UK Foundation Research Articles

A quantitative study of letters to the editor by medical students in medical education journals

ABSTRACT Letters to the Editor offer ways for readers to engage with authors’ publications. Letters are the shortest manuscript for medical students to publish and medical-education journals are best suited. The UK Foundation Programme rewards medical students achieving PubMed ID publications and we hypothesise that this is a main motivation for medical students to submit Letters to the Editor. A review of 15 medical-education journals with an impact factor was conducted to identify numbers and percentages of Letters to the Editor by medical students between July 2018 and June 2020. Affiliation of medical students was collected. Our results show over two years, 299 letters were published by medical students equating to 45.9% of total letters. There was a 60% overall increase in letters by medical students published in the first 12 months compared to second 12 months. During this period overall numbers of letters published increased by 27%. 86% of the letters published by medical students over the two-year period were from UK medical schools. Five schools accounted for 60.5% of these letters. The three medical schools with highest numbers of letters published were King’s College London, Imperial College London and University of Oxford for both 2018/19 and 2019/20. The increase in letters published overall with greater numbers published by students, may indicate greater awareness of Letters to the Editor as means of dissemination amongst medical students. UK medical schools published large numbers of letters, perhaps reflecting increasing importance to students of publications due to impacting on subsequent jobs. Results from our quantitative research revealing: large numbers of letters by medical students, increase in letters published from 2018/19 to 2019/20 and overrepresentation of UK medical students supports the hypothesis that medical students are publishing letters to achieve PubMed IDs. Further qualitative research is required to test our hypothesis.

“Incident Teaching (IT)” Lecture Series – Incorporating Education Surrounding Clinical Incidents and Complaints into Foundation Year 1 (FY1) Doctors’ Induction

ABSTRACT Patient safety incidents are any unintended or unexpected incidents which potentially could, or did, lead to harm to patients. Incident reports are crucial to improve patients’ care and to identify further actions needed to prevent harm. A common view among the FY1 doctors in our local NHS Trust involved a fearful opinion surrounding being involved in clinical incidents. Significant anxiety in those situations prompted the need for a focus on the topic of “clinical incidents” during their induction to the Trust in two consecutive years of 2018 and 2019. A near-peer lecture series was delivered to new FY1 with qualitative pre- and post-lecture series feedbacks. Results from lecture series from two consecutive years showed all FY1 doctors agreed or strongly agreed that they had a good understanding of incidents following the lecture. Compared with their pre-course feedback, there was an increase of 6-fold (2018) and 8-fold (2019) in those that strongly agreed. Post-course, more than 90% of doctors reported that they would feel comfortable sharing with colleagues their involvement in an incident. In a growing culture of blame and litigation, it is important to address the harm associated with a blame-based culture. The process of investigating an incident has the potential to expose the areas of deficiency relating to an individual. Reducing stigma associated with incidents could theoretically reduce the second victim phenomenon. An open culture to incident reporting is a fundamental part of medical education and quality improvement. Encouraging this attitude amongst medical professionals and creating a supporting environment surrounding sharing of experiences will help to form a generation of doctors that see incident reporting in a positive light. Our model of lecture series could be utilised in other UK Foundation Programmes with the aim of enriching the FY1s’ induction period.

498. Impact of COVID-19 on UK Foundation Doctors: Education and Safety

BackgroundTransmission of a novel coronavirus (SARS-COV2) from China has caused a global pandemic, resulting in an unprecedented burden on healthcare systems worldwide.Frontline healthcare workers face considerable risk due to the potential for repeated exposure to infected individuals, many of whom may be asymptomatic given the lengthy incubation period of 5–10 days. With rising incidence, prevalence, and mortality rates, appropriate training and support is paramount in safeguarding the wellbeing of NHS staff and patients. Foundation doctors are among frontline staff being redeployed to areas of need. They are a vital resource within the NHS; and are uniquely positioned to support and staff medical teams.MethodsA 24 question digital survey with a mix of open-ended, multiple-choice, and rating-scale questions was distributed to the 18 UK Foundation Schools. Questions established trainee demographics and the quantity of COVID-19 training received; with focused questions relating to personal safety and support for vulnerable individuals.Results714 doctors completed the survey; 55% in FY2, 43% in FY1, and 2% above FY2 level. 74% of respondents reported receiving no formal training on COVID-19. Mean confidence was 84% in diagnosing COVID-19, and 56% in managing it. 75% did not receive formal training on the requisite safety precautions for suspected COVID-19 cases. 67% had not been fit tested and 75% of those who failed their fit test were not provided with alternative equipment. 30 doctors reported being pregnant and none had received additional support regarding protective measures. 47 doctors reported being immunocompromised and 42 of them had received no additional support in view of their increased risk. 93% of doctors had not received definitive guidance regarding the impact of this on their ARCP sign-off and progression of training.ConclusionAlarming proportions of Foundation trainees are not currently being provided with formal training or support for their personal safety during the COVID-19 outbreak. This is remediable through the urgent implementation of formal COVID-19 training, standardised across NHS trusts to ensure a consistent standard of care for the protection of trainees and patients.Disclosures All Authors: No reported disclosures

