To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited reasons (5). Since centuries, the burden of pregnancy-related sufferings is very high in African and Asian countries. With all said above, I strongly commend the authors (1) for the challenges they have taken towards estimation of the pregnancy-related health crisis in India, Pakistan, Kenya, and Malavi. Regularization, standardization, and effectiveness are warned in pregnancy cares. In summary, India needs to act fast and effective to achieve the set sustainable developmental goals for safeguarding women's health.
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
Garg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or other interventions.
The cost of A-HPF (Augmented, Energy-Dense, Home-Prepared Food) was overestimated: (i) food was supplied at 1.5 times assumed requirements along with fuel, which merited costing or additional benefits adjustment; (ii) in Government programme, food procurement costs will be substantially lower because of expected integration with Public Distribution System and National Food Security Act; (iii) for bulk procurement, multivitamin mineral mix costs would be lower than pharmaceutical syrup used; (iv) as with exclusion of hospitalisation expenses, iron supplementation costs for anemic children should not be included because it is part of the National Iron Plus Initiative; (v) long-term benefits for the index child and family members, of extra counselling time for preparing various recipes needed to be factored in. Similarly, in the RUTF-L (Locally produced ready-to-use food) arm, employment and local economy benefits could have been accounted for.
It is unrealistic to expect a meagrely incentivised (INR 150) ASHA with several competing responsibilities to provide the same intensity and efficiency of ‘peer support’ as in the trial (incentive INR 700). The government guidelines cited to justify the ASHA incentive actually pertain to USHAs in urban contexts, which are awaiting implementation. Considering the potential for spontaneous recovery and lack of robust cost-effectiveness data from a “real world” Indian setting, a recommendation for scaling up CMAM through ASHAs is very premature.
Finite resources for public health spending invariably compel governments in LMICs to choose among interventions labelled as “very cost-effective”. An illustrative dilemma in Government setting comprises choices between cost of recovery for one SAM child, maternity cash entitlement (INR 6000) for four women, enrolling 20-24 additional families for Ayushman Bharat (annual health insurance cover of INR 5 lakh)3, or eggs twice a week for 46-58 children. All stakeholders, particularly the intended beneficiaries, should be an integral part of such selection process.4
References
1. Bhandari N, Mohan SB, Bose A, Iyengar SD, Taneja S, Mazumder S, Pricilla RA, Iyengar K, Sachdev HS, Mohan VR, Suhalka V, Yoshida S, Martines J, Bahl R, for the Study Group. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Global Health 2016;1:e000144. doi:10.1136/bmjgh-2016-000144.
2. Sachdev HS, Sinha S, Sareen N, Pandey RM, Kapil U. Survival and recovery in severely wasted under-five children without community management of acute malnutrition programme. Indian Pediatr 2017;54:817-24.
3. FE Bureau. Modicare: Cabinet nod for Ayushman Bharat. Financial Express, New Delhi, March 22, 2018. https://www.financialexpress.com/industry/modicare-cabinet-nod-for-ayush... accessed April 18, 2018.
4. Marseille E, Larson B, Kazi DS, Kahn JG, Rosen S. Thresholds for the cost–effectiveness of interventions: alternative approaches. WHO Bulletin 2015;93:118-24.
The information conveyed by Valerie Evans, Peter Roderick, and Allyson Pollock is compelling and of serious concern. While I agree that the explosion of brand-name fixed dose combination (FDC) medications in the Indian market is not safe or rational, I worry that the presentation of the information in this analysis may create some hysteria based on some of the lay media coverage of this study. It is unfortunate that there is such little clinical evidence on the safety and efficacy of the most commonly used Metformin FDCs that are sold to treat type 2 diabetes in India, but is irresponsible to publish such an article without some discussion of the potential harms that could come from abruptly stopping the Metformin FDCs .
I agree that “the convenience of FDCs should not trump efficacy” - but there is already significant distrust in Western medicine by many patients in India without further added hysteria. The authors of this study bring to light the importance of tighter regulation and improved standards for the pharmaceutical industry in India, but the paper would have been better with a more evenhanded presentation of the information. Efficacy data on the Metformin FDCs may be limited, but there is no telling the degree of hyperglycemic crises that may emerge if many patients stop all their medications on the basis of lay media coverage of this analysis without first consulting with their prescribing physicians.
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious fait...
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious faith can influence the way individuals approach and access healthcare services available 3.
If evidence of the importance of religious faith is required, one need look no further than social and psychological resilience. Religious faith features powerfully in the stories of some of the most vulnerable populations, for example survivors of military conflict and torture. Faith is also recognised as an independent protective factor against depression and suicide 5. Increased rates of migration, conflict, and the epidemiological transition towards chronic physical and mental conditions are likely to make religious faith more relevant to health on a national and global level.
