Sex is biological and gender is social – right?

Recent social media debates have shown that misunderstandings about ‘biological sex’ are common. In our latest blog, DEPTH Director Professor Cicely Marston discusses how simplistic ideas now circulating about biological sex miss the mark – and why it matters. 

Photo by Liv Bruce on Unsplash

Isn’t it the case that biological sex can only be binary – that you can only be biologically male or biologically female? And why does it matter anyway? In this blog I’ll discuss why biological sex is more complicated than many people think.

A popular way to explain the concept of ‘gender’ is to say that ‘sex is biological and gender is social’. This can help get the idea across that gender is ‘social’ – that is to say, it is something created by people, involving things like expectations, behaviours, and beliefs about masculinity and femininity. It’s true that gender is indeed social, but this leaves the idea that ‘sex is biological’ unexamined – and in some aspects in fact, ‘biological’ sex is social too.

But how can ‘biological sex’ possibly be in any way social? The basic thing to understand is that categories and labels – even words themselves – are social. For instance, if I call something a table you will know roughly what I mean. The table is real, material, and can vary: for example being made of different materials, in different sizes, and so on. We agree as speakers of the language roughly what we mean by “table”. 

Photo by Abel Y Costa on Unsplash

All the word “table” reflects is what we have decided, collectively over time, counts as a table. E.g. a table generally has legs, but not always the same number. It might be raised high off the floor, or be low. Through usage, all that diversity comes to be labelled with the same word “table”. 

When differentiating tables becomes socially important, language adapts, and the word “table” might be qualified (“occasional table” or “coffee table”). 

In the same way, “biological sex” is what we conceptualise, as a society, as “biological sex”. It is a label used to describe a collection of indicators, biologies, and anatomies. Indicators (e.g. chromosomes, gametes), that have changed over time and with scientific discoveries. It’s not a failsafe way to know what a particular individual’s biology is in every case.

This is why we can say that the biological sex binary is socially constructed– biological sex as male or female is a shorthand for categorisations of the material world that we find useful.

Photo by hessam nabavi on Unsplash

To take the most obvious example, many people see a “biological” binary in genital shape, yet this is an imperfect heuristic. (Content warning: genital cutting mentioned below). In many places, babies are assigned to the category “male” or “female” based on the shape of their genitals at birth. However, individuals may have a genotype that appears to “contradict” their assigned sex, or that in other ways doesn’t match the simplified XX vs XY that we learn at school. Unsurprisingly, people who assert that biological sex is binary seem to offer varying and sometimes contradictory biological markers that they claim divide everyone in the world neatly into two categories. Is it chromosomes? Gametes? Testosterone levels? Genital appearance? Nobody seems to be sure. 

“Biological sex” is a construct that helps our highly gendered society to categorise and label others.

“Biological sex” is a construct that helps our highly gendered society to categorise and label others. But why bother? The sex binary has major social significance (so much so that children with genitals less easy to read as male/female may be subject to genital cutting), and people who do not present in line with the sex they were assigned at birth, or who are not read as clearly “male” or “female”, continue to experience social disapproval, discrimination, and violence.

The idea of “naturalness” or the intrinsic/immutable binary nature of “biological sex” is important socially too. If the binary is “natural” or “biology” there’s nothing we can do about it, and departures from the typical become “disorders” rather than simply variation. Similar ideas also underpin arguments that differences (and inequalities) between men and women are biologically determined and so cannot be overcome. 

The biological sex binary oversimplification does particular harm when it is weaponized to vilify or discriminate against individuals or groups who are deemed not to fit such as people not easily read as “female” or “male”, and when backwards logic is used to try to gloss over discrimination and vilification by representing it as simply a consequence of the “natural” order of things. 

To summarise, “biological sex” involves not only the material but also the social. The crucial point is that the idea of a strict and immutable binary is socially constructed. The concept of “biological sex” is not inevitable because we have bodies, it is a response to how we see those bodies and how, as a society, we want to divide them up into categories. So the whole argument about gender and sex binaries is not an argument about science – however much people want to present it as one – it is an argument about classification and how we as a society choose to label people. Biological sex is social as well as material: and that matters.

Photo by Luca Vavassori on Unsplash

What do you think? Thoughts, questions – and answers – are, as ever, welcomed in the comments section below this blog.  (NB: If you’re reading this article on the DEPTH blog mainpage, click on the title of this post and comments will open at the bottom).

