Title: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild case...
Title: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild cases. Simultaneously, we worked with nurses and doctors to build their capacity in infection prevention and control measures, and the care of severe cases of COVID-19 in health facilities.
So far, we have trained 1359 CHWs (68% of CHWs in Siaya) and reached 412’005 people in 82’401 households. In addition, we have built the capacity of 54 clinicians from 27 facilities with oxygen capacity. We provided pulse oximeters to all 27 facilities improving the pulse oximeter coverage from 3.7% to 100%. We improved the diagnostic and referral capacity of CHWs with contactless thermometers and for the first time pulse oximeters. With the Siaya MOH, we ensured essential maternal and child health services coverage and utilization.
To date, Siaya with a population of 993’000, has had 224 confirmed cases of COVID-19 and 6 deaths since the pandemic was declared on March 11th 2020 (2,3). These figures represent a small proportion of the total number of COVID-19 cases and deaths in the country (Figure 1: Source: Siaya MOH -3).
Our approach has been unique in its comprehensiveness, its integration of activities from the community to the health system, its responsiveness in addressing needs of Siaya communities, CHWs and clinicians, and in the true partnership that has developed with the Siaya county MOH with systems integration.
In the coming months, we will continue to reinforce critical components of the intervention and follow key indicators in preparation for a potential surge in cases as schools reopen and movements between hotspots and Siaya continue.
We thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus...
We thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus on highly skilled providers and not just facilities. Hanson et al highlight the importance of midwifery-led care and we concur: we call midwifery a potential “cornerstone” of health system redesign and address midwifery-led models in detail in Table 1. However, even the most competent midwife would not be able to save a woman’s life in a remote primary care facility if she needs an emergency hysterectomy or blood transfusion. Anyone who has managed a severe post-partum hemorrhage or an asphyxiated newborn knows that it takes a system to save a life. Our central arguments for redesigning maternity care include eliminating the need to find emergency transport and having unstable patients travel long distances on poor roads. The majority of neonatal deaths occur in the first three days of life 5 and any major effort to reduce neonatal mortality must address these challenges.
We concur with Hanson that hospitals are not the only places for delivery; freestanding maternity centers proximate to advanced care can provide excellent services. Ultimately, the decision on the best configuration of delivery facilities will be made by countries to fit local health systems and resources. We agree that no single approach will fit all settings, even within a single country, and we do not propose any such model. As we say in the paper, governments will lead the charge for system redesign and reforms need to be pursued with full consultation of leaders from multiple sectors, the population, providers, and managers and carefully tracked and evaluated.
Hanson et al argue that our claim that the majority of women are now living relatively close to hospitals is overly optimistic. While multiple studies have documented this6,7, any particular woman’s access clearly depends on the local context, which is why we propose that regions contemplating redesign conduct feasibility assessments that measure access to care and consults women and health workers, as the government of Kakamega County in Kenya is doing now.
We recognize that our paper challenges the status quo and we thank Hanson and colleagues as well as the paper’s reviewers, other maternal and newborn health experts, and national policymakers for their careful analysis of redesign; their input has unquestionably improved the concept. We acknowledge that reorganizing health systems is daunting and that many details remain to be worked out. But as COVID-19 has forced the world to take a fresh look at how health systems are working for people and the clamor for universal health coverage is growing, let’s be bold in demanding higher standards for the world’s poorest families.
Margaret E. Kruk
Sanam Roder-DeWan
Kojo Nimako
Nana AY Twum-Danso
Ana Langer
Archana Amatya
References
1. Hanson C, Waiswa P, Pembe A, Sandall J, Schellenberg J. Health system redesign for equity in maternal and newborn health must be codesigned, country led, adapted to context and fit for purpose. BMJ Global Health 2020; 5(10): e003748.
2. Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Global Health 2020; 5(10): e002539.
3. Larson E, Gage AD, Mbaruku GM, Mbatia R, Haneuse S, Kruk ME. Effect of a maternal and newborn health system quality improvement project on the use of facilities for childbirth: a cluster-randomised study in rural Tanzania. Tropical medicine & international health : TM & IH 2019; 24(5): 636-46.
4. Semrau KEA, Hirschhorn LR, Marx Delaney M, et al. Outcomes of a Coaching-Based WHO Safe Childbirth Checklist Program in India. New England Journal of Medicine 2017; 377(24): 2313-24.