We argue that faith operates beyond social capital and may not be captured through other secular social concepts such as community, social cohesion or culture. Researchers and policymakers are unlikely to harness positive aspects of religious faith if its status as a key social determinant of health is unacknowledged. Such recognition is also important to ensure that the influence of religious faith – positive and negative – is incorporated in undergraduate and postgraduate medical curriculums.
We hope that this letter serves as a stimulus to greater recognition of religious faith within the social determinants of health.
References:
1. Donkin A, Goldblatt P, Allen J, Nathanson V, Marmot M. Global action on the social determinants of health. BMJ Glob Health. 2018;3(Suppl 1):e000603.
2. The Changing Global Religious Landscape. Pew Research Center; April 5, 2017.
3. Shenouda JEA, Cooper MJF. "One Big Family": Pastoral Care and Treatment Seeking in an Egyptian Coptic Church in England. J Relig Health. 2017;56(4):1450-9.
4. Murdock, GP. “Theories of Illness. A world survey”. University of Pitsburgh Press, 1980 page 26.
5. Norko MA, Freeman D, Phillips J, Hunter W, Lewis R, Viswanathan R. Can Religion Protect Against Suicide? J Nerv Ment Dis. 2017;205(1):9-14.
We, read with interest the article by Garg et al on costing of therapeutic feeds.
We report our results on a similar trial conducted on 1092 tribal children of SAM,randomly given 3 therapeutic feeds i.e .C-RUTF(commercially produced ready to use therapeutic food),L-RUTF (locally produced RUTF) and ARF(Amylase rich energy dense food) giving 550,513 and 420 kcals respectively.Pea nut paste,sugar ,milk powder,oil were common ingredients,in identical proportions in C-RUTF and L-RUTF while ARF contained amylase rich flour instead of peanut paste.Micro nutrients were present in all three alike.At the end of 8 weeks of treatment,52.8% recovered in C-RUTF group,43.5% in L-RUTF group and 44.8% recovered in ARF group; the difference being statistically significant.The cost of treatment was 63, 59 and 43 USD approx. in the 3 groups respectively.Thus, though cost of ARF was the least compared to C-RUTF and L-RUTF ,recovery rates in ARF group were also compromised.The logistics of preparing the feeds in tribal village Anganwadis,issues of cleanliness in food preparation,time and labour required were also matters of concern.All these factors will require consideration while scaling up of community management of SAM.
The clinical trial was registered under clinical trial registry of India,no.CTRI/2014/09/004958 and the data is the property of the Govt. of Maharashtra,India.
I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total...
I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total fund utilized for renovation and equipment procurement were USD 170,000 and we can work on all the organisms which can be handled in a BSL-3 laboratory including viral and Orientia tsutsugamushi culture. We are also capable of performing PCR and RT PCR. We now propose that such One Health laboratories may be established at district headquarters.
Integrated diagnostic platform: Our laboratory is unique in the manner that we use integrated diagnostic platform for various organisms following the concept of public health laboratory given by Parson et al.3
Frontline Healthcare workers: In India, we have accredited social health activists (ASHA) working with community and the central government has recently started a course on frontline healthcare workers (akin to community health worker, CHW) as part of skill development. We propose to train these workers on animal health as well so as to make them One Health workers. They will also have access to smart phones with an innovative application for use of the CHW, medical officer and the local and central laboratories for maintaining health records of the patient using a biometric system, generation of requisition for various tests, tracking of samples shipped in a specially designed container to the reference laboratory, retrieval of results and prescription of treatment.
Newer Diagnostics for diseases of zoonotic importance: In tune of newer diagnostics for TB, we are also working on development of diagnostics tools for diseases common in our area, viz. malaria, brucellosis, scrub typhus and leptospirosis.
References:
Thierry Nyatanyi, Michael Wilkes, Haley McDermott, Serge Nzietchueng, Isidore Gafarasi, Antoine Mudakikwa, Jean Felix Kinani, Joseph Rukelibuga, Jared Omolo, Denise Mupfasoni, Adeline Kabeja, Jose Nyamusore, Julius Nziza, Jean Leonard Hakizimana, Julius Kamugisha, Richard Nkunda, Robert Kibuuka, Etienne Rugigana, Paul Farmer, Philip Cotton, AgnesBinagwaho. Implementing One Health as an integrated approach to health in Rwanda. BMJ Global Health Feb 2017, 2 (1) e000121; DOI: 10.1136/bmjgh-2016-000121
Narang R, Narang P, Deotale V. Containment Laboratory Running on Hybrid Power Sources: A Solution for Countries With Limited Access to Electricity? Int J Tuberc Lung Dis 2017; 21 (4), 480.
