this week BACTERIOPHAGES page 213 • SCREENING page 214 • CRISIS IN A&E page 216 GETTY IAMGES Bullying was rife in NHS Highland

Leaders of Scotland’s health service are to feeling “sidelined, criticised, victimised, Scottish health secretary be brought together to look at how working undermined, and ostracised for raising Jeane Freeman said the relationships can be improved after a series matters of concern,” while managers were Sturrock report contained lessons for the whole NHS of reports on bullying and harassment. seen as autocratic and defensive. The move follows an independent The board’s failure to act prompted a inquiry into complaints raised at NHS group of clinicians to raise their concerns Highland, where doctors alleged “a culture in a letter to the Herald, leading to the of fear and intimidation” had existed for review being commissioned. NHS Highland the past decade. The report, compiled by chairman David Alston and its medical John Sturrock QC, said that while it was director Rod Harvey left the board in not possible to conclude a bullying culture February, and its chief executive Elaine existed, “it seems possible that many Meade retired at the end of last year. hundreds have experienced behaviour that The inquiry calls for people centred is inappropriate. That seems far too many.” leadership, early action to resolve problems, The inquiry’s findings were supported by more use of mediation, better training, and health secretary Jeane Freeman. She said an effective whistleblowing system. NHS LATEST ONLINE the report contained lessons for the whole Highland is preparing an action plan to Most hospital doctors of the NHS and a summer summit will be implement the changes, said the new chief experienced staff held involving managers, trade unions, executive, Iain Stewart. A statement from shortages last winter, and the royal colleges to discuss the best the whistleblowers said, “We look forward says RCP way to achieve an open and honest working to a time of healing but we need to be Dozens of US states environment. She also announced that by confident this won’t happen again.” sue 20 generic the end of the year every health board will NHS Ayrshire and Arran is the latest drug makers over appoint a whistleblowing champion. Scottish board to face bullying allegations, “industry-wide The inquiry heard from 340 people, of with 85 radiology staff raising a collective conspiracy” to drive whom 66% reported bullying. The report grievance. A BMA Scotland survey last year up prices says that “in many instances these were showed that nearly four in 10 doctors said Around one in seven significant, harmful, and multi-layered at bullying was a problem in their workplace. of the world’s babies all staff levels, in many geographic areas Bryan Christie, Edinburgh has low birth weight and disciplines.” Staff complained of Cite this as: BMJ 2019;365:l2166 the bmj | 18 May 2019 211 SEVEN DAYS IN GPs in England’s deprived areas face most severe pressure, analysis shows General practices in deprived areas of England are being disproportionately affected by “a mounting cycle of pressures” driven by workforce shortages and higher patient volumes, the Health Foundation has found. A separate analysis by the Nuffield Trust for the BBC showed that the number of GPs for each 100 000 people in the UK fell from nearly 65 in 2014 to 60 in 2018, the biggest consecutive fall since the 1960s. The Health Foundation’s analysis estimated that the number of patients for each qualified permanent GP in England had risen by 8% in the past three years, up from 2000 to 2160, owing to a fall in full time equivalent (FTE) GPs and population growth. In the most deprived 10% of areas patient numbers per GP were 15% higher than in the least deprived 10%. The foundation also highlighted that this higher practice workload was exacerbated by patients in the most deprived areas experiencing worse health. Ben Gershlick, the foundation’s senior economist, said, “To make good on the commitment in the NHS long term plan to reducing health inequalities, a set of coherent actions are needed, focused on encouraging recruitment to areas of high deprivation.”

Gareth Iacobucci, The BMJ Cite this as: BMJ 2019;365:l2104

Homelessness adjustments to support students on the UK government and the Research integrity Local authorities can bid and trainees through medical devolved administrations to give Coke contracts could for homeless funding school, clinical placements, and parents universal education on “quash” bad findings Public Health England opened work settings. nutrition to help tackle childhood applications for local authorities obesity. It said that education on to bid for a share of £1.9m Multiple sclerosis healthy diets for children and the to support homeless people Roche deal could lead to importance of exercise should be in moving off the streets and NICE approval available at antenatal classes and accessing healthcare. Successful NHS England struck a deal with at nursery through to secondary projects will focus on improving the manufacturer Roche to school. Children who start school access to health services and give eligible patients with obese are more likely to be obese Coca-Cola may be able to continuity of care for people multiple sclerosis access in adulthood. The obesity rate suppress unfavourable findings with mental ill health and to the drug ocrelizumab in adults is 29% in England and from the health research it funds substance misuse problems (Ocrevus, left) at a reduced Scotland and 27% in Northern at public universities in the US who are sleeping rough or at risk price. The drug, which is Ireland. and Canada, a study published in of it. The government’s Rough given as an infusion every six the Journal of Public Health Policy Sleeping Strategy, announced months, costs around £19 000 Rural prevalence rises found. Researchers studied more last August, set a goal of halving per patient a year at full price. more rapidly than 87 000 papers and found rough sleeping by 2022. It is suitable for people with Global strategies to combat clauses that allow the drinks primary progressive MS and has rising obesity may need to be giant to end research without Workforce been shown to help them stay reconsidered, said researchers, reason and keep the data. Disabled doctors and active for longer. The deal after they found that from 1985 students get new support means that ocrelizumab can to 2017 the average body mass COPD The GMC advised medical be considered for approval index in rural areas worldwide Spirometry does not occur schools and training providers by NICE, as it now meets increased by 2.1 in women in 60% of admissions on steps to ensure that all its threshold for cost and men. In cities it increased A spirometry test is essential to students and trainee doctors effectiveness. An by 1.3 in women and 1.6 in confirm a diagnosis of chronic can fulfil their potential, estimated 2700 men. The authors wrote in obstructive pulmonary disorder, including those with disabilities. patients could be Nature, “As economic growth but a large clinical audit showed These steps, outlined in the eligible. and rural nutrition programmes it was not recorded in 60% of GMC’s Welcomed and Valued reduce rural caloric deficiency, patients admitted to hospital with guidance, include allocating Obesity the rural undernutrition an acute COPD exacerbation. The specific contacts, agreeing Dietary advice disadvantage may be Royal College of Physicians’ audit confidentiality arrangements, is urged for replaced with a more covered 75 000 admissions to 179 and creating action plans to parents general and complex hospitals in England and Wales. It meet the demands of courses The Royal College malnutrition that entails found better care of COPD patients or training. It also includes of Physicians of excessive consumption than in 2018 but noted significant advice on making reasonable Edinburgh called of low quality calories.” areas for improvement.

