comment “After the pandemic will we return to our old ways?” DAVID OLIVER “Pride in our colleagues is matched by anger at government failures” HELEN SALISBURY PLUS Family doctors in the US; the human lessons from other crises

THE BOTTOM LINE Partha Kar Covid-19: we must keep faith in our experts

e live in the age of information In short, as a healthcare professional, ensure that overload. Once you factor in the you’ve given any patients with diabetes the appropriate unregulated world of social media number of testing strips; ensure that they have access to and self-appointed experts, as well telephone support for queries and that they know what W as the urge for people to jump in to do when ill; and reinforce the basics of hand hygiene with their two pennies’ worth and a disregard for real and social distancing, as advocated by Public Health experts, it becomes quite diffi cult to fi nd sources you England. As things stand, it doesn’t matter what your can trust. Then covid-19 appears, and the information age is, what your type is, what your control is if you have world looks like a maze full of pitfalls for anyone diabetes. If it isn’t essential work or travel, stay at home. trying to ascertain the correct information. These are extraordinary times, and we need to have Understandable worries abound, and recent faith in the people leading us, from a healthcare point times have also shown the impact that healthcare of view. It’s perhaps not very modern to say so—but professionals can have, in positive and negative ways. trust the experts. My parents are both in high risk Huge social media followings don’t necessarily mean groups, and they’re here visiting the UK as part of their that account holders have expertise, yet their views are golden wedding anniversary. With those high stakes, seen and taken on board by large numbers of people, I place my faith in Chris Whitty, England’s chief many of whom will be isolating themselves from their medical offi cer and his team. usual, face-to-face social networks. It’s time we all adhered to that principle and let the Misinformation is spreading along with the virus. team do their job. There’s Polarised political views, and the scars of the Brexit a time when we all need to debate, have perhaps made some people forget the learn to follow. This would importance of working together as a nation, and being be it. kind to others in these diffi cult times. Partha Kar, consultant in diabetes When a healthcare professional, or anyone else, and endocrinology, Portsmouth tweets something along the lines of “Many will die— Hospitals NHS Trust especially the elderly,” they need to think about the [email protected] eff ect this has on older people and those who are Twitter @parthaskar vulnerable or whose relatives are. We know that fear Cite this as: BMJ 2020;368:m1143 will exacerbate many mental and physical health issues, but somewhere this knowledge seems to have Social media been lost by some fellow healthcare professionals. In misinformation an eff ort to make a political point, is the ethos of “be is spreading kind” getting lost? along with People with diabetes are at increased risk of the virus illness if they contract covid-19. Thankfully, there is some reliable information around. If you’re a healthcare professional and you’d like to direct your patient to a reliable source, it’s worth looking at the information from Diabetes UK and the Juvenile Diabetes Research Foundation (JDRF UK), which has been developed in conjunction with NHS England and Public Health England. the bmj | 4 April 2020 25 YANKEE DOODLING Douglas Kamerow Don’t forget covid-19’s impact on US primary care

There are twice as many family doctors in America as in emergency departments, yet they have received little to no guidance

uring the exponential growth The most important thing to understand There are dramatic differences in of covid-19 in parts of the US, about systematic changes in US healthcare how practices have reacted to the we have heard a great deal delivery is, of course, that we have no single coronavirus epidemic in the media about brave, healthcare system. A primary care medical Dexhausted emergency room practice may be a small, self-owned group, authorities. They have reacted in diff erent doctors and staff . Very little that I have seen, part of a larger hospital system, owned by the ways, some suspending routine well-patient however, has focused on a much larger state or federal government, or a community visits in favour of treating only urgent and group of doctors who are also on the front owned non-profi t corporation. symptomatic patients. Others with larger, lines: those who deliver primary care. Family doctors, for example, may own their multi-site practices have routed high risk In the US there are more than twice as practice with full authority to set and change patients to one specifi c location, trying to many family doctors as ER doctors and practice policies or they may be salaried maintain chronic care visits for the rest of their almost three times as many paediatricians, employees who lead the clinical team but patients. most of whom work exclusively in primary have little or no say in management. This Once policies for testing and triage are care. Altogether there are more than fi ve means that there are dramatic diff erences in set, practices’ size and ownership aff ect times more primary care doctors than ER how practices have reacted to the coronavirus implementation of patient communication doctors, and that is not counting general epidemic and in what their doctors think and triage. Doctors in small, independent internists, many of whom in the US are also about those changes. practices report diffi culty reaching all patients primary care doctors. before visiting to appropriately triage them. What is going on in primary care? I Constantly changing guidance Larger practices, with more resources have spoke to friends and colleagues to fi nd out, Every doctor I spoke to reported feeling more staff , online patient portals, apps, even and I heard three main points. Dramatic bewildered by constantly changing guidance outreach workers who can guide patients. changes in practice have come very quickly, from experts and regulators about coronavirus Some doctors have ample supplies of the without much prior preparation. Little testing and triage policies. personal protective equipment that enable assistance, or even clear guidance, has come They were often confused by changing them to see high risk patients, while others from authorities. And the resulting changes recommendations from trusted sources, as report shortages. vary widely by practice organisational well as confl icting recommendations from One doctor told me they were switching structure. local, state, medical specialty, and federal from 90% in-person visits and 10% online

