Category Archives: thoughts

beliefs, thoughts

Transgenderism

A few days ago Brad Warner, one of our favourite Zen Masters, wrote an interesting blog post titled Transgenderism: A Buddhist Perspective.

It is indeed just as the title says. Brad gives a reasoned view of his interpretation of Buddhist philosophy as applied to transgenderism. It may not accord with everyone’s view – indeed it may not be the view of all Buddhists – but he ends up saying pretty much what I have thought for a long time:

[W]hen I see people trying to solve their deep suffering by altering their bodies with chemicals and surgery, I wonder if they are making a mistake. And I wonder if we should be so quick to allow children to make permanent changes to their physical bodies that they may come to regret. It may be better to reserve that for adults who have had adequate time to consider the ramifications of such drastic alterations … I think that, rather than trying to alter one’s body to align it with one’s ideas about one’s “true self”, it would be better to learn to live as comfortably as possible with the mind and body that one’s past karma has manifested in this life.

I would go a little further … Many boys will wonder, and ask about, what it’s like to be a girl – and vice versa. That’s a natural part of childhood curiosity. But it seems to me likely that many well-meaning but misguided adults who are in a position of care and influence pick up on this and, knowingly or not, end up over-influencing the child to “act out” their inquisitiveness without any checks and balances. As Brad says, this should be left to mature consideration in adulthood, or perhaps better to learn to live with what you were given. But then none of that is easy.

arts, books, thoughts

On Poetry

Until now I had never read TS Eliot’s The Waste Land. So when Simon Barnes (yes, that Simon Barnes: environmentalist, journalist, author, former Chief Sports Writer of The Times) had a piece recently in The New European I took notice.

I know Barnes slightly; he’s a great fan of Anthony Powell’s A Dance to the Music of Time and gave the 2022 Anthony Powell Society Annual Lecture just a few weeks ago. So of course I took notice – especially as he read English at the University of Bristol, and I know him to be a thinker.

Why had I not read The Waste Land before? Well, I’m not a great reader of poetry; I never have been, partly because, like so much of English Literature, I was put off it by school. It’s not that I dislike poetry but all the

I wondered lonely as a cloud of golden daffodils

[sic] stuff turns me off, as does most modern so-called poetry that doesn’t scan and doesn’t rhyme – and I’m not even sure how Shakespeare brings off blank verse. So spare me, inter alia, Wordsworth, Tennyson, Longfellow (of the first type) and Allen Ginsberg, Simon Armitage, Carol Ann Duffy (of the second).

But there is poetry I like. Coleridge, https://www.poetryfoundation.org/poems/43997/the-rime-of-the-ancient-mariner-text-of-1834. Lewis Carroll, https://www.poetryfoundation.org/poems/43909/the-hunting-of-the-snark. TS Eliot’s Old Possum’s Book of Practical Cats (see Eliot can write “proper” verse) – I knew the entire 66 lines of Skimbleshanks off by heart when I was about seven or eight. Roger McGough, Summer with Monika. C Day Lewis, Requiem for the Living. John Updike. Christopher Smart, Jubilate Agno.

But I’m sorry, The Waste Land is pretentious garbage – and the Four Quartets are not that far behind. It neither rhymes (OK, there’s the odd couplet) nor scans. For me it is in the same rubbish bin as Ulysses, Finnegan’s Wake, Salman Rushdie’s Satanic Verses, Edith Sitwell’s Façade. None of them make sense, and they’re pretty unreadable. Pseudo-profound bullshit, one suspects written to make money from a clutch of gullible critics. And were they gulled.

No, sorry, you enjoy it if you want to, but it says nothing to me. Just leave me alone to be a Philistine.

beliefs, environment, science, thoughts

Mars & the Moon

Stop building a spaceship to Mars
(and the Moon too)
and just plant some damn trees.

Stop building a spaceship to Mars and just plants some damn trees
Isn’t it more important that we protect this planet against global worming etc.?
Just think how much good all that money could do, and how much
environmental refurbishment could be done by just 10% of the money.

medical, personal, thoughts

On Depression – VIII

1 Comment

It’s three years since I last wrote about depression.

That’s not only because my depression has gone away; there just doesn’t seem to have been anything much worth saying about depression.

