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Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles.

Re: GPs in England should become “predominantly salaried,” says report backed by Javid
Re: GPs in England should become “predominantly salaried,” says report backed by Javid Jonathan Gornall. 376:doi 10.1136/bmj.o594

Dear Editor

Let's hope this is not the return to poorly kept Health Centres that it might be. State purchasing is just the start, maintenance and new building is just as if not more important. The value of GP investment over many years may have been seriously underestimated.

Competing interests: No competing interests

15 March 2022
Simon Price
GP retired
Chichester
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Teasing out the effects of Brexit from the spend on 2020-21: we may have more to worry about than COVID-19 itself
Re: The public finance cost of covid-19 John Appleby. 376:doi 10.1136/bmj.o490

Dear Editors

The COVID-19 health crisis, later a pandemic, came at a time when the UK was having a transition of national devolution and ultimately withdrawal from the European common market over 12 months in 2020, the current government having won the Dec 2019 election on their proposed version of the Brexit platform (except someone forgot to ask the EU if they agreed to it).

The UK's uncoupling from the EU has been expected to significantly (and negatively) impact many local businesses despite claims of better conditions for local markets having wrestled the bureaucratic control off Brussels; some predictions suggest requiring subsidies or monetary support for businesses to retain employment in various sectors. Many economists expected the UK's per capita income to be reduced in the long term as a result of Brexit, but the uncertainty of the protracted negotiation between London and Brussels over the actual terms of the divorce (including the threat of a "no deal" outcome) during the transition made the UK even less attractive to foreign investors.

All these during the first wave of the pandemic in Europe and the UK.

I am impressed that the National Audit Office can actually differentiate the impact of COVID-19 measures and uncertainty from those of the Brexit transition and the spectre of a no-deal withdrawal on UK businesses. Considering a large proportion (40%) of the estimated £260 billion spend so far is spent to prop up employment retention and payment, I cannot but help wonder about how the NAO managed to draw a line in the sand to attribute the risks to UK jobs as purely a healthcare/pandemic one, rather than Brexit.

Frankly we might never know what would have been the true effect of Brexit if the pandemic didn't come around at the same time, and I have certainly not addressed the other surprise in the report, that direct healthcare costs in the UK pandemic response only accounts for 20% of the spend, and worse, that the much criticised (ref 1) test and trace program alone accounts for 32% of the healthcare spend (or 7% of the overall COVID-19 costs).

If this reflects the expectations and standard of any new agency established under the Boris government, perhaps we have more to worry about than the COVID-19 pandemic itself.

Reference
1. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(21)00714-3/fulltext

Competing interests: No competing interests

14 March 2022
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia
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Re: South Africa's Health: Traditional healers in South Africa: a parallel health care system connecting tribal healers to primary health care: A dire need to alleviate health of indigenous and tribal populations
Re: South Africa's Health: Traditional healers in South Africa: a parallel health care system Rajendra Kale. 310:doi 10.1136/bmj.310.6988.1182

Dear Editor,

The article by Rajendra Kale (1) is indeed interesting and so is the motion by Suyesh Shrivastava and colleagues (2). The proposition of integrating traditional healers, especially in pockets where tribal and indigenous populations thrive, has been a long-standing one (3). It is well accepted that globally, and more so in developing countries like India and South Africa, the health status of the tribal and indigenous people languishes significantly when compared to the general population (4, 5). This has been the case in the present times and in 1995 when Rajendra Kale published the original article. Governments and institutions have pumped in enough money for the development of tribes (6), including their health, but the results are not encouraging. What has remained a constant is a reluctance and inhibition to recognize the traditional healer as a player, if not the key player, when it comes to the health of indigenous and tribal populations.

Let us see why it is important to integrate traditional healers to PHC in tribal and indigenous pockets and a bet worth taking for strengthening PHC delivery in such areas:

(i) According to the modern definition of PHC (7), it is important to focus on people’s health needs and that too as early as possible and as close as possible to people’s everyday environment. Today’s era is about ‘Health of the people, for the people and by the people’. In our view, the traditional healers very beautifully embody a people and community-centred approach and could augment in building better health care systems.