Publication Component of the UK Foundation Programme Application: Perception of Medical Students.

IntroductionThe 2-year UK foundation programme (FP) application is based on a scoring system and final year medical students are ranked and allocated to their preferred choice of region to work and train in based on their scores following graduation. Points are allocated to academic components including publications. We aim to evaluate UK medical students’ perception of the publication component of the application.MethodsA 15-item online survey based on students’ perception of the publication component of the FP application was distributed to final year medical students from all UK medical schools. Opinions were sought via a 5-point Likert scale.ResultsA total of 155 final year medical students from 9 medical schools completed the survey (response rate 155/1926, 8.05%). In the survey, 69.7% of students felt under pressure to achieve PubMed-indexed (PMI) publications, 7.1% were not aware that the FP application included points for PMI publications and 72.9% had no publications at the time of application. The main reasons for publishing were for the FP application (81.3% agreed) and to increase competitiveness for future specialty training (85.0% agreed). In contrast, 27.1% agreed that they were motivated to publish due to disseminating knowledge; 22.6% and 25.8% agreed that their medical school did not provide adequate training or opportunities for them to achieve PMI publications, respectively.ConclusionThe majority of students felt under pressure to publish with their primary motivation cited as enhancing their FP application. Overall training and opportunities to publish appear to be inadequate amongst the cohort studied. Medical schools should consider providing academic training and opportunities early to highlight the importance and rationale behind research/audits, minimise pressure and optimise research outputs in preparation for FP application.

Respiratory patient experience of measures to reduce risk of COVID-19: findings from a descriptive cross-sectional UK wide survey

ObjectivesTo assess the experience of people with long-term respiratory conditions regarding the impact of measures to reduce risk of COVID-19.DesignAnalysis of data (n=9515) from the Asthma UK and British Lung...

The new cultural norm: reasons why UK foundation doctors are choosing not to go straight into speciality training

BackgroundThe number of UK foundation doctors choosing to go straight into speciality training has fallen drastically over the last 10 years: We sought to explore and understand the reasons for this change.MethodsWe undertook semi-structured interviews with 16 foundation year two doctors, who had not applied to speciality training, from two regional foundation schools. Transcripts were thematically analysed.ResultsThe reasons that foundation doctors are choosing not to go straight into speciality training centre around the themes of feeling undervalued, career uncertainty and a new cultural norm. They report major feelings of uncertainty regarding career choice at such an early stage of their profession and this challenge was magnified by a perceived lack of flexibility of training and the growing normality of taking time out from training. Trainees feel a lack of support in planning and undertaking an “FY3” year and being helped back into the workforce.Trainees overwhelmingly reported that they feel undervalued by their employers. Importantly, however, not going into training directly was not always a reflection of dissatisfaction with training. Many trainees spoke very positively about their planned activities and often saw a break in training as an excellent way to recharge, develop skills and prepare for the rest of their careers in medicine.ConclusionsTaking a year or more out of training after foundation years has become the new cultural norm for UK junior doctors and reasons for this include feeling undervalued, career uncertainty and the perception that this is now “normal”. Exploring these factors with participants has generated a number of recommendations related to improving the workplace environment, allowing more flexibility in training and supporting those who chose to take an FY3.

Prepared for practice? UK Foundation doctors’ confidence in dealing with ethical issues in the workplace

This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General...

