comment - bmj.com

I t’s all around you, especially if you venture into social media: GPs against hospital specialists, hospital specialists against GPs, and specialists against one another. Everyone is eager to score

points, having underlying angst about what others are doing, feeling hard done by and mistreated, or thinking that colleagues deserve more respect. And when a comment cuts too close to the bone, one person’s bit of old school stereotyping becomes another person’s disrespectful insult.

Some seem to believe that this simply refl ects the tough times we live in—perhaps the frustration of reduced resources or a huge patient backlog, combined with the aftermath of dealing with the pandemic and future uncertainties. Indeed, there is that element to it. Yet this ignores decades of history regarding “banter” between specialties, in hospital corridors and medical social circles. The stereotypes of diff erent specialties are never too far from medics’ general consciousness. You hear them from seniors as you develop in your training. And it would be blatant hypocrisy if we, as a profession, failed to recognise that you become part of that history when you perpetuate those stereotypes to your trainees.

W hat used to happen in the private social circles of medics is now happening in the open, on social media. And with that, all of the scars of interprofessional jealousy, rivalry, and disdain are laid bare to the public.

As clinicians we have our choices to make, and we have to bear the consequences. We could calm the rhetoric—and the specialty stereotyping—and have a workforce with a degree of mutual respect. Or we could accept that this discourse is simply part of the culture we’ve created and accept the toxicity that comes with it (after all, it’s not new—it’s simply more public). But if you decide this is simply part of medicine’s culture, and you then decide to have a go at another specialty with some sarcastic comment, you need to be ready to take it on the chin when the other party fi res back with gusto.

I’ve worked for many years as a consultant in diabetes and have heard more than enough barbs against the

specialty, some as “banter” and some with added spikes: “The lazy specialty,” “Glorifi ed GP,” “Just go and do some general medicine,” or “Why does diabetes need a consultant anyway?” Those comments used to sting. With time you learn to ignore some, answer some with humour, and try to stay away from a retort. With time, they’ve all quietened down. My approach has been to stay away from any judgmental comments about other specialties, which has reaped dividends.

For what it’s worth, try doing your own small bit too. It’s important we all recognise this bad feeling between specialties is a problem we need to refl ect on. If you ease off the mockery, the barbed comments, or the clever slights to gain kudos among your followers, then maybe you will have contributed to breaking the incessant cycle of in-fi ghting . Partha Kar, consultant in diabetes and

endocrinology, Portsmouth Hospitals

NHS Trust [email protected] Twitter @parthaskar

Cite this as: BMJ 2021;374:n2080

commentcomment

The scars of interprofessional jealousy, rivalry, and disdain are laid bare

the bmj | 4 September 2021 273

THE BOTTOM LINE Partha Kar

The toxicity of specialty stereotyping

“Slogans and quick fixes are more digestible than the reality of a virus” DAVID OLIVER “GPs need a safe place to vent our own sadness or frustration” HELEN SALISBURYPLUS Three point plan for school safety; looming food poverty crisis

274 4 September 2021 | the bmj

The highly transmissible delta variant of SARS-CoV-2 is now dominant in Europe and North America. While vaccinations are protecting adults from severe

disease quite eff ectively, children remain mostly unvaccinated. In England, the rate of children being admitted to hospital with covid reached its highest of the entire pandemic at the end of July (an average of 53 admissions a day), just after the school term ended.

This surge started after June’s half term holiday, when delta was dominant and after England moved to step 3 of the government’s roadmap. Although cases and admissions fell over the summer, admissions of under 18s remain near the January peak (about 40 a day in mid-August). Current overall case rates in England are fi ve times higher than in early June (25 000 v 5000) and are rising slowly. Children are currently returning to school.

The recent schools infection survey by the Offi ce for National Statistics (ONS) reported that case rates in schoolchildren were lower in June than in November. It concluded that schools were not “hubs of infection,” partly due to measures in place last summer such as frequent testing, isolation of contacts in

schools, mask wearing (which continued in many schools even when it was no longer mandatory), and low community covid rates. Unfortunately, the November and June fi gures both miss the peaks of infections in schoolchildren, in December and July.

For schools to be a problem, they don’t have to be worse than any other crowded indoor space. The problem is that they are another crowded indoor space, one where children spend 35 hours a week. We know delta spreads easily in such spaces, particularly if they are poorly ventilated. This is compounded by children being the population group with the least immunity to covid because they are largely unvaccinated.

If we want to avoid more children in hospital this autumn we need to get cases low, and keep them low, as they return to school. There are three ways to achieve this, and they work most eff ectively when used together.

Vaccines

Most high income countries are off ering vaccines to all 12-17 year olds (none is licensed for under 12s), but the UK is off ering them only to 16-17 year olds and a small group of clinically extremely vulnerable 12-15 year

olds. Vaccines have been shown to be highly eff ective in adolescents in preventing severe illness and symptomatic infection and would act to cut transmission in secondary schools.

Protective measures

Countries have used a variety of measures to reduce transmission within schools, but most include social distancing (smaller class sizes, staggered breaks); ventilation (CO2 monitors, HEPA fi lters, outdoor learning); cleaning; mask wearing; keeping children in bubbles; frequent testing; and isolation of contacts of cases.

The European Centre for Disease Prevention and Control has updated its guidance to recommend a combination of interventions in schools to protect children this autumn.

Community rates

As highlighted by the ONS survey, perhaps the biggest impact on cases in school age children is from rates of transmission in the community. When cases are high in general, it’s much harder to keep cases down in schools.

Food banks have come to expect busy Augusts as the UK’s social security safety net continues to be eroded. As parents try to scrape together the cost of school uniforms and taking care of their children through the summer holidays, money for food runs dry.

But this summer is different—there is a sense of foreboding among members of the Independent Food Aid Network (IFAN). A perfect storm is brewing, with an overnight cut to universal credit, the end of the furlough scheme, and a big increase in energy prices all planned for the start of October.