212 18 May 2019 | the bmj SIXTY SECONDS MEDICINE ON . . . Glyphosate BACTERIOPHAGES Monsanto must pay couple A NEW WEAPON AGAINST RESISTANCE? $2bn over cancer claims The potential for bacteriophages—viruses A jury in California ordered that target and kill specific bacteria—as a way Monsanto to pay more than to defeat antibiotic resistant infections took $2bn (£1.54bn) to a couple a leap forward last week when researchers who developed non-Hodgkin’s reported significant recovery in the first lymphoma after using the patient to be treated with phages. weedkiller Roundup (right), BACK TO THE PAST? which contains glyphosate— You could say so. Phages were explored more identified as a probable human than a century ago but lost out to antibiotics. carcinogen by the World Health The resurgence is due to the rise in antibiotic Organization’s International resistant bacteria. Over the past two years Agency for Research on Cancer. in South East Asia from 3.5 L to phages have treated a multidrug resistant The victory for Alva and Alberta 4.7 L, in the US from 9.3 L to 9.8 L, DEFICITS Acinetobacter baumannii infection and a Pilliod is the third verdict against and in China from 7.1 L to 7.4 L. NHS hospital trusts Pseudomonas aeruginosa infection. Monsanto, which is now owned A LAST RESORT by Bayer. The companies said that Regulation are forecasting In the latest skirmish, teenager Isabelle they would appeal the verdict FDA ends report system a combined Carnell-Holdaway (below) was deteriorating that hid device failures overspend of with a Mycobacterium abscessus infection Public health The US Food and Drug after a lung transplantation. Her Great Philadelphia’s sugar tax Administration announced it will £1.2bn Ormond Street Hospital team tried many may boost sales elsewhere end the “alternative summary in 2018-19. The antibiotics and had moved her on to a Taxing sugar sweetened reporting” programme that has highest projected palliative care plan before turning to phages. and artificially sweetened allowed millions of medical deficits were beverages (by 1.5c per ounce) device injuries to escape public BUILDING A LETHAL WEAPON The GOSH researchers, in the city of Philadelphia in notice over two decades. Much of 2017 cut the volume of drinks the information will be published £182m with the University of Pittsburgh, which has sold by 1.3 billion ounces within weeks, the agency said. at King’s College more than 10 000 phages, (51%), a study published in The programme went largely Hospital, London, targeted mycobacteria to JAMA found. However, this unnoticed, until it was unearthed identify those most likely decrease was partially offset by by a Kaiser Health News £94m to kill Isabelle’s infection. increased sales of 308.2 m oz in investigation in March. at Cambridge They found three: “Muddy,” which killed surrounding areas that had no University the strain, and “Zoe” and “BPs,” genetically sugar tax, offsetting the drop in Black box warnings put on Hospitals, and engineered to boost the killing power. Philadelphia’s sales by 24.4%. common insomnia drugs The FDA applied its strongest SOUNDING THE RETREAT Global alcohol target is “black box” warnings to the £89m After a topical test dose, Isabelle began likely to be missed common sleep drugs eszopiclone at United intravenous therapy every 12 hours for six months. Phages were detected in her serum The World Health Organization’s (Lunesta), zaleplon (Sonata), Lincolnshire just a day after starting treatment, and she target to cut harmful use of and zolpidem (Ambien, Ambien Hospitals left GOSH nine days later for home treatment. alcohol by 10% by CR, Edluar, Intermezzo, and [NHS Improvement] 2025 is unlikely to Zolpimist). It found 66 examples WHO WON THE BATTLE? be met, researchers of patients taking one of these After a month, Isabelle’s wound had improved warned, after finding non-benzodiazepine hypnotics more than other skin lesions so the team the volume consumed for insomnia and experiencing added daily topical therapy to the infusions. worldwide each year rose by serious injury or dying from an At six months she showed “objective clinical 70% from 1990 to 2017. Alcohol activity performed unconsciously improvement,” including her surgical wound’s intake rose by 0.6 L of pure as “complex sleep behaviour.” closure, said her team in Nature Medicine. alcohol per adult a year (up from The regulator has reports of 46 SO, RESISTANCE IS (NOW) FUTILE? 5.9 L to 6.5 L). This is predicted serious injuries from causes as Not quite. “We have to be cautious about to reach 7.6 L by 2030, a study varied as accidental overdoses, what can be concluded from one clinical case in the Lancet found. Although burns, exposure to extreme cold report,” said Helen Spencer, the respiratory alcohol consumption in the UK leading to limb loss, gunshot paediatrician who led Isabelle’s care. The next dropped from 12.3 L in 2010 to wounds, and suicide attempts. step? Proper clinical trials, of course. 11.4 L in 2017, other countries saw increases. Consumption rose Cite this as: BMJ 2019;365:l2197 Susan Mayor, London Cite this as: BMJ 2019;365:l2183

the bmj | 18 May 2019 213 Royal college’s new tech guide warns against “maverick” surgeons

urgeons should refrain artificial intelligence, robotics, and from using new procedures nanotechnology were exciting and and techniques if they had much potential, there were lack the training and “significant risks” in allowing supervision to ensure innovation in the absence of clear patients’S safety, the Royal College of guidelines. It has previously called Surgeons has warned. for a national protocol on introducing The guidance on the best practice new procedures and technologies for using new techniques follows and has offered to create one with the the death of a patient who had Department of Health and Social Care multiple organ failure after robot and the GMC. assisted heart valve surgery. It It is also pushing for all new outlines the principles all surgeons surgical procedures and devices to be should consider when developing registered, with related data collected new techniques, instruments, or in appropriate national audits, before devices, as well as how surgeons being routinely offered to patients. can demonstrate the safety and The college’s guidance advises effectiveness of those innovations. all surgeons to keep an accurate It is absolutely vital that all innovation puts The college said that although new and accessible record of their patients’ safety centre stage Peter Lamont, RCS technologies such as 3D printing, surgical activity and to submit data

NHS is “losing its grip” on cancer screening

A damning report into health doing enough to ensure everyone used to identify the eligible screening has accused the who is eligible is being screened, population was described by government of “losing its grip” and do not know if everyone who DHSC in 2011 as “not fit for as it revealed that the number of should be invited has been. purpose” but has yet to be women accessing the cervical The report showed a replaced. As a result the national cancer programme has fallen to a “massive” disparity across the oversight of screening has failed 21 year low. country, with parts of the north patients, resulting in thousands east reaching more of their of women not being invited for Missed targets eligible population for cervical breast and cervical screening IN 2017-18 The Public Accounts Committee screening than areas of London. or waiting too long for their eight million people report covers four of England’s 11 But it said that the Department screening results, the report said. were screened, costing screening programmes: bowel, of Health and Social Care, NHS The national bodies have breast and cervical cancers, and England, and Public Health been too slow to recognise abdominal aortic aneurysm. England do not have a plan to and respond to the problems, £423m None met targets for ensuring the reduce these health inequalities, including holding local screening waiting for delayed results eligible population was screened and don’t know what stops providers to account for long term will suffer anxiety, stress, and in 2017-18. certain groups from attending, so failure, it said. uncertainty. Those delays also MPs on the committee said cannot effectively target them. In 2017-18, almost eight million stretch beyond the department’s that national bodies are not It added that the IT system people were screened for the four target waiting periods. conditions at a cost of £423m. “The government’s Just 71.7% of the eligible population, or 3.2 million women, , the committee understanding of variation across chair, said millions of people the country and the barriers were screened for cervical cancer in 2017-18, and only were not benefitting from facing different demographics of one of 207 clinical commissioning group areas succeeded in screening. “Our inquiry has the population is patchy, which meeting the target of screening 80%. The results for exposed a health service that constrains their capacity to act. breast cancer screening were is losing its grip on screening “This is a question of health 72.1% programmes. Many people equality. The government has a