5. Sankar MJ, Natarajan CK, Das RR, Agarwal R, Chandrasekaran A, Paul VK. When do newborns die? A systematic review of timing of overall and cause-specific neonatal deaths in developing countries. J Perinatol 2016; 36 Suppl 1(Suppl 1): S1-S11.
6. Juran S, Broer PN, Klug SJ, et al. Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Global Health 2018; 3(4): e000875.
7. Gage AD, Carnes F, Blossom J, et al. In Low- And Middle-Income Countries, Is Delivery In High-Quality Obstetric Facilities Geographically Feasible? Health Affairs 2019; 38(9): 1576-84.
We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...
We read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interventions list but was not included in the DCP3 HPP(2). Furthermore, several essential services that are listed by Blanchet et al, e.g. contraception, maternal wellbeing, and vaccinations, do not appear to be contextualised to postnatal care where they would be most critical to be provided. The spectrum of newborn conditions and interventions was captured on this list much more holistically, with its own category.
We highlight this important omission as the postnatal period presents a high risk of complications leading to maternal morbidity and mortality - particularly in LMICs and humanitarian settings. The largest burden of maternal deaths occurs during labour, delivery and the immediate postnatal period (first 24-hour period after the expulsion of the placenta), followed by the extended postnatal period (up to 42 days after the end of the pregnancy)(3). Between 20% and 44% of maternal deaths in sub-Saharan Africa, for example, are estimated to occur in the postnatal period(4)(5). Yet, the Countdown to 2030 report showed that postnatal services to have the lowest median national coverage of interventions on the continuum of maternal healthcare (6). The most important causes of postnatal deaths among women are haemorrhage, sepsis, hypertensive diseases of pregnancy, and indirect causes such as postnatal depression, HIV and malaria. The vast majority of these deaths are preventable with timely access to good quality care.
The WHO currently recommends a package of routine postnatal care interventions(7)(8).This package of critical elements enables health providers to detect and manage conditions with a very high risk of maternal mortality and morbidity (such as late-onset eclampsia, and postpartum haemorrhage and sepsis), monitor physical and mental wellbeing of postpartum women, and provide supportive care in order to initiate and sustain breastfeeding, education on newborn care and warning signs, and ensure continuity of care such as access to postpartum contraception. We stress here that these interventions comprise a package, and are not a list of one-off, unrelated, solely clinical care components. It is a holistic package of observations, diagnoses, treatments, and nutritional, physical and mental support components which are essential to be provided to every woman postnatally to support her and her newborn. The timescale of provision of this package begins at birth and last for a minimum of six weeks. Its elements can be provided by a range of health professionals and allied health personnel in joint cooperation within a functioning system on various levels, including in health facilities, on an outpatient level, and in the community.
Given that the largest burden of maternal ill-health occurs in the postnatal period, we call for inclusion of postnatal care services for women as a separate category within the essential list of services during the COVID-19 pandemic. We understand that the list presented by Blanchet et al was based on the DCP3 HPP. However, to make progress in reducing maternal mortality and morbidity in limited-resource settings during this unprecedented crisis, we must use such pre-existing “laundry lists” of individual interventions critically. Entanglement with other aspects of the obstetric continuum can result in postnatal care being pushed or missed off the global maternal and newborn health agenda. To harness the maximal value of the comprehensive package of essential services in maternal care we must ensure it is coordinated and inclusive across the entire obstetric continuum and not a scattering of elements here or there. Postnatal care for women is already a neglected service, we cannot afford for it to fall further off the agenda especially during the COVID-19 pandemic.
References
1. Jamison DT, Alwan A, Mock CN, Nugent R, Watkins D, Adeyi O et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. The Lancet. 2018 Mar 17;391(10125):1108-1120. https://doi.org/10.1016/S0140-6736(17)32906-9
2. The Partnership for Maternal, Newborn & Child Health. 2011. A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health (RMNCH). Geneva, Switzerland: PMNCH
3. World Health Organization. Trends in maternal mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 2015
4. Merdad L, Ali MM. Timing of maternal death: Levels, trends, and ecological correlates using sibling data from 34 sub-Saharan African countries. PLoS One. 2018 17;13(1): e0189416.