Despite campaigns from IFAN and many other charities for a cash first approach to food insecurity and to urge the government to address the root causes of food poverty, matters are about to get much worse. Food

banks are trying to prepare as best they can for what looks set to be the busiest and most difficult winter on record.

In March, the Department for Work and Pensions published food insecurity data for the first time. Its family resources survey found that between April 2019 and March 2020, 8% of households were food insecure. However, that figure increased to 43% for households relying on the pre-pandemic rate of universal credit. The government’s own data show that the £20 increase to universal credit payments was essential.

Lucy Bannister of the Joseph Rowntree Foundation explains, “In October, six million

Not only is the government not

achieving low transmission rates—

it’s not even trying to

This looks set to be the busiest and

most difficult winter on recordFood banks’ sense of forboding as autumn approaches

PERSONAL VIEW Christina Pagel

Schools: a gaping hole in England’s covid strategy The country is an anomaly in not undertaking any of three common strategies to prevent transmission in classrooms

BMJ OPINION Sabine Goodwin

RICH

ARD

H S

MIT

H


Most countries are using a combination of these approaches to allow children to return to school more safely. England is an anomaly in that it is undertaking none of the three. Almost all protective health measures have been removed: there will be no requirement for mask wearing; no rollout of CO2 monitors or support for ventilation; no social distancing; no bubbles; no requirement for under 18s to isolate if a household member has covid; and minimal contact tracing within schools.

Finally, community rates in England remain very high. With almost all public health measures removed and full capacity events such as football matches restarting, not only is the government not achieving low transmission rates—it’s not even trying to.

We need to join international colleagues, take infections in children seriously, and urge the government to follow international best practice as laid out by the European and US Centers for Disease Prevention and Control, to make schools as safe as possible.Christina Pagel, director, Clinical Operational Research

Unit, University College London [email protected] this as: BMJ 2021;374:n2115

As The BMJ went to press, the JCVI had not made a decision

on vaccinating children aged 12-15.

families will face the biggest overnight cut to the basic rate of social security since the second world war. This will pull half a million more people into poverty and increase hardship for many more, with far reaching consequences for the health and stability of families around the UK.”

IFAN envisions a society without the need for charitable food aid and is calling for an adequate social security system, as well as fair wages and job security. We believe that a living income is essential so everyone is guaranteed an adequate standard of living and is able to afford healthy and nutritious food. However, first and foremost, the devastating cut to universal credit planned for 6 October simply cannot happen. Sabine Goodwin, coordinator, IFAN, UK

A soundbite isn’t a logistical, risk assessed plan

The former BBC director general Mark Thompson, in his 2016 book Enough Said , explored the rise of simplistic, populist rhetoric in politics and public

discourse at the expense of complexity, nuance, and professional expertise.

We’ve experienced this soundbite culture around covid. Slogans and quick fi xes are more digestible than the messy reality of a virus with variables that can’t always be controlled or predicted. But a soundbite isn’t a logistical, risk assessed plan.

In England’s covid response, the politicians have proved fond of three point sloganeering: “Hands, face, space”; “Stay alert, save lives, protect the NHS”; and, after “freedom day” on 19 July, “Keep life moving.” At least the fi rst contained some health protection suggestions; the other two are merely ambiguous and opaque.

Ministers have also been obsessed with quoting big numbers—“100 000 tests a day”; “761 million pieces of personal protective equipment” —as if these were ends in themselves, when what matters is whether people can access them in a timely fashion and whether they’re eff ective. At least the government’s boasts about the success of the vaccination rollout related to a key solution in exiting the pandemic.

Beyond ministerial communications teams are other simplistic soundbites. For example, we’ve heard, “Stop telling us to protect the NHS. It should be there to protect us.” That may sound compelling, but the NHS has limited beds, staff , and resources, with no

ability to expand at pace. Without the public health protection measures, the service could have become so overwhelmed many others would have died avoidable deaths.

In a similar vein, we hear the NHS has favoured covid patients at the expense of people with other conditions, as if completely avoidable decisions were made to sacrifi ce non-acute care. To be clear: if intensive care facilities have doubled in size and are relying on anaesthetists, staff , and equipment from operating theatres; if one in three acute beds is taken up by someone with covid; and if vulnerable people would be at risk by coming to that same building—there isn’t an easy choice. The soundbite doesn’t come with any workable solutions.

Another favourite is, “We’ll have to learn to live with covid,” often followed by seasonal fl u comparisons. Short of “zero covid” approaches (another buzz phrase in want of a sustainable action plan), what does that mean? It seems to be used by people opposed to protective measures. But maybe “living with the virus” means some physical distancing, some indoor mask wearing, testing, and, of course, vaccination. What are the policy implications?

As covid has shown, I wouldn’t rely on people who repeatedly use soundbites to run anything beyond an advertising or election campaign—let alone a response to a global pandemic . David Oliver, consultant in geriatrics and acute

general medicine , Berkshire

[email protected] @mancunianmedic


ACUTE PERSPECTIVE David Oliver

Soundbites won’t solve a pandemic


Many uplifting things happen in medicine: babies are born safely, illnesses are prevented or cured, and even

deaths may be timely and comfortable. However, the larger part of any doctor’s workload will inevitably involve patients whose treatments have not been wholly successful, leaving people distressed or in pain despite our best eff orts.

Tangled up with these medical problems come a host of other issues concerning family, relationships, work, and money, all of which are brought to us in the consulting room.

When I’m at my best as a doctor, I listen to it all and try to pick out the bits that may have a medical cause or solution. I aim to be present and attentive to the whole patient, responding with warmth and empathy, while at the same time engaging the analytical, medical part of my brain.

But what do we do with the pain, grief, and anger that are presented to us each day? They are not ours, and only with practice and good fortune can we close the door on the consulting room and other people’s problems at the end of the day. We don’t always manage it, and sometimes we carry patients home with us in our heads, worrying about what will happen to them or what we may have missed.

