunteers
Britain will help to fund trials using a manufactured COVID-19 virus to deliberately infect young healthy volunteers with the hope of accelerating the development of vaccines against it. The government said on Tuesday it will invest 33.6 million pounds ($43.5 million) in the so-called “human challenge” trials in partnership with Imperial College London, laboratory and trial services company hVIVO and the Royal Free London NHS Foundation Trust. If approved by regulators and an ethics committee, the studies will start in January with results expected by May 2021, the government said. Using controlled doses of virus, the aim of the research team  will initially be to discover the smallest amount of virus it takes to cause COVID-19 infection in small groups of healthy young people, aged between 18 and 30, who are  at the lowest risk of harm, the scientists leading the studies said in a briefing.
Up to 90 volunteers could be involved at the initial stages, they said, and virus to be used will be manufactured in labs at London’s Great Ormond Street Hospital.

19. Australia: AusDoc: Death sparks warning over shift to telehealth in rural areas
There would be ‘uproar’ if telehealth were replacing on-site doctors in cities like Sydney, says a regional NSW GP in the wake of a woman’s death
A GP is warning that patients in country areas are in danger of substandard care as a result of moves to replace on-site doctors with telehealth. Dr Phillip Jolly made his comments in the wake of a woman’s death at a NSW regional hospital where no doctor was present. In mid September, Dawn Trevitt, 66, was taken by ambulance to the Gulgong Multi-Purpose Service where her daughter said she died from a gastrointestinal rupture. She was treated by nurses on site and a doctor through telehealth, Hayley Olivares told the ABC. The health authority also failed to renew the contract of Rural and Remote Medical Services (RARMS), according to the Sydney Morning Herald. RARMS is a non-profit organisation which provides doctors to Bourke, Brewarrina, Coonamble, Collarenebri, Walgett and Lightning Ridge. “I was first of all shocked, bitterly disappointed, and mildly mortified that that was an acceptable level of healthcare.” According to the ABC, the Gulgong service hasn’t had a doctor since June when the Western NSW Local Health District failed to renew the contract of Dr Nebras Yahya.
Dr Yahya told the ABC the authority had wanted to reduce his VMO contract pay by 40%, and planned to support more patients with telehealth. Ms Trevitt’s case illustrated the potential outcomes of losing medical personnel in rural areas, said Dr Jolly, a Melbourne-based GP who works in Lightning Ridge through RARMS. “(It) unfortunately demonstrates that one less skilled pair of hands in rural communities will have consequences,” Dr Jolly told 6minutes. He said changes favouring telehealth in the state’s west appeared to be being introduced by the department by stealth. “There’s been a process here that’s making everybody very anxious,” Dr Jolly said. “I just think that sooner or later, when communities find out what they’re proposing, they’re going to get angry. “We don’t get much traction out in the regional areas but I actually think if this were proposed for a Sydney hospital there would be absolute uproar. “But because it’s going on in the bush people turn a blind eye.” He also said the increasing use telehealth more broadly could have implications for doctors around Australia. “It also demonstrates a trend all Australian doctors should be worried about. At present patients value face-to-face interactions,” Dr Jolly said. “If telehealth becomes the new norm, then there is nothing stopping all services being farmed out offshore. ” The Western NSW Local Health District has been contacted for comment.
Full article printed

20. UK: The Guardian: Hospital bosses urge NHS England to drop ‘unfair’ fines as Covid admissions rise
Exclusive: targets on returning patient care to pre-pandemic levels ‘impossible’ to meet, say trusts Hospitals in England will be fined for failing to meet “impossible” targets on patient care within weeks, in a scheme criticised by NHS trust bosses as “mad, wrong and unfair”. NHS England is facing calls to urgently rethink plans to impose financial penalties on trusts that fail to return non-emergency operations to near-normal levels by the end of this month.The directive, which has sparked alarm among regional public health directors and local councils, was issued to hospitals in August and is still going ahead despite a resurgence of coronavirus cases that threatens to seriously disrupt the NHS this winter.