Early dynamics of transmission and control of COVID-19: a mathematical modelling study

SummaryBackgroundAn outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to 95 333 confirmed cases as of March 5, 2020. Understanding the early transmission dynamics of the infection and evaluating the effectiveness of control measures is crucial for assessing the potential for sustained transmission to occur in new areas. Combining a mathematical model of severe SARS-CoV-2 transmission with four datasets from within and outside Wuhan, we estimated how transmission in Wuhan varied between December, 2019, and February, 2020. We used these estimates to assess the potential for sustained human-to-human transmission to occur in locations outside Wuhan if cases were introduced.MethodsWe combined a stochastic transmission model with data on cases of coronavirus disease 2019 (COVID-19) in Wuhan and international cases that originated in Wuhan to estimate how transmission had varied over time during January, 2020, and February, 2020. Based on these estimates, we then calculated the probability that newly introduced cases might generate outbreaks in other areas. To estimate the early dynamics of transmission in Wuhan, we fitted a stochastic transmission dynamic model to multiple publicly available datasets on cases in Wuhan and internationally exported cases from Wuhan. The four datasets we fitted to were: daily number of new internationally exported cases (or lack thereof), by date of onset, as of Jan 26, 2020; daily number of new cases in Wuhan with no market exposure, by date of onset, between Dec 1, 2019, and Jan 1, 2020; daily number of new cases in China, by date of onset, between Dec 29, 2019, and Jan 23, 2020; and proportion of infected passengers on evacuation flights between Jan 29, 2020, and Feb 4, 2020. We used an additional two datasets for comparison with model outputs: daily number of new exported cases from Wuhan (or lack thereof) in countries with high connectivity to Wuhan (ie, top 20 most at-risk countries), by date of confirmation, as of Feb 10, 2020; and data on new confirmed cases reported in Wuhan between Jan 16, 2020, and Feb 11, 2020.FindingsWe estimated that the median daily reproduction number (Rt) in Wuhan declined from 2·35 (95% CI 1·15–4·77) 1 week before travel restrictions were introduced on Jan 23, 2020, to 1·05 (0·41–2·39) 1 week after. Based on our estimates of Rt, assuming SARS-like variation, we calculated that in locations with similar transmission potential to Wuhan in early January, once there are at least four independently introduced cases, there is a more than 50% chance the infection will establish within that population.InterpretationOur results show that COVID-19 transmission probably declined in Wuhan during late January, 2020, coinciding with the introduction of travel control measures. As more cases arrive in international locations with similar transmission potential to Wuhan before these control measures, it is likely many chains of transmission will fail to establish initially, but might lead to new outbreaks eventually.FundingWellcome Trust, Health Data Research UK, Bill & Melinda Gates Foundation, and National Institute for Health Research.

Millennial learners – a blended approach to simulation for sepsis

The UK Foundation Programme curriculum highlights the need for competency in the identification, assessment and immediate management of the acutely unwell patient.1 With the introduction of NEWS2 and the ‘Surviving Sepsis’ campaign, we identified a requirement to update our trust induction. The aim of this was to ensure the induction aligned with national updates and provided an educational tool for employees on early identification of unwell patients, including recognising and managing sepsis.2,3 Technology has transformed healthcare and learning preferences, bringing diversity through e-books, podcasts, social media and videos.4,5 Teaching can harness technology to reflect this. …

Introduction of standardised tobacco packaging and minimum excise tax on in the UK: a prospective study