PHI|Lab Field Trip to Sainsbury’s Online Fulfilment Centre



For the start of 2020 we decided it would be good to get out of the office once in a while and go and see something interesting related to our work. For those of us who are geographers, the field-trip is an essential part of learning and a great way to bring to life thing you only read about in books or scientific papers or explore through data. The PHI|Lab field-trip was born!

An emerging area of work for us is exploring how digital technology is transforming how we access and consume food. Coincidentally, the father of our new PhD student Robert, helped start and run Tesco’s online delivery service nearly 25 years ago in the very early days of digital. He gave us an introduction to the manager of Sainsbury’s only ‘dark store’ in the UK and thus our second field-trip of the year was on!

The compound, in Bromley-By-Bow, London, is very large (and very secure) and super-interesting. There is a ‘dark store’ – essentially an area laid out like a traditional supermarket where staff ‘pickers’ take products off the shelf to fulfil orders – they pick c240-280 items an hour at peak times. There is also a fridge the size of a small warehouse where chilled foods are stored. The pickers wear wrist-mounted displays with a finger-tip barcode scanner and load items into barcoded ‘totes’ that are then transferred to an automated conveyor. The pickers only pick for their category (ie frozen) and so the barcoded totes are automatically combined in the conveyor system to make up a household’s order.


The order, combined on the conveyor as it goes, travels through the building to a loading dock where the totes are scanned and loaded into the back of a delivery van by the driver. The van can take around 70 totes (approx. 15 orders).

Most of the picking and loading happens at night as orders are usually placed in the later afternoon and evening for next day delivery, thus the store runs 24 hours a day. Interestingly the geographical footprint of the store varies over time. Postcodes can be added or dropped from the stores range – the slack being picked up from traditional superstores. The Bromley-By-Bow Online Fulfilment Centre has a fleet of 120 delivery vans (the average traditional store has about 5), and fulfils about 10,000 orders per week (and has the capacity for 20,000).

The Online Fulfilment Centre also hosts a number of laboratories for product testing, customer complaints, food fraud and the testing of cooking instructions!! It also has a bakery school that trains all of the companies store bakers.

It was a great team trip, followed by a coffee at Cody Dock ArtSpace a short walk away – but let’s hope Andrea and Alex can navigate a bit better next time …



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PHI|Lab Field Trip to Sainsbury’s Online Fulfilment Centre

For the start of 2020 we decided it would be good to get out of the office once in a while and go and see something interesting related to our work. For those of us who are geographers, the field-trip is an essential part of learning and a great way to bring to life thing you only read about in books or scientific papers or explore through data. The PHI|Lab field-trip was born!

An emerging area of work for us is exploring how digital technology is transforming how we access and consume food. Coincidentally, the father of our new PhD student Robert, helped start and run Tesco’s online delivery service nearly 25 years ago in the very early days of digital. He gave us an introduction to the manager of Sainsbury’s only ‘dark store’ in the UK and thus our second field-trip of the year was on!

The compound, in Bromley-By-Bow, London, is very large (and very secure) and super-interesting. There is a ‘dark store’ – essentially an area laid out like a traditional supermarket where staff ‘pickers’ take products off the shelf to fulfil orders – they pick c240-280 items an hour at peak times. There is also a fridge the size of a small warehouse where chilled foods are stored. The pickers wear wrist-mounted displays with a finger-tip barcode scanner and load items into barcoded ‘totes’ that are then transferred to an automated conveyor. The pickers only pick for their category (ie frozen) and so the barcoded totes are automatically combined in the conveyor system to make up a household’s order.


The order, combined on the conveyor as it goes, travels through the building to a loading dock where the totes are scanned and loaded into the back of a delivery van by the driver. The van can take around 70 totes (approx. 15 orders).

Most of the picking and loading happens at night as orders are usually placed in the later afternoon and evening for next day delivery, thus the store runs 24 hours a day. Interestingly the geographical footprint of the store varies over time. Postcodes can be added or dropped from the stores range – the slack being picked up from traditional superstores. The Bromley-By-Bow Online Fulfilment Centre has a fleet of 120 delivery vans (the average traditional store has about 5), and fulfils about 10,000 orders per week (and has the capacity for 20,000).

The Online Fulfilment Centre also hosts a number of laboratories for product testing, customer complaints, food fraud and the testing of cooking instructions!! It also has a bakery school that trains all of the companies store bakers.

It was a great team trip, followed by a coffee at Cody Dock ArtSpace a short walk away – but let’s hope Andrea and Alex can navigate a bit better next time …

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Alumni Innovators: Pioneering Doctor Najeeba Al Mulla

Dr Najeeba Al Mulla was the first woman doctor in Kuwait in the 1960s, working for decades in her country’s public health sector.

