The myth of John Snow and the long shadow of nineteenth century public health

Public health is a historically conscious discipline.  History figures centrally in many module’s introductory lectures taught as part of the MSc in Public Health at the LSHTM.  There is a dedicated History and Health Module available to students studying in London and at a distance.  The history of public health, as any member of the Centre for History in Public Health can tell you, is a diverse and exciting topic.  And yet, despite our best efforts to expand and enrich our understanding of public health in the past, there are certain stories, myths even, about the history of public health that tend to dominate wider conceptions of public health history.

The most prevalent of these surrounds John Snow and the Broad Street pump.  The story goes that in the mid nineteenth century Snow hypothesized that cholera was a waterborne disease.  During the 1853-4 outbreak, he identified a single water supply as the source of the disease in Soho.  Snow got the handle of the water pump on Broad Street removed, and mortality subsequently fell.

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John Snow memorial and pub, Broadwick Street, London [Photographer: User:Justinc]

As a result, John Snow has become something of a hero of public health history.  When a new lecture theatre was built at the LSHTM, it was named after John Snow.  We even held a birthday party for him in 2013 to celebrate the bicentenary of his birth.  Now, I must confess that this provoked a certain amount of eye-rolling from the historians.  In part, this is because whilst Snow was important, there is some debate about exactly how important.  As Tom Koch as demonstrated, Snow did not single-handedly prove that cholera was waterborne.  Snow’s work was partial and not all that well-executed.  The notion that cholera was waterborne grew out of and was developed by a wider community of science.  Indeed, some have questioned whether Snow was really the first person to correctly identify contaminated water as the source of cholera: there have been some suggestions that he was simply a better self-publicist!

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The John Snow Lecture Theatre.  And the Broad Street Pump.

London School of Hygiene & Tropical Medicine.

If that’s correct, then Snow’s ability clearly extends well beyond his death, as this is a very familiar story.  Despite there being almost a cottage industry amongst historians, geographers and epidemiologists in attempting to debunk various John Snow legends, these persist.

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John Snow and the Broad Street pump. [Illustration: Alexander Bertram Powell]

But, in our grumbling perhaps we miss the wider point – here is a story with ongoing cultural resonance.

Why?

Well, to begin with Koch’s argument, the idea of the lone scientist, right when everyone else is wrong, battling against the establishment, is a powerful myth.   But I think there are a set of other reasons too, and these point to some interesting dimensions of the more recent history of epidemiology, public health and the public’s understanding of these.

The glorification of John Snow is certainly not a new phenomenon.  JP Vandebrouke and colleagues suggest that John Snow’s work was ‘rediscovered’ by the American epidemiologist WH Frost in the 1930s.  They suggest that Snow’s work fitted well with the bacteriological paradigm of the times and offered a neat, clear historical example with which to instruct students.

This might help explain the enduring place that Snow occupies in introduction to public health and epidemiology courses around the world, but I think there’s a broader cultural legacy at work here that surrounds nineteenth century public health.

For instance, public health exhibitions held during the post-war period often harked back to the nineteenth century.  Displays depicted the progress that had been made: improvements in living conditions, falls in infant mortality, the defeat of infectious disease.  There was a perceived need to transmit confidence about the future, about public health’s ability to overcome significant challenges facing country at the time.  A neat narrative of progress was comforting – we did it in the past, so we can do it again.

But this was also a time when the role of public health practice and theory was uncertain.  The effects of the epidemiological transition were starting to be felt.  Public health had successfully (or at least mostly successfully) overcome infectious disease, how was it going to deal with chronic conditions?  Would the pre-war approach offered by social medicine be developed in the post war period?

There were no clear answers to these questions.  Instead, the apparent victory over infectious disease and the improvement of living conditions in the nineteenth century offered a reassuring degree of certainty in very uncertain times.

Of course, this was not something peculiar to Britain in the immediate post-war period.  As we’ve seen, myths about nineteenth public health and the relative importance of people like Snow continue.  This is because they still carry weight, both in terms of our assumptions about the past, and the present.

Alex Mold, 16 March 2017

 

 

Just how bad is the NHS at innovation? The answer – we don’t know

BY James Barlow

“There is strong encouragement for the NHS to make better use of innovation, but we’ve not known how our system performs internationally. Now we are developing a potential measure.”