BackgroundStandardised packaging for factory made and roll your own tobacco was implemented in the UK in May, 2017, alongside a minimum excise tax for factory made products. As other jurisdictions attempt to implement standardised packaging, the tobacco industry continues to suggest that it would be counterproductive, in part by leading to falls in price due to commoditisation. Here, we assess the impact of the introduction of these policies on the UK tobacco market. MethodsWe did a prospective study of UK commercial electronic point-of-sale data from 11 constituent geographic areas. The main outcomes were changes in sales volumes, volume-weighted real prices, and tobacco industry revenue. These were assessed using trend estimation from generalised additive mixed models. Products distributed to less than 10% of stores were excluded for sample design reasons; nevertheless, the analysis included an estimated 91% of the UK tobacco market products. The study did not require ethical approval. Findings107 572 monthly observations of products from May, 2015, to April,2018were included in the analysis. Introduction of standardised packaging and a minimum excise tax was associated with a doubling of the rate of sales decline. The most marked change in sales volumes was among the cheapest factory-made brands, where substantial sales growth stopped and prices rose markedly (prices increased by 0·035 p for the cheapest factory-made brands compared with 0·016 p across all factory-made brands and a 0·004 p increase across all products from May, 2015, to April, 2018). There was no evidence of commoditisation as market segmentation (price differentiation and different price trajectories for premium and lower priced products) continued. Company monthly net revenues declined from GBP £231 million (95% CI £222 million to £240 million) in May, 2015, to £192 million (£182 million to £201 million) in April, 2018. InterpretationThe concurrently introduced policies of standardised packaging and minimum excise tax were associated with declining tobacco sales and tobacco industry revenue, which might underpin the tobacco industry's opposition to the policies. Prices at the end of the period were higher than the at the start, implying no long-term price falls. A minimum excise tax might limit the tobacco industry's ability to keep low-priced tobacco, which is popular with young and disadvantaged smokers, available. The complementary introduction of standardised packaging and the minimum excise tax meant effects could not be distinguished statistically. FundingCancer Research UK and British Heart Foundation (grant number C27260/A23168).

Exploring the perceived medical ethics and law training needs of UK foundation doctors

Foundation doctors (FDs) encounter a wide range of ethical and legal issues during their first two years of work. Despite ethics being a key part of most modern undergraduate curricula, FDs can struggle with the issues they see. This study is based on results from an on-line survey answered by 479 UK FDs regarding their medical law and ethics learning needs, and their undergraduate training in this area. Over two-thirds stated they would wish to receive MEL training as an FD on self-discharge against medical advice (∼71%), sedating patients (∼70%), decision making in emergency medicine (∼67%), and withholding and withdrawing treatment (∼66%). Over half of all respondents want MEL training during their Foundation Programme on DNACPR orders (∼63%), dealing with patients with suicidal intent (∼59%), Mental Health Act (∼55%), Deprivation of Liberty Safeguards (∼54%), and end of life care (∼53%). We therefore propose a minimum curriculum for ethics and law training for FDs based on these topics, as well as cases brought by the FDs themselves.

Does initial postgraduate career intention and social demographics predict perceived career behaviour? A national cross-sectional survey of UK postgraduate doctors

ObjectiveStudies indicate that initial career intentions and personal characteristics (eg, gender) can influence medical career decision-making. However, little is known about how personal characteristics and intention interact with career decision-making....

REVEALING THE TRUE COST OF FINANCIAL CRIME, FOCUS ON EUROPE

In March 2018, Refinitiv commissioned a global survey to better understand the true cost of financial crime and to raise awareness of its wider impact on business, individuals and society as a whole. In total, over 2,300 senior managers from large organizations across 19 countries participated. We also supplemented the survey findings by conducting in-depth research and holding interviews with leading NGOs (Education Endowment Foundation, Transparency International UK and Walk Free Foundation) and the European Union’s law enforcement agency to gain perspective on the human cost of financial crime. This report specifically examines the findings in Europe.

Improving junior doctor experience at Sheffield Teaching Hospitals

Sheffield Teaching Hospitals Foundation Trust (STHFT) is one of the largest UK foundation trusts with 17,000 staff, approximately 1,000 junior doctors (JDs) in training and around 700 career grade doctors. The previous chief executive officer and medical director had a vision to improve the relationship between junior doctors and senior management in the trust. By fostering this relationship, the ultimate goal was to make the JD cohort feel connected, involved and valued …

