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Saudi Arabia is 2,000 miles from Ukraine and even more politically distant, so at first glance it might seem like it has nothing to do with the ongoing war there. But the Gulf state has emerged as a key intermediary in the most serious ceasefire negotiations since Russia invaded its neighbor three years ago.

While it is U.S. officials who are undoubtedly leading the efforts for an agreement, it is the Saudi capital of Riyadh that has been staging the crucial talks.

In a flurry of diplomatic activity on March 10, 2025, Saudi Crown Prince Mohammed bin Salman, the country’s top political authority, hosted separate meetings with Ukrainian President Volodymyr Zelenskyy and a U.S. delegation led by Secretary of State Marco Rubio and national security adviser Mike Waltz.

The following day, senior Saudi officials facilitated face-to-face meetings between U.S. and Ukrainian delegations.

The resulting agreement, which is now being mulled in Moscow, is all the more notable given that it followed a diplomatic breakdown just weeks before at the Oval Office between Zelenskyy, President Donald Trump and Vice President JD Vance.

Whether the proposed interim 30-day ceasefire materializes is still uncertain. On March 14, Russian President Vladimir Putin said he agreed with the proposal in principle, but he added that a lot of the details needed to be sorted out.

Should a deal be reached, there is every reason to believe it will be inked in Saudi Arabia, which has hosted not only the latest U.S.-Ukrainian talks but earlier rounds of high-level Russian-U.S. meetings.

But why is a Gulf nation playing mediator in a conflict in Eastern Europe? As an expert on Saudi politics, I believe the answer to that lies in the kingdom’s diplomatic ambitions and its desire to present a more positive image to the world. And in the background is the goal of better positioning the nation in the event of diplomatic maneuvers in its own region, notably in regards to any talks between U.S. and Iran.

The diplomatic convertion of MBS

Saudi Arabia’s growing diplomatic role has been a feature of the kingdom’s foreign policy since 2022.

Crown Prince Mohammed, who that year succeeded his father as prime minister, views Saudi Arabia as the convening power in the Arab and Islamic world.

Accordingly, officials in the kingdom have been directed to lead regional diplomacy over a number of pressing issues, including the conflicts in Gaza and Sudan.

At the same time, Saudis have started the process of reconciliation with Iran, which has long been perceived as the chief regional rival to Saudi influence.

This turn to diplomacy marks a shift away from the confrontational policies adopted by the crown prince during his rise to power in Saudi Arabia between 2015 and 2018. Policies such as Saudi Arabia’s military intervention in Yemen, its blockade of Qatar, the detention of Lebanon’s Prime Minister Saad Hariri and the conversion of the Ritz-Carlton hotel in Riyadh into a makeshift prison all fed an image of the young prince as an impulsive decision-maker. Then in 2018 came the murder of journalist Jamal Khashoggi in the Saudi Consulate in Istanbul.

This approach brought little in the way of stability. Rather, it left the country ensnared in an unwinnable war in Yemen, a fruitless row with Qatar, and diplomatic isolation by Western officials.

A friend to Ukraine and Russia

In regards to the war in Ukraine, Saudi Arabia’s intermediary role is helped by a perception of the kingdom as a neutral nation on the conflict.

Saudi officials, in common with their counterparts in the other Gulf states, have long sought to avoid taking sides in the emerging era of great power competition and strategic rivalry. As such, the kingdom has maintained working relations with both Russia and pro-Western Ukraine since the outbreak of war in Europe.

Russian President Vladimir Putin and Saudi Crown Prince Mohammed bin Salman meet in Riyadh on Dec. 6, 2023.
Alexey Nikolsky/AFP via Getty Images

In 2022, for example, Saudi Arabia and Russia – both leaders of OPEC+ – coordinated oil production cuts to cushion Moscow from the effects of global sanctions the West imposed after it invaded Ukraine. Yet just months later, Saudi Arabia invited Zelenskyy to address an Arab League summit in the Saudi city of Jeddah.

It was a prelude to a 2023 international summit, also in Jeddah, which brought together representatives from 40 countries to discuss the ongoing war.

Despite failing to produce a breakthrough, the meeting illustrated the convening reach of the crown prince and his intention to act as a diplomatic go-between in the Ukraine-Russia war.

Saudi Arabia and neighboring United Arab Emirates later facilitated occasional prisoner exchanges between the two countries – rare diplomatic successes in three years of conflict.

Staging ground for diplomacy

Direct engagement in high-stakes international diplomacy over the largest war in Europe since 1945 is undoubtedly a step up in Saudi ambitions. But the country’s efforts aren’t purely altruistic. Riyadh believes there’s mileage to be gained in such diplomatic endeavors.

The advent of a Trump presidency has fit Saudi desires. Trump has made his desire to be seen as a dealmaker and peacemaker clear, but he needs a neutral venue in which the hard work of diplomacy can flourish.

Just weeks into the new U.S. administration, the Saudi capital hosted the first meeting between a U.S. secretary of state and Russian foreign minister since Russia invaded in 2022.

It yielded an agreement to “re-establish the bilateral relationship” and establish a consultation mechanism to “address irritants” in ties.

The two rounds of dialogue in Riyadh – first with Russia, then Ukraine – have positioned the Saudi leadership firmly in the diplomatic process. It has also gone some way to rehabilitate Mohammed bin Salman’s image.

The sight of the crown prince warmly greeting Zelenskyy contrasted sharply with the images from a fractious White House meeting that went around the world, presenting the crown prince as a statesmanlike figure.

Turning to Tehran

Such positive optics would have seemed inconceivable as recently as 2019, when the crown prince was shunned and then presidential candidate Joe Biden labeled the country a “pariah” state.

Changing this negative global perception of Saudi Arabia is crucial if the kingdom is to attract the tens of millions of visitors that are pivotal to the success of the “giga-projects” – sports, culture and tourism events that the Saudis hope will drive its economy and allow the kingdom to be less economically dependent on fossil fuel exports.

Whereas easing tensions with Iran and supporting Yemen’s fragile truce are about derisking the kingdom’s vulnerability to regional volatility, facilitating diplomacy over Ukraine is a relatively cost-free way to reinforce the changing narratives about Saudi Arabia.