(ii) It is a fact that traditional healers are not “trained” in the modern medicine sense, but, at the same time, their knowledge is experiential imbibing the immense time spent by their predecessors in acquiring this knowledge. Further, it is not an absolute truth, rather a myopic view, that in every tribal community disease is construed only as disharmony in vital powers. For instance, Sowa Rigpa is a traditional medicine system having roots in tribal communities of the Himalayan region in India and defines fifteen categories of diseases in the Rgyud-bzhi text (8, 9).

(iii) In emergency cases golden hours are being missed only because people immediately report to the traditional healer is probably a harsh view. Rather, the lack of basic and emergency health care infrastructure in rural and tribal pockets of developing nations like India (10) is the fallout.

At last, it will be unfair to say that traditional healers only thrive in the absence of a public health system. Numerous studies are there from countries like South Africa, India, etc. (11, 12) which show that people make a conscious choice with valid reasons for going to these healers in times of distress. Rather, the responsibility of documentation, evaluation and validation of traditional therapies and practices must be taken over by the scientific community who is well versed with the appropriate methodologies, validation criteria and tools and techniques to do so. In real scientific terms, we cannot presume it to be an unverified system until no one has tried to do it.

In our view, the end goal in keeping with the ethos of SDGs should be to provide and make available acceptable health solutions to all marginalized sections of the society in their backyard. One possibility is that in tribal areas the modern medicine-based public health care system instead of counting on traditional healers, rather imbibes them in such a way that they act as agents to channelize people towards the system and in turn can keep alive their losing art. Thus, traditional healers act as facilitators of the public health system, especially in areas dominated by the presence of indigenous and tribal groups.

Competing interests: We declare no competing interests.
References:

1. Kale R. South Africa’s Health: Traditional Healers in South Africa: A parallel health care system. BMJ. 1995;310:1182–5.
2. Sharivastava S, Verma AK, Saha KB. South Africa’s Health: Traditional healers in South Africa: a parallel health care system | The BMJ [Internet]. BMJ. 2022 [cited 2022 Feb 28]. Available from: https://www.bmj.com/content/310/6988/1182/rapid-responses
3. Hammond-Tooke WD. Rituals and medicines : indigenous healing in South Africa. Ad. Donker. 1989.
4. Anderson I, Robson B, Connolly M, Al-Yaman F, Bjertness E, King A, et al. Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study. Lancet. 2016;388(10040):137–57.
5. Ministry of Health and Family Welfare G of I, Ministry of Tribal Affairs G of I. Tribal Health in India: Bridging the Gap and a Roadmap for the Future [Internet]. 2011. Available from: http://www.censusindia.gov.in/2011census/PCA/PCA_Highlights
6. Sharma N. Tribal welfare Scheme: Less than 50% of funds spent so far [Internet]. The Economic Times. 2018 [cited 2022 Mar 5]. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/tribal-wel...
7. World Health Organization. Primary health care [Internet]. 2021 [cited 2022 Mar 5]. Available from: https://www.who.int/news-room/fact-sheets/detail/primary-health-care
8. Dhondrup W, Tso D, Wangyal R, Dhondrup G, Liu Z, Dolma T, et al. Dataset of illness classifications in Sowa Rigpa: Compilations from the Oral Instructions Treatise of the Tibetan medical classic (Rgyud bzhi). Data Br. 2020;29.
9. Kloos S, Pordié L. The Indian Face of Sowa Rigpa. In: Kloos S, Pordié L, editors. Healing at the Periphery: Ethnographies of Tibetan Medicine in India [Internet]. NC: Duke University Press (sous presse,2021); 2021. p. 1–24. Available from: https://hal.archives-ouvertes.fr/hal-03102907/document
10. Behera M, Dassani P. Livelihood Vulnerabilities of Tribals during COVID-19 : Challenges and Policy Measures. Econ Polit Wkly [Internet]. 2021 [cited 2022 Mar 7];56(11). Available from: https://www.epw.in/journal/2021/11/commentary/livelihood-vulnerabilities...
11. Word Health Organization Regional Office for Africa. Traditional healers broaden health care in Ghana [Internet]. World Health Organization. 2019 [cited 2022 Mar 7]. Available from: https://www.afro.who.int/photo-story/traditional-healers-broaden-health-...
12. Maske AP, Sawant PA, Joseph S, Mahajan US, Kudale AM. Socio-cultural features and help-seeking preferences for leprosy and tuberculosis: A cultural epidemiological study in a tribal district of Maharashtra, India. Infect Dis Poverty. 2015;4(1):1–4.