21. 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.”

22. International: The Guardian: The pursuit of herd immunity is a folly – so who’s funding this bad science?
Links between an anti-lockdown declaration and a libertarian thinktank suggest a hidden agenda
Earlier this month, in a wood-panelled room at a country estate in Massachusetts, three defiantly unmasked professors gathered around a large oak table to sign a declaration about the global response to the pandemic. One academic had flown across the Atlantic from Oxford; another had travelled from California. The signing ceremony had been carefully orchestrated for media attention, with a slick website and video produced to accompany the event, and an ostentatious champagne toast to follow.
You may not have heard of the “Great Barrington declaration” but you’ll likely have seen the headlines that followed it. Journalists have written excitedly about an emerging rift in the scientific community as the consensus around the most effective response to Covid supposedly disintegrates. The declaration, which called for an immediate resumption of “life as normal” for everyone but the “vulnerable”, fuelled these notions by casting doubt on the utility of lockdown restrictions. “We know that all populations will eventually reach herd immunity”, it stated.
Scientists were swift in their response. The declaration’s core assumption, that population immunity will be achieved by allowing life to go on as normal and shielding only the most vulnerable from the virus, is entirely speculative. The thrust of its argument is based on a false opposition between those who argue for lockdown and those who are against it, when in fact lockdowns are one of numerous measures that scientists have called for, and are seen as a short-term last resort to regain control.

23. UK: BBC: Coronavirus: Severe mental health problems rise amid pandemic
Doctors are seeing a rise in people reporting severe mental health difficulties, a group of NHS leaders says. It follows a more than 30% drop in referrals to mental health services during the peak of the pandemic. But there are predictions that the recent rise will mean demand actually outstrips pre-coronavirus levels – perhaps by as much as 20%. The NHS Confederation said those who needed help should come forward.
But the group, which represents health and care leaders, said in a report that mental services required “intensive support and investment” in order to continue to be able to help those who needed it. The NHS Confederation’s mental health lead, Sean Duggan, said that when coronavirus cases were at their highest, people stayed away from services, as they did from other parts of the NHS. “A&E numbers were down, GP numbers were down. The same occurred in some of our mental health services,” he said, as people tried to ease the burden on the health service and sought to avoid catching the virus. “The concern is, if you leave problems they can get worse.”
This may explain some of the rise in more severe cases coming forward.
As well as people whose conditions deteriorated during lockdown, NHS services also expect an increase in demand for mental health services as a direct result of the pandemic itself, the report said.

24. 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.”

25. Ukraine: Reuters: Ukraine’s coronavirus-linked deaths at record as infections grow
The number of daily coronavirus deaths in Ukraine jumped to 141 from the previous record of 113 deaths registered on Tuesday, the national security council said on Wednesday. The council also reported a record 6,719 new coronavirus cases registered in the past 24 hours, bringing the total number to 315,826 cases with 5,927 deaths. Ukrainian health minister Maksym Stepanov said on Tuesday the number of coronavirus cases may rise to 8,000-10,000 a day in the coming weeks.
The daily tally of cases spiked above 5,000 in October, prompting the government to extend lockdown measures until the end of 2020.
Stepanov said Ukraine would introduce stricter lockdown restrictions if cases rise to 11,000-15,000 daily. He warned that the resources of the medical system would run out if the number of daily cases exceeds 20,000.

