Pardon my literary brevity, but this article does little in the way of actually helping poor communities . All you are
doing is changing words around to sugar coat widespread healthcare inequalities ( disparities ) in this country. Why not just call it what it is and do something about it, ipso facto ? It is dissapointing to read an article where the primary debate centers on linguistics or terminology and not practical solutions to real life health problems. So what if a country is 'developing', we used to call them "third world " what the hell is the difference? My bigger point is should we not concentrate on helping each other instead of finding different ways to be woke .
This is a thought-provoking article and I can see similar tensions and themes in my own collaborative relationships. I would have liked to see more discussion of how the funding opportunity shaped and contributed to these tensions and what the role of the funder is in contributing to healthy equitable collaborations. Many of the decisions were driven by how to meet the expectations of the funder. It would also be interesting to examine these tensions in long-term collaborations that exist outside of any one specific funding opportunity.
I would like to thank the authors for their analysis of the structural imbalances of power that exist in global health. I particularly agree with their argument that diversity, equity and inclusion initiatives work only to strengthen existing structures rather than to dismantle them.
However, I would like to problematise the framing of the power relation in this article and suggest an alternative.
To describe the contemporary problems with the “structural imbalance of power” in global health as feudal perhaps implies that they are somehow historic or located in the past, when they are operating and located within modern political economy. Feudalism, as a system of production, is predominantly associated with medieval Europe. Therefore there is a danger, in this piece, that the solution gestured towards is one of modernisation, to develop the relations from these feudal ones. However, from feudalism developed capitalism, both in Europe (Marx et al., 1981; Robinson, 2000) and also, as Alavi (1980) argues, in the colonial Indian context the authors explore in detail in their article.
Colonisation is inseparable from the rise of capitalism as a means of production (Vergès, 2021), of which developing healthcare infrastructure to support the colonisers was an integral part, as the authors identify. Colonial expansions were not primarily a thirst for adventure but a thirst for profits, for resources, for land and for new people to exploit (Blaut, 1989; Bryan...
I would like to thank the authors for their analysis of the structural imbalances of power that exist in global health. I particularly agree with their argument that diversity, equity and inclusion initiatives work only to strengthen existing structures rather than to dismantle them.
However, I would like to problematise the framing of the power relation in this article and suggest an alternative.
To describe the contemporary problems with the “structural imbalance of power” in global health as feudal perhaps implies that they are somehow historic or located in the past, when they are operating and located within modern political economy. Feudalism, as a system of production, is predominantly associated with medieval Europe. Therefore there is a danger, in this piece, that the solution gestured towards is one of modernisation, to develop the relations from these feudal ones. However, from feudalism developed capitalism, both in Europe (Marx et al., 1981; Robinson, 2000) and also, as Alavi (1980) argues, in the colonial Indian context the authors explore in detail in their article.
Colonisation is inseparable from the rise of capitalism as a means of production (Vergès, 2021), of which developing healthcare infrastructure to support the colonisers was an integral part, as the authors identify. Colonial expansions were not primarily a thirst for adventure but a thirst for profits, for resources, for land and for new people to exploit (Blaut, 1989; Bryan et al., 2018). As Walter Rodney demonstrates (Rodney and Recorded Books, 2012), the profits from British colonial endeavours were directed back to Britain, developing British society and infrastructure at the cost of underdeveloping colonial countries. The global North, built as it is on theft of the world’s wealth, is a creation of the global South (Fanon, 1963; Vergès, 2021). Therefore, to be anti-colonial one must be anti-capitalist.
The alternative I would suggest in this article is to name these relations as capitalism, not feudalism. To understand the persistence of colonial and neo-colonial relationships in global health, it’s necessary to understand how these relationships are related to our current system of production, oppression and exploitation: capitalism. For example, the well-documented phenomenon of “brain drain” where doctors are being lost to their global South contexts can be understood, in part, as an expression of the contradictions of capitalism. The structures that enable imperialist exploitation of the global South for the benefit of the global North, including through the global health ecosystem are capitalist, not feudal.
