What strategies should governments adopt to improve the health of their citizens? Amid the COVID-19 syndemic it would be easy to focus attention on global health security—at a minimum, strong public health and health-care systems. WHO has based its global health strategy on three pillars: universal health coverage, health emergencies, and better health and wellbeing. The indispensable elements of robust public health and health care are well known and endlessly rehearsed—a capable health workforce; effective, safe, and high-quality service delivery; health information systems; access to essential medicines; sufficient financing; and good governance.

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides a rules-based synthesis of the available evidence on levels and trends in health outcomes, a diverse set of risk factors, and health system responses. GBD 2019 covered 204 countries and territories, as well as first administrative level disaggregations for 22 countries, from 1990 to 2019. Because GBD is highly standardised and comprehensive, spanning both fatal and non-fatal outcomes, and uses a mutually exclusive and collectively exhaustive list of hierarchical disease and injury causes, the study provides a powerful basis for detailed and broad insights on global health trends and emerging challenges.

Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition.

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

Overall, the record for reducing exposure to harmful risks over the past three decades is poor. Success with reducing smoking and lead exposure through regulatory policy might point the way for a stronger role for public policy on other risks in addition to continued efforts to provide information on risk factor harm to the general public.

The theme of this year's World Mental Health Day, on Oct 10, is increased investment in mental health. Why invest, and why now? The answer is simple. At the best of times, good mental health is needed for a society to thrive. During a pandemic, good mental health is more important than ever. Without a focus on mental health, any response to COVID-19 will be deficient, reducing individual and societal resilience, and impeding social, economic, and cultural recovery.

Racial and ethnic injustice is a burning issue of our time. This year, the appalling police killings of George Floyd, Breonna Taylor, and other Black men and women in the USA and worldwide were met with global condemnation. The groundswell of emotion and anger among the Lancet Group staff prompted self-reflection and brought our own work and environment into sharp focus. Elsevier, our publisher, has expressed its continued commitment to ensure a culture and practice of equity, diversity, and inclusion and announced a formal pledge to eliminate systemic racism in health and research.

Fatigue. Despair. Misery. Cracks are beginning to appear in our mental resilience. 10 months of this calamity. How much more can we bear? It was always so. When the Bishop of Winchester died of plague in 1626, John Milton issued a searing cry of anguish in his Elegia Tertia. The great poet was just 17 years old, “sad...with no companion, and many sorrows clung to my soul”. He sought to commemorate this “grim killing” of a revered literary figure, a “dreadful death, fearsome with her sepulchral torch”.

Harvey Alter, Michael Houghton, and Charles Rice have been awarded the 2020 Nobel Prize in Physiology or Medicine for their work in identifying the hepatitis C virus. Talha Burki reports.

The COVID-19 pandemic's damage to education and the economy could reverse decades of progress on child marriage and pregnancy. Sophie Cousins reports.

“Taking on a new adventure” is how Barbara Stoll views her recent appointment as President of the China Medical Board (CMB), a US-based philanthropic foundation for health development in China and southeast Asia. “I'm incredibly lucky to be given this opportunity, and will try my best to fill the large shoes of outgoing CMB President Lincoln Chen, who has done an extraordinary job over the past 14 years, building partnerships and extending CMB's reach”, she says. It was Chen who helped open Stoll's eyes to the wider world of global health, encouraging her to pursue research opportunities in Bangladesh early in her career.

The COVID-19 pandemic is inescapable. From curtailing our daily social and professional interactions, locking down or physically distancing our communities, and drawing our anxious attention to daily updates of international case and death statistics, the lived experience of the pandemic is at once personal, local, and global. It is also a shared experience that emphasises, through the pandemic's pervasive disruption, the social interactions and behaviours that define our shared world. One cultural response to the disruption and uncertainty during an infectious disease outbreak is the construction of what Priscilla Wald terms the “outbreak narrative”, a formulaic plot that serves to shape our collective understanding of a pandemic.

Cummings and colleagues1 reported the epidemiology, clinical course, and outcomes of 257 critically ill adults with laboratory-confirmed COVID-19 admitted to two hospitals in New York City. The primary outcome was the rate of in-hospital death, and each patient had at least 28 days of observation. The authors report that, as of April 28, 2020, 101 (39%) of 257 patients had died, 94 (37%) remained hospitalised, four (2%) were transferred to another hospital, and 58 (23%) were discharged alive. Surprisingly, the authors show in figure 1 of their Article1 a cumulative incidence of in-hospital death of approximately 45% at 28 days.

We agree with Daniele Piovani and Stephanos Bonovas that informative censoring, if present, could represent a potential source of bias in the survival analyses in our Article.1 However, sensitivity analysis suggests that any such bias is likely to be minimal.

Breastfeeding offers numerous immunological, developmental, and psychological advantages to the infant–mother dyad. The risks posed to infant and maternal health through any loss of support for breastfeeding mean that public health messaging during the COVID-19 pandemic should be careful. As academic leads of human milk banks, we are acutely aware of the importance of understanding the risks posed by novel infectious pathogens in human milk and the mitigation of risk to susceptible infants.

In the ongoing COVID-19 pandemic, questions regarding possible methods of virus transmission, including the safety of breastfeeding by mothers who are infected, are of great importance. We reported1 the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA (not viral particles, as incorrectly stated by Natalie Shenker and colleagues) in consecutive milk samples from an infected mother and interpreted our findings with the greatest caution. In particular, we did not claim that SARS-CoV-2 is transmitted via contaminated breastmilk or that breastfeeding should be discontinued by mothers with the infection.

We read, with great interest, about the outcomes in a cohort of patients with cancer and COVID-19 by Nicole Kuderer and colleagues.1 The authors showed that among patients with cancer and COVID-19, 30-day all-cause mortality was high and associated with general and cancer-specific risk factors, with a mortality of 13·3%.

Nicole Kuderer and colleagues1 identified several independent prognostic factors to be conferring an increased risk of 30-day all-cause mortality: increased age, male sex, being a former smoker, multiple medical comorbidities, high Eastern Cooperative Oncology Group performance status score (≥2), and an active cancer. However, haematological malignancies, instead of increasing 30-day all-cause mor­tality, were associated with severe clinical outcomes, intensive care unit admissions, and meeting composite severe illness endpoints.

We thank Dimitrios Moris and col­leagues and Alexandre Malek and colleagues for their insightful commentary about the CCC19 study findings.1 We value the opportunity to further characterise mortality outcomes beyond our initial report.1

To corroborate the Editors'1 appeal for Indigenous Peoples' right to self-determination as fundamental to ensure their health, we wish to draw attention to the dire situation faced by Indigenous populations in the Amazon, and mainly in Brazil.