this week TWINS page 423 • VACCINATING CHILDREN page 424 • BRITISH CYCLING page 427 FRANK HOERMANN/DPA/PA/ALAMY FRANK WHO backs rollout of AstraZeneca vaccine

Doctors have warned of the risks associated On 16 March WHO’s chief scientist, Soumya The World Health Organization with pausing or delaying vaccination Swaminathan, said, “We do not want has urged people not to panic programmes against covid-19, as the people to panic, and we would, for the time amid reports of blood clotting number of European countries that have being, recommend that countries continue disorders in patients receiving the vaccine halted use of the Oxford University and vaccinating with AstraZeneca . . . So far, we AstraZeneca vaccine rose to 16. do not fi nd an association between these Denmark, Norway, Bulgaria, Iceland, events and the vaccine.” France, Germany, Italy, Spain, Portugal, The EMA said there had been 30 reports Slovenia, and Cyprus have suspended all of thromboembolic events among nearly use of the vaccine. Five other countries fi ve million people given the AstraZeneca (Austria, Estonia, Latvia, Lithuania, and vaccine in the European Economic Area. Luxembourg) have paused the use of a AstraZeneca has said 37 blood clots have LATEST ONLINE batch of a million doses of the vaccine. been reported among more than 17 million NHS and social The moves came after reports of people vaccinated in the EU and Britain. care need an extra blood clotting disorders. The Norwegian Five of the cases were deep vein thrombosis, £12bn to get back Medicines Agency said last week it was and 22 were pulmonary embolisms. “This on track after looking into several cases of blood clots is much lower than would be expected to pandemic, says or reduced platelet counts, including at occur naturally in a general population of think tank least one death from a brain haemorrhage. this size and is similar across other licensed Covid-19: Danish authorities also launched a safety covid-19 vaccines,” it said in a statement. Underfunding of review after the death of a recipient, while Phil Bryan, vaccines safety lead at the health workforce Austrian offi cials said a person who had UK Medicines and Healthcare Products left many multiple thrombosis diagnosed after Regulatory Agency, said, “Blood clots can European nations vulnerable, says vaccination had died and another was occur naturally and are not uncommon. commission recovering from pulmonary embolism. “More than 11 million doses of The World Health Organization and the the AstraZeneca vaccine have been Italy reimposes widespread European Medicines Agency have said administered across the UK, and the lockdown as there does not seem to be an increased risk number of blood clots reported after having transmission rate of blood clots with the vaccine and have the vaccine is not greater than the number rises again advised that vaccinations should continue. (Continued on page 424) the bmj | 20 March 2021 421 SEVEN DAYS IN Capsule endoscopies will be trialled in England Miniature cameras in a capsule for patients to swallow are set to be trialled in England to check for colorectal cancer and other bowel disorders such as Crohn’s disease. The imaging technology, known as colon capsule endoscopy, takes two pictures a second as it passes through the body over about 5-8 hours and transmits the images to a data recorder worn on the patient’s waist. Patients can be treated at home with minimal disruption to their day, NHS England said. A group of 11 000 patients in more than 40 areas will receive the cameras initially. Although traditional endoscopies are still being performed, the infection control measures required to make them covid secure mean that they take much longer to do, reducing the number of people who can have them. Ed Seward, a consultant gastroenterologist at University College London Hospital who has been using the technology, said the device is useful for people who don’t want to leave home. Alastair McKinlay, president of the British Society of Gastroenterology, said the cameras may off er a real advantage for patients. “We welcome the opportunity for a proper service evaluation so the limitations and advantages of this technique can be properly assessed,” he said. “This information will put the UK at the forefront of the world in this important new area.”

GASTROLAB/SPL Zosia Kmietowicz , The BMJ Cite this as: BMJ 2021;372:n692

Covid-19 whether a shorter schedule may continued to accelerate. GPs have reaching their full potential and Vaccine is linked to lower be offered if people are unlikely to already been inviting patients will offer solutions to improve household transmission return for the second dose at 12 with underlying conditions such children’s lives and develop A study by Scotland weeks, it said. as diabetes and some forms of tough targets to hold the and the cancer. The NHS texts are part of government and others to of 300 000 healthcare workers EMA recommends J&J a renewed effort to reach people account. employed by the NHS in Scotland vaccine for authorisation who have not been vaccinated, and their households showed The European Medicines giving them a link to arrange a Lung cancer that the rate of SARS-CoV-2 Agency recommended granting jab at a vaccination centre or Screen over 50s who infection in people living with a conditional marketing pharmacy led service. smoke, says US taskforce healthcare workers was at least authorisation for Johnson 30% lower when the worker had & Johnson’s covid vaccine Child health been vaccinated after a single in over 18s. The single dose Launch of “Beveridge dose and at least 54% lower vaccine made by Janssen, the report for children” after the second vaccination. pharmaceutical arm of Johnson England’s new children’s As household members can & Johnson, will be the fourth commissioner, Rachel de also be infected through other vaccine approved in the EU, after Souza (below), announced a people, this 30% relative risk Pfizer-BioNTech, Moderna, and once-in-a-generation review of reduction is an underestimate of Oxford-AstraZeneca. “Authorities the future of childhood, with The US Preventive Services Task the true effect of vaccination on across the European Union will an ambitious call to rebuild Force updated its guidance transmission. have another option to combat childhood after the covid-19 on lung cancer screening to the pandemic and protect the pandemic. The Childhood recommend that people over Prioritise homeless people lives and health of their citizens,” Commission will be inspired 50 with a smoking history of at for vaccine, says JCVI said Emer Cooke, the EMA’s by the ambition of William least 20 pack years should be The Joint Committee on executive director. Beveridge’s pioneering offered an annual scan using low Vaccination and Immunisation 1940s report, which dose computed tomography, advised the UK government to NHS texts vulnerable laid the foundations increasing the number of people prioritise homeless people for the people for vaccination of the postwar social eligible for screening from covid vaccine, including those The NHS sent text security system. The nine million to 15 million. The sleeping rough. It said that local messages to millions commission new guidelines advise against teams should consider offering of clinically vulnerable will identify screening people who stopped vaccines to homeless adults people this week to the smoking at least 15 years ago alongside those in priority group encourage them to get barriers or those who cannot benefit 6 without the need for an NHS a covid vaccination preventing from early detection because number or GP registration. Local as its national children they are unwilling or unable to decisions should be taken on programme from have surgery.