Parsons LM, Somoskövi Á, Gutierrez C, Lee E, Paramasivan CN, Abimiku AL, Spector S, Roscigno G, Nkengasong J. Laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities. Clinical microbiology reviews. 2011 Apr 1;24(2):314-50
We thank Cooney and Partridge for their interest in our article.1 We believe, however, that they have misunderstood much of what we wrote. We accessed websites with publicly available national and subnational data on population-level rates of religious affiliation and breastfeeding initiation. As we explained, two other selection criteria reduced the number of countries we examined: (1) sufficient within-population variability in both religious affiliation and breastfeeding initiation and (2) data on both variables, so that they could be associated at the same ecological (geographical) level. As we acknowledged, we did not find Lander-level data for Germany, the country that best met our selection criteria. Our inclusion of data from French-speaking regions is clearly a strength of our study--not a limitation. We used Protestant affiliation as defined in the databases we found, and we focused on the major Protestant groups in the general population. Since the data we used are publicly available, we invite Cooney and Partridge to analyse the associations between minor Protestant groups and breastfeeding rates in Ireland. Regarding the definition of Protestants, any degree of misclassification should have reduced, rather than increased, the associations we observed. Our scatterplots show the crude (unadjusted) data together with the crude correlations. For France, Ireland, the UK and Canada, crude and adjusted results were all in the same direction: a negative correlation be...
We thank Cooney and Partridge for their interest in our article.1 We believe, however, that they have misunderstood much of what we wrote. We accessed websites with publicly available national and subnational data on population-level rates of religious affiliation and breastfeeding initiation. As we explained, two other selection criteria reduced the number of countries we examined: (1) sufficient within-population variability in both religious affiliation and breastfeeding initiation and (2) data on both variables, so that they could be associated at the same ecological (geographical) level. As we acknowledged, we did not find Lander-level data for Germany, the country that best met our selection criteria. Our inclusion of data from French-speaking regions is clearly a strength of our study--not a limitation. We used Protestant affiliation as defined in the databases we found, and we focused on the major Protestant groups in the general population. Since the data we used are publicly available, we invite Cooney and Partridge to analyse the associations between minor Protestant groups and breastfeeding rates in Ireland. Regarding the definition of Protestants, any degree of misclassification should have reduced, rather than increased, the associations we observed. Our scatterplots show the crude (unadjusted) data together with the crude correlations. For France, Ireland, the UK and Canada, crude and adjusted results were all in the same direction: a negative correlation between rates of Catholic affiliation and breastfeeding initiation. For the U.S., however, the crude correlations were in the opposite direction, because they were confounded by race/ethnicity and education. Displaying the crude data for U.S. states would therefore mislead the reader from the “true” (unconfounded) result: again, a negative correlation between the rates of Catholics affiliation and breastfeeding initiation among non-Hispanic Whites. We do not deny that other factors affect breastfeeding initiation rates in Western countries and could confound the association we observed with religious affiliation. They might also modify the effect of religious affiliation on breastfeeding. Race/ethnicity is one such factor, which is why we stratified our analysis of U.S. states by race/ethnicity. 1. Bernard JY, Cohen E, Kramer MS. Breastfeeding initiation rate across Western countries: does religion matter? An ecological study. BMJ Glob Health 2016;1(4):e000151. doi:10.1136/bmjgh-2016-000151.
Drs. Dadhich and Prasad raise important issues in their comments and questions about our study on home-based management of children with uncomplicated severe acute malnutrition (SAM). We are grateful for the opportunity to respond to them.
In our view, there are two distinct goals in the management of children with SAM. The first, and more urgent, is to treat and move them away from severe malnutrition, a state of high risk of death. The second is to rehabilitate them to the point they are no longer malnourished. The treatments examined in the study achieved the first goal well. By the end of the treatment phase, 84.5% of the children in the RUTF-L group were no longer SAM. However, they did less well in achieving the second goal. By the end of the treatment phase, 57% of those receiving RUTF-L had recovered to the point of no longer being malnourished. Should we have applied the same approach as most studies to calculate their WHZ - using height at enrolment and current weight, rather than concurrently measured height and weight - 81% of the children in the RUTF-L group would no longer be classified as malnourished by the end of the treatment phase.
We note Dr. Prasad’s misunderstanding that over 40% of the children in our study remained SAM by the end of the treatment with RUTF-L. Should her interpretation have been correct, it would justify her expressed concern. However, as stated above, by the end of the treatment phase 84.5% of the c...
