This is a personal view from London as the Covid-19 pandemic continues to spread here and the situation changes from day to day. As such it can only be a snapshot caught in time; it is not a diary of events. The Coronavirus Act 2020 gives Government enormous powers and was passed by Parliament in one day of debate immediately before it closed early for the Easter break. In March, the government imposed a “lockdown: the closure of all” but “essential” businesses and people other than essential workers must work from home but are allowed out for exercise and food shopping but must maintain 2 m apart, the “social distancing rule”. The aim is to suppress the spread of the virus, reduce the death toll and “protect the National Health Service (NHS)” which needed time to empty wards and expand its intensive care unit (ICU) capability to deal with an expected influx of thousands of very sick patients. I discuss whether this strategy is working, how and why it has rapidly been altered to respond to criticism. Why was the Government so slow to seek the help of private laboratories to assist with testing? Why was the personal protective equipment (PPE) guidance altered only after criticism? I look at the impact of the lockdown on the UK economy, the changes to practice of medicine and speeding of scientific research. Cooperating with the lockdown has its price; is it harming the health and mental health of children, people living in households with potentially abusive partners or parents and those who are disabled or financially desperate? Is the cure worse than the disease? The Economy is being devastated by the lockdown and each day of lockdown it is worse. Is litigation being seeded even now by the pandemic? Notwithstanding unprecedented Government financial help many businesses are on the edge of collapse, people will lose their jobs and pensioners income. The winners include pharmacies, supermarkets, online food retailers, Amazon, online apps, providers of video games, services, streaming and scientific research laboratories, manufacturers of testing kits, ventilators, hand sanitisers, coffins, undertakers, etc. The British public is cooperating with lockdown but are we less productive at home? Parents with babies and children often child minders, school, grandparents or paid help which is not now available. Will current reliance on video-conferencing and video calls permanently change the way we work and will we need smaller city offices? Will we travel less? Will medical and legal practice and civil and criminal trials be generally carried out remotely? Will social distancing with self-isolation and job losses and business failures fuel depression? Is Covid-19 comparable to past epidemics like the Plague and Spanish flu?

Introduction: It has been estimated that about 50% of screen-detected cases might be over-diagnosed and over-treated. In this paper we analysed the mortality of patients with screen detected cancers in the TARGIT-A trial in which patients >=45 years with an invasive duct carcinoma <=3.5 cm in size and suitable for breast conserving therapy were randomly allocated to receive either risk-adapted TARGIT IORT or conventional course of several weeks of fractionated external beam radiotherapy (EBRT). Method: This was a post-hoc subgroup analysis limited to patients whose cancers were detected by screening mammography, and we compared breast cancer mortality, non-breast cancer mortality and overall mortality between TARGIT and EBRT with Kaplan Meier plots and logrank test. The allocation of cause of death was performed by an independent clinician who was blinded to the randomisation arms of the trial. Results: A total of 3451 patients were recruited into the TARGIT-A trial. Of these, there were 2102 patients whose cancers were diagnosed by mammographic screening (61% of the total). There were 30 deaths recorded: TARGIT 10/1060vs EBRT 20/1042): 7 from breast cancer (TARGIT 4 vs. EBRT 3), 23 from other causes (TARGIT 6, EBRT 17). The overall survival with TARGIT was 2% higher than with EBRT (5-year rates: 98.03% 95%CI 95.97 – 99.04, vs 96.03% 95%CI 93.41 – 97.62, Logrank p = 0.0522), with a doubling of mortality from 2% to 4% in this population. The breast cancer-specific survival was identical between the groups (99%). The difference in overall survival was due to higher non-breast-cancer survival in the TARGIT arm (TARGIT 99.2% and EBRT 96.7%) attributable to deaths in the EBRT arm from cardiac causes and other cancers (TARGIT 3 vs. EBRT 14). Interpretation: Harm from overtreatment of patients with screen detected cancers eligible to receive TARGIT IORT (<3.5 cm ductal cancers), who form a large proportion of the eligible group, in the form of deaths due cardiac causes and other cancers could be potentially avoided if they were instead treated by receive TARGIT IORT instead of conventional external beam radiotherapy. After discussions and volunteers with personal case histories to relate and a break there was a final session to consider the ethical and legal responsibility of doctors in the new era of shared decision-making with a brief run-through of key cases by Suzanne White of Leigh Day solicitors and then a keen Q&A discussion. Should we try for a Judicial Review of the failure to provide IORT in the NHS? Should a case be brought under the Human Rights Act using crowd funding? Something must be done if the medical establishment does not put IORT into practice in the NHS round the country.

More concerns related to sex are once again being reported. However, on this occasion, the concerns relate to gender. Unfortunately, gender has a number of meanings including masculinity/femininity, sexual category and sexual role (and probably more). In this issue, Charles Lewis’s article discusses sexually related behaviour and current social attitudes and in particular to ‘equalising’ expectations to boys and girls, gender dysphoria and transgender within the school and other environments. It is worth exploring further some of the issues and confusions that may arise. For clarity, gender dysphoria refers to those who express discomfort at living as and being seen as their genetic gender. We may start by noting that females have two similar chromosomes labelled XX and males have one X and a rather scrubby little one labelled Y. These determine the usual physical characteristics for females and males. Transgender refers to those who have taken some form of action in order to be perceived as being of the other sex. Starting with gender dysphoria, it is as yet unclear as to why some children and young people feel they would prefer to be the other sex. There are several reasons that may and indeed can contribute differently in different young people; perhaps for some, there is an intrinsic physical factor, for others, early parental attitudes (you are my lovely boy, but I wish I’d had a girl) and for yet others, perhaps jealousy. Incidentally the overall rate of comorbid psychological problems, particularly anxiety and mood disorders, is higher in those with gender dysphoria than in the general population. There is research indicating that some of these people do better overall if they are enabled to live as the other sex whereas some, perhaps with help, seem to work through these feelings and then continue their lives according to their genetic sex. Unfortunately, transition to the other sex is, on the whole, better if it is commenced before puberty, but at that early stage, we do not have the means of knowing which option is best for each individual – namely, to remain in their genetic sex or to transgender to the opposite sex. More careful research is needed, particularly research that recognises that not all people with gender dysphoria are the same. Transgender itself raises a variety of difficulties in our current state of knowledge. Should a person be allowed to legally be considered of the other sex solely if they say that is how they see their own identity or should they have to agree to complete treatment for physical change to a nominated extent first? If somebody who is transgender gets into a relationship, should the law demand that they inform their partner of their gender origins? It may be that there are no rational answers to these and similar questions. A different matter relates to whether males and females should be treated in exactly the same way so that at schools boys can wear skirts etc. This perhaps raises a different question about what equality for boys and girls actually means. Males and females are not physically the same nor are they psychologically the same. Demanding identical behaviour is probably removing equality. Ensuring the boys and girls have the same educational chances and career opportunities whilst making allowances for their differences is probably more appropriate. However, what is probably most important is that these issues should not be considered as shameful, to be hidden and not talked about. It is to be hoped that articles of this nature will promote open and constructive discussion. In the meantime, perhaps it would be better if in schools we did not blur gender identity for young developing people.

How should a practitioner of “alternative” medicine be judged? Against the skills of others in the same field or those of orthodox medical practitioners? A landmark case reported on Oct 4 (2000 4 All ER 181) has for the first time considered this important issue in the UK.

On June 23, a UK High Court judge ruled that secret screening of complaints by the General Medical Council (GMC) was flawed and breached the Human Rights Act. He warned that in future the process had to be transparent and seen to be fair and more so when the doctor was still in practice.