BMJ OPINION Mary E Black This too shall pass Serbia, I have been here before. What I have Laughing is a way to build community learned is this: resilience. Let's not make it cruel And so we enter a new world of social • Nothing focuses the mind more than an distancing, people stocking their larders, existential threat. At our core, humans three month supplies of nappies while and limitations on how we can gather. Having want to survive. We will check we have the others can’t fi nd any. Profi teering, pilfering, grown up in Northern Ireland during the fundamentals and learn to live without the and petty theft . Troubles, worked through a war in Bosnia, non-essentials we used to rely on. • We will see cabin fever. The government is and brought up a baby under UN sanctions in • Nudge theory does not encompass what concerned about lockdown for more than will happen next. Social norms will shift 12 weeks. Sarajevo, and other cities under because we will look to those around us siege, did it for four years, and countries and change our behaviour accordingly. like Yemen live with this constantly. Sales • We will see the best of human behaviour, of jigsaws and Jenga will rise, but domestic extreme acts of kindness. Volunteer violence will flare up and children at risk networks will spring up everywhere. We will will be less visible. witness the selflessness of health workers • Those marginalised in society are most who will turn up day aft er day, exhausted at risk. Anything we can do to protect the and exposed. We will owe them our lives. homeless, asylum seekers, the very poor, • We will see the worst of human behaviour. the socially isolated, the frail, and the Absolute greed as families stock up on elderly, we must do now.

26 4 April 2020 | the bmj ACUTE PERSPECTIVE David Oliver Some activities may never return

