164 e-Letters

  • Utterly false and misleading

    What the article does is discard the ethnic movement of the madhesi people (terai people) who have been marginalised in through out history. The dominant thinking is India blocked the movement of goods in to Nepal, but ehich is not true, it was the people who led a strike and prevented the flow of goods. By blaming external forces it can look away from the real issues. Also during riots and strikes transport companies are reluctant to send their vehicles in those areas since insurances do not cover if any mishaps occur.

    A reputed journal publishing such baseless articles provides fuel to the fire and discards the historical domination of the Terai people.

  • Perspectives from On the Ground in the DPRK

    We read this piece about public health in DPRK with interest, as it will surely expedite understanding of public health about the DPRK among the public. We offer our perspectives about some conclusions based on a viewpoint developed from firsthand experience in the DPRK working for the United Nations, and another viewpoint developed from having worked with multiple NGOs who have spent decades in the country.

    We write this letter, not to point out limitations, but to advocate for a stronger appreciation of the data that already exists through an interdisciplinary and culturally sensitive lens. DPRK is an often misunderstood and unique political context, and the authors have created value by listing some publicly available articles in one source. Unlike conventional systematic reviews that analyzes the data within papers, this review builds an argument based on the number of publications in a select number of broad categories. While they argue this was made necessary by the heterogeneity of articles, the comparison between publications, DALYs, and research priorities would have been improved if each of these variables had been deconstructed by even some basic measures. For example, the publications could have been broken down by sample size, gender, or rural versus the urban area of Pyongyang. Surveys from the UN show that regions in the DPRK are very different. A National TB Prevalence Survey from 2015-2016 showed that TB prevalence in rural areas is 1.14 times that...

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  • Reciprocal learning across borders and disease programmes

    The report on the reciprocal learning approach used for the Self-Management and Reciprocal learning for the prevention and management of Type 2 Diabetes (SMART2D) project is a valuable example of how interventions, specifically those improving the strength and equity of health systems, can be improved through partnerships across borders (1). The project emphasises the need to adapt interventions to local contexts, and share this learning among researchers and health workers. This report also alludes to the challenges that can stem from cultural and power differences both between researcher and participants, and between collaborating researchers. This indicates the importance of shared leadership and decision-making, as well as shared learning, throughout the process of intervention design.

    The groundwork of the SMART2D project included a literature review of the role of community health workers (CHWs), and this has provided an insightful compass for future research (2). The vast majority of studies evaluating the role of the CHWs have been conducted in the US. CWHs in the US perform diverse tasks going beyond patient education and medication adherence, including connecting patients to community resources such as exercise groups, and advocating for them in a complex medical system. Despite patients' frequent contact with primary care, this system often fails to provide them with adequate understanding of their condition (3). Diabetes management in high-income co...

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  • Example of a modeller’s temptation to seek alternative trial results

    Recently, Colbourn et al questioned the use of modelling to seek alternative trial results1. They cited a radio intervention study from Burkina Faso that based on mathematical modelling suggested that the radio intervention was associated with a 7.1% reduction in under-5 mortality, whereas the actual trial results suggested no effect (Rate ratio: 1.00 (95% CI: 0.82-1.22))1. Colbourn and colleagues raised the important point that modelled estimates should not take precedence over empirical mortality data.
    We would like to support the point raised by Colbourn and colleagues with an example from the field of vaccinology.
    The phase 3 trial of the RTS,S/AS01 malaria vaccine found a vaccine efficacy of 18-36% against clinical malaria2. The study was not powered to assess mortality endpoints, but the results suggested that RTS,S/AS01 was associated with 24% (95% CI: -3 – 58%) higher all-cause mortality3. This was obviously not what was expected; a vaccine that reduces clinical malaria would be expected to reduce all-cause mortality. However, based on our experience, it could indicate that the vaccine, like other non-live vaccines, could have negative non-specific effects4. If that was the case, we predicted that the negative effect would be strongest in females as seen for the other non-live vaccines3. Subsequent analyses indeed revealed that RTS,S/AS01 was associated with higher mortality in girls (Relative Risk of death for RTS,S/AS01 compared with control (RR): 1.9...

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  • Tobacco Policy Implementation Pros and Cons

    Standardized packaging may be the way to go in terms reducing smoking prevalence (McNeill et al, 2017). Although plain packaging has reduced smoking and brand appeal in Australia, it did not restrict launching of new products and diminish tobaccos’ extensive, highly differentiated brand variant ranges, (Greenland S.J., 2016). As countries prepare to use this policy they should take into account the influence of the tobacco industry on both the economy and social life of people.

    India is amongst few countries implementing healthy warning and in sharp contrast, it is also, as stated in the article, the largest producer and the second largest consumer of tobacco in the world. This presents a cross roads and this is illustrated by the delay seen between policy formation and implementation of the current tobacco control policy in India which stipulates health warning branding using(85%) space on all tobacco products. This has given enough time for the tobacco industry to fight back the policies and to make most sales out of the hesitancy. These strategies have been used in the legal frontiers citing international trade organization laws (Eckhardt et al 2016)

    This is a challenge to World Health Organization (WHO) and its policies as they are challenged by laws governing trade and competition. In the interest of successful implementation of such policies there is need for more collaboration between WHO and World Trade Organization (WTO), as this can be the key to...