Drs. Dadhich and Prasad raise important issues in their comments and questions about our study on home-based management of children with uncomplicated severe acute malnutrition (SAM). We are grateful for the opportunity to respond to them.
In our view, there are two distinct goals in the management of children with SAM. The first, and more urgent, is to treat and move them away from severe malnutrition, a state of high risk of death. The second is to rehabilitate them to the point they are no longer malnourished. The treatments examined in the study achieved the first goal well. By the end of the treatment phase, 84.5% of the children in the RUTF-L group were no longer SAM. However, they did less well in achieving the second goal. By the end of the treatment phase, 57% of those receiving RUTF-L had recovered to the point of no longer being malnourished. Should we have applied the same approach as most studies to calculate their WHZ - using height at enrolment and current weight, rather than concurrently measured height and weight - 81% of the children in the RUTF-L group would no longer be classified as malnourished by the end of the treatment phase.
We note Dr. Prasad’s misunderstanding that over 40% of the children in our study remained SAM by the end of the treatment with RUTF-L. Should her interpretation have been correct, it would justify her expressed concern. However, as stated above, by the end of the treatment phase 84.5% of the children in the RUTF-L group were no longer SAM.
We also note the concern that the ease and extent of recovery in our study is less than reported in African trials. However, as indicated in the paper, the population in our trial was significantly different from that in African trials: only 0.2% of our children had oedema, while it ranged from 38-80% in African trials. The mean WHZ score in our trial population was -3.5 while the mean ranged from -2.0 to -2.8 in Africa. Such differences make comparisons on ease and speed of recovery quite hazardous. One informed expectation is that recovery in the Indian population would take longer as they were further from the target of WHZ ≥ -2 SD.
We acknowledge Dr. Dadhich’s interest in the comparison of the performance of RUTF-C and RUTF-L. However, the trial was not designed to compare them. Given the lack of power for this comparison, we refrained from examining possible differences in their efficacy. We know that the composition of the two products was essentially the same and believe that any potential differences would likely be due to users’ preferences.
We agree that additional ways need to be found to rehabilitate these children. We see that in responding to SAM needs actions at the hospital level for children with complicated SAM, and at the community level, for treatment of uncomplicated cases, rehabilitation and prevention. Success requires that we provide treatment and also support families through comprehensive child care and promoting the best use of local resources. The rehabilitation of malnourished children, the sustainability of improvements and prevention of SAM need greater attention and possibly new approaches. We may need to extend the period of treatment while scaling down the management with therapeutic foods, or we may be more successful by increasing efforts to improve complementary feeding while continuing to use therapeutic foods as a supplement, or we may focus our efforts on improving complementary feeding without recourse to supplements. These approaches – or other that may be identified – should be tested to guide future efforts.
In the end, rehabilitation by whatever means must be a part of a comprehensive program and reach all target infants and children. This will require engagement at home, community and facility and not only facility-based interaction. It may be that some redesign of our overall strategy is needed. The issue of nutrition and growth in early life is critical and needs an evidence-based, thoughtful and yet practical way forward.
Medicines supplied in low and middle income countries are a matter of concern especially in regard to their quality. This article has raised a very genuine issue regarding the quality of medicine supplied to low and middle income countries(Nebot Giralt et al. 2017). This comment has been written in context to Nepal, a low income country as per the World Bank classification with population of around 28 million, out of which around 25 % of the people are living below the poverty line and 80% of the people living in rural areas(Central Bureau of Statistics 2015). The current ongoing Mass Drug Administration (MDA) for Elephantiasis in Nepal as a target to eliminate filariasis by 2020 has not been able to achieve its target due to poor compliance to the medicine. One of the reason could be due to people questioning about the quality of medicine distributed by government which could be the result of news spread five years back which stated five deaths, which later on was declared MDA not being the cause of death and more than 800 people falling ill after taking the medications. But still the fact cannot be ignored without proper investigation(Pandey 2012).
Still, many regions of the country lack access to basic health facility and essential medicine. The government of Nepal as per the national health policy has listed around 70 different drugs like anti-viral, anti-protozoal, some drugs for non-communicable diseases and so on to be distributed free of cost. The few p...
Medicines supplied in low and middle income countries are a matter of concern especially in regard to their quality. This article has raised a very genuine issue regarding the quality of medicine supplied to low and middle income countries(Nebot Giralt et al. 2017). This comment has been written in context to Nepal, a low income country as per the World Bank classification with population of around 28 million, out of which around 25 % of the people are living below the poverty line and 80% of the people living in rural areas(Central Bureau of Statistics 2015). The current ongoing Mass Drug Administration (MDA) for Elephantiasis in Nepal as a target to eliminate filariasis by 2020 has not been able to achieve its target due to poor compliance to the medicine. One of the reason could be due to people questioning about the quality of medicine distributed by government which could be the result of news spread five years back which stated five deaths, which later on was declared MDA not being the cause of death and more than 800 people falling ill after taking the medications. But still the fact cannot be ignored without proper investigation(Pandey 2012).