s the saying goes, “necessity also redeploying specialist clinicians to is the mother of invention.” allow more fast-track access to their skills, In the pandemic, we’re away from overcrowded and pressurised seeing scientifi c evidence emergency departments. This is overdue. A evolve quickly, technologies A recent letter sent by the NHS's chief develop, and real time, ever changing plans executive, Simon Stevens, and chief virtual visits to the opposite, reducing for epidemiology, public protection, and operating offi cer, Amanda Pritchard, their in-person visits to 10% of their ensuring that health services remain viable. included a provision to move away from patient encounters. Smaller practices When we’re through this crisis and have “payment by results” tariff s towards had fewer resources to even attempt such time to refl ect, no doubt some practices will block contracts, removing some fi nancial a dramatic change. see a change for the better. Our planning, penalties for trusts in defi cit. This Also, salaried doctors in practices preparedness, and understanding of purchaser-provider split has always been backed by large organisations were not transmission, protection, and treatment will fraught. Apart from the bureaucracy, worried about how they were going to be have to change. But what of the things we transaction costs, and incentives to focus on paid for these virtual visits or whether they stop doing? Will we return to our old ways the “business model,” the tariff paid to acute could aff ord to keep their practice staff or be grateful for what we’ve learnt? hospitals for urgent activity doesn’t refl ect its on payroll with dramatically declining In acute hospitals, we’re already moving true cost—but it allows us to make a margin fee-for-service income. Not so with a to stop most non-urgent outpatient on outpatient and elective work, eff ectively private practice paediatrician who was activities. Many more consultations cross subsidising unscheduled care. This very concerned at whether they were being are moving online or to the telephone. creates all kinds of perverse incentives, reimbursed for telemedicine visits and Clearly, we don’t want this war footing to when we may be better collaborating to worried whether they could continue to become the new norm. Patients in many plan care for a local population. make staff payroll. cases rely on such work and have their For now, hospitals seem to be suspending It is a very tough time for primary care lives saved or transformed. Clinicians the annual consultant job planning cycle. medicine. It would be helped by clear get valuable training in those settings. The process has its virtues, but how much policy guidance and fi nancial assistance However, organisations such as the Health would we miss it? As for the paperwork to enable delivery of the appropriate, safe Foundation and the Royal College of involved in revalidation, appraisal, and a care that all patients need and expect. Physicians have argued for some time that whole raft of mandatory training, perhaps Douglas Kamerow, senior scholar, Robert Graham outpatient appointments need reform, as we’ll learn that it can be slimmed down—as Center for policy studies in primary care, professor have the NHS 10 year plan and the Getting it it will have to be if we’re to welcome recent of family medicine at Georgetown University, and Right First Time programme. This may help retirees back to work, who might not have associate editor, The BMJ accelerate the process of focusing on value. retired were it not for the paperwork. Cite this as: BMJ 2020;368:m1260 Perhaps we need more one stop, rapid I suspect the crisis will reveal which access clinics for new patients and more staff groups are critical to the healthcare self-directed follow-up—often with business—and which individuals, quangos, advice and remote consultation or consulting fi rms won’t be missed. • The Great British Queue will stretch, not rather than physical trips to David Oliver, consultant in geriatrics and only getting longer, but also more spaced clinic suites, which are especially acute general medicine , Berkshire out. Expect cartoons and editorials that burdensome for patients with [email protected] poke fun at this. Laughing is a way to build multiple conditions seeing Twitter @mancunianmedic community resilience. There is a point to several teams. Hospitals are Cite this as: BMJ 2020;369:m1148 black humour, but let’s not make it cruel. • When it is all over expect an explosion of life and colour. Once again, we will marvel at live theatre, holler for our favourite Organisations team, and share intergenerational Sunday have argued lunches. We will enjoy these things even for some more, knowing what it is like to do without. In times of crisis, we all get to decide. Courage time that and kindness or looking out for yourself? outpatient The fi rst will sustain us, individually and appointments collectively. Choose decency. Then add a large need reform dose of medicine and science, mix with a dollop of common sense and garnish with courage. Mary E Black is a public health doctor the bmj | 4 April 2020 27 PRIMARY COLOUR Helen Salisbury BMJ OPINION Stephen L Roberts Fear in the time of covid-19