Imperialism, to which the authors allude, is not called the highest stage of capitalism for nothing (Lenin, 1916). The financial leverage that imperial countries hold over colonial and neo-colonial countries cannot be broken only by considering the positionality of individual actors but rather by dismantling and reforming the existing relations of production, returning genuine autonomy to the global South. I hope that through this, global health is truly transformed.
Bibliography
Alavi, H. (1980) India: Transition from feudalism to colonial capitalism. Journal of Contemporary Asia 10, (4) 359–399. https://doi.org/10.1080/00472338085390251
Blaut, J. M. (1989) Colonialism and the Rise of Capitalism. Science & Society 53, (3) 260–296
Bryan, B., Dadzie, S., Scafe, S., and Okolosie, L. (2018) The heart of the race: Black women’s lives in Britain. London ; New York: Verso
Fanon, F. (1963) The wretched of the earth. New York: Grove
Lenin, V. (1916) Imperialism, the Highest Stage of Capitalism. https://www.marxists.org/archive/lenin/works/1916/imp-hsc/
Marx, K., Fowkes, B., and Fernbach, D. (1981) Capital: a critique of political economy. London ; New York, N.Y: Penguin Books in association with New Left Review
Robinson, C. J. (2000) Black marxism: The making of the Black radical tradition. Chapel Hill, N.C: University of North Carolina Press
Rodney, W., and Recorded Books, I. (2012) How Europe Underdeveloped Africa. Baltimore, MD: Black Classic Press
Vergès, F. (2021) A decolonial feminism. Trans. by Bohrer, A. J. London: Pluto Press
We read the systematic review by Dong et al. [1] with great interest. The authors aimed to describe global seroprevalence estimates for B. burgdorferi s.l., the causal agent of Lyme disease.
First, estimating seropositivity for a target population (here, the global population) has two challenges we would like to address:
1) The age and sex distribution of the population providing sample(s) and the target population should correspond. The simple reason is that advancing age and male sex are well-established risk factors for a positive IgG antibody serostatus [2]. Therefore, one may not conclude the general population seropositivity from an aged sample with a large share of males if not corrected accordingly, e.g., by applying weights; otherwise, seropositivity may be overestimated. Unfortunately, the age and sex profiles of the individual studies were seemingly not considered or discussed for their final seropositivity estimates.
2) Then, as already stated in the first reply to this manuscript by A. Semper et al., the studies containing subjects with medical conditions or even patients with suspected or confirmed Lyme disease symptomatology are of little use for general population estimates of seropositivity (e.g., [3, 4], included by Dong et al.), as these populations do not correspond to the global population. Also, pooling seropositivity proportions for high-risk populations to obtain global estimates potentially introduces bias and, hence, should be a...
We read the systematic review by Dong et al. [1] with great interest. The authors aimed to describe global seroprevalence estimates for B. burgdorferi s.l., the causal agent of Lyme disease.
First, estimating seropositivity for a target population (here, the global population) has two challenges we would like to address:
1) The age and sex distribution of the population providing sample(s) and the target population should correspond. The simple reason is that advancing age and male sex are well-established risk factors for a positive IgG antibody serostatus [2]. Therefore, one may not conclude the general population seropositivity from an aged sample with a large share of males if not corrected accordingly, e.g., by applying weights; otherwise, seropositivity may be overestimated. Unfortunately, the age and sex profiles of the individual studies were seemingly not considered or discussed for their final seropositivity estimates.
2) Then, as already stated in the first reply to this manuscript by A. Semper et al., the studies containing subjects with medical conditions or even patients with suspected or confirmed Lyme disease symptomatology are of little use for general population estimates of seropositivity (e.g., [3, 4], included by Dong et al.), as these populations do not correspond to the global population. Also, pooling seropositivity proportions for high-risk populations to obtain global estimates potentially introduces bias and, hence, should be avoided [5].
Furthermore, one study [6] included by Dong et al. [1] considered US, UK, Australian, and German serosamples seems to match the exclusion criteria, as it does not provide participant categories corresponding to the samples. Also, this study aimed to compare assays and test results between laboratories, not to assess seroprevalence. According to [6], the samples considered partially were previously tested for Lyme disease or originate from endemic areas, which indicates that these samples may not be representative of the general population and, therefore, may not be suited for general population estimates.
