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The covid-19 yearbook: world leaders edition In times of crisis, great leaders step up. So, asks Mun-Keat Looi, how did the class of 2020 fare? Most likely to misinform Most likely to approve a vaccine

Donald Trump, President of the United States Vladimir Putin, President of Russia What to say about the man who fi rst claimed Long carrying one of the biggest covid-19 covid-19 would “disappear,” then blamed caseloads, Russia’s infections have soared China, then withdrew from the WHO, then throughout 2020, yet deaths per capita are told citizens to inject bleach, repeatedly relatively low, despite reports of a healthcare tried to discredit his own infectious diseases system struggling with ageing equipment lead, and caught the virus himself only and hospitals almost constantly near to continue to fl aunt his refusal to adopt capacity. Putin put restrictions in relatively prevention measures? Trump has made the swiftly but refused to introduce a lockdown pandemic a partisan, political issue in the and is pinning hopes on his country’s own Most likely to impose a US, hampering public health eff orts. Soon to vaccine development. He has spared no stringent lockdown be former president of the United States, to opportunity to laud Russia’s progress and the relief of many. fl abbergasted the world by approving one Xi Jinping, President of China vaccine candidate before phase 3 trials From original concern to almost full had reported any results. He claimed it was normality, China is both reprobate and safe because his own daughter had been role model to the world in how to handle administered it, though not yet himself. an epidemic. Chinese offi cials have been accused of covering up initial signs of the Most likely to understand infection, but they were quick to impose an the science unprecedented lockdown on the Wuhan region. It was stringent and perhaps Angela Merkel, Chancellor of Germany unreplicable elsewhere, but Xi Jinping’s One of the few world leaders with a scientifi c decision, as well as zero tolerance follow-up background, Merkel quickly grasped the measures (including invasive surveillance, situation when the novel coronavirus hit mass testing of the entire Wuhan region, and Europe. Germany’s effi cient public health clamping down on any cluster outbreaks), system and clear communication with its has meant China is one of the few countries state governors, as well as neighbouring in recovery (health-wise and economically) in Most likely to claim to be countries, meant it has coped with alarming the world. “world beating” infection numbers 1 with a robust test-and- trace system and clear, eff ective prevention Most likely to deny everything Boris Johnson, UK Prime Minister measures. Not everyone is happy, of The decision to lock down later than the rest course—protests by far-right anti-mask Javier Bolsanaro, President of Brazil of Europe left the UK with one of the highest groups continue—but Merkel, together with A man who is at least consistent. Even when death rates in the world. In November it Emmanuel Macron of France, have been he himself caught the virus, Bolsanaro became the fi rst country in Europe to pass prominent in steering Europe through what maintained his dismissal of it as “the 50 000 deaths, although the NHS has coped is still a highly turbulent time. little fl u.” His blatant disregard for masks, admirably, and initial problems with PPE social distancing, or any kind of preventive seem to have been ironed out. However, measures led to clashes with, and the confusion over constantly changing rules, eventual dismissal of, two health ministers a struggling “world beating” test-and-trace in the space of three months, and ran system, and allegations of cronyism in key counter to regional governors’ attempts to appointments and the awarding of contracts get the world’s third largest outbreak under to private companies for pandemic services— control. Brazil still suff ers, particularly not to mention overlooking the incident of with an underfunded universal healthcare Dominic Cummings’s trip to Barnard Castle— system, 2 but Bolsanaro remains defi ant: have severely eroded public trust despite “All of us are going to die someday… We Johnson earning early sympathy after must stop being a country of sissies,” he suff ering a serious bout of covid-19. said in November.

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Most likely to eliminate the virus

Jacinda Ardern, Prime Minister of New Zealand Universally lauded for being one of the few countries to achieve eff ective elimination of covid-19, some may argue that New Zealand’s Ardern benefi tted from a relatively remote and sparsely populated country, making closed borders and restrictions easier to enforce. But there’s no doubt her decision to follow scientifi c advice and aim for the “zero COVID” strategy that other countries rejected as unachievable has allowed New Zealand to return to normal. Ardern’s reassuring yet fi rm demeanour and swift action in response to subsequent cluster outbreaks have won admirers abroad and at home, helping her to an absolute majority in New Zealand’s 2020 election.

Most likely to give a clear and Most likely to refuse to measured national address wear a mask

Emmanuel Macron, President of France Andrés Manuel López Obrador, Nationally broadcast addresses can be President of Mexico double-edged swords, but Emmanuel “You know when I’m going to put on a Macron has wielded them with some skill. mask? When there is no corruption,” said They’ve proved crucial in communicating López Obrador in July. He has repeatedly two strict but necessary lockdowns and broken physical distancing guidelines numerous curfews and restrictions on French and continued to travel even as Mexico citizens, balancing his country’s teetering rocketed up the caseload rankings over the economy, racial tensions, and the world’s fi fth summer. With austerity foremost on his biggest coronavirus burden. His leadership agenda, he has kept testing and tracing at domestically as well as on the continent has a minimum and forgone any mandatory earned him credit, but, as France’s hospitals national lockdown, instead focusing on an struggle with a second wave already worse expansion of hospital beds. The result is Most likely to act first than the fi rst, he will need to off er more than one of the highest caseloads and mortality reassurance in the months ahead. rates per capita in the world. Tsai Ing-Wen, President of Taiwan If there’s a leader who did everything right, it’s Tsai. The fi rst to take preventive action over SARS-CoV-2, she ordered health screenings for all fl ights from Wuhan from 31 December 2019 and in January mobilised the Central Epidemic Command Center to coordinate the response. She introduced travel restrictions, began quarantining high risk travellers, and limited the number of people allowed at gatherings. Aided by a robust healthcare system and universal health coverage, Taiwan has a strong track, trace, and isolate programme following lessons learned from the SARS epidemic in the early 2000s.4 Tsai’s government even produced its own masks, partnering with the country’s private companies to keep stocks high and prices aff ordable for hospitals and the public, and donating 10 million to other countries at a time of global shortages and Mun-Keat Looi, international features editor , The BMJ [email protected] international division. Cite this as: BMJ 2020;371:m4728 the bmj | 19 December 2020 - 2 January 2021 469 HOUSE OF GOD