hile London’s practices we’ve been sourcing our own— hospitals are nearing scouring the internet for scrubs, masks, capacity, many goggles, and gowns—but supplies are other areas are still drying up. Win the “phoney Most regions have plans to set up war” stage of this pandemic. Never has “hot hubs,” where patients who need so much work been done, so quickly, to be assessed face to face in primary in so many hospitals. New critical care care can be seen by a dedicated team. The crisis in global politics wards have been created, operating It’s still not clear how these will operate, suites repurposed, and emergency who will work there, or what will be Covid-19 is a pandemic. It is also a diagnostic for departments completely reorganised to done to minimise the risk to staff . The understanding and evaluating the ongoing crisis of try to concentrate infective patients in one learning curve will be steep. A serology international politics. place. Changes that would usually have test that could tell us who has already Throughout this pandemic, covid-19 has exposed taken years of wrangling about money been infected and is therefore relatively and emphasised the ways in which populations have happened in the space of a week, immune would be hugely useful. access, perceive, and respond to changes in their with superhuman eff orts from healthcare The emotional rollercoaster is a hard communities, political structures, and societies. workers and managers alike. I am in awe. ride. Pride in our colleagues is matched Widespread smartphone use and real time social Our academic colleagues are also by anger at the government’s failure to media access have been central to the proliferation working in overdrive, rapidly synthesising prioritise the testing, personal protective of viral misinformation. evidence and getting it out to clinicians equipment, and ventilators we need. The pandemic has also exacerbated underlying who need it. It’s hard to keep up, but every Many of us, knowing hospital colleagues tensions between global powers. We have seen piece of trusted information helps when have no choice, are feeling cowardly that this in Donald Trump’s referencing of the “Chinese struggling with an unfamiliar disease. we haven’t yet volunteered for the hubs. virus,” China’s expulsion of US journalists, and In general practice, we’ve changed our Fear is all around—for ourselves, for concerns over Russian misinformation campaigns way of working. We’ve put off everything our families, and for our patients. We impacting on global responses. Covid-19 has that can safely be postponed. The doors know some will die from covid-19 despite become the most recent arena where competing are locked, and patients set foot in the the best that modern medicine can off er. practices, politics, and ideologies play out across building only when it’s clear that their The bigger fear is that hospitals will be an international backdrop of rising state-centric problem can’t be solved remotely and that overwhelmed, as in Italy, bringing many populism, antiglobalisation, and authoritarianism. they’re deemed to be low risk. more preventable deaths. I’m still holding The spread of covid-19 has further propagated But what is low risk? As asymptomatic on to the hope that the capacity increases, the rise of social malaises including racism and shedding of the virus in the early stages combined with reduced transmission xenophobia. Yet discussing the rise solely in this seems to be the norm, and some people from social distancing, will context misses a larger and critical picture. Deeply have only very mild symptoms for their be enough. troubling expressions of racism were also witnessed entire illness, we can’t be sure. From NHS Helen Salisbury , GP, Oxford during previous health emergencies including HIV/ supplies, we’ve received a delivery of helen.salisbury@phc. AIDS, SARS, and Ebola. While covid-19 has given rise 150 fl uid resistant surgical masks ox.ac.uk Twitter @ to new channels in which racism can be more openly and plastic aprons and gloves, HelenRSalisbury expressed, its persistence as a long standing global which won’t last long if we use them Cite this as: BMJ ill speaks first to the complacency or failure of many for every contact. Like many other 2020;368:m1286 states to counter and eliminate expressions and practices of racism in non-outbreak settings. Pride in our Covid-19 has exposed resource inequities. This colleagues is has been most widely witnessed in the amassing of matched by anger food, drugs, and medical products seen as essential by populations with the ability to pay. These at government behaviour trends have led to claims that covid-19 failure to prevention practices are far more accessible for prioritise financially secure groups. The pandemic has not produced these chasms in resource inequities, but it testing, PPE, has accentuated and deepened them. and ventilators These pre-existent challenges mean the study of politics and the cognate social sciences within global pandemics has never been more vital. Stephen L Roberts, LSE fellow in global health policy, London School of Economics