Other caring professions have developed formal

mechanisms for debriefi ng, timetabled supervisions in which practitioners can talk about cases that are troubling them. These days very few GPs have the time or energy for the Balint groups that once fulfi lled this function in general practice. When consultations go wrong—or even when they go well but leave us feeling drained—we need an opportunity to share our experiences with trusted colleagues. We may need reassurance that we’ve done the right things, ideas about what else we might try, or just a safe place to vent our own sadness or frustration.

As general practice seems ever more pressed, and doctors become siloed in their consulting rooms for 12 hours at a time, there’s a real risk of isolation and depression. Some doctors recognise the toll it’s taking on their mental wellbeing and seek help, but many just carry on, fi nding no time to stop and refl ect until eventually they hit a brick wall.

As many have already pointed out, we’re at a crisis point in general practice. We’ve been painted as greedy and lazy by a hostile press, even as we work heroic hours to try to keep our patients safe. If we fail to set aside time to support each other and properly attend to our own needs, one day soon we may look around and fi nd that we have no colleagues—and many patients will have no doctor .

Helen Salisbury , GP, Oxford

[email protected] Twitter @HelenRSalisbury


Listen and subscribe to The BMJ podcast on Apple Podcasts, Spotify, and other major podcast apps

Edited by Kelly Brendel, deputy digital content editor, The BMJ

What do we do with the pain, grief, and anger that are presented to us each day?

Pre-diabetes or a borderline HbA1c resultA borderline HbA1c result that is above normal but below the diagnostic threshold for diabetes inevitably leads to a consultation with a patient to discuss these results. In this Deep Breath In episode Sam Finnikin, an academic GP, gives some helpful tips on having that discussion and explaining risk to patients. For starters, Finnikin argues that non-diabetic hyperglycaemia is a more useful and accurate term than pre-diabetes:

“We’re used to using ‘pre-diabetes,’ but we’re trying to shift away from that to ‘non-diabetic hyperglycaemia,’ which is not as easy to say, but is more accurate. Pre-diabetes confers this inevitability to the situation—you have high sugar levels and it’s only a matter of time until you develop diabetes. But that isn’t necessarily true and, actually, there’s growing evidence that a lot of people with a raised HbA1c won’t go on to develop diabetes. We can estimate what the risk of someone going on to develop diabetes is using tools such as QDiabetes, and HbA1c is only one part of that.”

Finnikin explains how he approaches this conversation: “I tend to start with making sure the patient understands that I haven’t diagnosed them with anything—they haven’t got a disease and they’re not ill. What we’re talking about is a risk factor for developing diabetes. But actually, more broadly, we’re talking about a risk factor for cardiovascular disease, because primarily we care about diabetes because it’s a significant risk factor for cardiovascular disease.

"So if I had time, what I’d like to do is focus on a holistic, risk based discussion about cardiovascular disease, of which developing diabetes is one factor. And the great thing about looking at it like that, and considering someone’s blood pressure and lipids as well in this conversation, is it highlights the fact that we’re not treating someone’s numbers.”

PRIMARY COLOUR Helen Salisbury

Looking after each otherLATEST PODCAST


At the current

global

vaccination

rate, it will

take years

to achieve

the needed

level of global

immunity

By late June 2021, 46% of people in high income countries had received at least one dose of the covid-19 vaccine compared with 20% in middle income countries and only 0.9% in low income countries. 1 This inequity has been driven by a global political economy that has permitted some countries to purchase more

vaccine than they require while others have very limited supplies. Canada, for example, with a gross domestic product (GDP) of $46 000 (£32 000) per head has vaccines for 434% of its population, whereas Jordan, which has twice the incidence of covid-19 and a GDP of $4400 per head, has secured doses for only 6% of its people. 2 As covid-19 variants are already showing some ability to evade the current vaccines, it is evident that without global vaccine equity and immunity, our eff orts against covid-19 are in jeopardy.

Equitable vaccine distribution to the world’s highest risk populations requires a multipronged approach that includes vaccine development and approval; scaling manufacturing; streamlining shipment, storage, and distribution; and building vaccine confi dence. International collaborations have helped tackle several of these fundamentals. However, the global community remains deeply divided on how to overcome the scarcity of supply. Pharmaceutical trade associations claim that supply is not a problem as manufacturers can supposedly provide 10 billion doses by the end of 2021. 3 But as suppliers consistently fall short in achieving manufacturing targets, production is clearly a bottleneck to global vaccination. 3 Indeed, at the current global vaccination rate, it will take years to achieve the needed level of global immunity. 4

The barrier to adequate vaccine supply today is not lack of vaccine options, nor even theoretical production capacity; the problem is the intellectual property (IP) protection governing production and access to vaccines—and ultimately, the political and moral will to waive these protections in a time of global crisis. Without such liberty, there will not be enough vaccine fast enough to prevent the spread of variants, the avoidable deaths, and the continued choking of low and middle income countries (LMICs) through poor health.

Beyond donor based models of global vaccine equity As covid-19 became a pandemic, global eff orts emerged to help ensure vaccines would be delivered across the globe to the highest risk populations. One of the fi rst was Covax, a risk sharing mechanism in which countries, tiered by means, contribute to collectively source and equitably distribute vaccines globally. The eff ort, however laudable in intent, has been undercut by vaccine scarcity and underfunding. Covax aims to vaccinate 20% of the population in 92 LMICs by the end of 2021. At the end of April, however, it had shipped only one fi fth of its projected estimates and lacked critical resources for distribution. 3

LMICs are wary about participating in well worn dynamics of global health aid. Instead, they are mobilising to overcome the fundamental paucity of available vaccines by challenging established global IP rules. At issue is the 1995 Trade Related Aspects of Intellectual Property Rights (TRIPS) Agreement, which established minimum protection standards for IP—including patents, industrial designs, trade secrets, and copyright—that all 164 members of the World Trade Organization (WTO) must respect. 5 Subsequent rulings (such as the Doha declaration) have strived to clarify safeguards on patents, including compulsory licensing, which allows