422 20 March 2021 | the bmj SIXTY SECONDS MEDICINE ON . . . TWINS Vaccination AM I SEEING DOUBLE? Novavax vaccine is highly Very probably. The chances of seeing twins effective, results show are higher now than ever. Since the 1980s the The covid-19 vaccine developed twinning rate has risen from 9 to 12 per 1000 deliveries, says a global overview in Human by the US company Novavax is Reproduction. About 1.6 million twins are 96% effective against the original born each year—one in every 42 newborns. variant of SARS-CoV-2 and 86% effective in protecting against the WHAT’S BEHIND THE BUMP? variant B1.1.7 discovered in Kent, Novavax data show its A major reason is the growth in medically the company disclosed. Phase III vaccine is 96% effective against assisted reproduction. The various trial results from a UK based study the original variant of the virus techniques started in wealthier countries showed overall effectiveness in the 1970s and in Asia and Latin America of 90%. Novavax said a smaller are biologically plausible reasons in the 1980s and 90s, reaching more phase IIb trial in South Africa, why smoking may worsen mental NHS prosperous parts of South Asia and Africa where the more transmissible health through neuroadaptations aft er 2000. Another cause is the delay in B1.351 variant is circulating, had arising from chronic smoking, childbearing, since the twinning rate rises CARE with the mother’s age. found an efficacy of 55.4% among leading to frequent nicotine HIV negative trial participants. withdrawal symptoms (e.g. Out of 3200 IS IT IDENTICAL AROUND THE WORLD? anxiety, depression, irritability), NHS patients No, there are clear diff erences. Among 122 Intensive care in which case smoking cessation who said they countries that had data from 1980-85 and Staff will feel covid impact may help to improve rather than increased their 2010-15, the twinning rate increased by for “years to come” worsen mental health.” more than 10% in 83 countries and fell by use of technology more than 10% in seven. North America saw Elective care to access care a bouncing 71% increase, while Europe saw a More than 300 000 wait during the first 58% rise and Asia 31%. over a year for treatment phase of the WHAT ABOUT AFRICA? The number of people in England covid pandemic Good question. Africa has the highest waiting longer than a year for twinning rate, with little change in three planned hospital treatment 83% rated decades. It was 16.5 per 1000 births in has risen to 304 044 during their experience the 1980s and 17.1 in the 2000s. The Seven in 10 intensive care the pandemic, NHS statistics study author, Christiaan Monden of Oxford professionals (70%) will need showed, and the overall reported as positive, but University, says the reason is “the high some form of psychological waiting list is 4.59 million people. number of dizygotic twins [twins from two support because of the A year earlier, in January 2020, 42% said eggs] born there—most likely to be due to pandemic, said the Intensive only 1643 people in England the quality of care genetic diff erences between the African Care Society. It warned that the were waiting more than a year. was worse population and other populations.” psychological trauma of the Tim Mitchell, vice president of [Health HAVE WE REACHED PEAK TWINS? pandemic “continues to be the Royal College of Surgeons of Foundation] It looks like it, especially in high income relentless” and staff must be England, said, “Dealing with this countries. Africa will be one of the main given additional resources and daunting backlog will take time drivers of twins in coming decades, says wellbeing support. Staff had been and sustained investment.” Gilles Pison, study author at the French spread “thinner than ever,” had Museum of Natural History—although seen “more death in the past A s s a u l t the eff ect of lower fertility, older year than they would have in their “Violence against women maternal age, and more medically entire career,” and had had “little is public health problem” assisted reproduction is uncertain. or no break since March 2020.” Physical and sexual violence Pison says, “Advances in IVF make against women should be it more likely than not we will see Smoking treated as a public health fewer twin births as a result of IVF.” Quitting may improve problem, said WHO. It called THAT’S GOOD NEWS, SURELY? mental health, review finds for healthcare workers to be Twin births are now safer than ever, People who stop smoking are not trained in “responding to the but infant mortality among twins likely to experience a long term needs of survivors holistically is still high in some low and middle income worsening in mood and may see and empathetically.” Figures countries, such as in sub-Saharan Africa, mental health improvements, show 30% of women experience where up to 300 000 babies are thought to such as reduced anxiety and violence in their lifetime. lose their twin in the fi rst year of life. depression, a Cochrane review Zosia Kmietowicz , The BMJ found. The authors wrote, “There Cite this as: BMJ 2021;372:n713 Cite this as: BMJ 2021;372:n709

the bmj | 20 March 2021 423 COVID-19

(Continued from page 421) that would have occurred naturally in Vaccine could be rolled out the vaccinated population. “We are working closely with to children by the autumn international counterparts in understanding the safety experience of covid vaccines and on the rapid ome covid-19 vaccines could Boaz Lev, said, “We didn’t see any major side sharing of safety data and reports. be rolled out to children in the eff ects, and even minor [ones] are quite rare. People should still get their covid-19 UK later this year, as early, real This is encouraging.” vaccine when asked to do so.” world reports indicate few adverse Belgium, Poland, Ukraine, and the S events. Trials in children Czech Republic have followed advice In Israel, where 106 vaccine doses have Clinical trials also are currently under way from the UK’s regulators to keep been administered for every 100 adults, to test the Pfi zer, Moderna, and Oxford- vaccinations going. the health ministry recently recommended AstraZeneca vaccines in children. Pfi zer has vaccinating some older children with enrolled more than 2000 children aged 12-15 Data review underlying conditions that make them for a trial that was announced in October. It WHO’s Advisory Committee on vulnerable to the eff ects of the virus, such also expects to run a second trial in children Vaccine Safety and the EMA were both as cystic fi brosis. Some 600 children aged aged 5-11 years. Pfi zer’s chief executive, due to meet to review the available between 12 and 16 have been given the Albert Bourla, told Reuters in March he data on 16 March, as The BMJ went Pfi zer vaccine, and early results have expected younger teens to be eligible for to press. The EMA said it hoped to indicated no serious side eff ects. vaccination in the autumn and primary advise on what action, if any, was The head of Israel’s , school children by the end of the year. recommended after its scientifi c evaluation committee reported on Thursday 18 March. NHS will continue to offer vaccines Stephen Griffi n, associate professor to staff who refuse, says minister at Leeds School of Medicine, said the The NHS will continue to such as ethnic minority moves through the diff erent response of many contact and hold one-to-one communities, which he said priority groups, people countries was disproportionate. meetings with doctors and the government was tackling who might have been “Since many European countries are other staff who haven’t taken through a range of measures, hesitant initially would be experiencing another resurgence of up the off er of a covid vaccine including a media campaign approached again. “We keep infections and yet are lagging behind to tackle any hesitancy, the in many languages, the off er evergreen,” he said. in terms of rollout, the importance vaccines minister said this community champions, and “We’ll constantly return of continuing the vaccination week. outreach with healthcare to make sure we are nudging programmes cannot be overestimated. (below) providers and faith leaders. up those numbers to as high “It should also be noted that told MPs on the Women as possible. If we can get to gestures such as this are bound to fuel and Equalities House of Misinformation where the [Offi ce for National hesitancy, or more extreme antivaccine Commons Committee on 10 He added some hesitancy Statistics] suggests, which is sentiment,” he said. March that, although uptake had also been driven by the 94% of the adult population Paul Hunter, professor in medicine among health staff had been spread of misinformation vaccinated, that’s a great at the University of East Anglia, said, “incredibly high,” with over that the vaccines could aff ect place to be.” “The infection mortality rate in men 90% of those off ered taking fertility, which is “proving to But Zahawi said the high in their mid-40s from covid-19 is of up the vaccine, the NHS was be quite sadly quite potent,” uptake overall was evidence the order 0.1% or about 1000 deaths not resting on its laurels. despite clinical experts that the UK’s messaging per million infections, substantially “If you are looking after a saying there is no evidence strategy had been successful. greater than the risk of cerebral venous vulnerable person it is your for the claims. “We’ve got the “This is the highest uptake, thrombosis. Clearly, this possible professional duty if off ered NHS talking to their staff who I think, in the history of association needs to be investigated, the jab to take the jab,” he haven’t [taken up the off er] vaccine deployment in but we do need to consider the real said. on a one-to-one basis,” he the UK. We already have harm from delays in immunisation Zahawi said. “Some of the evidence very high levels of vaccine campaigns when the incidence of acknowledged that suggests that those 10-15 positivity, I think very much covid is still increasing in several uptake had been lower minute conversations make a because the strategy has European countries.” among some huge diff erence to staff .” been right.” There has been no evidence groups of the Zahawi said that, as the Gareth Iacobucci, The BMJ of serious adverse eff ects from general public, vaccination programme Cite this as: BMJ 2021;372:n702 trials of the vaccine. Elisabeth Mahase, The BMJ If you are looking after a vulnerable person then it is your Cite this as: BMJ 2021;372:n728 professional duty if offered the jab to take the jab Nadhim Zahawi