After all, any breakdown in the Russia-U.S.-Ukraine negotiations is unlikely to be blamed on the Saudis.

Indeed, Saudi officials may view their engagement with U.S. officials over Ukraine as the prelude to further diplomatic cooperation. And this will be especially true if Crown Prince Mohammed is able to establish himself as an indispensable partner in the eyes of Trump.

Saudi officials were excluded from the last major talks between Iran and the U.S., which also involved several other major world powers and led to the 2016 Iran nuclear deal. Trump withdrew from the deal shortly after assuming office for the first time in 2017, and U.S.-Iranian relations have been moribund since then.

The U.S. administration has already mooted the idea of a resumption of negotiations with Tehran over its nuclear capabilities.

Placing Saudi Arabia in the middle of any attempts to secure a new nuclear agreement that would replace or supersede that earlier deal would be a high-risk move, given the intensity of feeling on both the U.S. and Iranian sides and the uneasy coexistence between Tehran and Riyadh.

But doing so would give the kingdom what it most desires: a seat at the table. Läs mer…

The recently appointed White House press secretary, Karoline Leavitt, has begun her tenure combatively, aggressively defending the Trump administration’s policies and, at times, mimicking Donald Trump’s methods of dealing with the mainstream news media.

Faced recently with a legitimate question by an Associated Press (AP) reporter who challenged Trump’s introduction of tariffs against several countries, she accused the reporter of doubting her knowledge of economics. She then dismissed him, saying: “I now regret giving a question to the Associated Press.”

AP is one of the key media organisations reporting on the White House. The largest news agency in the US, its stories are carried by news groups around the world. But recently, AP was ejected from the “press pool” that covers White House business

It was excluded in mid-February for refusing to call the Gulf of Mexico “the Gulf of America”, after Trump changed its name by executive order. This was followed by an announcement that the White House would take greater control of the press pool and choose which outlets would be given most access to the president. This is likely to be based on favourable coverage rather than quality of reporting.

To appreciate how significant this is, it is important to first state the fundamental purpose of journalism in a democratic society, which is to hold the powerful to account. This is known as its “watchdog” function.

The work of Washington Post reporters Bob Woodward and Carl Bernstein in exposing the Watergate scandal during the 1970s is often held up as the gold standard of watchdog journalism. It ultimately led to the resignation of Richard Nixon as president and the imprisonment of his lawyer, John Dean.

“Pooling” describes the process by which a prominent organisation or individual attempts to oversee journalistic scrutiny by managing access. King Charles, for example, also operates a press pool.

It works in two stages. First, news organisations or individual journalists apply to be members of the pool. Then, a handful of journalists from the pool are selected each day or week for access. These journalists – through their pool contract – are required to share the information they gather with the other journalists in the pool, which often leads to a genericisation of the content.

Thus, while political organisations or elite individuals might claim the pooling system is used as a benign and fair tool to manage consistent press interest, in reality it is a weapon of communications control.

The White House’s press pool was first established under President Dwight Eisenhower as a reflection of the growing number of journalists based in Washington. But in the modern era, the use of pooling was most controversial during and after the first Gulf War of the early 1990s.

Rather than roaming the battlefields of Iraq and Kuwait, most western reporters spent the conflict at the media centre in Dhahran, Saudi Arabia, some 250 miles from the Kuwait border. Here they were fed the information that the US military wanted the public to know. A small number of pooled journalists were then occasionally accompanied by US troops to the battlefield in what was a clear case of censorship by access and perspective limitation.

This military-media power dynamic – and the subsequent mismatch between the actuality of the war and the reporting of it – led the French philosopher Jean Baudrillard to declare in a 1991 essay, published by Liberation and The Guardian, that “The Gulf war did not take place”.

General “Stormin” Norman Schwarzkopf’s famous “luckiest man in Iraq” briefing is indicative of the close relationship that developed between military and media professionals during the conflict. Schwarzkopf showed journalists footage taken through the crosshairs of a US bomber of an Iraqi private car driving over a bridge moments before a US airstrike destroys it. You can hear the journalists laughing with Schwarzkopf as they watch this lucky escape.

Legacy of Vietnam

Despite widespread understanding that scrutiny is an important part of public officialdom, the legacy of the Vietnam War – a conflict the US was perceived both at home and around the world to have lost – led to a significant amount of distrust of journalists. US media analyst Daniel Hallin referred to Vietnam as the “uncensored war”. By this he meant that journalists enjoyed an unprecedented amount of freedom – exacerbated by the relatively new medium of television, which brought stark images of war directly into people’s living rooms.

Controlling the message: US secretary of defense Robert McNamara delivers a press briefing at the Pentagon in 1965.
Zuma Press/Alamy Stock Photo

By February 1968, the US military’s daily briefings from the Rex Hotel in Saigon had become known as the “five o’clock follies”, on account of the gulf between official claims of the war’s “progress” and what was being reported by journalists who had ventured into the field. The military consistently presented a positive narrative – in stark contrast to the esteemed CBS reporter Walter Cronkite’s analysis that: “To say that we are mired in stalemate seems the only realistic, yet unsatisfactory, conclusion.”

Vietnam could have been an opportunity for governments to think about their obligation to truth and the requirement to be more ethical in their approach. Instead, the feeling in Washington was that unfavourable press coverage had lost the war, and that journalists needed to be curtailed.

Controlling the message

The recent decision by the Trump administration to take over selection of pool journalists from the notionally independent White House Correspondents’ Association is unsurprising. The approach is consistent with the first Trump presidency’s refusal to answer questions from journalists who tried to carry out the press’s watchdog function.

It also fits with Trump’s electioneering approach during 2024 when he shunned traditional news outlets, focusing instead on social media and appearing on the podcasts of Joe Rogan and Andrew Schulz, for example.

To this end, the White House’s decision amounts to a power grab against the institution of modern journalism – even if much of the US media has been in thrall to the powerful ever since Vietnam. Läs mer…

Pakistan’s army has freed hundreds of hostages from a passenger train that was seized by armed militants in the south-western province of Balochistan on Tuesday, March 11. A number of those on board were military officials and police personnel travelling from Balochistan’s capital, Quetta, to Peshawar further north.