5. Alliance for Maternal and Newborn Health Improvement (AMANHI) mortality study group. Population-based rates, timing, and causes of maternal deaths, stillbirths, and neonatal deaths in south Asia and sub-Saharan Africa: a multi-country prospective cohort study. Lancet Glob Health. 2018 Dec;6(12):e1297-e1308.
6. Boerma T, Requejo J, Victora CG, Amouzou A, George A, Agyepong I, et al. Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Vol. 391, The Lancet. Lancet Publishing Group; 2018. p. 1538–48.
7. WHO. 2015. Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice. Third Edition. 2015. Geneva, Switzerland.
8. WHO. WHO recommendations on postnatal care of the mother and newborn. 2013. Geneva, Switzerland.
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same compound as the hospital(4). The gap to high-quality care should be closed by health system redesign.
References:
1. Roder-DeWan S, Nimako K, Twum-Danso NAY, Amatya A, Langer A, Kruk M. Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap. BMJ Glob Health. 2020 Oct 1;5(10):e002539.
2. WHO | SDG 3: Ensure healthy lives and promote wellbeing for all at all ages [Internet]. WHO. World Health Organization; [cited 2020 Nov 1]. Available from: http://www.who.int/sdg/targets/en/
3. Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019 Aug 1;7(8):e1074–87.
4. Niyitegeka J, Nshimirimana G, Silverstein A, Odhiambo J, Lin Y, Nkurunziza T, et al. Longer travel time to district hospital worsens neonatal outcomes: a retrospective cross-sectional study of the effect of delays in receiving emergency cesarean section in Rwanda. BMC Pregnancy Childbirth [Internet]. 2017 Jul 25 [cited 2020 Nov 2];17. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5526290/
Dear Editor,
Gilmore. B., et al have highlighted that the community involvement is pivotal to improving on prevention and control of Covid-19. We believed that governments should implement strict policies, to foster a culture of compliance and trust, not infringing on human rights (B., 2009). Take Taiwan for example, who learned from their experiences with SARS in 2003, developed and implemented policies and infrastructure in 2004 to combat any similar outbreaks in future. In 2004, the year after the SARS outbreak, the Taiwan government established the National Health Command Center (NHCC). The NHCC is part of a disaster management center that focuses on large-outbreak response and acts as the operational command point for direct communications among central, regional, and local authorities (C. Jason Wang, Chun Y. Ng, & Robert H. Brook, 2020). Such a policy is able to encourage the dissemination of pertinent information to the people, increase transparency and build trust in the framework. Furthermore, the use of Info dynamics should take precedence to minimize the spread of misinformation among communities. In a 2020 issue, Tangcharoensathien V et al (Tangcharoensathien. V., 2020), the WHO presented a framework for managing the Covid-19 infodemic (G., 2020) which can continue strengthening on a trusting relationship among people and healthcare personnel. Therefore, rallying community members for various roles in disease prevention and control will be widely ac...
Dear Editor,
Gilmore. B., et al have highlighted that the community involvement is pivotal to improving on prevention and control of Covid-19. We believed that governments should implement strict policies, to foster a culture of compliance and trust, not infringing on human rights (B., 2009). Take Taiwan for example, who learned from their experiences with SARS in 2003, developed and implemented policies and infrastructure in 2004 to combat any similar outbreaks in future. In 2004, the year after the SARS outbreak, the Taiwan government established the National Health Command Center (NHCC). The NHCC is part of a disaster management center that focuses on large-outbreak response and acts as the operational command point for direct communications among central, regional, and local authorities (C. Jason Wang, Chun Y. Ng, & Robert H. Brook, 2020). Such a policy is able to encourage the dissemination of pertinent information to the people, increase transparency and build trust in the framework. Furthermore, the use of Info dynamics should take precedence to minimize the spread of misinformation among communities. In a 2020 issue, Tangcharoensathien V et al (Tangcharoensathien. V., 2020), the WHO presented a framework for managing the Covid-19 infodemic (G., 2020) which can continue strengthening on a trusting relationship among people and healthcare personnel. Therefore, rallying community members for various roles in disease prevention and control will be widely accepted and followed. (Gikmore. B., 2020).