424 20 March 2021 | the bmj “The more adults we can protect with the MODERNA vaccines the less the vaccination of children announced it would be would matter. However, to achieve as much testing its vaccine in suppression of viral circulation and to get to community immunity which can then 3000 young suppress transmission and evolution of people aged 12-17 new variants, [including children in the vaccination programme] could be justifi ed,” In December Moderna announced it unaff ected by coronavirus and are unlikely she said, adding it was unlikely children would be testing its vaccine in 3000 young to become unwell with the infection, it under 5 would be vaccinated. people aged 12-17. is important to establish the safety and Commenting on what evidence would be , director of the US National immune response to the vaccine in children needed to extend authorisation to children, Institute of Allergy and Infectious Diseases, and young people as some children may Kampmann, a professor of paediatric has said that high school students should be benefi t from vaccination.” infection and immunity, said, “We need to able to get a vaccine in the autumn. exclude side eff ects in children, and we need The Oxford research group is also testing Transmission to show that the vaccines induce a similar its vaccine in children aged 6-17, in a trial Beate Kampmann, director of the London immune profi le as we have seen in the funded by the National Institute for Health School of Hygiene and Tropical Medicine’s already highly protected adults—then the Research and AstraZeneca. Oxford’s chief Vaccine Centre, told The BMJ that, while vaccines could be approved on the ground of investigator, Andrew Pollard, a professor most children were not at risk of severe covid- so called immunobridging.” of paediatric infection and immunity, 19 illness, they may have an important role Elisabeth Mahase, The BMJ said, “While most children are relatively when it comes to transmission. Cite this as: BMJ 2021;372:n723 Check covid status “Government wilfully evaded scrutiny” before emergency Ministers’ failure to share the The report criticised the bowel surgery data behind their decisions government’s engagement during the pandemic is with the committee during Clinicians are being advised to seriously likely to have undermined the inquiry. It said that the consider a patient’s covid-19 infection the response and placed a minister for the Cabinet status when planning emergency bowel “needless strain on public Offi ce, Michael Gove, surgery, as a national audit has found that confi dence,” MPs have said “declined to appear before patients who tested positive for the virus in a damning report. the committee when called Michael Gove “declined had significantly higher mortality rates. The Public Administration and ministers sent in his to appear before the The research, carried out during the and Constitutional Aff airs place were poorly briefed committee when called” first wave of the pandemic, found that Committee emphasised the and unable to answer the patients with covid were 26% more likely importance of publishing the questions put to them.” Committee chair William to die within 30 days of their surgery than data used to justify policy Meanwhile, written Wragg said, “Delays in would have been expected if they did not decisions and accused the responses to the committee’s sharing vital data, and a have covid-19. Even in non-pandemic government of wilfully questions often “failed to reluctance to share detailed times emergency laparotomy is one of evading scrutiny. provide the information data, almost certainly the highest risk operations a patient can requested.” hampered the local response. undergo, with a risk of death almost 10 “Absolute clarity” “This is wilful evasion of This over-centralisation must times greater than from major elective The committee said parliamentary scrutiny,” the not be repeated.” gastrointestinal surgery. ministers must now provide report said. The committee The committee’s Ravi Mahajan, president of the Royal “absolute clarity” on the reminded the government of recommendations included College of Anaesthetists, which led the data underpinning the its “obligation to hold itself that the Cabinet Offi ce research, said, “We cannot ignore the easing of restrictions to “live open to scrutiny and expects must clearly outline serious impact a positive covid test has up to the prime minister’s each recommendation to be responsibilities for on the 30 day mortality rates for patients commitment to ‘data not responded to in full.” decision making before the undergoing the surgery. We call on all dates.’” Coronavirus Act is considered clinicians to seriously consider covid They must also stop “Held to account” for renewal after 25 March. infection status when planning care and “moving the goalposts” The committee said it This should include clear discussing treatment options. It is vital when it comes to lockdown “expects Gove to respond to lines of accountability and everyone is fully informed before making decisions and should this report, clearly outlining state which minister is a decision to undergo a surgery that may outline the range of data his understanding of his own accountable for ensuring have devastating consequences.” and information they would responsibilities, and the ways decisions are based on data. Jacqui Wise , London use to lift current and future in which he should be held to Elisabeth Mahase, The BMJ Cite this as: BMJ 2021;372:n695 lockdowns, the MPs said. account by Parliament.” Cite this as: BMJ 2021;372:n717 the bmj | 20 March 2021 425