Dr Al Mulla was awarded a Kuwait government scholarship to study medicine in London. She graduated in 1964 from St Mary’s School of Medicine and earned her MSc degree in Infectious and Tropical Diseases from LSHTM in 1984.

Dr Al Mulla trained in haematology at the Royal Infirmary of Edinburgh, sponsored by the World Health Organisation (WHO). In Yemen, she researched ethnic medicine in Islam. She undertook research on haematology in Kuwait, where she trained staff and introduced lab control. She is a member of the International Society of Haematology.

As a member of LSHTM’s Director’s Circle, Dr Al Mulla was the only Arab doctor at a luncheon on 8 October 2014 at Buckingham Palace hosted by HRH Prince Philip.

Dr Al Mulla says, “I believe that innovation and research are instrumental in finding solutions to medical problems. I strongly believe in family and community awareness of such problems. In my tour of duty in Yemen, I instructed young students to appreciate local remedies and encouraged them to network with their local community in addition to scientific knowledge.”

Navigating fragility? What’s the big idea?

By Alastair Ager, NIHR Global Health Research Unit on Health in Situations of Fragility, Queen Margaret University, Edinburgh.

There’s a growing interest in the concept of fragility. Initially just a new label given to ‘failed states’ to foster a more respectful form of engagement with countries marked by deep and persistent weakness of government, OECD interest has sparked a more nuanced approach. First there was the recognition that fragility is not just a condition that can affect a nation state but rather a broader range of ‘situations’. Then there was the insight that fragility is multi-dimensional. Conflict and insecurity is clearly a factor deepening fragility. But economic, environmental, political, and broader societal conditions are all now recognised as also contributing.

With colleagues at the NIHR Research Unit on Health in Fragility – based in Edinburgh, but with major partners in Lebanon and Sierra Leone – we have been exploring what a more nuanced understanding of fragility means for health systems and the communities there serve [see June 2019 WHO Bulletin editorial]. This includes a recent scoping review of over 377 papers that have used the term in the context of health provision.

Health systems and local communities

What’s emerging is the crucial importance in fragile situations of the interface between the health system and local communities. Obviously of relevance in all contexts, in situations of fragility this interface seems particularly vital for supporting access, quality and relevance of provision… and exceptionally vulnerable to fragmentation, distrust and exclusion.

We’ve been developing methodologies to explore the dynamics of this interface across a range of fragile settings in the Middle East (including Syria, Lebanon and Jordan) and in West Africa (including Sierra Leone and the northern region of Ghana). Group model building – a participatory method based on system dynamics principles – has proved an especially powerful tool.  This provides a way of working that is meaningful and accessible to both health providers and community members in eliciting their understandings of the barriers that need to be overcome in promoting health in situations of fragility. In so doing, it provides a mechanism that brings these groups together to consider appropriate systems interventions to address these challenges.

I have used a wide range of methodologies in my work in the field of global health over the last thirty years. But few have brought the vivid insights into the dynamics of health provision that group model building has provided, ranging from the reluctance of disclosing mental health needs beyond the household for fear of stigma and rejection, through the anguish of those with high blood pressure knowing that supply of their anti-hypertensive medication (or their income to purchase it) is unreliable, to the dawning realisation of health managers that it is the mechanics of health systems governance that drives staff non-compliance not their lack of care or competence. Trust is at the heart of each of these examples, and was a recurrent theme in our literature review across a very wide range of fragile situations (including those in high income and politically stable settings).

What’s the ‘big idea’?

So, in the context f health provision, what’s the ‘big idea’ in navigating fragility? It’s certainly important to be aware of the many different drivers of fragility, and that it has relevance as a concept beyond a listing of fragile-and-conflict-affected states. It’s likely useful to have that interface between health systems and communities (and the resources available through each) front-and-centre in our analyses of promoting health in contexts marked by fragility. It’s certainly worthwhile to consider the place of participatory research methods like group model building to explore that interface. But it’s probably trust –  including the processes that have eroded it and the mechanisms to rebuild it – that is best seen as the core idea with which to navigate fragility. Indeed, measures to build trust within communities and between communities and state health providers are not only likely to support improved health provision. They are likely to redress some of the key drivers of fragility itself.