80 8 Fig 1 | Body weight ORIGINAL RESEARCH and energy intake, A very introspective study beginning with a 60 6 daily energy intake of <5000 kJ for 14 Estimating my days, then jumping Body weight (kg) 40 4 to approximately Body weight 7500 kJ for 15 days. Energy intake equilibrium Energy intake (kJ 000s) Note that a greater 20 2 than 50% step energy Target intake <5000 kJ Target intake 7500 kJ increase in intake 0 0 produces a negligible 1 8 15 22 29 proportional change intake during Day in weight lockdown Introduction: naive and kicking in coronavirus disease 2019 (covid-19) isolation meant that unknown quantities R A L e w i s Trust me, I’m a physicist. Not a physician. of unknown foods—from working lunches, Mass and energy I know about. My research dinner parties, or restaurant meals 9 10—were O b j e c t i v e To estimate the daily dietary energy question was simple: what energy input do eschewed rather than chewed. The identity intake for me to maintain a constant body weight. I need to maintain my mass (henceforth, of every food was known, the amount How hard can it be? “weight”)? The answer should be simple of every food was audited. Secondly, the Design Very introspective study. to fi nd. But there are more answers than proportion of diff erent foods was largely the Setting At home. In lockdown. (Except every questions when it comes to diet. I might need same each day. Thus, even if the absolute Tuesday afternoon and Saturday morning, when I 7950 kJ or 10 878 kJ per day.1 - 6 I wanted energy content for one food was incorrect, went for a run.) more precision than that; I’m a physicist. So, that remained consistent across the study. Participants Me. n=1. I turned to self-experimentation,7 which may Thirdly, energy intake was largely changed Main outcome measures 8 My weight, measured be worse than worthless . by varying the amounts of the same foods, each day. not by introducing new foods. Results Sleeping, I shed about a kilogram each Methods: a balancing act Lockdown also meant that my activity was night (1.07 (SD 0.25) kg). Running 5 km, I shed similar day to day. Each lockdown day was about half a kilogram (0.57 (0.15) kg). My daily Food supplies energy. Activity uses energy. the same: wake, weigh, emails, breakfast, equilibrium energy intake is about 10 000 kJ If more energy is supplied than is used, then Zoom, elevenses, Zoom, lunch, Zoom, time (10 286 (SD 201) kJ). Every kJ above (or below) body weight goes up, and vice versa. My goal for a little nap, Zoom, dinner, and so to 10 000 kJ adds (or subtracts) about 40 mg (35.4 was to fi nd the sweet spot (avoiding sweets) bed. I weighed myself on bathroom scales. mg, SD 3.2 mg). where energy in equals energy out. I knew My reference weight was that measured in Conclusions Body weight data show persistent there was more to it than that. the morning, immediately after waking, variability, even when the screws of control are To measure the food energy content, a undressing, and urinating. tightened and tightened. calorimeter was impractical.9 Instead, I relied Of course, energy balance studies have School of Physics, Faculty of Engineering and on the food packaging or, if unpackaged, the been pursued for a long time. As reported Information Sciences, University of Wollongong, New web.6 I measured food portions on kitchen as long ago as 1897, A W Smith, a physicist, South Wales scales. Multiplying the energy density and was locked in a “respiration chamber” 7 feet Correspondence to: [email protected] Cite this as: BMJ 2020;371:m4561 mass gave the energy content. Three factors long, 4 feet wide, and 6 1/3 feet high for 12 Find the full version with references at regulated my energy input. First, being days.11 Now that’s isolation. http://dx.doi.org/10.1136/bmj.m4561

5 km run Elevenses Time for a WHAT IS ALREADY KNOWN ON THIS TOPIC Wake up Shower Lunch little nap Dinner • People like me need to take in between 7000 and 76.0 11 000 kJ each day to maintain their body weight 75.5 WHAT THIS STUDY ADDS 75.0 • Determining maintenance energy intake is ody weight (kg)

challenging, even during lockdown, when there are B 74.5 no work lunches, no skipped meals, no dinner parties, no restaurants, and the same old same old routine day 74.0 in day out 73.5 • Step changes in dietary intake—even steep steps—are not refl ected in step changes in body weight 73.0 6am 9am 12pm 3pm 6pm 9pm 12am • A simple model accounts for the data and allows an estimation of the equilibrium energy intake even in Time of day the face of substantial fl uctuations in body weight Fig 2 | Body weight measured across one day, with seven life events indicated.Five hour by hour and day by day measurements were made on each occasion, demonstrating good scale reproducibility. Body weight fluctuated by more than 2 kg over the course of a single day