26. Asia: WSJ: Video: Why East Asia Is Beating the West in Controlling Coronavirus
While life in South Korea, China and Japan has broadly returned to normal, the U.S. and Europe face new surges in Covid-19 cases. WSJ explains how countries in East Asia have kept the virus in check without nationwide lockdowns. Photos: Abdulmonam Eassa and Hector Retamal/AFP via Getty
S ED Video

27. Brazil: BBC: Covid: China’s Sinovac vaccine to be included in Brazil immunisation plan
Brazil plans to use a Chinese-made coronavirus vaccine as part of a national immunisation programme, officials have announced.
São Paulo Governor João Doria said the federal government had agreed to buy 46 million doses of the vaccine CoronaVac. He said the immunisation programme could begin as soon as January 2021, making it one of the first such efforts in the world to fight the pandemic. Brazil has been one of the countries worst affected by coronavirus. It has had nearly 5.3 million confirmed cases – the third highest tally in the world after the US and India – and is second only to the US in terms of deaths, with nearly 155,000 registered so far, according to data collated by Johns Hopkins University. If approved by the country’s health regulator, CoronaVac – developed by Chinese company Sinovac Biotech – will be one of two vaccines included in Brazil’s immunisation programme. The country also plans to administer a vaccine being created by England’s Oxford University and the drug giant AstraZeneca.

28. USA: Time Magazine: Rural U.S. Hospitals Are on Life Support as a Third Wave of COVID-19 Strikes
When COVID-19 hit the Southwest Georgia Regional Medical Center in Cuthbert, a small rural town in Randolph County, in late March, the facility—which includes a 25-bed hospital, an adjacent nursing home and a family-medicine clinic, was quickly overwhelmed. In just a matter of days, 45 of the 62 nursing home residents tested positive. Negative residents were isolated in the hospital while the severely ill patients from both the nursing home and the local community were transferred to other better-equipped facilities.
“We were trying to get the patients out as fast as possible,” says Steve Whatley, Southwest Georgia Regional’s board chairman. “It was a daily nightmare.”
The scramble was exacerbated by a dire lack of medical necessities. Employees had to diligently conserve personal protective equipment. The hospital had no ventilators. And the nursing home’s air systems had to be retrofitted to create negative-pressure rooms to contain the airborne virus particles. Making matters even worse, one of the county’s only two physicians became ill with a severe respiratory disease unrelated to the coronavirus, while the other had an unexpected surgery requiring eight weeks of recovery time. Nurse practitioners stepped up as Southwest Georgia Regional waited for backup from neighboring health care organizations. More than 30 of 200 employees stopped working out of fear or because they got sick; the state of Georgia provided six nurses and two respiratory therapists as emergency relief. Despite the heroic efforts of the center’s staff, more than a dozen nursing home residents died within eight weeks of the virus’ arrival, though it’s unclear how many were directly due to COVID-19.

29. India: BBC: Coronavirus: ‘India must cut pollution to avoid Covid disaster’
India’s dreaded pollution season has returned as air quality in the capital Delhi and other northern cities rapidly deteriorated in the last two weeks.
This is bad news for India’s fight against coronavirus because several studies around the world have linked air pollution to higher Covid-19 case numbers and deaths.
A Harvard University study shows that an increase of only one microgram per cubic metre in PM 2.5 – dangerous tiny pollutants in the air – is associated with an 8% increase in the Covid-19 death rate. Another study by scientists at the UK’s University of Cambridge also found a link between the severity of Covid-19 infection and long-term exposure to air pollutants, including nitrogen oxides and ground-level ozone from car exhaust fumes or burning of fossil fuels.
“Such pollutants can also cause a persistent inflammatory response and increase the risk of infection by viruses that target the respiratory tract,” Marco Travaglio, one of the co-authors of the study, told the BBC. PM2.5 levels in Delhi have averaged around 180-300 micrograms per cubic metre in recent weeks – 12 times higher than the WHO’s safe limits. This is a depressing reversal. Delhi residents were able to breathe clean air for most of the year because a stringent lockdown brought industries and traffic to a grinding halt. There have been no studies in India yet to examine the affect of air pollution on Covid-19 infection or recovery rates. But doctors and epidemiologists have long warned that toxic air will only hamper India’s fight against the virus.