28 4 April 2020 | the bmj LETTERS Selected from rapid responses on bmj.com

LETTER OF THE WEEK YOUR RESULTS MAY VARY Medicine, so far Don’t blame the tools

22 February 2020 368:261-302 No 8234 | ISSN 1759-2151 McCormack and Holmes discuss the cancer if digital rectal examination from an exact Tamiflu: what have we learnt? p 274 Quantifying multimorbidity p 277 imprecision of medical measurements of the prostate is abnormal. An science Using genes to predict disease p 285 Mapping prescribing cascades p 294 1 CPD hour in the education section (Practice Pointer, 22 February). abnormally high PSA level of 100 ng/mL McCormack and Holmes’s If a perfect laboratory test existed, is not concerning if the patient has article clearly shows patients could cut out the intermediary had bladder retention and prostate how far the practice of and do a direct-to-consumer diagnostic biopsy has shown inflammation only. medicine is from an exact test. They might be imperfect, but Busy clinicians already have a science, how much it is laboratory tests complement other plethora of laboratory tests to contend still an art dependent on clinical information. Results must be with; adding complexity to existing the performer (Practice interpreted in the context of patient test results should be done only Pointer, 22 February). symptoms, medical history, clinical if high quality evidence indicates In medical school we findings, and radiology. improvement in clinical care. YOUR RESULTS MAY VARY are taught to treat not The imprecision of Take prostate specific antigen levels Santhanam Sundar, consultant oncologist , the test but the patient, medical measurements as an example. A low normal PSA of Nottingham but test results, even 2.0 ng/mL does not rule out prostate Cite this as: BMJ 2020;368:m1162 repeated, might simply show physiological variation and not a trend NURSES’ JUDGMENT indicating the need for treatment. Medicine has lost its way The other part of the patient record—non- numerical data—can be even less helpful. The loss of a valuable nurse because of an irrational decision by the Nursing and Midwifery Clinicians are infrequent coders, and electronic Council will damage nurses’ confidence in the council and increase the number of health records contain abundant free text inappropriate cardiopulmonary resuscitation (CPR) attempts (David Oliver, 22 February). without a mechanism for processing and Inflicting CPR on a dying person is not sensible or dignified. We need appropriate care for comparing data, analysing trends, auditing, or people according to their stage of life; one of them is dying, which cannot be reversed. implementing supportive diagnostic tools. The quality of our death is important for us and our families, and how it is managed can Defensive medicine is now becoming a ease grief. A caring nurse using their professional judgment can help, and this should be the process of collecting data, many of them primary obligation. unnecessary and stored in an oversized, Modern medicine, for all its brilliant achievements, has lost its caring, its balance, and shared electronic health record. The outcome professional judgment. Restoring this is urgent. It needs to be part of a wider debate on the of this information management is the direction of medicine and the irrational and unrealistic expectations of it. dismissal of most of the available data and David Reilly, retired surgeon, Llandudno the collection of more facts. The result is Cite this as: BMJ 2020;368:m1191 not knowledge but confusion. There is too much talk about improving outcomes and HIP REPLACEMENT OUTCOMES population health management, but the lack Understanding patient flow of adequate data and the misinterpretation of information lead only to ignorance. Complications after total hip replacement Medical professionals are not managing often present to an NHS hospital, even when the vast amount of patient data available. the primary procedure was undertaken in the They are failing to use the information private sector. Overall patient reported outcome at their disposal adequately, to find the measures are skewed by this, and outcome knowledge that could change their diagnosis metrics reported by private hospitals might be and management plans, and to acquire the misleading if they fail to take this into account. MARK THOMAS wisdom that could make medical practice Appleby reports overall parity between safer. In consequence, they are failing to NHS and non-NHS hospitals in EQ-5D scores (Data Briefing, 22 February), but without improve the outcome for patients. understanding the flow of patients between the two sectors, the cost effectiveness (or Information is power, and as medicine clinical effectiveness) of outsourcing care to the private sector cannot be determined. cannot control its vast collection of data, The funnel plot shows very few outliers after adjustment for case mix as described by NHS it is becoming powerless, incapable of England. Adding body mass index and ASA grade to the adjustment might reduce the number progressing or harnessing the benefits other of outliers further. Multilevel modelling is another approach to measuring variation between sciences, such as informatics, can provide. hospitals that helps determine the relative importance of patient, surgeon, and hospital factors. Pablo Millares-Martin, GP , Leeds Adam M Ali, Frank Knox fellow, Cambridge, MA Cite this as: BMJ 2020;368:m1188 Alex Bottle, professor of medical statistics , London Cite this as: BMJ 2020;368:m1161 the bmj | 4 April 2020 29 Longer versions are on bmj.com. Submit obituaries with a contact telephone number to [email protected]

