this week COVID INQUIRY page 128 • TEST AND TRACE page 130 • FUTURE OF SAGE page 132 DANIEL LEAL-OLIVAS/PA LEAL-OLIVAS/PA DANIEL Doctors get “grossly unfair” 2.8% pay rise

Hospital doctors and salaried GPs in hospital doctors and salaried GPs as “grossly Salaried GPs will receive the England will receive a 2.8% pay rise unfair” and called on the government to increase, but not GP partners backdated to April this year, the Department give a greater award to all doctors. who are in the second year of a multi-year pay deal of Health and Social Care has announced. Chaand Nagpaul, BMA council chair, In Wales the pay rise extends more said, “This year tens of thousands of widely: consultants, specialty and associate healthcare workers have faced probably the specialist doctors, junior doctors, and most stressful period of their careers, with salaried GPs will all receive a 2.8% increase. many putting their lives at risk and worse, The BMA expressed disappointment that but they’re not being recognised for it. the pay rise in England did not apply to all “If ever there was a time for a pay LATEST ONLINE doctors. Hospital doctors in England will uplift to recognise the work done receive a 2.8% pay rise worth £2200-£3000 by all doctors, along with years of NICE advises for consultants, £1100-£2100 for specialty underpayment, it is now.” against use of graded exercise doctors, and £1500-£2600 for associate Rob Harwood, chair of the BMA’s therapy for specialists, the government said. consultants committee, said 2.8% would patients recovering For salaried GPs the minimum and mean many doctors’ take home pay would from covid-19 maximum pay range will rise by 2.8%, rise by £15-£24 a week. “Doctors quite Shropshire trust at in line with recommendations from the rightly should be bitterly disappointed and centre of maternity Review Body on Doctors’ and Dentists’ may even be insulted by this news,” he said. scandal is under Remuneration (DDRB). Phil Banfi eld, chair of the BMA’s Welsh threat of special But the increase does not apply to GP consultants committee, said there was administration partners or doctors in training, as both disappointment that the rise in Wales did Society of groups are in the second year of multi-year not include recommendations on uplifts Homeopaths is deals. NHS staff (including nurses) who are for commitment or clinical excellence investigated covered by the three year Agenda for Change awards. “We have spoken with the over claims are also not covered by the pay deal. Welsh government and have agreed to that standards The BMA said that the GPs’ and trainees’ work together to address the reward of chief promoted pay deals failed to consider the eff ort made consultants in Wales,” he said. anti-vaccination by doctors in responding to covid-19. The Abi Rimmer, The BMJ material association described the pay award for Cite this as: BMJ 2020;370:m2926 the bmj | 25 July-1 August 2020 127 SEVEN DAYS IN PM promises covid-19 inquiry but says it won’t happen during pandemic Boris Johnson (left ) has committed to an independent inquiry into the country’s handling of the covid-19 pandemic but said that now was “not the right time” to launch it. The announcement during prime minister’s questions on 15 July was in response to a question from the acting leader of the Liberal Democrats, Ed Davey. Johnson replied, “I do not believe now, in the middle of combating the pandemic, is the right moment to devote huge amounts of offi cial time to an inquiry.” He added, “Of course, we will seek to learn the lessons of this pandemic in the future, and certainly we will have an independent inquiry into what happened.” Davey said on Twitter aft er the announcement, “We need an independent, judge- led inquiry into the handling of coronavirus. I am pleased that at PMQs I got the prime minister to commit to holding that inquiry. We now need to keep up the pressure to make sure he stands by his words today.” The campaigning group Covid-19 Bereaved Families for Justice said, “We need to know whether it will be a statutory public inquiry with family input and full disclosure of evidence . . . it needs to be now in advance of a second wave, not in fi ve years’ time.”

Gareth Iacobucci , The BMJ Cite this as: BMJ 2020;370:m2869

Covid-19 Doctors in France report College sets up taskforce tetanus, and pertussis—the first Six clusters of symptoms an in utero case to tackle racism reduction in 28 years. could be prediction tool French doctors reported the The Royal College of Obstetricians An analysis of data obtained first documented case of and Gynaecologists launched Cancer from a symptom tracker app transplacental transmission of a taskforce to explore racial Relatives warn of dangers showed six distinct “types” of the SARS-CoV-2 virus. A 23 year disparities in women’s healthcare of alternative therapies covid-19, each distinguished by old woman in the last weeks and to examine racism in the Families of people who died from a particular cluster of symptoms. of pregnancy was admitted to obstetrics and gynaecology cancer, who might have survived The researchers said these hospital in March with covid-19. workforce. Edward Morris, college had they not turned to alternative types could be used to predict She gave birth by caesarean president, said, “The taskforce therapies, warn of the risks the need for respiratory support section to a baby boy who aims to highlight where of shunning conventional in severe covid-19. The study is was also found to have the health disparities exist, treatments in a BBC available online as a preprint infection, said a report in Nature improve our understanding documentary, False Hope? and has been submitted to Communications. The baby of the causes behind Alternative Cancer Cures. a scientific journal for rapid recovered and was discharged inequalities, and Therapies offered included peer review and publication. from hospital after 18 days. collaborate with government to mistletoe (above) injections, The COVID Symptom Study create meaningful solutions to coffee enemas, and a caustic app was developed by King’s Racial inequalities improve healthcare experiences ointment called black salve. One College, London and the health Kennedy leads diversity and outcomes for all ethnic woman who died had had regular technology company ZOE. review at RCS in England minority women.” thermography scans—heat Helena Kennedy (below) will images of the body—believing UK signs deal for 90 chair an independent review Immunisation they were tracking her cancer. million vaccine doses of diversity in the professional Child vaccination falls The UK signed a deal with drug leadership of the Royal College of “alarmingly” in pandemic Research funding companies for early access Surgeons of England. The review The World Health Organization Cancer charity will be to covid-19 vaccines, said is the first of four commitments and Unicef warned of an “leaner” after income drop the business secretary, Alok the college made in a recent “alarming decline” in children Cancer Research UK said it was Sharma, on 20 July. The deals statement on “challenging receiving vaccinations around being forced to adapt in response are with BioNTech/Pfizer racism and championing the world because of disruptions to a 30% fall in income due to the (30 million doses) and Valneva diversity.” The to the delivery and uptake of pandemic. It expects a drop of (60 million doses), which college’s new immunisation services during £160m this year and of £300m are developing innovative president, Neil the pandemic. Preliminary over three years. It will cut 500 vaccines to protect people Mortensen, said, data from the first four roles, reducing its workforce by against coronavirus. These are “We need to better months of 2020 point 24%. Research spending will be in addition to the 100 million understand the to a substantial fall in cut by £150m to £250m within doses of the Oxford University barriers that exist, children completing four to five years. The charity vaccine being developed with so we can act and three doses of vaccine called on the government to help AstraZeneca. remove them.” against diphtheria, solve the funding gap.