The depression hasn’t gone away. If anything it’s got worse. I seem to have descended from “I just don’t want to do anything” … through “I just can’t make myself do anything” … to “why am I even bothering to do anything”.

The rationale (such as it is) for not bothering isn’t just a lack of visible results for my efforts – although that doesn’t help – but has been significantly impacted by the plague of the last 18 months and the ongoing need to stay isolated.

No, it goes deeper. I’ve reached my “three score years and ten” and I’m not going to be around here for very much longer – especially given my medical history etc. Obviously I want to make it to at least 80 in a reasonable state; if I do I shall consider it a result. However I’m not optimistic that I will make 80. Which seems to make anything I do even more pointless.

But then, as Noreen pointed out to me last night, I have loads of longevity genes on both sides of my family. If I look at my parents and their siblings (8 of them) their ages at death were:

Men: 86, 3 (severely handicapped), 93 (and still going)
Women: 90, 99, 99, 78, 89
[I’ve ignored my father’s three half-sisters as they’re only half related to me.]

And if I go back to my grandparents and their siblings (23 of them) their ages were:

Men: 54, 1, 61, 3, 80, <1, 84, 9, 82, 80, 62, 24 (WWI), 78, 73, <1
Women: 26, 84, <1, 72, 83, 40, 88, <1

Stretching a point and going back to my great-grandparents generation (another 60 people) of the 29 I know about we find ages of:

Men: 57, 96, 71, 57, 40, 54, 43, <1, <1, 91, 87, 37, 46, 6, 67, 3
Women: 57, 73, 71, 57, <1, 66, 79, <1, 81, 76, 46, 88, 75

This last isn’t so brilliant, but remember with my great-grandparents we are talking about people born in roughly the middle third of the 19th century.

In all this we also need to remember:

  • We are not talking about wealthy people – even if my parents generation eventually became comfortable with advancing years.
  • Until post-WWII medical care was fairly basic, and had to be paid for (no money; no doctor); and it was more basic the further back you go.
  • Also pre-WWII child mortality was significant, and perinatal death not uncommon; again worse the further back you go.
  • There was relatively little regard to health & safety in the workplace, so industrial accidents were more common.

There are a number of interesting things which pop out at me in this data (though I admit it is incomplete).

  • Almost a quarter (14/60) don’t make their 10th birthday.
  • If you make 10 then you have an evens chance (23/45) of making at least 75; a 40% chance of making 80; and a 1 in 8 chance of making 90.
  • While I don’t know he cause of death for many of these people, only 3 of the 22 adult women could even plausibly have been perinatal deaths. That seems surprisingly few.
  • Only one of the cohort was lost in WWI.

So all other things being equal – which of course they’re not; if it weren’t for modern medicine I’d likely not be here now – I must have a decent chance of having another 10 years.

What would be interesting is to know how much of my depression has a genetic basis, and how much is environmental (in the widest sense). My father had depression (largely unrecognised, except by him, and latterly me) and his father was also depressive (although that was ascribed to trench fever from WWI). How many others of my (recent) forebears suffered from depression we shall never know.

Does that make me feel any better? Well sadly, as a fully paid-up pessimist, it doesn’t. Most people would doubtless say it should; but depression doesn’t work that way. And despite all my efforts I’ve yet to find anything which will kick this “black dog” hard enough in the nuts; although the antidepressants do keep me mostly functioning.

To cap it all, I just can’t get my head round the thought of not being here, doing what I do. How can I not be here, leaving everything in limbo?! It just feels so wrong; so unlikely; so frustrating; and yes, even depressing. Which luckily means I’ve never had any serious thoughts of self-harm or suicide.

Wish me luck!

thoughts

On Privilege

Subsequent to my recent post on Living Like the Gentry, I’ve been thinking more about privilege, and as a generalisation I think there are at least two different types.

Innate Privilege. One is born into this. It would include things like: being white; family wealth; money being spent on posh schooling; being titled; family connections and networking.

Earned Privilege. This one acquires through one’s own efforts. This would include: making the most of educational opportunities; working to rise above family background; working hard to acquire good employment (with commensurate salary, pension etc.); learning to network.

By contrast there is also:

Dis-Privilege. This is usually largely accidental or lifestyle imposed, and would include: physical and mental disability; not being cis-gendered; being too openly LGBGT+; poverty (of money, accommodation etc.); low paid and/or insecure work; or just being born into insuperable Dis-Privilege.