470 19 December 2020 - 2 January 2021 | the bmj HOUSE OF GOD

80 16 Body weight Energy intake

78 12

Body weight (kg) 76 8 Area of figure 2 Eat. Run. Sleep. Repeat 74 4 Energy intake (kJ 000s) These intra-day variations stimulated a closer Area of figure 1 look at some systematics. I found that my weight 72 0 loss during a 5 km run averaged 0.57 (SD 0.15) 01020 30 40 50 60 70 80 90 100 110 120 kg. I found that the weight lost between going to Day sleep and waking up averaged 1.07 (0.25) kg. <5000 kJ 7500 kJ 8000 kJ 8500 kJ 9500 kJ 10 500 kJ 11 500 kJ 12 500 kJ Target intake Day after day, day after day: baked beans Fig 3 | Daily reference body weight measured first thing every morning over 16 weeks and daily energy What more could I do? I had been on a fi xed intake over the same period energy intake, but I decided to have exactly the same food every day. This was tough. The baked beans, in particular, proved hard to swallow, day 80 16 Body weight Energy intake Model in, day out. My admiration grew for physicist A W Smith who managed 120 g of baked beans a 78 12 day for 12 days straight.11 Yet my weight data still fl uctuated. Then, after a fi nal fl ing at 12 500 kJ, I pulled the plug on the experiment, conceding Body weight (kg) 76 8 Area of figure 2 defeat. Energy intake (kJ 000s) 74 4 Discussion: retrospection Area of figure 1 72 0 01020 30 40 50 60 70 80 90 100 110 120 The daily data taken as a whole (fi g 3) suggested that weight was lost at a daily energy intake of Day <5000 kJ 7500 kJ 8000 kJ 8500 kJ 9500 kJ 10 500 kJ 11 500 kJ 12 500 kJ 7500 kJ and gained at 12 500 kJ—an equilibrium daily intake of (10 000±2 500) kJ. Is that all from Fig 4 | Daily reference body weight measured first thing every morning over 16 weeks and daily energy intake 114 days of self-imposed, self-disciplined self- over the same period with a model of 10 286 kJ equilibrium intake and ±35.38 mg per ±kJ superimposed experimentation? Weight, what about a mathematical model?14 - 16 Results I stepped up to 8000 kJ per day and Being a physicist, I tried the simplest model I stuck at that for two weeks. But the weight could conceive, with only two parameters: the Detailed data are in the supplementary data seemed to be trending down still. So, daily equilibrium energy intake and the rate table online; here I provide a descriptive I made another baby step to 8500 kJ. Still, at which excessive energy intake adds weight. narrative. Step 1 was to eat less12 to lose my weight seemed to be dropping. Eight Weight and energy intake on one day then predict weight. 13 I began below 5000 kJ per day. My weeks with no answer. Time to weight on the next day. The best fi t to the data was weight dropped from 79.61 kg to 77.38 kg take a bigger step: up to 9500 kJ for for equilibrium intake of 10 286 kJ/day, within in 11 days. Yet the daily weight loss was not two weeks. My weight might be going up the range of reference values1 - 6 and about what uniform. On three of the 11 days, my weight or going down or staying the same. Who my spouse thought before the whole thing began. even increased. knows? Then a fortnight at 10 500 kJ. Body weight increased at 35.38 mg/kJ (fi g 4), Next, I increased energy intake, to slow Same. corresponding to an energy defi cit per weight loss weight loss and reach a steady weight. But I was getting desperate. I stepped up to of 28 MJ/kg.17 I didn’t want to overshoot and start gaining 11 500 kJ. Why weren’t the data clear as to weight. So I tried 7500 kJ per day for a few whether I was losing or gaining weight? I Bonus days. There was little change in my weight tried weighing myself more often to see if (fi g 1). I continued for a week. Still not this gave more systematic data. An extra apple a day18 (148 kJ) will add about 5 much to see. So, I persisted for a second On 6 June I weighed myself fi ve times g to my weight, or about 2 kg over a year. Were I week. This was harder than I thought. in quick succession at seven time points not to eat at all, my weight would reduce by the Amazing to me, a substantial throughout the day (fi g 2). The bathroom product of 10 286 kJ and 35.38 mg/kJ, namely proportional change in energy intake scale fl uctuation was variable—probably 364 g/day or about 2.5 kg/week. At the start I was (>50%, from <5000 kJ to 7500 kJ) produced related to life events. Across this about halfway between eating nothing at all and a negligible proportional change in weight particular day, my weight changed by my equilibrium intake and so losing about 2.5 kg (80 kg to 76 kg, 5%). Also surprising, the more than 2 kg. Here is the challenge. I per fortnight (fi g 1). abrupt step in energy intake did not result had not appreciated how big the intra-day The limitations are pretty much those of a in any discernible step change in weight. fl uctuations were relative to the inter-day previous study.19 Overall, I am happy, but would My weight kept drifting down. change I was hoping to measure. rather be 1.07 (SD 0.25) kg lighter. And so to bed. the bmj | 19 December 2020 - 2 January 2021 471 HOUSE OF GOD