Nearly all doctors face a NHS staff’s stress complaint in their career levels rose last year as Nearly all GPs (97%) who responded to a survey from the Medical Defence Union said they had received pandemic took its toll a complaint against them during the course of their career, with slightly lower figures for consultants lmost half (44%) of NHS provided equal opportunities, (88%) and trainees (71%). staff in England have compared with 87% of white staff . The survey, conducted in December, was sent to reported feeling unwell Although only 13% of staff reported 32 000 MDU members and received 741 responses because of work related experiencing discrimination at work, (a 2.32% response rate), including 296 from GPs, stress, the highest rate ethnic background continued to be the 274 from consultants, and 59 from trainees. The main A recorded in the past fi ve years, the most common reason given and was findings were: latest NHS Staff Survey has shown. mentioned by 48% of staff who said • About half of complaints were made within the past And around a third of staff said they they had experienced discrimination. five years were considering quitting their job, However, more positive results were • The most common complaints (46%) about while a fi fth indicated they may leave that a third of staff (33%) said their GPs were related to an alleged delayed or missed the health service completely. trust took positive action on health diagnosis The NHS Staff Survey 2020 received and wellbeing, up from 29.3% in • The most common complaints (30%) about 595 270 responses (a 47% response 2019, and 60% believed they had consultants were related to alleged treatment rate) from staff at 280 organisations adequate materials, supplies, and complications, while most complaints against in England, between last September equipment to do their work, up from trainees (43%) related to an alleged breakdown in and December. The survey has been 56% the previous year. Most staff communication carried out annually since 2003. (82%) were satisfi ed with the quality • Of the complaints against GPs, 40% were resolved Results showed that 44% of all staff of care they gave patients, up slightly locally within the individual’s own clinical team. (and 40% of doctors) reported being from 81% in 2019. Among consultants 55% of complaints were ill because of work related stress—a resolved at senior management level, while 45% marked increase from previous years, Considering quitting were resolved within the individual’s own clinical such as in 2019 (40% of all staff ) and Despite these fi ndings, the proportion team. Most complaints (66%) against trainees were 2016 (37%). of staff who said they were considering resolved within the clinical team Around a third of staff (34%) had leaving their organisation was 34%, • GPs were most likely to say that the complaint had an worked on a covid-19 specifi c ward or although this has fallen slightly from impact on their professional (70%) or personal lives area at some time last year, and half of 36% in 2019. Similarly, the proportion (65%), although about half of all doctors said their those (50%) reported feeling unwell as of staff considering leaving the NHS lives were affected in some way. a result of work related stress. altogether was 18%, down slightly Other worrying results included from 20% in the 2019 survey. Zosia Kmietowicz , The BMJ that only 69% of ethnic minority staff Rob Harwood, chair of the BMA’s Cite this as: BMJ 2021;372:n707 who reported that their organisation Consultants Committee, said the Fast track research approval is “here to stay,” says HRA

The UK research regulator has urgent public health studies Tizzard said time was gained committees can’t be done via said it wants to sustain “in identified by the chief medical through virtual working, a rota algorithms; they need dialogue peacetime” the fast track methods officer and delivered by the of volunteers who sit on ethics and conversation, so we need to it developed for reviewing studies National Institute for Health committees, and unusual ways find ways of supporting people during the covid-19 pandemic. Research within 24 hours of of working such as ad hoc and giving them a sense of At the height of the pandemic submission as well as fast committees and working out of community.” the Health Research Authority review for other types of clinical hours. “And, of course, there was cut around 90% off its approval trials—vaccines, therapeutics, a sense of urgency and national Ethics review timeline. Speaking last week, diagnostics—within 36 hours at focus on something we all wanted The HRA is piloting an ethics Juliet Tizzard, its director of the height of pandemic research to address quickly,” she added. review process that reduces policy and partnership, said that response,” she said. “We want to maintain speed review time for clinical trials and around 700 covid-19 studies of review for new research; we phase I studies by about 50%. were reviewed in total over the now know prioritisation and The pilot, looking at 25 studies, past year, half of these within 36 fast tracking works. But we will be evaluated next month. hours and some within 24 hours. need to find a way of sustaining Martin Landray, professor “We provided a fast track this in peacetime. These are of medicine and epidemiology

review service, prioritising the ANDREW MILLIGAN/PA people centred activities. Ethics at the University of Oxford and

426 20 March 2021 | the bmj Former British Cycling doctor ordered banned testosterone gel for athlete, tribunal finds

The former chief doctor for British Cycling and Team Sky, Richard Freeman, ordered banned testosterone “knowing or believing it was to be administered to an athlete to improve their athletic performance,” a medical practitioners tribunal has concluded. GO NAKAMURA/GETTY Freeman was charged with ordering 30 sachets of the testosterone gel fi ndings underlined the intense The 44% of Testogel for an unnamed athlete in 2011. The gel is on the World Anti- pressure staff had been under in the staff who Doping Agency’s list of banned substances and methods. past year. “As vast swathes of the reported being He admitted 18 of 22 charges against him, including destroying a laptop country stayed at home, healthcare ill because of with a screwdriver or blunt instrument before giving it to forensic experts workers continued to go to work,” he work related who were conducting a doping investigation, but he denied the main said. “Not only were many coming stress is a charge of buying testosterone to improve performance. face to face with a deadly virus, often Freeman, a former GP, insisted in an without adequate protection, but stark yet interview with UK Anti-Doping in 2017 a large proportion were working in unsurprising that the Testogel had been ordered for FREEMAN unfamiliar environments as they figure a non-athlete, later confi rming that it was charged with agreed to be redeployed to other roles. Rob Harwood was for the head coach, Shane Sutton. “That 44% reported being ill because He gave evidence at the tribunal that he ordering 30 sachets of work related stress is a stark yet had obtained it for Sutton for erectile of the testosterone unsurprising fi gure, given all that they dysfunction, claiming that he had been gel Testogel for an have been through. They have dealt bullied by Sutton, but Sutton denied that unnamed athlete in 2011 with death and illness on a scale the he had needed or received it. NHS was completely unprepared for, The tribunal found Sutton’s behaviour while giving evidence which tragically far too often included “intemperate” but decided that he was a “credible and consistent witness.” their own friends and colleagues.” Freeman’s evidence, on the other hand, was “implausible” and his story an Adrian O’Dowd, London “elaborate falsehood,” said the tribunal chair, Neil Dalton. Cite this as: BMJ 2021;372:n703 Dalton outlined several points in Freeman’s evidence where the tribunal considered that he had lied. The chair added, “The tribunal found that Dr The survey showed that 44% of all staff (and 40% of Freeman’s account of having ordered the Testogel for Mr Sutton required it to believe too many implausible, unsupported assertions, as well as having doctors) reported being ill because of work related stress—a to overlook further falsehoods, on the back of those Dr Freeman had marked increase from previous years, such as in 2019 already admitted.” (40% of all staff) and 2016 (37%) Freeman had already admitted a number of allegations regarding treating staff members without access to their medical records instead of referring them to their GPs, failing to inform GPs of medication prescribed, and failing to maintain an adequate record management system. joint chief investigator for the lead to slower decisions. Recovery trial, backed the The past 12 months have Fitness to practise moves to maintain pace in the shown just what can be The case will go back to the tribunal on 17 March for a decision on approvals process. He said possible. We do, though, whether Freeman’s fi tness to practise is impaired. The tribunal will sit the HRA, particularly its ethics need to systematise and again in May to decide the sanction to be imposed. review, had been “careful, professionalise (with a small John Etherington, president of the Faculty of Sport and Exercise considered, but rapid” over and large ‘p’). Much of what Medicine, said it would review Freeman’s fellowship at the next the past 12 months. has happened over the past opportunity. He added, “The evidence presented has revealed a He said, “As we start year has happened because working culture within the sport that is not in keeping with to turn our attention to a a relatively small number good medical practice. The environment described at the somewhat more peaceful of people have worked tribunal does not refl ect the high professional standards that time, there are definite exceptionally hard—that’s not we as sport and exercise physicians adhere to. lessons to learn. Delay and sustainable for the individuals “There are lessons to be learnt from this incident. The ‘win excessive deliberation do not or the enterprise.” at all costs’ mentality revealed can and must be challenged. necessarily result in better Rebecca Coombes, The BMJ Many sporting bodies have already made the changes decisions, but they certainly Cite this as: BMJ 2021;372:n705 needed to safeguard both medical professionals and the athletes they support.” We’ve seen that delay and excessive deliberation do not Clare Dyer , The BMJ necessarily result in better decisions Martin Landray Cite this as: BMJ 2021;372:n711 the bmj | 20 March 2021 427 428 20 March 2021 | the bmj the Alison Shepherd , some of theworld’s richest nations at thetop of the vaccination table. distributing Since thebeginningof year Santiag world’s vaccination league Chile joins top five in the Chile just behind Israel, theUAE, and theUK interms of jabs delivered. June. This week around 25%had received at least onedose,putting government’s ambitious goal is to vaccinate 80%of its populationby enough to fully vaccinate more than double its 19million people.The was given to in thecountry. Johnson &Johnson, Sinovac, and CanSino to hold phase IIItrials with companies developing vaccines. It voters at its angry pandemic response, held early price negotiations realising that aneff infections. More than 20 000 Chileans have died from covid-19. Santiago. Thec aft THE BIGPICTURE er thestart of adrive to vaccinate all care homeresidents (top) in To date thecountry The stra Its biggest order is for 66million doses from Sinovac, oneof which bmj