Then, we perceive that Dong et al. [1] did not differentiate between IgG and IgM class antibodies for their global estimates, despite reported differences in seropositivity proportions for each antibody class (Fig 2). Ideally, IgG and IgM are considered separately and not pooled for global estimates, as IgM serostatus may underestimate long-term serostatus due to its short-term detectability compared to IgG [7].
We want to add the limitation that different serological tests used over time result in differing seropositivity due to varying sensitivity and specificity [8], i.e., hamper comparability, which may contribute to the heterogeneity found by Dong et al.
Finally, some minor remarks: it is not clear to us whether the authors only considered peer-reviewed papers, as indicated by the abstract, or also grey literature, as indicated in the methods section. Then, the search strategies presented in the abstract differ substantially from the strategies presented in Supplementary appendix 2. Further unclear aspects from the literature search are: 1) how the search could have started back in 1984, 2) how the last date of the literature lies past the article submission date, with no indication of an updated search during the review procedure, 3) why the authors considered literature with PCR testing methods, as these are not of use for antibody detection.
References
1 Dong Y, Zhou G, Cao W, et al. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health 2022;7(6). doi: 10.1136/bmjgh-2021-007744
2 Wilking H, Fingerle V, Klier C, et al. Antibodies against Borrelia burgdorferi sensu lato among Adults, Germany, 2008-2011. Emerg Infect Dis 2015;21(1):107–10. doi:10.3201/eid2101.140009
3 Karatolios K, Maisch B, Pankuweit S. Suspected inflammatory cardiomyopathy. Prevalence of Borrelia burgdorferi in endomyocardial biopsies with positive serological evidence. Herz 2015;40 Suppl 1:91–95. doi:10.1007/s00059-014-4118-x
4 Dersch R, Sarnes A, Maul M, et al. Immunoblot reactivity at follow-up in treated patients with Lyme neuroborreliosis and healthy controls. Ticks Tick Borne Dis 2019;10(1):166–69. doi:10.1016/j.ttbdis.2018.09.011 [published Online First: 26 September 2018].
5 Spronk I, Korevaar JC, Poos R, et al. Calculating incidence rates and prevalence proportions: not as simple as it seems. BMC Public Health 2019;19(1):512. doi:10.1186/s12889-019-6820-3 [published Online First: 6 May 2019].
6 Best SJ, Tschaepe MI, Wilson KM. Investigation of the performance of serological assays used for Lyme disease testing in Australia. PLoS One 2019;14(4):e0214402. doi:10.1371/journal.pone.0214402 [published Online First: 29 April 2019].
7 Coors A, Hassenstein MJ, Krause G, et al. Regional seropositivity for Borrelia burgdorferi and associated risk factors: findings from the Rhineland Study, Germany. Parasit Vectors 2022;15(1):241. doi:10.1186/s13071-022-05354-z [published Online First: 4 July 2022].
8 Cook MJ, Puri BK. Commercial test kits for detection of Lyme borreliosis: a meta-analysis of test accuracy. Int J Gen Med 2016;9:427–40. doi:10.2147/IJGM.S122313 [published Online First: 18 November 2016].
As an infectious diseases clinician who has managed patients with complicated monkeypox virus infections since 2018, I agree with Webb et al. that clinical management guidelines are helpful to those managing cases of monkeypox and welcome their efforts to identify potential gaps in available guidance. However, as the principal author for the original PHE guidance on monkeypox, I feel it is important to point out that the publicly available guidance for England was not intended to be detailed clinical guidance, which is likely why it was assigned such a low score in the systematic review by Webb et al.
Prior to 2022, clinical management of sporadic cases of mostly travel-associated monkeypox cases in England was the responsibility of five NHS England-commissioned Airborne HCID treatment centres. Readers of this systematic review may be under the false impression that, in the absence of published national clinical management guidance, those caring for cases in England had no access to advice or guidance, which is simply not the case. In addition to information shared through an active specialist peer-support network, not all guidance was published, and HCID treatment centres follow their own standardised protocols for HCID infection prevention and control, which are not published under the banner of 'monkeypox clinical guidance'. The case series describing the management of patients hospitalised with monkeypox in England between 2018 and 2021 (Adler H et al...