128 25 July-1 August 2020 | the bmj SIXTY SECONDS MEDICINE ON . . . PPE OUTBREAK Actors offer tips on coping with restrictive PPE THE DUSTIN HOFFMAN FILM? A new guide for healthcare Sadly not, although the fi lm’s introduction professionals, designed feels relevant: “The single biggest threat to to help them cope with man’s continued dominance on the planet is the virus.” Instead, we are concerned with wearing personal protective the use of the word “outbreak.” equipment (PPE) for extended periods and improve IS IT BUGGING PEOPLE? communication with I should say so. Peter Soulsby, the mayor patients, was launched of Leicester—which has been under local by the Performing Medicine lockdown for the past few weeks—has programme in partnership questioned its use. He is confused because, with University College Actors who wore prosthetics in the despite being told by Public Health England London Hospitals. The guide stage production of War Horse have OBESITY on 15 June it had not identifi ed a covid-19 has been developed using tips for healthcare staff using PPE “outbreak” in his city, three days later the Some 11 117 health secretary, Matt Hancock, announced tips from performers and there was an “outbreak” in Leicester. designers involved in theatre Research news hospital productions such as War Gum disease may raise admissions among WHY DOES THAT MATTER? Horse and His Dark Materials. risk of some cancers people of all ages In this case, it just adds to the confusion. At Actors who are used to wearing People with a history of were directly the time, Soulsby said Leicester had only one restrictive costumes, masks, periodontal disease seem to attributable to covid-19 testing station and the city council did not receive data on the number of people and prosthetics offered have a higher risk of developing obesity in guidance that could be useful oesophageal and gastric cancer, who had tested positive until 11 days aft er when wearing PPE. research published in the 2018-19—up Hancock’s declaration of an “outbreak.” journal Gut showed. Researchers 4% from the BUT WHAT DOES “OUTBREAK” MEAN? BMA: England lacks clear examined data on 98 459 women Good question. PHE usually defi nes it as “two guidance on face covering from the Nurses’ Health Study previous year. or more people experiencing a similar illness, The British Medical and 49 685 men from the Health And obesity which appears to be linked to a place.” But Association criticised the Professionals Follow-Up Study. was a factor in it can also be “a single case of an unusual or government over its guidance A history of periodontal disease another 876 000 rare infection” or “a greater than expected was associated with a 43% rate of infection compared with the usual increased risk of oesophageal admissions— background rate that is expected in that cancer and gastric cancer in an increase of population for that place or time.” women and 52% in men. 23% CONFUSING . . . Yes—and it gets worse. The World Health “Identify risk factors” to [Labour Party Organization describes a disease outbreak as help stop Alzheimer’s analysis of NHS “the occurrence of disease cases in excess of Doctors should identify and target normal expectancy.” on face covering in England, 10 risk factors in their attempt to England figures] saying that the rules were not prevent Alzheimer’s disease, said SHOULD WE STOP USING IT? clear or consistent, and had researchers. A study published Well, maybe not. Jimmy Whitworth, professor of international public health at the London caused widespread confusion. in the Journal of Neurology, School of Hygiene and Tropical Medicine, It said that messages on Neurosurgery & Psychiatry says that it is quite valid to whether the public should assessed 395 studies looking use the term when there are wear face coverings in at Alzheimer’s prevention. They more cases of a disease than takeaway food shops were found 10 suggestions backed by expected, as was the case in mixed and that government strong evidence, which included Leicester. ministers had been pictured receiving as much education as wearing inappropriate possible in early life; participating SO, “OUTBREAK” ISN’T masks or no covering at all. in mentally stimulating activities, CANCELLED? Some businesses, including such as reading; and avoiding No, it’s still OK. But, as the hairdressers, are being diabetes, stress, depression, fi lm’s strapline says, “Try to remain calm.” advised to use visors or face head trauma, and high blood shields rather than the face pressure in midlife. Abi Rimmer, The BMJ coverings that were more effective, the BMA added. Cite this as: BMJ 2020;370:m2901 Cite this as: BMJ 2020;370:m2900

the bmj | 25 July-1 August 2020 129 COVID-19

Test and trace system Rates fell rapidly on Isle still missing target to reach 80% of contacts of Wight after test and trace launch, finds study More than a fifth of people in England who tested positive for covid-19 in the most recent week measured were not reached by the NHS’s test and Geography he Isle of Wight moved from having one of the trace programme, latest figures show. alone can’t worst covid-19 reproduction rates in England Although the head of the programme said there explain all the to one of the best after the test, trace, and were “sustained improvements” in how it was island’s success isolate programme and app were introduced performing, the figures for the week of 2 to 8 July Michelle Kendall, T there, a preliminary analysis has found. showed that 21% of the 3579 people who tested author A preprint paper from Oxford University researchers positive for covid-19 and whose details were passed found a rapidly declining total incidence, per capita to the contact tracing incidence, and reproduction number (R) levels among system were not found. The majority (79%) of people hospital and community tested cases after a pilot of the UK’s The system, which who tested positive were reached and test and trace programme was launched on 5 May 2020. began on 28 May, has The Isle of Wight moved from having the third highest of those 2815 people, 2201 gave details around 27 000 contact reproduction number R in England (ranking at 147 of tracers. The disclosure of at least one recent contact. This meant 150 upper tier local authorities) in mid-April before the that the government that 13 807 people were identified as programme launched to the 10th lowest at the end of the spent £10bn on it has close contacts who may have been study period on 29 June. The study team of epidemiologists, drawn criticism. exposed to the virus, but only 9811 of mathematical modellers, and economists said a more Overall, fewer people detailed breakdown of data was needed to determine the them were reached and are testing positive (71%) exact causes of the island’s success and to inform local and for covid-19 as the asked to self-isolate. This is below SAGE’s national intervention strategies. prevalence of the virus 80% target for tracing close contacts Speaking at a Science Media Centre press briefi ng on slowly declines. The 15 July, Michelle Kendall, a senior researcher at Oxford latest statistics, covering the sixth week of the test and trace programme, showed it had reached 155 889 people who may have otherwise unknowingly spread Local public health teams “denied the virus to others and asked them to self-isolate. The speed of testing has increased, with 96% of data they need to trace cases” in-person results being received the day after the test was taken at regional testing sites and mobile units. Local public health virus, to understand teams are not being transmission, and to More accessible service provided with the stop outbreaks. The government said efforts were being made to make patient identifi able Kate Ardern, director the service more accessible, by offering translation information on of public health for services in more than 200 languages.There are also covid-19 cases they Wigan council, said, “I plans to set up more walk-in test sites, and work is need to manage and am going to have to go onging with behavioural scientists to find ways of prevent local outbreaks I am going to have to and knock up at least engaging the public to make greater use of the service. eff ectively, directors of go and knock up at 200 households [to track From 16 July, the programme will publish data on public health have said. least 200 households down an individual], a smaller scale for population groups of between Data received from Kate Ardern, Wigan which is a bit silly when 5000 and 15 000 people, so that a person can see the drive-through testing someone has got the statistics for their town or village. And data will move centres and home “super-spreader.” They contact details.” from weekly to daily publication. testing kits (“pillar 2” are also being denied A Department for Dido Harding (left), executive chair of NHS of the testing scheme) access to identifi able Health and Social Care Test and Trace, said, “Each week there are anonymised, information held by spokesperson said that have been sustained improvements to and postcode and the national NHS Test Public Health England reach more people and help stop those occupational data are and Trace programme, had introduced a who may have been in contact with the often missing. As a preventing them platform on 20 July virus unknowingly passing it on. We have result, local teams say from contact tracing to give public health made testing and tracing quicker and more they cannot examine themselves. directors access to accessible, and we remain committed to possible connections Public health positive test results and develop the service further.” between cases, such as directors said the system case data. Adrian O’Dowd, London a workplace, or whether was hampering their Ingrid Torjesen, London Cite this as: BMJ 2020;370:m2875 an individual could be a ability to detect the Cite this as: BMJ 2020;370:m2883