 
Like all these things, this is a gross generalisation. There is a spectrum of privilege. These categories can, of course, overlap and there are always grey areas. For instance people with Innate (or Earned) Privilege could also be Dis-Privileged, through (for instance) disability (consider Stephen Hawking); the former often ameliorating the latter.

The biggest grey area is the large mass of the population who fall between Earned Privilege and Dis-Privilege. These are the people who have never worked to earn privilege but equally don’t have anything much going against them. Many are content just to bumble along (and in many ways who blames them) without engaging their brain; they can’t see that it is possible to bootstrap themselves into something better.** They are capable of thinking, but oh so often fail to stretch themselves to make the most of what they’ve been given – they tend to suffer what my late father would have called “poverty of mind”. Clearly that’s also a generalisation; many people do get out and use what they’ve got to improve themselves, even if that is only to be a plumber, taxi driver or seamstress – these people are just as valuable as dentists, wealth managers and lawyers; arguably they do more to keep the wheels turning.

Innate Privilege is there regardless of what one does. These people tend to be the cream rising (effortlessly) to the top of the heap. However through effort they can ameliorate it, “humanise” themselves, and become more in tune with the populous at large. Many do ameliorate their privilege, but equally many cash in, mercilessly and selfishly milking the system for all they can get – think Boris Johnson, David Cameron or Jacob Rees-Mogg.

The lower echelons of Earned Privilege is where Noreen and I are. We both come from humble origins, without wealth or connections to pull us up the ladder. But we’ve had good (free, state) education, made as much of it as we can, learned to think for ourselves, and consequently had decent, though not high-flying or insanely lucrative, jobs. While we’re not wealthy, we are fairly comfortable. What our Victorian forebears would have considered solidly middle class.

All this sort of, very roughly, meshes with the traditional view of the British class structure:

  • Those with Innate Privilege tend to be the Upper and Upper Middle Classes.
  • Those with Earned Privilege are likely to be the majority of the Middle Class.
  • The great bulk of the ordinary population would be the Working and Lower Middle Classes.
  • While the Dis-Privileged would be the Under Class and the lowest reaches of the Working Class.

Whatever any state might do to level this playing field (in terms of wealth, or whatever) there always will be this type of stratification. The intelligent and more intellectually able will always rise towards the top – because they can. And the more physically able will be the valued artisans.

Is this stratification wrong? Well maybe; it all depends on one’s modus vivendi. Clearly there is something wrong if the “uppers” do nothing but play their privilege for their own benefit and to Hell with the plebs; equally if the “lowers” despise and set out to arbitrarily demonise the “uppers”. But people from all layers of society can (and do) do much good while working within the system. One doesn’t have to like, or agree with, the system to be able to work within it and to overcome its failings; or indeed to try to change or dismantle it.

While one doesn’t like privilege, especially Innate Privilege, it’s here. And it ain’t going away real soon, or real easy. However much we’d like it to.

** Remember, as Robert Heinlein is quoted as saying: “There are perhaps 5% of the population that simply can’t think. There are another 5% who can, and do. The remaining 90% can think, but don’t“.
Or according to Thomas Edison: “Five percent of the people think; ten percent of the people think they think; and the other eighty-five percent would rather die than think“.

personal, thoughts

Living Like the Gentry

Some days ago, someone on one of the family history groups I follow posited the question of what our ancestors would have thought of our family history researches. Which in some ways amount to delving into their lives.

I don’t know what they would have thought. No! Wait! Actually I do: they would have wondered why we find them so interesting. It’s a bit like how Noreen reckons the medieval masons would wonder about why we spend so much time, effort and money shoring up our old churches and cathedrals: I’m sure their attitude would be “Why are you repairing it? Can’t you already do better than that!”

I’m also fairly sure that our ancestors would be astonished at our lifestyles. OK, so we live in a 1930s terraced house, which is really the 1930s version of a Victorian two-up-two-down. But we have more space, better amenities, and more money than most of them ever would.

One thing Noreen and I have been doing over the last year, during lockdown, is making sure that we eat well. Actually we always did eat well; just it got a bit better! Food and wine are two of life’s pleasures, so they help with keeping morale up and helping keep us healthy (maybe!).