As an infectious diseases clinician who has managed patients with complicated monkeypox virus infections since 2018, I agree with Webb et al. that clinical management guidelines are helpful to those managing cases of monkeypox and welcome their efforts to identify potential gaps in available guidance. However, as the principal author for the original PHE guidance on monkeypox, I feel it is important to point out that the publicly available guidance for England was not intended to be detailed clinical guidance, which is likely why it was assigned such a low score in the systematic review by Webb et al.
Prior to 2022, clinical management of sporadic cases of mostly travel-associated monkeypox cases in England was the responsibility of five NHS England-commissioned Airborne HCID treatment centres. Readers of this systematic review may be under the false impression that, in the absence of published national clinical management guidance, those caring for cases in England had no access to advice or guidance, which is simply not the case. In addition to information shared through an active specialist peer-support network, not all guidance was published, and HCID treatment centres follow their own standardised protocols for HCID infection prevention and control, which are not published under the banner of 'monkeypox clinical guidance'. The case series describing the management of patients hospitalised with monkeypox in England between 2018 and 2021 (Adler H et al. Lancet Infectious Diseases, May 2022) suggests that there was no significant guidance void in England; in fact, that experience meant specialist hospitals in England were better prepared to care for hospitalised patients when the unprecedented outbreak began in May 2022, and various guidance documents - public facing and 'internal' were rapidly updated or produced to support clinicians working in a new outbreak context. Most importantly, and perhaps more useful that any written guidance, was the information sharing network for hospital physicians, which continues to meet to this day.
Guidance takes many different forms. Without understanding the scope, aims and target audience of publicly available guidance, it is inevitable that a systematic review will assign a low quality score when a piece of guidance never set out to be the comprehensive clinical guidance that the review is assessing; thus, one is effectively scoring the wrong thing.
While I welcome and am part of efforts to produce national and international clinical management guidelines for monkeypox, it is also clear that there is a not a single approach to managing patients, even hospitalised patients; clinical manifestations and the required and available treatment approaches will differ between countries and outbreaks. If a systematic review of clinical management guidelines for monkeypox is to be repeated, this is an important point to consider, along with ensuring the scope and aims of published guidance are fully appreciated in systematic reviews. For low-incidence emerging infections, it it also important to recognise that some countries may not publish all of their detailed guidance in a single document online.
Coming from an international relations background, I'm pleased to see more discussion of topics like this in global health, which were absent from my Global Health studies. Public health too often doesn't directly deal with power, though power is so central to health outcomes- positive and negative. I think our engagement with power imbalances is a big part of understanding power in public health, which includes seeking economic justice for marginalised groups.
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of th...
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of the global epidemiology of Lyme disease. Caution should be exercised here since Lyme disease as a clinical entity is only reliably described from temperate areas of the northern hemisphere, mirroring the distribution of its tick vectors (2). At least 20 species of bacteria belong to the Bbsl complex (2, 3) and could be transmitted to humans through a tick bite, but only a handful are pathogenic and cause Lyme disease (3). The serology assays used internationally to estimate borrelia exposure may recognise antibodies generated against non-pathogenic Bbsl species. Consequently, the Bbsl global seroprevalence estimate overestimates those who have experienced clinical Lyme disease (or asymptomatic infection) and may explain why Dong et al give Bbsl seroprevalence estimates for countries where no Lyme disease cases have been confirmed.
Dong et al derived a seroprevalence estimate for the UK in the 11-20% range based on two Scottish studies, with calculated seroprevalence estimates of 4.17% and 36.48% (4, 5). One (4) used Scottish blood donors. The other (5) utilised sera from individuals with suspected Lyme disease; it was not a study on either seroprevalence or incidence, was not representative of the general population and its inclusion introduces bias into the results. The true seroprevalence figure for Scotland is likely closer to the 4.2% estimate but importantly, there is regional variation (0 - 8.6%) within Scotland (4). Dong et al have used the biased Scottish estimate to extrapolate from one UK nation to others (England, Wales and Northern Ireland). This is misleading since published data on lab-confirmed Lyme disease cases show a higher incidence for Scotland than the other UK nations (6), although published seroprevalence data for the general populations in the other UK nations is lacking (6).