214 18 May 2019 | the bmj to national audits, registries, and Royal college’s new tech databases. It also gives surgeons GP struck off for information on training, patient lack of indemnity guide warns against consent, ethical considerations, regulatory requirements, and cost insurance implications. Prescription rules are “maverick” surgeons A GP who worked for six years without Patients’ safety “overly complex indemnity insurance, and who provided Peter Lamont, a college council and cause mistakes” fake information in three appraisals to member who helped develop the make it appear he was covered, has been guidance, said that as a new wave Rules on prescription exemptions set by the struck off the UK medical register. of technologies was expected to Department of Health are too complicated, Between 2014 and 2016 Augustine affect every type of surgery, it was causing patients to make genuine mistakes, Onojeje-Oraka filled in the indemnity “absolutely vital” that this innovation the National Audit Office has said. coverage sections of three appraisal put patients’ safety and best interests The spending watchdog investigated forms, claiming to be covered by either at centre stage. penalty charge notices (PCNs) issued to the Medical Defence Union or the Medical He said, “The introduction of new patients who claim free prescriptions or and Dental Defence Union of Scotland, technologies or techniques in surgery dental treatment fraudulently or in error, and and giving false membership numbers, has no place for the maverick surgeon it found a significant increase in checks and knowing his insurance lapsed in 2010. who proceeds without appropriate fines issued. In February The BMJ reported The fraud was revealed during a Care peer review or training. that the number of PCNs issued to patients Quality Commission inspection of his “Surgeons by nature are in England had risen by a third last year and practice in Borough, south London. innovators, and we hope that these by 60% in the past three years. Onojeje-Oraka, who qualified at guidelines will help them bring their The NHS estimates that this type of fraud Benin University in 1985, did not attend new ideas forward in a way that most costs £256m a year and has set a target to a Manchester hearing of the medical benefits patient care.” halve the losses by 2020. “The NHS practitioners tribunal, but previously Elisabeth Mahase, The BMJ However, the report said must take gave evidence to a performers list Cite this as: BMJ 2019;365:l2170 many factors may be urgent steps to decision panel, to which he was referred causing confusion and avoid causing by NHS England. In that evidence, the wrong claims, including tribunal heard, he did not deny his lack unnecessary duty to ensure that everyone has the introduction of of coverage, nor that he faked policies, access to health screening.” universal credit rules and distress to but he denied dishonesty. In an email to The committee is pressing the people not understanding patients” NHS England soon after the inspection, department and NHS England to differences between benefits. Additionally, he blamed a “constellation of mitigating set out a plan of action to better some exemptions may vary between circumstances.” These included partners hold local screening providers to prescriptions and dental treatments; and in reluctant to join a group cover scheme, account, overhaul governance specific circumstances, such as pregnancy, pressure of work, a declining practice arrangements, and develop an IT the patient may need to apply for exemption income, and personal stressors, said the system that works as intended. certificates that have varying time limits. tribunal chair, Linda Lee. His MDU insurance had lapsed, he IT to be replaced Valid exemptions claimed, because of “an administrative The system is to be replaced next Nearly a third (30%; 1.7 million) of PCNs error requesting lump sum payment,” year, but until then, the report issued since 2014, worth £188m, were which he could not afford. “I kept going said there remains a risk that more withdrawn because of a valid exemption. back to [the MDU] in the hope they might eligible people will not be invited for This means that many patients are reinstate me,” Onojeje-Oraka told the screening. incorrectly receiving “distressing, decision panel. “I did make an attempt NHS England has commissioned threatening letters or fines” that could affect but because of the pressure that I was a review of adult screening services, their mental wellbeing, said Richard Vautrey, under I think I did lose track of it.” the results of which are expected chair of the BMA’s GP committee. But the tribunal found no evidence this summer. Meg Hillier (right), chair of the Public to support his claims for mitigation, The health department is waiting Accounts Committee, said, “The said Lee, who added that “doctors in his for its recommendations but is NHS must take urgent steps if it position, by nature, have stressful jobs, pushing ahead with changes to help is to avoid causing unnecessary and this is not an excuse to practise detect as many cancers as early distress to patients, tripped up without valid indemnity insurance or to as possible, a spokesperson said, by an overly complex system, be dishonest.” She added, “At no point adding, “The NHS in England is who end up facing large penalty has Dr Onojeje-Oraka acknowledged investing £200m to fund new ways charges.” the impact of his actions or accepted to rapidly detect and treat cancer.” Elisabeth Mahase, The BMJ responsibility for them.” Jacqui Thornton, London Cite this as: BMJ 2019;365:l2200 Clare Dyer, The BMJ Cite this as: BMJ 2019;365:l2168 Cite this as: BMJ 2019;365:l2181

the bmj | 18 May 2019 215 CRISIS IN A&E “Give us simple, intuitive systems” NHS leaders continue to grapple with one of its biggest challenges: how to staunch the rising number of patients attending emergency departments. Gareth Iacobucci reports

he NHS in England has was noted by Siva Anandaciva, Kirkham said the scheme had been trying to get to grips chief analyst at the King’s Fund, succeeded because of hospitals’ with rising numbers of when welcoming NHS leaders, “willingness to give up resources,” accident and emergency senior clinicians, and patients’ a population health management attendances and representatives to a conference on approach with proactive care admissionsT for several years, with the urgent and emergency care on 9 May. planning, anticipatory care plans It has never 2013 Keogh review, the 2014 Five Year “It has never been less clear how the for patients, and having a shared been less clear Forward View, and the recent long various different initiatives fit together electronic care record in place. It how the various term plan all proposing solutions. into a coherent whole,” he said. also had strong clinical leadership. different But the trend continues. The latest The experts at the conference initiatives fit figures show a 7% rise from April Shifting the focus acknowledged that these conditions together into a 2018 in daily attendances and the Trying to shed some light was Mark existed in only a minority of places coherent whole worst performance on record against England, NHS England’s deputy and would take a lot of effort and the target for 95% of patients to be national director of urgent and perseverance to implement. Siva Anandaciva, admitted, transferred, or discharged emergency care, who said the complex But Chris Moulton, vice president King’s Fund within four hours. The NHS wants to system had often been “too focused on of the Royal College of Emergency replace this target, which has not been A&E.” Providing more proactive care Medicine (RCEM), said an achievable met since July 2015. to the most complex patients—5% ambition would be to “re-engineer The NHS long term plan pledged of A&E attendances take up 54% of systems to make them simpler, more investment in primary and community hospital bed days—could make a huge intuitive, and easier for people.” care to divert more non-emergency difference to capacity, he said. Derek Prentice, RCEM’s lead patient cases to “new service channels” such Karen Kirkham, a Dorset GP and representative, expressed exasperation as urgent treatment centres and a NHS England’s clinical adviser for at the repeated push by policymakers beefed-up version of NHS 111. Also primary care, described how a Dorset to discourage patients from using A&E being trialled is “same day emergency area had seen a drop in emergency departments. “Patients don’t like being care,” with the aim of cutting admissions after testing an approach told ‘you need to be educated,’” he overnight stays in hospital. that shifted resources out of hospital, said. “People use the A&E department All this is a lot for patients—and improved access to primary care, and because they regard it as the only for the service itself—to grasp. This shared the workforce across services. place of safe access for them. They

