104 e-Letters

published between 2019 and 2022

  • Premature program release negatively impacts program sustainability, placing maternal and perinatal outcomes at risk

    To the editor,

    With interest we read the recent paper by Caviglia et al, describing the relation between prehospital ambulance time and outcome in terms of maternal and perinatal outcomes in the setting of Sierra Leone1. Sierra Leone has one of the highest rates of maternal (1360 in 100.000 life births) and infant (87 in 1.000 births) mortality worldwide2. The National Emergency Medical Service (NEMS) was designed and started in this country, an effort by or in collaboration with part of the authors of the current manuscript3. The results show that longer prehospital ambulance times are associated with poor outcome. Furthermore, only in the capital and its surroundings the 2-hour target is met in a high percentage of patients, with only 24-65% of patients meeting this mark in the more rural areas of the country. The authors conclude that there are still major geographical barriers for timely access to care, and that any intervention to strengthen the existing primary health system may help reduce maternal and perinatal mortality.

    The elaborate NEMS system, including 81 fully equipped and staffed ambulances with a centralized operations centre, was operational since 2018, with the last districts connected to the service in 2019. The system was managed by the local ministry of health and sanitation (MoHS) and funded through the governmental budget, with help from the World Bank, Doctors with Africa (CUAMM, Padua, Italy), the Regional Government of Veneto (Ita...

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  • Covid-19 vaccination in Africa: a call for equity (and not equality)

    Dear Editor,

    We agree with Sam-Agudu et al. on the importance of equity in public health (1), and for these reasons raise major concerns regarding the remainder of the Commentary’s focus, and similar view prevalent in this Journal (2) and the wider global health community. We respectfully outline these here, as they affect the current health focus being applied to over a billion people in sub-Saharan countries.

    Sam-Agudu and co-authors state that ‘Global, equitable access to safe and effective vaccines for all age groups is critical to ending the COVID-19 pandemic’. This statement, reflecting those of the COVAX programme of the World Health Organization (WHO) and other agencies, is flawed. Equity in health means opportunity for good health, based on individual need, not measured by access to a particular pharmaceutical. A vaccine that does not significantly reduce transmission (3,4) will not end a pandemic, and where risk of severity is low from intrinsic or acquired immune status, will not significantly change outcomes. This flawed assertion also ignores costs of vaccination, both in potential adverse effects, and in resource diversion from other health programmes (public health programmes do not operate in isolation).
    Regarding the evidence base used to support their argumentation, and related expected benefits of vaccination, much of Sam-Agudu et al.’s arguments are based on the African Forum for Research and Education in Health (AFREhealth) study r...

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  • Disruptions in maternal health Covid 19, Women's health-occurrence of neural tube defects

    Covid 19- women’s health, occurrence of neural tube defects and severe acute malnutrition in children

    Phadke M1,Nair R2,Menon P3,Jotkar R4, Saunik S5
    Dear sir,

    We read with interest the article on ‘Disruptions in maternal health service use during Covid 19 pandemic by Zeus Aranda, Thierry Binde et.al that has appeared in the B.M. J. Global Health Vol7. Issue 1,2021(http://dx.doi.org/10.1136/bmjgh-2021-007247) and wish to respond to it.
    India has been battling the Covid 19 pandemic like most other countries of the world. The first two waves, particularly the second wave produced devastating effects on many aspects of human health and welfare .Disease mortality and morbidity was unparalleled. In addition to these direct effects of Covid 19 disease itself, one had to face a number of indirect effects of Covid 19 on women, adolescent girls and children. Lockdowns, loss of jobs, decrease in salaries, migration, supply chain disruption, inadequacy and inaccessibility of foods, green vegetables, stoppage of midday meals due to school closures, inadequate distribution of iron folic acid tablets from anganwadis to children, adolescents and antenatal women will probably impact women and children’s nutrition.
    In the article by Zeus Aranda 1, they have predicted enormous disruptions in maternal health services1. We have observed the same in Maharashtra, a state in India.’
    India has now...

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  • Ethical Committees a must for grass-root filed research

    Dear authors,
    Since I have worked in remotest of PHCs in Himachal Pradesh, India and now am supervising them, the most unfavorable atmosphere for embedded research at grass roots is non availability of ethical committees and due to that either doctor fail to do research in field conditions or their research is hijacked by the medical colleges as PIs . Most of the medical colleges don't allow outside field doctors to get ethical clearance and have condition that medical college faculty would be PI for any research proposal/project, only then anyone can get research proposal listed in IEC.
    I am trying to have an ethical committee notified at the level of Directorate of health so that PHC doctors can also get ethical clearance for their research this paper is talking about.
    Thanks for raising this issue at global level.
    Dr. Omesh Kumar Bharti, Field Epidemiologist

  • Risk of bias

    Its more of a doubt. I would like to know what risk of bias tool was used by the team? What were the findings on risk of bias, since I couldn't find anywhere in the article reporting the same.