The study by Dong et al has been widely reported by media outlets leading to headlines claiming 1 in 7 people globally have been exposed to B. burgdorferi at some time (7). As described above, the interpretation of the ‘global’ seroprevalence estimate is flawed as are media releases based on it and may mislead and alarm the public unnecessarily. What is most important is that the public understand where high risk areas are locally and when travelling overseas, so that they can take appropriate measures to limit their exposure to ticks and to prevent Lyme and other tick-borne diseases.
References
1. Dong Y, Zhou G, Cao W, Xu X, Zhang Y, Ji Z, et al. Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis. BMJ Glob Health. 2022;7(6).
2. Mead PS. Epidemiology of Lyme disease. Infect Dis Clin North Am. 2015;29(2):187-210.
3. Bobe JR, Jutras BL, Horn EJ, Embers ME, Bailey A, Moritz RL, et al. Recent Progress in Lyme Disease and Remaining Challenges. Front Med (Lausanne). 2021;8:666554.
4. Munro H, Mavin S, Duffy K, Evans R, Jarvis LM. Seroprevalence of lyme borreliosis in Scottish blood donors. Transfus Med. 2015;25(4):284-6.
5. Mavin S, Evans R, Milner RM, Chatterton JM, Ho-Yen DO. Local Borrelia burgdorferi sensu stricto and Borrelia afzelii strains in a single mixed antigen improves western blot sensitivity. J Clin Pathol. 2009;62(6):552-4.
6. Lorenc T, Jones-Diette J, Blanchard L, et al. Incidence and surveillance of Lyme disease: systematic review and policy mapping. London: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London; 2017.
7. Wetzel C. More than 1 in 7 people worldwide have had Lyme disease. New Scientist. 2022.
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "e...
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "emerging infectious diseases", 70% of which would originate, in turn, from one or more animal reservoirs, as definitely proven with the two betacoronaviruses SARS-CoV and MERS-CoV, while being largely plausible and highly suspect also in the case of the pandemic SARS-CoV-2 betacoronavirus (2).
The seven years between 2015 and 2021 have been the hottest ones ever recorded on Earth within the last 140 years, with this significantly impacting also the vectorial efficiency of arthropods toward their respective pathogens. Indeed, under the present meteo-climatological conditions insects and ticks are now being increasingly reported to overcome the autumn and winter seasons ("overwintering") far more easily than in past decades. These progressively higher and higher average temperatures are responsible, in fact, for a (more or less) consistent reduction of the life cycle and replication ("extrinsic incubation period") of the infectious pathogens carried inside insects' and ticks' bodies. Based upon the above, a progressive "transfer to northern latitudes" of arthropod-borne infections, of either viral or non-viral aetiology, has been documented in more or less recent years, as clearly shown by the emergence of bluetongue virus - carried by Culicoides spp. - among ruminants from northern European Countries (3), as well as by the detection of Leishmania spp. - carried by Phlebotomus spp. - in dogs from UK (4).
In consideration of the above and, most importantly, in view of the documented zoonotic potential of many viral and non-viral, arthropod-borne pathogens (including WNV), a "One Health"-based and multidisciplinary approach would be absolutely needed for an "ad hoc" management of the complex ecology and epidemiology of the infections caused by such agents, with this reminding us (once again!) that human, animal and environmental health are mutually and inextricably linked to each other.
References
1) Cantile C, Di Guardo G, Eleni C, Arispici M. (2000). Clinical and neuropathological features of West Nile virus equine encephalomyelitis in Italy. Equine Veterinary Journal 32:31-35. doi: 10.2746/042516400777612080.