Antibiotics after assisted childbirth could halve infections Giving women a single dose of antibiotics after such births could assigned to receive intravenous preventive antibiotic after childbirth help to reduce antibiotic use by amoxicillin and clavulanic acid or involving forceps or vacuum 17%, the researchers said. placebo within six hours of assisted extraction could prevent almost half In 2016 around 19 500 women vaginal delivery. The researchers of maternal infections, equivalent to in the world died from pregnancy monitored confirmed or suspected more than 7000 every year in the UK. related infections. However, for maternal infections within six weeks The finding came from a every woman who dies, another of delivery and assessed the effect randomised trial of 27 UK obstetric 70 develop a severe infection and of the preventive antibiotic dose on units involving 3420 women. The survive, often with long term health overall antibiotic use. study also found that, for every consequences, previous research Rates of perineal wound infection additional 100 doses of preventive has found. or burst stiches, perineal pain, and antibiotic given, 168 doses could The latest study, published in the need for extra perineal care were be avoided overall because of the Lancet, was carried out between also substantially lower in the reduction in infections after delivery. March 2016 and June 2018 and antibiotic group. From the findings Implementing a policy of routine involved women who were randomly the researchers estimated that an average of £52.60 per women could be saved by the NHS within the first RESEARCHERS estimated that an average of £52.60 six weeks after birth. per woman could be saved within the first six weeks after birth Marian Knight, from Oxford

216 18 May 2019 | the bmj FIVE MINUTES WITH . . . Paul McNeive The Irish novelist on his unlikely antibiotic resistance collaboration with the chief medical officer

suffered bad burns in a car accident in 1982 which culminated in losing both my legs. I was learning to walk on prosthetic legs, and I picked up cuts, bruises, and blisters which would sometimes get infected. know they are going to be seen 24/7 if been prompted by the NHS’s inability “About“ 10 I years ago I went to the doctor with a routine they can’t get hold of a GP or any other to meet the four hour target. But the looking skin infection. I was prescribed antibiotics, but appropriate service at the time they emergency medicine consultant Cliff nothing happened. I went back and was prescribed a need it. We need to recognise what Mann, a former RCEM president and longer course; again nothing happened. I tried another, patients want.” clinical lead for A&E improvement and then another; nothing happened. I had a multi- Eileen Sutton, head of urgent and plan at NHS England, said the resistant bacteria infection and the antibiotics didn’t emergency care at the Healthy London rationale was sensible. work any more. Partnership, said that many patients, “Eventually I had to have a skin graft to get rid of it. The particularly frail elderly people, would Fifteen million patients a year infection caused me to retire because the consultants choose not to go to an emergency He said, “I don’t think anyone is trying warned me they were running out of options. I had department if community services to give up on the four hour standard. sepsis a couple of the times I had been were available. “Patients don’t want It did a great job in the early 2000s. admitted to hospital, and there to go to A&E at the end of their life. It’s But then emergency departments were was a risk of losing my remaining not one size fits all. We need to think seeing around 10 million patients knee, which is crucial to my about them,” she said. a year—now it’s 15 million. More mobility. This all caused me to As part of a wider clinical review of importantly, we were admitting about look into antibiotic resistance, its waiting time targets, NHS England 15%, we now admit 31%.” which I knew nothing about. I is piloting plans to replace the four He added, “A clinical review of became more appalled at what hour goal with other measures, such as standards has to shine a much greater was going on. To me, it’s on the time to initial clinical assessment, time light on admitted patients who are same level as global warming; I WAS THE to emergency treatment of critically in emergency departments for an it’s that level of catastrophe. PATIENT FACE ill and injured patients, and mean unacceptably long period of time.” “I had written one non- THAT COULD waiting time across all departments. Gareth Iacobucci, The BMJ fiction book and I wanted to HELP BRING THE Some critics have argued that this has Cite this as: BMJ 2019;365:l2193 write more. I retired and wrote PROBLEM TO LIFE The Manhattan Project. The book explores the idea of whether terrorists could induce and accelerate the Antibiotics after assisted childbirth could halve infections University, who led the study, consumption of antibiotics—for example, by getting said, “These findings highlight Researchers found that women who more of them into the food chain, by disrupting hospital the urgent need to change WHO received a single dose of antibiotic cleaning, or by spreading bacteria around hospital antibiotic guidelines and guidance wards. had significantly fewer suspected or from organisations in the UK, North America, and Australasia that do confirmed infections: 11% Initiatives not recommend routine antibiotic in the antibiotic group and “Six months ago, the publisher sent a copy to [England’s prophylaxis for assisted childbirth. in the placebo group (risk chief medical officer] Sally Davies, because she’s “This intervention could be used 19% one of the best known and most outspoken voices on to prevent maternal infections in ratio 0.58 (95% confidence interval antimicrobial resistance (AMR). She invited me to meet low and middle income countries 0.49 to 0.69)). her and said that I was the patient face that could help where intravenous antibiotics are bring the problem to life—beyond the sterile “doctors available.” warn about AMR threat” newspaper story that Joe Public The study team noted that one in Women who received antibiotic switches away from very quickly. She asked me to help 10 women still had a suspected or prophylaxis were 56% her with some initiatives, and I’m grateful for her interest. confirmed infection, so more research less likely to have confirmed “I don’t think the problem is getting the political was needed to assess whether earlier, attention that it should be. Hopefully, people who read prenatal, or repeated administration sepsis proved by culture than the book will get an entertaining read and also be a lot would be more effective. women receiving the placebo wiser about the problem.” Elisabeth Mahase, The BMJ (0.6% versus 1.5%). The Manhattan Project is published by Black and White Publishing Cite this as: BMJ 2019;365:l2188 Gareth Iacobucci, The BMJ Cite this as: BMJ 2019;365:l2189

the bmj | 18 May 2019 217 INVESTIGATION Big tobacco, the new politics, and the threat to : spoke at IEA’s David Davis: received £1949 from : wrote an essay “On the public health birthday celebrations IEA to attend meetings in the US nanny state” for an IEA website With several Tory leadership hatever the eventual than 25 serving Conservative MPs, including consequences of several candidates for May’s job. contenders sympathetic to for the NHS, an article The IEA is secretive about its funding its ideology, the Institute of published in the Daily sources, but The BMJ can report that the Economic Affairs is closer Telegraph in March made organisation is part funded by British Wit clear that an even greater threat to public American Tobacco. In the past it has also to power than ever before. health in the UK may emerge from the battle taken money from the gambling, alcohol, In an exclusive investigation, for control of the Conservative Party. sugar, and soft drink industries. Meanwhile, Jonathan Gornall reveals In an essay published on 31 March, entitled politicians with links to the IEA seem to be “The next Tory leader must be a bullish progressing ever closer to power. The concern how the organisation is libertarian,” the director general of the free is that public health policies could be put at funded by British American market think tank the Institute of Economic risk under a new Tory leadership, including Tobacco and, after orchestrating Affairs (IEA) set out what amounted to a current plans for calorie labelling and for manifesto for a new party leader. advertising restrictions designed to tackle attacks on the “nanny state”, it The leadership election, wrote Mark childhood obesity, as well as progress towards may now hold the key to Littlewood, was a chance “to rediscover an a minimum unit price for alcohol. No 10 agenda supportive of . . . free markets and a smaller state.” ’s successor POLITICAL LINKS should ensure that “the plethora of censorious and hectoring measures over what British Among the MPs most closely and publicly adults choose to eat, drink and smoke must associated ideologically with the IEA is come to an end.” Dominic Raab, MP for Esher and Walton in What the IEA says matters. “Bullish Surrey since 2010. libertarianism” appeals to a significant Raab, backed for the leadership by a Tory faction, and, as the showcasing of “Ready for Raab” social media campaign Littlewood’s prescription in the Telegraph launched within days of his resignation in attests, any prospective leader is likely to 2018 as secretary of state for exiting the emerge from the ranks of those who subscribe European Union, has performed well in Tory to the IEA’s ideology. grassroots polls and had his candidature The institute has a longstanding endorsed by David Davis (another former commitment to dismissing public health Brexit secretary). initiatives as “nanny state” interventions. Its In 2015 he spoke at the IEA’s 60th birthday recent research publications have challenged celebrations, where he acknowledged his the childhood obesity strategy, dismissed ideological debt to the organisation. He “sin taxes” as regressive, and ridiculed the recalled a time he had been swimming off a link between fast food outlets and obesity. In Brazilian beach, pleasantly swept along by the past year alone it has issued more than a an unseen current. In “the fight for economic dozen statements criticising everything from freedom,” he told the audience, “the IEA alcohol controls to sugar taxes as “pointless,” . . . will be like the warm, irresistible tide on “absurd,” and “draconian.” that Brazilian beach—gently, powerfully, All of this might not be quite so worrying sometimes without us even knowing it, were it not for two facts: the IEA is or has been shifting the debate to a whole new place.” funded by some of the very industries that Raab remains close to the institute. Last stand to gain commercially from its attacks on month he appeared in an online video to public health initiatives, and it is connected— launch the Richard Koch Breakthrough ideologically, financially, or both—to no fewer Prize, the IEA’s annual essay competition.

