To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a must for being qualified as DP. Mere presence of a Sub-center, Primary Health Center or Community Health Center (three levels of health care facilities in India) does not ensure existence of a DP. In brief, the strategy stresses on presence functional health facilities, rather than increasing number of hospital buildings. Consideration of these facts would help the readers understand the challenges better.
References
1. Iyer V, Sidney K, Mehta R, et al. Availability and provision of emergency obstetric care under a public– private partnership in three districts of Gujarat, India: lessons for Universal Health Coverage. BMJ Global Health 2016;1:e000019. doi:10.1136/bmjgh-2015-000019
2. Government of India. Maternal and newborn health toolkit. Ministry of health and family welfare. New Delhi. 2013.
3. WHO, UNICEF, UNFPA and AMDD. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organisation, 2009.
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced di...
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced differences between multidisciplinary surgery and the solitary surgeon are not only of importance in relation to credibly building effective alliances. Those who control national, regional and local budgets do not understand the differences and view surgery and surgeon as the same. Stories are already emerging where health ministries have cut funding to anaesthesia and nursing so as to fund the training of more surgeons. More surgeons unable to perform surgery because of the absence of the others needed for the team is not a goal we should aspire to. It behooves all of us in this enterprise to speak carefully, accurately, and consistently.
References:
Ng-Kamstra JS et al. BMJ Global Health. Global Surgery 2030: a roadmap for high income country actors. DOI: 10.1136/bmjgh-2015-000011 Published 6 April 2016
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other h...
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other high income countries we recognise that the opportunities to contribute in low and middle income country (LMIC) settings are heterogeneous, ad hoc and largely self-directed. Currently, higher surgical training in the UK has no accredited global surgical programme or fellowship. Time spent undertaking clinical, research or health systems strengthening work in a non-UK setting do not formally count towards completion of training.
There is no body of literature detailing the UK trainee experience, needs or barriers to contribution to global surgery. Reports from Canada and the US, where established programmes exist, suggest that both technical and non-technical skills can be acquired through global surgical experience and represent an advantage to their home healthcare system. (6) With the current strains on our National Health Service, we believe there is potential to benefit from motivated, inspired and well-rounded healthcare workers in LMICs when we engage in the spirit of co-development.
We surveyed 38 trainee members of the Global Anaesthesia Surgical and Obstetric Collaboration (GASOC) and Association of Surgeons of Great Britain and Ireland (ASGBI) (31 surgical, 4 obstetric and 3 anaesthetic) to establish UK opinion on the role of the Colleges, training programmes and academia. In addition to their medical school elective placement, all demonstrated commitment to global surgery, 100% having spent volitional time in LMICs. The most valuable opportunities available to a trainee through global surgical experience were reported as technical skills (96%), teaching (88%) and international policy (79%). Of those interested in combining research with a clinical placement (68%), the majority had an appetite for a formal research qualification.
The leading barriers to taking time out of formal training for global surgical experience were financial concerns (70%), lack of consultant mentorship (67%) and personal commitments (63%). Despite recognition of the considerable barriers, 88% said that they would select a training programme based on an opportunity in global surgery. The majority of respondents thought this should be just before or towards the end of specialty training, and with a clinical component of 6-36 months.
Currently there is good will and energy among trainees. UK trainees came together at the launch of the LCoGS in London and formed GASOC. The global health leaders of the future are advocating a coordinated, recognised network of opportunities, endorsed by our training Colleges, governmental, non-governmental organisations, and existing healthcare partnerships. We are committed to the roadmap suggested by Ng-Kastra et al. in the goal to improve access and quality of surgical care to individual patients all around the world (1).
Acknowledgements
We are grateful to GASOC and ASGBI International Development Committee for distributing the survey.
1. Ng-Kamstra J, Greenberg S, Abdullah F et al. Global Surgery 2030: a roadmap for high income countries. BMJ Glob Health. 2016;1:e000011.
2. Meara J, Leather A, Hargander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
3. Disease Control Priorities, Third Edition (Volume 1): Essential Surgery. 3rd ed. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk M and Mock C, editors. World Bank Publishing: 2015.
4. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Resolution A68/31 at the 68th World Health Assembly: 2015 Mar 20. Available athttp://www.apps.who.int/GB/ebwha/pdf_files/WHA68/A68_31-en.pdf (accessed on 30/05/2016).
5. http://www.theg4alliance.org (accessed on 30/05/2016).
6. Drain PK HK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs and opportunities. Acad Med. 2009;84(3):320-5.
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonial...
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonialism’ throughout this roadmap. Admittedly, this language is emotive in the context of historic and current relationships between some LMICs and Europe. However, it is not a concept universally understood or experienced by all LMICs globally. It further feeds into the narrative that all people in LMICs are subalterns, subject to decisions and control by Western nations. We ask the authors to be mindful of surgical imperialism, which assumes answers to problems of surgical delivery are held by Western academics and not by those who work in LMICs.
