More comprehensive understanding of gender inequality is required, particularly the broader structural drivers that underpin the political economy of gender power relations, say Asha George and colleagues In sub-Saharan Africa, four out five new HIV infections among 15-19 year olds are in girls according to UNAIDS 2019 estimates.1 Surveys during 2011-16 showed that more than half of rural women aged 15–24 in sub-Saharan Africa had been pregnant before their 18th birthday,2 and as recently as 2016, 40% of young women in sub-Saharan Africa and 30% in South Asia were married while still children.3 These examples highlight how gender power relations profoundly affect adolescent girls with lifelong consequences. Research on gender inequality in global health has focused on factors operating at the individual level (age of marriage, literacy, etc), household level (decision making, household composition4), or community level (social norms,56 access to services78). Although gender inequality is experienced by and between individuals, it is also a result of power relations that structure how societies are organised, laws are set, economies function, and ideologies are shaped.9 We review some of these structural determinants of gender inequality, unpacking what they are and why they matter, with a focus on the sexual and reproductive health of adolescent girls. Puberty is a formative period of rapid physical, cognitive, social, emotional, and sexual development, when differences in gender roles and gender inequalities become ingrained.10 These influence adolescent mortality and risk factors everywhere but particularly in low income countries (tables 1 and 2). Gender norms that encourage men to be strong and take risks partly explain the health harming risk behaviours of boys.1112 Gender inequalities are also particularly harmful to the sexual and reproductive health of adolescent girls and reverberate with lifelong effects. View this table: Table 1 Leading causes …

Progress has been made in priority interventions, but we need new measurement systems that include the whole life course and give better assessment of equity of coverage, argue Jennifer Requejo and colleagues Embedded within the framework of the United Nations sustainable development goals (SDG) for 2030 is the principle of equity, with the aim of reaching universal health coverage. Soon after the framework was adopted in 2015, the Every Woman Every Child global strategy for women’s, children’s and adolescents’ health was launched.12 The global strategy translates the SDG agenda into concrete guidance on how to accelerate progress in women’s, children’s and adolescents’ health through a multisectoral approach. It includes a monitoring framework with 60 indicators to help countries and their partners promote accountability in ending preventable deaths (survive), ensuring health and wellbeing (thrive), and expanding enabling environments, so that all women, children, and adolescents can reach their potential (transform).3 Previous assessments show mixed progress, with some indicators advancing more rapidly than others but with pervasive inequities between and within countries.4 The Countdown to 2030 initiative also regularly tracks progress in the countries experiencing the highest burdens of maternal and child mortality. Countdown’s 2017 report,5 together with those from Every Woman Every Child, highlight laudable reductions in maternal and child mortality over the past two decades, but many settings will need to increase efforts to achieve the 2030 goals. Coverage of essential health interventions is unacceptably low in many contexts and among specific populations; considerable policy and programmatic work is needed to shore up primary healthcare systems to make universal health coverage a reality.5 We combine the countdown and global strategy indicators to take stock of progress in all 138 low and middle income countries plus Panama, which was reclassified as a high income country …

Poor nutrition contributes substantially to global disease, diminishing the wellbeing of women and children in low and middle income countries, and better nutrition must be part of the universal health coverage agenda, say Rebecca Heidkamp and colleagues ### Key messages Over the past decade, global efforts to raise awareness of malnutrition have been accompanied by national movements to gain high level political commitment and accelerate actions, proved to work, to improve nutrition.1 Despite this momentum, by 2018 just under half of countries are on track to meet at least one of nine nutrition related targets set by the World Health Assembly for 2025 (table 1).4 Many countries are not achieving the goals because coverage of effective interventions remaHealth systems are the primary vehicle for nutrition interventions in many low and middle income countries. Ideally, health systems reach women and children through frequent antenatal care, normal and emergency delivery services, early postnatal care, and preventive and curative care throughout early childhood. Nutrition interventions commonly include counselling about diets and infant and young child feeding during antenatal care, postnatal care, and for the first two years of life. Additionally, weight gain is monitored and nutritional …