218 18 May 2019 | the bmj This graphic shows 32 Conservative MPs linked financially, directly MPs who have received funding or indirectly, to the Institute of Economic Affairs (IEA) or gifts from Michael Hintze Patrick McLoughlin No value declared MPs who have David Willetts £2000 received expenses Andrew Bingham from the IEA £5000 David Davis £10 000 Robert Buckland Phillip Lee Nicholas Soames Michael Hintze Owen Paterson IEA trustee and founder of asset MPs who have management company CQS received funding Lorraine Fullbrook from Neil Record George Eustice

Institute of Luke Hall Paul Uppal Eric Ollerenshaw Economic Affairs Theresa May

Jesse Norman Nigel Vinson Life Vice President and former Will Quince Chair of the IEA board of trustees James Arbuthnot Neil Record Chair of the IEA Paul Scully board of trustees

John Stevenson £3.9m*

Hugo Swire £0.4m* George Osborne John Lamont

The Conservative Visual summary Party Data sources: The Electoral Commission: https://www.electoralcommission.org.uk/ Register of Members’ Financial Interests, 2008 to 2018: https://www.parliament.uk/mps-lords-and-offices/standards-and-financial-interests/ * Arrows for these two large party donations are not to scale parliamentary-commissioner-for-standards/registers-of-interests/register-of-members-financial-interests/

The institute, he said, was “well known for The IEA is connected— and Hancock began by promoting free market principles, and they’re ideologically, financially, or both— crediting the IEA for having “undertaken absolutely essential, now more than ever . . . to 25 serving Conservative MPs extensive research on so-called ‘sock get thinking, send us your ideas.” puppets,’ exposing the practice of taxpayers’ Asked by The BMJ whether Raab Tory leadership race, does not have direct money given to pressure groups being supported Littlewood’s libertarian call to links with the IEA but in recent years has diverted to fund lobbying rather than . . . arms, a spokesperson for the MP sought to received funding from Neil Record, who good causes.” distance him from the IEA’s view that public became chair of the IEA board of trustees Since his appointment as health secretary health initiatives were undesirable “nanny in 2015. From 2010 until his appointment Hancock has shown that he is aligned with state” interventions that should be scrapped. as health secretary in July 2018, Hancock the IEA’s position on minimum unit pricing “Dominic has always been a strong supporter received £32 000 from Record, the founder (MUP) for alcohol, prompting concern in the of public health initiatives to make the UK of a currency management company who public health community that he might be healthier and reduce pressures on the NHS joined the IEA’s board of trustees in 2008. “listening to the views of . . . vested interests [and] a big believer in the power of sport The funding, given in a personal capacity above those of the health community.” to transform people’s mental and physical in support of Hancock’s “parliamentary work Hancock did not respond directly to health and the need for more education to and travel costs” and recorded in the Register The BMJ’s request to confirm whether tackle issues like childhood obesity,” the of Members’ Financial Interests, ceased he had been aware that the IEA was spokesperson told The BMJ. before Hancock became health secretary. funded by a tobacco company when Raab also believed that “all interventions Hancock, as paymaster general and he accepted donations from its chair of need to be proportionate and evidence Cabinet Office minister, sided with the IEA’s trustees. A spokesperson said only that based. He therefore fully supported measures view that charities funded by the government “all donations have been declared in line such as the ban on smoking in public places should not be allowed to lobby it. “When with parliamentary regulations.” Hancock and better labelling and information on government funds the lobbying of itself,” the also did not respond directly when asked calorie content.” The spokesperson declined IEA has argued, “it is subverting democracy whether he supported the IEA’s call for to be drawn on whether Raab was aware and debasing the concept of charity.” In the next Tory leader to scrap “censorious that the IEA was funded by a major tobacco February 2016 Hancock announced that and hectoring” public health measures. company. charities and others receiving government Instead his spokesperson referred to a Matt Hancock, England’s health secretary grants were to be banned from lobbying. speech Hancock gave at the International and considered to be a frontrunner in the A press release issued jointly by the Conference on Obesity. Here, he highlighted the bmj | 18 May 2019 219 Comments from public health figures “Unnecessary and seemingly ineffective, minimum unit pricing Graham MacGregor, professor of cardiovascular medicine, Wolfson Institute has no place in a free society”— of Preventive Medicine, and founder of Action on Sugar and Action on Salt Christopher Snowdon “The prospect of a government following the IEA’s lead on public health initiatives is extremely concerning.” initiatives such as calorie labelling in Tim Lang, professor of food policy, City University London restaurants and restrictions on advertising of “Mark Littlewood’s leadership manifesto should ring alarm bells. Over the junk food and cited the success of the sugar past nine years the catastrophe of obesity has become ever more clear, MacGregor: tax in reducing sugar in soft drinks as evidence and since 2010 three Conservative led governments have only with great “Extremely that “population-wide measures work, and concerning” reluctance added some public health protection measures. Now the IEA is are necessary, alongside promoting healthier saying, ‘We don’t like this,’ and I think that serves as a very good warning to people in public health that the gloves are coming off.” behaviours and empowering individuals to make better choices.” Ian Gilmore, director of the Liverpool Centre for Alcohol Research and chair of But he added, “I am no fan of nanny state Alcohol Health Alliance UK interventions that treat everyone the same, “Public health would be an early victim of populist free marketism and the or punish the masses for the problems of victims would be the most vulnerable—including children. We are already a minority . . . the modern public health in the middle of a public health crisis through the move of public health into problems of largely non-communicable Lang: “Alarm bells local government and central government cutting funding to local authorities. diseases need a much more targeted should ring” ‘Shrinking the state’ would make this even worse.” approach.” On alcohol pricing, he added, Corinna Hawkes, director of the Centre for Food Policy, “For 95% of people, the alcohol we drink is City University London perfectly safe and normal. Let’s not punish “Public health interventions are ultimately about what future we want our the masses for perfectly healthy behaviour.” children to have. Do we want as a society to do everything we can to support The IEA has long expressed opposition children in making healthy decisions? If the answer is yes, then we need to MUP and did so once again in an April public health interventions that prevent the intrusion of negative influences article by Christopher Snowdon, its head into children’s lives. If banning cartoon characters provides an environment of lifestyle economics. MUP, he wrote, Gilmore: “Victims of that makes it easier for children to accept a wider range of foods, that’s was “a shamelessly paternalistic and free marketism will increasing choice, not removing it.” be the vulnerable” patently regressive policy. Unnecessary and Nick Sheron, head of the Population Hepatology Research Group, seemingly ineffective, it has no place in a University free society.” “The prime health challenge of the 21st century will be the diseases The institute has repeatedly refused to caused by alcohol, smoking, and obesity. The vectors for these diseases confirm that it is, or has been, funded by the are profitable commercial organisations who consistently and forcefully alcohol industry. But, in a rapid response to oppose effective, evidence based measures such as protecting children from a 2014 article in The BMJ, Snowdon seemed marketing or increasing price through taxation. to imply that it was —and, in an undercover “There is clear blue water between the health of populations and the recording made by Greenpeace in 2018, IEA’s Hawkes: “What shareholder wealth of commercial interests, and previous conservative director general Littlewood, illustrating for future do we want leaders have tended to float offshore. They have actioned evidence on for our children?” the benefit of a supposed prospective client smoking, done a bare minimum for childhood obesity, and completely failed how the IEA worked, admitted that “we to tackle alcohol. The results are clear to see: tremendous reductions in would take money from alcohol companies.” smoking deaths, a future health crisis from obesity, and colossal increases It certainly has no objection to working with in alcohol related deaths, to the extent that more working years are lost from them. At the Tory Party conference in 2017 the alcohol than from the 10 most frequent cancer types combined. IEA hosted a debate on alcohol policies (“How “The consequences of a future leader aligning against health and in favour much is too much?”) with the drinks company of the tobacco, alcohol, and obesity industries are deeply concerning.” Pernod Ricard UK, and it staged another John Coggon, codirector of the Centre for Health, Law, and Society, (“Standing Up for the British Beer Industry”) Sheron: “Commercial University of Bristol Law School with the support of the world’s largest brewer, interests are vectors “In a lightly regulated marketplace, the impacts of large corporations on Anheuser-Busch InBev. for these diseases” people’s decisions are enormous, potentially coming at the cost of great Snowdon’s article about MUP had personal and social harm and without the sorts of democratic checks and transparency requirements against which public actors and agencies are first appeared on the website of a new held to account. organisation called Freer, whose purpose “Within the small state, the power to influence health affecting decisions, is to “refocus the political debate, shifting however negatively, is considered to be benign to the point of being a attention towards free enterprise and social fundamental right when in the hands of big business, notwithstanding freedom.” Although Freer is “financed, overarching organisational aims to maximise wealth; yet health affecting run and operated by the IEA,” based at the Coggon: “Large interventions, however positive, are considered an unjustifiable interference institute’s offices and headed by Rebecca corporations need with freedom when exercised by agencies whose remit is promotion of the Lowe, a research fellow at the IEA, it is not democratic checks” public interest.“ registered as a charity and is therefore not