The Accelerated Access Review (AAR) – which aims to help speed the introduction of health innovations into the NHS – was published last October. Readers with long memories may recall a string of previous reports all tackling the need to improve the UK’s health innovation system: the House of Commons Health Committee’s inquiry into the use of new medical technologies (2005)1, Best Research for Best Health (2006)2, the Cooksey review (2006)3, Innovation for Health (2007)4, Our NHS Our Future (2012)5, Innovation Health and Wealth (2012)6.

The AAR calls for a broader remit for NICE, to include more medtech and digital health innovations. Other recommendations are for closer alignment between regulatory requirements and processes, and for once-only assessment by NHS England of innovations not referred to NICE. Simpler and swifter procurement processes are part of the future agenda. And in an implicit nod towards the work of Clayton Christensen, the AAR suggests there should be some funding to support the commercialisation of disruptive innovations that have the potential to significantly improve care pathways.

These are all sound recommendations, but they are only the beginning. Recommendations now need to be turned into specific actions with budgets, owners, milestones and deliverables.

The good news from the AAR is that consensus seems to have broken out, with a genuine belief by government and NHS leaders in the potential of innovative technologies to improve patient care. The consensus extends to a call for more flexible approaches to pricing and reimbursement which can support the adoption of innovations.

The bad news is that the NHS is in deep financial trouble. For all the Churchillian rhetoric of healthcare leaders – “we have run out of money, now we must think” – and exhortations that a crisis is a great opportunity for innovation, the distinct tendency in the NHS is to hunker down, deal with the immediate concerns and shuffle innovation into the “too difficult” pile.

Goals, targets or crisis can of course concentrate the mind and, when coupled with the right kind of support and incentives, generate useful new ideas – a good example was Scotland’s Unscheduled Care Collaborative Programme in the mid-2000s7. However, the magnitude of the challenge of modernising the NHS, whilst continuing to run services with shrinking budgets, seems overwhelming. We know we need innovation, we know what kinds of innovation we need and we have a pretty good idea what is the potential impact of many innovations on improving care – the problem is introducing and establishing them in the NHS.

The AAR, if its recommendations are implemented, might help to speed up the flow of some new technologies into everyday practice, but it will not tackle the other layers of innovation that are needed. These were nicely described by the Health Foundation in 20158 as five interlinked components of a framework for change, all of which require innovative thinking – population health management, ways of delivering care, process improvement, active cost management, and scientific discovery, technology and skills. The report argued that all these are capable of delivering improvement over different timescales. Interestingly, the last of these – science and technology – is felt to have the most limited potential impact.

But just how bad is the NHS at innovation? There is much anecdote and received wisdom – “the UK is great at generating innovations but poor at adopting them”, “the NHS is always a late adopter”, “developing countries health systems are where the really interesting new ideas are”, “the USA over-adopts healthcare technology”.

Much seems to depend on perception. The 2016 Global Diffusion of Healthcare Innovation study surveyed 1,356 frontline health workers and healthcare leaders in six countries and found that the USA and UK were ranked as the two most important sources of innovation, but there were variations partly according to location – India was perceived as by far the most important by interviewees in some countries.

The volume of research on healthcare innovation processes has grown over the last fifteen years or so. We know what constrains the adoption of innovation and we know what innovators need to support them from research to commercialisation.

What we lack, though, is any kind of assessment of where different countries stand in relation to each other in their healthcare innovation capacity – how good they are at adopting innovative solutions developed elsewhere and originating innovations themselves. None of the reports on the state of healthcare innovation in the UK described above provide any real insight into our performance compared to other countries. Apart from limited work by Deloitte9, PWC10 and Accenture11, there has been no attempt to create an international comparative healthcare innovation index (the Global Diffusion of Healthcare Innovation is not an index because it teases out perceptions of innovativeness).

There are many indices or composite indicators measuring aspects of national performance in innovation in general. Indicators include measures of entrepreneurship, technology development and scientific research, innovation in general, and innovation in public sector organisations. However, these remain underdeveloped in relation to health.

A carefully constructed global health innovation index would be valuable in two ways:

• It would focus attention on the relative performance of the UK’s (or any other country’s) health system, pinpointing its strengths and weaknesses, identifying bottlenecks and issues for attention. This would enable policy makers and the healthcare sector to identify and prioritise the levers that can have the greatest impact on innovation.