n an age of social media outrage, it is history, death that wasn’t through war, hardly surprising that hospital staff Danse Macabre violence, famine, and plague was through a dressed in full personal protective rapid decline due to infectious disease (now Iequipment, posting videos of Our present predicament should largely curable) with a short illness. themselves dancing along to a jaunty make us think more about We have an opportunity to consider our track on TikTok, Twitter, or Facebook might mortality—the closeness to death seen by be the targets of digital ire. I’m torn. death and how we die—but we many through this crisis should give us On the one hand I can see the benefi t in probably won’t , says Paul Keeley pause to relish life and value every day. Yet maintaining morale in diffi cult times. On it also gives us a chance to examine the the other hand, I am aware that while loved asserted by medicine might be better limits to medical care that we would want ones are dying alone on wards because claimed by improved nutrition, hygiene, if we were to become acutely or gravely ill. their relatives cannot be with them, it might and, only later, by superior physic. In the What are the civilised limits we put to the be somewhat galling to see staff twerking intervening years, clinical practice can claim interventions we are willing to accept when around their clinical areas. I doubt staff more success in increases in longevity from we are older and more infi rm? motives are anything other than benign, but the treatment of cancer, heart disease, and such videos could be considered crass. other chronic ailments. We can hold off The aftermath death, but only for so long. In the process In the aftermath of the “Spanish fl u” Iconography of death of doing so, we change the mode of death pandemic in 1918-19, the events of the Dancing around death is from the short infectious disease of most outbreak were quickly consigned to oblivion. nothing new. Many English human history to the prolonged The death toll of the pandemic, at an parish churches were adorned trajectory of degenerative estimated 50 million, far outstripped, at with Danses Macabres, until illness and organ failure. least numerically, the carnage of the fi rst they were whitewashed world war. Yet the subsequent events of the over during the protestant An opportunity in the middle of a drama early 20th century—the depression (to which reformation. In these vivid wall A plague, pestilence, or viral pandemic— it was undoubtedly a contributory factor), paintings skeletons, representing call it what you please—we are in a drama the rise of fascism and Nazism in Europe, death, cavorted with all the that has brought illness—potentially life and Japanese militarism in the East leading estates of society—popes, kings, threatening illness, to the forefront and to a second world war, left the pandemic bishops, lords, priests, and centre of our perception. As we distance largely forgotten. It did not become a subject peasants—a reminder that death ourselves from each other, as did the of academic interest until nearly a century is the great leveller and we should citizens of Italian city states quarantining later, perhaps in the aftermath of further prepare for it. themselves from the black death, it might pandemics—severe acute respiratory The modern iconography of be the moment to contemplate what it all syndrome, Middle East respiratory death is somewhat diff erent. On means. As the shielding Israelites in Egypt syndrome, and swine fl u. The internet is both the front of the building until stayed indoors while the angel of death a blessing and a curse to memorialisation. recently occupied by the passed over, we might consider from what We are unlikely to forget this pandemic— Fulton County Department of Health and we are being shielded. given the electronic footprint it will have, but Wellness in Atlanta, Georgia, is a bas-relief Mark Taubert, a palliative care consultant, our attention span seems to have shortened by the sculptor, Julian Hoke Harris. The recently praised Albert Camus’ novel, The as our use of social media increases. This sculpture, called Keeping Away Death, Plague, as an exemplar of how we might fi nd recent brush with death’s latest manifestation shows a muscular man, bearing the Rod of meaning from such an epidemic.1 Camus’ gives us a chance to think about how we deal Asclepius and thus an avatar of medicine, story is a propagandistic caricature of the with death and dying. The sad thing is, when holding off skeletal death, robed and noble atheist Dr Rieux who, in his battle things have settled, we will probably go back holding a scythe. The image is striking, but to save his patients from illness, is pitted to ignoring our own mortality again. self-defeating. The ultimate cause of our against the grotesque, moralising priest, Paul Keeley, consultant in palliative medicine, Glasgow success in prolonging life is contested. The Father Paneloux. Camus’ view was that Royal Infirmary [email protected] epidemiologist and historian of medicine plague was not a modern way to die. I tend Cite this as: BMJ 2020;371:m4600 Thomas McKeown pointed out more than to disagree. Coronavirus is both a modern This article is dedicated to the memory of Professor John 50 years ago that the reductions in mortality and ancient way to die. For most of human Cash, 1936-2020

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EDITORIAL Climate action: the best gift for global health The health community mobilised against covid-19 and can mobilise again