Image credit: Professor Alastair Ager

Professor Alastair Ager holds academic appointments as Director of the Institute for Global Health and Development at Queen Margaret University, Edinburgh (where he is Director of the NIHR Research Unit on Health in Situations of Fragility) and with the Department of Population and Family Health at Mailman school of Public Health, Columbia University. He has worked in the field of global health and development for over thirty years, after originally training in psychology at the universities of Keele, Wales and Birmingham in the UK. He has previously held academic positions with the University of Leicester and the University of Malawi. He has worked as a consultant across sub-Saharan Africa, south Asia, Europe and North America, with a broad range of agencies including UNICEF, UNHCR, WHO, Oxfam, Save the Children, World Vision, Lutheran World Federation and Islamic Relief Worldwide. He is active in several areas of research related to forced migration and humanitarian crisis including: the evaluation of humanitarian programming (particularly with regard to protection and psychosocial support of refugee children), processes of resilience in war-affected settings, and the engagement of local faith communities in supporting humanitarian response. He was appointed a Fellow of the Royal Society of Edinburgh in March 2019. He currently holds the position of Deputy Chief Scientific Adviser to the UK Department for International Development.

A Very Persistent Woman

International Women’s day, on 8 March, feels like the perfect opportunity to celebrate the ‘persistent’ spirit of Lady Mary Simpson, one of history’s lesser known figures.

Lady Mary Simpson was the wife of Sir William Simpson, an expert in tropical hygiene who after serving as the Chief Medical Officer of Calcutta was instrumental in the founding of both the London School of Hygiene and Tropical Medicine and the Ross Institute. Although not a great deal is known about the life of Mary Simpson it can be assumed that her time in India influenced the invention of a ‘Mosquito Hood’ which she claimed could provide protection for those working in tropical climes.

As she outlines in a letter to Ronald Ross on the matter, dated 5. April 1917 ‘the chief feature is that it can be worn at night with comfort when asleep, securing complete protection against the bites of mosquitos’. Furthermore, as Simpson’s letter from 30. June 1917 states ‘the front of the hood can be quickly turned back so you can shoot, smoke or do anything without having to take it off’.

A letter from Simpson to Ross 28. May 1917

After the outbreak of the First World War Simpson entered into a correspondence with Ross, urging him to use his influence in the War Office, as the then Minister of Malaria, to promote her Mosquito Hood to the British Army. What follows is a forthright exchange of letters. For example, in a letter from May 1917 Simpson refers to an order from the Pasteur Institute for 500 hoods for ‘experimental purposes’, before going on to boast that ‘it is expected the French Minister of War will order a million as they are very much taken with the hood’. She ends the letter with the slightly provocative line ‘surely we are not to be behind the French?’ before imploring Ross to ‘get the authorities to give a large order’.

Letter from Simpson to Ross 28. May 1917 (cont.)

Ross responds to Simpson on 30. May 1917 by explaining that although he did attempt to promote the hood to his colleagues unfortunately ‘the committee preferred another type’ however they had ‘taken her sample out to the front to compare on the spot’.

In another letter from June 1917, presumably in direct response to a request from Simpson in connection with the hood, Ross states that ‘it would not do for me to give any certificate in connection with such matters, as this would not be allowed, but I can show your nets to people who visit me’.

Clearly disappointed in the War Office’s decision and what she sees as Ross’ lack of commitment in promoting the hood, Simpson, undaunted, sends another letter to Ross on 30. June 1917. She suggests that ‘the committees you mentioned . . . could not have understood the advantages of my invention otherwise they would have favoured it.’ She then, boldly, goes on to express a wish that Ross might ‘induce them to allow me to come and demonstrate and show off all the good points in its favour.’

The letter goes on to further list the many advantages of the invention before, perhaps reflecting on the rather determined tone of her correspondence, Simpson ends with the line ‘I am afraid you will think me a very persistent woman!’

Extract from a letter from Simpson to Ross 30. June 1917

From the tone of her letters and her position as the wife of a highly regarded expert in the field of tropical medicine, it is evident that Lady Mary Simpson enjoyed a degree of social privilege that would have undoubtedly assisted her in her quest to promote the Mosquito Hood. Regardless of her place within society, her determination, strength of character and ‘persistent’ spirit are no less admirable. Her refusal to accept the final word of (presumably) men in positions of power within the War Office – at a time when women’s ideas were rarely heard or taken seriously – is something we can all continue to take inspiration from.

The correspondence between Mary Simpson and Ronald Ross is available in the archives for researchers, please see the archives website for further information on access

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20 – 26 February

A snapshot of media coverage on the coronavirus outbreak:

David Heymann speaks to…

(26/02) Newsweek about why caution needs to be used when describing the outbreak as a pandemic. David said: “Terms such as pandemic are distracting. What is necessary is to understand the current situation in each country. It is for WHO to determine when the outbreaks should be called a pandemic and they will do this based on information from many different sources.”