| 20 March 2021 tegy wasdev tegy millions of President Sebasti Te BMJ The ity has ective programme could win back support from Cite this as:

has or been hitby eloped last covid-19 vaccine dered over 88 million BMJ án Piñera (right), inFebruary just days 2021;372:n718 2021;372:n718 summer, whenthegovernment, more thanathird of also invited AstraZeneca, o airport inChi o airport s as the country the country doses of vaccine, le has Chile’s 812 344 has j been busy oined 429

IVAN ALVARADO/REUTERS/ALAMY EDITORIAL Alcohol deaths rise sharply in England and Wales A spike is concerning but we mustn’t lose sight of longer term trends across the UK

rovisional data for received international praise England and Wales from for consistently implementing, the Offi ce for National evaluating, and updating evidence Statistics (ONS) show a based alcohol policies within a clear P sharp increase in deaths public health framework.12 Public from alcohol specifi c causes between debate has focused on minimum unit April and September 2020. 1 The pricing, but major policy changes fi gures add to concerns that the wider around alcohol licensing, early health and wellbeing consequences intervention, treatment provision, of the covid-19 pandemic include drink-driving, and retail practices in an increase in alcohol related harm, Scotland amount to a systemic change although the reasons behind this rise Changes in One plausible explanation is that of the kind argued to be necessary to are unclear. both people’s desire or ability to access achieve lasting health gains. News media have highlighted drinking specialist alcohol treatment services The Welsh government has large increases in alcohol sales in and service or healthcare more generally may sought to follow the Scottish model, the UK during the pandemic, but provision may have been aff ected by the pandemic, despite its more limited powers, and these typically relate only to shop leading to worse outcomes for at-risk introduced minimum unit pricing in have affected bought alcohol and do not account for groups. Overall, changes in both 2020. In contrast, proposed changes similarly large reductions in drinking alcohol deaths drinking and service provision may to alcohol policy in Northern Ireland in pubs and restaurants.2 Analyses have aff ected alcohol deaths. stalled when the power sharing that include all alcohol sales suggest government collapsed in 2017 and smaller changes.3 Shifting patterns have not been revived. This is despite Small changes in consumption at Alongside provisional data for 2020, the alcohol specifi c death rate in the population level may, however, the ONS released its annual update Northern Ireland rising by 54% since mask large increases in higher risk on alcohol specifi c deaths, including 2013, surpassing that of Scotland for groups. Surveys consistently fi nd that fi nal data for 2019.10 Two details merit the fi rst time in 2019. 10 15-30% of drinkers report consuming discussion. It is the UK government, though, more during the pandemic than First, the recent steep decline that attracts greatest scrutiny. Its previously, with many studies also in youth drinking in the UK and fl agship green paper Advancing fi nding that a similar proportion report other high income countries is our Health: Prevention in the 2020s drinking less.4 - 8 Moreover, people at now translating into reduced adult includes only one specifi c alcohol higher risk of alcohol related harm— mortality, 11 with a 22% drop in the policy for England: to increase the such as those already drinking heavily, alcohol specifi c death rate among availability of low alcohol and no in lower socioeconomic groups, or 30-34 year olds between 2001 and alcohol drinks.13 Another important with worse mental health 4 - 7 —were 2019. In contrast, the rate increased policy process has attracted less over-represented among those by between 23% and 49% for the attention. The government recently who had increased their drinking, age groups from 55 to 84 years. The consulted on options for reforming bolstering arguments that rises in sharp decline in youth drinking is the alcohol taxation system, which consumption explain the spike in good news that may yield major public is riddled with inconsistencies and alcohol specifi c deaths. health benefi ts in decades to come, but inequities that benefi t neither public This is not, however, an open and the ongoing failure to tackle heavier health nor the exchequer.14 Leaving shut case. Many of these surveys rely drinking in older generations means the European Union aff ords greater on self-selecting samples, use weak that overall levels of alcohol related freedom to reform alcohol tax rules, measurements, or changed their mortality and morbidity may get worse and the damage to public fi nances by survey methods during the pandemic. before they get better. the pandemic creates an incentive to John Holmes, Furthermore, despite evidence of Second, the remarkable decline do so. The next public health debate professor of alcohol similar changes in consumption across in Scotland’s alcohol specifi c around alcohol in the UK may therefore 3 policy Great Britain, provisional data from john.holmes@ death rate continues. In 2005, the focus on tax reforms rather than the Scotland do not replicate the increase sheffield.ac.uk age standardised rate in Scotland pandemic’s eff ects on alcohol harms or 9 in alcohol deaths seen in England. Colin Angus, senior was more than double that of the the government’s green paper. These inconsistencies suggest a need research fellow, other three UK nations, but it has Cite this as: BMJ 2021;372:n607 to consider other explanations for any University of since fallen by 35%. The Scottish Find the full version with references at increase in deaths. Sheffield government and its partners have http://dx.doi.org/10.1136/bmj.n607