• It would help medical technology and life sciences companies by providing an understanding of the attractiveness of each country’s health system as a market for products, as a source of innovations, and as a location for R&D.

A project funded by PIRU has carried out the groundwork needed to develop a global health innovation index12. We reviewed existing global innovation indices and explored the conceptual, methodological and practical issues that must be addressed. We draw three conclusions from our review.

First, one should proceed with caution when deriving policy, research or other implications from composite indicators. Before we can be confident of their implications for the comparative performance of countries or regions and establish benchmarks to underpin policy or other decisions, it is essential to understand how innovation indicators impact on innovation processes. This in turn requires indices to be underpinned by a clear and strong theoretical framework.

Second, there are a number of data issues which have to be addressed. To explore the dynamics and evolution of health innovation across countries through an index requires panel data (collected over time). While the availability of cross-sectional data (between countries) is fraught with difficulties, the use of panel data is even more so. Another issue is variation at the regional or local level. Policy makers are interested not only in their national scores, but in whether different regions in their country perform differently.

Finally, policy makers should be careful not to draw conclusions about the relationship between composite innovation indicators and other indicators of policy interest such as health outcomes. While it may be of interest to correlate innovation index scores with those of an index of health outcomes, we must always remember that correlation does not mean causality – introducing a new drug or device may well lead to better health outcomes, but an index will not tell us this.

We are now hoping to create a prototype index for a few countries. This involves investigating data sources and more work on what the index is measuring, for whom and for what purpose.

Anyone interested in finding out more should contact James Barlow at Imperial College Business School, j.barlow@imperial.ac.uk

James Barlow is a Professor of Technology and Innovation Management (Healthcare) at Imperial College Business School and a member of PIRU. His latest book, Managing Innovation in Healthcare, was published by World Scientific in January 2017.

1House of Commons Health Committee (2005) The Use of New Medical Technologies Within the NHS: Fifth Report of Session 2004–2005.
2Department of Health (2006) Best Research for Best Health: A New National Health Research Strategy: The NHS Contribution to Health Research in England.
3HM Treasury (2006) A Review of UK Health Research Funding.
4Strategic Implementation Group & Healthcare Industries Task Force (2007) Innovation for Health: Making a Difference.
5Department of Health (2007) Our NHS Our Future: NHS Next Stage Review – Interim Report.
6Department of Health (2011) Innovation Health and Wealth, accelerating adoption and diffusion in the NHS.
7Dattée B, Barlow J (in press) Multilevel organizational adaptation: Scale invariance in the Scottish healthcare system. Organization Science; Dattée B, Barlow J (2010) Complexity and whole-system change programmes. Journal of Health Services Research & Policy 15, S2, 12-18.
8The Health Foundation (2015) Shaping the Future. A Strategic Framework for a Successful NHS.
9Deloitte (2012) Innovation Indicators for Healthcare in Emerging Countries. Understanding and Promoting Innovation in Emerging Markets.
10PWC (2011) Medical Technology Innovation Scorecard. The race for global leadership.
11Accenture (2013) Measuring the Unmeasurable. A New Framework for Assessing Healthcare Innovation.
12Cravo Oliveira T, Barrenho E, Vernet A, Autio E, Barlow J (2017) Developing a Global Healthcare Innovation Index. PIRU Reports 2017-20. http://www.piru.ac.uk/publications/piru-publications.html

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Royal visit to Commonwealth Eye Health Consortium programmes in Malawi

HRH The Countess of Wessex tries out Peek at Mchesi Primary School

HRH The Countess of Wessex tries out Peek at Mchesi Primary School

Her Royal Highness The Countess of Wessex marked Commonwealth Week by visiting a hospital and school in Malawi to see activities to end avoidable blindness and champion young leaders.

The Commonwealth Eye Health Consortium programmes are funded by The Queen Elizabeth Diamond Jubilee Trust and coordinated by the International Centre for Eye Health at the London School of Hygiene & Tropical Medicine.

The Countess, who is Vice Patron of The Queen Elizabeth Diamond Jubilee Trust, visited Lilongwe’s Kamuzu Hospital to see how the Consortium is contributing to long-term capacity building for the delivery of quality eye care services.