(25/02) National Geographic about the difficulty in predicting whether warming Spring temperatures will slow the spread of the outbreak. David said: “The risk of making predictions without an evidence base is that they could, if they prove to be wrong, be taken as verity and give a false security. The emphasis today should continue to be on containment to elimination where possible.” David’s comment also features in The Express.

(25/02) Nature about the importance of outbreak preparedness. David said: “I think that people put way too much emphasis on a pandemic. I think what’s important is a basic understanding of outbreaks and how to deal with them.”

(25/02) The Indian Express about a possible decrease in COVID-19 transmission rates in China, citing the containment strategies used during the 2003 SARS outbreak. David said: “China was able to stop outbreaks outside the epicenter in Guangdong province by meticulous outbreak containment and control.”

(24/02) BBC News about Italy’s emergency measures, amid the country reporting it’s first deaths. David said: “They’re looking hard to find patient zero but they’re also trying to control the outbreak. Hopefully these measures will be effective in interrupting transition.”

(24/02) Al Jazeera about Iran’s response to the coronavirus outbreak. David said: “I was in Iran at the time of the earthquake and I saw a rapid and effective response to the health needs of the people who were in that  earthquake situation so I know that Iran has the capability of mobilising many different groups when they need to.

(24/02) Daily Mail about how better understanding of the transmissibility of the novel coronavirus is needed to guide other countries on appropriate response measures. David said: “Transmissibility in the community is not yet fully understood – what is necessary is to understand the current situation in each country. It is for WHO to determine when the outbreaks should be called a pandemic and they will do this based on information from many different sources.”

(22/02) South China Morning Post about the WHO’s work in assessing next containment steps in China. David said: “They’ll be looking at the number of asymptomatic and other types of infection to better understand the mortality ratio in China. Clearly China has been very transparent and open in sharing its data. They’re sharing it very well and they opened up all of their files with the WHO present.”

(21/02) The Guardian about who is most at risk of contracting coronavirus. David said: “This is a new disease in humans, so no-one has immunity– health workers, like everyone else, don’t have immunity. At the moment it appears that people who are at greater risk are the elderly and probably the very young. But it is part of the natural history of such infections that we will get deaths across the age ranges. The same pathophysiology can happen in the young as in the old.”

Roz Eggo speaks to…

(25/02) Channel 4 News (from 5:25) about the effectiveness of China’s containment efforts. Roz said: “It’s difficult to ascribe cause to effect, but there have been very strong interventions in China for over a month now and it does appear that the number of cases has been falling, and so that is good evidence that it is possible to decrease transmission of the virus. What that has really done is provide the rest of us more time to prepare.”

Adam Kucharski speaks to…

(26/02) Sky News about why reliance on symptom-based screening may be ineffective at curbing the spread of COVID-19. Adam said: “If you have a lot of people who travel in the incubation period they probably won’t have developed symptoms so won’t be picked up by screening. There is varying screening ability in countries, usually depending on how wealthy or not they are.”

(21/02) South China Morning Post about the apparent slow-down in coronavirus cases in China, consistent with his earlier predictions. Adam said: “However, we are cautious about claiming that recent patterns reflect a peak in transmission across China, as there have been changes in case definition, reporting and testing capacity that may also be influencing observed patterns. Transmission may also continue to change as control measures and social behaviour further adapt in response to the outbreak.”

(20/02) Forbes about the lessons that can be learnt from the coronavirus-hit Diamond Princess cruise ship. Adam said: “If passengers have had clearly defined exposures to other cases, it could be helpful for refining estimates of the incubation period and transmission risk following different types of interaction. However, a cruise ship is unlikely to be representative of spread in other settings, so it’s not clear how generalisable some of the information about transmission will be.”

Peter Piot speaks to…

(25/02) Peter Piot speaks to BBC Radio 4’s Today Programme (from 2:37:00) about the importance of global preparedness. Peter said: “We can’t be over prepared. Whether this is a pandemic or not is immaterial because it doesn’t make any difference to what we have to do. Every country has to prepare and some are better prepared than others. The UK have one of the best public health systems in in the world and all measures up to now have been able to contain the spread, but in today’s world an epidemic  thousands of miles away from here  is no longer just a local affair.”