References
B., R. S. (2009). Lessons from community participation in health programmes: a review of the post Alma-Ata experience. Elsevier, 32. doi:doi:10.1016/j.inhe.2009.02.001
C. Jason Wang, M. P., Chun Y. Ng, M. M., & Robert H. Brook, M. (2020). Response to COVID-19 in Taiwan Big Data Analytics, New Technology, and Proactive Testing. Viewpoint, 1341. doi:doi:10.1001/jama.2020.3151
G., E. (2020). How to Fight an Infodemic: The Four Pillars of Infodemic Management. Journal of Medical Internet Research. doi:10.2196/21820
Gikmore. B., e. a. (2020). Community engagement for COVID-19 prevention and control: a rapid evidence synthesis. BMJ Global Health, 1. doi:doi:10.1136/bmjgh-2020-003188
Tangcharoensathien. V., e. a. (2020). Framework for Managing the COVID-19 Infodemic: Methods and Results of an Online, Crowdsourced WHO Technical Consultation. J Med Internet Res. doi:10.2196/19659
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
This paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same compound as the hospital(4). The gap to high-quality care should be closed by health system redesign.
I write a quick note to correct what is probably an editing error. Both the abstract and the text state that under-five mortality has increased in sub-Saharan Africa 1990-2018, while decreasing in the rest of the world. In fact, the Unicef data referenced in the paper (https://data.unicef.org/topic/child-survival/under-five-mortality/) indicate that under five mortality has decreased from 178 per 1000 live births in 1990 to 78 per 1000 in 2018, a reduction of 100 per 1000 or 56%. The UN inter-agency group for child mortality estimation (IGME) has similar estimates (https://childmortality.org/data/SDG%20Regions%20%3E%20Sub-Saharan%20Africa).
Arnab and colleagues reported the findings from their research study in India, UK, and the USA that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election. (1) By early September, India came only next to the US in terms of COVID 19 burden. Officially, India collects and reports data in terms of geographical variations, disaggregated by age and sex. India also reports the count of deaths among patients with and without comorbidities. However, none of the States report COVID 19 data disaggregated by social determinants, primarily castes and wealth quintiles, which are the most important determinants from an Indian perspective.
The caste system in India is a ‘disabling myth’ which contributes to preventable and inequitable mortality in women and children.(2) Globally, COVID 19 has once again exposed the vulnerability of disadvantaged groups due to ongoing social discrimination and economic deprivation.(3) Emerging data shows that the racial minorities in the US are disproportionately affected by the pandemic. Data shows that Non-Hispanic Blacks have five times the risk of hospitalization compared to non-Hispanic Whites (age-adjusted) and Hispanic and Latinos have 4 times the risk compared to non-Hispanic Whites.(4,5) However, realizing the importance of having more accurate data to understand the impact of COVID 19, foundations and agencies came forward to support and set-up mechanisms to track rac...
Arnab and colleagues reported the findings from their research study in India, UK, and the USA that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election. (1) By early September, India came only next to the US in terms of COVID 19 burden. Officially, India collects and reports data in terms of geographical variations, disaggregated by age and sex. India also reports the count of deaths among patients with and without comorbidities. However, none of the States report COVID 19 data disaggregated by social determinants, primarily castes and wealth quintiles, which are the most important determinants from an Indian perspective.
The caste system in India is a ‘disabling myth’ which contributes to preventable and inequitable mortality in women and children.(2) Globally, COVID 19 has once again exposed the vulnerability of disadvantaged groups due to ongoing social discrimination and economic deprivation.(3) Emerging data shows that the racial minorities in the US are disproportionately affected by the pandemic. Data shows that Non-Hispanic Blacks have five times the risk of hospitalization compared to non-Hispanic Whites (age-adjusted) and Hispanic and Latinos have 4 times the risk compared to non-Hispanic Whites.(4,5) However, realizing the importance of having more accurate data to understand the impact of COVID 19, foundations and agencies came forward to support and set-up mechanisms to track racial disparity in COVID in the US. (6,7) Ongoing data collection shows that COVID-19 is affecting minorities the most and that Black people are dying at 2.3 times the rate of white people. (8) The same is the case with minorities in other countries including the UK.
The last round of India’s Demographic and Health Survey (National Family Health Survey, 2015-16), gives some indication of the differences in the risk between castes and wealth quintiles. (9) Hand washing is one of the most recognized and irrefutable preventive measures to avoid COVID. NFHS data shows that the upper castes have the luxury of soap and water in close to three-fourth of their households, while more than 60% of the scheduled tribes (most backward castes) and half of the scheduled castes (backward castes) do not have soap and water facilities. Every one-in-five households of schedules tribes didn’t even have water, soap, or other cleansing agents. This is almost four times more than the proportion among higher castes.