Mindfulness intervention for foundation year doctors: a feasibility study

BackgroundMindfulness has been shown to reduce stress and burnout in medical students and healthcare professionals. This is a quality improvement study which assessed the feasibility of conducting a full-scale evaluation of a mindfulness intervention among UK foundation doctors to reduce stress and burnout.MethodsThis is an uncontrolled before and after study taking place in a single university teaching hospital. The RE-AIM framework which comprises of five dimensions including Reach, Adoption, Effectiveness, Implementation, and Maintenance was used to guide this assessment. The intervention was a 6-week ‘Mindfulness in the Workplace’ course. The primary measure was change in self-reported levels of stress immediately before and after the course. Additional measures explored the subjective experiences of participating doctors through the use of questionnaires handed out before and after the course.ResultsAll 20 places on the course were filled from the population of 108 foundation doctors at the trust with an equal number of foundation year 1 (n = 10) and foundation year 2 (n = 10) doctors. Sixteen participants (80%) attended one or more sessions. The median baseline stress score of the participants was 6.5 (range = 2 to 9). The median post-course stress score was 5.0 (range = 2 to 8). The Mann-Witney test indicated that the stress levels of participants were significantly lower at the end of the course compared to baseline, U = 74.50, p = .04. Additional measures suggested that the intervention may be associated with some other potential promising benefits for doctors including greater wellbeing, improved working life, and more satisfactory relationships with patients. Implementation of this intervention requires further work at the institutional level because only 35% of participants completed the full intervention, the main barrier being work commitments.ConclusionThis is the first programme of research to evaluate the feasibility of trialling and implementing a modified ‘Mindfulness in the Workplace’ intervention for foundation junior doctors in the UK. Based on the findings from this study, we conclude that this intervention is promising but further modifications are required such as the use of validated outcome measures and improving delivery aspects before this intervention programme is trialled among foundation doctors in the UK.

Relationship between sociodemographic factors and specialty destination of UK trainee doctors: a national cohort study

ObjectivesMany countries are driving forward policies to widen the socioeconomic profile of medical students and to train more medical students for certain specialties. However, little is known about how socioeconomic...

Why UK Junior Doctors Defer Postgraduate Training.

Objectives National surveys have identified a declining trend in UK Foundation Year 2 doctors (FY2s) entering directly into training positions. Last year less than half entered training directly. We aimed to investigate the reasons why current FY2s choose not to enter training directly. Methods This is a qualitative study using semi-structured interviews. We used thematic framework analysis to code the data into themes for analysis. Results “Feeling unprepared for training” and “lack of flexibility” were the two main themes identified from the interviews as reasons to delay training. A lack of clinical exposure and career advice were cited as reasons to feel unprepared. Flexibility was very important in terms of family considerations, working abroad and financial reasons which were felt to be absent from a rigid training programme. Conclusions Defering training after FY2 appears to have become normalised in the UK. Many other international training programmes appear less structured than the UK and expect juniors to spend time in non-training jobs prior to entering training. It is impossible to say which system is superior but it appears no system can dictate the speed of postgraduate medical training.

Transforming the landscape of liver disease in the UK

In 2014, The Lancet published the inaugural report of the Lancet Commission on Liver Disease in the UK. 1 Williams R Aspinall R Bellis M et al. Addressing liver disease in the UK: a blueprint for attaining excellence in health care and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity, and viral hepatitis. Lancet. 2014; 384: 1953-1997 Summary Full Text Full Text PDF PubMed Scopus (405) Google Scholar With mortality from liver diseases having risen four-fold over the previous four decades, the report was timely and urgently needed. Led by Roger Williams of the UK's Foundation for Liver Research, Institute of Hepatology, King's College London, the Commission provided a comprehensive analysis of the disease burden in the UK and carefully examined access to, and quality of, care for patients with liver disease. Having accumulated a strong foundation of evidence, the Commission made ten recommendations aimed at reducing unacceptable premature mortality and improving care for patients. The recommendations addressed unmet needs of patients with liver disease, as well as areas in which the greatest population-wide impacts could be made. They covered the full spectrum of health care, including community, general practice, specialised services, and paediatric care. Obesity, alcohol, and hepatitis were identified as key modifiable risk factors. The need for a response to commercial drivers of poor liver health—the alcohol and food industries—was also highlighted as a priority area to focus political action. Gathering momentum for the way ahead: fifth report of the Lancet Standing Commission on Liver Disease in the UKThis report presents further evidence on the escalating alcohol consumption in the UK and the burden of liver disease associated with this major risk factor, as well as the effects on hospital and primary care. We reiterate the need for fiscal regulation by the UK Government if overall alcohol consumption is to be reduced sufficiently to improve health outcomes. We also draw attention to the effects of drastic cuts in public services for alcohol treatment, the repeated failures of voluntary agreements with the drinks industry, and the influence of the industry through its lobbying activities. Full-Text PDF Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based studyThe high risk of hospital death in patients with sepsis, hepatorenal syndrome, or peritonitis warrants further investigation, and the low chance of hospital death in patients with alcohol-related disorders also needs to be explored. Prevention strategies and end-of-life care services are urgently needed to prevent and tackle harms from liver disease. Full-Text PDF Alcohol drinking patterns and liver cirrhosis risk: analysis of the prospective UK Million Women StudyIn middle-aged women, cirrhosis incidence increases with total alcohol intake, even at moderate levels of consumption. For a given weekly intake of alcohol, this excess incidence of cirrhosis is higher if consumption is usually without meals, or with daily drinking. Full-Text PDF Open Access

