180 e-Letters

  • Semantics : Acta non verba

    Pardon my literary brevity, but this article does little in the way of actually helping poor communities . All you are
    doing is changing words around to sugar coat widespread healthcare inequalities ( disparities ) in this country. Why not just call it what it is and do something about it, ipso facto ? It is dissapointing to read an article where the primary debate centers on linguistics or terminology and not practical solutions to real life health problems. So what if a country is 'developing', we used to call them "third world " what the hell is the difference? My bigger point is should we not concentrate on helping each other instead of finding different ways to be woke .

  • Fundamental values cannot be defeated by the argument from proportionality

    The article does not adequately take into account a crucial ethical and (by implication, legal) fact: the argument from proportionality does not justify arbitrary violations of the right to life or the removal of the right to free medical consent, for the following reasons.

    Summary of the three strongest arguments against the ethical permissibility of vaccine mandates and why any medical procedure imposed by coercion must be refused.

    1. Vaccine mandates imply that all humans are born in a defective, inherently harmful state that must be biotechnologically augmented to allow their unrestricted participation in society, and this constitutes discrimination on the basis of healthy, innate characteristics of the human race. (This point derives from my paper published here: https://jme.bmj.com/content/48/4/240).

    2. Medical consent must be free – not coerced – in order to be valid. Any discrimination against the unvaccinated is economic or social opportunity coercion, precluding the possibility of valid medical consent. The right to free, uncoerced medical consent is not negotiable, under any circumstances, because without it we have no rights at all; every other right can be subverted by medical coercion. Crucially, by accepting any medical treatment imposed by coercion we would be acquiescing to the taking away of the right to free medical consent not just from ourselves but from our children and from futur...

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  • Caution advised when comparing or pooling seropositivity proportions

    We read the systematic review by Dong et al. [1] with great interest. The authors aimed to describe global seroprevalence estimates for B. burgdorferi s.l., the causal agent of Lyme disease.

    First, estimating seropositivity for a target population (here, the global population) has two challenges we would like to address:
    1) The age and sex distribution of the population providing sample(s) and the target population should correspond. The simple reason is that advancing age and male sex are well-established risk factors for a positive IgG antibody serostatus [2]. Therefore, one may not conclude the general population seropositivity from an aged sample with a large share of males if not corrected accordingly, e.g., by applying weights; otherwise, seropositivity may be overestimated. Unfortunately, the age and sex profiles of the individual studies were seemingly not considered or discussed for their final seropositivity estimates.
    2) Then, as already stated in the first reply to this manuscript by A. Semper et al., the studies containing subjects with medical conditions or even patients with suspected or confirmed Lyme disease symptomatology are of little use for general population estimates of seropositivity (e.g., [3, 4], included by Dong et al.), as these populations do not correspond to the global population. Also, pooling seropositivity proportions for high-risk populations to obtain global estimates potentially introduces bias and, hence, should be a...

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  • What is the responsibility of the funder?

    This is a thought-provoking article and I can see similar tensions and themes in my own collaborative relationships. I would have liked to see more discussion of how the funding opportunity shaped and contributed to these tensions and what the role of the funder is in contributing to healthy equitable collaborations. Many of the decisions were driven by how to meet the expectations of the funder. It would also be interesting to examine these tensions in long-term collaborations that exist outside of any one specific funding opportunity.

  • Reframing the power relation: from feudalism to capitalism

    I would like to thank the authors for their analysis of the structural imbalances of power that exist in global health. I particularly agree with their argument that diversity, equity and inclusion initiatives work only to strengthen existing structures rather than to dismantle them.

    However, I would like to problematise the framing of the power relation in this article and suggest an alternative.

    To describe the contemporary problems with the “structural imbalance of power” in global health as feudal perhaps implies that they are somehow historic or located in the past, when they are operating and located within modern political economy. Feudalism, as a system of production, is predominantly associated with medieval Europe. Therefore there is a danger, in this piece, that the solution gestured towards is one of modernisation, to develop the relations from these feudal ones. However, from feudalism developed capitalism, both in Europe (Marx et al., 1981; Robinson, 2000) and also, as Alavi (1980) argues, in the colonial Indian context the authors explore in detail in their article.

    Colonisation is inseparable from the rise of capitalism as a means of production (Vergès, 2021), of which developing healthcare infrastructure to support the colonisers was an integral part, as the authors identify. Colonial expansions were not primarily a thirst for adventure but a thirst for profits, for resources, for land and for new people to exploit (Blaut, 1989; Bryan...

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  • Guidance takes many forms and may not always be public

    As an infectious diseases clinician who has managed patients with complicated monkeypox virus infections since 2018, I agree with Webb et al. that clinical management guidelines are helpful to those managing cases of monkeypox and welcome their efforts to identify potential gaps in available guidance. However, as the principal author for the original PHE guidance on monkeypox, I feel it is important to point out that the publicly available guidance for England was not intended to be detailed clinical guidance, which is likely why it was assigned such a low score in the systematic review by Webb et al.

