60 e-Letters

  • RE: Reading Between the Lines of the RUTF trial, India

        Reading Between the Lines of the RUTF trial, India
    Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
    It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...

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  • Researching the Syrian tragedy: The need for evidence and moral reflexivity

    ‘The nationalist not only does not disapprove of atrocities committed by his own side, but he has a remarkable capacity for not even hearing about them’ (George Orwell, Notes on Nationalism 1945).
    We read with concern Sen and colleagues’ discussion of potential breaches of ethical neutrality in the reporting of events in Syria by Non-Governmental Organisations (NGOs) and academic researchers. We fully concur that any research must be based on rigorous methodologies and robust ethical frameworks. However, when engaging in debates on ethics and critiques of existing research one should adopt a morally reflexive position and consider all the evidence that exists no matter who has produced it.

    Over the past five years a large body of evidence from credible humanitarian and international organisations has been accumulated which clearly documents the use of chemical weapons, heavy weaponry, ballistic missiles, cluster and barrel munitions deployed by Syrian Arab Army (SAA) forces and its allies. It is unfortunate that in the Syrian context, no side has spared civilians or prioritised the protection and well-being of civilians. Human rights abuses have been carried out by all sides. However, abundant evidence exists that the SAA have been largely responsible for the mass of civilian casualties. A major study in the British Medical Journal of the causes of mortality in Syria attests to this. Since September 2015 the SAA has been assisted by the Russ...

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  • Essential Medicines List: a good start, but just a start

    The comparison of national vs. WHO essential medicine lists (EML) with respect to medications used in pediatric endocrinology by Rowlands et al. highlights an important health care delivery gap for children with endocrine disorders.

    However, as the authors correctly point out, accessibility is far more limited than reflected by the EMLs. We argue that many medications listed on EMLs are not actually available to most patients in resource-limited settings and that all five dimensions of access including availability, affordability, accessibility, acceptability, and quality (1), are suboptimal for medications relevant to pediatric endocrinology. While EMLs may be a rough surrogate of availability, as a metric they cannot take into account stock-outs and limited numbers of pharmacies carrying the medication, both frequent occurences in resource-constrained settings. Similar to cardiovascular medications (2), limited affordability is a major access barrier in a country like Haiti where close to 60% and 25% of the population live under the national and extreme poverty lines, respectively (3). Accessibility adds to the barriers where pharmacies are distant from patient residencies, acceptability can be challenging in cultures where traditional practices are common, and quality of medications may vary widely in settings with little regulatory supervision and compliance. A case in point is propylthyrouracil, a drug that carries a black box warning (4), which is on the EML,...

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  • RE: Women's health and men's health - let's move forward together

    Dr Peters et al's call for action to reduce the global burden of disease more efficiently in women and men is very well made.

    Their article focuses on women's health but many similar points could be made about men's. WHO data shows that, globally in 2012, 52% of all deaths from NCDs were male. Males were more likely than females to die prematurely (under 70 years) from NCDs in almost every country. The major risk factors for NCDs include unhealthy diets, tobacco use and the harmful use of alcohol and men do worse than women in respect of all of these. Data from the Global Burden of Disease Study 2010 shows that, in that year, 55% of deaths from dietary risk factors were male as were 72% of deaths from tobacco smoking and 65% of deaths from alcohol.
    Life expectancy data also highlights the health burden borne by men. Globally, male life expectancy at birth, at 68 years, lags five years behind female life expectancy and the global ‘gap’ is predicted to increase over the next 15 years: by 2030, male life expectancy could well be seven years shorter than female life expectancy.
    Global as well as the almost all national health policies have largely ignored men. The UN’s Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-30) overlooks boys and world leaders at the 2016 G7 Ise-Shima Summit in Japan made important commitments to improving women’s health but did not mention men.


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  • Contextual factors influencing village health sanitation and nutrition committees in India

    I read with interest the abstract on contextual factors influencing village health sanitation and nutrition committee (VHSNC)[1]. The authors mention that none of the 50 VHSNCs in their study received the “untied funds” (Rs.10,000/- per annum) during 18 months of study period. These funds are provided to empower the VHSNCs to address immediate health needs of the community, and to stimulate local action towards raising health awareness and organising village level meetings, sanitation drives and other identified health need. As VHSNCs are expected to leverage funds from other sources, it would have been useful to know how much additional amount these VHSNCs under study were able to generate on their own?

    From my personal experience I can say that two contextual factors play key role in success of any such schemes in rural India: a) local village politics, and b) corruption. Authors have mentioned that many VHSNCs were unable to engage crucial elected representatives (Sarpanchs) and instead had to work with the lowest level elected representative (Ward-Panchayat), thereby having little influence. One of the possible reasons for this could be that Sarpanchs despite knowing that VHSNC is a subcommittee of Panchayat, might have viewed it as a parallel authority diluting their role especially as the chairperson of VHSNC has to be a female ward-Panchayat preferably from underprivileged sections of society. 

    This becomes more evident if the chairm...

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  • How much do LMICs need HICs?

    We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
    There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
    We are also concerned with the persistent use of ‘colonial...

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  • We need training opportunities in global surgery for HIC professionals

    As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
    (1) The Lancet Commission for Global Surgery (LCoGS) (2)
    (2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
    (3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
    (4) The launch of the G4 Alliance (5).
    The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
    The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other h...

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  • Global Surgery and Global Surgeon are not synonymous

    I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
    It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
    The nuanced di...

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  • Emergency obstetric care in India

    To the Editor
    The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
    However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
    The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...

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  • Production of tobacco and prevention of tobacco use in India: two sides of the same coin?

    Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
    In addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
    There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoti...

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