Whilst we are supportive of a call to arms for actors in HIC to work in collaboration with those from other settings, as budding surgeons of the future and an international coalition of students, we are disappointed by the representation of the papers authors; 75% from the USA, and just 12% from LMICs. Whilst HIC actors have an important and continuing role in the delivery of surgical care to the world’s most vulnerable, it is those of us in LMICs who will bear the brunt of this task and ought to be better represented and empowered to dictate the future of our health systems.
1. http://www.smartglobalhealth.org/pages/kenya-mission/kenya-health
http://blogs.worldbank.org/africacan/three-myths-about-aid-to-kenya
I read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?
From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society.
I read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?
From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society.
This becomes more evident if the chairman of the VHSNC and tha Sarapanch have different political affiliations. Although VHSNCs are formed through a consultative process within the village, any favouritism and impartial selection of members of VHSNC (e.g. from a particular political party only) can generate mistrust and decrease its acceptability at large. Keeping such local dynamics in view, it is paramount that the selection of members of VHSNC is transparent and fair, and any grievance related to selection of members is promptly addressed.
Though the untied fund of ₹10,000 per annum is very little, the potential of corruption and bias in spending even such a meagre amount cannot be excluded in Indian context. The vague guidelines to spend this amount also leave lacunae for same. For example, untied funds can be used to help destitute women or poor households to meet their healthcare needs [2]. Understandably these guidelines provide overarching guidance only and give freedom to VHSNCs. However in the absence of clear guidelines to identify such population, it is possible that VHSNC members might spend untied funds on destitute women and poor household of their own ward/locality only. Hence it is important that VHSNCs frame criteria in advance to identify such population and spend money in a transparent manner.
Better management of village politics and corruption risk could help in successful implementation of VHSNCs.
Reference
1. Scott K, Sheikh K, George A, et al. Understanding the contextual factors that influence village health sanitation and nutrition committees in northern India. BMJ Glob Health 2016;1(Suppl 1):A15-A16.
2. Ministry of Health and Family Welfare, Government of India. Handbook for members of village health sanitation and nutrition committee. Available from http://nrhm.gov.in/images/pdf/communitisation/vhsnc/Resources/Handbook_for_Members_of_VHSNC-English.pdf
Dr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
Dr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
There should not be a competition between the advocates of men's health and those of women's health to demonstrate which sex is worse off or to grab resources from each other. This must not be a zero sum game. We need action, gendered as and when appropriate, to improve the health of both sexes. Without such an approach, the SDG targets, amongst others, will be far harder to achieve.
The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...
The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML, while the safer antithyroid medication, methimazole, is not.
The Pediatric Endocrinology Education Program for Haiti, supported by the Pediatric Endocrine Society and the European Society for Pediatric Endocrinology, aims to introduce pediatric endocrine care to a country where no pediatric endocrinologist currently practices. Unpublished data from teleconsultations as part of this program demonstrate that the majority of children diagnosed with endocrine disorders do not have access to the medications they need – even if these are listed on the national EML. For example, hydrocortisone and fludrocortisone, essential medications for children with adrenal insufficiency, are on Haiti’s EML but were unavailable despite extensive searches. Even inexpensive medications such as levothyroxine and routine supplements such as calcium carbonate and vitamin D2/D3 are often difficult to find and calcitriol is entirely unavailable. The list of inaccessible medications is long, including vital medications such as growth hormone and diazoxide for neonatal hypoglycemia.
Maybe most reflective of the alarming situation is access to insulin. While listed on all EMLs, the reality of children who are diagnosed with diabetes is different. The Kay Mackenson Clinic, a center for children with chronic diseases in Haiti, recently assessed the availability of insulin in Haiti and showed that close to one third of patients do not have access to insulin at the time of diagnosis and close to half lack access to insulin after they are discharged from the hospital following initial diagnosis (5). Further, long-acting and ultra-short acting insulin analogs, mainstay of therapy for intensive diabetes control, are virtually inaccessible.
Inequities in access to essential medications in pediatric endocrinology remain unacceptable. The comparison of EMLs by Rowlands et al should stimulate further research into actual accessibility, including its predictors and barriers.
References:
1. Penchansky R, Thomas JW. The concept of access: definition and relationship to consumer satisfaction. Med Care. 1981;19:127–140.
2. van Mourik MS, Cameron A, Ewen M, Laing RO. Availability, price and affordability of cardiovascular medicines: a comparison across 36 countries using WHO/HAI data
3. http://www.worldbank.org/en/country/haiti/overview
4. http://www.fda.gov/Drugs/DrugSafety/ucm209023.htm
5. von Oettingen J, Carolan E, Jean-Baptise E, Larco N, Larco P, Ogle G, Lorgeat V, Mascary M, Bonnell R, Carpenter C. (2016). Health care delivery gaps affect children with new onset diabetes in
‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...
‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russian army’s air force in addition to other allies leading to the accelerated destruction of physical infrastructure particularly healthcare facilities.
Despite their insistence that research on Syria is politically one-sided and relies heavily on social media reports, Sen et al do not appear to have properly scrutinised the many reports that document the targeting and destruction of health facilities by all sides. This research particularly that of Physicians for Human Rights has painstakingly made efforts to utilise multiple sources regardless of their political affiliations – government and opposition eyewitnesses in order to corroborate events on the ground. It is clear from this research that SAA forces and their allies are responsible for the bulk of civilian mortality and injuries. This mainly stems from the fact that the official opposition and other rebel groups do not possess air force capabilities which have inflicted the largest amount of damage.
In their previous work Sen et al have continually cited economic sanctions as being the primary cause of the detrimental health impacts on civilians in Syria and a driver of the refugee crisis. It is factually and statistically incorrect to claim that sanctions have had a greater health impact on the Syrian population than almost six years of direct military attacks on civilians, healthcare and systematic destruction of public infrastructure including water plants and sewage farms in opposition-held areas by three major armies (Syrian, Russian and Iranian).
We acknowledge the difficulties of collecting verifiable data in conflict zones and welcome further research on the health and social situation of those living in Government Controlled Areas. This is an issue which has been lacking in the coverage of the Syrian crisis and has often been filled by journalistic sources. However, obtaining reliable data and information from the Syrian government such as the Ministries of Health and Social Affairs in Damascus has proved almost impossible for researchers, multi-lateral and donor agencies. Indeed, accurate mortality statistics for SAA soldiers are impossible to access and yet could provide a more balanced understanding of losses on all sides.
Academics have a moral obligation to engage widely and with neutrality in information gathering, taking data provided by different sides of highly politicised debates into account. However, the facts-on-the-ground and weight of evidence in the Syrian crisis shows that parties on one side of the conflict – Syrian government forces and their allies in the air and on the ground – are committing the vast majority of violations. Failure to acknowledge this imbalance is academically, ethically and philosophically bad practice. The conclusion by Sen and colleagues that ‘the Syrian conflict urgently needs a reassessment of research ethics’ is out of touch with the urgent need for the Syrian government and its allies to cease targeting civilians, stop attacking healthcare facilities and lift the siege on over one million civilians.
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied in the augmented home foods category, but had to be cooked, also underplays this issue and complicates the results, as does the fact that peer support was different in each arm (though statistically insignificant) and this was adjusted for in the results, without offering details on these differences and adjustments.
Nonetheless, results show that the differences between A- HPF and RUTF-C were not significant. RUTF-L (being different from RUTF-C only in texture) was found to be inexplicably better than A-HPF, achieving a 57% recovery rate compared to 43% in 16 weeks. However, 16 weeks after the intervention, the overall numbers of children cured had dwindled to 15%.
Thus, the data clearly shows that the overall impact across all three arms is low, with over 40% children remaining in SAM even after a prolonged period of intervention in the strongest arm. Even these gains are unacceptably temporary. In addition, the element of supervised feeding ‘several times a day’ by a paid peer counselor seems quintessential to the results across the arms. Far from encouraging the use of RUTF in India, all these facts seem to suggest that, given a certain equivalence of quality, the choice of product is largely irrelevant for the community management of malnutrition.
The question this paper should rather be discussing is, whether it is logical, practical, acceptable and cost- effective to have individualized paid workers offering supervised feeding of RUTF-L several times a day at sparsely scattered households, to be able to achieve only moderate and highly unsustained gains in treating SAM.
Instead, the existing alternative hypothesis for SAM prevention and managementiii ; supporting families through comprehensive childcare programmes that organize care, health and nutrition using local resources, needs to be taken seriously and tested if required.
Word count: 498
i Sachdeva HPS, Kapil U, Gupta A, Prasad V. “Sustainable developmental solutions or product- based illusions for addressing severe acute malnutrition?” Paper submitted to the World Nutrition Conference2016, held in Cape Town, South Africa from 30th August to 2nd September 2016. Available http://www2.tulane.edu/publichealth/internut/magic-bullets-workshop.cfm
ii Prasad V, Holla R, Gupta A. Should India use commercially produced ready to use therapeutic foods (RUTF) for severe acute malnutrition (SAM)? Social Medicine 2009; 4(1): 52-5.
iii Prasad V, Sinha D. Potentials, Experiences and Outcomes of a Comprehensive Community Based Programme to Address Malnutrition in Tribal India. International Journal of Child Health and Nutrition, 2015, 4, 151-162

Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
To the Editor
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However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
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The nuanced di...
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
Show More(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
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We are also concerned with the persistent use of ‘colonial...
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This becomes more evident if the chairm...
Show MoreDr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.
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Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.
The...
Show MoreThe comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.
However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...
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We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.
Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...
Show MoreReading Between the Lines of the RUTF trial, India
Show MoreNita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
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