3) Carpenter S., Wilson A., Mellor P.S. (2009). Culicoides and the emergence of bluetongue virus in northern Europe. Trends in Microbiology 17:172-178. doi: 10.1016/j.tim.2009.01.001.
4) McKenna M., Attipa C., Tasker S., Augusto M. (2019). Leishmaniosis in a dog with no travel history outside of the UK. Veterinary Record 184:441. doi: 10.1136/vr.105157.
The article does not adequately take into account a crucial ethical and (by implication, legal) fact: the argument from proportionality does not justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
Summary of the three strongest arguments against the ethical permissibility of vaccine mandates and why any medical procedure imposed by coercion must be refused.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social opportunity coercion, precluding the possibility of valid medical consent. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not just from ourselves but from our children and from futur...
The article does not adequately take into account a crucial ethical and (by implication, legal) fact: the argument from proportionality does not justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
Summary of the three strongest arguments against the ethical permissibility of vaccine mandates and why any medical procedure imposed by coercion must be refused.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social opportunity coercion, precluding the possibility of valid medical consent. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not just from ourselves but from our children and from future generations, and we do not have the right to do this. Acquiescence to medical coercion is always unethical, even if the mandated intervention were a placebo.
3. Covid vaccines are known to occasionally cause deaths of healthy people. When an employee is required to receive Covid vaccination as a condition of employment, that employee is economically coerced to participate in an activity where some percentage of employees are expected to die ‘in the course of employment’ as a direct result of the mandated activity. This goes against the fundamental principles of medical ethics and workplace safety. It may be objected that Covid-19 also kills people, but these two categories of deaths are not ethically equivalent. Infection with SARS-CoV-2 is not mandated, whereas deaths resulting from mandatory vaccination are mandated deaths, a legalised killing of some people for the prospective benefit of the majority. Critically, any discrimination against the unvaccinated (or a privileged treatment of the vaccinated) amounts to a violation of the right to life, because a small percentage of the targeted population are expected to die as a result of this coercive treatment.
As the Australian economist Sanjeev Sabhlok said: “Governments are not authorised by law - by analogy - to burn down additional homes and kill unaffected people in order to save those who might be at risk of being engulfed in a bushfire.”
An earlier version of these arguments were formally submitted to the Inquiry into Public Health Amendment Bill 2021 (No 2) ACT, Australia:
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had r...
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had received ethical approval, which were typically met with shared concern. Whilst the editorial board had numerous scientific experts examining the study designs and methodologies, they did not have a dedicated ‘ethics expert’ responsible for appraising the ethical appropriateness of the submitted studies. The experience left me with doubt that the editorial team had the interest or capacity to proficiently identify ethical issues in the papers submitted for publication.
Doherty et al.’s commentary together with similar published concerns and my own experiences have left me wondering: is it time to explore the pros and cons of appointing ‘ethics experts’ to the editorial boards of peer-reviewed journals?
Yours sincerely,
Dr Robert Torrance
References:
1. Attarwala, H. TGN1412: From Discovery to Disaster. JYP 2010;2:332.
2. Doshi, P. WHO’s malaria vaccine study represents a “serious breach of international ethical standards.” BMJ 2020.368.
Pardon my literary brevity, but this article does little in the way of actually helping poor communities . All you are
doing is changing words around to sugar coat widespread healthcare inequalities ( disparities ) in this country. Why not just call it what it is and do something about it, ipso facto ? It is dissapointing to read an article where the primary debate centers on linguistics or terminology and not practical solutions to real life health problems. So what if a country is 'developing', we used to call them "third world " what the hell is the difference? My bigger point is should we not concentrate on helping each other instead of finding different ways to be woke .
This is a thought-provoking article and I can see similar tensions and themes in my own collaborative relationships. I would have liked to see more discussion of how the funding opportunity shaped and contributed to these tensions and what the role of the funder is in contributing to healthy equitable collaborations. Many of the decisions were driven by how to meet the expectations of the funder. It would also be interesting to examine these tensions in long-term collaborations that exist outside of any one specific funding opportunity.
I would like to thank the authors for their analysis of the structural imbalances of power that exist in global health. I particularly agree with their argument that diversity, equity and inclusion initiatives work only to strengthen existing structures rather than to dismantle them.