430 20 March 2021 | the bmj EDITORIAL The deteriorating mental health of children Pandemic eff ects are clearest among families already struggling

any peer reviewed to increase the numbers of families Known triggers by pandemic restrictions, including and non-peer under fi nancial strain.1 10 for self-harm separation from friends, arguments reviewed studies Deteriorating mental health is and poor with parents, unresolvable report fl uctuating by no means uniform. A sizeable mental health arguments on social media, strained M mental health and proportion of 19 000 8-18 year olds are aggravated fi nances, academic stress, and suicide risk during the pandemic, from 237 English schools surveyed feelings of isolation. School closures but few focus on children and during early summer 2020 reported by pandemic are particularly diffi cult for families young people under the age of 18.1 feeling happier.13 Similarly, a quarter restrictions facing other adversities. 12 - 25 Interpretation of those that do is of young people in the MHCYP survey The evolving consequences diffi cult because of diff erences in reported that lockdown had made of the pandemic are set against methodology and underlying trends their life better.1 longstanding concerns about in the prevalence of mental health deteriorating mental health among conditions.2 3 Suicide and self harm children and young people, and the The mental health of the UK’s Early data from England’s National inadequacy of service provision. children and young people was Child Mortality Database for 23 Although children are at lowest risk deteriorating before the pandemic. March to 17 May 2020 raised of death from covid-19, concerning Between 2004 and 2017 anxiety, concerns about suicides among signals remain about the pandemic’s depression, and self-harm increased, young people aged under 18 years eff ects on their mental health, particularly among teenage girls. 7 during the fi rst lockdown, 16 although which are unevenly experienced Self-harm is an important risk factor numbers were too small (25 deaths) across diff erent age groups and for suicide, so it is not surprising to be defi nitive. socioeconomic circumstances.24 25 that rates of suicide among the UK’s A more reassuring picture emerged The long term eff ects also remain children and young people also from Japan, where suicide rates in uncertain. What we do know is that increased,8 though numbers remain children under 20 years seemed Tamsin Ford, education has been disrupted and low—fewer than 100 people aged unchanged up to May 2020.17 professor of child many young people now face an under 18 died by suicide each year in Although the English database and adolescent uncertain future. 24 25 Policy makers England between 2014 and 2016. 9 shows the incidence of child suicide psychiatry , University must recognise the importance of Studies carried out during the has returned to pre-pandemic of Cambridge education to social and mental health tjf52@medschl. pandemic suggest that, although levels (www.ncmd.info/ , personal cam.ac.uk outcomes alongside an appropriate some families are coping well, communication), more recent data focus on employment and economic Ann John, professor others are facing fi nancial adversity, from Japan fl ag a concerning rise in prospects. As “children are the living of public health and struggling to home school, and children and adolescents during the psychiatry, Swansea message we send to a time we will not 26 risk experiencing vicious cycles of second wave and resulting school University see,” we urgently need to improve 1-11 18 increasing distress. Probable closures. David Gunnell , our eff orts to meet their needs. mental health conditions increased The incidence of self-harm professor of Cite this as: BMJ 2021;372:n614 from 10.8% in 2017 to 16% in July recorded in primary care was epidemiology, Find the full version with references at 2020 across all age, sex, and ethnic substantially lower than expected University of Bristol http://dx.doi.org/10.1136/bmj. n614 groups according to England’s Mental for 10-17 year olds in April 2020 Health of Children and Young People but returned to pre-pandemic Survey (MHCYP).12 levels by September 2020. 19 A probability based sample of 2673 Similar patterns were detected parents reported deteriorating mental for all mental health referrals in health and increased behavioural England,20 with reductions in problems among children aged 4 to urgent psychiatric presentations 11 years between March and May reported across Europe, 21 2020 (during lockdown) but reduced suggesting possible unmet need. emotional symptoms among 11-16 The national referral statistics for year olds.11 eating disorders in England show The more socioeconomically a doubling in the number of urgent deprived respondents had referrals during 2020 and a smaller consistently worse mental health in increase in non-urgent referrals.22 both surveys— a stark warning given Known triggers for self-harm and that economic recession is expected poor mental health are aggravated the bmj | 20 March 2021 431 BRIEFING What we know about mass lateral flow testing in schools Ingrid Torjesen reports on the questions and concerns over a key plank of the strategy to keep pupils and staff in their classrooms

How is testing being implemented After that they will be tested every three to in secondary schools? fi ve days. Twice weekly self-testing is probably the maximum frequency needed for “active P upils across England, who began to return management,” says Tim Peto, professor of to school on 8 March, must wear face medicine at the University of Oxford, who coverings in class and get to grips with self- has led assessments of the tests for the testing for covid-19 using rapid lateral fl ow government. OLI SCARF/GETTYIMAGES (LFT) devices. “Once a week is better than once a their rates, but also because samples can be LFTs are not as sensitive as polymerase fortnight, and twice a week better than once sequenced to pick up and track variants. The chain reaction (PCR) but they are relatively a week,” he says, adding that there is little World Health Organization recommends the cheap, provide results in less than 30 benefi t to doing it any more frequently. “The practice in low prevalence settings because minutes, and are capable of identifying those more often you do it after twice a week you the “rate of false positives compared to true with the highest viral loads, and therefore get really a very small pick-up rate and it’s positive results will be high.” considered to be the most infectious. School probably not worth it.” Up until 27 January, confi rmatory PCR testing uses the Innova test, although the testing was available for positive LFTs taken Department of Health and Social Care says What happens if a result is positive? under supervision at sites in England. The that other brands might be used in the future. DHSC says this was suspended because Execution of the programme is mixed. Anyone who tests positive must follow the of the “high prevalence of coronavirus Some schools asked pupils to attend for government coronavirus infection guidelines infections” and advice from Public Health testing the week before they reopened, and immediately isolate for 10 days with England (PHE) that “the performance of so pupils could go straight into their other members of their household, as lateral fl ow devices and PCRs are broadly classrooms. Others staggered the return of must anyone deemed to be a close contact comparable for infectivity and expected to be pupils over the week. according to government defi nitions. This indistinguishable when used at test sites.” Pupils taking their fi rst tests were potentially includes a pupil’s classmates, supervised in schools to familiarise but not the entire year group. The DfE says What happens if the confirmatory themselves with the swabbing process, and the school should determine who is a close PCR test is negative? then, like staff , will receive two kits a week to contact, based on its environment and social self-test at home. All self-test results must be distancing arrangements. Again, it depends on where the test was reported to NHS Test and Trace, either online Other members of contacts’ households do done. If it was taken at home, the PCR result or by telephone, and shared with the school to not have to self-isolate, so siblings can still “overrides the lateral fl ow test” and pupils help with contact tracing. attend school. can return to school, says the DfE. But if Testing is voluntary but strongly the test was taken at school, the LFT result encouraged. Children who did not give Should a positive LFT result be stands and the child, their family, and their consent were still supposed to return to confirmed by a PCR test? classmates must self-isolate. The department face-to-face learning, but there have says that this is because there is “minimal” been reports of schools banning them This depends on where the test was taken. chance of an incorrect LFT result if the test is from face-to face lessons, eff ectively The DfE says that when an LFT has been taken done under supervision. “blackmailing” parents to consent. under supervision, at tests sites or at school, This rule has sparked an angry reaction “the chance of it being incorrect is minimal so from parents. Rachel Clarke, a palliative care How frequently are pupils tested? there is no need for a further test to confi rm doctor in Oxford, reported that, at her son’s the result.” But there is a “slightly higher school, 30 pupils were told to self-isolate for Most pupils will take three tests at school chance” of a positive result being wrong if the 10 days after one LFT came back positive before beginning home testing, but some test was taken at home, so those should be but a subsequent PCR test was negative. schools might choose to do two or four, a confi rmed by a PCR. Clarke described the policy as “unscientifi c Department for Education (DfE) spokesperson Confi rmatory PCR is important not only madness.” “Just because an LFT was taken told The BMJ. “It is about [schools] putting for identifying false positives and tracking at school, not home, it doesn’t mean it’s the time into making sure the students have confi dence in how testing works before they TTherehere havehave beenbeen reportsreports ofof schoolsschools banningbanning fromfrom face-toface-to faceface start to do it at home.” llessonsessons ppupilsupils whowho havehave notnot ggiveniven cconsentonsent ttoo bbee ttestedested