Ninety-three percent of households in the wealthiest quintile had soap and water, while not even a quarter of households in the lowest quintile had them. One in every five households in the lowest wealth quintile lacked water, soap, and other cleansing agents. The upper castes are predominantly rich (57% of the upper castes are in the richest two quintiles) while 70% scheduled tribes and 50% of scheduled castes belong to the lowest two quintiles.12
The startling disparity in having access to such simple preventive measures as soap and water for handwashing will have a differential impact on the burden of COVID among people in the lower castes and or wealth groups. Previous studies have shown that the difference persists in terms of access to care as well. (10) It is in this context that the lack of disaggregated data for COVID 19 in India, the second-largest population in the world becomes important. It’s high time that research agencies and philanthropies invest in and collect, analyze, and disseminate data on the caste and wealth differentials on COVID 19 including mortality rates. Bringing in such evidence also helps to increase the political relevance of public health issues.
Reference:
1. Arnab Acharya, Gerring J, Reeves A. Is health politically irrelevant? Experimental evidence during a global pandemic. BMJ Global Health. 2020;5(10):e004222. doi:10.1136/bmjgh-2020-004222
2. The Lancet. The health of India: a future that must be devoid of caste. Lancet 2014; 384: 1901. doi: https://doi.org/10.1016/S0140-6736(14)62261-3
3. Kirby T. Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet Respir Med. 2020;8(6):547-548. doi:10.1016/S2213-2600(20)30228-9
4. Dorn AV, Cooney RE, Sabin ML. COVID-19 exacerbating inequalities in the US. Lancet. 2020;395(10232):1243-1244. doi:10.1016/S0140-6736(20)30893-X
5. CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. Published February 11, 2020. Accessed July 6, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/racial-...
6. Marguerite Casey Foundation Announces $3.5 Million in COVID-19 Grant Funding to Tackle Racial Disparities Resulting from Pandemic | Marguerite Casey Foundation. Marguerite Casey Foundation. Published April 23, 2020. Accessed October 24, 2020. https://caseygrants.org/who-we-are/inside-mcf/marguerite-casey-foundatio...
7. The Rockefeller Foundation Commits $1.5 Million to Support the Boston University Center for Antiracist Research - The Rockefeller Foundation. The Rockefeller Foundation. Published September 30, 2020. Accessed October 24, 2020. https://www.rockefellerfoundation.org/news/the-rockefeller-foundation-co...
8. The COVID Racial Data Tracker. The COVID Tracking Project. Published 2018. Accessed October 24, 2020. https://covidtracking.com/race
9. International Institute for Population Sciences (IIPS) and ICF. 2017. National Family Health Survey (NFHS-4), 2015-16: India. Mumbai: IIPS.
10. Shaikh M, Miraldo M, Renner A-T. Waiting time at health facilities and social class: Evidence from the Indian caste system. Kamolz L-P, ed. PLOS ONE. 2018;13(10):e0205641. doi:10.1371/journal.pone.0205641
Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the...
Williams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the cost-effectiveness/cost-benefit analysis of tranexamic acid for the treatment of TBI by including variables of disease severity should also be conducted.
References
1. Williams J, Roberts I, Shakur-Still H, et al. Cost-effectiveness analysis of tranexamic acid for the treatment of traumatic brain injury, based on the results of the CRASH-3 randomised trial: a decision modelling approach. BMJ Glob Health. 2020;5(9):e002716.
2. Rowell SE, Meier EN, McKnight B, et al. Effect of out-of-hospital tranexamic acid vs placebo on 6-month functional neurologic outcomes in patients with moderate or severe traumatic brain injury. JAMA. 2020;324(10):961-974.
3. Cone DC, Spaite DW, Coats TJ. Out-of-Hospital Tranexamic Acid for Traumatic Brain Injury. JAMA. 2020;324(10):946-947.
4. Kawada T. The efficacy of tranexamic acid for brain injury. Am J Emerg Med. 2020 doi:10.1016/j.ajem.2020.07.048
To the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...