Competing interests: No competing interests

14 March 2022
Nishant Saxena
Scientist 'B'
Stuti Singh (Project Scientist 'B', ICMR-RMRC Gorakhpur, Field Station Keylong, Himachal Pradesh - 175132, India)
ICMR - National Institute of Research in Tribal Health (NIRTH), Jabalpur, India
Room No. 115, ICMR-NIRTH Complex, Nagpur Road, Jabalpur -482003, Madhya Pradesh, India
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Re: Sixty seconds on . . . RSV
Re: Sixty seconds on . . . RSV Jacqui Wise. 376:doi 10.1136/bmj.o590

Dear Editor

At present in the UK, the rates of respiratory syncytial virus (RSV) infections are low. This is considered to be due to the covid-19 pandemic, which led to lockdowns and hygiene measures involving use of face masks and hand washing measures leading to reduced spread of all viruses (1).

Dr. Ryohei Hirose and colleagues from Japan have observed that washing of hands even without soap (washing of hands with rubbing under running water) removes mucus and viruses (2). Hand hygiene procedures are helpful in reducing the spread of infections at home and in the community (3). Wearing a face mask also helps in protection of respiratory viral infections (4). But the eyes are not protected with this. (4) In addition to frequent hand washing, physical distancing and use of face masks and eye protection also helps in prevention of the spread of RSV (5).

Frequent hand washing is helpful in preventing spread of RSV diseases, other respiratory infections and gastrointestinal infections which are prevalent in many countries.

References:
1. Wise J Sixty seconds on . . . RSV BMJ 2022;376:o590
2. https://www.cidrap.umn.edu/news-perspective/2019/09/hand-sanitizer-shown...
3. Bloomfield SF, Aiello AE, Cookson B, O'Boyle C, Larson EL. The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers. Am J Infect Control. 2007;35(10):S27-S64.
4. Cherry JD. The Role of Face Protection for Respiratory Viral Infections: A Historical Perspective. J Pediatric Infect Dis Soc. 2020;9(4):411-412.
5. Chu DK, Akl EA, Duda S, et al. . Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. Lancet 2020. doi:10.1016/S0140-6736(20)31142-9

Competing interests: No competing interests

14 March 2022
Suraj M Math
Specialty Registrar. General Surgery,
General Surgery, WWL NHS Trust, UK
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Mr Javid wants prevention without policy
Re: What needs to be done to make the NHS fit for the future? Chris Ham. 376:doi 10.1136/bmj.o641

Dear Editor,

Sajid Javid’s sweeping speech to the Royal College of Physicians on the 9th of March should be carefully scrutinised by healthcare professionals as it gives us a good indication of the ideology informing health care policy1. The speech opened with the usual bluster about healthcare being free at the point of care and the often-quoted argument that the NHS at inception was designed for infectious rather than chronic disease and a population a fraction of the size it is today. It was peppered with platitudes (”It’s not just three letters; it’s a whole ecosystem”) and inane quotes (“ It’s about being able to weather a storm and recover”) but on closer inspection it is also Mr. Javid communicating the ideology that is informing his attempt to reform the NHS. He repeatedly reminded us that he is a small state conservative but struggled to outline what that actually means in terms of how you craft healthcare policy (“There is no small state which isn’t a ‘pre-emptive state’.”)

We should applaud Mr. Javid for specifically highlighting the importance of prevention; it appears it has taken a pandemic for the conservative government to finally understand what public health actually is and does. Mr. Javid specifically mentions cardiovascular disease as an area that he wants to address through this new prevention strategy and cites a story of how family intervention was the key to helping his father quit smoking. This personal anecdote reveals where Mr. Javid continues to make the same mistakes about the prevention of cardiovascular disease as his “small state” predecessors. Of course, families can help individuals quit smoking, but it is thanks to a barrage of tobacco control legislation over the last 3 decades that have ensured that smoking prevalence has dropped on a population level and many thousands of lives have been saved.