KEY MESSAGES

• Global covid-19 vaccine inequity is driven by accumulation of vaccines by high income countries and restricted vaccine production by a small number of manufacturers

• Donor based approaches to global vaccine equity will continue to yield limited results

• Sharing intellectual property and technological know-how is essential to help rapidly expand covid-19 vaccine production

• Countries must agree on a temporary intellectual waiver for covid-19 goods to achieve global herd immunity and advance global health equity

ANALYSIS

Intellectual property waiver for covid-19 vaccines will advance global health equity Parsa Erfani and colleagues argue that a temporary halt to legal restrictions is vital to increase supply, achieve global herd immunity, and improve equality of access across the world BR

IAN

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/REU

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/ALA

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governments to license patents to a third party without consent (table). 6 Today, these rules provide strong IP protection for vaccine technologies and aff ect the quantity and location of vaccine production and availability.

In October 2020, South Africa and India submitted a proposal to the WTO to temporarily waive certain provisions of the TRIPS agreement for covid-19 health products and technologies. The waiver would prevent companies that hold the IP for covid-19 vaccines from blocking vaccine production elsewhere on the grounds of IP and allow countries to produce covid-19 medical goods locally and import or export them expeditiously (table). Although the proposed IP waiver is supported by over 100 countries, WTO has not reached a consensus on the proposal because of opposition and fi libustering by several high income countries, including the UK, Germany, and Japan. 7

Waiver opponents argue that the limited capacity of LMICs to produce complex covid-19 vaccines safely is the true barrier to global production, not IP. They suggest that the TRIPS waiver would penalise drug companies, stifl e biomedical innovation, and deter future investments in research and development—in sum, that it would reduce returns on investment and dismantle an IP system that provided the goods needed to end the pandemic. Others are concerned that an IP waiver would fuel supply chain bottlenecks for raw materials and undermine ongoing production. Moreover, policy makers argue that a waiver is unnecessary as company driven voluntary licensing—in which companies decide when and how to license their technologies—and existing TRIPS fl exibilities (such as country determined compulsory licensing) should suffi ce in establishing production in LMICs (table). They suggest that waiving IP for covid-19 vaccines would provide no meaningful progress, but the data do not support this.

What effect would a waiver have?

Contrary to detractors’ concerns about the possible eff ect of a temporary TRIPS waiver, global health analyses suggest that it will be vital to equitable and eff ective action against covid-19. LMIC’s manufacturing capabilities have been underestimated, even though several LMICs have the scientifi c and manufacturing capacity to produce complex covid-19 vaccines. India, Egypt, and Thailand are already manufacturing viral vector or mRNA-based covid-19 vaccines, 8 - 10 and vaccine production lines could be established within months in some other LMICs, 11 off ering substantial benefi t in a pandemic that will last years. 11

Companies in India and China have already developed complex pneumococcal and hepatitis B recombinant vaccines, challenging existing vaccine monopolies. 12 The World Health Organization launched an mRNA technology transfer hub in April 2021 to provide the logistical, training, and know-how support needed for manufacturers in LMICs to repurpose or expand existing manufacturing capacity to produce covid-19 vaccines and to help navigate accessing IP rights for the technology. 13 Twenty fi ve respondents from LMICs expressed interest, and South Africa was selected as the fi rst hub, with plans to start producing the vaccine through the Biovac Institute in the coming months. 14

Removing IP barriers through the waiver will facilitate these eff orts, more rapidly enable future hubs, engage a greater number of manufacturers, and ultimately yield more doses faster. Moreover, as the waiver facilitates vaccine production, demand for raw materials and active ingredients will increase. Coupled with pre-emptive planning to anticipate and expand raw material production, the waiver—which encompasses the IP of all covid-19 vaccine-related technology— can off er a path to overcome bottlenecks and expand production of necessary vaccine materials.

Current licensing mechanisms inadequate

Voluntary licences have not and will not keep pace with public health demand. Since companies determine the terms of voluntary licences, they are often granted to LMICs that can aff ord them, leaving out poorer regions. 10 For example, in South Asia, AstraZeneca has voluntarily licensed its vaccine to the Serum Institute of India, even though the region has multiple capable vaccine manufacturers. 9 Many covid-19 vaccine developers have not taken steps towards licensing their technologies, simply because there is limited fi nancial incentive to do so. 11 To date, none have shared IP protected vaccine information with the WHO Covid-19 Technology Access Pool (C-TAP) established last year. 15 Relying on the moral compass of companies that answer to shareholders to voluntarily license their technologies will have limited eff ect on vaccine equity. Their market is driven by profi t margins, not public health.

Compulsory licensing by LMICs will also be insuffi cient in rapidly expanding vaccine production, as each patent licence must be negotiated separately by each country and for each product based on its own merit. From 1995 to 2016, 108 compulsory licences were attempted and only 53 were approved. 6 The case-by-case approach is slow and

Companies in India and China have

developed complex pneumococcal

and hepatitis B recombinant vaccines,

challenging existing vaccine monopolies

LICENSING OF INTELLECTUAL PROPERTY

Licence

Voluntary licence

Compulsory licence

Proposed intellectual property waiver

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MY

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/SO

PA /G

ETTY

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not suitable for a global crisis that requires swift action. In addition, TRIPS requires compulsory licences to be used predominantly for domestic supply, limiting exports of the licensed goods to nearby low income countries without production capacity. 5

Although a “special” compulsory licence system was agreed in the Doha declaration to allow for expeditious exportation and importation (formalised as the article 31bis amendment to TRIPS in 2017), the provision is limited by cumbersome logistical procedures and has been rarely used. 16 Governments may also be hesitant to pursue compulsory licences as high income countries have previously bullied them for doing so. Since India fi rst used compulsory licensing for sorafenib tosylate in 2012 (reducing the cancer drug’s price by 97%), the US has consistently pressured the country not to use further compulsory licences. 17 During this pandemic, Gilead sued the Russian government for issuing a compulsory licence for remdesivir. 18

Furthermore, while compulsory licences are primarily for patents, covid-19 vaccines often have other types of IP, including trade secrets, that are integral for production. 19 The emergency TRIPS waiver removes all IP as a barrier to starting production (not just patents) and negates the prolonged time, inconsistency,

frequent failure, and political pressure that accompany voluntary licensing and compulsory licensing eff orts. It also provides an expeditious path for new suppliers to import and export vaccines to countries in need without bureaucratic limitations.