ecember is a time for A united global medical community through active transportation also bring near refl ection, and there is much can be the missing ingredient needed term health benefi ts.13 for us to process from 2020. to catalyse action on climate change Long term, mitigating the health DThe covid-19 pandemic eff ects of climate change and minimising proved to be an unprecedented rise below 1.5°C in 2100 is likely to be out health system disruptions will improve global stress test for health systems—both of reach.5 7 There are grounds for optimism, health equity and benefi t populations in revealing and exacerbating problematic however, as the parallels and intersections profound ways that haven’t yet been fully areas. Disinformation and misinformation, with the covid-19 crisis have fostered quantifi ed 5 12 while also delivering evidence mixed with a festering distrust of science, advocacy for making climate action a critical based economic dividends. For example, not politicised age-old commonsense public part of pandemic recovery. 7 - 9 The health exceeding 1.5°C of global warming could health interventions. 1 2 When prevention community is well positioned10 to reinforce return $264tn-$610tn (£196tn-£450tn); in failed, even the best functioning healthcare and amplify two key messages. economic rewards by 2100.7 systems broke under the surge of covid-19 Yet data and science alone are not patients. While the rollout of vaccines will Integrated approach enough to motivate change.19 The lessen the pandemic burden, climate change First, climate action is essential for message, messenger, and method are still threatens to disrupt our health systems successfully tackling the other pressing critical components, and a global medical further and erode decades of health gains. global challenges aff ecting health, such as community united around climate change This month is the fi fth anniversary of the poverty and universal health coverage. 11 can be the missing ingredient needed Paris agreement, and we are at the critical Climate change underlies and exacerbates to catalyse action.10 20 Only 25% of a juncture of countries disclosing their eff orts barriers for improving health, threatening population is needed to change societal to meet commitments to cut emissions.3 So to increasingly undermine health gains and norms,21 and behavioural and social far, the political will to implement policies widen inequalities.12 Governments must scientists can serve as critical experts. that will avoid the most catastrophic health take an integrated approach when tackling Health professionals are trusted sources20 outcomes have failed to materialise; current these problems, and health professionals that exist in every corner of the world to policies place today’s world, already 1.2°C need to amplify the wide ranging health personalise the health benefi ts of climate warmer than in pre-industrial times, at up benefi ts of acting holistically.5 interventions. These are powerful tools to to 4°C warmer by 2100.4 5 Climate action, equity, health, and combat politicisation and misinformation.19 economic goals are dependent and reinforce Both the pandemic and climate Crop yields one another.5 - 13 Stimulus packages aimed change bind the world—and the health The fragility of health and health systems in at recovery from the pandemic off er a once community—together in a common destiny. a 1.2°C warmer world is already apparent, in a generation opportunity to rapidly The health community must recognise this though these eff ects are not felt equally. expand clean energy jobs and accelerate our connectedness and harness its collective Heatwave exposure among older people transition to net zero economies.7 - 9 Most of power. Together, we can galvanise the political reached a record high in 2019, the conditions the world has failed to capitalise on this.14 will required to fi ll the prescription for better for transmitting dengue, malaria, and The second key message is that moving health and equity through climate action. diseases caused by Vibrio are growing more away from fossil fuels has health benefi ts and Cite this as: BMJ 2020;371:m4723 favourable, and the yield potentials of major economic dividends in the short and long Find the full version with references at http://dx.doi.org/10.1136/bmj.m4723 crops continue to decline.5 Yet only half term. Although climate action yields greater of the countries surveyed have national gains for children and future generations, climate and health plans, and two thirds of people today will also benefi t, especially cities are concerned that climate change will vulnerable groups. Air pollution has the same overwhelm their public health infrastructure.5 root cause as climate change—the burning After the events of 2020, many in health of fossil fuels.15 Patients’ symptoms and may fi nd it hard to fathom tackling an healthcare use will improve in the weeks to existential crisis like climate change. Yet we months after air pollution is reduced, and are in the critical window for action6 and lives will be saved.16 The pandemic lockdowns without a 7.6% reduction in greenhouse gas showed us just how quickly air pollution can emissions each year over the next fi ve years improve.15 17 Transitioning away from fossil the goal of keeping the global temperature fuels could prevent 3.6 million premature deaths a year from air pollution alone and 5-18 Renee N Salas, emergency medicine physician, save nations billions in healthcare costs. Harvard Global Health Institute, Cambridge, Meanwhile, transitioning to more plant Massachusetts [email protected] based diets and increasing physical activity the bmj | 19 December 2020 - 2 January 2021 473 HOUSE OF GOD

To each child their own coronavirus

n the ancient Indian the forefront of policy makers’ drawing is one of the oldest Children, lacking drawing parable of the blind men concerns. This year children have forms of human expression. skill but free of the burden of and an elephant, the been denied access to school and Drawing could put a face on academic knowledge, provide Ishape of the animal is have had delayed access to care. SARS-CoV-2 and allow for a insight into the essence of things appreciated diff erently by Moreover, lockdown restrictions better grasp of the reality of through feelings as well as their six blind men who conceptualise have aff ected children both the pandemic. Twenty children eyes. To each child their own it only by touching part of its directly, and indirectly, through (12 girls and eight boys) aged coronavirus. body.1 In a similar way, children the impact these measures have between 4 and 14 years were Laetitia Martinerie, associate professor may conceptualise severe had on parents and caregivers, asked to draw a coronavirus as of medicine, Robert Debré Hospital, Paris acute respiratory syndrome leading to anxiety, symptoms of they imagined it. Their drawings Delphine Bernoux, doctor of medicine, Timone Enfant Hospital, Marseille coronavirus 2 (SARS-CoV-2) in post-traumatic stress disorder, mostly show the familiar Lisa Giovannini-Chami, professor of their own unique ways. and even child abuse. The shape depicted on screens and medicine , Hôpitaux pédiatriques de Nice Although the infection is less concurrent covid-19 “infodemic” publications: a circular virus CHU-Lenval severe in children (rare instances has contributed to a climate of particle with a crown of simple Alexandre Fabre, professor of medicine , of multisystem infl ammatory fear centred on the virus itself. or mushroom-shaped spikes, Aix Marseille Université syndrome notwithstanding), The walls of caves across colourful, sometimes happy, [email protected] young people have been at the world are a reminder that sometimes sad, but seldom evil. Cite this as: BMJ 2020;371:m4578

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BMJ OPINION Julie K Silver Should her name begin with “Doctor”?