432 20 March 2021 | the bmj PAUL ELLIS/GETTYIMAGES PAUL FFromrom thethe 1.51.5 millionmillion asymptomaticasymptomatic secondarysecondary ppupilsupils whowho werewere screenedscreened When will testing in schools stop ? iinn theirtheir firstfirst weekweek back,back, mmoreore tthanhan 660000 ppoositivesitive rresultsesults aarere eexpectedxpected The DHSC says: “The use of [lateral fl ow] more reliable than PCR,” she tweeted at the 300 of these would be negative on PCR. The testing remains under constant review, and education secretary, Gavin Williamson. reality could be worse, says Deeks, as LFT any changes in approach will be guided by Furthermore, a March analysis of the positivity rates in schools (as reported by Test the science.” Innova LFT concluded a confi rmatory PCR and Trace) have never been above 0.37%, test was not needed. Jon Deeks, who leads —about a quarter of the rates seen in adults. What happens to the data? the biostatistics, evidence synthesis, and test Most recently they have been only 0.05%. evaluation research group at the University This indicates that performance of LFTs “may Testing data are updated daily on the UK of Birmingham’s Institute of Applied Health be compromised in teenagers,” and “far more Coronavirus Dashboard, and a breakdown Research, called this conclusion “bizarre.” false positives than true positives” would of rapid asymptomatic tests (including A confi rmatory PCR would add little cost be expected among teenagers in schools, in education settings) is published in and most likely reduce false positives to one he says. Deeks points out that knowing the the weekly NHS Test and Trace statistics in a million, he says, while providing much false positive rate alone cannot answer the reports. These data will be analysed by needed evidence on the performance of LFTs question of how many of the test positives are PHE and discussed at the cross government in children, for which there are currently no false—this depends on how rare true positives weekly programme board, which includes data at all. are as well. representatives from the DHSC, NHS Test and Trace, and the DfE. What proportion of positive LFT Why is there a lower rate of results are likely to be false? positive LFT results from schools? How much has the programme cost?

In short, this is not known. A 2020 analysis The “implausibly low positivity rates” might We know the government is spending by PHE and Oxford University, led by Peto, be caused by poor technique or “people £100bn on mass testing through its estimated the specifi city of the Innova LFT at hiding or not reporting results they don’t programme, but how 99.68%. A more recent analysis, published want to report,” speculates Mike Gill, former much of this will go on school testing is in March and using data from the test in regional director of public health for the unclear. Schools have fl exibility when using active use by NHS Test and Trace, estimated South East of England. He thinks the reasons the extra funding they have received to cover a specifi city of 99.97%. This is based on for low rates should have been investigated the cost of the tests: some have brought in data collected when prevalence of infection before the programme was rolled out to the private sector providers, whereas others have was high (8.7%). Deeks says that at a lower entire school population. paid bonuses to staff to run the programme, prevalence (0.5%), around half of positive He fears being told to self-isolate for a false for example. tests would be false positives, “which would positive risks putting parents off consenting to indicate that half of the children, teachers, the tests altogether. Is the programme value for money? families, and their bubbles being asked to isolate this week are doing so unnecessarily.” Are any pupils exempt from testing? If each test costs around £10-20 to deliver, Over 1.5 million asymptomatic secondary and only one in 1500 comes back positive, pupils will have been screened in their fi rst Asked to clarify the situation, the DHSC says that would amount to £15 000-£30 000 to week back and more than 600 positive results that people testing positive by PCR are exempt detect one case, which might then be a false are expected. Sheila Bird, former programme from routine re-testing with either PCR or positive. leader at the MRC Biostatistics Unit at lateral fl ow device tests for 90 days unless Ingrid Torjesen, freelance journalist, London Cambridge University, estimates around they develop new covid-19 symptoms. Cite this as: BMJ 2021;372:n706 the bmj | 20 March 2021 433 PUBLIC HEALTH Covid has made the obesity epidemic worse, so why has it not provoked more action? The evidence is clear that a BMI of over 30 is a risk factor for severe disease and death from covid-19, but, as Meera Senthilingam reports, little is being to done to mitigate this other public health emergency

Before the tudies in the US have population is obese. And, as the world pandemic, shown that having a BMI becomes optimistic about vaccines around over 30—the threshold that helping us return to some form of 2.8 million defi nes obesity—increases normality, a preprint published in the risk of being admitted February reports that obesity might people S to hospital with covid-19 by 113%, correlate with a lower immune worldwide died of being admitted to intensive care response to the Pfi zer/BioNtech covid- each year from by 74%, and of dying by 48%. Public 19 vaccine, although the study was conditions Health England reported similar small and is yet to be peer reviewed. that stem numbers for mortality, with the risk These worrying developments have from being of death from covid-19 increasing by brought much needed attention to the overweight 90% in people with a BMI over 40. world’s obesity epidemic. This is irrespective of age, as being “The fact it’s chronic is the issue,” overweight or obese is associated says Steve Gortmaker, professor with worse outcomes in younger of the practice of health sociology and the taxation of products such as populations as well. People under at the Harvard TH Chan School of sugary drinks have had some eff ect: 60 years old with a BMI between Public Health. “Nowadays health in Mexico there was a 6.8% decrease 30 and 34 are twice as likely to be services are just asking people to in the chances of people consuming admitted to intensive care with covid- maintain their weight, not even lose medium to high volumes of sugary 19 than those with a lower BMI. it.” Gortmaker fi rst published about drinks just three years after a sugar A report from the World Obesity the US obesity burden in 1987. More tax was implemented in 2014. Yet Federation published on 4 March than two decades of government obesity rates remain high with one in showed further trends, emphasising programmes have had some impact, three adults and one in 10 children that death rates from covid-19 have but far from enough. being obese in 2018. been 10 times higher in countries Before the pandemic, around Pacifi c Island governments where more than half of the 2.8 million people worldwide died implemented the “Healthy Island” each year from conditions that stem vision over 20 years ago to tackle from being overweight, including many aspects of health, including heart disease, stroke, and diabetes. obesity, by targeting school meals Now covid-19 is added to the list. and education around healthy But are countries doing more to eating, as well as improving trade tackle this burden? Many experts say deals to increase the quality and no—or at least not as much as one variety of food entering the islands. might expect. But the region continues to have the highest obesity rates in the Two decades of world—over 55% of the population slow progress of Samoa is obese according to the World Obesity Federation. Countries with the greatest obesity Now Mexico has recorded one of burdens, such as the US, Mexico, the highest case counts of covid-19 in PACIFIC ISLANDS have and most of the Pacifi c Islands, have the world. The US, where obesity rates the world’s highest obesity rates —over been trying to tackle the problem are also notably high, has the highest for decades. Programmes focused number of covid infections and deaths 55% of the population of Samoa is obese on improving school meals, healthy in the world, and the UK, which has according to the World Obesity Federation eating and active lifestyle campaigns, the highest obesity rates in Europe,