Finally, there is no compelling evidence that the proposed TRIPS waiver would dismantle the IP system and its innovation incentives. The waiver is restricted to covid-19 related goods and is time limited, helping to protect future innovation. It would, however, reduce profi t margins on current covid-19 vaccines. With substantial earnings in the fi rst quarter of 2021, many drug companies have already recouped their research and development costs for covid-19 vaccines. 20 However, they have not been the sole investors in vaccine development, and they should not be the only ones to profi t. Most vaccines received a substantial portion of their direct funding from governments and not-for-profi t organisations—and for some, such as Moderna and Novavax, nearly all. 21 Decades of publicly funded research have laid the groundwork for current innovations in the background technologies used for vaccines. 22 Given that companies were granted upfront risk protection for covid-19 vaccine research and development, a waiver that advances global public health but reduces vaccine profi ts in a global crisis is reasonable.

Knowledge transfer

An IP waiver for covid-19 vaccines is integral to boosting vaccine supply, breaking vaccine monopolies, and making vaccines more aff ordable in LMICs. It is, however, only a fi rst, but necessary, step. Originator companies must transfer vaccine technology and share know-how with C-TAP, transfer hubs, or individual manufacturers to help suppliers begin production. 23 In addition, governments must leverage domestic law, private sector incentives, and contract terms with pharmaceutical companies to compel companies to cooperate with such transfers. 24 If necessary, governments can require technology transfers in exchange for continuing enterprise in a country or avoiding penalties.

Politicians and leaders are at a critical juncture: they will either take the necessary steps to make vaccine technology available to scale production, stimulate global collaboration, and create a path to equity or they will protect a hierarchical system based on an economic bottom line. The former will not only build a vaccination trajectory that puts equal value on the lives of the rich and the poor, but will also help stem the pandemic’s relentless momentum and quell the emergence of variants.

We are in the middle of one of the largest vaccination eff orts in human history. We cannot rely on companies to thread the needle of corporate social and moral responsibility with shareholder and stock value returns nor expect impacted governments to endure lengthy bureaucratic licensing processes in this time of crisis. It will be a legacy of apathy and unnecessary death. As the human impact of the proposed IP waiver becomes clear, consensus behind it is growing. Countries that previously opposed the waiver—such as the US and Brazil—now support written text based negotiations. 7 Opposing countries must stop blocking the waiver, engage in transparent text negotiations, and commit to reaching consensus swiftly.

The longer states stall, the more people die needlessly. Covid-19 has repeatedly shown that people without access to resources such as strong health systems, health workers, medicines, and vaccines will preferentially fall ill and die. For too long, this cycle has been “other people’s” problem. It is not. It is our problem. Parsa Erfani, Fogarty global health scholar , Harvard Medical

School, Boston

Agnes Binagwaho, vice chancellor , University of Global Health

Equity, Rwanda

Mohamed Juldeh Jalloh, vice president , Sierra Leone

Muhammad Yunus, chair , Yunus Centre, Bangladesh

Paul Farmer, professor , Harvard Medical School, Boston

Vanessa Kerry, associate professor , Seed Global Health

[email protected] Cite this as: BMJ 2021;374:n1837

Definition

Issued by the IP holder to a third party to produce the IP protected good. The licence usually sets

quality requirements, establishes payment, and defines the markets in which the licensee can

sell the product

Issued by a national government to a third party to produce a patented good without the patent

holder’s permission. The patent owner must still be “paid adequate remuneration” (adequate

not defined). Compulsory licences apply specifically to patents. Each licence must be considered

on its individual merit (TRIPS Article 31a). 5 Blanket licences cannot be granted for a technology

that has several patents. Under normal circumstances, the government must have first tried

to negotiate a voluntary licence with the patent holder. But during national emergencies,

other circumstances of extreme urgency, or public non-commercial use, governments can

pursue compulsory licensing directly (TRIPS Article 31b). 5 Under certain compulsory licences,

importation and exportation of the licensed good is restricted or includes bureaucratic hurdles

(TRIPS Article 31f, Article 31bis). 5 6

A waiver that allows WTO members to not enforce any IP for health products and technologies

related to the prevention, containment, or treatment of covid-19 for the duration of the

pandemic (circumstances justifying the waiver would be assessed after a minimum period

to determine its termination). The waiver includes all IP rights, not just patents, and allows for

expeditious importation and exportation of covid-19 medical goods


LETTERS Selected from rapid responses on bmj.com LETTER OF THE WEEK

We need public

health resources,

not more data

Scott and colleagues point out that data can save lives only if they inform practice (Editorial, 17 July). Public health is key because the social determinants of health account for most health outcomes.

Public Health England maintains the Fingertips resource, which is freely accessible and provides extensive population data on social determinants and healthcare at regional and local levels. These data inform the distribution of funding based on need and help monitor the success of interventions. Often, they merely show what we already know: disease risk factors associated with lifestyle are well correlated with deprivation, as are health (and healthcare) outcomes.

Directors of public health and their teams know their communities. They know where risk factors cluster, where deprivation is entrenched, and which groups require additional support to access services. They are expert in implementing interventions to tackle these complex problems. Yet over the past decade, local authorities have seen massive budget cuts.

The challenge therefore is not better data but resources to enact change. Despite this, population health management—data driven population risk stratification to inform targeted action—is receiving much attention. Population health management is shiny and sounds futuristic while public health actions often take longer than a political cycle to show effects. This incentivises policy makers to spend scarce resources (financial and human) on refining the illustration of problems we already understand, while meaningful public health actions on the social determinants of health continue to be the opportunity cost.