Geoffrey Lester, associate clinical lecturer and basic physician trainee in Sydney, Australia, tells Francesca Robinson why he always takes a lunch break “It’s important for me to make time to eat and have a break, irrespective of what’s going on in my working day,” Lester says. “I can’t function in the afternoon if I don’t have a full belly and some coffee at lunchtime.” This is a concept that was drummed into him as a child. “My dad always drilled into us the importance of sitting down and having a good lunch with time to allow it to digest,” he explains. Aged 34, Lester is more conscious than most people of the importance of a healthy lifestyle, having nearly died three times as the result of a ruptured aorta. He has non-syndromic thoracic aortic aneurysm and dissection …

Lack of capacity means the specifications are set up to fail Back in July when primary care networks (PCNs) got off to a flying start, I warned of two key risks to this good beginning.1 The first was that these emergent PCNs would get overburdened with too many commitments, and the second that some commitments might look sensible in theory but prove too hard to implement in practice. These risks exist because of the multiple challenges to which primary care networks are meant to be the answer: firstly, to stabilise general practice given the current workforce and morale crisis; secondly, to bridge a gap in the evolving reformed structure of the NHS by acting as the principal link between general practice and the rest of the health and care system; and, lastly, to deliver key elements of the long term plan through a set of new service specifications. In December, NHS England and NHS Improvement released five …

A marathon that requires a concerted effort If the sustainable development goals (SDGs) were a marathon we’d be approaching the 14 km mark after a slow start. There would be more than 28 km still to go, and everyone has to finish the race. We’re entering the final 10 years of the SDGs. Some runners are already falling behind and are at risk of not making the 2030 finishing line. The precursors to the SDGs, the millennium development goals, created an impetus that led to unprecedented progress in maternal and child health.1 Even though reducing inequalities was not explicit in the goals’ 2015 targets, disadvantaged populations often made faster progress than more privileged populations in the goals of improved maternal and child survival and coverage of health interventions mainly because they started from a very low baseline.23 The progress made should be applauded, but the millennium development goals were a marathon that many participants could not complete. Most of the 2015 targets were not met, and poor-rich and other inequities remained large. The SDGs’ mantra, which all countries signed up to through the United Nations, is “Leave no one behind.” The 2030 goals target health and wellbeing for all and the UN’s …

Stronger accountability is key In 2015 the UN secretary general launched the Every Woman Every Child (EWEC) global strategy to give new momentum to the urgent task of transforming the health of women, children, and adolescents by 2030.1 One of its recommendations was to convene an independent panel to regularly review progress on the global strategy’s targets and the sustainable development goals (SDGs). The EWEC independent accountability panel was established in 2016 and advocates for a shared understanding of accountability founded on human rights. The panel uses a monitor, review, remedy, and act framework that has evolved over a decade of experience.2 Our role is to review the results of progress reports on the health of women, children, and adolescents and to make recommendations to tackle failings A new collection of articles published by The BMJ and BMJ Global Health (www.bmj.com/leaving-no-one-behind) offers insight into how countries are progressing towards their EWEC and SDG targets with a focus on equity. Two overarching issues that could prevent countries achieving their targets by 2030 are apparent. Firstly, as noted in several articles in the collection, global progress is too slow and too uneven. Barriers to progress include violation of rights and structural disparities in society, such as entrenched gender and …

Wield is right to point out that staff grade, associate specialist, and specialty (SAS) doctors make a vital contribution to clinical care and that too often that contribution is overlooked.1 But it would be wrong to say that the General Medical Council fails to recognise their plight. We recently published …

We thank Martin for her response to our editorial.12 Electronic health records bring many benefits for patients, health professionals, and the NHS.3 Health …

How reassuring that The BMJ allows authors to perpetuate myths, albeit whimsically, encouraging us all to do likewise, without fearing pedantic intervention from editors or rabid responses.1 Kasten’s assertion that George Bernard Shaw said that the USA and the UK were “two nations, divided by a common language” is unsupported by evidence.2 Oscar Wilde, however, in The Canterville Ghost (1887) wrote that …

A UK epidemiologist and Cochrane Collaboration researcher is suing the drug company Roche in the US, claiming that it defrauded federal and state governments by falsely claiming that its antiviral drug oseltamivir (Tamiflu) could be a powerful tool in mitigating a flu pandemic. Tom Jefferson, a frequent contributor to The BMJ, is suing as a private whistleblower for $1.5bn (£1.1bn; €1.4bn), roughly the amount that US public health authorities spent building up their pandemic stockpile of oseltamivir. The stockpile is still maintained today, though recent purchases have involved generic versions, as Tamiflu’s main patent expired in 2016. Should Jefferson win, he would be awarded up to 30% of any monies recovered, while the rest would be returned to public coffers. Jefferson’s Cochrane acute respiratory infections group was engaged by the UK government to undertake a major review of the effectiveness of oseltamivir in 2009, after …