Now our ancestors (both mine and Noreen’s) were in large part AgLabs, labourers (skilled and unskilled), mariners and fishermen. They would not have had a lot of money; nor good housing; and they may well not have had access to good or sufficient food, with the possible exception of bread and beer.

One of the comments Noreen often makes is to wonder what our ancestors would have thought of our food habits. We can (and sometimes do) have strawberries and cream in the winter; pheasant; decent sized pieces of good meat; fresh and smoked salmon; duck salad with asparagus (in season); wine with a meal; and at weekends a liqueur with our strawberries. As she says, they’d probably say we were living like the gentry.

But then compared with them we are the gentry! At least in terms of our disposable (and secure) income, secure housing, and easy access to good food.


The cottage in Rolvenden, Kent, in which my paternal great-grandfather,
Stephen Marshall (1849-1946) was born.
Top: as it was probably c.1900. Bottom: as it was in 2014.

It is salutary to think that my father’s maternal great-grandfather Jabez Hicks (so my great-great-grandfather; born c.1820, died 1905), a mariner in Dover, would likely not have had a very wonderful diet, or good housing – even after he became a coal & wood merchant and lived his last few years on his own means. He lived in a pretty ramshackle area of Dover, near the docks, for most of his life. His sons mostly did well for themselves: working on the railway; in a senior position for Dover Council; with a business as a fly-proprietor (the taxi/car hire company of the day). But then, largely due to two World Wars, things pretty much stagnated until our generation and the easier availability of good secondary education and universities.

Although we were born with no silver spoons in sight and we’d both say we’re working class (at the very, very best lowest middle class) by origin, yes, we’re privileged on many counts:

  • We’re white, cis, able-bodied, heterosexuals.
  • Our parents were married before we were born.
  • Although our families were never well off, they got by without state help or social workers.
  • We can read, write and think fluently.
  • Our parents engaged with us, encouraged us, and taught us many things outside school.
  • We had the last of the good, free, grammar school education in the 1960s.
  • We also had state funded university education (around 10 years between us) in academic subjects.
  • That enabled us both to have professional jobs for prestigious institutions.
  • Our jobs paid enough for us to buy our own house (despite stinging interest rates), without recourse to the Bank of Mum & Dad.
  • Our jobs also provided us with pensions; and our parents frugality with some money in the bank.
  • We’re our own people, with our own, considered, views and beliefs.

To our ancestors (in general) most of that would have been things to aspire to, and would certainly mark us out as at least solidly middle class. All basically thanks to our hard work and our parents’ thrift and foresight.

We may be privileged, but it is largely privilege of our own making. Thanks to the inexorable rise of capitalism (I blame a combination of Harold Wilson and Margaret Thatcher) sadly a lot of the younger generations today do not have many of those opportunities we had. I’m sorry to say that our generation of “boomers” forgot its (mostly hard-earned) privilege and we’ve buggered it up for the younger generations.

current affairs, medical, thoughts

Horrible Times 19: Easing Lockdown

So our dearly unbeloved Boris thinks he’s going to end all lockdown restrictions on 21 June. All I can say is that like everything which emanates from BJ’s mouth this is either madness or fiction – and quite possibly both. Let’s take a look.
[Links to some relevant BBC News reports at the end.]

  1. Lockdown ends on 21 June. But all UK adults aren’t going to be offered their first vaccination until 31 July. When do they get their second jab? Well at least 3-4 weeks later, which takes us effectively until the end of August, or 8+ weeks after 21 June. So we have a minimum period of 8 weeks with no lockdown and with the UK not as fully vaccinated as it can be. Does not compute.
     
  2. Can we hit the 31 July target? Given that the rate of vaccination is reported to have fallen in recent days, partly due to a lack of vaccine supply, this seems unlikely. Moreover the priority sequence for those under 50 has not yet been decided. Yes, it might be possible if we get the volume of vaccine we need. But there’s many a slip ‘twixt cup and lip.
     
  3. That is ignoring that we don’t yet have very much data on the effectiveness of the current vaccines against the new variants of the virus. Nor are there updated vaccines available (or even nearly so).
     