130 25 July-1 August 2020 | the bmj University’s Nuffi eld Department of Medicine and the report’s fi rst author, said, “Infections . . . and the R number on the Isle of Wight began high and decreased really rapidly after the test and trace launch . . . and the incidence decreased faster than in other comparable areas. So it really seems like something diff erent happened on the Isle of Wight from elsewhere.” The island’s test and trace programme included community testing and human contact tracing, which is now operational across the UK. But the Isle of Wight also used the NHS contact tracing app, which is not yet ISLA BINNIE/REUTERS available elsewhere. English areas that closely resembled the Isle of Wight with I am David Bonsall, clinician and senior researcher at the regard to initial R, age distribution, and ethnicity. The disappointed Nuffi eld Department of Medicine and a coauthor of the epidemic on the Isle of Wight improved signifi cantly more that the app study, said, “I am disappointed that the app hasn’t been quickly than would have been expected in the absence hasn’t been released in the UK by now. The policy decisions are not ours of the test and trace programme, with R as low as 0.25 in released in to take, but we are supportive of the app being included as mid-May, when R in a similar region would be expected to the UK by now part of an integrated approach.” be around 0.75. David Bonsall, Kendall added, “For areas that were comparable in their study author Pillars 1 and 2 R number beforehand . . . there were no other areas that had The team estimated incidence and the R value by using the same trajectory or even close. reported covid-19 cases tested in hospital laboratories under “If infection numbers had been low throughout, it would “pillar 1” of the government’s testing scheme. Additional be easier to say [that] because it’s an island it’s diff erent. But analysis of community testing data under “pillar 2” of the because it started off with a bad epidemic, the geography government’s scheme confi rmed the trends, with the Isle of alone can’t explain all of the success that it’s had.” Wight’s R number estimated to be 20-25% lower than the The study was funded by an award from the Li Ka Shing national level during May and June. Foundation to Christophe Fraser, lead author and group To validate their results the researchers created a leader in pathogen dynamics at Oxford University. “synthetic control” approach combining data from other Gareth Iacobucci , The BMJ Cite this as: BMJ 2020;370:m2861 Leicester’s lockdown to be eased as infection rates drop

Some lockdown restrictions According to Hancock, the surrounding areas,” he said. paused, in all settings, until are to be eased in Leicester two seven day infection rate fell The restrictions will be reviewed further notice.” weeks after local measures were from 135 cases per 100 000 again in two weeks. When asked for more details, put in place, health secretary people when the local lockdown he said that “CE certifi cation Matt Hancock has announced. was announced, to 119 cases Swab test problems was not forthcoming. Physical In the House of Commons per 100 000. Meanwhile, the The health secretary also told checks were done and we found on 16 July Hancock said a fall percentage of people who have MPs of problems with some that the swabs weren’t up to in the seven day infection rate tested positive is now 4.8%. of the covid-19 swab tests the standards that we expect. meant restrictions on schools “These are positive supplied by a diagnostics He added that access to testing and early years childcare would indicators, especially in light company Randox. would not be aff ected by the be eased, and non-essential of the huge increase in testing Hancock said, “We’ve withdrawal of the Randox kits. shops could reopen from 24 in the local area. But they identifi ed some swabs that are S hadow health secretary Jon July. But he said the local remain well above the national not up to the high standard Ashworth criticised Hancock government had the power to average and the average of the we expect and will be carrying for giving contracts to private reclose shops if necessary. out further testing of this companies rather than funding “Other restrictions like those batch as a precautionary existing public systems. “He’s for travel and only having social measure. Clinical advice is throwing good money after gatherings of up to six people that there is no evidence of bad,” he said. “Why doesn’t he will remain in force. National any harm, the test results invest in public health services, measures introduced on 4 July, are not aff ected. While we primary care, and local health like opening the hospitality investigate further, we’re teams to do this testing?” sector, will also not yet apply,” requesting that the use of Elisabeth Mahase, The BMJ

he said. IMAGES TALLIS/AFP/GETTY JUSTIN Randox swab test kits are Cite this as: BMJ 2020;370:m2897

RANDOX is thought to be responsible for around 17% of the total tests carried out in the UK. The company was given the £133m contract to produce testing kits by the government in March the bmj | 25 July-1 August 2020 131 COVID-19

NEWS ANALYSIS Is the government intending to marginalise scientists?