If the health system put every penny it plans to spend on data over the next five years into making communities greener, making them easier to cycle and walk around, and making healthy foods more available and affordable, which would save more lives? Sebastian Walsh, academic public health specialty

registrar , Cambridge


“DATA SAVES LIVES”

Ethical data provision is critical

Scott and colleagues suggest rethinking how we use health data in informative ways (Editorial, 17 July). But we need to broaden our thinking and consider how to get data in ethically sound ways. We should focus on improving data donation—before and after death. This would avoid data waste and could save and improve lives.

Scott and colleagues call for patient involvement but do not mention the importance of gaining patient consent. Worse, consent is mentioned only once in the Data Saves Lives policy paper as being a burdensome barrier rather than an important process.

A learning health and care system must strive for continuous quality and quantity improvement. In rethinking data use, ethical data provision should not be forgotten. Consent must remain central to allow us to save, share, and donate data before and after death. David Shaw, senior researcher , Basel and Maastricht; Thomas Erren, director and chair , Institute and

Policlinic for Occupational Medicine, Environmental Medicine and Prevention Research, Cologne


SHARING MEDICAL DATA

Scottish register allows

researchers to contact patients

Salisbury concludes that presumed consent is not enough for sharing medical data (Helen Salisbury, 3 July).

We have asked people to join SHARE, the Scottish Health Research Register. They give consent for their NHS data to be used to identify them for research projects and are contacted with details of research that may be appropriate for them. With their further consent, their contact details are given to research teams. They can also give permission for their unused blood from routine investigations to be used anonymously for genetic research.

Almost 300 000 people have signed up. Most are told about it by trained recruiters while attending hospital or GP appointments; around 90% of those approached say yes. Very few (around 50 per year) subsequently withdraw, usually for reasons of frailty or serious illness. Brian McKinstry, emeritus professor of eHealth ,

Edinburgh; Frank Sullivan, professor of primary care

medicine , St Andrews; Shobna Vasishta, national

project manager , SHARE Scottish Health Research

Register


GPs AND PATIENT DATA

The worst form of paternalism Whatever you think about NHS Digital’s GP Data for Planning and Research programme, the threat by GPs in Tower Hamlets unilaterally to withhold their patients’ data just compounds the

Technology platforms

Learninghealth

system

Practice

Data

Knowle

dge

problem (This Week, 17 July). I would be furious if my GP blocked the use of my de-identified personal data for planning and research without consulting me. This is the worst form of paternalism.

I want my medical data to be used for public benefit, and I believe this scheme will deliver that. Decisions to opt out belong to the individual, not their GP. Angela Coulter, member, BMJ International Patient

Panel , Oxford


EAR WAX REMOVAL

Core services in general practice

Minerva finds it inexplicable that many general practices no longer remove impacted ear wax (Minerva, 17 July).

People might not be aware of the distinction between core services and what has commonly been considered part of primary care. The policies need sorting out. GPs are part of clinical commissioning groups (CCGs), but ear wax removal is not commissioned. Some services will remove wax for about £60, but many patients cannot afford it. The NHS provides free training for practice staff to learn these skills.

The BMJ is not the forum to debate what is core, but historically GPs had to buy their own computers and other things now provided by CCGs. The way forward may be new GP networks, with healthcare practitioners providing microsuction free on the NHS. John Sharvill , portfolio GP , Deal



DEBATE ON COVID-19 VACCINATION IN CHILDREN

Children’s rights have been neglected

Wilkinson and colleagues give the reasons for and against covid-19 vaccination for children and adolescents (Head to Head, 17 July) but do not mention the consequences of the “secondary pandemic” on this population.

Of particular concern are the effects on mental health and wellbeing: anxiety, depression, disturbances in sleep and appetite, isolation, and self-harm have increased. Prolonged school closures have produced dramatic learning loss, particularly among the most disadvantaged students, which will translate into an epidemic of school failures, dropouts, and gloomy life perspectives for many.

The risk to benefit ratio of vaccination for children and adolescents favours the benefits—for individuals (and society)―as only vaccination can allow them to restore their normal social and educational process and have their rights, widely neglected during the pandemic, respected. The way children and adolescents have been forced to live for over a year has been the most dangerous “variant” of their lives. Federico Marchetti , director , Department of Paediatrics, Santa Maria delle

Croci Hospital, Ravenna ; Giorgio Tamburlini, director , Centro per la Salute del

Bambino, Trieste


ADUCANUMAB FOR ALZHEIMER’S DISEASE?

Aducanumab and culture wars

Despite evidence of ineffectiveness, aducanumab has received “accelerated approval” from the US Food and Drug Administration on the grounds of unmet need (Editorial, 10 July). Unmet need is not an evidentiary threshold and should not override regulatory standards.

We have two concerns. Firstly, the FDA’s approval of aducanumab can be read as an approval of the amyloid hypothesis, despite the failure to translate the amyloid model into an effective treatment over decades.

Secondly, the libertarian turn in the US has fostered “right to try” legislation, whereby people can seek treatment with aducanumab and if thwarted claim a right to try the drug in the courts. Supporters talk about bringing preventive therapies directly to vulnerable patients, shaking up slow drug approval processes, and striking a blow for the common people. Aducanumab could gain a niche in the culture wars currently threatening the US and could do the same in the UK. Steve Iliff e, emeritus professor of primary care for older people : Jill Manthorpe,

professor of social work , London


DOCTORS’ PAY

Pay cuts exacerbate the workforce crisis

Mathew is right that the debate on doctors’ pay is not about the money (Rammya Mathew, 17 July)—it’s about the future of the NHS.

When pensioners are guaranteed an index linked pension rise annually, and punitive, ill thought through taxation is used to pay for public sector pensions, a pay increase that is again below the rate of inflation is another factor in doctors choosing early retirement.