  4. So lockdown is eased in five steps on 8 March, 29 March, 12 April, 17 May and 21 June. (The media are reporting this as four stages by lumping together the two March dates.) These appear to be the earliest dates for each round of eased restrictions. They will only happen if four conditions are met:
    • The coronavirus vaccine programme continues to go to plan
    • Vaccines are sufficiently reducing the number of people dying with the virus or needing hospital treatment
    • Infection rates do not risk a surge in hospital admissions
    • New coronavirus variants do not fundamentally change the risk of lifting restrictions

    WTF do these conditions mean? They are flabby and woolly at best. Without specific numbers against them, published up-front, they’re worthless as the government can flex them any-which-way it likes. They’re about as ethereal as mist.

  5. When they return to school, secondary school children will be required to have two Covid (lateral flow) tests a week. It seems the first three will be conducted in school but thereafter parents will be expected to administer the tests at home and report the results to the school. How many parents will (a) bother administering the tests, (b) do the tests properly, and (c) report the results accurately? This is going to end well, isn’t it!?

I’m not even going to talk about the rest of contents of each round of restriction easing. As you’ll realise from the above it is all rather academic when we don’t know the detailed baselines and criteria being used.

But what I will say is that if this timeline is adhered to, we’ll most likely have an up-tick in cases in May (as a result of schools going back) and another one in August (due to incomplete vaccine coverage).

Now don’t get me wrong. I want to see lockdown removed just as much as anyone else. But I want to see it done safely. For everyone’s sake.

Links
What’s the roadmap for lifting lockdown?
Lockdown review: What are the risks of schools, pubs and shops reopening?
Covid: When will schools reopen?
Covid: Why can’t we unlock more quickly?
Number of UK Covid vaccinations falls by a third as vaccine supply dips

current affairs, thoughts

They Think It’s All Over

So the Biden supporters in America are jubilant that he has ousted Trump as President. They think it’s all over! But I wouldn’t be quite so jubilant yet …

  • Has there been a handover of power?
  • Are there any outstanding lawsuits relating to the election?
  • Has Trump been physically removed from the White House?
  • Has the fat lady sung?

Answer “no” to any of these and a Biden Presidency is not assured.

Trump will do everything he can to stay in power; it is the way of tyrants.

Watch out for a confetti of lawsuits – all spurious but outwardly plausible – on top of the usual tirade of abuse, misinformation and lies.

Oh and of course there are over 70 days before the Inauguration. Time enough for Trump to wreak untold damage and havoc.

A pessimistic outlook? Certainly. And I hope I’m wrong. But Trump doesn’t have a good track record for acting decently.

current affairs, medical, thoughts

On Vaccine Logistics

Let’s think first about flu vaccination – not the vaccine itself but the logistics involved to get a needle stuck in my arm.

It is very tempting to ridicule the NHS and the UK government for failures to supply sufficient vaccines – especially flu vaccine – in sufficient quantity, and on time, when the requirements are apparently well understood. And indeed there have been supply failures in recent years. However it is salutary to consider the complexities of the logistics involved.

Somewhere around 30 million doses of vaccine have to be manufactured, packaged and shipped. Those 30 million are split between six different vaccines, made by five different companies. And there are tens of thousands of shipping endpoints (almost 10,000 GP practices in England alone, plus pharmacies, hospitals, …), all with differing requirements.

30 million doses can’t be manufactured, packed and shipped in the twinkling of a politician’s brain. It takes time, and the NHS isn’t the only customer of the manufacturers. So the supply from manufacturer to NHS warehouse will be phased; so the final shipping to the endpoint will also likely be phased. Which means at any time a given vaccine may not be available at every outlet, even if they did get their requirements correct the first time.

Keep in mind too that these vaccines are temperature sensitive and must be held in refrigerated storage at all times. That too complicates the distribution.

All of that is before one even thinks about the GP identifying, and calling those eligible for vaccination, and making enough clinic time (space, appointments, clinicians) available to actually stick needles in arms. Oh and chasing up those who don’t respond.

I know from experience of logistics at a much simpler level it is almost impossible to get this 100% correct every single time — hard though one might try! It’s almost inevitable that on this scale things will go wrong; and the further back in the chain the problem occurs the bigger the knock on effect out at the clinic.

(Incidentally it’s the same with supermarkets and getting things like loo roll on the shelves. Don’t just blame people for panic buying – although, yes, they do – but think about the logistics and supply chain involved.)