With the main scientifi c advisory group set for a less prominent role, Ingrid Torjesen fi nds out what this means for future pandemic policy

t the start of the advice at the heart of government of a pandemic “seemed an odd time to pandemic the decision making, to inform the set up a new organisation.” government’s mantra national strategic response to the “I absolutely don’t know the reason was “we will be led by coronavirus epidemic,” a government why JBC was set up, as opposed to A the science.” As the spokesperson said. “As we move getting another organisation to do that weeks passed this changed to “guided into the next phase of the response, role,” he said. by.” Now, under the growing influence the JBC will complement the work of Horby said the way that JBC interacts of data analysts, political advisers, I absolutely SAGE, providing more operational with SAGE and organisations such and economists, it appears to be don’t know focus, including data analysis and as PHE and NHS England and NHS shifting further still. why the Joint epidemiological expertise, with the Improvement would be “a learning With more now known about the Biosecurity aim of ensuring that outbreaks of curve” in terms of responsibilities, behaviour of covid-19, and more Centre was coronavirus are detected and brought data sharing, and avoiding duplication extensive testing data available, set up under control quickly.” of effort. “I think the vision is that the government is cutting the input Peter Horby, [JBC] will assume more and more of the Scientific Advisory Group for Oxford University Future of PHE importance, and they will become Emergencies (SAGE). It will meet less The new centre, which will be based the clear major player for outbreak often, focus on long term issues and in the Department for Health building scenarios, but they will not necessarily emerging evidence, and have less of a in central London (above), will work manage them,” he said. role in analysing day to day infection closely with Public Health England, Members of at least one SAGE data. That job will fall to the new Joint which has been criticised for its subcommittee are reported to have Biosecurity Centre, modelled on the handling of the pandemic, raising been told they will report to the Joint Terrorism Analysis Centre and questions about its long term future. government in the future but they were headed by Clare Gardiner, director Peter Horby, professor of emerging unclear whether this meant ministers of national resilience and strategy at infectious diseases at Oxford or JBC. The government has said they the National Cyber Security Centre University and chair of SAGE’s new would remain SAGE subcommittees (part of Government Communications and emerging respiratory virus threats but also be encouraged to work Headquarters or GCHQ). advisory group (NERVTAG), said the directly with policy makers. “SAGE will continue to provide a JBC had a “completely different” remit Susan Michie, director of University single consensus view of scientific from SAGE’s but added that the middle College London’s Centre for Behaviour Data show 5000 fewer hospital admissions for acute coronary syndrome during pandemic

Around 5000 fewer 2019 baseline rate of The decline started the proportion receiving people were admitted to 3017 a week to 1813 before the UK lockdown [a percutaneous coronary hospitals in England for by the end of March, a began on 23 March intervention] on the CAVALLINI/SPL JAMES acute coronary syndrome reduction of 40% (95% and “was qualitatively day of admission and than expected from this confi dence interval 37% similar throughout the a continued reduction By the end of March January to the end of May, to 43%). The authors country, with only minor in the median length of admissions for ST-elevation myocardial infarction (STEMI) an analysis has shown. also observed a partial variations in diff erent stay,” they added. The results, published recovery in admissions demographic groups,” “The reduced number had fallen by 23% in the Lancet, indicate from April, and by the the authors wrote. of admissions is likely (CI 16 to 30) to 477, from many patients missed out last week of May there Among patients to have resulted in the 2019 average of 621, on lifesaving treatments were 2522 admissions admitted to hospital increases in out-of- while in the same period during the pandemic. a week—a 16% (13% with acute myocardial hospital deaths and admissions for non-STEMI From mid-February to 20%) reduction from infarction there was a long-term complications fell by 42% (CI 38 to 46), admissions fell from a baseline. “sustained increase in of myocardial from 1267 to 733

132 25 July-1 August 2020 | the bmj Change, who sits on both SAGE and its 19 advisory group, acknowledged behavioural science subcommittee, different nations had made N ew guidance on DNAR said downgrading SAGE to rely on different judgments but said, JBC was “really concerning.” “JBC is “There are occasions where I think orders to be issued divorced from the UK’s public health it is reasonable not to do what infrastructure,” she said. “There is very SAGE suggests. There is the health after legal challenge little information about its funding and perspective and then there’s lots of lines of accountability.” non-health considerations which are The government has announced it will publish new not necessarily in the remit of what national guidance for England on “do not attempt Unanswered questions SAGE looks at.” resuscitation” orders, amid concern that blanket bans Michie said that key scientific Michie agreed but said ministers on cardiopulmonary resuscitation were being imposed questions—including how best to should give reasons through “direct, by some healthcare providers during the pandemic. support patients dealing with long honest, open communication.” She The move comes after a threat of legal action against term consequences of covid-19, why said, “That is not what happened.” the government from Kate Masters, the daughter of a outbreaks often occurred in meat man who successfully fought to establish that patients facilities, and emerging evidence on Elimination strategy have a right to be consulted on resuscitation. In May an increasingly likely role for aerosol The government set up a review of Masters launched a High Court challenge against the transmission—remained unanswered. the two metre distancing rule headed health secretary for England, Matt Hancock, over the An example of the government by Simon Case, permanent secretary government’s failure to issue opting not to follow SAGE’s advice to the prime minister, which took clear national guidance to ensure was the relaxation of the two metre evidence from various sources, patients’ rights were protected. social distancing rule in England to including economists as well as Hancock initially maintained “one metre plus” from 4 July to allow scientists. But the review has not the matter was for local health the hospitality sector to reopen. The been published. bodies to oversee but has now other UK nations, which also receive Michie said the best way of getting responded as the case was being SAGE advice, have taken a more England’s economy back on track prepared for court. He promised to cautious approach. Horby said that was to pursue an “elimination publish guidance for patients and After the decision the government was in an “invidious strategy,” as Scotland is doing. families on DNAR decisions for to put DNAR position” because it couldn’t lock “What’s not going to get the economy the fi rst time on the NHS website, information on everything down indefinitely. going is having to maintain lots of alongside updated information the NHS website Vittal Katikireddi, senior clinical these restrictions, by having local for NHS staff to provide clarity on I will not proceed research fellow and honorary outbreaks, and by businesses not making DNAR decisions. with my case Kate consultant in public health at knowing where they are because Masters Glasgow University and a member they don’t know whether there will be Court of Appeal of the Scottish government’s covid- lockdowns or not,” she said. In 2014 Masters’s father, David Tracey, took University The BMJ requested an interview Hospitals Cambridge NHS Foundation Trust to the High Really concerning . . . JBC is with a JBC representative but had no Court and Court of Appeal after his wife, Janet, who divorced from the public health response by the time of publication. had terminal lung cancer, had a DNAR notice put in her infrastructure in the UK Ingrid Torjesen, London records at Addenbrooke’s Hospital without consultation. Susan Michie, UCL Cite this as: BMJ 2020;370:m2874 Since then the law has been clear that article 8 of the European Convention of Human Rights requires that patients or their family are consulted on DNAR decisions infarction and missed strokes, could get it in a patterns and in-hospital and that patients know in advance how decisions will be opportunities to off er safe way.” management, similar made and the process if there is disagreement. secondary prevention The lead author observations have been Masters, who provided evidence that the article 8 treatment for patients,” of the Lancet report, made in Spain, Italy, rights of patients were being systematically violated they concluded. Marion Mafham, from Austria, and the US. in the UK, said she was pleased the government had Nick Linker, NHS Oxford University’s Barbara Casadei, responded to the “unacceptable” situation. England’s clinical Nuffi eld Department of professor of “My dad fought for people to have the right to be heart disease director, Population Health, said cardiovascular involved in a DNACPR decision. It is hard for them to said, “NHS staff pulled her team would publish medicine at Oxford do this without knowing the process and their legal out all the stops to treat updated analyses University, said, rights. It’s a fundamental omission. Matt Hancock has over 100 000 people for each month online, to “These fi ndings must reassured me that what I have asked him to do is now in coronavirus in hospitals, track whether weekly be taken into serious hand, and following his commitment to provide patient but they also made sure admissions return to consideration in the facing information on DNACPR decisions on the NHS everyone who needed normal or rise above the event a second wave website I have decided to not proceed with my action.” urgent and emergency historical baseline. develops as lockdowns But she added, “I do not rule out taking this further if treatment for other Although lacking are eased worldwide.” it is not addressed appropriately or in a timely manner.” conditions, including quantitative information Shaun Griffin, London for heart attacks and about admission Cite this as: BMJ 2020;370:m2852 Gareth Iacobucci, The BMJ Cite this as: BMJ 2020;370:m2848 the bmj | 25 July-1 August 2020 133 THE BIG PICTURE In Belgium “real heroes never sleep”

