74 e-Letters

published between 2017 and 2020

  • Healthcare evidence from conflict settings

    To the Editor;
    Three articles(1,2,3) appeared on the latest special issue of the journal reviewed the medical care in humanitarian emergencies and pointed out significant gap existed in knowledge especially women and children. Two of them(1,3) showed the number of articles published annually. One of them (1) limited the article search year within 5 years so that they can separate emergency from the issues related to chronic poverty and development.
    We examined the correlation between the number of healthcare articles and Overseas Development Assistance (ODA) in Afghanistan through the PubMed database between 1980 and 2015, from the first Soviet war until the peak of ODA to the country in 2015. Afghanistan is unique since it has been one of the sustained emergencies (4).
    The PubMed database was searched using the key words “Afghan” or “Afghanistan,” and the search was limited to English literature published between 1980 and 2015. Since Afghan or Afghanistan is a distinctive term for a literature search, it was assumed that it could identify specific articles to the area. 4669 articles were identified on the initial search (3/11/15); both authors individually verified the articles, 4380 of them were selected for analysis after 289 articles were eliminated as ineligible. The ineligibility was mostly due to veterinary medicine articles, genome research, or Afghan as an author’s name, and other articles inadvertently selected in the search process.
    The t...

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  • Socioeconomic Inequalities in Neglected Tropical Diseases

    Dear Editor,

    It is with great interest that I read the original research by Lobkowicz et al, ascertaining that coinfections do not strongly influence clinical manifestations of uncomplicated ZIKV infections [1]. With this interesting finding in mind, it is important to remember that Neglected Tropical Diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioural and physical environment [2]. More than 70% of countries and territories affected by NTDs are low-income and low and middle income countries [2]. Thus, there are extreme inequalities with regards to disease distribution. People are affected by NTDs because of an array of social determinants. It is plausible that these social determinants may allow for coinfections of Zika (ZIKV), dengue virus (DENV) and chikungunya (CHIKV).

    Social Determinants of Health (SDH) are the conditions in which individuals are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life [3]. SDH encompass socioeconomic factors, environmental factors and biological factors. These factors play a fundamental role in the proliferation of vector-borne diseases such as ZIKV, DENV and CHIKV. The relationship between the vector and SDH is complex, yet it is extremely important to recognise in order to evaluate the impact of socioeconomic factors on infectious diseases.

    There are major ineq...

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  • Simple to use App guides antimicrobial prescribing decisions in LMICS and UK

    Responding to https://gh.bmj.com/content/5/4/e002094
    ‘The Commonwealth Pharmacists Association (CPA) https://commonwealthpharmacy.org/welcomes the publication of this systematic review which confirms the views held by the CPA that usable, point of prescribing decision information in low and middle income countries, is often not readily available where it is most needed. This of particular concern when we consider the prescribing and appropriate use of antimicrobials.
    The UK DHSC Fleming Fund (https://www.flemingfund.org/) Commonwealth Partnership for Antimicrobial Stewardship (CwPAMS) Project has for the last 6 months been piloting an App for use in Ghana, Tanzania, Uganda and Zambia. This is part of the wider CwPAMS programme which is a collaboration between CPA and The Tropical Health and Education Trust (THET) https://www.thet.org/our-work/grants/cwpams/
    The App guides prescribers as per national guidelines, and contains links to WHO resources and other training materials. It is explained clearly in this short u-tube video https://www.youtube.com/watch?v=MJ7fa_aLgCI It is free, to download to a smart phone or device anywhere in the world where there is access to the internet and then...

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  • Ethics in Implementation Research

    Implementation research is crucial to determining effectiveness and appropriateness of interventions that are urgently needed in many contexts, constituting "global health". There is, however, an ongoing surprising relative lack of discussion on the need for appropriate understand of the ethical implications of Implementation research. Ethics committees and researchers are often not well versed in the ethics implications, and how these differ form traditional clinical research. the potential for unintended harm is great in the vulnerable circumstances wheer implementation research is often conducted. It is vital that if implementation research is conducted, ethical implications are considered throughout the process (i.e. continuing throughout the implementation itself and post-research). These issues have been laid out in an online teaching tool (by TDR/Global health Ethics Unit at WHO) and in the following publications:

  • Health and Disease - Just Two States of the Same System

    Paul et al [1] argue for a systemic approach to global health policy. This shift is long overdue, and as they pointed out systems thinking has long been suppressed by the all-powerful reductionist research industry.

    Part of the problem is understanding of health and disease as distinctly dichotomous. However, the experience of health and dis-ease are dynamic as much in the presence as absence of identifiable disease [2]. In addition, health, illness dis-ease and disease occur on a continuum in the same person over time. It entails a continuous change in the physiological dynamics within the person that ultimately leads to changes that we recognise as one or the other disease. The process can lead to multiple expressions of disease, nevertheless, they are nothing more than the result of the overall physiological dysfunction within the same person [3].

    As is well known health and disease disparities follow the socioeconomic gradient [4]. The question arises – how? There is increasing evidence from psychoneuroimmunology research that shows the longterm effects of psychosocial stress on the physiological stress response pathways resulting in chronic inflammatory dysregulation and its link to disease burden [5, 6].

    Taken together, these findings provide a complex adaptive system explanation of the nature of health and disease arising through the network interaction between our environmental, socio-cultural and economic-political contexts and our biological...

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  • Model Hazard?

    Richardson (1) argues three substantive points:
    1. Models are merely fables dressed in formal language.
    2. Fables are unscientific.
    3. Models serve as epistemic confines to our understanding.