Fewer doctors are being trained and fewer are practising. The resultant exacerbation of the workforce crisis cannot be patched by reliance on overseas doctors and increases the threat of privatisation.

Perhaps we should not expect more than an effective 1.5% pay cut. But this does not mean that the profession and its unions should not strive to bring these concerns to the public attention and highlight the effect this further pay cut will have on the service that the public expects. Phil Raines, consultant respiratory physician , Yeovil


HOSPITAL BED NUMBERS

Understaffing is the problem

Oliver rightly says that hospital bed numbers were inadequate before the pandemic and will continue to be so (David Oliver, 17 July). I am sure that he would agree that the issue is not beds but staff. The Nightingale hospitals showed this: beds and equipment were assembled in a very short time but were barely used because staff were lacking.

In the early 1990s, spokespeople for the Department of Health (as it then was) and for regional management teams said that hospitals needed to sweat their assets to optimise their financial position. A chronically bad situation with beds and staff became obviously worse.

I am also sure that NHS staff would value the opportunity to work in departments that are not chronically understaffed. They are currently exhausted most of the time and believe that they have let patients down because they didn’t have the time to look after them properly. Roger A Fisken, retired consultant physician , Reading


TAKEOVER OF LONDON GENERAL PRACTICES

Scotland is ripe for corporate takeover

London doctors fear privatisation, but in Scotland it could be happening already (The Big Picture, 17 July).

Health boards in Scotland don’t always know who they are giving money to, because partnerships have no legal obligation to declare their members (which might include limited companies with separate legal identities) or their accounts. A large company could partner with one or more GPs and sort out investment and profits in an undisclosed partnership agreement.

Individual doctors are regulated by GMC responsible officers, but “there are no regulatory inspections of general medical practices in Scotland.” Private practices are inspected by Health Improvement Scotland. “Cross cover” between branches of the same organisations allows care to be devolved from centralised qualified GPs to local nurses and healthcare assistants.

There is no public evidence that general practices in Scotland have been privatised, but the unique circumstances mean there is no way of showing that they haven’t. Andrew J Ashworth, GP and occupational physician , Bo’ness



OBITUARIES

Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

Prem Nath Satsangi GP and surgeon (b 1932; q Lucknow 1954;

MS Lucknow, FRCS Edin, FRCS Lond),

died from cerebral vasculitis, and

complications of frailty of old age on

10 November 2020

Prem Nath Satsangi left India in 1961 with his wife, Nirmal, an anaesthetist, and their first son to travel to England, to complete his higher training in surgery. He completed substantive registrar appointments in surgery at Ashington General Hospital, Northumberland, and at Victoria Hospital, Romford. He did locum appointments in England and Scotland, before moving into general practice. He worked as a singlehanded practitioner in Gidea Park, Essex, for 30 years but also continued to travel to Scotland to work in locum consultant surgical appointments in his holidays until 1987, and developed a love of the country and landscape, especially the Highlands and Western Isles. Predeceased by Nirmal in 2009, he leaves two sons and four grandchildren. Jack Satsangi


Aria Nikjooy Paediatric doctor (b 1990;

q Birmingham 2014),

died from metastatic

medulloblastoma on

8 February 2021

Aria Nikjooy was born in 1990 in Sheffield to a French mother and Iranian father. At Birmingham Medical School he immersed himself fully in university life. He was eager to put his medical knowledge into practice and had a natural bedside manner. After qualifying he worked as a junior doctor in Birmingham for three years until he started paediatric training in Manchester in 2017, just a couple of months after the birth of his son, Eliyas. Aria was diagnosed with medulloblastoma in November 2018 and underwent surgery, radiotherapy, and chemotherapy. During his recovery, he turned to writing children’s books to help other families deal with illness and loss while raising awareness of brain cancers. Shortly after he died, his family published his personal memoir. Aria leaves his wife, Naomi, and their son. Naomi Jiagbogu , Edris Nikjooy


George David Hurrell General practitioner

(b 1932; q Durham 1955;

DObst RCOG), d 22 March

2021

George David Hurrell, known as David, was the son of chest physician George Hurrell. He began his career as a houseman at Royal Victoria Infirmary, Newcastle, then completed national service largely in Troon on the Ayrshire coast. After a year at Dilston Maternity Hospital he spent a year as a trainee GP with Wilfred Hall in Embleton on the north Northumberland coast. He entered general practice at Prospect House in the west end of Newcastle, where he remained for the rest of his career. He was held in the highest regard by his patients and colleagues and was a conscientious and committed doctor. In retirement he undertook regular medical boards and took up golf to go along with his passion for music, walking, gardening, and DIY. He died peacefully at home with his family and leaves Joan, his wife of 64 years; four children; and eight grandchildren. Sue Hurrell , Alan Craft


Bryan Eric Humphriss GP (b 1931; q Liverpool

1956; FRCGP), died

from biliary sepsis and

metastatic renal cancer on

20 March 2021

Bryan Eric Humphriss was born in Woolton, a village suburb of Liverpool, and joined Woolton House Surgery in 1962, where he worked for the rest of his career. The surgery provided clinical care for patients in Sunnybank, the Marie Curie Hospice, from its opening until 1992. Bryan was a supportive teacher and mentor. He served on the Liverpool local medical committee, including as its chair, and was a member of the operational services group that helped commission the Royal Liverpool Hospital. Away from medicine his interests were many and varied, including music and the piano, sailing, hill walking, and golf. He continued to read The BMJ throughout his retirement. He died after a short illness and leaves Bev, his wife of 60 years; a son; and two grandchildren. David Humphriss


William Smith Mitchell Consultant rheumatologist

and general physician

(b 1952; q Glasgow, 1977;