Evi Polak, a Belgian photographer and former A&E nurse, returned to Antwerp University Hospital to capture life in the emergency department under covid-19. In her submission to the Helsinki Photo Festival, she wrote, “Real heroes never sleep . . . Yet trust them, because they save lives! “Belgium is fi ghting very hard against covid-19 and for moments like these I am proud to be a nurse and a photographer.” According to Johns Hopkins University, Belgium has the second highest deaths per head of population in the world (85.80 deaths per 100,000 population). The festival, which has the theme of trust, is open until 30 September and features 58 international and Nordic photographers displayed in venues around the city. Alison Shepherd, The BMJ Cite this as: BMJ 2020;370:m2904

134 25 July-1 August 2020 | the bmj the bmj | 25 July-1 August 2020 135 EDITORIAL Face masks and hearing loss Innovation is urgently needed to ensure clear communication in medical settings he covid-19 pandemic masks remain in medical settings. 12 has literally changed Clearing these barriers is an urgent the face of medical care: priority. Around the world, people with clinicians, nurses, other hearing loss, including those in the staff , and patients are all Deaf community, are fashioning their T 13 wearing masks. With masks covering own clear masks. the faces around us, we are unable to Virtual consultations are a access the facial expressions and lip potential solution for some patients. movements that are so vital to daily But many people with hearing loss communication. need captioning to understand Masking is challenging for speech delivered through online everyone in healthcare settings, but platforms. High quality real time it is especially diffi cult for people speech-to-text captioning is off ered with hearing loss. Masks also create for free on some platforms (such as enormous challenges for members Google Meet and Microsoft Teams), of the Deaf community who use sign but other platforms (such as Zoom language, clinicians with hearing loss, and FaceTime) lag behind.14 Free and other populations. AUGSTEIN/SHUTTERSTOCK FRANK access to online captions is another Communication between patient Masking is over 70 have clinically signifi cant loss.8 priority for innovation.15 and clinician is at the heart of medical challenging Second, basic steps can often improve Patients and healthcare workers care. Even before masks became for everyone communication. Face the patient, get who are members of the Deaf ubiquitous, people with hearing in healthcare their attention before speaking, speak community and use sign language loss struggled to communicate reasonably slowly, raise the volume of face the greatest obstacles with 1-3 settings, but in healthcare settings, and it is especially our voices slightly, and always check masking, since facial expressions poor communication was the difficult for for understanding. Non-response or an and lip movements are fundamental likely cause of their documented inappropriate response might be a sign components of sign language. In worse health outcomes. 4 5 Spoken people with of hearing diffi culty. healthcare settings, remote (video) communication has always been hearing loss sign language interpretation services especially challenging in emergency Low tech must be provided, or patients and departments and hospital wards Low tech aids such as white boards interpreters should be allowed to owing to high levels of noise and poor or yellow pads can be useful. remove masks. These issues should be environmental engineering.6 Those Smartphones and tablets off er real resolved urgently as good healthcare challenges remain, but masks bring time speech-to-text transcription, and outcomes depend on clear channels of new barriers: in addition to blocking some tech savvy patients are using communication, particularly during a lip movements and facial expressions them. Healthcare facilities might be lethal pandemic. (which are so important when hearing required under law to provide speech- Face masks are likely to be a feature is marginal), masks muffl e the high to-text transcription for patients of patient care for a long time to frequency portions of sound that are needing it.9 10 come. In early June the World Health essential to speech.7 For some patients, a handy Organization noted that mask use How can we preserve facilitator of spoken communication is in medical care settings introduces communication with patients with the personal amplifi er, which consists potential harms and risks that “should hearing loss in this new masked world? of a microphone and an amplifi er that be carefully taken into account” First, we can be mindful that many feeds the conversational partner’s when caring for members of several patients will struggle to understand voice directly into the wearer’s ears populations, including the deaf speech delivered through a mask. through wired headphones or earbuds. and hard of hearing community.”16 We should be especially alert to the They can be stocked with hospital Masking in healthcare will be an area possibility of hearing loss with older supplies and cost around $60-$200 of activism and practice innovation patients, as over two thirds of people (£50-£160). in the months to come. Adopting Face masks with clear windows simple strategies can help maximise Joshua Chodosh , Michael L Freedman professor of geriatric medicine could allow access to facial communication while innovation Barbara E Weinstein, professor of audiology expressions and lip movements, ramps up. Jan Blustein, professor of health policy and medicine, New York but there are few manufacturers Cite this as: BMJ 2020;370:m2683 University Grossman School of Medicine and supplies are low.11 Moreover, Find the full version with references at [email protected] regulatory barriers to the use of clear http://dx.doi.org/10.1136/bmj.m2683