30. India: Rueters: Video: Pollution and Covid-19: Delhi hit by ‘double whammy’
While India struggles to keep its Covid-19 caseload in check, another crisis has taken over its capital city and adjoining states. Delhi has reported very poor air quality this month, which experts fear could significantly increase coronavirus cases in North India. CNN’s Vedika Sud reports.
N Video

31. UK: BBC: Long Covid: Who is more likely to get it?
Old age and having a wide range of initial symptoms increase the risk of “long Covid”, say scientists. The study, seen by the BBC, estimates one in 20 people are sick for least eight weeks. The research at King’s College London also showed being female, excess weight and asthma raised the risk.
The aim is to develop an early warning signal that can identify patients who need extra care or who might benefit from early treatment. The findings come from an analysis of people entering their symptoms and test results into the Covid Symptom Study app. Scientists scoured the data for patterns that could predict who would get long-lasting illness. The results, which are due to be published online, show long Covid can affect anyone, but some things do raise the risk.

32. India: BBC: India Covid-19: From losing loved ones to volunteering for a vaccine
In September, a close friend of Anil Hebbar died of Covid-19 in India’s western city of Mumbai after being ferried around three hospitals over five days.
Mr Hebbar, who runs a medical equipment firm, had visited his 62-year-old friend, a well-known social worker, in the intensive care unit, hours before his life ended.
The social worker was not the only friend Mr Hebbar lost during the pandemic. Since March, 10 people he knew well have succumbed to the virus in Mumbai, which quickly emerged as a hotspot. The city has reported more than 230,000 cases so far.
“It was all very overwhelming. I felt this had to stop. That’s one reason I decided to volunteer for the Covid-19 vaccine trial,” Mr Hebbar, 56, told me.
Earlier this month, he signed himself up for the clinical trials for a vaccine being developed by pharmaceuticals group AstraZeneca and Oxford University.
The vaccine is made from a virus which is a weakened version of a common cold virus that causes infections in chimpanzees. It has been genetically changed so that it is impossible to grow in humans, according to Dr Tania Thomas of the Oxford Vaccine Group. It is also one of the most promising Covid-19 vaccines among some 180 being tested around the world. None has yet completed clinical trials.

33. UK: CNBC: Coronavirus likely to become as ‘endemic’ as the flu and a vaccine might not be able to stop it, top UK scientist says
Covid-19 is likely to become as “endemic” as the annual flu virus, according to the U.K.’s chief scientific advisor. Some potential vaccines are in late-stage clinical trials, but Patrick Vallance said none is likely to eradicate the virus.“The notion of eliminating Covid from anywhere is not right, because it will come back,” he said, noting there had only been one human disease “truly eradicated” thanks to a highly effective vaccine and that was smallpox. “We can’t be certain, but I think it’s unlikely we will end up with a truly sterilizing vaccine, (that is) something that completely stops infection, and it’s likely this disease will circulate and be endemic, that’s my best assessment,” Vallance told the National Security Strategy Committee in London on Monday.“Clearly as management becomes better, as you get vaccination which would decrease the chance of infection and the severity of disease … this then starts to look more like annual flu than anything else, and that may be the direction we end up going,” he said.

34. USA: Reuters: Exclusive: U.S. trial of AstraZeneca COVID-19 vaccine may resume this week – sources
AstraZeneca Plc’s AZN.L COVID-19 vaccine trial in the United States is expected to resume as early as this week after the U.S. Food and Drug Administration completed its review of a serious illness in a study participant, four sources told Reuters.
AstraZeneca’s large, late-stage U.S. trial has been on hold since Sept. 6, after a participant in the company’s UK trial fell ill with what was suspected to be a rare spinal inflammatory disorder called transverse myelitis.
The sources, who were briefed on the matter but asked to remain anonymous, said they have been told the trial could resume later this week. It was unclear how the FDA would characterize the illness, they said. An FDA spokeswoman declined to comment.The agency is requiring researchers conducting the trial to add information about the incident to consent forms signed by study participants, according to one of the sources.
UK regulatory officials previously reviewed the illness and determined there was “insufficient evidence to say for certain” that it was or was not related to the vaccine. It permitted the trial to resume in the UK, according to a draft of the updated consent form shared with Reuters.