434 20 March 2021 | the bmj AUSAID/ALAMY has a disproportionate covid death package labelling regulations on Pacific Island in the most deprived areas are rate compared with other countries. unhealthy foods to help people governments have now more than twice as likely to This should be a wake-up call to improve their diets. Some of its launched healthy be obese than those in the least tackle the obesity burden, and some states have also banned sales of junk eating campaigns deprived areas, and the gap is countries were motivated to act in food to children, and others have widening,” says Marriott. “When 2020. The Department of Health and removed salt shakers from tables in the government asks individuals to Social Care for England announced restaurants in a bid to reduce salt change their behaviour we see some a new strategy in July, emphasising being added to meals. India’s Food benefi t for the better off , while the the increased risks associated with Safety and Standards Authority Children in the worse off —whose environment and covid-19. “Excess weight is one of the has banned the sale and marketing most deprived circumstances can make lifestyle few modifi able factors for covid-19 of unhealthy foods (high in fat or areas are more change far harder to achieve—are and so supporting people to achieve sugar) in school canteens or other than twice as typically left ever further behind.” a healthier weight will be crucial to educational institutions, as well This trend can be seen in low and likely to be keeping people fi t and well as we as the sale of such foods within 50 middle income countries in recent move forward,” the strategy states. metres of school gates. obese than years, where obesity rates have risen It outlines seven measures to target But some experts think the eff orts those in the as unhealthy foods have become obesity, including the expansion don’t get to the core of the problem. least deprived more available and aff ordable. of weight management services Christina Marriott, chief executive of areas, and the “You can spend a few dollars and available through the NHS, legislation the Royal Society of Public Health, gap is widening eat a few hundred calories in a few requiring food businesses to add said of the UK strategy, “It does not Christina Marriott minutes,” says Gortmaker. “And food calorie labelling to their foods, and a outline how the root causes of obesity ban on the advertising of foods high in will be addressed. Without this, it is fat, salt, or sugar on television before diffi cult to see how we can disrupt our 9 pm. In December, the strategy added current trajectory.” restrictions on promoting unhealthy foods at checkouts, entrances, and Where the power lies the ends of aisles in supermarkets and other food stores, stating that That root cause, Marriot says, is “location promotions often lead to poverty and inequity, which have ‘pester power’ from children.” also magnifi ed the eff ects of covid Mexico has introduced front of in some populations. “Children the bmj | 20 March 2021 435 marketing encourages us to eat every campaign manager for NCD Alliance. moment of the day.” “The way the industries are supported Truly tackling obesity also means and encouraged is worrying . . . there reducing the power of the food needs to be a signifi cant rethink about and beverage industry in opposing where the power lies.” legislation that aff ects them. Marriott says that eff orts to tackle Gortmaker says that such changes obesity “must be supported by a remain politically diffi cult owing government unafraid to robustly stand to the power of the industry, with up to industry” to implement eff ective measures such as taxation or bans on interventions, such as taxes. The advertising mostly introduced at the sugar tax introduced on soft drinks state level in the US as a result. in the UK in 2016 led to a 28.8% fall Covid Mexican secretary of health, at the The industry’s grip has only in the sugar content of drinks from its lockdowns World Health Assembly in May. tightened during the pandemic. A announcement to implementation, have led to In the Pacifi c Islands, experts say report from the NCD Alliance (a civil yet the new strategy has omitted such people cooking the pandemic response has helped society network aiming to control measures on other unhealthy foods. make the population healthier. at home more, and prevent non-communicable It also missed the opportunity to Dyxon Hansell, health adviser for the diseases) published in September focus on making healthy foods more resulting in World Health Organization’s Samoa listed hundreds of ways the food and aff ordable, Marriot says. healthier offi ce, told The BMJ that lockdowns drink industry has used the pandemic meals have led to people cooking at home to promote its products and capitalise A window for change Dyxon Hansell more, resulting in healthier meals. on the situation—particularly alcohol, Some island governments are also sugary drinks, and ultra processed Yet Westerman thinks that the off ering free online training on how food. This includes food packs and pandemic has opened a window for to provide healthy food and drink in contributions that contain unhealthy new policies. “Covid-19 has been schools; healthy diets and recipes products and promote brands, the wrecking ball, revealing how for home preparation; and online such as Heineken Russia, which interconnected health conditions ordering of healthy food for delivery. donated meals to health workers and the determinants of them are,” With people being at home more, alongside its energy drink, and she says. She thinks that authorities they are also being encouraged to FEMSA, which distributed unhealthy are now realising that if they grow more of their own food. snacks and sugary drinks in deprived continue to neglect chronic disease These are steps in the right neighbourhoods in Mexico. Many fast prevention, they risk undermining There was a 6.8% direction, but they are far from food chains also off ered free meals or the health security of their fall in the chances being a quick fi x. Experts think products to health workers, the report populations in the future. of people in that truly tackling obesity requires states. The BMJ contacted Heineken “There hasn’t been a better Mexico consuming a multifactorial approach across and FEMSA for comment, but neither opportunity in history to increase high volumes of governments, including agriculture company responded. our eff orts to ensure good nutrition sugary drinks and transport departments as well as after a sugar tax “There are so many powerful and assume environmental health as was introduced in health. Ultimately, Gortmaker thinks economic interests at stake,” an indivisible determinant of human 2014, but obesity that obesity needs attention from says Lucy Westerman, policy and health,” said Jorge Alcocer Varela, rates remain high the top, not just state or local health departments. “So far, it’s just not received that kind of attention,” he says, and when it does “somebody comes in, starts up a programme and then leaves.” But this has long been the case, and if a global pandemic that has killed hundreds of thousands of people with obesity—and led to hospital admissions for many more—doesn’t galvanise enough action, what will? “We just can’t miss this moment,” says Westerman. “It’s an opportunity for governments to make something slightly better out of a really horrible situation.” Meera Senthilingam, freelance journalist , London [email protected] BMJ JEFF GREENBERG/GETTYIMAGES Cite this as: 2021;372:n411

436 20 March 2021 | the bmj