Addressing cardiovascular disease risk on a population level is not something that can be done with simply more testing centres and some family involvement as Mr. Javid suggests. Individuals in the UK, and in particular those from more deprived areas, continue to live in environments that are full of risk factors for cardiovascular disease. Truly addressing cardiovascular disease prevention requires brave legislation and tackling issues that lie outside of a health service such as improving air quality, tackling obesity through levies on unhealthy foods, and investing in active travel infrastructure to promote healthy lifestyles. Mr Javid wants to ensure that the NHS does not become a “national hospital service”, to achieve this lofty aim he should remind himself of the policies and legislation that have been so successful in reducing the populations cardiovascular risk to date.

Dr. Jonathan Hudson MPH MRCP DTM&H
Cardiology Registrar South London
NIHR Academic Clinical Fellow

Competing interests: No competing interests

14 March 2022
Jonathan Hudson
Cardiology Registrar
London
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Gender based employment research needs to be considered in context
Re: Most female doctors return part time after maternity leave, analysis shows Ingrid Torjesen. 376:doi 10.1136/bmj.o635

Dear Editors

I would like to point out a few things not entirely reflected in this article, and perhaps put some findings in the right context.

1. "Female doctors in male dominated specialties were less likely to go on maternity leave, and those that did returned on higher contracted hours. For example, fewer than one in four cardiothoracic and vascular surgeons are women, and the average FTE hours of female surgeons returning from maternity leave was 18% higher than for female doctors returning to acute internal medicine."

This may be related to life-style choices or self-selecting personality traits which value their work very high on their priorities.

However the actual report by Kelly & Stockton further speculates on this phenomenon:

"There is clear evidence that working patterns after maternity leave differ by specialty. This descriptive evidence does not however allow us to draw conclusions as to why this is the case. The hours that we observe may be down to selection: women who choose to specialise in these male-dominated specialties may also prefer to work more hours. Alternatively, it may be that some women in these specialties would prefer to work fewer hours but feel unable to do so. This could be due the workplace culture, potential career consequences or because requests for lower FTE contracts are not approved. This would have implications not just for the women currently working in those specialties, but the specialty choice of young women before they have children."

If there is any unwritten rule about lower FTE hours contracts in these surgical specialities, I would have expected it would apply equally to all genders within the craftgroup, although some may not consider equal treatment as equity in view of perceptions of personal need.

2. This article lauded the finding that "while female doctors returning after maternity leave are likely to work shorter hours, they are also more likely than average to stay working in the NHS than male and female doctors overall. The data show that 91% of female doctors and dentists are still working in the NHS acute and community sectors two years after starting maternity leave compared with a male and female average of 88%."

I would like to point out the male and female average of 88% includes very much those in the retirement age whereas the female doctors and dentists taking maternity leave are very likely at a much younger age, with a less stable financial foundation, probably debt from studies and other personal priorities, so the need to maintain some form of income longer than 2 years after maternity leave is of no surprise. Hence that should not be any surprise to anyone.

Gender research can be highly nuanced with many findings needed to be considered in the appropriate context.

Reference
1. Kelly E, Stockton I. lnstitute for Fiscal Studies briefing note: maternity and the labour supply of NHS doctors and nurses. March 2022. https://ifs.org.uk/uploads/BN340-Maternity-and-the-labour-supply-of-NHS-....

Competing interests: No competing interests

14 March 2022
Shyan Goh
Orthopaedic Surgeon
Sydney, Australia
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Re: Release of vulnerable people from immigration detention is often medically unsafe and chaotic, says charity
Re: Release of vulnerable people from immigration detention is often medically unsafe and chaotic, says charity Adrian O’Dowd. 376:doi 10.1136/bmj.o583

Dear Editor

We applaud Medical Justice for their report showing discontinuities of care for people released from immigration detention (1), as highlighted by O'Dowd (2). The Home Office responded by claiming they work closely with relevant partners to "ensure the safe release" of detainees (2).