Still, many regions of the country lack access to basic health facility and essential medicine. The government of Nepal as per the national health policy has listed around 70 different drugs like anti-viral, anti-protozoal, some drugs for non-communicable diseases and so on to be distributed free of cost. The few published studies have suggested inadequate quality of drugs, bureaucratic process of drugs approval as barrier to the implementation of free drugs service which should not be ignored(Singh et al. 2017). Furthermore a cross sectional study done in Kathmandu, Nepal to assess the quality of drugs present in Nepalese market concluded that substandard medicine are available in Nepalese market and weak regulation and no uniformity in similar pharmaceuticals products(Gyanwali et al. 2015).
Although there are production of some essential medicines in Nepal more than half of the drugs required are imported from other countries and majority of them are distributed through different government and non-government organizations and international humanitarian aids. According to National List of Essential Medicines 2011, Of the 537 products in various strengths and dosages, Nepali companies were producing less than one third, 176 products(Brhlikova et al. 2015). Nepali health programs funded by international aid largely bypass government regulators and local producers as international agencies procure through large companies with an international GMP certificate. The Nepali local pharmaceutical industry has been growing significantly over the last decade. Many local producers are not affected by international quality standards as they do not export medicines and the Department of drug administration (DDA) does not enforce the WHO GMP standards strictly.
Further research exploring the quality of medicines in the Nepalese context seems as the need of the hour.
Brhlikova, P. et al., 2015. Aid conditionalities, international Good Manufacturing Practice standards and local production rights: a case study of local production in Nepal. Globalization and health, 11(1), p.25. Available at: http://www.scopus.com/inward/record.url?eid=2-s2.0-84935862368&partnerID=tZOtx3y1.
Central Bureau of Statistics, 2015. Nepal in Figures,
Gyanwali, P. et al., 2015. Surveillance of Quality of Medicines Available in the Nepalese Market: A Study from Kathmandu Valley. Journal of Nepal Health Research Council, 13(31), pp.233–240.
Nebot Giralt, A. et al., 2017. Quality assurance of medicines supplied to low-income and middle-income countries: poor products in shiny boxes? BMJ Global Health, 2(2), pp.1–7. Available at: http://gh.bmj.com/content/2/2/e000172.
Pandey, J., 2012. Elephantiasis : Banke folk worried about campaign. The Kathmandu Post. Available at: http://kathmandupost.ekantipur.com/printedition/news/2012-01-07/elephantiasis-banke-folk-worried-about-campaign.html.
Singh, D. et al., 2017. Designing the Free Drugs List in Nepal. MDM Policy & Practice, 2(1), p.238146831769176. Available at: http://journals.sagepub.com/doi/10.1177/2381468317691766.
We are concerned that the recent paper by Bernard et al published in BMJ Global Health 2016 fails to provide a scientific basis to support the stated conclusion that within Western countries the proportion of Catholics in the population influences the breastfeeding initiation rates.
The paper does not include a literature review on the role of religion in relation to infant feeding and there is no convincing scientific rationale presented to support the hypothesis being tested. There then follows a description of the study’s methods and results which reveals a series of methodological and reporting problems which, in our view, renders the work wide open to biases, confounders and incorrect deductions.There is evidence of selection bias in the five countries selected for within-country analyses, all limited to specific Western countries, with no explanation as why these particular countries were selected for inclusion. It is noteworthy that of these selected five, the dominant languages for each is either English or French which suggests language bias may also be a factor.
A further problem with the methods is the unexplained differences in the selection of the Protestant populations for each of the five countries. For the US the researchers included two categories of Protestants in their analysis (Evangelical Protestants and Mainline Protestants), for Canada and France the category of Protestants was used but then for the U...
We are concerned that the recent paper by Bernard et al published in BMJ Global Health 2016 fails to provide a scientific basis to support the stated conclusion that within Western countries the proportion of Catholics in the population influences the breastfeeding initiation rates.
The paper does not include a literature review on the role of religion in relation to infant feeding and there is no convincing scientific rationale presented to support the hypothesis being tested. There then follows a description of the study’s methods and results which reveals a series of methodological and reporting problems which, in our view, renders the work wide open to biases, confounders and incorrect deductions.There is evidence of selection bias in the five countries selected for within-country analyses, all limited to specific Western countries, with no explanation as why these particular countries were selected for inclusion. It is noteworthy that of these selected five, the dominant languages for each is either English or French which suggests language bias may also be a factor.