220 18 May 2019 | the bmj Policies at risk: calorie labelling and advertising restrictions designed to tackle childhood obesity

Government plans to oblige all the consultation, which ended healthier labour force—would range Mark Littlewood: cafes, restaurants, and meal in December. On the day it was from £4.84bn to £10.57bn. Calorie labelling on delivery companies to give calorie launched Mark Littlewood, IEA The department said originally it menus is using a information about the food they sell director general, told the Daily would respond to the consultation “sledgehammer to are already in the IEA’s sights. Telegraph that the scheme was “yet by Easter, but a spokesperson told fail to crack a nut” At the end of last year the another example of the government The BMJ this had been delayed further cut salt levels Department of Health ran a three using a sledgehammer to fail to by a couple of months as the in food, especially in the out-of- month public consultation on crack a nut” and that, while this consultation “received a high level home sector. Tougher policies, he the proposals, which it said were would not change consumer habits, of interest and it takes time to argued, were necessary to make fast designed “to make sure people it would harm business. It was, analyse feedback.” food healthier. have clear and accurate information he said, “disappointing that the There is also a consultation Now he is “desperately about the calorie content of the food government seems increasingly running on more advertising concerned” by the message and drink they and their families are obsessed with further adding to restrictions to reduce children’s being put out by the IEA. He says, eating when dining out, so they can the red tape that afflicts British exposure to products high in salt, “I thought that as a society we’d make informed and healthy choices.” business.” fat, and sugar, which is due to reached an understanding that The initiative, it said, was driven The stand-off perfectly illustrates close on 10 June. The measures some protection is needed at least by concern that “nearly one in four the problem at the heart of the were proposed as part 2 of the plan for some people, if not all. The children in England are obese or IEA’s business-centric, free market for action on childhood obesity, free market offers no protection in overweight by the time they start philosophy. As was made clear launched last June. health, and society simply has to primary school, and this rises to in the department’s economic The IEA’s views on childhood pick up the costs down the line. one in three by the time they leave assessment of the impact of obesity have been expressed “The ‘nanny state’ gets criticised, primary school.” options, from a mandatory energy frequently. Obesity is “a statistical but it isn’t taking away people’s The department says it is still labelling scheme for all businesses invention,” created by “flawed free choice—it’s just saying that, analysing feedback to to one excluding smaller methodology” that “has led to the in terms of health, ‘This is what we businesses, the sector would face number of obese children being recommend and we’ve set some costs over 25 years ranging from greatly exaggerated.” limits.’ The companies themselves £220m to an estimated maximum The prospect of an IEA fellow make these decisions for us every of £630m. The benefits to society traveller and free market ideologue day, and nobody objects to that. as a whole, however—in taking the reins of the Conservative “We think we have choice, but terms of reduced health Party fills Martin Caraher, professor that’s determined by where you live, and social care costs of food and health policy at City your social profile, and whether you and increased University of London, with dismay. have a Waitrose or Tesco nearby. All economic In an editorial in The BMJ in March, that the state is doing is introducing activity by a Caraher welcomed the proposals to a little control.” subject to the same political lobbying OPAQUE FUNDING years. For example, in 2012 the National restrictions that constrain the IEA. Casino Industry Forum gave £8000 to the IEA Freer’s co-chairs are the Conservative MPs The IEA makes much of the fact that it seeks after the publication of a discussion paper Luke Graham and . Contacted by and receives no government funding. It is, written by Snowdon. The BMJ, Graham declined to say whether however, less forthcoming about where it In 2013 the cigarette companies Philip or not he supported the IEA’s “nanny state” obtains its money. Morris International, British American stance but said, “The Freer initiative, like In a recent appearance on BBC Two’s Tobacco, Japan Tobacco International, and the IEA, has no corporate line on public Politics Live Littlewood repeatedly avoided Imperial all confirmed that they had financed policy proposals. It is united by people answering direct questions from the the IEA, which had campaigned against who broadly support free markets and free presenter, Jo Coburn, about whether his plain packaging of tobacco products as “a people. All views published by the IEA or organisation received money from the sugar, draconian attack on the freedom of smokers, Freer are the author’s own.” Rowley did not tobacco, alcohol, or casino industries. retailers and manufacturers.” These relations respond to a comment request. As a charity and a private company limited came as little surprise to anyone familiar On 16 July 2018 Freer held a summer by guarantee, the IEA publishes accounts with the multiple references to the IEA in party at the IEA’s offices, featuring with the Charity Commission and Companies documents that emerged during litigation speeches by Liz Truss, chief secretary to House, but there is no legal requirement between US states and the tobacco industry, the Treasury, and Raab. Freer’s launch in to identify individual donors. The most which are now held in the Truth Tobacco 2018 was also attended by a number of granular funding detail offered is that, in Industry Documents online archive created by MPs including Truss, Raab, and Michael 2017, its income of £2m came primarily from the University of California, San Francisco. Gove. In April, Freer published On Social unnamed “foundations and trusts” (23%), What is surprising, however, is that at Freedom, its first collection of essays, “large businesses” (23%), and “individuals, least one major tobacco company says that featuring contributions from Tory MPs entrepreneurs and family firms” (20%). it continues to support the IEA to this day, as Truss (“On the nanny state”), Graham (“On Despite the IEA’s penchant for funding The BMJ has discovered. cannabis”), and Ben Bradley (“On taxing secrecy, details of its involvement with a One document in those archives is an IEA meat and sugar”), as well as the IEA’s range of industries whose products are bad fundraising prospectus aimed at potential US Snowdon (“On minimum unit pricing”). for public health have trickled out over the based corporate donors, who are promised the bmj | 18 May 2019 221 Few in public health will be happy at the prospect of