Amazingly this works the vast majority of times in developed countries. For instance, the UK currently has among the highest national coverage of flu vaccine in the world, vaccinating around 75% of the over-65s against flu every year; most countries either do worse or have no vaccination programmes for older people. But in places where the infrastructure and healthcare systems are more fragile, things break down quite quickly.

Now let’s extend this to vaccine(s) for Covid-19.

First of all let’s say that all of the above logistics still apply, but things get worse …

We don’t yet have a vaccine (or vaccines), so as yet we have no clue how many of what we are trying to deploy, or where, or how.

We don’t know if the vaccine(s) will require refrigerated storage, or actual cold storage. If cold storage (ie. freezer temperatures) is required – and this seems likely for many of the vaccines currently being trialled – this hugely complicates the distribution chain (and makes it pretty much impossible in developing countries).

How many shots of vaccine are required to provide immunity? Will just a single shot be enough? Or will patients need a booster (or two, or three, …). Again it looks as is many of the potential vaccines will need a booster shot after a few weeks. That doesn’t just double the amount of vaccine required; it doubles everything right down to ensuring patients get their booster.

And who is eligible for the vaccine? And when? Government is likely to plan on getting the vaccine to the most important people (eg. healthcare workers, food supply people) first, followed by vulnerable groups, and then everyone else. Ultimately they will want to catch everyone (barring the small number of nay-sayers): that’s 60+ million in England alone, with potentially two shots of vaccine – so four or five times the flu programme.

That’s a potential 120+ million doses of vaccine for England alone together with a huge amount of distribution and a great deal of clinical effort. That deployment will take time; maybe as much as an elapsed year! By which time the first recipients may need repeat vaccination if the immunity decays, as it well may.

All of that is before we even think about … How effective the vaccine(s) are (no vaccine is 100% effective). How many vaccines are available. Are particular vaccines (in)appropriate for particular groups of patients. How do we handle the case where the first vaccine available is followed up by one which is much more effective? – Do we revaccinate the first recipients now, or later, or not at all? What advertising campaign, or other incentives (maybe even legislation?), do we need to ensure the vast majority of people get vaccinated?

Of course, we don’t yet have a vaccine to deploy. The front runners are all still in Phase III trials which are unlikely to complete until at least the end of this year. Even if one (or more) of the candidate vaccines looks really good, it is very unlikely we’ll see an emergency approval much before next Spring. And then there may be the question of how that affects other ongoing trials.

Now you can be pretty sure that there will be people in the Department of Health and the NHS sweating blood to try to work all this out, now, even before we have a vaccine. And however well they do their job you can be sure they will get some of it wrong – because the problem is just too complex and contains too many risks and pitfalls. It isn’t at all easy, and it’s human nature to complain when things don’t work perfectly, but it helps to try to see the bigger picture.

So … (a) cut the healthcare system some slack when things don’t work 100% every time, but (b) do call the government to account if it’s their policies which cause the failures, and (c) don’t pin all your hopes on a Covid-19 vaccine being available to everyone (anyone?) real soon.

Further Reading

  1. Derek Lowe; “The Vaccine Tightrope”; Science Translational Medicine; 21 October 2020; https://blogs.sciencemag.org/pipeline/archives/2020/10/21/the-vaccine-tightrope
  2. David Salisbury; “If you’re pinning your hopes on a Covid vaccine, here’s a dose of realism”; Guardian; 21 October 2020; https://www.theguardian.com/commentisfree/2020/oct/21/covid-vaccine-immunisation-protection
  3. Jeremy Farrar; “Let’s get real. No vaccine will work as if by magic, returning us to ‘normal’”; Guardian; 6 September 2020; https://www.theguardian.com/commentisfree/2020/sep/06/lets-get-real-no-vaccine-will-work-as-if-by-magic-returning-us-to-normal
  4. Derek Lowe; “Cold Chain (And Colder Chain) Distribution”; Science Translational Medicine; 31 August 2020; https://blogs.sciencemag.org/pipeline/archives/2020/08/31/cold-chain-and-colder-chain-distribution
  5. Derek Lowe; “Preparing For the Vaccine Results”; Science Translational Medicine; 25 August 2020; https://blogs.sciencemag.org/pipeline/archives/2020/08/25/preparing-for-the-vaccine-results
  6. Megan Scudellari; “How the pandemic might play out in 2021 and beyond”; Nature; 5 August 2020; https://www.nature.com/articles/d41586-020-02278-5