A further problem with the methods is the unexplained differences in the selection of the Protestant populations for each of the five countries. For the US the researchers included two categories of Protestants in their analysis (Evangelical Protestants and Mainline Protestants), for Canada and France the category of Protestants was used but then for the UK and Ireland they select only Protestants of Anglican religion – specifically, for the UK regions, the category Anglicans was used and then for Ireland Anglicans (Church of Ireland) is used. The rationale for confining the analysis to Anglican Protestants alone is not explained and the exclusion of data on the other Protestant religions such as Presbyterians, Methodists etc. strikes us as an important omission. For example, in Ireland the percentage of Anglicans is 2.9% (Ref 1). If other Protestant religions were included, this proportion would increase by a quarter to 3.6%. Similarly for the UK, the exclusion of non-Anglican Protestants in the four UK regions is also likely to have impacted on the results. Not being consistent and complete in the manner in which the Protestant groups were determined and enumerated undermines the scientific credibility of this work.
The presentation of results is of concern. The authors fail to clarify that each dot in Figure 2 represents findings from population groups that vary in size from the largest at a population of 53 million population for England to just under 32,000 for the smallest county In Ireland. Presenting results from such disparate population sizes can mislead reader’s interpretation of the scatter plot. Also, it is odd that the US data is presented separately from the other four countries included in the within-country analysis. Of note is the fact that the US was the outlier in that it differed from the others in having breast feeding rates that actually positively correlated with state-level proportions of Catholics. However, the authors subjected these data to a different analysis and presented the results separately. Of concern to us is that, unlike what had been done for the other four countries as displayed in Figure 2 and Table 3, the results by US state is not presented. Rather, the US data analysis included additional stratification by ethnicity (Non-Hispanic white, Hispanic white and Black) and presented separately in Table 4. As a result of this further analysis, the finding of the positive correlation with proportion of Catholics in US states is somewhat diluted.
There are a number of political factors and economic factors that impact on breastfeeding initiation rates and yet the authors have not included or considered these in this paper. It would have been particularly helpful if they had considered important potential confounders that may be associated with historical religious affiliations and infant feeding practices such as the economic importance of the dairy industry, including formula milk production, as well as demographic factors such as urban/rural population ratios.
Low levels of breastfeeding is a serious public health problem in many countries. In Ireland, we have one of the lowest breastfeeding rates in the world and, significantly, Ireland currently holds 10% of the global market share of infant formula production (Ref 2). Those of us working at improving breastfeeding rates seek to use the best evidence to inform the range of necessary interventions. We feel that it is therefore very important to highlight our concerns about the limited scope, flawed methods and difficulties in the presentation of the results of this study. In the interests of policy, practice and research, we argue that this paper fails to present convincing evidence to support the stated conclusion.
1.The Central Statistics Office Ireland, Census 2011, accessed 22nd Mar 2017 at: http://www.cso.ie/en/census/
2.Performance and Prospects 2014-2015 Bord Bia, Irish Food Board, accessed 22nd Mar 2017 at: http://www.bordbia.ie/industry/manufacturers/insight/publications/MarketReviews/Documents/Export-Performance-and-Prospects-2015.pdf
To an extent, poverty is the root cause of all illness (physical, social and psychological) and it also stands true to pregnancy-related complications. Both poverty and economic biases have been cited the strong cause of pregnancy-related deaths in India (1, 2). Inadequate healthcare infrastructures, lack of skilled attendance at the delivery site, un-optimized nursing care in maternity wards in post-delivery time, unprofessional attitude exhibited by hospital staffs, socioeconomic discriminations and marginalization, systemic corruption and improper dissemination of medical treatments are life-threatening to the pregnant women's and/or to their newborn (2).
Issues like post-partum hemorrhage (PPH) are quite manageable, but nothing pursued with effectiveness. Albeit Janani Suraksha Yojana is playing the crucial role in the promotion of institutional deliveries through availing incentives, but still, lots of uninstitutional delivers are in practice across India (3). In 2016, maternity mortality rate for India was reported as 174 deaths per 100,000 live births that counts to 5 death/hour or 45,000 deaths/year (4). The issue loudly states that Indian healthcare system is failing to achieve with sustainable development goals and the made signs of progress in the health care system are not sufficient enough to meet the standards. Moreover, the lawsuits and healthcare system do not have any accountabilities and catch holds on foul acts happening with whatever cited...