However, I would like to problematise the framing of the power relation in this article and suggest an alternative.
To describe the contemporary problems with the “structural imbalance of power” in global health as feudal perhaps implies that they are somehow historic or located in the past, when they are operating and located within modern political economy. Feudalism, as a system of production, is predominantly associated with medieval Europe. Therefore there is a danger, in this piece, that the solution gestured towards is one of modernisation, to develop the relations from these feudal ones. However, from feudalism developed capitalism, both in Europe (Marx et al., 1981; Robinson, 2000) and also, as Alavi (1980) argues, in the colonial Indian context the authors explore in detail in their article.
Colonisation is inseparable from the rise of capitalism as a means of production (Vergès, 2021), of which developing healthcare infrastructure to support the colonisers was an integral part, as the authors identify. Colonial expansions were not primarily a thirst for adventure but a thirst for profits, for resources, for land and for new people to exploit (Blaut, 1989; Bryan...
Show MoreWe read the systematic review by Dong et al. [1] with great interest. The authors aimed to describe global seroprevalence estimates for B. burgdorferi s.l., the causal agent of Lyme disease.
First, estimating seropositivity for a target population (here, the global population) has two challenges we would like to address:
Show More1) The age and sex distribution of the population providing sample(s) and the target population should correspond. The simple reason is that advancing age and male sex are well-established risk factors for a positive IgG antibody serostatus [2]. Therefore, one may not conclude the general population seropositivity from an aged sample with a large share of males if not corrected accordingly, e.g., by applying weights; otherwise, seropositivity may be overestimated. Unfortunately, the age and sex profiles of the individual studies were seemingly not considered or discussed for their final seropositivity estimates.
2) Then, as already stated in the first reply to this manuscript by A. Semper et al., the studies containing subjects with medical conditions or even patients with suspected or confirmed Lyme disease symptomatology are of little use for general population estimates of seropositivity (e.g., [3, 4], included by Dong et al.), as these populations do not correspond to the global population. Also, pooling seropositivity proportions for high-risk populations to obtain global estimates potentially introduces bias and, hence, should be a...
As an infectious diseases clinician who has managed patients with complicated monkeypox virus infections since 2018, I agree with Webb et al. that clinical management guidelines are helpful to those managing cases of monkeypox and welcome their efforts to identify potential gaps in available guidance. However, as the principal author for the original PHE guidance on monkeypox, I feel it is important to point out that the publicly available guidance for England was not intended to be detailed clinical guidance, which is likely why it was assigned such a low score in the systematic review by Webb et al.
Prior to 2022, clinical management of sporadic cases of mostly travel-associated monkeypox cases in England was the responsibility of five NHS England-commissioned Airborne HCID treatment centres. Readers of this systematic review may be under the false impression that, in the absence of published national clinical management guidance, those caring for cases in England had no access to advice or guidance, which is simply not the case. In addition to information shared through an active specialist peer-support network, not all guidance was published, and HCID treatment centres follow their own standardised protocols for HCID infection prevention and control, which are not published under the banner of 'monkeypox clinical guidance'. The case series describing the management of patients hospitalised with monkeypox in England between 2018 and 2021 (Adler H et al...
Show MoreComing from an international relations background, I'm pleased to see more discussion of topics like this in global health, which were absent from my Global Health studies. Public health too often doesn't directly deal with power, though power is so central to health outcomes- positive and negative. I think our engagement with power imbalances is a big part of understanding power in public health, which includes seeking economic justice for marginalised groups.
Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.
As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.
Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of th...
Show MoreDear Editor,
The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
Show MoreAs far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "e...
The article does not adequately take into account a crucial ethical and (by implication, legal) fact: the argument from proportionality does not justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.
Summary of the three strongest arguments against the ethical permissibility of vaccine mandates and why any medical procedure imposed by coercion must be refused.
1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).
2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social opportunity coercion, precluding the possibility of valid medical consent. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not just from ourselves but from our children and from futur...
Show MoreDear Editor,
It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?
As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had r...
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