(25/02) The Evening Standard about the likelihood of a vaccine being developed before the outbreak ends. Peter said: “I don’t expect that there will be a vaccine available for millions of people who would need it before the end of the year. I am very skeptical that we will have a vaccine before this epidemic is brought under control. But it may be very useful to have one if this becomes seasonal and every year we have a wave of this.”

(24/02) The New York Times about the situation in Iran, amid the country reporting the highest number of deaths from the virus outside of China. Peter said: “It is a recipe for a massive viral outbreak.”

Jimmy Whitworth speaks to…

(26/02) Bloomberg Radio about the ongoing spread of the outbreak. Jimmy said: “The worry is that it has now spilled over into a number of countries and regions in the world. In the Middle East we have this focus on Iran which is worrying because that’s getting into countries that have very weak health systems – places like Afghanistan and Pakistan. We’ve got an expansion of cases in Italy which is crossing borders and threatens Western Europe. This is an infectious disease, it does not recognise international borders and will spread wherever people move.”

(25/02) The Independent about the effectiveness of face masks in preventing the spread of coronavirus. Jimmy said: “There’s little evidence they are very effective. They’re more beneficial if you have a virus and don’t want to pass it on than to prevent catching anything.”

(25/02) BBC News about whether the outbreak could be considered a pandemic. Jimmy said: “I think many people would consider the current situation a pandemic, we have ongoing transmission in multiple regions of the world. The virus is spreading around the world and the link with China is becoming less strong.”

Brendan Wren speaks to…

(25/02) Brendan Wren speaks to BBC News about vaccine development for COVID-19. Brendan said: “There’s 30 or 40 groups worldwide currently developing vaccines against the coronavirus. An advantage here is that we only need a DNA sequence which the Chinese authorities made available immediately and that means from the DNA sequence we can rapidly make the antigens that will respond to the human immune system.”

(24/02) LBC about public health measures. Brendan said: “I’d advise good hygiene practice. Washing your hands even if it’s not endemic in this country.”

Other LSHTM experts…

(24/02) Sam Clifford talks to National Geographic about the effectiveness of air traveler screening for COVID-19. Sam said: “We’d probably only catch about 45 percent of infected travelers using exit screening. Out of the remaining 55 percent of people who aren’t caught, we can catch a few more on entry. You’ve got 42 percent of the people with coronavirus still making it into the country.”

(22/02) Peter Smith discusses vaccine development for the novel coronavirus in South China Morning Post. Peter said: “I would expect human studies on some candidates to start in the coming months, but the later stage studies which are required to test the safety and efficacy of a vaccine before licensure or widespread use seem unlikely to be completed this year.”

(20/02) Preliminary research by LSHTM’s Centre for the Mathematical Modelling of Infectious Diseases on the projected transmission rates of COVID-19 features in The Korea Times.

Further LSHTM coverage…

Stephan Evans comments on a study that found taking antibiotics in early pregnancy has some links to birth defects in The Independent. Stephan said: “It is already well-known that the prescribing of drugs, including antibiotics, should be done with caution in pregnancy. Even if the evidence for harm of macrolides in general is not as strong as these authors suggest, there is no real evidence of absence of harm. Caution is certainly reasonable.”

Mary Cameron discusses vector-borne diseases such as leishmaniasis on BBC World Service’s CrowdScience programme (from 03:00).

May van Schalkwyk about the safety of cigarette filters on BBC Radio 4’s Inside Health Programme.

Heidi Larson speaks to Yahoo! News about vaccination rates falling globally. Heidi said: “We thought the health intervention of vaccinating would be as normal as tooth brushing, but we’ve had some challenges. Concerns are safety, safety, safety.”

Analysis by LSHTM on the impact of a large-scale distribution of water filters on diarrhea and acute respiratory infection in Rwanda features in The Conversation.

How can locally-based research institutions support COVID-19 preparedness and response? African example

By: Professor Martin Antonio (LSHTM and WHO Collaborating Centre for New Vaccines Surveillance)

The global outbreak of novel coronavirus disease (renamed COVID-19) has brought to attention the preparedness of African countries and health systems to be able to address the COVID-19 outbreak. On 31 Jan 2020 the WHO Director-General, Dr Tedros Adhanom Ghebreyesus, declared the outbreak a public health emergency of international concern (PHEIC) and emphasised during this declaration that we are not yet aware of the damage this virus will do if it spreads to weaker health systems.