Most patients and general practitioners prefer outpatient letters to be written directly to patients Ask patients’ permission before sending them printed letters; written consent is needed for letters via email Consider patients’ best interests and whether the content could be harmful before writing directly to them In many countries (including the UK and Australia) it is still common practice for hospital doctors to write letters to patients’ general practitioners (GPs) following outpatient consultations, and for patients to receive copies of these letters. However, our experience suggests that hospital doctors who have changed their practice to include writing letters directly to patients have more patient centred consultations and experience smoother handovers with other members of their multidisciplinary teams.1 Writing letters to patients is also being used as an educational tool for improving medical students’ empathy and rapport with patients.23 A large proportion of patient complaints and litigation originate from poor communication.4 Correspondence that is delayed, not patient centred, and lacking information has been highlighted as a risk to patient safety.5 Writing prompt letters directly to patients can help reduce these risks.6 In this article, we offer practical advice on how to construct letters to be sent directly to patients, and suggest how these letters might encourage collaborative working centred on patients’ needs and wishes. Evidence on this topic is limited but includes a small number of quality improvement studies looking at the impact of clinic doctors writing letters directly to patients or to the parents of paediatric patients, and these have consistently shown positive outcomes. Four of us—Hugh Rayner, Nigel Mathers, Peter Rees, and Robina Shah—contributed to the 2018 guidelines on writing outpatient letters to patients for the Academy of Medical Royal Colleges (AoMRC) in the UK.7 These guidelines were based on our personal …

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

NHS England is establishing an expert panel to set out how the NHS can get to “net zero” on greenhouse gases ahead of the national target of 2050, the world’s first major health service to do so. The expert panel will examine changes that can be made to reduce the NHS’s carbon footprint by looking at its supply chain and energy use. It will submit an interim report to NHS England in the summer, and the final report is expected in the autumn, ahead of the COP26 climate change summit in Glasgow in November. In the UK, healthcare is responsible for 5.4% of the country’s net emissions, says a recent a report from Health Care Without Harm.1 The causes of air pollution and climate change are often the same, and both contribute to increased pressure on health services. …

NHS England has announced plans to create multidisciplinary rapid response teams that will provide support for older people and adults with complex health needs who have very urgent care needs. However, clinicians have warned that the plans must not divert staff and funding away from existing services or place additional pressure on them. The rapid response teams, which will be piloted at seven sites in England, will comprise a mix of NHS staff including GPs, specialty and associate specialist doctors, nurses, physiotherapists and occupational therapists, and social care staff. Backed by £14m of investment, the teams will launch in April, aiming to get at least three areas fully up and running by next winter. NHS England said that the teams would …

Richard Horton's Comment was extremely heartfelt, and we felt as if it were phrased in our very own words. For more than 10 years, the Integrated Curriculum for Anthroposophic Medicine at Witten/Herdecke University has been teaching medical ethics through the example of medicine in national socialism. In 2017, in light of increasing concerns about dehumanisation in medicine, we strengthened our efforts and developed a 3-year elective interprofessional curriculum entitled Cultivating Medical Awareness and Ethics through the Example of Medicine in National Socialism. This curriculum includes seminars, individual and small group reflection on documentaries of survivors, readings on the history of medicine during national socialism and the Holocaust (including stories of survival and resistance),,  and study excursions to memorial sites (eg, Auschwitz or the Hadamar euthanasia centre). The health humanities component includes reflective writing, arts, and meditation (guided by author HSW). At the end of each year, students organise a public symposium to present their experiences within self-selected topics related to course themes.

On behalf of the international group of academics, bioethicists, and clinicians that created the , which calls for mandatory teaching about the legacy of health professional involvement in the Holocaust in all health profession training programmes—we applaud Richard Horton's efforts to emphasise the importance of this topic.