hat we call ourselves, and Black/African American and Hispanic/Latina fi lling out their instructor’s evaluation: how others refer to us, women are at an inexorable zero level for full “Student evaluations play an important matters. This is perhaps professors and deans. Minority women have role in the review of faculty. Your opinions Wnowhere more important entered medicine for decades, so zeros at the infl uence the review of instructors that than in a professional top cannot be explained by a lack of mature takes place every year. Iowa State University setting, where the use of titles or fi rst names talent in the pipeline. Since thousands of recognizes that student evaluations of has the potential to bring up gender and reports have documented workforce disparities teaching are often infl uenced by students’ equity issues. for women in medicine, subject matter experts unconscious and unintentional biases about A recent column in The BMJ by David Oliver tend to agree that gender bias (which is often the race and gender of the instructor. Women on whether doctors should use their fi rst combined with other forms of discrimination) and instructors of color are systematically names,started a lively debate in the rapid is a more plausible explanation. rated lower in their teaching evaluations than responses. Oliver wrote, “I work in an 800 Importantly, much of the evidence base white men, even when there are no actual bed hospital employing over 4000 people, yet documents “macroinequities” with commonly diff erences in the instruction or in what everyone knows the chief executive and the used metrics such as compensation, students have learned. chief operating offi cer as ‘Steve’ and ‘Dom.’” promotion, publications, grant funding, and “As you fi ll out the course evaluation please Notably, these examples are men , so one might recognition awards. However, researchers keep this in mind and make an eff ort to resist consider how the culture of using fi rst names have begun to focus on “microinequity” stereotypes about professors. Focus on your may be infl uenced by a cloak of privilege at studies. This area of research is growing, and opinions about the content of the course . . . the top. After all, women in the US and many similar to microinequity research, studies and not unrelated matters (the instructor’s other countries are often represented in top tend to be quantitative and to analyse data appearance).” leadership positions at very low levels. For to show diff erences in how men and women The researchers found that students in the example, there are more men named John are treated. Clinical analogies include studies anti-bias language group gave signifi cantly than there are women in many leadership that focus on subtle symptoms of raised blood higher rankings of female instructors than positions. pressure or glycaemic markers—precursors to those in the group that did not read the A deep dive into the promotion of women in a future diagnosis of hypertension or diabetes, statement. There were no diff erences between medicine by Richter and colleagues, studying respectively. groups for male instructors. more than 500 000 graduates from 134 US Notably, both clinical and workforce equity medical schools over 35 years, found that “micro” studies focus on a pattern (rather than Consider the science women in academic medical centres were less a one-time event). Dayal and colleagues, for Oliver cited a landmark study by Files and likely than men to be promoted to associate example, analysed 33 456 direct observation colleagues in which the authors examined professor, full professor, or department resident evaluations in the US and Canada video recordings of lectures and found that chair. Alarmingly, they found no apparent using Accreditation Council for Graduate women nearly always used the title “doctor” improvement over time. Medical Education milestones and found to introduce speakers (96% of the time) the rate of attaining milestones was higher while the men who made introductions Inexorable zero for male residents as they progressed in used it two thirds of the time (66%). When Since zero is a particularly powerful number, training across all subcompetencies. In other it came to men introducing men, they US courts have used the concept “inexorable words, male physicians outperformed female used formal titles 73% of the time—when zero,” a true or near zero number, to assume physicians in 100% of the milestones, and in introducing women this dropped to 49%. discrimination. Meritocracy arguments tend striking contrast women outperformed men Patricia Friedrich, a coauthor of the study, to fall apart when there is an inexorable zero. in 0% of the milestones. Not surprisingly, a points out, “There is no logical, professional, After all, it is challenging for reasonable systematic review evaluating graduate medical or practical reason to use titles diff erently

WILLETT people to believe that there are essentially no education highlighted the issue of gender bias across genders.” qualifi ed individuals from in evaluations. The path to systemic gender bias and a particular group who discrimination at the macro level is paved could have been hired or Tipping the balance with microinequities that are increasingly promoted. Just as there are interventions to address documented in the literature. When In the Her Time Is subtle symptoms before they reach the considering whether her name should begin Now report, I used threshold of disease, there are opportunities with “doctor” in professional settings, one data from the to prevent some microinequities. One thing we can all agree on is to consider the Association randomised study focused on a well science as we tackle this important issue. of American documented problem—women instructors Julie K Silver , associ ate professor , Harvard Medical School, Medical Colleges tend to receive lower student ratings at Boston, Massachussets [email protected] Twitter @JulieSilverMD to show that in all levels of higher education than male Editor’s note: The BMJ style is to not use “Dr” and this was most specialties colleagues. The intervention was simple— applied consistently in this article in the US both students read an anti-bias statement before Cite this as: BMJ 2020;371:m4754

the bmj | 19 December 2020 - 2 January 2021 475 HOUSE OF GOD

ORIGINAL RESEARCH Pseudo-systematic review It’s Christmas time, but is now the time to act? Nathan Ford , 1 Grania Brigden ,2 Tom Ellman , 3 Edward J Mills 4

