94 e-Letters

  • 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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  • Research Under pressure in Iran from both sides of sanctions and domestic political crisis

    United States withdrawal from the Iran nuclear deal in May 2018 has led to increasing pressure on all members of society (1). Economic sanctions against Iran have not formally targeted health care or access to drugs and ordinary people, but they have indirectly serious impact on health services and consequently on research programs. Economic sanctions resulted in decline in the value of Iran's currency and government faced big budget deficit. Therefore, the cost of research programs and initial equipments for conducting any projects will increase too much. In this case they are unaffordable by institutions (1-3). Based the on Kokabisaghi et al. paper published in BMJ Global Health in 2019, the economic sanctions imposed more problems on Iran’s research and publishing. Also they claimed that academic boycotts violate researchers’ freedom and curtail progress (2). Free exchange of ideas irrespective of creed is needed to optimize global scientific progress (2). But it seems that another factor can indirectly effects on research programs in Iran. Economic sanctions and scientific boycotts are among the most important problems for researchers on Iran. In the meantime importance of domestic political crisis due to economic sanctions has been ignored. This is not mentioned in this study. With decreased national budget and GDP (gross domestic product) per capita, the government was forced to raise prices of energy and oil carriers; as a result, it created a major political c...

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  • A partnership approach to strengthening IHR compliance

    Dear Editor,

    We read with interest the recent analysis of Joint External Evaluations (JEE) to assess International Health Regulations (IHR) compliance in the WHO African region. It is fantastic to see the engagement in the African region with this voluntary process, with 40 of 47 countries having been evaluated to date and 41 published mission reports (including Zanzibar), the highest proportion of completed JEEs for any WHO region. We congratulate the WHO Regional Office for Africa (WHO AFRO) for its leadership of this critical process. We would like to add our perspective as a technical agency engaged with and supportive of the JEE process.

    As part of Public Health England’s (PHE) IHR Strengthening Project we have been engaging with National Public Health Institutes (NPHIs) in four African countries namely: Ethiopia, Nigeria, Sierra Leone and Zambia. In addition, we work with regional public health institutions such as the Africa Centres for Disease Control and Prevention (Africa CDC), and WHO AFRO to extend our reach beyond the bilateral engagement countries listed. The JEE process, with the subsequent development of a National Action Plan for Health Security (NAPHS), has been instrumental in informing and shaping our areas of engagement. In each of our partner countries, we have worked closely with the leadership of the NPHI and the relevant government ministries to develop workplans that address the gaps and needs highlighted in the JEE and prioritised...

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  • Unpacking the imbalances in authorship in global health.

    DISCLAIMER: Views expressed in this letter are those of the authors only, and do not represent the views or interests of the Bill & Melinda Gates Foundation.

    We enthusiastically agree with the Editor's observation that what underlies the growing concerns about imbalances in authorship are the questions of power asymmetries in the production and benefits of knowledge in global health.

    Critical and open self-reflections and reflexivity on "gaze" (who we write for) and "pose" (position from which we write) are much needed steps towards moving beyond representation on the list of authors.

    However, if what underlies the imbalances in authorship is in fact power asymmetries, solving the problem of imbalances in authors requires directly interrogating the relations of power. Indeed, in our recent article, we identified marginalization the scholarship that interrogates the relations of power represents one of the persistent manifestations of the dominant norms of global health along with democratic deficit and depoliticization of the discourse (Kim et al. 2019). These manifestations may overlap or confound the relation between country/community of origin. We further argue that these manifestations are ideological in character in that they are not merely tendencies but functional in naturalizing and universalizing the implicit assumptions and norms of the dominant narrative.

    The editorial raises an extremely important poin...

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  • Should a paper published by a 'local' researcher about a local country be more valuable?

    Thank you for this extraordinary piece! It provides a more nuanced picture of the concern regarding unequal authorship in global health publishing. In the spirit of your argument, I would like to share my experience and thoughts on this with an example. I have recently received a reviewers comments on an article I submitted for publication that stated that the author is encouraged to review the article, especially if Cameroonian because more research on the topic from Cameroonians is necessary. The article needed more work, I am new to publishing and I am not arguing with that. However, I felt a lot of frustration with the comment about the piece being worth more if written by a Cameroonian as opposed to me a ‘foreigner’/’northerner’. To add to your wonderful piece, I have two reflections on my example: First, I echo your argument that sometimes ‘foreign’ researchers are better placed to conduct ‘local’ research. I conducted research on a very controversial global health project whereby millions of dollars disappeared. If a Cameroonian would ask the questions I asked, they would risk their life. My research took place in an authoritarian state, Cameroonian researchers select very carefully what they say and what they can’t say because of a simple well-founded fear of persecution. They also worry about how critiquing a health programme could affect their future job opportunities with these actors. Second, some Cameroonians don’t want to do the write up because they have sev...