She met with Malawian eye doctors and other health workers who have received scholarships for academic training in public health and clinical fellowships funded through the Consortium. She observed first hand a training session on screening for diabetic retinopathy being conducted by a VISION 2020 LINKS team from Fife, UK. The LINK between Lilongwe and Fife is part of the Diabetic Retinopathy Network which aims to strengthen screening and treatment in DR through developing Diabetic Retinopathy Services within LINK institutions. There are two Diabetic Retinopathy Network LINKS within Malawi supported through the Consortium. The other LINK is between Blantyre and Liverpool.

Peek is part of the Consortium and works in partnership with the School. It creates technology including apps and knowledge to empower healthcare providers to deliver quality, eye care to everyone. During the visit, the Countess tested a pupil’s vision at Mchesi Primary School with the Peek Acuity app as part of a demonstration of the Peek schools screening system to identify children with visual impairment.

She also looked at a retina (the back of the eye) using Peek Retina, a smartphone camera adapter which she first saw as a prototype during a visit to the School in 2015. Since then it has been modified and certified as a medical device and will go on general release soon.

Her Royal Highness also travelled to the Kasungu district where she saw Trust-funded activities with the Malawian Ministry of Health and the International Coalition for Trachoma Control to eliminate blinding trachoma. The Countess’ visit comes at an exciting time in Malawi as the country reaches an historic milestone in its fight against blinding trachoma: from now on no one in Malawi need lose their sight from this ancient, painful infectious disease. The country is on track to meet by 2018 the World Health Organisation criteria where trachoma is no longer a public health problem and verification of elimination by 2020.

Since its launch in 2014, the Commonwealth Eye Health Consortium has sponsored four Malawian ophthalmologists to undergo clinical fellowships around the world; awarded scholarships to two Malawians to study for Masters in Public Health; supported two Malawian LINKS which are part of the Diabetic Retinopathy Network to address diabetic retinopathy through screening and treatment services including training support from the UK/Scottish partners. The Consortium is now supporting training, research and other activities involving 34 Commonwealth countries.

Professor Matthew Burton, Professor of International Eye Health and Commonwealth Eye Health Consortium Director, represented the Consortium during the Countess’s visit to Malawi.

He said: “Malawi is making great strides in its efforts to increase eye care services and tackle avoidable blindness. The scholars and fellows the Countess met today are playing a key role in leading eye-health developments in the country.

“I am delighted that the Countess is so supportive of eye health and that she was able to see how our Trust-funded programmes are working to increase capacity and bring long-term and large-scale improvements through people, knowledge and tools.”

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Next step: develop Social Investment Partnerships

by Ben Jupp

The experience of Social Impact Bonds can inform a wider set of relationships to help address social needs, argues a key innovator in the field.

The health and social care system I work in has rarely been in greater need of transformative investment. As demographic and financial pressures threaten to pull it apart, better responses to people’s needs are urgently required.

In my experience, developing more community focused and preventative health and care services will rest on approaches which combine both innovation and rigour. It will rely on strengthening the capacity of services to understand needs, learn from others, adapt and implement change. It will take an approach that looks beyond the annual budgeting of the NHS.

Many Social Impact Bonds seek to change systems
To me, and my colleagues at Social Finance, Social Impact Bonds (SIBs) have always been one tool to support such transformative responses. Take, for example, the Reconnections Service in Worcestershire. It aims to address chronic loneliness, responding to a need that was highlighted by older people in the county themselves.

Establishing Reconnections has involved designing a new service, pioneering long-term cost-benefit analysis on the impact of chronic loneliness, and helping draw together a partnership with a network of half a dozen voluntary and community sector organisations. For the range of commissioners involved, an outcome-based contract was attractive: making payments only if and when the new approach is effective. For the service itself, an outcome-based contract has also enabled flexibility and innovation.

The first year of Reconnections has been hard. Service providers, volunteers and investors have all had to work in ways they had not expected. We have had to learn and adapt. But, slowly, the six charities and community organisations are developing better responses to needs that have often been neglected for far too long, to the detriment of individuals and the health and care system as a whole.

The value of Social Investment Partnerships
Our experience of developing the Reconnections Social Impact Bond and other transformative programmes has also highlighted the value of creating broader Social Investment Partnerships (SIPs) in health and care.