In an article discussing the Holocaust and medicine, Shmuel Reis wrote “Medicine is a hierarchical profession…the combination of elements of hierarchy, obedience, and power constitutes a risk factor for abuse of power”. This suggests that members of the medical profession were at higher risk for Nazi ideology. The role of lawyers, priests, the media, and politicians appears to have been disregarded—and all have a certain influence over people who obey authorities.

Oxygen therapy is one of the most ubiquitously applied therapies in modern medicine. Clinicians usually react rapidly to declining oxygen saturations. Although this response is appropriate in the setting of hypoxia, there are many circumstances in which excess oxygen is indiscriminately administered for extended periods. Medicine has recently experienced a shift from “more is better” to “less is more” as more has been learned about the ability of the human body to adapt to extreme physiological conditions and about the inappropriate use of various therapies. Examples include hemoglobin thresholds and carbon dioxide levels. Attention in recent years has focused on the potential harms associated with excess oxygen therapy. Oxygen toxicity was first recognized clinically in an outbreak of retinal hyperplasia in premature infants leading to childhood blindness in the 1940s. Reports of oxygen pneumonitis were first described in the 1970s when autopsy findings demonstrated lung injury across patients who were exposed to concentrations of oxygen greater than 0.60 for at least 3 days of mechanical ventilation. In critical care, an early focus on harms of hyperoxia was attenuated after recognition of ventilator–associated lung injury, which shifted the cause from hyperoxia to injurious ventilation.

Ambient intelligence in hospitals is an emerging form of technology characterized by a constant awareness of activity in designated physical spaces and of the use of that awareness to assist health care workers such as physicians and nurses in delivering quality care. Recently, advances in artificial intelligence (AI) and, in particular, computer vision, the domain of AI focused on machine interpretation of visual data, have propelled broad classes of ambient intelligence applications based on continuous video capture. One important goal is for computer vision-driven ambient intelligence to serve as a constant and fatigue-free observer at the patient bedside, monitoring for deviations from intended bedside practices, such as reliable hand hygiene and central line insertions.1 While early studies took place in single patient rooms,2 more recent work has demonstrated ambient intelligence systems that can detect patient mobilization activities across 7 rooms in an ICU ward3 and detect hand hygiene activity across 2 wards in 2 hospitals.4 As computer vision–driven ambient intelligence accelerates toward a future when its capabilities will most likely be widely adopted in hospitals, it also raises new ethical and legal questions. Although some of these concerns are familiar from other health surveillance technologies, what is distinct about ambient intelligence is that the technology not only captures video data as many surveillance systems do but does so by targeting the physical spaces where sensitive patient care activities take place, and furthermore interprets the video such that the behaviors of patients, health care workers, and visitors may be constantly analyzed. This Viewpoint focuses on 3 specific concerns: (1) privacy and reidentification risk, (2) consent, and (3) liability.

Phase III trials of the RTS,S malaria vaccine identified three safety concerns: higher risks of meningitis, cerebral malaria, and doubled female mortality These safety concerns are now being investigated in pilot implementation studies with 720 000 participating children in Ghana, Kenya, and Malawi, planned to last 4-5 years Owing to the urgency of improving malaria control, the World Health Organization intends to decide on extending the vaccine to other African countries after only 24 months using the prevention of “severe malaria” as a surrogate marker for overall mortality Severe malaria is not a good marker for all cause mortality; it is not even a good marker for malaria mortality, as data indicate that case fatality from severe malaria might be higher in the malaria vaccine group An early decision after 24 months might be biased in favour of the vaccine, which was more efficacious in the first year of follow-up in the phase III trials; the relative risks of both cerebral malaria and female mortality increased after the booster dose at 20 months We recommend that the pilot studies use “overall mortality” to assess vaccine performance and that study populations are followed for the full 4-5 years of the study before a decision on rollout is made World malaria day on 23 April 2019 saw the start of the first routine malaria vaccine programme in Africa—a pilot study in Malawi. Ghana and Kenya have now followed. The RTS,S/AS01 malaria vaccine has been under development by GlaxoSmithKline for 30 years and is the first malaria vaccine to receive regulatory approval for human use. The pilot study aims to enrol 720 000 children in vaccination and control clusters over a two year period; it is planned to last about 50 months. Media and leading medical journals have celebrated the news,1234 …