the Tories the Conservative Party contesting the general adopting a leader wedded to anti-“nanny state” ideology election in 2020.” In 2016 it published its first report, written by Kristian Niemietz, “immediate access to IEA’s network of health initiatives as undesirable the IEA’s head of political economy, experts—authors, policymakers, business “nanny state” interference. They which compared the NHS unfavourably leaders and media.” Prepared for use by the had “nothing further to add” to the with other national health systems. In a American Friends of the Institute of Economic IEA’s statement, the spokeswoman speech launching the report, Paterson Affairs, the document lists more than 153 said. questioned whether “a centralised corporate supporters of the IEA in the UK. The IEA’s most generous known state-run monopoly of healthcare On the list are several companies whose benefactor is the Nigel Vinson is the best and only way to run a products had public health implications Charitable Trust, which donated universal healthcare system that is fair.” and would clearly have benefited from the £450 000 to the organisation between Paterson has complied with parliamentary IEA’s commitment to deregulation, including 2013 and 2018. Vinson, who from 1968 rules by declaring receipt of donations from British American Tobacco, Rothmans UK to 1975 was a member of the Sugar Board, his own think tank, which does not reveal its Holdings, Tate and Lyle, Whitbread, and joined the IEA board in 1971 and, since funders, but he has declined to say where its Coca-Cola Great Britain and Ireland. stepping down in 2004, has remained a life money comes from. Although undated, the document seems vice president. Links between the IEA and other leading to be from about 1999. In the intervening In 2016 he gave £5.5m to the University of Tory MPs emerged in September 2018, 20 years many companies on the list have Buckingham to create a Centre for Economics when the institute published a report, Plan been restructured or have changed owners, and Entrepreneurship in collaboration with A+—Creating a Prosperous Post-Brexit UK, but The BMJ asked a number of them if they the IEA. The university, which offers a range dismissed by one of many critics as a “product still supported the IEA. Some declined to of medical courses in addition to degrees in of fanaticism [with] dangerous consequences comment, and others were evasive. But one economics and entrepreneurship, declined to for the NHS.” At the launch were the MPs company admitted that it still supported the discuss the appropriateness of establishing Davis and Jacob Rees-Mogg, and the former IEA: British American Tobacco (BAT). such a relation with the IEA, an organisation foreign secretary Boris Johnson hailed the “We support like minded organisations that accepts funds from the tobacco industry. report as “a very good piece of work.” on issues that are important to our business A spokesperson told The BMJ, “We can’t The Charity Commission was less and our consumers,” Simon Cleverly, BAT’s speak on behalf of other organisations but impressed. The report and its launch, it said group head of corporate affairs, toldThe BMJ. are committed to the principles of academic in a statement in December 2018, “sought A spokesperson confirmed BAT was still an freedom and free speech and encourage explicitly to change government policy on an IEA supporter but declined to say how much debate on matters of public policy.” issue unrelated to the charity’s purposes— it donated. The Register of Members’ Financial Interests furthering education—which constitutes The MPs Raab, Hancock, and Truss, as well shows that, in the past 10 years, direct a breach of the commission’s guidance on as IEA’s trustee Record and life vice president funding of MPs by the IEA itself, rather than political activity and campaigning.” The Nigel Vinson, did not respond to requests by senior figures on its board of trustees, warning issued to the IEA under section from The BMJ to clarify whether they were has been rare. Although the amounts have 75A of the Charities Act 2011 called on it to ever aware of the institute’s financial relations been insignificant, the significance lies in the remove the report from circulation. with BAT, which was part of an industry ideological relations the payments highlight. Uncertainty over the Conservative Party’s responsible for “the single largest cause of For example, in September 2014 the IEA future will continue for some time. In the preventable deaths and one of the largest gave £735 to Phillip Lee, a part time GP who meantime, no progress is likely on any public causes of health inequalities in England.” is Tory MP for Bracknell, to allow him to health initiatives, such as plans to introduce An IEA spokesperson declined to confirm attend an IEA conference on privatisation in calorie labelling on food consumed outside it was receiving donations from BAT or from Slovenia. In January 2018 the Daily Express the home or further restrictions on advertising any company or industry body producing soft reported that Theresa May was considering to reduce children’s exposure to products high drinks, alcohol, food, or tobacco products. Lee as ’s successor as health in salt, fat, and sugar. “We respect the privacy of our donors secretary, and in March he was reported to Few in public health will be happy at and don’t place a list of them in the public be “considering a run” in the Tory leadership the prospect of the Conservatives adopting domain,” she told The BMJ. “It is a matter for race. Lee did not respond to a request for more a leader wedded to the IEA’s anti-“nanny individual donors whether they wish their information about his relations with the IEA. state,” free market ideology, but the signs donation to be public or private.” Funders, The register of interests also records that, in are not good. Three days before Littlewood’s she added, were “not permitted to influence November 2018, the IEA paid for David Davis rallying cry in the Telegraph, a round-up of the conclusions of our analysis, neither across to fly to the US for meetings in Washington and contenders published by the New Statesman a programme nor within a single publication Oklahoma. His travel expenses cost the IEA listed no fewer than seven candidates for the or communication about it. We uphold strict £1949. Davis was accompanied by another job who had demonstrated various degrees rules to protect our academic independence, Conservative MP, Owen Paterson, who of involvement with the IEA or empathy with including clear guidance to potential donors recorded a contribution of £84 from the IEA. its views. They included Davis, Raab, Truss, and a rigorous system of peer review.” In 2014 Paterson, a former environment Hancock, and Lee. The BMJ also asked for comment from secretary, formed his own “independent Jonathan Gornall, freelance journalist, Suffolk Record and Vinson on whether they agreed centre-right think tank” called UK 2020, set [email protected] with the institute’s characterisation of public up “to produce a manifesto for the leader of Cite this as: BMJ 2019;365:l2164