Objective To identify any medical or public health Introduction rationale for claims that the time to act is now. Design Pseudo-systematic review. There is almost no such thing as ready. There is only now. And you may as well do it now. Generally speaking, now is as good a time as any Data sources PubMed. Hugh Laurie (AKA Dr Gregory House) Study selection Studies that included the claim “time is now” in the title, with or without exclamation The time to act is now! This is a commonly used clarion call in medical journals. It marks. No language or date restriction was applied. can be found in titles of editorials, commentaries, letters, and, occasionally, original Results 512 articles were included for review. No research. During 2020 health systems around the world were stretched to breaking relation was identified between time to act and point managing the coronavirus disease 2019 (covid-19) pandemic. Nevertheless, we disease burden, severity, or specialty. Claims that were told that the time is now to standardise sedation training,1 diff erentiate service the time to act was Christmas were almost entirely delivery,2 certify cardiac anaesthetists, 3 address the mental health impact of climate without basis. A clustering of claims that it is time change,4 and end the HIV epidemic.5 to act in the first quarter of the year suggested a Two articles claimed that the time is now to consider universal mask wearing possible association with New Year’s resolutions. to protect against covid-19 which, to be fair, was timeous.6 7 Nevertheless, we are Conclusions Now is as good a time as any. concerned about the potentially endless stream of demands placed on health professionals around the world to Act Now! without any obvious rationale, and little WHAT IS ALREADY KNOWN ON regard for competing priorities. Claims that the time is now have doubled in the past THIS TOPIC decade, from 26 articles published in 2010 to 52 in 2019 (fi gure). We suspect 2020 will be a bumper year. • Articles across specialties increasingly implore us that it is time to act Methods WHAT THIS STUDY ADDS • The fi ndings of this review suggest that We searched PubMed up to 30 September 2020 for studies that made the claim someone, somewhere, thinks that the time “time is now” in the title. We intended to search the grey literature via Google to act is now Scholar but after an initial screen yielded 6.6 million results we decided to omit this step. 9 1 It has been suggested that Christmas time is the season to be lazy. We explored Centre for Infectious Disease Epidemiology and Research, School of Public Health, University of Cape Town which disciplines considered the time to act was Christmas by tabulating articles 2 Department of Tuberculosis, International Union Against published on the nearest day to Christmas from 2010 to 2019 (see table) and assessed Tuberculosis and Lung Disease, Geneva the appropriateness of these claims through visual inspection of results and applying 3South African Medical Unit, Médecins Sans Frontières, Cape personal opinion. Town We were unsure whether authors only wanted people to act now, or whether 4 Department of Health Research Methods, Evidence, and deferred action was also a desirable goal. We therefore undertook a sensitivity Impact, McMaster University, Hamilton, Canada analysis that included the following statements: “the time to act is later” and “the Correspondence to: N Ford [email protected] time to act is in a bit.” We carried out subgroup analyses to assess the use of question Cite this as: BMJ 2020;371:m4143 marks or exclamation marks to provide particular emphasis to the claim that time is Find the full version with references at http://dx.doi.org/10.1136/bmj. m4143 of the essence .

The time to act is Christmas Date of When is it publication time to act? Issue requiring Yuletide action December 2019 Now The opioid epidemic and psychiatry: the time for action is now20 December 2018 Now Paid parental leave in radiology: the time is now21 December 2017 Now Reducing radiation exposure from nuclear myocardial perfusion imaging: time to act is now22 December 2016 Now Time is now: venous thromboembolism prophylaxis in blunt splenic injury23 December 2015 Now Making physical activity counselling a priority in clinical practice: the time for action is now24 December 2014 Now Understanding the risk of donor-derived infections in paediatric transplantation: the time is now25 December 2013 Now The time is now to fix SGR26 December 2012 Now! Interprofessional Education (IPE) Activity among health sciences students at Sultan Qaboos University: the time is now!27 December 2011 Now End-of-life care: the time for a meaningful discussion is now28 December 2010 Now! Alcohol and the elderly: the time to act is now!29 HANNA KUPREVICH / ALAMY / HANNA KUPREVICH

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Results: is now the time? elderly: the time to act is now!—could be considered to have some relevance to Christmas. The rest could have been published at any Our initial search yielded 595 titles, of which 512 studies were time of year. included for review. On screening of the abstracts we noted that In 2019, 49 published articles instructed that it was time to act, only 16 articles (3%) could be considered related to research, with a clustering of articles in the fi rst three months of the year (19 suggesting that claims that the time is now are rarely empirically articles, versus 10 articles for other quarters). While diff erences are derived. Of 46 articles claiming the time is now during 2020, not statistically signifi cant, this upsurge in the fi rst quarter of the only three called for action against the ongoing pandemic—one year could be associated with New Year’s resolutions. about serosurveys10 and two about masks.6 7 The rest either made reference to the pandemic opportunistically to promote a perennial Let’s wait a bit concern, or didn’t refer to it at all. We were unable to fi nd any studies that claimed “the time to act We included studies that used exclamation marks, even though is later” or “the time to act is after a nap,” or “let’s wait a bit.” most style guides agree that they should never be used.17 We found One study used the words “to do it now or later” in the title, but 50 studies that used an exclamation mark, presumably because this discussed the neural correlates of procrastinations and was stating that the time to act is now was considered insuffi cient to possibly the only study to ever have meaningfully used the time is express urgency. Examples include: Colorectal cancer screening now construct.31 (The time is now!), 8 Collaboration between nurses and doctors (The Time is Now!),18 and Next-generation molecular genetic diagnostics Discussion in nephrology (the time is now!).19 Thankfully, no studies were identifi ed that used multiple exclamation marks. The fi ndings of our review suggest that it is always time to act. An important limitation of our review is that we did not assess The time to act is Christmas whether appeals to act now changed behaviour, including the We undertook a subgroup analysis to determine the Yuletide behaviour of the authors making the claim. Editorials, while relevance of eligible studies published at Christmas over the potentially powerful motivating materials, are hardly matched by past decade (table). Of these, only one paper—Alcohol and the basic eff orts to actually conduct the advocated approach. The claim that the time is now! is rarely found in corrections— 60 for example, when authors have had second thoughts about when to act. It is also never found in obituaries. No link is seen 50 between whether the topic in question really does deserve 40 action today, as opposed to yesterday or tomorrow. Our study was limited to claims made in the title. We suspect that if we 30 broadened our search to include, for example, the last line of study No of publications 20 conclusions, many more examples would have been found. We doubt, however, that any of them would have a stronger basis for 10 their claim. 0 If it is always time to act, this led us to wonder why the 2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020 complacency? A rapid search found 40 articles with the words “No Year room for complacency” in the title. This could be an interesting Time is increasingly Now. Claims made in the past 20 years. Data from PubMed question for future Christmas research in The BMJ . the bmj | 19 December 2020 - 2 January 2021 477 HOUSE OF GOD