Addendum to the Acknowledgements: How Online Communities of People With Long-Term Conditions Function and Evolve: Network Analysis of the Structure and Dynamics of the Asthma UK and British Lung Foundation Online Communities.

Addendum to the Acknowledgements: How Online Communities of People With Long-Term Conditions Function and Evolve: Network Analysis of the Structure and Dynamics of the Asthma UK and British Lung Foundation Online Communities.

Human candidate gene polymorphisms and risk of severe malaria in children in Kilifi, Kenya: a case-control association study

SummaryBackgroundHuman genetic factors are important determinants of malaria risk. We investigated associations between multiple candidate polymorphisms—many related to the structure or function of red blood cells—and risk for severe Plasmodium falciparum malaria and its specific phenotypes, including cerebral malaria, severe malaria anaemia, and respiratory distress.MethodsWe did a case-control study in Kilifi County, Kenya. We recruited as cases children presenting with severe malaria to the high-dependency ward of Kilifi County Hospital. We included as controls infants born in the local community between Aug 1, 2006, and Sept 30, 2010, who were part of a genetics study. We tested for associations between a range of candidate malaria-protective genes and risk for severe malaria and its specific phenotypes. We used a permutation approach to account for multiple comparisons between polymorphisms and severe malaria. We judged p values less than 0·005 significant for the primary analysis of the association between candidate genes and severe malaria.FindingsBetween June 11, 1995, and June 12, 2008, 2244 children with severe malaria were recruited to the study, and 3949 infants were included as controls. Overall, 263 (12%) of 2244 children with severe malaria died in hospital, including 196 (16%) of 1233 with cerebral malaria. We investigated 121 polymorphisms in 70 candidate severe malaria-associated genes. We found significant associations between risk for severe malaria overall and polymorphisms in 15 genes or locations, of which most were related to red blood cells: ABO, ATP2B4, ARL14, CD40LG, FREM3, INPP4B, G6PD, HBA (both HBA1 and HBA2), HBB, IL10, LPHN2 (also known as ADGRL2), LOC727982, RPS6KL1, CAND1, and GNAS. Combined, these genetic associations accounted for 5·2% of the variance in risk for developing severe malaria among individuals in the general population. We confirmed established associations between severe malaria and sickle-cell trait (odds ratio [OR] 0·15, 95% CI 0·11–0·20; p=2·61 × 10−58), blood group O (0·74, 0·66–0·82; p=6·26 × 10−8), and –α3·7-thalassaemia (0·83, 0·76–0·90; p=2·06 × 10−6). We also found strong associations between overall risk of severe malaria and polymorphisms in both ATP2B4 (OR 0·76, 95% CI 0·63–0·92; p=0·001) and FREM3 (0·64, 0·53–0·79; p=3·18 × 10−14). The association with FREM3 could be accounted for by linkage disequilibrium with a complex structural mutation within the glycophorin gene region (comprising GYPA, GYPB, and GYPE) that encodes for the rare Dantu blood group antigen. Heterozygosity for Dantu was associated with risk for severe malaria (OR 0·57, 95% CI 0·49–0·68; p=3·22 × 10−11), as was homozygosity (0·26, 0·11–0·62; p=0·002).InterpretationBoth ATP2B4 and the Dantu blood group antigen are associated with the structure and function of red blood cells. ATP2B4 codes for plasma membrane calcium-transporting ATPase 4 (the major calcium pump on red blood cells) and the glycophorins are ligands for parasites to invade red blood cells. Future work should aim at uncovering the mechanisms by which these polymorphisms can result in severe malaria protection and investigate the implications of these associations for wider health.FundingWellcome Trust, UK Medical Research Council, European Union, and Foundation for the National Institutes of Health as part of the Bill & Melinda Gates Grand Challenges in Global Health Initiative.