OBITUARIES Iain Smith Macdonald Mohammad Fahim Siddiqui John Smith Public health medical Chief of surgery and Consultant anaesthetist officer (b 1927; departmental director (b 1945; q Liverpool q Glasgow 1950; CB, MD, (b 1941; q Liaquat 1969; FFARCS, died after DPH, FRCPE, FFPH, QHP), Medical College 1965; a long illness on died from old age on FRCS), died from a 30 December 2019 4 January 2020 sudden cardiac arrest on John Smith was Iain Smith Macdonald 22 December 2019 appointed as a was born in Greenock. Mohammad Fahim consultant to Selly Oak After graduating, he did national service in Siddiqui was born in Bareilly, British Hospital, University Hospitals Birmingham, North Africa, then qualified in public health India, but the family emigrated to Pakistan in 1982. His enthusiasm for his specialty led medicine and did a spell as a lecturer at after partition. He moved to the UK in him to develop an interest in the management Glasgow University. After posts as deputy 1968 and worked for the NHS for 11 years. of difficult airways. John rapidly became medical officer of health in Lancashire, In 1979 he moved with his family to Saudi known nationally as a pioneer in the use he joined the Scottish Home and Health Arabia, where he practised for over 40 of fibreoptic laryngoscopes and published Department in 1964, serving as chief years. He published Arabic For Hospital numerous papers, presenting his work at medical officer of Scotland from 1985 to Staff to help non-Arab medical personnel many national meetings. Once the technique 1988. His wartime experience of evacuation communicate with their Arab patients. became established, his research moved on to Kingussie kindled an abiding interest in Fahim specialised in haemorrhoidectomies to cover aspects of training in difficult airway Scottish history and the roots of the family and worked right until the very last day of management. He developed one of the first in Glencoe. This led him, in retirement, to his life—the Ministry of Health renewed his fibreoptic training courses and taught both undertake research leading to the publication licence year after year. He had his funeral local trainees and those from further afield of several scholarly articles and, in 2005, prayers with his community in Saudi Arabia who were among some of the first “airway a book, Glencoe and Beyond: The Sheep- and was buried back in England, next to fellows.” In retirement he enjoyed spending farming Years 1780-1830 . He leaves Sheila, his wife, who had died in February 2019. time with his family and planning the many his wife of 61 years; two children; and two He leaves four daughters and six holidays they enjoyed together. John leaves grandchildren. grandchildren. his wife, Fang, and a daughter. Angus Macdonald, Morag McQuade Nasima Siddiqui Nicola Osborn , Tina McLeod Cite this as: BMJ 2020;368:m796 Cite this as: BMJ 2020;368:m699 Cite this as: BMJ 2020;368:m700 Joseph Charles Stoddart Charles Arthur Veys Euan Wallace Consultant anaesthetist Chief medical officer General practitioner and intensivist Newcastle Michelin, Stoke-on- Petersfield (b 1938; (b 1932; q Durham 1956; Trent; honorary senior q Cambridge/St Thomas’ MD Newc, FRCA, FRCP research fellow, Primary 1965; MA Camb, MRCP Lond), died after a long Care Research Centre, UK, DObst RCOG), died debilitating illness on Keele University (b 1933; from pancreatic cancer 26 October 2019 Liverpool 1956; OBE, on 20 December 2019 During his military FFOM, MD, MIOH, DPH, Euan David Wallace service Joseph Charles Stoddart (“Joe”) DIH), died after a long battle with progressive combined rigorous scientific principles with was attached to the aviation medicine supranuclear palsy on 30 November 2019 shrewd clinical acumen in all his work, which department at Farnborough, where he came Charles Arthur Veys was born in Antwerp, but included roles as a GP trainer, palliative care under the influence of Edgar Pask, famous for his family moved to Sheffield in 1935. In 1962, physician, and clinical assistant in diabetes the development of survival suits for airmen. he started his career in occupational medicine and dermatology. A colleague described him Joe returned to Newcastle to work with Pask. through postgraduate studies in public and as “never being interested in status, power The massive flu epidemic in 1969 led to a industrial health at Liverpool University. He or money, but five minutes in his company need for dedicated wards and specialists worked at Pilkington glass manufacturers would just make you feel better about life.” for intensive care and Stoddart was at the before moving to the Michelin tyre company Having survived two different cancers, he forefront of this, setting up an excellent in Stoke-on-Trent. He also conducted described himself as a “hardy perennial, the unit in Newcastle’s Royal Victoria Infirmary. epidemiological studies into cancer rates in longest surviving medical wreck around.” With colleagues he developed the specialty the area. In 1979 he joined the new industrial In retirement he enjoyed playing the piano, of intensive care medicine and national and community health research centre, linked choir singing, playing tennis, travelling for training programmes, and wrote a standard to Keele University, as a base for his academic ornithology and photography, but above all textbook. He was an avid bibliophile. In 1956 activities. He leaves his wife, Sally; five he loved walking. Predeceased by his wife, he married Sally; she predeceased him. He children; and 13 grandchildren (including five Jill, and his son, he leaves three daughters leaves four children. now in the medical profession). and seven grandchildren. Anna Batchelor, Alan Craft Peter Croft , Jane Veys , Paul Veys David H Jones Cite this as: BMJ 2020;368:m701 Cite this as: BMJ 2020;368:m703 Cite this as: BMJ 2020;368:m704 the bmj | 4 April 2020 41 OBITUARIES Peter Salama Medical epidemiologist who transformed global eff orts to tackle major disease emergencies