The Baloch Liberation Army (BLA) quickly claimed responsibility for the hijacking. In a written statement sent to the Guardian, the group said its actions were “a direct response to Pakistan’s decades-long colonial occupation of Balochistan and the relentless war crimes committed against the Baloch people”.

Ever since 1948, when Balochistan became a province of Pakistan months after partition from India, this territory has been marginalised by the Pakistani state. The authorities have struggled to accommodate the diverse ethnic and linguistic groups within Balochistan, leading to several rounds of insurgency.

During the recent hijack, the BLA demanded that Pakistan’s military release Baloch activists, missing people and political prisoners, and threatened to kill many of the hostages if the authorities did not comply. The subsequent military operation, which lasted two days, resulted in the deaths of all 33 militants, as well as 21 hostages and four army personnel.

The brazen nature and scale of the attack has raised difficult questions for the Pakistani state about how it addresses escalating discontent and militancy in Balochistan.

People in Hyderabad, Pakistan, attend a rally in solidarity with the armed forces after the train hijacking incident.
Nadeem Khawer / EPA

Who are the BLA?

The BLA is a separatist group that emerged in the early 2000s. It is considered a terrorist organisation by the Pakistani authorities and several western countries.

Unlike more moderate Baloch nationalist groups, which are committed to remaining part of the Pakistani state despite longstanding grievances with it, the BLA aims to achieve an independent Balochistan.

Some of the grievances expressed by the Baloch include a lack of representation both in the federal government and the armed forces. Baloch nationalists also allege the Pakistani state has exploited the province’s coal, gold, copper and gas resources while providing very little for the Baloch people in return.

Revenues from the Saindak gold and copper mine, for example, are largely shared between the Chinese company that operates it and the Pakistani government. The Balochistan provincial government only receives around 5% of the mine’s revenue.

Chaghi, the mineral-rich district of Balochistan that hosts the Saindak mine, remains one of the most underdeveloped areas of the country. Local people employed at the mine claim they are only offered menial jobs and work in unsafe conditions.

Balochistan’s persistent underdevelopment means a poor quality of life for its citizens. It consistently ranks as the Pakistani province with the lowest human development index (HDI) rating, scoring 0.421 in 2017. This index is a summary rating between 0 (low) and 1 (high) based on measures of health, education and standard of living. Punjab has the highest HDI rating at 0.732.

Balochistan is located in south-west Pakistan.
Calligraphy786 / Shutterstock

The separatist movement in Balochistan intensified after Nawab Akbar Bugti, a prominent Baloch nationalist leader, was killed in a military operation in 2006. The BLA was soon banned by the Pakistani government, and the military’s operations intensified in the province.

Baloch human rights defenders and activists have persistently accused Pakistan’s security forces of harassment and relying on excessive force. Protesters believe there have been thousands of enforced disappearances and extrajudicial killings, which the Pakistani authorities have denied.

The issue has been raised by human rights organisations both in Pakistan and abroad. Families of missing people have filed cases against the government with the Pakistan Supreme Court, and disappearances have been investigated through special commissions of inquiry.

Supreme Court rulings have held the state responsible for enforced disappearances. While some missing people have been traced as a result of these rulings and inquiries, the International Commission of Jurists notes that “there has been no apparent effort made to fix responsibility for this heinous crime”.

Attacking foreign investments

The BLA’s tactics have typically involved carrying out attacks against state installations. However, in recent years, attacks against Chinese citizens and infrastructure have become the group’s focus.

Balochistan has a strategically important coastline, providing access to the Indian Ocean. China has invested heavily in the region as part of its Belt and Road Initiative, including in a deep-sea port at Gwadar. But these investments have failed to benefit local people, fuelling accusations by many in the province that the Pakistani state is systematically neglecting their needs.

The BLA’s suicide squad was responsible for an attack that injured three Chinese engineers working in the Balochistan city of Dalbandin in 2018. Later that year, BLA militants attacked the Chinese consulate in Karachi – though Chinese nationals remained safe in that attack.

The group seems to have no difficulty attracting young and well-educated Baloch people, who see the state’s actions and Chinese presence in Balochistan as exploitative. In 2022, a female graduate student carried out a suicide attack on behalf of the BLA that killed three Chinese teachers at the University of Karachi.

Pakistani security officials inspect a suicide bomb blast at a railway station in Quetta in November 2024.
Fayyaz Ahmad / EPA

The BLA’s activities have expanded substantially in recent years. It has conducted more than 150 attacks in the past year alone, including on Quetta railway station and on a convoy carrying Chinese workers near Karachi airport.

However, experts have noted that the train hijacking was unprecedented in scale. It represents a significant escalation by the BLA in terms of the planning, resources and intelligence required to execute such an operation.

The Pakistani government and military appear to have mishandled Balochistan’s security situation. But they have also failed to address the growing resentment and alienation that is driving people to groups like the BLA.

According to Farzana Sheikh, an associate fellow at Chatham House, Pakistan’s military continues to favour “a heavy-handed security response to deal with what is widely judged to be a political crisis”.

Accusations of state exploitation and neglect will not go away until the Pakistani state radically alters its stance on Balochistan, starting by ensuring accountability for perpetrators of human rights violations. Only then can trust be rebuilt with the people of this province who, according to the Human Rights Commission of Pakistan, live in “a climate of fear”. Läs mer…

Opus, the film debut of former GQ editor-turned-director Mark Anthony Green has been described as a horror-musical. And while this new hybrid-genre film clearly has something to say, what that is remains frustratingly unclear.

Produced by independent film company A24, often a hallmark of quality, the film follows Ariel Ecton (Ayo Edebiri), a young writer striving to make her mark in entertainment journalism. While it gestures toward themes of celebrity culture and the toxicity of extreme fandom, the film ultimately feels tangled in a jumble of unfocused ideas and derivative references to other – arguably stronger – works.