Show MoreGarg et al. provide a useful, but somewhat incomplete, economic perspective on Community Management of Acute Malnutrition (CMAM) in India. Potential returns, like cost per recovered child, adjusted for spontaneous improvement under the existing system, are crucial for policy makers. Sixteen weeks after completion of the treatment phase (sustenance phase), only 123/838 children (14.7%) met the definition of recovery.1 For simplicity’s sake, we ignore: (i) anticipated lower recovery rates in public programme settings; and (ii) costs for linkages with the government-run Anganwadi centres for supplementary food during the sustenance phase.1 With these assumptions, our calculation of costs per recovered child are 6.8 (100/14.7) times higher than those of Garg et al.: US$ 1575/- (Rs. 97,650/-) and US$ 381 (Rs. 23,622/-) in research and Government settings, respectively. Further, annual budgetary requirements may be considerably higher due to non-response, relapse, and fresh cases of Severe Acute Malnutrition (SAM). Data from rural Meerut, near Delhi, provides a ballpark estimate of spontaneous recovery rates (27%) within a similar follow-up period.2 Actual costs per child recovered, even unadjusted for potentially equivalent spontaneous healing, are thus much higher than those quoted by Garg et al. However, they offer no cost-effectiveness analysis reporting cost per life saved or Disability-Adjusted Life Year averted to enable robust comparisons with the existing system or oth...
Show MoreThe information conveyed by Valerie Evans, Peter Roderick, and Allyson Pollock is compelling and of serious concern. While I agree that the explosion of brand-name fixed dose combination (FDC) medications in the Indian market is not safe or rational, I worry that the presentation of the information in this analysis may create some hysteria based on some of the lay media coverage of this study. It is unfortunate that there is such little clinical evidence on the safety and efficacy of the most commonly used Metformin FDCs that are sold to treat type 2 diabetes in India, but is irresponsible to publish such an article without some discussion of the potential harms that could come from abruptly stopping the Metformin FDCs .
I agree that “the convenience of FDCs should not trump efficacy” - but there is already significant distrust in Western medicine by many patients in India without further added hysteria. The authors of this study bring to light the importance of tighter regulation and improved standards for the pharmaceutical industry in India, but the paper would have been better with a more evenhanded presentation of the information. Efficacy data on the Metformin FDCs may be limited, but there is no telling the degree of hyperglycemic crises that may emerge if many patients stop all their medications on the basis of lay media coverage of this analysis without first consulting with their prescribing physicians.
Donkin et al have highlighted the constructive steps being taken to implement policy change facilitating the Social Determinants of Health (SDH) across the globe 1. Although progress is not universal, what has been achieved deserves praise.
We write, however, to highlight one key omission from the standard SDH model: religious faith. This deserves greater recognition as a social determinant of health for two reasons. First, is scale: a recent study demonstrated that 84% of the world’s 7.4 billion people affiliated themselves to a religious group 2. Second is the impact of religious faith on health, shaping both health beliefs and use of healthcare services 3.
Theories of supernatural causation of illness are ancient and diverse. They are also universal: a 1980 study of health belief systems worldwide found evidence that supernatural causes of illness “far outweigh” natural ones 4. Of course many such models may be counter to the Western biomedical model. They should, however, still be acknowledged, not least because when believers encounter Western biomedicine the two models typically become mixed without any sense of conflict.
The close link between healthcare services and religion is evident in both the historical (for example, medieval Christian hospitals in Europe) and contemporary (e.g. faith-based non-governmental organisations worldwide) contexts. The relationship between religion and healthcare is not confined to simple delivery. Religious fait...
Show MoreWe, read with interest the article by Garg et al on costing of therapeutic feeds.
We report our results on a similar trial conducted on 1092 tribal children of SAM,randomly given 3 therapeutic feeds i.e .C-RUTF(commercially produced ready to use therapeutic food),L-RUTF (locally produced RUTF) and ARF(Amylase rich energy dense food) giving 550,513 and 420 kcals respectively.Pea nut paste,sugar ,milk powder,oil were common ingredients,in identical proportions in C-RUTF and L-RUTF while ARF contained amylase rich flour instead of peanut paste.Micro nutrients were present in all three alike.At the end of 8 weeks of treatment,52.8% recovered in C-RUTF group,43.5% in L-RUTF group and 44.8% recovered in ARF group; the difference being statistically significant.The cost of treatment was 63, 59 and 43 USD approx. in the 3 groups respectively.Thus, though cost of ARF was the least compared to C-RUTF and L-RUTF ,recovery rates in ARF group were also compromised.The logistics of preparing the feeds in tribal village Anganwadis,issues of cleanliness in food preparation,time and labour required were also matters of concern.All these factors will require consideration while scaling up of community management of SAM.