MD, FRCP Glas), died from

idiopathic pulmonary

fibrosis on 18 February

2021

William Smith Mitchell (“Bill”) was a consultant general physician and rheumatologist at Furness General Hospital in Barrow for over 30 years. He was consultant physician on call in 2002 during an outbreak of Legionnaires’ disease in Barrow—the worst ever seen in the UK. Bill’s identification of the infection undoubtedly saved lives. He had a keen interest in the education and training of junior doctors. With his wife, Maureen, Bill enjoyed line dancing and ballroom dancing. He had a great interest in literature and poetry and was a keen hillwalker. He had been conducting clinics while shielding from covid-19 up until the day before he was admitted to hospital in early February 2021. He leaves Maureen, his wife of 43 years; four children; and five grandchildren. John J Keating , Fiona Wood, Alan Barton


Constance Mary Hunter GP Chapeltown, Leeds

(b 1934; q Leeds 1958),

died from vascular

dementia and Alzheimer’s

disease on 3 April 2021

Constance Mary Hunter (née Wilton) became a GP in Chapeltown, Leeds, in 1961 and spent most of her working life there. She was committed to the principles of the NHS and was an active member of several organisations led by medical professionals and formed to defend GP practices and wider health services. Constance went on fact finding trips to Cuba and the Soviet Union, and helped to found the first rural diabetes clinic in Jamaica. Constance retired in 2014 and unfortunately mobility issues prevented her from undertaking some of the trips she had planned to visit her many friends and family. She developed vascular dementia and Alzheimer’s, and it was these conditions that led to her death three years after diagnosis. She leaves three children and their families. Frances Hunter



Born in the hills of Shimla, northern India, on 10 June 1948, Kailash Chand Malhotra grew up in a large family. His father, Harish Chander, worked on the railways, and his mother, Hem Lata, was a housewife. Chand was educated in the village school of Adhoya, in the Kurukshetra district in the state of Haryana. Athletic, as well as academic, he excelled at cricket and both founded and captained the school’s fi rst cricket team at the age of 15.

In 1968 Chand entered the Government Medical School, in Patiala, Punjab, through the “sports quota” on the back of his cricketing prowess, a sport that he continued to enjoy playing throughout his impressive career. An admired paternal uncle who was involved in politics and keen to help disadvantaged people sparked his own interest in politics.

In the early 1970s, Chand, along with other medical students,

became involved in two uprisings when they stood up for farmers’ rights after the Indian government imposed harsh landowning restrictions. Wearing his white doctor’s coat, Chand was arrested twice and released on bail. Thankfully, his medical studies were unaff ected.

Medical career

In Delhi, after a year’s internship at the Northern Railway Hospital, Chand worked as a junior doctor at Safdarjung Hospital, where he met his future wife, Anisha, also a junior doctor. They married in 1974 and had two sons, Amit and Aseem, before deciding to move to England. On arriving in Liverpool in 1978, Chand worked at Alder Hey Hospital as a junior paediatric doctor and was devastated when a senior consultant told him that, as an immigrant, he had no chance of a successful career. He considered returning to India, but decided to remain and work

for the NHS, in which he and his wife believed. The family moved to Manchester, where Chand joined a general practice in the town of Stalybridge.

After a few years he set up his own general practice at Stamford House, which was opened by Andy Burnham, then MP for Wigan and Leigh. Chand had a role in the election of Burnham as mayor of Greater Manchester, acting as his health adviser. They became great friends, sharing a passion for tackling longstanding problems of poverty in Manchester. Chand also chaired his local medical committee and represented his local community of GPs, always ready with support and advice. He retired from general practice in 2009.

Andy Burnham paid tribute to Chand on Twitter: “Heartbroken about the sudden loss of my dear friend Kailash. He was everything to me and the NHS was everything to him.”

Chand’s colleague JS Bamrah recalled, “My memory of Kailash is his passion for rightfulness and campaigns, for supporting the underdog and underprivileged, and for extolling the virtues of a healthcare system which he saw to be the best in the world, with much justifi cation. He had intellect, as well as compassion.”

A prolifi c medical writer, Chand contributed regular articles to the Guardian , Pulse , the Independent , and the Mirror and wrote opinion pieces for The BMJ .

Medical politician

In his other roles as a member of the BMA’s General Practitioners Committee and chair of Tameside and Glossop Primary Care Trust, he tirelessly campaigned to improve local health and reduce inequalities. From 2015 he was a director of Arawak Housing Association, Manchester. More

recently, he was the vice president of the BMA and a member of the BMA board and council.

Chaand Nagpaul, BMA chair, paid tribute: “I have known Kailash for over 20 years. After he was elected to the BMA GPs committee we soon became natural allies and close friends. His consistent and enduring character was one of conviction, passion, and uncompromising values. He had a deep commitment to the NHS and was fearless in challenging any political policy or politician of any hue that threatened its values. He was generous with his time for others. I owe him a debt of gratitude for his unfailing faith in me—guiding, encouraging, and supporting me to progress within the BMA. He has contributed to the BMA immensely—he was the fi rst deputy chair of council from an ethnic minority background and has been honoured as a vice president of the association. Kailash led a life of service—to other doctors, to patients, and to the health service.”

Throughout the covid pandemic, Chand provided his expert opinion to local and national media as well as the public. He recently appeared on the BBC’s Our NHS—A Hidden History .

For relaxation, he enjoyed poetry, Bollywood fi lms, Indian music, and long walks.

He was awarded an OBE in 2009 for his services to the NHS and healthcare.

He died suddenly at home after experiencing central chest pain.

Kailash Chand’s son Amit died in 1988, and his wife, Anisha, in 2018. He leaves his son, Aseem Malhotra, a consultant cardiologist. Rebecca Wallersteiner , London [email protected] Cite this as: BMJ 2021;374:n2041

OBITUARIES

Chand tirelessly

campaigned to

improve local

health and reduce

inequalities

Kailash Chand (b 1948; q Punjabi University, India,1972; OBE, DTM&H

Liverpool; FPA; FRCGP), died suddenly from a cardiac arrest on 26 July 2021

Kailash Chand General practitioner, NHS campaigner, and medical politician

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