As of 24th Feb 2020, we know that there are an estimated 3-4,000 new cases being reported per day and 2,465 deaths globally with one death being reported in Egypt, Africa to date. The Africa CDC along with The MRC Unit The Gambia at the London School of Hygiene and Tropical Medicine (LSHTM) are building health capacity in Africa as part of health system strengthening efforts, including The MRC Unit The Gambia being the designated COVID-19 testing centre for The Gambia health services and in West Africa. We are employing the next generation whole genome sequencing as well as The Africa CDC’s real-time polymerase chain reaction (PCR) technique in order tounderstand the biology of the organism and help inform future vaccine design.

During the 2017 meningitis outbreak in Nigeria, some of the challenges facing Nigeria (and most of Africa) was health system strengthening and the importance of engaging policymakers to take heed of the outbreak. Once The MRC Unit The Gambia team had political support from the leaders of Nigeria, we were able to train the human health resources needed to contain the outbreak including health personnel (doctors, nurses, scientists, data managers etc.). We were also able to assist the ministry in financing the outbreak via WHO, UK Government and The MRC Unit The Gambia along with other partners. The information technology (IT) team were instrumental in ensuring that all the cases recruitment was linked to the disease. The medical supply team ensured vaccination kits, needles, reagents, fridges, freezers etc. were in place and successfully deployed.

For COVID-19 we need to similarly ensure strong leadership and governance as well as strengthening of the primary health care system to be able to prevent or at least adequately respond to future outbreaks within the community. For example, sharing appropriate standards of practice as well as deliverance of training are key. The utilisation of faith-based organisations to help spread these messages and social media messaging will also be vital within the region to increase public awareness and knowledge.

Conclusion

In conclusion, the case definition is of course different for COVID-19 in relation to other outbreaks but similar lessons can be learnt from previous outbreaks in terms of health systems strengthening and engaging policymakers. We will continue to work together with Africa CDC, WHO AFRO and The London School of Hygiene & Tropical Medicine to prepare Africa and our health systems in the event of an outbreak.


Image credit: CDC/ Alissa Eckert, MS; Dan Higgins, MAM – This media comes from the Centers for Disease Control and Prevention‘s Public Health Image Library (PHIL), with identification number #23312.

This illustration, created at the Centers for Disease Control and Prevention (CDC), reveals ultrastructural morphology exhibited by coronaviruses. Note the spikes that adorn the outer surface of the virus, which impart the look of a corona surrounding the virion, when viewed electron microscopically. A novel coronavirus, named Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), was identified as the cause of an outbreak of respiratory illness first detected in Wuhan, China in 2019. The illness caused by this virus has been named coronavirus disease 2019 (COVID-19).

Sugar levy had no lasting negative impacts on the UK soft drinks industry

In 2016, the Soft Drinks Industry Levy (SDIL) was introduced as part of the UK Government’s Childhood Obesity Plan. The levy applies to drinks containing more than 5g of sugar per 100ml, but not to fruit juices and milk-based drinks, or to companies with sales of less than one million litres per year. On its announcement, the soft drinks industry claimed the SDIL would negatively affect businesses across the soft drink supply chain, leading to job losses and a reduction in UK GDP.

To assess how the SDIL could have affected the industry, we conducted an analysis of stock market returns of soft drinks companies registered on the London Stock Exchange. We found that the abnormal stock returns in response to the SDIL news were negative but short-lived. We also observed continuous increase in the soft drinks companies’ stock prices over the following two years to the end of the study, despite widespread industry fears the tax would harm their businesses. This research which was published today in Economics & Human Biology was led by PHI|Lab members Dr Cherry Law, Dr Laura Cornelsen and Professor Richard Smith, in collaboration with researchers from Cambridge and Bath Universities.

How did we conduct this study?

This research looked at stock returns of companies quoted on the London Stock Exchange under the beverage sector, excluding private label producers and eliminating alcoholic beverage manufacturers. This resulted in four companies – including the largest UK soft-drink firm – listed on the London Stock Exchange*. We analysed stock returns from July 2015 to July 2018, noting four key dates – the SDIL announcement on 16 March 2016; the release of draft SDIL legislation and consultation summary on 5 December 2016; the announcement of SDIL rates on 8 March 2017 and when the tax came into effect on 6 April, 2018.

* The companies studied were: A.G. Barr Plc, Britvic Plc, Fever-Tree Drinks Plc and Nichols Plc. The analysis excluded UK operating soft drink producers not listed on LSE such as Coca Cola Enterprises.

What are the main results?

On the day of the announcement, three of the four soft drinks firms experienced a statistically significant and abnormal decline in their stock return but stocks had returned to their normal levels within four trading days.