Despite talent and determination, Ariel struggles with her boss Stan (Murray Bartlett) who redeploys her ideas to other senior colleagues and is often too self-absorbed to nurture her career development.

The very watchable Edebiri eases into centre stage after catapulting to global fame in the TV show The Bear (2022-present), for which she has received a Golden Globe and an Emmy.

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In contrast to the achievements of The Bear’s Sydney, her character Ariel’s success as a writer seems out of reach in Opus. In an early scene, she articulates her frustrations to a friend who responds by pointing to Ariel’s ordinariness and comfortable upbringing. Apparently, her lack of disadvantage is precisely what’s holding her back, leaving her “too middle” to be noticed, promoted or considered.

Here we have the first clue that Ariel will be destined to experience trauma which will come by way of the “final girl” horror trope (a reference to the last woman standing) by the end of the film.

To Ariel’s surprise, she is selected to accompany Stan to a remote desert compound with other journalists to cover the story of reclusive pop legend Alfred Moretti (John Malkovich, returning to the big screen for the first time in five years).

Coincidentally, Moretti is about to make a return to public life after a 30-year hiatus and reset his reputation with a new album. Malkovich seems to relish the role, cranking up his flamboyant eccentricity in what feels like a mash-up of Ziggy Stardust and Frank-N-Furter.

Moretti’s ostentatiousness in contrast to Ariel’s subdued “middle-ness”, seems to be one of several binaries that the film explores, with an epilogue that discusses the left and right sides of the brain, and the division between destruction and creativity.

The theme of creativeness is a driving force in the film, with Moretti’s and Ariel’s respective musical and literary artistry used as fuel in the narrative, from a director with a similar writing background to Ariel.

Unfortunately, the film often feels more derivative than creative because of the numerous sources it takes as its inspiration. Moretti’s compound turns out, of course, to be a cult where Ariel, Stan and other invited guests will find something even more sinister than Malkovich’s rhythmic hip thrusts.

The rules of the compound mean that all guests must hand over their phones and electronic devices, so that in typical horror fashion, the characters are completely cut off from the outside world.

The knowing nod to this horror cliché is perhaps done for comedic value, but becomes another of the film’s weak spots, in the sense that it never really commits to any one thing. It’s not quite a comedy, a horror or a musical but something that is more fragmentary, borrowing elements of each.

It’s as if the director has assembled his favourite genres, but only in notes that have not yet been successfully put together. For example, there is an explicit recreation of a very distinct scene from Takashi Miike’s harrowing Audition (1999), while other parts are heavily influenced by Ari Aster’s disturbing Midsommar, (2019) a folk horror film also made by A24.

There are also nods to Mark Mylod’s The Menu (2022) in which an eccentric celebrity chef creates a meal for a group of sycophant critics with lethal consequences. As a dark comedy-horror, The Menu succeeds in satirising the absurdity of reality cooking shows, where competitiveness and TV chefs are caricatured.

Director Anthony Michael Green on set with Ayo Edebiri and John Malkovich.
Everett Collection / Alamy

However, Green’s attempt at satire in Opus doesn’t really work. That’s not to imply that the film hasn’t got something to say – Green appears to be interested in the relationship between celebrity culture and fandom. However, that idea doesn’t feel fully fleshed out, particularly when other films like Brandon Cronenberg’s dangerously underrated Antiviral (2012) was addressing this idea with visceral originality more than a decade ago.

Moretti’s songs have a deliberately dated sound which seems to be inspired by Michael Jackson, particularly around the time of his 2001 Invincible tour and album, which both failed to return the singer to his “king of pop” status.
Again, films such as Coralie Fargeat’s The Substance (2024) tackle the idea of the ageing celebrity with more clarity and originality, even while clearly being inspired by other movies.

Consequently, Opus has quite a 1990s feel to it, perhaps aided by the casting of Malkovich and Juliette Lewis, both huge stars during that decade. The film also gets a bit meta, nodding to Spike Jonze’s Being John Malkovich (1999) through a similar use of star cameos and a puppet show – both interesting elements, but again which feel disjointed in Opus.

I think Green has stronger films in him to come but, although his work raises interesting points, there are too many ideas here for a convincing film to properly materialise. I was unclear on a number of things including Moretti’s motives and his contempt for critics, including the positive ones.

Opus perhaps bites off more than it can chew, leaving me feeling that Green’s directorial opus is still to come. Läs mer…

Getting a headache and feeling sick are common side-effects for many medicines. Indulging in risky sexual behaviour or pathological gambling – not so common.

But a BBC investigation has highlighted that some drug treatments for restless leg syndrome and Parkinson’s disease can lead to such risky behaviour.

Over 150,000 people in the UK live with Parkinson’s – a degenerative condition that affects the brain. The main part of their brain that is damaged is the area that produces dopamine, a chemical messenger that regulates movement. Less dopamine in the brain can lead to symptoms such as tremors, muscle stiffness, slow movements and problems with balance.

Another movement disorder is restless legs syndrome (RLS), which affects between 5% and 10% of people in the UK, US and Europe. Twice as many women as men have RLS among those aged over 35.

Read more:
Restless legs syndrome is incurable – here’s how to manage the symptoms

People with RLS feel they need to uncontrollably move their legs, and may experience a crawling, creeping or tingling sensation in them. Usually, the symptoms are worse at night when dopamine levels tend to be lower. Although the exact cause of RLS is unknown, it has been linked to genes, underlying health conditions, and an imbalance of dopamine.

One of the main treatments for movement disorders is a group of drugs called dopamine-receptor agonists, which include cabergoline, ropinirole, bromocriptine and pramipexole. Dopamine-receptor agonists increase the levels of dopamine in the brain and help regulate movement.

Dopamine is known as the “happy” hormone because it is part of the brain’s reward system. When people do something fun or pleasurable, dopamine is released in their brain. But using dopamine-receptor agonist drugs can elevate these feelings, leading to impulsive behaviour.

While common side-effects include headaches, feeling sick and sleepiness, these drugs are also linked with the more unusual side-effect of impulse-control disorders. These include risky sexual behaviour (hypersexuality), pathological gambling, compulsive shopping, and binge eating. Hypersexuality encompasses behaviour such as a stronger-than-usual urge to have sexual activity, or being unable to resist performing a sexual act that may be harmful.