Peter Salama (b 1968; Ebola response to have access. They have to be to executive levels, accumulating q Melbourne University, Australia, More than 11 000 people died in protected from a security point extensive knowledge of how 1993), died from a suspected the Ebola outbreak that wrecked of view. That confl uence is going to meet health needs. He also heart attack on 23 January 2020 economies in Guinea, Liberia, to challenge us more and more.” led research and published and Sierra Leone from 2013 to Salama sought to build up extensively on maternal and Medical epidemiologist Peter 2016. During 2014-15, Salama capacity after a damaging cycle neonatal health, vaccine Salama, a leading fi gure in the led Unicef’s global response of budget cuts and ensure closer preventable diseases, HIV, World Health Organization and to the crisis and developed working with technical experts nutrition, war related mortality Unicef, shook up global eff orts to community based approaches and other partners. and violence, and refugee and tackle major disease emergencies to care and support that helped Rick Brennan, regional emergency health. such as Ebola. He is credited “substantially” to control the emergency director for WHO’s with helping to rebuild WHO’s outbreak, say colleagues. Eastern Mediterranean region, Life and career reputation after experts criticised David Nabarro, professor of says Salama provided “clear Salama’s family had migrated its slow and disorganised global health at Imperial College vision and leadership,” recruited to Australia, his birthplace. response to the Ebola outbreak London, says, “Pete consistently well, and engaged organisation- His mother was a refugee from in west Africa (2013-16). His made the point that establishing wide support to prioritise WHO’s Palestine, and his father an sudden death has shocked the trusted relationships between emergency work. The way a accountant from Egypt. After his global health community. communities and responders is at subsequent Ebola outbreak, in medical studies at Melbourne Jeremy Farrar, director of the the heart of eff ective responses to Democratic Republic of Congo’s University, Salama obtained Wellcome Trust, says Salama’s disease outbreaks.” UN agencies Equateur province in 2018, was a master of public health at infl uence can be found in a more and others were determined to quickly controlled “demonstrated Harvard University, where he was proactive and research based prevent repeat catastrophes. WHO’s strengthened operational a Harkness and Fulbright scholar approach to tackling epidemics. From 2016, Salama, as WHO capacities and improved ability in public policy. He completed His “energy and drive” at WHO executive director for emergency to partner with key agencies,” the Epidemic Intelligence Service were important in supporting the preparedness and response, says Brennan. programme at the US Centers development of an Ebola vaccine led 1000 staff in implementing However, a subsequent Ebola for Disease Control in Atlanta, and its use “as a public health reforms. He said in 2016, “It’s not outbreak in DRC’s North Kivu US, in 2001, and worked as a tool which has had a dramatic just about sending the infectious province, has proved harder medical offi cer with Concern and impact,” says Farrar. disease experts in. They have to defeat. It has claimed more Médecins Sans Frontières. He joined Unicef in 2002 and Salama “embodied supported the design of the everything that is post-Taliban health system in best about WHO and Afghanistan (2002-04). Between the UN—professionalism, 2004 and 2009 he was chief of commitment, and immunisation, principal adviser compassion” for HIV/AIDS, and chief for global health for Unicef in New York. He than 2000 lives and some later became Unicef’s country experts have criticised the global representative in Zimbabwe and health community’s response. Ethiopia (2009-15). From 2015 Whitworth says responders he was Unicef’s regional director have faced a “perfect storm” for the Middle East and North of challenges in a highly Africa, based in Jordan. volatile region with warring WHO’s director general, Tedros militias, diffi cult logistics, and Adhanom Ghebreyesus, says communities distrustful of Salama “embodied everything outside agencies. He says that that is best about WHO and the while the outbreak has not been United Nations—professionalism, eliminated “it’s not been allowed commitment, and compassion.” to expand,” thanks in part to the Salama leaves his wife, benefi ts of vaccination. Annalies Borel, and three sons. Salama worked in many Matt Limb , Croydon countries in Africa, Asia, and the [email protected] Middle East, and at local through Cite this as: BMJ 2020;368:m725 WHO

42 4 April 2020 | the bmj