Such Social Investment Partnerships encompass approaches to address social needs which include Social Impact Bonds but also wider forms of collaboration where commissioners, providers and investors share risk and pool knowledge and experience in the design and delivery of services. Highlighting partnerships reflects the need for commissioners, investors and providers to work collaboratively and flexibility, rather than the more adversarial separation between ”purchasers” and ”providers” of services that has characterised the NHS in England for the last 30 years.

For example, in a Social Investment Partnership to improve community-based end of life care, we have been working collaboratively with commissioners and providers for six months to scope out the need jointly. The investors and commissioners have then jointly considered which organisation would be best placed to develop the service; sometimes through a competitive process, sometimes by just building on an existing service.

Alternatives to outcome-based contracts
In such partnerships, we have also found that an outcomes-based contract is only one way to transform services. A focus on the underlying outcomes enabled by a service is important: an outcome-based contract can have significant advantages in terms of allowing service flexibility and providing focus. But for other areas, it’s impossible to capture the full range of people’s needs with a focus on a small number of objectives.

That is why, for example, in our partnerships to develop better Shared Lives social care (the Shared Lives Incubator), we have invested directly in the provider without an outcomes-based contract. Creating the conditions in which someone wants to share their home with another person in need of care is difficult to stipulate in a contract which prioritises one or two impacts. So the investors and commissioners jointly identify the provider, based on their overall qualities and experience. The investor then provides the upfront funding for developing the local service and repayment is made simply as proportion of the service revenue, if and when it grows. In other partnerships, risks are likely to be shared on the basis of a capitated budget – a set amount of funding for the population.

Drawing in investment from a range of sources
Finally, I have found that the concept of a “Social Investment Partnership” draws attention to the need for new resources and capacity and a long-term approach when tackling social challenges, rather than focusing on a particular type of financing. In some of the partnerships which we are building, such as those that develop better employment support for people with health conditions, the source of the funding is a mixture of public sector, charitable and external socially motivated investment. In nearly all such partnerships, we are combining financial investment with access to clinical and operational support. For example, because Health and Employment Partnerships operates across multiple areas, it has the scale to able to employ clinicians and service managers with deep experience of managing similar services before and is helping to manage NHS innovation funding as well as social investment.

I’m proud of the pioneering approaches that my team and colleagues across the sector are engaged in through Social Impact Bonds such as Reconnections. By broadening the approach to developing Social Investment Partnerships, we now have the opportunity to enable a wider range of contractual forms, further blur traditional adversarial relationships, and draw in resources from a number of sources.

These partnerships, whether traditional Social Impact Bonds or a not, are united by a passion for supporting communities and the most vulnerable in particular. They also recognise the importance of both innovation and rigour to achieve social change and ensure that organisations and systems have the capacity to adapt.

Ben Jupp is a Director at Social Finance. He was Director of Public Services Strategy at the Cabinet Office. He has also been Director of the Office of the Third Sector in the Cabinet Office.

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Point of contact

MSc Epidemiology student Stephanie VandenBerg shares the story behind her photograph Kalukembe Neonate, which recently won a photography competition hosted by the London International Development Centre (LIDC).

Thirty seconds old. The crash of my world into them and theirs into mine. I had travelled to rural Angola as a wide-eyed, under-prepared medical student, armed with a stethoscope and a camera. I had not expected this baby in this place, one born with the help of an emergency surgery in a poor village with no electricity, four hours away from any city centre, with no physician in sight. After all, wasn’t Angola, despite the oil wealth of an elite few, one of the most impoverished countries in Southern Africa? Yet here we were, clothed in the costumes of a surgeon, watching caesarean sections being performed by trained nursing staff in a simple operating room, saving women from years of labour-related complications and, in some cases, death. How was I going to explain this? How was I going to be able to resolve the facts I knew about infant mortality (Angola has one of the highest rates of children dying before they reach their 5th birthday) and maternal death (also high in Angola) [1] with the type of “first-world” health care I was seeing? My stethoscope was not going to help me communicate this. I reached for my camera.