To the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportionately affects women (who are often managing unpaid work, including caretaking responsibilities, while continuing to engage in paid work), migrant workers, asylum seekers, and other marginalized groups (5). Global health organisations are often run by leaders who came from high-income countries and it is difficult for them to accept civil society representation on their boards (6). Even if they have diverse representation, many of those appointed do not have decision-making privileges (6). These are the “discriminatory social arrangement(s) that, when encoded into laws, policies and norms, unduly privileges some social groups while harming others” to which Buyum et al refer.
However, recent observations suggest that a human rights approach is needed in order to achieve equity for all. In September 2020 in Melbourne, Australia a man experiencing an exacerbation of severe mental illness was intentionally hit by a police car and kicked in the head by a police officer as he struggled on the ground (7). The police officers involved have been suspended on full pay pending criminal investigations but this excessive use of force is symptomatic of state-sanctioned violence within the Australian police force. An Australian nationwide survey of more than 6000 international students and other temporary migrants conducted during the pandemic found systemic racism against international students in Australia (8). The study revealed the depth of Australia’s racist COVID policies (8). Although there is anti-racist rhetoric in Australia, (e.g. the National Anti-Racism Strategy) (9), there are many cases of racial discrimination against Asian students, particularly during the pandemic (9). In early June, the Chinese Ministry of Culture and Tourism warned Chinese citizens about a significant rise in racial discrimination and violence against Chinese and Asian people in Australia as an impact of the COVID-19 pandemic (10). In addition, in many countries around the world the small progress that has been made in ensuring girls receive an education is predicted to be undone by the COVID shelter at home restrictions (11). Increased “household responsibilities, child labour, early marriage and teenage pregnancy may prevent many girls from returning to school” (11). Other structural determinants include prioritisation of funding to other economic activities, instead of education, as countries emerge from the pandemic. Among those girls who do return to school post COVID, gender norms may inhibit their ambition. Education for women is consistent with part of the solution posed by Buyum et al namely a ‘knowledge shift’ which makes education widespread, bi-directional, and inclusive of new learning.
A human rights-based approach is a conceptual framework that can be applied to a broad range of program areas, including health. It is informed by international human rights law (12). The approach asserts that the integration of human rights law and principles should be visible in all activities and should contribute directly to the realization of human rights. Key elements of a human rights-based approach include participation, accountability, non-discrimination, empowerment, linkage to rights and sustainability. Applying this to the case of police brutality against people with mental illness suggests police be called on to view those with mental illness as human beings first with entitlements rather than letting the stigmatization of mental illness drive their actions. Police brutality to a marginalized group with little accountability is discriminatory, disempowering and dislocated from international human rights. It is unsustainable, and is unacceptable. In the case of maternal education a human rights-based approach would recognize the right of girls to an education. It would recognize there are no human rights, as enshrined in the Universal Declaration of Human Rights and other humanitarian instruments, without their universal application, irrespective of gender, ethnicity, occupation, country of birth. More broadly a human rights-based approach to structural determinants would re-orientate key public services and structures across multiple jurisdictions to ensure equity in participation and treatment irrespective of human characteristics.
Dismantling structural oppression is indeed key to improving global health. A human rights-based approach for addressing structural violence is a way of achieving this.
Aarya Desai MPH Student
Sundeep Manoth MPH Student
John Oldroyd MPH Co-ordinator
Australian Catholic University, Fitzroy, Australia.
Title: An integrated primary health care response to COVID-19 in Siaya, Kenya
Authors: Neema Kaseje, Andy Haines, Kennedy Oruenjo, Dan Kaseje, and Marcel Tanner.
We note that the article makes a strong case for the critical role of community health workers (CHWs) in pandemics, and we would like to outline the experience of rapid scale up of a programme to support CHWs in Siaya, Western Kenya.
On November 6th 2020, the Kenya Ministry of Health (MOH) reported a total of 59’595 COVID-19 cases and 1072 deaths due to COVID-19 (1).
In the last 4 months, to respond to the COVID-19 pandemic, we deployed CHWs, equipped with mobile technology, and accompanied by young university graduates under 30 years old. They visited households door to door and screened community members for symptoms of COVID-19. They isolated, tested, and managed suspected cases of COVID-19. Symptomatic testing was performed at home (by the Siaya rapid response team) and in health facilities (by clinicians). Youth were included to build their capacity in health interventions and provide them with practical experience during the lockdown period in Kenya. They were selected based on their academic credentials, their interest in working with CHWs, and their ability to use digital tools. CHWs and youth educated households about preventive measures including frequent handwashing, universal mask wearing (indoors when visitors are present and outdoors), and home management of mild case...
