Disruptions in health, to heal and to harm: an appeal for values, evidence, and charity

The opportunities to harm health are legion, from bench to bedside to boardroom to bombardment. Doing what’s right for health is easily lost in the throes of academic competition, professional rivalry, or the worship of profit—all of which are best consumed in moderation. The downside of competing priorities was evident at COP29, the rich world betraying the poor (doi:10.1136/bmj.q2651),1 again raising the challenge of decision making for public benefit by people conflicted by commercial or political interests.

Transparency has got us only so far, argue Chris van Tulleken and colleagues. Foxes guard the henhouse, and we need disruptive change that’s “intentional, systematic, evidence based, and robust.” They demand zero tolerance of industry influence for all decision makers who influence health outcomes, including politicians, health leaders, clinicians, and medical and science journals (doi:10.1136/bmj.q2574).2

But what does zero tolerance mean? A new BMJ investigation finds that over the past six years medical journals have published at least 180 articles funded by fossil fuel companies, and over 1000 articles include authors working for a fossil fuel company or related organisation (doi:10.1136/bmj.q2589).3 Is that legitimate debate or is it, as David McCoy puts it, giving industry the “social licence to continue to behave in the way that they behave”?

The BMJ doesn’t accept funding or research from industries (such as tobacco and fossil fuel) that have a negative effect on public health and a history of manipulating research (doi:10.1136/bmj.q2197).4 The tobacco policy is well established across our portfolio of journals, and we’re now extending our fossil fuel policy. We also don’t publish clinical education articles or editorials by authors with relevant competing interests (doi:10.1136/bmj.g7197).5 Talk is cheap when it comes to zero tolerance of competing interests and, in our experience, where we lead in taking action, few others follow.

Do-gooder disruptors can only dream of the disruptive power in the hands of Donald Trump, whose proposed appointments and policies underpinned by a “distrust in science” are set to harm health, both in the US and worldwide (doi:10.1136/bmj.q2587).6 Performative disruption of the type Trump is championing puts ideologies, political gains, and professional vendettas first, when leadership in medicine and health demands a focus on values and policies informed by a dispassionate appraisal of the science and evidence. Trump’s endeavour is not disruptive change; it is destructive chaos.

The UK’s attempts at disruptive change, meanwhile, are somewhat mixed: disruptions to heal and to harm. With one hand the government announces a welcome review of physician associates (doi:10.1136/bmj.q2608 doi:10.1136/bmj.q2613)78 and better regulation of managers (doi:10.1136/bmj.q2648),9 while with the other it brings back the perverse incentive of hospital league tables (doi:10.1136/bmj.q2606)10 and deepens the financial crisis in general practice with its tax reforms (doi:10.1136/bmj.q2642 doi:10.1136/bmj.q2635).1112

Disruption and harming health come together in new research that links higher monthly turnover rates of hospital nurses and senior doctors with higher rates of death after emergency admission (doi:10.1136/bmj-2024-079987).13 The message is clear, say our editorialists: “retention of healthcare staff should be a priority to improve continuity and quality of care for patients” (doi:10.1136/bmj.q2521).14 As with competing interests, we can continue to document the harms of failed workforce policies, but it’s tangible action that is required.

David Miliband, former UK foreign secretary, was a child of refugee parents fleeing the Holocaust in different ways, their lives disrupted by war and genocide. He now heads the International Rescue Committee (IRC)—founded by another refugee, Albert Einstein, to help people escape Nazi occupied Europe. The IRC helps people “whose lives are shattered,” disrupted, and harmed by conflict and disaster, including in Gaza and Sudan. The IRC is the chosen beneficiary for this year’s BMJ annual appeal. In an exclusive interview with The BMJ Miliband discusses hospital attacks, Trump, and the IRC in a “flammable world” (doi:10.1136/bmj.q2591).15