    We argue that 2., a premise he makes implicitly, is wrong. Formal language in fables cannot produce an ‘illusion’ of scientific-ness, because there is no division between ‘fables’ and ‘science’. We suggest that scientific models are stories (2) in some real sense, and therefore it does not make sense to say that models are unscientific because they are fables. Science is composed of a complex web of interacting models (stories) whose aims are to explain and understand the world. This would be consistent with Sugden’s (3) view of economic models as credible worlds.
    Richardson cites Rubinstein (4) to buttress his argument that models are merely fictions. This misuses Rubinstein, who argues ‘The models presented… are nothing but fables. Neither of them describes reality, but both of them still describe something from reality… studying both of them together helps to some extent in understanding economic mechanisms.’ (p.182). It does not seem fair to brand models as ‘merely’ fables on this reading, and nor does this give us licence to dismiss fables as unscientific.
    Epidemiologists often make significant assumptions in order to model disease progression. Many parameters are unknown, and there are often practical constraints to modelling significant hete...

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  • India: air pollution and CKD

    As highlighted by Bowe and colleagues, air pollution is closely linked to burden of Chronic Kidney Disease (CKD). (1) A recent article on cardio-pulmonary mortality also highlighted similar issue, with a focus on provision of ventilation. (2)
    India faces similar issues due to air pollution attributable to wide spread traditional habit of cooking with biomass. The contribution of CKD to Disability Adjusted Life Years (DALY) in the country has increased from 0.8% in 1990 to 1.6% in 2016 and it is the 9th common cause of mortality. (3)
    With focus on prevention, CKD has been included under National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, the flagship program for Non-Communicable Diseases (NCD). Through NCD Clinics, diabetes and hypertension, two common risk factors for CKD, are being addressed. Population based screening is also underway for prevention, awareness and early diagnosis of these two morbidities. (4) Pradhan Mantri National Dialysis Program has been put in place to meet the need of dialysis services by the poor people at free of cost. (5) Ujjwala scheme has recently been introduced, under which more than 80 million families have been provided clean fuel. The scheme specifically targets rural areas where biomass is considered as one of the major mean for cooking. (6)
    With so many initiatives, researches are warranted from India to estimate their effects in mitigating CKD burden and to tailor hea...

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  • COVID-19: Considerations of domestic violence amongst low- and middle-income countries.

    Dear Editor,

    We read with great interest the original research by Coll CVN, Ewerling F, García-Moreno C, et al which found that domestic violence in low- and middle-income countries was more prevalent amongst certain groups of women.

    The ongoing COVID-19 pandemic has already ravaged countries within Asia, Europe and the United States, defined as high-income by the World Bank Group. [1] Actions taken to prevent the spread of the virus has meant a large proportion of the population in these countries is currently under some degree of confinement, and consequently, an alarming increase in domestic violence has been reported by the news. [2]

    Coll CVN, Ewerling F, García-Moreno C, et al recognises Africa and SouthEast Asia to have a higher prevalence of domestic violence. At the time of writing (29/03/2020), the WHO has already reported 3005 cases and 51 deaths in Africa and 3709 cases and 139 deaths in SouthEast Asia, with no doubt that these numbers will continue to grow. [3]

    Resources to fight the COVID-19 epidemics in these regions are limited and thus, efforts aiming to curb the transmission will soon undoubtedly follow other countries’ mitigation plans; police enforcing a lockdown, healthcare workers treating COVID-19 patients and government officials attempting to gather the necessary equipment for the care of its citizens. This means an extensive proportion of the workforce needed to help women undergoing domestic violence will already be si...

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  • Defining global health as public health everywhere else

    While liking the idea, I find two main problems with the suggested definition of global health as "public health somewhere else": 1) it is too narrow and 2) it sounds dismissive. In "global health", the word "global" is inclusive and suggests a health agenda embracing all the communities of the rest of the world. This is lost in the definition. Then there is the dismissive sound of "somewhere else" ("You can join our club or go somewhere else", "This could be Paradise or it could be somewhere else", etc.). I may be thin-skinned, but disdaining to specify a location sounds to me like a slur. For these reasons, and for all the other good reasons offered in the original Commentary, I suggest amending the definition to "public health everywhere else". This follows the original in asserting "elseness", while being inclusive and positive.

  • Trust and culture

    Why the first sentence of this article with its exaggerated claim about the health outcomes of Aboriginal and Torres Strait Islander Australians? The reference cited, 1 does not support the comparison with other populations globally, and the article itself seeks to move beyond negative images of Aboriginal and Torres Strait Islander people. Beginning with this negative statement – regardless of its veracity - continues the long history of deficit discourse used in discussing Aboriginal and Torres Strait Islander people. Rather than contribute to improved outcomes deficit discourse can actually reinforce and perpetuate approaches and behaviours such as those the article seeks to address. 2

    Overall the article presents important new research moving beyond negative stereotypes of Aboriginal and Torres Strait Islander people, highlighting their perspectives and insights, and encouraging a more culturally driven approach. This makes the opening even more inappropriate and unnecessary.


    1. Gracey M, King M. Indigenous health part 1: determinants and disease patterns. Lancet. 2009;374:65-74.
    2. Fogarty W, Bulloch H, McDonnell S et al. Deficit Discourse and Indigenous Health: How narrative framings of Aboriginal and Torres Strait Islander people are reproduced in policy. Melbourne: The Lowitja Institute; 2018 [cited 20 Jan 2020]. Available from:...

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