Show MoreWe thank Hanson and colleagues for their editorial response1 to our paper, Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap2. Reassessment of care models for childbirth in low-income countries is urgently needed to change stubbornly flat trajectories of maternal and newborn mortality. The central point of our paper is that the current childbirth care model that sends one-third or more of pregnant women to deliver in under-equipped, understaffed, low-volume health clinics in the highest mortality countries is not evidence-based, ethical or equitable and that convergence with global best practice—delivery in highly skilled facilities—is long overdue.
Hanson and colleagues note that primary care facilities might perform better if they were “staffed and equipped to standard”, but evidence does not support this strategy3. For example, the most rigorous randomized study in this field, the Better Birth Study, showed that despite extensive coaching and support, primary care facilities in India failed to reduce mortality over control facilities4. High and middle-income countries have long determined that low birth volumes and lack of surgical and advanced care make primary care delivery unadvisable. This clinical reality is no different in low-income settings.
Other points that Hanson and colleagues make align with the core arguments we offer for health system redesign. We agree that redesign should focus...
Show MoreWe read with interest the article by Blanchet et al on Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic. We concur with this paper’s message that essential health services in maternal and newborn health must be prioritised and protected during the pandemic, and welcome the priority list of 120 essential services which has been co-produced with context-specific expertise from Afghanistan, Ethiopia, Pakistan and Zanzibar. This list was based on the Disease Control Priorities, 3rd edition, Highest Priority Package (DCP3 HPP) which listed 108 key interventions thought most important to achieve essential universal health coverage(1).
However, we were dismayed not to find a separate category of interventions to provide essential elements of postnatal care to women. Several components of this care are listed under other categories (e.g. safe blood transfusion to treat postpartum haemorrhage, management of maternal sepsis, manual removal of the placenta). However, the list does not distinguish which of these components relate directly to postnatal care and therefore conflates these components with other aspects of care within the broader obstetric continuum. There is additionally a lack of representation of key conditions that occur frequently and primarily in the postnatal period (e.g. lactational mastitis and postnatal depression), which exists within the WHO essential interv...
Show MoreIt was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
Show MoreThis paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
Dear Editor,
Show MoreGilmore. B., et al have highlighted that the community involvement is pivotal to improving on prevention and control of Covid-19. We believed that governments should implement strict policies, to foster a culture of compliance and trust, not infringing on human rights (B., 2009). Take Taiwan for example, who learned from their experiences with SARS in 2003, developed and implemented policies and infrastructure in 2004 to combat any similar outbreaks in future. In 2004, the year after the SARS outbreak, the Taiwan government established the National Health Command Center (NHCC). The NHCC is part of a disaster management center that focuses on large-outbreak response and acts as the operational command point for direct communications among central, regional, and local authorities (C. Jason Wang, Chun Y. Ng, & Robert H. Brook, 2020). Such a policy is able to encourage the dissemination of pertinent information to the people, increase transparency and build trust in the framework. Furthermore, the use of Info dynamics should take precedence to minimize the spread of misinformation among communities. In a 2020 issue, Tangcharoensathien V et al (Tangcharoensathien. V., 2020), the WHO presented a framework for managing the Covid-19 infodemic (G., 2020) which can continue strengthening on a trusting relationship among people and healthcare personnel. Therefore, rallying community members for various roles in disease prevention and control will be widely ac...
It was interesting to read Roder-DeWan S et al.,(1) paper entitle Health system redesign for maternal and newborn survival: rethinking care models to close the global equity gap.
Show MoreThis paper focuses on problems with the current approach, discuss the feasibility of redesign, propose reforms to transform current health systems. We support the authors that health system redesign is needed to enhance people’s access to standard care and reduce newborn mortality rate especially in low- income country which is higher than in high-income countries about nine times(1). This is also in line with Sustainable Development Goal No.3 (SDGs) target 3.1 that by 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births(2). Gabrysch S et al,(2019) found in their study that giving birth in a health care facility does not necessarily gives assurance of a survival benefit for women or babies however it should be recommended in facilities capable of providing emergency obstetric and newborn care and capable of safeguarding uncomplicated births(3).