From an epidemiologic point of view, the patterns are clear. No matter which way you slice it, the poor in any country have shorter lifespans, they die more often from preventable diseases, accidents or illnesses that we have simple treatments for. As Paul Farmer, American doctor, anthropologist and humanitarian puts it, “the poor are sicker than the nonpoor”[2]. While statistics and statements like the ones above convey sterile information, photographs hold the distinct honour of bearing witness and transporting these realities directly into our collective consciousness. This photo, entitled “Kalukembe”, captures a moment in a human life, a moment that holds decades of healthcare advocacy and a stubborn belief that health systems can be radically empowered to care for a traditionally poor population, no matter which passport they hold. The story goes like this:

There is no more fitting a name for this rural community of Kalukembe. In the mother tongue of the tribal people, it is called Kakula – a name meaning “stay here”. In the 1970s a Swiss physician and a Zambian born, Canadian surgeon joined the community at the invitation of its leaders. By the 1980s and for thirty years to follow, a brutal civil war raged. When given the chance to be evacuated, the physicians stayed, showing solidarity with their Angolan counterparts. Today, the 188-bed hospital is staffed completely by nurses with a physician/surgeon flying in monthly to lend a hand with the more complicated surgeries. The baby in this picture is testament to social change by a group of people advocating to bring safer maternal health care.  He is one of a set of twins born by caesarean section – a surgical delivery used when the mother encounters difficulty in natural labour. The same physicians who stayed to help care for wounded Angolans during the war set up a surgical training program that resulted in the certification of two senior nurses in the surgical techniques required to perform a surgical delivery. This seemly small capacity building project has saved the lives of countless mothers and babies.

Stephanie VandenBerg

The story and responsibility of this photograph weigh on me because the image holds me accountable to this child’s future and the future of the mothers, fathers and families that come after him. To be held accountable means that we are implicated in the structures that improve or destroy their opportunity. Robert McAfee Brown, paraphrasing the words of the Uruguayan Jesuit Juan Segundo puts it succinctly when he writes, “unless we agree that the world should not be the way it is … there is no point of contact, because the world that is satisfying to us is the same world that is utterly devastating to them”[3]. It has become a part of my practice of “photography as advocacy”, to hold myself and others accountable to a radical belief in social change and I will forever be thankful for a glimpse into a world that was a little less devastating because of the vision of a community committed to promoting women and children’s health.

[1] World Health Organization, “Angola – ‘Maternal Child Adolescent Heatlh.’”

[2] Farmer, Paul The Preferential Option for the Poor beyond Theology 2013. University of Notre Dame Press.”Chapter 11: Health, Healing, and Social Justice” pg  200.

[3] Farmer, Paul The Preferential Option for the Poor beyond Theology 2013. University of Notre Dame Press.”Chapter 11: Health, Healing, and Social Justice” pg  204

This post originally appeared on the website of Photovoice, a photography charity which judged the LIDC’s competition.

4 – 10 March 2017

Elisa Roma provides comment to Reuters about the benefits of toilets filled with tiger worms. They take up less space than pit latrines, need to be emptied less often and can turn waste into fertiliser. In order for them to be a success, Elisa says: “There needs to be a sustained demand for such products… [and] viable business models that allow the innovation to operate without subsidies and beyond initial aid from international funders.” The article generates coverage in Daily Mail, AllAfrica and The Malay Mail.

Joy Lawn speaks to CNN following a report released by the World Health Organization that found  polluted environments kill 1.7 million children yearly: “We also need to be careful in attributing these deaths just to dirty water or pollution. To prevent deaths from pneumonia, we also need vaccines and antibiotics; from malaria, we also need bed nets and anti-malarials. It is not just about pollution.”

Ngozi Erondu writes a blog for the Huffington Post on global health security and preparing for the next pandemic: “We cannot afford any longer to keep talking about the need to strengthen health systems—we must invest more in health systems in low-income countries now.”

An article in The Guardian discussing unnecessary Caesarean-sections in India references research conducted by Meenakshi Gautham highlighting private hospitals as the most “scalpel happy.”

During the week of International Women’s Day, Tammy Maclean co-authors a blog for Canada’s The Globe and Mail arguing that there is an important role for men in women’s equality: “Only then will we build the shared understanding that everyone, including men and boys, will benefit when women and girls’ equal rights are protected.”

Optometry Today cover research co-authored by the School highlighting the inequalities in access to cataract treatments, identifying illiterate women in rural areas as the most vulnerable.

Canada.com publish a blog by Mike Callaghan on the topic of mumps after an outbreak was declared in Toronto: “A vaccine alone can’t win out against the massed forces of history, culture and politics. There is a whole social world that needs to support that vaccine, long after the virus itself has slipped from memory.”