Previous reported cases include a 53-year-old woman taking ropinirole and exhibiting impulsive behaviour such as accessing internet pornography, using sex chat rooms, meeting strangers for sexual intercourse, and compulsive shopping. Another case highlighted a 32-year-old man who, after taking ropinirole, started binge eating and gambling compulsively, such that he lost his life savings.

When the drug was first being prescribed in the early 2000s, it was thought that impulse-control disorders were a rare side-effect associated with these drugs. But in 2007, a UK Medicines and Healthcare Products Regulatory Agency (MHRA) public assessment report advised that “healthcare professionals should warn patients that compulsive behaviour with dopamine agonists may be dose-related”.

Between 6% and 17% of people with RLS who take dopamine agonists develop some form of impulse-control disorder, while up to 20% of people living with Parkinson’s may experience impulse control disorders.

But the true figures may be even higher, as many some patients may not associate changes in behaviour with their medication, or may be too embarrassed to report it. Case reports show that in most instances, impulsive behaviour stops when the drug is stopped.

Lawsuits

There have been several individual and class-action lawsuits against pharmaceutical companies including GlaxoSmithKline, which produces ReQuip® (ropinirole), and Pfizer, which makes Cabaser® (cabergoline). Patients taking action against these companies claimed they were unaware of these impulsive behaviour side-effects.

For example, in 2012, a French court ordered GlaxoSmithKline to pay £160,000 in damages to Didier Jambart, after he experienced “devastating-side effects” when taking the firm’s Parkinson’s drug Requip. And in 2014, an Australian federal court approved a settlement against Pfizer for a class-action lawsuit regarding its Parkinson’s drug, Cabaser. 150 patients claimed they did not have warning of potential side-effects – including increased gambling, sex addiction and other high-risk activities – of taking Cabaser.

It is now clearer in the patient information leaflets given with all prescribed medication for movement disorders that impulsive behaviour can occur in some patients.

In 2023, the MHRA advised there had been increased reports of pathological gambling with a drug called aripiprazole. This antipsychotic drug, used in the treatment of schizophrenia and mania, partly acts as a dopamine-receptor agonist.

Any drug that increases dopamine levels could theoretically be linked to impulse control disorders, and it is important to keep monitoring patients and their behaviour in such cases.

Not everyone will experience side-effects. Before you begin any course of treatment, your doctor or pharmacist should explain the potential side-effects – but it is also important to read the information leaflet with any medicine. And if you experience any impulsive behaviours with these medicines, speak to your doctor or pharmacist immediately. Läs mer…

Heston Blumenthal, the celebrity chef known for his experimental cuisine, recently shared his experience of being sectioned under the UK’s Mental Health Act, saying it was “the best thing” that could have happened to him. His openness about living with bipolar disorder highlights the little-discussed fact that people with this condition face one of the highest suicide risks of any mental illness.

Bipolar disorder is a severe mental illness characterised by episodes of mania (high energy, impulsivity) and depression (hopelessness, fatigue). Suicidal thoughts and behaviour are a core feature of the disorder, with fluctuating risk that can persist over long periods.

Although bipolar disorder affects around 2% of the population, studies suggest that up to 50% of people with the condition attempt suicide at least once, and 15-20% die by suicide – a rate much higher than in the general population. Unlike global suicide rates, suicide deaths in bipolar disorder have not declined.

Understanding why suicide is so common in people with this disorder is difficult. But one major factor is mood instability. Rapid shifts between emotional highs and lows, as well as mixed states where symptoms of mania (impulsivity) and depression (despair) occur together, can be particularly dangerous.

Social and economic factors also play a role. Research we conducted at Swansea University shows that the population suffering from bipolar disorder has become poorer over the last two decades. Financial strain, social isolation and poorer access to healthcare all lead to worse outcomes. Beyond suicide, people with the condition die up to 20 years earlier than the general population, often from preventable health problems such as heart disease.

While bipolar disorder cannot be cured, it can be managed. The most commonly used drug, lithium, has been found to reduce suicide risk significantly in some patients. However, people with the condition struggle to take it regularly.

The drug’s side-effects can affect the kidneys, thyroid, metabolism, cognition and cardiovascular health. Managing these side-effects requires regular blood tests and continuous monitoring, making long-term treatment difficult.

Many people stop taking their medication during manic phases, believing they are cured.

Other treatments, such as antipsychotics, mood stabilisers and electroconvulsive therapy (where electric currents are passed through the brain while the patient is under anaesthesia), can also be effective in some types and phases of bipolar – for example, in states of mixed mania and depression where there is a high risk of suicide – but they come with their own harms and limitations.

Some psychiatrists now question whether continuous lifelong treatment is necessary for all patients.

Even when people seek help, healthcare systems often fail to intervene effectively. Suicide risk is highest in the days following discharge from a psychiatric hospital. Many people who later die by suicide have recently visited emergency rooms after hurting themselves, but the help they received was either delayed or not enough to prevent further harm.

Existing tools to identify and measure suicide risk, such as checklists, questionnaires and structured interviews, are ineffective. Many people with bipolar disorder who die by suicide are assessed as “low risk” shortly beforehand, exposing a crucial gap between doctor and patient perceptions. This is in great part because these tools rely too heavily on past factors such as suicide attempts (which may not be disclosed), rather than dynamic, real-time distress or mood instability.

Despite the significant effect that bipolar disorder has on individuals, families and society, the development of new drugs has been frustratingly slow. Lithium, first used in the 1940s, remains the go-to treatment, while most other drugs were originally designed to treat schizophrenia. No truly new treatments have emerged in decades.

Not a single disorder

One difficulty is that bipolar is not a single disorder but a spectrum of conditions, rendering the one-size-fits-all approach inadequate — lithium is effective in only about one in three patients.

Drug development for bipolar disorder is particularly challenging. The complexity of bipolar disorder calls for equally complex trials that need to consider patient variability, ethical concerns and strict safety requirements. New treatments also face strict approval hurdles because lithium – despite its limitations – is highly effective for some patients. This results in slow treatment development, leaving patients with limited options.