However, the Home Office safeguards to protect vulnerable individuals who are detained have been criticised as being unfit for purpose in a review which they themselves commissioned (3). Although the Home Office introduced an ‘Adults at Risk’ policy purporting to address the concerns identified, the follow-up to that review in 2018 highlighted that its recommendations had not been acted upon sufficiently and that major deficiencies in care remained, including regarding continuity of care (4). Although further changes to the Adult at Risk policy have been made, its fundamental flaws remain, which was reiterated in the Independent Chief Inspector of Borders and Immigration’s recent review in October 2021 (5).

In our collective experience, independent research within immigration detention is rendered virtually impossible by bureaucratic barriers, leaving the only feasible research being with people who have already been released into the community – this itself is challenging because people are widely dispersed following release (6). It is time that these bureaucratic barriers to research are removed and that high-quality independent research within detention centres is permitted.

Furthermore, all doctors have requirements under the General Medical Council's Good Medical Practice to ensure adequate continuity of care for their patients, raise concerns and evaluate their performance (7). These requirements extend to immigration detention healthcare. The Home Office, detention centre subcontractors and detention centre healthcare providers must initiate and support their own research and service evaluation, and review findings critically and openly in order to ensure continual improvement.

1) Medical Justice. Detained and discarded: vulnerable people released from immigration detention in medically unsafe way. March 2022. http://www.medicaljustice.org.uk/wp-content/uploads/2022/03/2022_Detaine....
2) O’Dowd A. Release of vulnerable people from immigration detention is often medically unsafe and chaotic, says charity, BMJ 2022; 376 :o583 doi:10.1136/bmj.o583
3) Shaw S. Review into the welfare in detention of vulnerable persons. Jan 2016. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...
4) Shaw S. Welfare in detention of vulnerable persons review: progress report. July 2018. https://www.gov.uk/government/publications/welfare-in-detention-of-vulne...
5) Independent Chief Inspector of Borders and Immigration. Inspection Report Published: Second Annual Inspection of ‘Adults at risk in immigration detention’, Oct 2021. https://www.gov.uk/government/news/inspection-report-published-second-an...
6) Chaplin L, Ng L, Katona C. Refugee mental health research: Challenges and policy implications. BJPsych Open 2020; 6(5), E102. doi:10.1192/bjo.2020.90
7) General medical council. Good medical practice. April 2013. https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/goo...

Competing interests: MP has personal experience of the UK asylum system and immigration detention. LZW, CK and MP are members of the Royal College of Psychiatrists’ Working Group for the Health of Refugees and Asylum Seekers. CK is medical and research director at the Helen Bamber Foundation, a human rights charity. FA is clinical director of Forrest Medico-Legal Services. He conducts forensic medical examinations in connection with claims of human rights abuses by asylum seekers and others and is sometimes paid for doing so.

14 March 2022
Lauren Z Waterman
ST6 Psychiatry Trainee
2) Frank Arnold - Doctor - Medact, Grayston Centre, London N1 6HT, UK; 3) Mishka Pillay – Trustee and lived experience campaigner – Freedom from Torture, London, UK; 4) Cornelius Katona – Medical and research director - Helen Bamber Foundation, London, UK
South London and Maudsley NHS Foundation Trust
Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK
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Re: Review of gender identity services for children and young people
Re: Review of gender identity services for children and young people Hilary Cass. 376:doi 10.1136/bmj.o629

Dear Editor,

We welcome the

Independent review of gender identity services for children and young people: Interim report (the "Cass Review").- https://cass.independent-review.uk/publications/interim-report/

We are also pleased to see this opinion piece by Dr Cass in the BMJ encouraging clinical staff at all levels in the NHS and the Royal Colleges to support the findings of the report and work to improve the quality and safety of care of these children and young people with gender dysphoria. We also welcome the recommendation in the Cass report that any other clinical presentations be addressed, and that psychological and social support be available.

This is a detailed and thorough report and addresses many of our concerns as clinicians. The report makes clear that the very rapid rise in the number of cases and the large changes in the demographics of the patient population mean that the current model is the wrong model and that a national service provider is the wrong structure. The report makes clear the very poor evidence base for treatment.