The clinical trial was registered under clinical trial registry of India,no.CTRI/2014/09/004958 and the data is the property of the Govt. of Maharashtra,India.
I read the article “Implementing One Health as an integrated approach to health in Rwanda” by Nyatanyi et al1 with great interest and wish to share our efforts on Implementation of One Health in a Rural Medical School following concept of Public Money Stewardship. We have been working on human health coupled with ecological studies for a long time; however, we started working on One Health after sanction of a project on zoonosis by a joint task force of Indian Council for Medical Research and Indian Council for Agricultural Research (ICMR-ICAR) in 2015. The work is being carried out in project mode but we are working on various factors, as given below, so that we may give guidelines to the government for its implementation in programme mode, now preferably in a manner similar to that given in the study by Nyatanyi et al1.
One health laboratory: We have created a facility harbouring a containment laboratory, a BSL-2 laboratory as well as separate laboratories for serology and molecular testing. Planning for this facility included assessment of workload and availability of space and funds. Since we had limited funds made available to us from public money, we designed the facility for optimum use and thus followed the concept of public money stewardship given by Mahatma Gandhi whose principles we follow in our Institute. We also wanted to make this laboratory to be environmentally conscious and thus used solar panels to power it in a hybrid manner.2 Total...
Show MoreWe thank Cooney and Partridge for their interest in our article.1 We believe, however, that they have misunderstood much of what we wrote. We accessed websites with publicly available national and subnational data on population-level rates of religious affiliation and breastfeeding initiation. As we explained, two other selection criteria reduced the number of countries we examined: (1) sufficient within-population variability in both religious affiliation and breastfeeding initiation and (2) data on both variables, so that they could be associated at the same ecological (geographical) level. As we acknowledged, we did not find Lander-level data for Germany, the country that best met our selection criteria. Our inclusion of data from French-speaking regions is clearly a strength of our study--not a limitation. We used Protestant affiliation as defined in the databases we found, and we focused on the major Protestant groups in the general population. Since the data we used are publicly available, we invite Cooney and Partridge to analyse the associations between minor Protestant groups and breastfeeding rates in Ireland. Regarding the definition of Protestants, any degree of misclassification should have reduced, rather than increased, the associations we observed. Our scatterplots show the crude (unadjusted) data together with the crude correlations. For France, Ireland, the UK and Canada, crude and adjusted results were all in the same direction: a negative correlation be...
Show MoreDrs. Dadhich and Prasad raise important issues in their comments and questions about our study on home-based management of children with uncomplicated severe acute malnutrition (SAM). We are grateful for the opportunity to respond to them.
In our view, there are two distinct goals in the management of children with SAM. The first, and more urgent, is to treat and move them away from severe malnutrition, a state of high risk of death. The second is to rehabilitate them to the point they are no longer malnourished. The treatments examined in the study achieved the first goal well. By the end of the treatment phase, 84.5% of the children in the RUTF-L group were no longer SAM. However, they did less well in achieving the second goal. By the end of the treatment phase, 57% of those receiving RUTF-L had recovered to the point of no longer being malnourished. Should we have applied the same approach as most studies to calculate their WHZ - using height at enrolment and current weight, rather than concurrently measured height and weight - 81% of the children in the RUTF-L group would no longer be classified as malnourished by the end of the treatment phase.
We note Dr. Prasad’s misunderstanding that over 40% of the children in our study remained SAM by the end of the treatment with RUTF-L. Should her interpretation have been correct, it would justify her expressed concern. However, as stated above, by the end of the treatment phase 84.5% of the c...
Show MoreMedicines supplied in low and middle income countries are a matter of concern especially in regard to their quality. This article has raised a very genuine issue regarding the quality of medicine supplied to low and middle income countries(Nebot Giralt et al. 2017). This comment has been written in context to Nepal, a low income country as per the World Bank classification with population of around 28 million, out of which around 25 % of the people are living below the poverty line and 80% of the people living in rural areas(Central Bureau of Statistics 2015). The current ongoing Mass Drug Administration (MDA) for Elephantiasis in Nepal as a target to eliminate filariasis by 2020 has not been able to achieve its target due to poor compliance to the medicine. One of the reason could be due to people questioning about the quality of medicine distributed by government which could be the result of news spread five years back which stated five deaths, which later on was declared MDA not being the cause of death and more than 800 people falling ill after taking the medications. But still the fact cannot be ignored without proper investigation(Pandey 2012).
Show MoreStill, many regions of the country lack access to basic health facility and essential medicine. The government of Nepal as per the national health policy has listed around 70 different drugs like anti-viral, anti-protozoal, some drugs for non-communicable diseases and so on to be distributed free of cost. The few p...
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