Lithium only works for about one in three people with bipolar disorder.
photo_gonzo / Alamy Stock Photo

Research is also slowed by concerns about whether it’s ethical to involve patients in trials. But it’s important to include people with the disorder who have experienced suicidal thoughts and behaviour, to better understand their mindset and decision-making.

However, new approaches offer hope. Several research projects, such as Datamind, are developing artificial intelligence platforms to help find new drugs quicker and to personalise treatments based on patients’ genetic and clinical profiles. AI could lead to faster, more effective therapies tailored to individual needs.

Blumenthal’s story highlights that being sectioned, while traumatic, can save lives and keep people safe. Yet the stigma around psychiatric hospitalisation prevents many from seeking care. There is a widespread belief that hospitalisation should be avoided at all costs – but for some, it can be the difference between life and death.

However, hospitalisation alone is not enough. The mental health system must do better to ensure that people with bipolar disorder receive long-term care, particularly during high-risk periods like hospital discharge. To prevent suicide, we need to rethink how risk is assessed, improve follow-up care, and reduce barriers to treatment.

While the statistics on bipolar are alarming, the message should be one of hope. The condition is treatable and suicide is preventable, but only if we commit to improving access to care, reducing stigma and advancing research. Läs mer…

China’s marriage rate is in steep decline. There were 6.1 million marriage registrations nationwide in 2024, down from 7.7 million the previous year. This decline has prompted Chen Songxi, a Chinese national political adviser, to propose lowering the legal marriage age from 22 to 18.

The drop in China’s marriage rate has been driven by a combination of factors. These include increased economic pressures, evolving social attitudes towards marriage, and higher levels of education.

Urban Chinese women, in particular, are increasingly pushing back against traditional gender expectations, which emphasise marriage and childbearing as essential life milestones. Rising living costs are also making it increasingly difficult for many young people to afford to get married.

At the same time, China is grappling with a longstanding gender imbalance, a legacy of the country’s sweeping one-child policy and cultural preference for male children. In the early 2000s, when the imbalance was at its peak, China’s sex ratio at birth reached 121 boys for every 100 girls. For every 100 girls born in some provinces, there were more than 130 boys.

The gender imbalance is particularly pronounced among those born in the 1980s, a generation I belong to. This is due to the widespread use of ultrasound technology from the mid-1980s onward, which offered parents the ability to terminate pregnancies if their child was female.

Unmarried men in China have become part of the so-called “era of leftover men” (shengnan shidai in Chinese). This is an internet term that loosely refers to the period between 2020 and 2050, when an estimated 30 million to 50 million Chinese men are expected to be unable to find a wife.

A Chinese couple walk through Beijing with their child in 2015.
TonyV3112 / Shutterstock

The conundrum is that many of these “leftover” men want to marry – I know this firsthand. Some of my peers from primary and secondary school have been desperately searching for a wife, but have struggled to find a spouse. A widely used phrase in China, “difficulty in getting married” (jiehun nan), encapsulates this struggle.

Unable to find a domestic spouse, some Chinese men have turned to “purchasing” foreign brides. The growing demand for these brides, particularly in rural areas, has fuelled a rise in illegal marriages. This includes marriages involving children and women who have been trafficked into China primarily from neighbouring countries in south-east Asia.

According to a Human Rights Watch report released in 2019 on bride trafficking from Myanmar to China “a porous border and lack of response by law enforcement agencies on both sides [has] created an environment in which traffickers flourish”.

The Chinese government has now pledged to crack down on the industry. In March 2024, China’s Ministry of Public Security launched a campaign against the transnational trafficking of women and children, calling for enhanced international cooperation to eliminate these crimes.

‘Purchased’ foreign brides

These marriages are often arranged through informal networks or commercial agencies, both of which are illegal according to China’s state council.

Human Rights Watch says that women and girls in neighbouring countries are typically tricked by brokers who promise well-paid employment in China. They find themselves at the mercy of the brokers once they reach China, and are sold for between US$3,000 (£2,300) and US$13,000 to Chinese men.

Determining the extent of illegal cross-border marriages in China is challenging due to the clandestine nature of these activities. But the most recent data from the UK’s Home Office suggests that 75% of Vietnamese human-trafficking victims were smuggled to China, with women and children making up 90% of cases.

The Woman from Myanmar, an award-winning documentary from 2022, follows the story of a trafficked Myanmar woman who was sold into marriage in China. The film exposes the harsh realities faced by many trafficked brides.

It captures not only the coercion and abuse many of these women endure, but also their struggle for autonomy and survival in a system that treats them as commodities. Larry, a trafficked woman who features in the documentary, explained that she saw her capacity to bear children as her pathway to survival.

The Chinese authorities constantly warn of scams involving brides purchased from abroad. In November 2024, for example, two people were prosecuted over their involvement in an illegal cross-border matchmaking scheme. Chinese men were lured into extremely expensive “marriage tours” abroad with promises of “affordable” foreign wives.

There have also been cases where the undocumented brides themselves have disappeared with large sums of money before marriage arrangements are completed.

Most of the foreign brides are trafficked into China from neighbouring countries in south-east Asia.
MuchMania / Shutterstock

China’s marriage crisis has far-reaching implications for the country’s demographic future. A shrinking and ageing population is often cited as the greatest challenge for Chinese economic growth and social stability. Beijing has resisted this characterisation, saying that constant technological innovations will continue to drive economic growth.

The labour force is undoubtedly important when it comes to economic growth. But according to Justin Lin Yifu, a member of the Chinese People’s Political Consultative Conference advisory body, what matters more is effective labour – the product of both the quantity and quality of the labour force.

China has increased its investment in education continually over recent years in anticipation of future challenges surrounding its ageing population.

But, notwithstanding this, an even greater concern is the large number of leftover men, as this could pose a serious threat to social stability. Studies have found a positive correlation between high male-to-female sex ratios and crime rates both in China and India, where there is also a significant gender imbalance.