It helpfully states that an affirmative approach is not appropriate for this patient group and is at odds with the ordinary practice of clinical care. The interim report provides an excellent overview of the risks of puberty blockers and also the lack of clinical evidence for their effectiveness. It clarifies that social transitioning should not be regarded as a neutral intervention.

We are particularly pleased that the review has chosen to include within its recommendation young people aged 16-25.

Dr David Bell
Retired Consultant Psychiatrist

Dr Lucy Griffin
Consultant Psychiatrist

Dr Seth Bhunoo
Consultant Psychiatrist

Dr Sallie Baxendale
Consultant Neuropsychologist. Honorary Associate Professor UCL

Dr Az Hakeem
Consultant Psychiatrist. Hon Clinical associate professor UCL

Dr Louise Irvine
GP

Dr John Higgon
Consultant Clinical neuropsychologist

Dr Angela Dixon
GP

Dr Madeleine Ni Dhalaigh
GP

Dr Robin Ion
Senior lecturer in mental health nursing

Bob Withers
Analytical Psychotherapist

Prof David Pilgrim
Chartered Clinical Psychologist

Dr Maja Bowen

Dr Tessa Katz
GP

Dr Ellen Wright
GP

Competing interests: No competing interests

13 March 2022
Angela Dixon
GP
Dr David Bell, Dr Lucy Griffin, Dr Seth Bhunoo, Dr Sallie Baxendale, Dr Az Hakeem, Dr Louise irvine, Dr John Higgon, Dr Madeleine Ni Dhalaigh, Dr Robin Ion, Bob Withers, Prof David Pilgrim, Dr Maja Bowen, Dr Tessa Katz, Dr Ellen Wright
Kirkcaldy Health Centre KY1 2NA
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Re: UK’s foundation training programme for 2022 was oversubscribed by almost 800 places
Re: UK’s foundation training programme for 2022 was oversubscribed by almost 800 places Pat Lok. 376:doi 10.1136/bmj.o650

Dear Editor,

I read this article with interest. It raises a question - what would be the impact on the future workforce? Are we heading into excess of doctors? Do we not have enough doctors or do we not have enough doctors to fill the rota gap? As currently junior doctors could only work 48 hours per week, inevitably there would be a gap in the rota in 24hrx7 hospital.

In the past few years, the UK government has opened up more than 10 new medical schools, the aim being to expand the "home-trained" doctors to 1.5K by 2024 (1). We are not yet in 2024. Additionally, there are limited higher speciality training post to accommodate the increase in junior doctors, as the availability of the higher speciality job posts has barely changed in past years. For those who cannot get into speciality training - what are they going to become? Or they would just need to reapply again until reaching the limits of the system?

Reference
1. https://assets.publishing.service.gov.uk/government/uploads/system/uploa...

Competing interests: No competing interests

13 March 2022
David Li
Foundation Doctor
ST George Hospital
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Re: Russia’s war: Why The BMJ opposes an academic boycott
Re: Russia’s war: Why The BMJ opposes an academic boycott Kamran Abbasi. 376:doi 10.1136/bmj.o613

Dear Editor,

In this article, in which you cannot resist the temptation to call the UK government’s attitude to refugees ‘immoral’, you advance the weak reason for not boycotting papers from Russia, that you don’t want to ‘risk further marginalising Russian scientists speaking for peace.’

The open letter from Russian health professionals you quote, with its 1000s of signatories, is clearly a self-censored document or a put-up job which goes out of its way to say ‘We are not looking for the guilty and we do not judge anyone’. It’s predictable that the effect of this appeal, assuming it’s genuine, on Putin the dictator of Russia, will be zero.

Dr Leo James’ robust view (11 March 2022) is what’s needed: ‘The only way in which the despotic Putin will be thwarted [is] by the systematic and total isolation of Russia from every and all engagement with the global community.’

The BMJ should do no less.

Yours sincerely,

Gabriel Symonds

symonds@tokyobritishclinic.com

Competing interests: No competing interests

13 March 2022
Gabriel Symonds
General practitioner
Tokyo, Japan
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