Our findings show that while the stock market initially perceived the SDIL announcement as detrimental to the soft drink companies, negative financial impact might not be as substantial as claimed by industry in the news media. This research provides an important foundation for more research into the value of fiscal interventions aiming at improving public health.

This study is funded by the National Institute for Health Research (NIHR).

Reference:

Law C, Cornelsen L, Adams J, Penney T, Rutter H, White M, Smith R (2020) An analysis of the stock market reaction to the announcements of the UK Soft Drinks Industry Levy Economics & Human Biology https://doi.org/10.1016/j.ehb.2019.100834

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14 – 19 February

A snapshot of media coverage on the coronavirus outbreak:

Jimmy Whitworth speaks to…

(19/02) CBC News about the strain placed on China’s health services as a result of the outbreak. Jimmy said: “As seen in China, this virus can spread rapidly in populations, and can cause a major strain on health services simply by the sheer number of cases.”

(18/02) BBC News about the situation on the coronavirus-hit Diamond Princess cruise ship. Jimmy said: “It was absolutely the right thing to do to quarantine the ship because we need to protect the health of the general public. But it is clear that the measures have not stopped all transmission. We need to remember that most people on that ship are still uninfected, so it has been successful to some extent.”

(18/02) Reuters about the decline in new cases. Jimmy said: “We can hope that the reports of falling numbers of new cases in China do show that the epidemic has peaked in Hubei province, but it is still too early to be sure.”

(18/02) Daily Mail about the challenges of containing infections in confined spaces, amid over 500 people testing positive for COVID-19 on the Diamond Princess cruise ship. Jimmy said: “Cruise ships are crowded and people are very close to each other. This is a respiratory virus so it’s going to be spreading by droplet spread, close contact and contaminated surfaces about the place. This virus is highly transmissible and is tough to control in this circumstance.”

David Heymann speaks to…

(17/02) The Guardian about the difficulty in predicting the ease of COVID-19 transmission amid concerns over the disembarkment of passengers from the Westerdam cruise ship in Cambodia, after one passenger later tested positive. David questions: “Whether the countries where [departing passengers] go have the proper surveillance systems in places to detect and test those people should they develop any kind of a fever or any signs or symptoms of a respiratory infection?”

(17/02) Reuters about the role urbanisation plays in facilitating the spread of diseases such as coronavirus. David said: “Urban areas are unique and must develop solutions in addition to strong disease detection and response systems to rapidly control emerging infections.”

Adam Kucharski speaks to…

(16/02) The Sunday Times about the importance of collaboration in epidemiology, citing the 2014 Ebola outbreak. Adam said: “You have to be careful about numbers. I’d compare it to the 2014 Ebola outbreak: at one point we saw cases tailing off. Then we realised a hospital had filled up, so it simply wasn’t reporting any more cases.”

(15/02) Newstalk (from 16:11) about how mathematical modelling is helping to map the spread of diseases such as COVID-19. Adam said: “We can distil it down to a few key numbers. One of the key values we look at early on in an outbreak is the reproduction number… But it’s not just the amount of growth that we are concerned about, it’s also about the speed at which it happens – the generation time.”

John Edmunds speaks to…

(16/02) The Sunday Times about the likelihood of the coronavirus spreading throughout the UK. John said: “It doesn’t mean to say everybody is going to be seriously ill. The vast majority would have mild illness, a cough and a cold, then recover and be perfectly well.” John’s comments were also picked up by The Sun.

(15/02) BBC Radio 4’s Today Programme (from 50:30) about the likelihood of the coronavirus outbreak becoming a pandemic in the UK, following projections of 50% of Britons being affected. John said: “Based on what we know at the moment that is a distinct possibility. Rates of illness could be as high as that. It may be significantly lower but it doesn’t mean to say everybody’s going to be very seriously ill.”

Other LSHTM experts:

(18/02) Preliminary research by LSHTM’s Centre for the Mathematical Modelling of Infectious Diseases on the projected peak of the outbreak features in Nature, Bloomberg, The Times of India and The Japan Times.

(14/02) Ed Parker discusses his motivation behind developing a new coronavirus mapping tool on BBC World Service. Ed said: “I started following the story just at the same time as the rest of the world but I didn’t feel I was getting more understanding of the disease with each passing headline.”

Further LSHTM coverage:

Analysis by LSHTM on the proliferation of counterfeit medicine in sub-Saharan African featured in The Conversation.

Martin McKee is quoted in The Guardian about the harmful effects of e-cigarettes.