y working day involves long tail of volume, whereas the same sound researching how acoustics The sound in your own home would take less time. In aff ect a musician’s a ward setting the sound of an alarm, at a Mperformance and thinking necessarily loud volume, would potentially about the intelligibility of of medicine have a long decay and begin merging with sound. I became interested in this through other sounds to create a cacophony. my part time role as a musician. I went from Hospitals are noisy and stressful This isn’t solely dependent on the size of the playing in the back rooms and basements places, and noise can induce room but also the surfaces and other factors of pubs to large venues almost overnight. I anxiety. James Weaver considers that can diff use (and, of course, increase) became aware that my performance changed sound. Rooms designed to be easily cleaned based on the natural acoustics of the space. whether more can be done to will likely have strong refl ective surfaces for This interest led me to my current doctorate, in improve soundscapes in hospitals sound, but carpeting and soft furnishings which I use computational methods to analyse would diff use it. And, of course, the larger the how diff erent reverberation conditions impact occlude speech—something she also found space, the longer the reverberation time and on musical performance and expressivity. with hearing aids. This led me to realise the the likelihood of larger surfaces that would In November 2019 my wife, Annabell, importance of the soundscape in a hospital refl ect sound. died from metastatic melanoma at and how important this is when designing Hospitals such as the Nightingales which St Bartholomew’s Hospital. I spent many facilities and spaces for patients. It also got are built in large facilities can be particularly days and nights in hospital with her, waiting me thinking about practical solutions. problematic. Long reverberation times in foyers surrounded by random bleeps The soundscape is the ordered (musical) and loud and cluttered soundscapes are and multiple conversations, and being on and non-ordered sounds of the environment. distressing for patients and families and wards where, in the quiet of the night, alarms Features of the soundscape can be divided also present diffi culties for doctor-patient sounded until someone attended to them. into keynotes, signals, and soundmarks. communication and conversations between Somewhat ironically, my research involving In a hospital these could be the following: health professionals. Factor in the use intelligibility of sound coincided with Annabell a keynote, that pervasive sound which of personal protective equipment and progressively losing her hearing. She became anchors the auditory landscape communication is challenging, profoundly deaf and subsequently used might be the low level hum of Quiet spaces to particularly for those with hearing hearing aids and fi nally a cochlear implant. equipment being used; the signal, discuss sensitive loss. a foreground sound that requires issues should Annabell and I discussed Soundscape of a ward attention would be an alarm feature diffusing diff erent tactics that could help Noise can be a pleasurable, comforting thing. sound coming from a fi nished material, make her experience better. As As anyone who has experienced an anechoic intravenous line, or from a patient such as carpet or hearing loss is a hidden disability (or even semi-anechoic) condition will attest, bed; and the soundmark is a soft furnishings it can be diffi cult to detect unless the absence of any noise is unpleasant. In sound that might be unique to declared. Annabell became so contrast, too much noise, particularly in a that environment—on a ward it could be adept at lip reading that sometimes people situation where one needs to discuss complex the particular noise of a machine or type of didn’t realise she was deaf and her hearing matters, or simply recuperate, can have a interaction. loss wasn’t always fully documented, so negative impact.1 - 3 This is a diffi cult balance in doctors or nursing staff would launch into a a hospital setting. Optimising the environment conversation at speed, facing their computer, Sound and noise became all encompassing A person on a ward might have their own and possibly in a space with large amounts of for Annabell, and me. We constantly variations on this, and if you are in this background noise. battled against her diminishing hearing, setting, I would encourage you to take a It would have been helpful if we had had especially in the hospital environment where minute and consider it. The soundscape of a access to quiet spaces to discuss sensitive communication is a key part of the patient ward can be a stressor to patients and their matters. These should feature some diff using experience. In the time between her complete families: for example, the natural night time material, such as carpet or soft furnishings, loss of hearing and having her cochlear quiet of a ward punctuated by an avoidable or have acoustic treatments such as wall implant activated, something Annabell alarm, or a key moment in an or ceiling panels; these can make a huge found particularly challenging important discussion disrupted by diff erence to the listening experience. Some was the speed and complexity of a parallel conversation. alarms are essential for patient safety, but information delivered to us, which, Hospitals are usually large research is needed into their necessity and as an understatement, is diffi cult buildings and sound is aff ected whether any could be rationed or vibrating to understand when you can’t hear. by the size of a room and can have devices be substituted without compromising Annabell was a skilled lip reader, but a long reverberation time. This patient safety. consultations became emotionally measurement looks at the decay Mitigation of these pervasive sounds and physically draining. of a sound from its original coupled with increased acoustic treatment After her implant she source. Think of, say, a and awareness of the problem would make a was better able to handle large religious venue, the better environment for both patients and staff . this situation, but it could sound of music or a call James Weaver, doctoral student, Queen Mary still be problematic as to prayer reverberates University of London [email protected] ambient noise can through the room with a Cite this as: BMJ 2020;371:m4682

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