35. USA: NPR: ‘All You Want Is To Be Believed’: Sick With COVID-19 And Facing Racial Bias In The ER
In mid-March, Karla Monterroso flew home to Alameda, Calif. after a hiking trip in Utah’s Zion National Park. Four days later she began to develop a bad, dry cough. Her lungs felt sticky. The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that on the worst night, she was in the shower on all fours, ice cold water running down her back, willing her temperature to go down.
“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembers. Then came a new batch of symptoms in the second month, headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their thirties were starting to report.
But still, she wasn’t sure if she should go to the hospital. “As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” says Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”

36. Argentina: NBC News: Argentina passes 1 million coronavirus case mark as virus spreads through Latin America
USHUAIA, Argentina—At the edge of Argentina in a city known as “The End of the World,” many thought they might be spared from the worst of the coronavirus pandemic.
Sitting far from the South American nation’s bustling capital, health workers in Ushuaia were initially able to contain a small outbreak among foreigners hoping to catch boats to the Antarctic at the start of the crisis.
But now it is now smaller cities like Ushuaia that are seeing some of the most notable upticks. Doctors have had to quadruple the number of beds for COVID-19 patients over the last month. At least 60% of those tested recently are coming back positive for the virus. “We were the example of the country,” said Dr. Carlos Guglielmi, director of the Ushuaia Regional Hospital. “Evidently someone arrived with the coronavirus.”
Across Latin America, three other nations are expected to reach the 1 million case milestone in the coming weeks — Colombia, Mexico and Peru. The grim mark comes as Latin America continues to register some of the world’s highest daily case counts. And though some nations have seen important declines, overall there has been little relief, with cases dropping in one municipality only to escalate in another.
The trajectory is showing that the pandemic is likely to leave no corner of Latin America unscathed.“The second wave is arriving without ever having finished the first,” said Dr. Luis Jorge Hernández, a public health professor at the University of the Andes in Colombia.

37. Africa: Mendelay: 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.

38. UK: Covid patients ‘less likely to die than in April’
Coronavirus patients admitted to intensive care have a better chance of surviving now than they did in April, according to the dean of the Faculty of Intensive Care Medicine. But these gains levelled off over the summer, Dr Alison Pittard said.
The proportion of patients admitted to critical care who die fell by almost a quarter from the peak and as much as half in hospitals overall. It is too soon to know the survival rate for patients admitted this autumn. A better understanding of the disease has allowed doctors to treat patients better, including using the steroid dexamethasone and less invasive types of ventilation.

The Intensive Care National Audit and Research Centre (ICNARC), which reports on the outcomes of patients who end up in critical care units, has begun separating out the cases of people admitted after 1 September.
The Health Service Journal reported these figures, which it said suggested a dramatic fall in the proportion of patients dying between the first wave (up until the end of August) and the second (from 1 September).
On average, 39% of patients admitted to critical care died between the start of the pandemic and the end of August and this appears to have fallen to just under 12%.
But while this appears a dramatic fall at first glance, Dr Pittard cautioned this was most likely to be a product of the fact that not enough time has passed to know the outcomes of patients admitted to hospital since the beginning of September.
Many will remain in intensive care and until a patient is either discharged or dies, they do not appear in the data.

39. 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.

40. UK: RCGP: 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.
Learning: https://ig.ft.com/coronavirus-global-data/?utm_source=Nature+Briefing&utm_campaign=a01241894e-briefing-dy-20201019&utm_medium=email&utm_term=0_c9dfd39373-a01241894e-45238390
S EDucation

41. 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.

42. International: CNBC: Remdesivir has ‘little or no effect’ in reducing coronavirus deaths, WHO says
Remdesivir is one of the drugs given to U.S. President Donald Trump after he tested positive for the coronavirus two weeks ago.
The randomized study by the WHO was conducted in 405 hospitals across 30 countries on 11,266 patients, with 2750 given remdesivir.
“No study drug definitely reduced mortality (in unventilated patients or any other subgroup of entry characteristics), initiation of ventilation or hospitalisation duration,” the authors of the study wrote.
Randomized controlled trials are considered the “gold standard” of clinical studies because they more effectively eliminate bias. However, the WHO study has not yet been peer reviewed, which means it has not been independently evaluated by other experts.