In China, research has found that skewed male sex ratios have accounted for around 14% of the rise in crime since the mid-1990s. And in India, modelling suggests that a 5.5% rise in the male sex ratio would increase the odds of unmarried women being harassed by more than 20%.

The question of who China’s leftover men will marry is becoming a pressing issue for Beijing. The government’s response will shape the country’s future for decades to come. Läs mer…

Optical illusions are great fun, and they fool virtually everyone. But have you ever wondered if you could train yourself to unsee these illusions? Our latest research suggests that you can.

Optical illusions tell a lot about how people see things. For example, look at the picture below.

The Ebbinghaus illusion.
Hermann Ebbinghaus

The two orange circles are identical, but the one on the right looks bigger. Why?
We use context to figure out what we are seeing. Something surrounded by smaller things is often quite big. Our visual system takes context into account, so it judges the orange circle on the right as bigger than the one on the left.

This illusion was discovered by German psychologist Herman Ebbinghaus in the 19th century. This and similar geometrical illusions have been studied by psychologists ever since.

How much you are affected by illusions like these depends on who you are. For example, women are more affected by the illusion than men – they see things more in context.

Young children do not see illusions at all. To a five-year-old, the two orange circles look the same. It takes time to learn how to use context cues.

Neurodevelopmental conditions similarly affect illusion perception. People with autism or schizophrenia are less likely to see illusions. This is because these people tend to pay greater attention to the central circle, and less to the surrounding ones.

The culture you grew up in also affects how much you attend to context. Research has found that east Asian perception is more holistic, taking everything into account. Western perception is more analytic, focusing on central objects.

These differences would predict greater illusion sensitivity in east Asia. And true enough, Japanese people seem to experience much stronger effects than British people in this kind of illusion.

This may also depend on environment. Japanese people typically live in urban environments. In crowded urban scenes, being able to keep track of objects relative to other objects is important. This requires more attention to context. Members of the nomadic Himba tribe in the almost uninhabited Namibian desert do not seem to be fooled by the illusion at all.

Gender, developmental, neurodevelopmental and cultural differences are all well established when it comes to optical illusions. However, what scientists did not know until now is whether people can learn to see illusions less intensely.

A hint came from our previous work comparing mathematical and social scientists’ judgements of illusions (we work in universities, so we sometimes study our colleagues). Social scientists, such as psychologists, see illusions more strongly.

Researchers like us have to take many factors into account. Perhaps this makes us more sensitive to context even in the way we see things. But also, it could be that your visual style affects what you choose to study. One of us (Martin) went to university to study physics, but left with a psychology degree. As it happens, his illusion perception is much stronger than normal.

Training your illusion skills

Despite all these individual differences, researchers have always thought that you have no choice over whether you see the illusion. Our recent research challenges this idea.

Radiologists need to be able to rapidly spot important information in medical scans. Doing this often means they have to ignore surrounding detail.

Radiologists train extensively, so does this make them better at seeing through illusions? We found it does. We studied 44 radiologists, compared to over 100 psychology and medical students.

Below is one of our images. The orange circle on the left is 6% smaller than the one on the right. Most people in the study saw it as larger.

The orange circle on the left is actually smaller.
Radoslaw Wincza, CC BY-NC-ND

Here is another image. Most non-radiologists still saw the left one as bigger. Yet, it is 10% smaller. Most radiologists got this one right.

Does the left orange circle look bigger or smaller to you?
Radoslaw Wincza, CC BY-NC-ND

It was not until the difference was nearly 18%, as shown in the image below, that most non-radiologists saw through the illusion.

The left orange circle is smaller.
Radoslaw Wincza, CC BY-NC-ND

Radiologists are not entirely immune to the illusion, but are much less susceptible. We also looked at radiologists just beginning training. Their illusion perception was no better than normal. It seems radiologists’ superior perception is a result of their extensive training.

According to current theories of expertise, this shouldn’t happen. Becoming an expert in chess, for example, makes you better at chess but not anything else. But our findings suggest that becoming an expert in medical image analysis also makes you better at seeing through some optical illusions.

There is plenty left to find out. Perhaps the most intriguing possibility is that training on optical illusions can improve radiologists’ skills at their own work.

So, how can you learn to see through illusions? Simple. Just five years of medical school, then seven more of radiology training and this skill can be yours too. Läs mer…

The NHS was hit hard by COVID. And no amount of appreciative clapping or painted rainbows could distract from the vulnerabilities which were exposed by the pandemic – or the challenges it created.

Some of those challenges – like the staggering backlog in patient care, or the huge mental and physical toll experienced by staff – will take years to overcome.

And anyone compelled to attend a hospital in the UK at the moment can see the evidence at first hand. Wards are very busy and staff are overstretched.

This is part of the legacy of a fast-spreading virus which killed 232,112 people in the UK and left an estimated 2 million suffering from the effects of long-COVID. It demanded urgent action from hospitals and health workers and brought immediate and widespread disruption to routine care, with appointments for elective surgery, cancer screenings and chronic disease management all delayed.

One 2024 study I worked on analysed appointment cancellations for cancer patients during the pandemic, and found that they waited an average of 19 days longer than before for rescheduled appointments. (Mortality rates remained stable though, indicating that the NHS effectively prioritised the most urgent cases.)

This kind of disruption has left the healthcare system facing a monumental backlog, with treatment waiting lists soaring to record levels. According to the British Medical Association, there are over 7.5 million people now on waiting lists (compared to 4.5 million before the pandemic) – and those waiting times are longer.

Cutting this waiting list is apparently one of the prime ministers’s priorities. But there is no easy fix.

The basic infrastructure of the NHS – the buildings, IT equipment, offices – is creaking, with outdated facilities, insufficient beds and a lack of specialised equipment. And one study suggests that capital funding – investment in assets that will be used for more than a year – for NHS trusts in England is down by 21% over the past five years.

This is primarily because the Department of Health and Social Care has been diverting long-term investment funds to cover day-to-day operational costs such as staff salaries and medicines.

Since 2019, £500 million of capital investment has been cancelled or postponed. And while overall NHS budgets have been growing, the increased spending has often been absorbed by inflation, rising demand and the need to address immediate pressures. This leaves little for infrastructure upgrades, new equipment or technological advancements.