It is therefore important to reconsider the healthcare systems so that every pregnant woman receives the best of healthcare. Niyitegeka J et al,(2017) in a study conducted in Rwanda found out that women who had to travel more than 90 minutes to the nearest district hospital had significantly worse neonatal outcomes compared to those had Odds Ratio 5.12 times referred from health centers located on the same...
I write a quick note to correct what is probably an editing error. Both the abstract and the text state that under-five mortality has increased in sub-Saharan Africa 1990-2018, while decreasing in the rest of the world. In fact, the Unicef data referenced in the paper (https://data.unicef.org/topic/child-survival/under-five-mortality/) indicate that under five mortality has decreased from 178 per 1000 live births in 1990 to 78 per 1000 in 2018, a reduction of 100 per 1000 or 56%. The UN inter-agency group for child mortality estimation (IGME) has similar estimates (https://childmortality.org/data/SDG%20Regions%20%3E%20Sub-Saharan%20Africa).
Arnab and colleagues reported the findings from their research study in India, UK, and the USA that politicians are unlikely to be punished or rewarded for their failures or successes in managing COVID-19 in the next election. (1) By early September, India came only next to the US in terms of COVID 19 burden. Officially, India collects and reports data in terms of geographical variations, disaggregated by age and sex. India also reports the count of deaths among patients with and without comorbidities. However, none of the States report COVID 19 data disaggregated by social determinants, primarily castes and wealth quintiles, which are the most important determinants from an Indian perspective.
The caste system in India is a ‘disabling myth’ which contributes to preventable and inequitable mortality in women and children.(2) Globally, COVID 19 has once again exposed the vulnerability of disadvantaged groups due to ongoing social discrimination and economic deprivation.(3) Emerging data shows that the racial minorities in the US are disproportionately affected by the pandemic. Data shows that Non-Hispanic Blacks have five times the risk of hospitalization compared to non-Hispanic Whites (age-adjusted) and Hispanic and Latinos have 4 times the risk compared to non-Hispanic Whites.(4,5) However, realizing the importance of having more accurate data to understand the impact of COVID 19, foundations and agencies came forward to support and set-up mechanisms to track rac...
Show MoreWilliams et al. examined the cost-effectiveness of tranexamic acid treatment for traumatic brain injury (TBI) (1). Tranexamic acid was highly cost-effective for patients with mild TBI and intracranial bleeding or patients with moderate TBI. In addition, tranexamic acid was even more cost-effective with earlier treatment administration. In contrast, the cost-effectiveness for those with severe TBI could not be clarified. I feel that cost-effectiveness viewpoint is very important for distributing medial resources effectively, and I present recent inconsistent results for the safety and effectiveness of tranexamic acid in TBI patients with special reference to disease severity.
Rowell et al. conducted a double-blinded, randomized clinical trial to determine whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI (2). They concluded that tranexamic acid administration did not improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. A large effectiveness trial with optimized dosing protocols, a mortality end point, and specific focus on the TBI severity cohorts might be needed to verify the existence of benefits (3).
There have been some meta-analyses on the efficacy of tranexamic acid for TBI, and I recently presented a comment regarding inconsistent results of the association (4). Based on the report by Williams et al., the...
Show MoreTo the editor
We read with interest the article by Büyüm AM, Kenney C, Koris A, et al. (Decolonising
global health: if not now, when? BMJ Global Health 2020;5:e003394. doi:10.1136/
bmjgh-2020-003394) Although it is not contested that Black, Indigenous and People of Color are most disadvantaged by structural oppression, we would argue that a human rights-based approach is a more inclusive approach to global health inequity than decolonising global health.
The economic impacts of COVID mediated by the structural determinants will see recent gains in poverty reduction lost (1). Structural determinants within key service institutions such as the police service, prison system as well as those affecting gender will result in widespread suboptimal health. For example, black people are 40 times more likely to be stopped and searched in the UK under powers that allow officers to search people if serious violence is anticipated (2). In the US, a study examining all fatalities resulting from the use of lethal force by on-duty law enforcement officers between 2009 to 2012 across 17 U.S. states found that while whites were killed more frequently, the fatality rate was 2.8 times higher among blacks than whites (3). In the US, the First Step Act prison reforms have resulted in some benefits for prisoners, but ironically, highlighted the disproportionate incarceration of blacks (38%) who comprises 13% of the US population (4). There is evidence COVID disproportio...
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