India: Indian Express: Global Hunger Index 2020: India ranks 94 out of 107 countries, under ‘serious’ category
Out of the total 107 countries, only 13 countries fare worse than India including countries like Rwanda (97), Nigeria (98), Afghanistan (99), Liberia (102), Mozambique (103), Chad (107) among others. India ranked 94 among 107 countries in the Global Hunger Index 2020 and is in the ‘serious’ hunger category with a score of 27.2, according to report released on Friday. India’s rank was 102 out of 117 countries last year. In the index, India features behind Nepal (73), Pakistan (88), Bangladesh (75), Indonesia (70) among others. Out of the total 107 countries, only 13 countries fare worse than India including countries like Rwanda (97), Nigeria (98), Afghanistan (99), Liberia (102), Mozambique (103), Chad (107) among others.
Seventeen nations, including China, Belarus, Ukraine, Turkey, Cuba and Kuwait, shared the top rank with GHI scores of less than five, the website of the Global Hunger Index, that tracks hunger and malnutrition, said. The under-five mortality rate stood at 3.7 per cent.

43. The Lancet: Mental health: time to invest in quality
The theme of this year’s World Mental Health Day, on Oct 10, is increased investment in mental health. Why invest, and why now? The answer is simple. At the best of times, good mental health is needed for a society to thrive. During a pandemic, good mental health is more important than ever. Without a focus on mental health, any response to COVID-19 will be deficient, reducing individual and societal resilience, and impeding social, economic, and cultural recovery.
2020 has been a difficult year for mental health. The threat of infection, repeated lockdowns, social isolation, and economic uncertainty have created widespread fear and anxiety. A Rapid Review published in The Lancet showed the negative psychological effects of enforced quarantines. Many people who previously thought themselves unaffected by mental health issues have discovered that they, too, are vulnerable. Those with pre-existing mental health conditions have often found their difficulties increased. The precise neurological and psychiatric consequences of infection, meanwhile, remain unknown but demand careful monitoring. What investment is needed from governments and non-governmental organisations to mitigate the mental health impact of COVID-19 and, more importantly, to improve mental health globally?
S ED Mental

44. Nature: What it’s really like to do science amid COVID-19
From Germany to India, researchers are grappling with how to run labs and lessons under extraordinary restrictions. Autumn heralds the start of a new academic year in much of the world, but in 2020, the term comes with the disruption of the COVID-19 outbreak and a surge in infections in many regions. Many universities have welcomed students and researchers back to campus — often for the first time since nations implemented stringent lockdowns in March. But the return to institutions comes with unprecedented safety and social-distancing measures, which hinder teaching and laboratory work. And despite these, outbreaks on campuses are becoming a major concern in countries worldwide. Although some institutions are offering in-person teaching, remote instruction has become the norm in many places. And for those who had already returned to the lab and adapted their work procedures because of the pandemic, the return of teaching brings an increased burden as they try to balance safety with the needs of students. Maintaining research necessities such as animal lineages can also be a struggle under the control measures. “Even in labs that are open, research is restricted,” says Jamal Nasir, a human geneticist at the University of Northampton, UK, who is returning to his lab after six months away.

45. 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.

46. Nature: Ventilator advances for babies are proving vital for adults
Ground breaking ventilator technology is now moving beyond neonatal units and into ICUs.
When Sabina Checketts holds her hand a certain way, the tiny scar on its back resembles a rocket ship. Checketts received the scar during the first few days of her life, during a tenuous struggle for survival, after she was born at 28 weeks, or 12 weeks premature. Her rocket ship scar, and a few other small ones, are marks left by lines inserted into her tiny body to keep her alive.
“I don’t point these out to parents,” Checketts says, “but to me they’re badges of honour, because I survived.”
The parents to whom Checketts refers are those of her patients. Thirty-three years after her early birth, Checketts now works as a neonatal doctor. Today, she has at her disposal vastly improved technologies and techniques over what existed three decades ago. Those mostly uncelebrated advances are now driving better outcomes for other premature babies, and more hope for their parents.