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  • Importance to Prevention of Mother to Child Transmission (PMTCT) in Sub-Saharan Africa

    Many countries in sub-Saharan African are implementing prevention of mother to child transmission (PMTCT) of HIV programs. In 2003, the World Health Organization (WHO launched a comprehensive four-pronged strategy to prevent HIV among infants and young children to combat mother to child transmission (MTCT). One of the elements in the strategy is prevention of unintended pregnancies particularly among those living with HIV.
    There is also a significant unmet need for family planning among many including women living with HIV in Sub-Saharan Africa. The WHO states that 214 million women of reproductive age in developing countries who want to avoid pregnancy are not using a modern contraceptive method (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). According to WHO, citing a study by Ross & Winfrey 2001, 95% of women who are 0 to 12 months postpartum want to avoid pregnancy in the next 24 months, but 70% of them are not using contraception. The WHO indicates that ‘pregnancies in the postpartum period pose the greatest risk for women and their infants, and have increased risks of adverse health outcomes. Providing postpartum family planning is therefore crucial for ensuring the health, human rights and well-being of women and their babies’ (Sexual and Reproductive Health, World Contraception Day 2018 report,WHO). A study by John B. Casterline et al (2004) cited a number of salient factors contributing to the unmet need including poor access...

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  • The reality of insulin pricing - a call to action for access

    Médecins Sans Frontières (MSF) welcomes the analysis of the cost of manufacturing of human and analogue insulins by Gotham and colleagues. This work provides a realistic estimate of significantly lower market prices that would be more affordable for both governments and individuals and should open the eyes of the global health community to the shameful reality of abusive pricing as well as the gross inequity in access to treatment for people living with diabetes.

    In resource-limited settings, access to insulin is centralised and rarely free of charge within the public health system. For those who can access insulin, many must travel once or often twice daily to a clinic to receive their injections, due to fears around home storage of phials and self-injecting - particularly in conflict-affected or insecure settings.

    Human insulin is the only type of insulin included on the WHO Essential Medicines List (EML), and when procured in phials, costs significantly less than analogue insulin or insulin within an adapted device (cartridge or pen) which may simplify delivery. Debates continue around the impact of analogue insulins on diabetes outcomes (HbA1c), but many experts recognise that access may make regimens safer, particularly in settings where MSF works.

    The market dominance of and excessive pricing by the three major human and analogue insulin producing companies - along with the lack of competition from biosimilar manufacturers to challenge this d...

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  • Understanding the Kenyan governance in context to deprived population to reduce under five child mortality: time to take off the blindfold

    Dear Editor, We have read with interest the paper ‘Accelerating Kenya’s progress to 2030: understanding the determinants of under-five mortality from 1990 to 2015’ by Keats et. al (May, 2018). The authors discuss drivers of change in mortality of under five year old children in Kenya in relation to health systems, policies and financing. We believe that further discussion of conflict and governance is required in order to understand Kenya’s progress towards sustainable development. The Composite Coverage Index (CCI) calculates the coverage of preventive and curative interventions. The index looks at coverage of family planning, skilled birth attendance, skilled antenatal care, BCG-measles and DPT3 vaccinations, diarrhoea treatment and pneumonia care. We agree that increasing health workforce increases coverage of interventions and raises the CCI. In contrast, the CCI remains low in areas of conflict, displaced populations and refugee settlements despite existence of a high health workforce. For example, in the North Rift Valley and North Eastern counties (except Turkana) there is a lower CCI than in southern counties (such as Tana River, Narok, Kajiado and Kilifi) despite a larger workforce [2]. Although refugee settlement areas receive huge workforce support from humanitarian organisations and the government for coverage of interventions targeted towards health of children under five, a household and death survey carried out by Médecins Sans...

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  • Geographic Coverage of Surveillance systems: is the Sub Saharan Africa region being misrepresented?

    Dear Editor,
    We read with interest the paper: ‘Geographic coverage of demographic surveillance systems for characterising the drivers of childhood mortality in sub-Saharan Africa’ (1). This paper raises a few points that we would like to discuss (1). We focus on the authors’ extrapolation of findings from their study on children’s under five mortality [U5M] rates to the entire sub-Saharan Africa region. Other determinants we discuss include urban-rural disparities, factors that affect accessibility to health care services and the effect of political conflict in the region on under five mortality rates.
    Firstly, we discuss the use of data from the east and the west regions in Africa generalised to the entire Sub Saharan Africa [SSA] region (1). The regions covered in the analysis are represented in figure 1 of the original paper by Utazi et al. (1). They point out that civil and vital registration systems are incomplete and weak in SSA (1) which makes data derived from Health and Demographic Surveillance Systems [HDSS] more important to monitor trends and causes of under-five mortality in the region (1). Although many countries in SSA region have similar features and characteristics, analysis from a limited number of countries from either the east or the west of SSA should not be used to generalise to all countries in the SSA region (2). The disadvantages of using data generalised to the broad SSA region were discussed by Cooper et al (2). We believe the resu...

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  • Ethics of Implementation Research

    This article is a valuable addition to guide researches in planning and conducting implementation research (IR). As a complement to this paper we would like to draw attention to a paper on the ethical issues relating to IR, which deserve specific consideration by researchers and must be taken into account by research ethics committees reviewing IR as outlined in https://implementationscience.biomedcentral.com/articles/10.1186/s13012-.... Specifically community engagement, sustainability, scalability, identification of all stakeholders and research participants and monitoring to anticipate/avoid harm is crucial. All ethical considerations must be taken into account from the planning stage and throughout the research activity.