136 25 July-1 August 2020 | the bmj EDITORIAL An opportunity to reduce unnecessary healthcare Health systems recovering from covid-19 should prioritise genuine need he continuing costs of the gastroesophageal refl ux 16—so some pandemic combined with of those children who missed visits the impending fi nancial may have avoided an unnecessary crisis will inevitably label, invasive diagnostic procedure, T mean having to do more or the complications of inappropriate with less. The tragedy of the pandemic treatment. Adults who missed an has paradoxically produced an annual health check-up may have opportunity to tackle the increasingly avoided an intervention of little or recognised challenge of “too much no benefi t that carries a risk of harm medicine” safely and fairly—to from unnecessary diagnoses.17 help improve both sustainability Analysing the eff ects of this and equity in healthcare. This well natural experiment in reduced described problem of unnecessary healthcare will be as challenging tests, diagnoses, and treatments as it is necessary. International causes harm and wastes resources collaborations are required between that could be better used for those in researchers, health system managers, genuine need.1 2 clinicians, and patient and public Reports from the US and the FURLONG/GETTY IMAGES CHRISTOPHER representatives. Initially, data can Organisation for Economic Campaigns systems to prioritise interventions be collated at local, regional, and Cooperation and Development suggest such as “that have demonstrated eff ectiveness national levels to determine how that at least a fi fth of routine healthcare Choosing and concrete benefi ts for patients.”11 rates of common tests, diagnoses, spending may be wasted, including Wisely are now Campaigns such as Choosing Wisely and treatments have changed. 3 4 10 on overdiagnosis and overuse. In more relevant that aim to avoid overuse, are now Those lists could then be mapped Canada, patients receive more than a than ever more relevant than ever. against lists of known low value care, million potentially unnecessary tests including overused interventions and and treatments each year, according Natural experiment overdiagnosed diseases.1 to recent estimates.5 The threats from The use of healthcare services has More focused studies can then overuse and overdiagnosis may be fallen steeply during the pandemic,12 - 14 investigate the eff ects of reduced even more serious in low and middle off ering a rare opportunity to analyse healthcare on patient outcomes and income countries.6 a natural experiment in less medical costs. Understanding the extent of Every health system experiences care. In the US, the number of visits to increased mortality and morbidity this problem,7 and some are starting hospitals, emergency departments, arising from missed care is critical, but to address it.8 9 More immediately, and family doctors almost halved so too is identifying and quantifying health system managers are facing at the height of the pandemic.12 - 14 any benefi ts. Qualitative analysis urgent questions about how to deal Clearly, many people were unable to of people’s motivations for, and with big backlogs in elective surgery access needed care, including routine experiences of, avoiding care will also and other procedures that have vaccinations,15 and lives have been be important. been postponed in recent months. lost as a result—for example, from This pandemic has provoked the Two year waiting lists for some heart disease. 13 Others, however, have best of human compassion and procedures are now a possibility in avoided unnecessary tests, diagnoses, solidarity, but those who manage our parts of Canada, for example. This has and treatments that would have health systems still face extraordinary forced a renewed focus on reducing caused them more harm than good. challenges including preparing for inappropriate care—such as magnetic Although recent analyses suggest the second wave. Looking beyond the resonance imaging for uncomplicated that use of healthcare is bouncing crisis, our collective learning about the osteoarthritis 10— requiring health back, there are still large “cumulative eff ects of the large falls in healthcare defi cits” of missed care over recent use can help inform and intensify Ray Moynihan, assistant professor, Bond University, Australia months.14 One of the biggest and eff orts to reduce unnecessary care. [email protected] most sustained falls has been in This in turn can prevent avoidable Minna Johansson, director , Cochrane Sustainable Healthcare, Sweden visits to doctors involving young harm to patients, enhance healthcare Alies Maybee, patient partner , Patient Advisors Network, Canada children.14 We know that children equity, and improve the sustainability Eddy Lang, professor , Department for Emergency Medicine, Cumming experience overdiagnosis and of health systems everywhere. School of Medicine, University of Calgary, Canada overtreatment—for example, through Cite this as: BMJ 2020;370:m2752 France Légaré, Canada research chair in shared decision making and an inappropriate label of attention Find the full version with references at knowledge translation, Laval University, Canada defi cit/hyperactivity disorder or http://dx.doi.org/10.1136/bmj.m2752 the bmj | 25 July-1 August 2020 137 CORONAVIRUS Sewage monitoring is the UK’s next defence against covid-19 Researchers have pioneered wastewater analysis and are now contributing to a nationwide programme, reports Chris Baraniuk

or the past few months, scientists in the UK have been quietly poring over samples of British faeces. F Researchers at a handful of universities around the country have been conducting pilot programmes to detect RNA from the SARS-CoV-2 virus deposited in sewage, which ends up at wastewater treatment plants. “We estimate if there’s one person infected in a population of 10 000, we can pick it up—it’s that sensitive,” says Davey Jones, professor of soil and environmental science at Bangor University. Every week since March, Jones’s team has been analysing wastewater—which fl ows into sewers from bathrooms, kitchens, and public drains—from cities including Cardiff , Liverpool, and Manchester. He says that the volume of viral RNA present in the samples noticeably “plummeted” after the UK went into lockdown in late March, an apparent indicator of the falling number of cases that resulted from social distancing. Now, he’s signed a contract to expand sampling to 20 wastewater treatment plants around Wales. It’s a “daughter project,” he says, of a UK-wide sewage surveillance programme to monitor the presence of the virus in wastewater, which was announced on 12 June by the Department for Environment, Food, and Rural Aff airs (DEFRA). Details of other projects in the scheme haven’t yet been made public, but The BMJ understands that, in total during the initial phase, around 50 wastewater treatment sites around

MENAHEM KAHANA/AFP/GETTY IMAGES MENAHEM KAHANA/AFP/GETTY the UK will be sampled a few times a Technicians extract sewage samples from a manhole in Ashkelon, Israel to try to track the RNA of covid-19 week. Researchers are sampling a few