A career in obstetrics and gynaecology is flexible, exciting, and fulfilling. There is a great variety of work within the specialty, with most doctors working in both obstetrics and gynaecology. Many consultants have an interest in a particular area, such as fertility care or high risk obstetrics, and some work solely in a specific area of practice. The specialty combines medical and surgical activity and involves close cooperation with other specialties such as colorectal surgery, oncology, and urology. Most hospitals have a team of consultants who are responsible for providing obstetric or gynaecological care. Clinical activities are diverse, depending on your area of specialisation. Emergencies may arise at any time, so 24 hour cover is always necessary. In obstetrics, most women, although pregnant, are otherwise fit and healthy. However, some will have acute or …

Jakes and colleagues summarise the maternal six week postnatal check.1 This is an important and integral part of primary care and presents general practitioners with opportunities …

Jakes and colleagues’ paper on the maternal six week postnatal check is timely but anachronistic.1 Although not stated, this is aimed at general practitioners. A letter to the Guardian from four royal colleges2 and the Royal College of Obstetricians and Gynaecologists’ publication Better for Women also emphasise the need to improve care at this check.3 This is against a background of lack of …

The death of a baby boy seven days after his emergency delivery at a hospital hit by a maternity care scandal was “wholly avoidable,” a coroner has ruled. Assistant coroner Christopher Sutton-Mattocks ruled that neglect was partly to blame for Harry Richford’s death at Queen Elizabeth the Queen Mother Hospital in Margate, Kent, in November 2017. The coroner heard that Harry was born by emergency caesarean section not crying or moving, in an operating theatre in which staff were “panicking.” He was delivered by a locum doctor who had not …

A junior doctor who worked in paediatrics before his arrest and conviction for downloading child pornography has been struck off the UK medical register. Ralph Harper, 32, pleaded guilty last March to multiple charges of making indecent photographs. He admitted downloading 36 videos involving children, of which 21 were in the most serious “A” category, which specifies penetrative sex, bestiality, or sadism. He was sentenced last April at Snaresbrook Crown Court, northeast London, to eight months imprisonment, suspended for 16 months.1 He was also placed on the sex …

Since reports of a mysterious pneumonia-like condition began circulating in December, the public health world has been keeping its eye on the events unfolding in China.1 As the numbers of confirmed cases and deaths have risen, details of the novel coronavirus now known as 2019-nCoV have dripped through. Here’s what we know so far about this evolving situation. The initial source of 2019-nCoV is still unknown, but the first cases were linked to a seafood market in the city of Wuhan, capital of the central Hubei province. The market was closed on 1 January 2020 as part of efforts to contain the outbreak.2 As at 24 January 830 cases and 26 deaths had been confirmed worldwide.3 Of the confirmed cases, around 25% are thought to be severe. Outside mainland China cases have been confirmed in Thailand, Japan, Hong Kong, Taiwan, South Korea, and the US. Cases had been reported in the UK but not yet confirmed. The MRC Centre for Global Infectious Disease Analysis at Imperial College London has estimated that by 18 January 4000 people in Wuhan should have shown symptoms caused by the novel disease (uncertainty …

US “executive screening programmes” offer expensive cardiovascular testing even though the tests are not justified and often not covered by insurance, according to a report published in JAMA Internal Medicine.1 Leading US medical centres offer “executive screening” at prices ranging from $995 (£760; €901) to $25 000 to wealthy people who can pay out of pocket for tests not covered by insurance. Professional organisations usually do not recommend the tests for asymptomatic people and there is no evidence they reduce deaths from heart disease. Not only is this bad medicine but …

Lisa Jane Newton was a much respected haematologist, who made a huge contribution to the population of south Yorkshire. Lisa and I did our A levels together and then went our separate ways to read medicine at university. She trained in Sheffield, having chosen that university above many others. She undertook an intercalated degree during her training a reflection of her academic ability and continuing desire to further her knowledge and push herself. She undertook general medical training in Sheffield, and, as fate would have it, we spent one …