    Prior to 2022, clinical management of sporadic cases of mostly travel-associated monkeypox cases in England was the responsibility of five NHS England-commissioned Airborne HCID treatment centres. Readers of this systematic review may be under the false impression that, in the absence of published national clinical management guidance, those caring for cases in England had no access to advice or guidance, which is simply not the case. In addition to information shared through an active specialist peer-support network, not all guidance was published, and HCID treatment centres follow their own standardised protocols for HCID infection prevention and control, which are not published under the banner of 'monkeypox clinical guidance'. The case series describing the management of patients hospitalised with monkeypox in England between 2018 and 2021 (Adler H et al...

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  • Welcoming this Framework

    Coming from an international relations background, I'm pleased to see more discussion of topics like this in global health, which were absent from my Global Health studies. Public health too often doesn't directly deal with power, though power is so central to health outcomes- positive and negative. I think our engagement with power imbalances is a big part of understanding power in public health, which includes seeking economic justice for marginalised groups.

  • Response to Dong et al: Global seroprevalence and sociodemographic characteristics of Borrelia burgdorferi sensu lato in human populations: a systematic review and meta-analysis

    Through a systematic review and meta-analysis, Dong et al (1) have calculated a global B. burgdorferi sensu lato (Bbsl) seroprevalence estimate of 14.5% (95% CI 12.8% to 16.3%). We question the accuracy and appropriateness of such an estimate.

    As the authors demonstrate, seroprevalence estimates based on orthogonal 2-tier serological testing with a confirmatory Western-blot assay decrease the risk of false-positive results and are more reliable than those using single assays. Yet the pooled 14.5% estimate includes studies that used single assays, apparently without adjusting for the decreased reliability of single-tier testing. When studies using single-tier assays were excluded, the pooled estimate was reduced to 11.6% (95% CI 9.5% to 14.0%). The 14.5% estimate is based on studies spanning four population categories general, high-risk, tick-bitten and having Lyme-like symptoms. When these sub-groups were compared, the general population had a pooled seropositivity rate of 5.7% (95% CI 4.3% to 7.3%). We argue that only the general population category is relevant when estimating an unbiased population seroprevalence.

    Irrespective of accuracy, using a headline global seroprevalence estimate may be misleading, implying homogeneity when, as the authors report, there is wide variation in B. burgdorferi seroprevalence between countries and regions. Furthermore, the authors suggest that analysis of seropositivity to anti-Bbsl antibodies enhances understanding of th...

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  • West Nile virus and arthropod-borne pathogens, a One Health-based approach is needed!

    Dear Editor,

    The cases of human encephalitis by West Nile virus (WNV) recently diagnosed in northern Italy (Emilia Romagna and Veneto Regions), two of which occurred in elderly patients who experienced a fatal outcome (unpublished data), deserve special concern. This should apply, more in general, to the eco-epidemiology of all arthropod-borne infections, many of which are of zoonotic relevance. We are dealing, in fact, with a large group of viral (Zika virus, Dengue virus, Yellow Fever virus, Tick-Borne Encephalitis viruses, etc.), bacterial (Ehrlichia spp.) and protozoan (Plasmodium malariae, Leishmania spp., Trypanosoma spp., etc.) pathogens, a portion of whose life cycle takes place in an invertebrate host (insect or tick), from which the infectious agent, once acquired from an infected human or animal host, will be subsequently transferred to another susceptible, human or animal, host.
    As far as WNV is specifically concerned, this zoonotic flaviviral pathogen showed up for the first time in Italy in 1998, thereby giving rise to a series of encephalomyelitis cases among horses from Tuscany Region (1).
    Culex spp. mosquitoes - namely Culex pipiens - represent the main WNV vectors. Indeed, successful virus isolation has been obtained from Culex spp. mosquito pools recently sampled in Veneto Region (unpublished data).
    Numerically speaking, arthropod-borne pathogens account for approximately two thirds of the biological noxae responsible for "e...

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  • Should academic journals appoint ethics experts to their editorial boards?

    Dear Editor,

    It is with great interest that I read Doherty et al.’s commentary in which the authors express concern about the ethical appropriateness of a randomised controlled trial that had received ethical approval. Doherty et al.’s study serves as a valuable reminder that a study is not ethical simply because it has received ethical approval, as previous studies have also emphasised.1 One might also add that just because a study has reported having obtained ethical approval, it cannot be assumed that the study has adhered to the recommendations of the research ethics committee or informed the committee of its plans in full. Doshi (2020) reported on bioethicist Charles Wiejer’s concern that a randomised controlled trial of malaria vaccine Mosquirix had waived the requirement of informed consent.2 Weijer was quoted as saying “It is difficult to see how a research ethics committee could have approved a waiver of consent for the WHO malaria vaccine pilot cluster randomized trial.”2 These studies raise the question of whether academic journals should play a greater role in scrutinising the ethical appropriateness of studies submitted for publication?

    As a doctoral student with a keen interest in public health ethics, I previously attended weekly editorial board meetings of a major scientific journal with the sole purpose of interrogating the submitted studies for ethical issues. In these meetings, I raised serious questions about some of the studies that had r...

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