  • Biased analysis, a dangerous precedent

    Dear Editor

    The article by Gesesew et al (1) presents a highly biased analysis of the impact of war on health systems in the Tigray region of Ethiopia. The analysis rests on a premise that the region of Tigray was “invaded” and provides selective references of “deliberate attacks by allied forces”. We respectfully point out that the characterization of an invasion is not only fundamentally inapplicable to a federal army in a region of its own country but is also wrong on the simple basis of chronology. It is crucial to acknowledge that war started because of the Tigray People’s Liberation Front (TPLF) concerted simultaneous attacks of several Ethiopian Federal Army bases stationed in Tigray on Nov 4, 2020, killing thousands of troops.

    In describing the human toll of the war, the analysis does not distinguish between civilian and military casualties, nor consider the impacts of TPLF guerilla tactics on the civilian population. Egregiously, it does not mention the well-documented massacre of hundreds of Amhara civilians in Mai- Kadra, Tigray (by forces allied with the TPLF) on Nov 9-10, 2020 (2). The analysis mentions “hunger and rape as weapons of war” and “independently confirmed ethnic cleansing” but fails to acknowledge a fundamental contradiction with the outcomes of independent investigations from the United Nation’s Office of High Commissioner for Human Rights (UN-OHCHR) and the Ethiopian Human Rights Commission (EHRC). These entities used internationa...

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  • Implementation and engineering science and the costs of revising and rolling out hand hygiene programmes

    Dear Editor
    Ross and co-authors have developed a usable model to estimate the costs of hand hygiene in household settings for the 46 least developed countries. (1)

    The authors conclude that costs could be covered by using resources from across government and partners, and could be reduced by “integrating hand hygiene with other behavioural change campaigns where appropriate.” (1) Models such as these are based on the assumption that gathering up all the relevant costs has been done – yet the authors note that “follow-up formative research to revise promotion interventions based on implementation experience was not included.” Their justification was that the cost of these revisions would be likely to be small.

    However, implementation and engineering science suggest that the costs of such revisions could be major. If there were problems with the original plan for promotion interventions, then multiple steps would be needed to enable their revision. These would include but would not be limited to understanding the problems, identifying what factors were causing the problems, planning a strategy for change and then tactics on how such change could be delivered, testing the change, and then rolling it out.

    When all these are taken into account, the cost of the revision process could be considerable and to this must be added the cost of the new implementation strategy that would then need to be rolled out.

    Thus, a new implementation strategy...

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  • Will vaccine passports ease international travels?

    Vaccines are our only promising key to minimizing the spread of the virus and returning to a normal life. Lockdowns and quarantines have a negative impact on people’s mental health and social lives. Vaccine passports can allow us to participate in certain activities such as traveling without having to go through extreme channels such as quarantining for weeks when you travel into or outside of a country. This can helps us transition back to life before COVID-19 while minimizing the fears of spreading the virus globally.

  • Re: Through a quantitative study design, could this lead to more answers from scientists?

    A very informative and well-round study that gives a somewhat comprehensive explantation (as a pioneer study) on how scientists from different fields interact with policymakers during the COVID19-pandemic. It gives a good explanation of how difficult the “sandwich position” seems to be when you have to work in a field requiring interdisciplinary competencies.
    Some critique points might include the fact that one of the interviewed scientists mentioned, that wearing a mask was not effective (P4, the Netherlands on page 5). Given the view from a very European perspective, a view over to the Asian neighbours would have or could have clarified this point. (1)
    The European point is another thing that needs to be taken into consideration. Although the authors mentioned that the result might not apply to other parts of the world, it is crucial to mention that this issue needs to be addressed if we talk about a better interdisciplinary workforce globally during a pandemic.
    Moreover, could a quantitative approach would have led to different results? Maybe the purview or range among scientists would have been more applicable with a fitting survey so that more scientists in related fields and positions could have been reached.
    Fears and reservations about anonymity could be eradicated by this study design over a potentially large(r) study population.
    However, I would like to thank you for this paper and hope that broader research on the field could bring...

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  • Lockdowns and Climate Change: A Spur to Action

    In the BMJ Global Health article, “Is the cure really worse than the disease? The health impacts of lockdowns during COVID-19“, Meyerowitz-Katz et al. (1) seek to assess the impact of lockdowns on population health. However, any comprehensive evaluation of the impacts of lockdown may benefit from including the broader effects that such restrictions may have on health due to environmental changes - particularly in regard to air pollution and greenhouse gas (GHG) emissions and the flow-on effects these have on human health due to climate change.

    As described by the authors, lockdowns are associated with broad detriments to human health and are generally undesirable. However, there is now considerable evidence that lockdowns result in noticeable decreases in air pollution. The 6th IPCC Assessment Report deems with high confidence that air quality improved as a result of COVID-19 lockdowns (2). When global lockdowns reached their most widespread point in April 2020, global CO2 emissions decreased by 17% (3), while global NOx emissions decreased by 30% (4), representing reductions in both long-lived and short-lived climate forcers.

    Unfortunately, though these variations are measurable, the effect of such fluctuations on climate change are likely to be negligible (4) and transitory in nature (5, 6). Despite the popular perception that “nature is healing” as a result of lockdowns, the effects are unlikely to mitigate climate change on their own.

    Yet even so...

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