It’s when big stuff hits and happens that the machinery of state (or the hospital or household) seems to step up and move fast and effectively to undertake activities it seemed to need months to do previously. Enormous clinical trials of agents to treat the complications of SARS-CoV2 have sprung into existence within weeks; hospitals have built ICU capacity where hernias had been being repaired; communities have mobilised to provide food for the shielded. We’ve probably all seen similar efforts when a disaster has struck, be that an earthquake, diagnosis of childhood malignancy or death of a colleague. Where everything seems to struggle is in addressing the apparently mundane but annoyingly aversive: the best management of fatigue after chemotherapy, drooling in children with cerebral palsy, excluding significant liver disease in mildly jaundiced babies. 

The types of studies which address these questions are often ‘poor quality’ but still the best we can get. Mundane challenges are frequently studied by looking over past experience, or by small studies labelled as ‘pilots’ but without a plan to move them onwards, and who may be riddled with missing data, unvalidated outcome measures and confounding factors. Evidence-based medicine is relatively straightforward if we can use a global randomised trial to choose our chemotherapy. It’s trickier to reduce the radiation exposure for children who’ve had their chest drains removed.

How can we meaningfully address this issue? We can continue to do the best we can with the evidence we have before us, but we can also use the reset-and-recovery phase of the pandemic to point out how we relied and undertook clinical studies and therapeutic trials to understand and guide us in the unknown; that these principles should apply to every condition and question, and maybe in the next years the memory of the world will help this happen.

• Archi