222 18 May 2019 | the bmj EDITORIAL Hans Eysenck: controversialist or worse? An independent and authoritative inquiry is needed into “unbelievable” work

ans Eysenck, who have led to substantial developments died in 1997, is in the conceptualising and treating of described in the cancer and heart disease. Dictionary of National Biography as having an “Merclessly manipulated” H“international prominence and impact In his latest paper Pelosi adds to the … unmatched among post-Second case against Eysenck and Grossarth- World War British psychologists.”1 Maticek by finding reports from He’s usually called “controversial” tobacco companies that doubt in that he denied the link between “the validity or even the integrity” smoking and cancer, had strong links of Grossarth-Maticek’s studies.3 with the tobacco industry, thought Others have found “unequivocal race was related to intelligence, evidence of manipulation of

opposed comprehensive schools, STEVE BENT/AN/SHUTTERSTOCK data sheets” and results that are nursed an intense hostility towards “better than perfect.” He reaches psychoanalysis, supported astrology If Eysenck’s than people with other personalities.4 the conclusion that Eysenck had and parapsychology, and declared work were to The relative risk for cancer, observed “mercilessly manipulated … an the entire discipline of economics be examined Pelosi and Appleby, “is perhaps untrained, isolated, and vulnerable 3 as worthless. Now David F Marks, with a critical the highest ever identified in non- collaborator.” the editor of the Journal of Health eye many infectious disease epidemiology.” Meanwhile, Robert Buchanan’s Psychology, has called for a formal of his 1100 Equally remarkable results came biography of Eysenck raises investigation of some of Eysenck’s from a randomised trial showing serious questions about how he could work and the retraction or correction journal articles that “bibliotherapy” (giving people get away with his reckless approach of 61 publications.2 and 80 books a short pamphlet containing advice to scientific endeavour throughout might begin like, “Your aim should always be to his career.9 Serious criticisms to unravel produce conditions which lead to Marks and Pelosi want an The Journal of Health Psychology also a happy and contented life”) given independent and authoritative published a paper by the psychiatrist to 600 participants resulted in an inquiry into the studies of Eysenck Anthony J Pelosi describing how all-cause mortality of 32% over the and Grossarth-Maticek.2 3 Some might serious criticisms of Eysenck’s work ensuing 13 years compared with 82% argue that the world clearly discounts date back three decades—and yet in the 600 untreated controls.4 these studies so why does it matter? there has been no investigation.3 The BMJ article detailed many But the studies are not retracted, Pelosi’s paper was originally accepted problems with these studies beyond are included in textbooks, and for Personality and Individual them being unbelievable, and undermine attempts at meta-analysis Differences, a journal founded by others too have cast severe doubts and future research. I suspect too Eysenck, for an issue to celebrate on them.5‑7 Eysenck responded in that if Eysenck’s work were to be Eysenck’s centenary—but it was The BMJ to Pelosi and Appleby’s examined with a critical eye many then “unaccepted.” It has taken him criticisms, noting cleverly and of his 1100 journal articles and 80 another three years to get the paper accurately that results being “too books might begin to unravel. published. good to be true” is “unfalsifiable” We need the truth about Eysenck’s Pelosi together with Louis Appleby and “hence not a scientific studies with Grossarth-Maticek. published an article in The BMJ in statement.”8 He also agreed with King’s College, London (where 1992 discussing studies Eysenck their assertion “that there should be Eysenck worked for many years), published in 1991 with a German a total re-examination and proper the British Psychological Study, or researcher, Ronald Grossarth-Maticek, analysis of the original data from this preferably a wholly independent showing that people with particular research.” There has been no such group should conduct the inquiry personalities were 121 times more examination. that Marks and Pelosi demand. likely to die from cancer and 27 times The world moved on and Eysenck Without an inquiry that sets the more likely to die from heart disease died with his reputation relatively record straight, psychology and the unscathed. Grossarth-Maticek whole of science could be polluted. Richard Smith, former editor of The BMJ, continued his studies, but his and Cite this as: BMJ 2019;365:l1897 London Eysenck’s results have not been Find the full version with references at [email protected] accepted—because if true they would http://dx.doi.org/10.1136/bmj.l1897 the bmj | 18 May 2019 223 EDITORIAL Tackling disinformation on vaccines Closing down trolls, bots, and content polluters would be a start

n April 2019, Unicef and the False social Internet Research Agency, which has professionals giving their children World Health Organization media also been implicated in messaging vaccines can be compelling. highlighted a global surge of in the 2016 US presidential election Those responsible for vaccination 1 2 messages 13 measles. There were 966 were liked and and the UK EU referendum. These programmes must ensure they have a cases of measles confirmed in accounts, many using the hashtag detailed understanding of knowledge shared more 14 Ithe UK in 2018, nearly four times as #VaccinateUS, spread messages and beliefs in their populations and many as in 20173; 91.2% of 2 year than those that both for and against vaccination, employ much more sophisticated olds in England had been given were accurate seemingly designed to create discord messages, recognising that many the MMR vaccine in 2018, down and undermine trust in authority. traditional ones can backfire.15 from 92.7% in 2013-14,4 with both Thus, they included messages rarely They should draw on a growing rates below the 95% considered found elsewhere, linking vaccines body of research, some in related necessary to prevent transmission to issues that are especially divisive fields such as climate change,16 in the population. Those seeking in the US, such as race and religion, on confronting disinformation. It an explanation have highlighted or the idea that vaccination is a is important not to overcomplicate the role played by disinformation conspiracy by the elite. messages or repeat erroneous ones, spread through social media. The A second source is sophisticated even to correct them14; “inoculating” English secretary of state for health, bots, which are automated the public with the facts before Matt Hancock, described “those accounts that promote particular disinformation takes hold may promoting the antivaccine myth content. These also contained a be effective.17 as having blood on their hands,” mix of messages for and against We also need a much better adding that he was “completely open vaccines. The third, characterised understanding of who is behind to all options” on how to bolster by antivaccine messages that seem the growing volume of internet vaccination rates, including making designed to stimulate curiosity, traffic on vaccination, exploiting immunisations compulsory.5 comprise “content polluters,” methodological advances in network Social media platforms such devised to spread malware or analysis and artificial intelligence18 as Facebook and Twitter have unsolicited commercial content and engaging with social media facilitated a massive increase in and to direct readers to sites that companies to reduce it. Twitter access to health related information, generate income. has already deleted millions of accurate or not. Antivaccine activists suspicious accounts.19 In addition, seized the opportunity.8 Studies of Fighting back legal measures should be considered. internet content have consistently So what can be done? The UK government proposes the found that a substantial share of the Vaccination rates toughest internet safety regulation in available content on vaccination was above 90% are the world20; might a public health misleading, and false messages were testimony to protection clause be possible, to liked and shared more than those the efforts of withdraw flagrantly dangerous that were accurate.9 10 community messages? Another option Researchers are now using nurses and is the US approach, with advanced techniques to identify the doctors whose vaccination a condition for sources of these messages. knowledge is still school entry.21 respected and Those involved in the Sources of disinformation whose guidance battle against infectious A recent study of vaccine related Martin McKee, is followed by most disease understand that posts on Twitter shed considerable professor of parents.7 Vaccine they must always strive to be light on what is a complex European public hesitancy is a natural one step ahead of constantly landscape.12 It identified three broad health, London response for any parent, evolving microorganisms. School of Hygiene categories of account especially and explaining the Exactly the same and Tropical likely to spread vaccine related benefits is essential. principle applies in Medicine disinformation. The first it termed Martin.McKee@ The personal what is now a rapidly Russian trolls. Trolls are people lshtm.ac.uk example of health evolving information who conceal their identity to post environment. John Middleton, A new generation of false accusations or inflammatory president, Faculty trolls are implicated in Cite this as: BMJ 2019;365:l2144 remarks. Many of those identified of Public Health, the online spread of Find the full version with references at were associated with the Russian London anti-vax messages http://dx.doi.org/10.1136/bmj.l2144

226 18 May 2019 | the bmj