Michael Hamilton was an early pioneer of the clinical research into effective management of essential hypertension, demonstrating for the efficacy of trials based within a community rather than a teaching hospital setting. Michael was born in Bradford, Yorkshire, to Archibald and Silvia (née Wolf). Archibald was a general practitioner with a distinguished first world war record as a captain in the Royal Army Medical Corps. A family friend was the physician Charles Wilson, who later became Baron Moran. Michael was educated at a primary school in Bradford, where a fellow pupil and future lifetime friend was Stanley Peart. His secondary education at the Royal Medical Benevolent College, Epsom (now Epsom College), followed the premature death of his father and the encouragement of Charles Wilson to seek a scholarship. Michael graduated with distinction in pathology and obstetrics, and undertook house officer posts at Amersham Hospital. He met Jane, a nurse, at the hospital, and they married in 1946. After national service, Michael returned to St Mary’s Hospital as a medical registrar and senior registrar …

Abbaraju Mohan Rao moved to the UK in 1981. Having chosen to specialise in anaesthetics, he worked initially in King’s Lynn and Stockton on Tees, before training in the Mersey region and Belfast. …

After working in Nottingham City Hospital, Lenox Jardine Millar gained his first experience of general practice in Australia, with his wife, Jo, also a doctor . He started in practice in Worksop in 1974, …

After a house job at Guy’s Hospital and three and a half years in the Royal Air Force, mostly as a family doctor in Malta, Arthur Graham Blyth was house surgeon in obstetrics at Winchester Hospital, before joining a practice in …

Bridget Concepta “Connie” Fahey (née MacDonagh) was part of the Irish medical generation who migrated to the UK in the 1950s. She initially trained in anaesthesia in the north of England but after meeting and marrying her husband, Seán, she joined him in general practice in 1960, initially in Wolverhampton and then in Oldbury. Together they ran a busy general practice in a deprived area of Birmingham, during a period with significant …

Heparins are the most widely used parenteral anticoagulants. Although it can be extracted from several animal sources, heparin derived from swine is the most common source and currently the only form of heparin used in the USA. Unfortunately, disruptions in manufacturing supply and an outbreak of African swine fever in China have threatened worldwide heparin supplies, mandating a re-examination of the current sources and potential alternatives for anticoagulation. In this Viewpoint, we review the history of heparin production and discuss current concerns regarding its supply and the potential implications of a severe shortage, before outlining a tiered response to this shortage.

Cousins S. Bushfires expose weaknesses in Australia's health system. Lancet 2020; 395: 175–76—In this World Report, Bek Hoffman was incorrectly described as male. The text should have read: “…she was ‘emotionally exhausted’. She wrote: ‘100% of my patients are fire affected…’”. This correction has been made to the online version as of Jan 23, 2020.

Attention-deficit hyperactivity disorder (ADHD), like other psychiatric disorders, represents an evolving construct that has been refined and developed over the past several decades in response to research into its clinical nature and structure. The clinical presentation and course of the disorder have been extensively characterised. Efficacious medication-based treatments are available and widely used, often alongside complementary psychosocial approaches. However, their effectiveness has been questioned because they might not address the broader clinical needs of many individuals with ADHD, especially over the longer term. Non-pharmacological approaches to treatment have proven less effective than previously thought, whereas scientific and clinical studies are starting to fundamentally challenge current conceptions of the causes of ADHD in ways that might have the potential to alter clinical approaches in the future. In view of this, we first provide an account of the diagnosis, epidemiology, and treatment of ADHD from the perspective of both the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the eleventh edition of the International Classification of Diseases. Second, we review the progress in our understanding of the causes and pathophysiology of ADHD on the basis of science over the past decade or so. Finally, using these discoveries, we explore some of the key challenges to both the current models and the treatment of ADHD, and the ways in which these findings can promote new perspectives.

Health-care systems worldwide face increasing demand, a rise in chronic disease, and resource constraints. At the same time, the use of digital health technologies in all care settings has led to an expansion of data. These data, if harnessed appropriately, could enable health-care providers to target the causes of ill-health and monitor the effectiveness of preventions and interventions. For this reason, policy makers, politicians, clinical entrepreneurs, and computer and data scientists argue that a key part of health-care solutions will be artificial Intelligence (AI), particularly machine learning. ,  AI forms a key part of the National Health Service (NHS) Long-Term Plan (2019) in England, the US National Institutes of Health Strategic Plan for Data Science (2018), and China's Healthy China 2030 strategy (2016).

Experts warn that the government's plan to privatise secondary care will seriously harm the health system. Dinesh C Sharma reports from New Delhi.

Global humanitarian needs are expected to escalate in 2020, but the widening gap in aid funds earmarked for health is causing concern. John Zarocostas reports.