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  • Zika virus surveillance gaps

    A common issue with Zika virus surveillance, including during the epidemic in the Americas, is the time gap between local virus establishment and detecting the first case. In the Americas, we found this gap to be about 1.5 years (https://www.cell.com/cell/fulltext/S0092-8674%2818%2930171-5).

    Based on the sequence data published by the ICMR (https://www.sciencedirect.com/science/article/pii/S1567134819300048), we estimate that Zika virus was established in Rajasthan in early 2017, meaning that there was local transmission for ~1.5 years before the outbreak was detected in 2018 (http://virological.org/t/preliminary-origins-of-the-2018-zika-outbreak-i...). This suggests that the virus may have spread further during that time period and local surveillance networks should remain vigilant to detect other "silent" outbreaks.

    Please email me at nathan.grubaugh@yale.edu if you have any questions about these comments.

  • Still not amused...

    As outlined in a blog on the making of the “Global Action Plan for healthy lives and well-being for all” published in June (http://g2h2.org/posts/still-not-amused/), the information on the GAP that are accessible on the WHO website (https://www.who.int/sdg/global-action-plan) have left us with many worries and unanswered questions. Today, and only two weeks ahead of its formal launch at an UNGA side event in New York, the final text of the GAP is still not available - and our questions and concerns remain unanswered. Instead of further coffee grounds reading, let us critically comment on the GAP once it is published, and let us critically watch its implementation, once the plan is in place.

  • Continuity in primary care: application and implications for trauma-informed care

    The recent study by Dan Schwartz and colleagues, Continuity in primary care: a critical but neglected component for achieving high-quality universal health coverage (2019) provides a valuable framework for optimizing primary care. The focus on continuity as one of the “Starfield ‘4C’ functions of effective primary care aligns strongly with those of trauma-informed care in an adult medical setting. The tension between continuity and access is acknowledged as reality, but not an obstacle, to expansion of access to care.

    The three core domains of relational, informational and managerial continuity described by Schwarz and team correlate strongly to the six trauma-informed care guiding principles: trust and trustworthiness, physical and psychological safety; collaboration and mutuality, empowerment, voice and choice, peer support, and cultural, historical and gender acknowledgment. These principles are grounded in the 4R’s of an organizational culture that includes: (1) realization of the ubiquity of trauma, (2) recognition of the ways in which trauma affects all individuals in the organization: patients and their families, clinicians and staff, (3) response through integration of knowledge about trauma into policies and procedures, and (4) avoidance of re-traumatizing patients and staff.

    Trauma-informed care is above all a resilience-focused approach, and primary care remains central to primary and secondary prevention in public health. Given the overall sh...

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  • 100% agreed

    Dear authors,
    thank you for your initiative to discuss this (possible) source of bias in global health studies! I could't agree more and can only underscore that good and reliable research results will in the end benefit the work of everybody, including donor agencies.
    thanks again and best regards,
    Jan Peter

  • Robust rapid diagnostics for CCHF in endemic seasons

    Crimean-Congo hemorrhagic Fever Virus (CCHF) is of increasing consequence in endemic regions as global climate changes increase the length of dry hot weather, facilitating the expansion of host tick populations which carry the virus. The virus is carried by the Ixodid (Hyalomma) tick found on a range of cattle and camel species. CCHFV is endemic to Africa, the Balkans, Middle-East and Asia. In the animal reservoir it results in sub-clinical infection but in humans, infection can lead to rashes, fevers and leads to hemorrhagic disease with a fatality ranging between 10 -40%. Mazzola LT et al., in their article discuss the importance of improved diagnostics for CCHFV and discuss the pros and cons of methods which have been reported in published literature and discussed the options for serological and RT-PCR based tests as LDT and commercial assays (1). The article however gave a limited statement about the reasons for the spread of CCHFV and this Letter aims to expand on that aspect.

    CCHFV in endemic regions has been associated with the Muslim religious festival of Eid-ul Azha when a large number of animal sacrifices occur, leading to increased contact between individuals who are not usually involved in animal husbandry or meat handling (2, 3). This change in the pattern of animal handling together with the influx of animals into urban areas for the festival increases contact with possibly infected animals, increasing risk of CCHF.

    Of note, the CCHF prevale...

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