The Health Foundation has warned that the lack of a long-term capital funding strategy could further jeopardise patient care in the future. Many NHS facilities no longer meet the needs of a modern health service, with some hospitals requiring complete refurbishment or replacement rather than just repairs.

And of course, treating patients is not just about equipment and buildings. Nurses and doctors are under extreme pressure, facing unprecedented levels of stress, burnout and trauma. A recent survey revealed that one in three NHS doctors are experiencing extreme tiredness, impairing their ability to treat patients effectively.

NHS key workers wave from inside Chelsea and Westminster Hospital, May 2020.
Guy William/Shutterstock

A similar number said their ability to practice medicine may have been negatively affected by fatigue, with some even reporting cases of patient harm or a near-miss incident.

Stressed NHS

And although the NHS workforce has actually grown over the past five years, it has not been sufficient to reduce waiting lists, deal with growing demand, or improve staff morale. Anxiety, stress and depression accounted for for over 624,300 working days lost in one month last year.

Without a healthy and motivated workforce, the NHS’s recovery efforts will remain severely hampered. Other contributing factors include increased demand for healthcare services, partly due to an ageing population and the growing prevalence of chronic conditions.

To address these challenges, the NHS needs a modernised approach to patient care. Research suggests that technology including telemedicine (online consultations) and AI-driven diagnostics, could streamline services and reduce waiting times.

Other possible steps include the expansion of community diagnostic centres, to ease access to tests, and screenings, to improve efficiency.

Overall, the pandemic has underscored the critical importance of a robust and resilient healthcare system. As the NHS navigates its own path to recovery, it must prioritise both immediate solutions to the backlog crisis and long-term strategies. This will require significant investment, but also a commitment to innovation and the wellbeing of healthcare workers.

The road ahead for the NHS will be tricky, but with the right measures in place, it could emerge stronger and more resilient than ever. The lessons learned from COVID should serve as a catalyst for transformative change, ensuring that the UK’s healthcare system is better prepared to face whatever the future may hold. Läs mer…

The UK prime minister, Keir Starmer, has announced plans to abolish NHS England, the organisation that oversees and manages the NHS in England, employing 19,000 people.

He declared he was bringing the NHS back under “democratic control” and cutting unnecessary bureaucracy by moving oversight of the NHS back into the Department of Health and Social Care (DHSC). This will reverse plans put in place by the Conservative-led coalition government in 2013 when it tried to “take the politics out of the NHS” by having NHS England as an independent body.

The NHS is the largest public sector organisation in England, seeing 1.7 million people each day including in patients’ own homes, local GP surgeries, pharmacies and hospitals. It employs 1.7 million people, is funded largely out of general taxation, and has an annual budget of about £190 billion.

The NHS is, however, one of the most centrally organised health systems in the world. This contrasts with many European and other countries where there is typically a national ministry of health to set strategy, with the detail of how this is implemented being left to regional and local councils, health authorities and hospitals.

Some analysts have suggested that the NHS has become even more centrally managed in recent years, but the truth is it has always been held very close by its political masters.

The NHS employs 1.7 million people.
Colin McPherson / Alamy Stock Photo

On the face of it, there are advantages to abolishing NHS England, allowing DHSC to focus on clarifying politicians’ priorities for how and on what NHS funding will be spent. These will include reducing waiting lists for operations, making it easier to get an appointment with a GP, and ensuring that emergency departments can deal quickly with patients without resorting to “corridor care”.

In turn, local NHS organisations such as integrated care boards (who among other things organise GP, dental, pharmacy and optometry services) and NHS trusts (who run hospitals, community, mental health and ambulance services) can concentrate on making sure these policy priorities are put into practice in ways that work best for local communities.

NHS England has a range of other important roles that will need to be reallocated, whether to an expanded DHSC or elsewhere. These include planning the training of healthcare staff, organising vaccination and screening programmes, purchasing medicines, and collating huge amounts of data about NHS activity and performance.

The government has also announced plans to halve staffing in the 42 local integrated care boards, so any move of former NHS England roles to this level will probably only happen if these local boards merge, which now seems likely.

The government appears therefore to have signalled another NHS management “redisorganisation” – something the NHS has suffered on a periodic basis, a consequence of its highly centralised and political nature. Research evidence is clear that management reorganisations struggle to achieve their objectives, causing instead significant distraction away from work to improve services for patients.

In his major review of the NHS for the new Labour government in September 2024, Lord Ara Darzi – a former Labour health minister – highlighted the urgent need for more skilled and effective managers to support NHS staff in restoring and improving the service after years of economic austerity and the challenges of the pandemic. This seems to run counter to recent announcements about “cutting bureaucracy”.

With careful planning, there is, however, potential for the abolition of NHS England to lead to a slimmer DHSC (more akin to some of its European counterparts) with a smaller number of well-resourced and managed integrated care boards who could effectively steer, support and monitor local NHS trusts and primary care services.

In 2002, Alan Milburn, then secretary of state for health in Tony Blair’s government, issued a white paper called Shifting the Balance of Power Within the NHS. Milburn is now a leading figure in the Starmer government’s health team, so it is perhaps not surprising that we have these new plans to slim the policy centre, shift power and decision-making more locally, and enable stronger accountability to politicians and the public.

What is likely to happen?

What will matter as much as what is done is how these changes are made. The government has Lord Darzi’s clear and comprehensive diagnosis of the NHS’s problems. It now needs to prioritise what should be done first and what can wait, and has made a good start on this with its recent planning guidance to the NHS.

What will be much more difficult will be to decide exactly how to reduce and then abolish NHS England – doing this in a way that ensures important roles are moved smoothly to DHSC, integrated care boards and NHS trusts.

History is not encouraging. There is a big risk that NHS managers will find themselves focusing too much attention on handling a major reorganisation when they (and patients) would rather they concentrate on improving services.

The government clearly wants to hold on to setting policy direction for the NHS while letting go of the detail of implementation to local level. But ultimately, it will be held to account by a population impatient for improvements to NHS services. Läs mer…