138 25 July-1 August 2020 | the bmj Some scientists say it may even from samples so this needs to be be possible to roughly quantify considered too, says Singer. how many infected people there are Corbishley adds that he has in a given town based on the amount tried to solve this by inserting a of viral RNA that turns up in that known quantity of pig virus into his town’s wastewater. samples to see how much is left by As with other aspects of the the time the specimen is purifi ed covid-19 response in the UK, and ready for analysis. eff orts to monitor sewage were not “It’s like detective work,” says initiated by the government but Singer. rather proposed and prototyped by We estimate academic researchers. Waiting to start if there’s “I got in touch with Scottish Water Another researcher who has been one person and asked if anybody was looking gathering samples and conducting infected in a sites already, with the rest to follow at the detection of coronavirus in early experiments in the UK is David population of by the end of the summer. Other wastewater. They said, ‘No, why Graham, professor of ecosystems 10 000, we countries, including Australia and don’t you crack on with it,’” says engineering at Newcastle University. can pick it up Spain, had previously committed to Alex Corbishley, lecturer in farm He says that only taking samples Davey Jones, similar monitoring programmes. animal practice at the University of from wastewater treatment plants Edinburgh. That was more than three limits the information scientists can Bangor Early warning system months ago. He’s since obtained gather about what parts of a city are University Infected people sometimes naturally multiple samples from six wastewater worst aff ected by covid-19. shed virus material in their faeces plants in Scotland and successfully “Say you’ve got the city of within a couple of days of symptoms detected SARS-CoV-2 in them. Newcastle, which has about appearing. This means that regular 400 000 people, and there’s two checks of sewage could theoretically Challenges waste treatment plants—that identify the presence of the virus There are, however, challenges doesn’t tell you very much about the before an infected person gets the involved in wastewater monitoring. epidemiology of the disease within a results of a swab test. To detect viral The proportion of the virus present city of that size,” he explains. material, a wastewater sample must in wastewater can change depending Since March, he and colleagues be brought to a laboratory where it is on the amount of rainwater entering have been gathering samples from purifi ed and fi ltered before the RNA the sewage system, for instance. Or, localised points instead: pump We are is extracted. This is then processed temperature and other factors could stations and junctions scattered across analysing the by quantitative polymerase chain alter the amount of viral material Newcastle’s sewer system. He says that first of 250 to reaction—the same sort of analysis that survives in one city’s sewers they’ve gathered between 250 and 300 vials of used to detect viral RNA in swab tests compared with another’s. 300 vials of wastewater and are now wastewater from patients. Wastewater from areas with more starting to analyse the fi rst of these. This approach is not 100% hospitals or care homes might Singer adds that analysis in the David Graham, specifi c, meaning that there are contain greater amounts of viral RNA. UK will be propped up by a research Newcastle likely to be occasional false positives. Plus, things can change over time. As programme to improve the overall University Scientists can, however, control for people move out of lockdown, the use sensitivity of wastewater analysis. possible contamination of samples of residential bathrooms will likely His proposal for this work received and eliminate poor results. fall, again altering what turns up at £1m in early July. RNA fragments in sewage are not the treatment plant. However, although DEFRA has likely to be infectious. However, To be able to take samples from committed to the wider nationwide fi nding them in wastewater a wastewater facility and make a sewage surveillance scheme, there reveals that there are infected people reliable estimate as to how many are few public details about it, notes in the community. people are infected in that area, all Singer. The BMJ asked the department “This is kind of an early warning of the above factors need to be taken if it could clarify the scope of the system,” says Barbara Kasprzyk- into account, says Andrew Singer, programme: a spokesperson declined Hordern, a professor in chemistry at senior scientist at the UK Centre for to comment but said more information the University of Bath, who thinks Ecology and Hydrology. would follow “in the coming weeks.” It’s like such monitoring could help local Researchers also need to control “Sampling has started across detective work authorities control local hotspots for the time of day at which a the country to further test the Andrew Singer, of the virus that may emerge in the sample was taken, since, as with the eff ectiveness of this new science. coming months. Some countries, electricity grid, demand on sewers Research remains at an early stage UK Centre for including Israel, have used sewage varies between morning and night. and we are still refi ning our methods.” Ecology and monitoring to detect outbreaks of Current methods of purifi cation Chris Baraniuk , Belfast Hydrology polio in the past, so the idea is not mean signifi cant proportions of viral [email protected] without precedent. material—up to 80%—can be lost Cite this as: BMJ 2020;370:m2599 the bmj | 25 July-1 August 2020 139 CORONAVIRUS Will medical tourism survive covid-19? Malaysia had big plans for 2020 to attract patients from abroad—only for the pandemic to hit. Megan Tatum reports on a sector once full of profi t and promise that is now full of uncertainty

arlier this year, Lee But Malaysia hopes that strong Kim Siea, a plastic and government support for the private reconstructive surgeon, healthcare industry, coupled with had been due to travel its swift and strict response to the E to Indonesia with the pandemic, could pave the way for a Malaysian government to appear at far quicker recovery in Malaysia than an annual showcase of Malaysia’s elsewhere. healthcare facilities. It was an opportunity to build on Government backing the 30% of patients at his private clinic in the state of Penang who travel Between 2011 and 2018 the number there from overseas—a proportion of international tourists travelling that has been increasing steadily for to Malaysia for medical treatment the last 15 years, he says. A “sizeable doubled from 643 000 to 1.2 million, following” comes from Indonesia, with visitors arriving from China, the and others fl y in from the Middle East, UK, and the US. Europe, and Australia. Central to this growth has been a The event was organised by the model of public-private partnership Malaysia Healthcare Travel Council rarely seen in medical tourism. Noting (MHTC), the government’s medical the growth of the sector in Thailand tourism arm, in what was expected and Singapore, the Malaysian to be a record breaking year for government launched targeted tax international healthcare travel. In allowances and incentives for private 2019, each week had brought news I’ve spent the last three months sending healthcare that fuelled 10 billion of an addition to Malaysia’s growing ringgit (£1.9bn) of private investment list of private hospitals. WhatsApp messages to patients to in the sector from 2011 to 2018. By January 2020, 15 000 beds were remind them we’re here The MHTC has also aggressively ready for the anticipated infl ux of Lee Kim Siea, a plastic and reconstructive surgeon marketed the country’s facilities international patients. The Malaysian overseas. It has forged agreements to government predicted that two million designate Malaysia as a healthcare international visitors—a 33% rise on destination of choice with the 2019—would arrive as part of its well governments of Kazakhstan, Libya, promoted Year of Healthcare Travel. and Oman, among others. But in March all that came to a halt, The team at Prince Court Medical when the Malaysian government Centre in Kuala Lumpur, where instigated a lockdown to curb the 30% of patients are from overseas, number of covid-19 infections. has received patients for open heart For hospitals that meant all but surgery from Brunei as a direct result essential healthcare was prohibited. of government level discussions, says With international borders closing all commercial director Vincent Wan. The over the world, it was a hammer blow MHTC has become the “backbone” to Malaysia’s medical tourism dream. of the private healthcare industry, he Across the world it’s a similar story. says. “They’ve put Malaysia on the The medical tourism market, worth world map, which is in contrast to up to £70bn annually, is expected to most countries where private hospitals shrink as patients avoid unnecessary must market the sector on their own.” travel. The management at Government backing has been Bumrungrad International Hospital instrumental in shaping the style of in Thailand, where half of patients medical tourism for which Malaysia come from overseas, predicts a 28% Sherene Azli is the chief executive of Malaysia Healthcare Travel is becoming known, says Shujaat drop in revenues by the end of 2020. Council, which has put the country’s facilities on the world map Ali, the founder of online platform