47. Africa: Project-Syndicate: Overcoming the COVID-19 Disruption to Essential Health Services
It is clear that COVID-19 will persist much longer than anticipated. If countries do not take action soon to ensure the continuity of essential health services during the pandemic, the future death toll from communicable and noncommunicable diseases will be unacceptably high. Health-care delivery in nearly every country has been disrupted by policymakers’ mistaken initial assumption that health systems would quickly win the fight against COVID-19. As the pandemic’s caseload and death toll are increasing daily, it is often stalling or reversing hard-won progress on minimizing the impact of other diseases, from diabetes to malaria.
At the start of the pandemic, many policymakers and health leaders considered a relatively short disruption of essential health services acceptable, but it is now clear that COVID-19 will persist much longer than anticipated. Countries can no longer postpone the delivery of crucial health services. Without immediate action to ensure their continuity, the future death toll from communicable and non-communicable diseases will be unacceptably high. In a grim recent assessment of the global costs of the COVID-19 crisis, the Bill & Melinda Gates Foundation reported that in 25 weeks, the pandemic had set the world back about 25 years in terms of vaccine coverage – a good proxy for how health systems are functioning overall. Clearly, now is the time to make sure that essential health services are not left behind.

48. USA: Washington Post: ‘Nobody has very clear answers for them’: Doctors search for treatments for covid-19 long-haulers
Covid-19 took its best shot at Edison Chiluisa in May, sending him to intensive care, but the disease is still not done with him. For the past four months, long after his release from the hospital, Chiluisa has been racked by lingering ailments: Paralyzing fatigue. Shortness of breath. A stutter he never had before. “The disease, it wears on you — body, mind and spirit,” Chiluisa, a 51-year-old hospital worker, said recently. “You can be fine all day, and then all of a sudden your body just shuts down. No explanation. No reason. It just shuts down.” But unlike some “long-haulers” in the early part of the pandemic who struggled to persuade anyone that symptoms of covid-19 could last for months, Chiluisa is being attended by a team of specialists.
He sees a pulmonologist, a cardiologist, a neurologist, a respiratory therapist and a physical therapist, and soon he will see a social worker — a first step toward getting help for the toll the coronavirus has inflicted on his psyche.

49. Australia: Washington Post: First ‘travel bubble’ flight from New Zealand lands in Australia
The first flight carrying hundreds of visitors from New Zealand arrived in Australia on Friday as the two countries began their experiment with a trans-Tasman travel bubble. So far, the easing of quarantine mandates is one-sided, with all Australian travelers still required to quarantine for two weeks upon arrival in New Zealand, Reuters reported. But passengers arriving from New Zealand can skip quarantine requirements upon arriving in New South Wales, the Northern Territory and the Australian Capital Territory.Plans to institute a travel bubble, which both countries hope will provide a much-needed tourism boost, were on hold for months after coronavirus cases popped up in New Zealand and as cases surged in parts of Australia in August. New Zealand has subsequently managed to bring its outbreak under control, and caseloads have fallen dramatically in Australia.
Victoria, the state at the center of the Australian outbreak, reported just two new cases on Friday, its lowest tally since June. Lockdown restrictions are still in place, but Premier Daniel Andrews has said that the rules could be eased, according to the Sydney Morning Herald. Australia’s Nine News reported that many of the passengers arriving in Sydney from New Zealand on Friday were reuniting with loved ones they had not seen for months. One passenger was a man who had not seen his wife since he traveled to New Zealand for work in February.

50. 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

Best wishes to you all and stay safe
John Wynn-Jones