140 25 July-1 August 2020 | the bmj Medical Travel Market. “They refer At one effi cient service. One patient claimed travel, the region has successfully to it as the ‘whole medical tourism private to have been given a “50/50 chance broadened the appeal of medical experience,’ which not many countries hospital to live” in Indonesia after a diagnosis tourism beyond just the most have invested in, and which involves of hepatitis, before recovering fully affl uent customers. connecting airlines and hotels in Penang, following treatment in Penang. with hospitals to create a complete revenues fell Malaysia has worked to leverage Uncertain future package.” In 2018, for example, the this appeal. In 2019 revenues from MHTC reached an agreement with 66% medical tourism accounted for But all that was before the pandemic. airline Air Asia to promote one another in April and 7.9% of total tourist revenues in the The uncertainty of covid-19, as the preferred destination and carrier country, according to authorities, lockdowns, border restrictions, for medical tourism. 55% worth 1.5 billion Malaysian ringgit. and social distancing has stalled in May as From a standing start that now puts international travel. The UN World Safety and affordability foreign it close on the heels of neighbouring Tourism Organisation estimates that Thailand, the long established the travel industry could decline by The most common treatments for patients market leader in the region, which 60% to 80% by the end of 2020, which patients come to Malaysia dropped to has revenues of around £480m from calling it the “worst crisis that are in orthopaedics, cardiology, IVF, zero medical tourists. international tourism has faced since neurology, and oncology, according Although the US remains the records began.” It says Asia and the to the MHTC, and aff ordable largest international market for Pacifi c have been the regions hardest cosmetic surgery is a further draw. medical tourists, accounting hit, with a loss of 33 million tourists. For patients whose home countries for around 36% of total spend, For Lee Kim Siea and for others, have less well developed healthcare countries across the Asia Pacifi c the closure of borders has meant a systems Malaysia off ers quality region have recorded the fastest precipitous drop in revenues. At one and safety, but at a lower cost than growth, at a predicted growth rate of private hospital in Penang, revenues nearby alternatives. Procedures in 15.5% between 2017 and 2023. fell 66% in April and 55% in May Malaysia cost up to 40% less than in Treatment in Asia is up to 90% as foreign patients dropped to zero Singapore, for example. cheaper than private healthcare in and local patients postponed all but In a 2019 paper looking at the the US. According to the MHTC, a essential treatment. motivations among Indonesians coronary artery bypass graft that Yet Asia’s relative success in travelling to Malaysia for treatment, would cost £72 000 in the US, containing the virus means it could patients cited misdiagnosis and poor costs less than £7800 in India, recover faster than other regions. safety standards from their domestic for example. Coupled with a steep “Countries in southeast Asia that providers, as well as slower, less reduction in the cost of long haul air have kept the infection rates very low the bmj | 25 July-1 August 141 LIM HUEY TENG/REUTERS LIM HUEY A nurse works inside the coronavirus disease ward at Kuala Lumpur Hospital, Malaysia, which is hoping to attract more international patients will defi nitely present themselves as But with healthcare systems still Success in on social media looking to bring in covid-safe destinations,” says Gary fearing resurgences of covid-19, implementing patients from overseas,” she says. Bowerman, an independent travel health authorities and staff may and Wan says Prince Court Medical analyst specialising in Asia. “Success be nervous about re-opening to maintaining Centre “is actively engaging with in suppressing the virus, and—very patients from overseas. “We’ve had rigorous our business partners in diff erent importantly—implementing and a push from existing patients that testing and countries, as well as focusing on maintaining rigorous testing and they’re eager to come back but we’re social networking online, such as tracing is tracing is already proving important in practising a very cautious approach,” holding Facebook Live events to tourism promotion.” says Stephanie Lee, chief operating proving remind international patients that Malaysia has proved itself strong offi cer at Penang’s Island Hospital, important we’re still here, to just hang on.” on this front, recording around where around half of patients came in tourism Ultimately, the fate of medical 8500 cases and 121 deaths at the from overseas before the pandemic. promotion tourism will be determined by time of writing, despite fears of a far “We’re looking at our entire actions outside the sector’s greater wave of infections. It was one screening facility and protocol for control. Bowerman says that of the fi rst countries to introduce patients, trying to get personal how governments have managed a government sanctioned contact protective equipment available healthcare and death rates “not only tracing app, with residents required and also the most up-to-date covid provides reassurance to travellers to check in using QR codes at any screening tool in the market.” when selecting a destination, but also location away from home. All arrivals In June the Malaysian government demonstrates proven covid-related to the country will also be required to agreed to allow medical tourists to be expertise, learnings, and capacities download and use the apps to enforce among the fi rst permitted back into the should there be tidal rises for quarantine and track movement. country, ahead of many expatriates infection rates once travel is phased Yet there remains considerable and foreign workers. Still, Lee told back, and—more importantly—in the uncertainty about when international The BMJ that the hospital will only event of a more sustained second or travel will resume, with many extend its services to existing patients, third wave.” countries maintaining border and only then where procedures are For now, it’s still a hazy future for closures or imposing quarantines deemed critical enough to warrant Lee Kim Siea. Rather than promoting of 14-21 days on visitors, even as international travel. his services at an international expo, they ease lockdown. One proposal he has spent the last three months is for countries that have contained Watch, wait, tweet combing through old international or eliminated the virus to open up patient records, sending WhatsApp travel corridors between themselves, Kimberley Lim, the manager of messages “to remind them we’re here,” waiving quarantine measures a private clinic in Kuala Lumpur, and off ering free video consultations. for visitors from those countries. thinks her country’s handling of His business can only wait to see if it Malaysia is reportedly considering the pandemic will put its medical will survive in the new covid world. such an arrangement with Indonesia, tourist sector in a good place once Megan Tatum, freelance journalist, Penang, which is by far its greatest source of international travel resumes. “The Malaysia [email protected] medical tourists. government is active continuously Cite this as: BMJ 2020;370:m2677

142 25 July-1 August 2020 | the bmj